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Joseph F. Panarelli MD, Steven J. Gedde, MD, and Vikram Paranjpe MD, MPH discuss the Primary Tube Versus Trabeculectomy (PTVT) study.



BLOG: The PTVT Trial and Clinical Applications

A recurring feature at the 2024 American Society of Cataract and Refractive Surgery (ASCRS) Annual Meeting in Boston, Massachusetts, was the call for environmentally friendly practices worldwide, with the goal of decreasing the impact of ophthalmic surgeries on the planet.

A driving force in this movement is EyeSustain

 an organization dedicated to the development of such friendly environmental practices, that exists as a global coalition of eye societies providing education and resources to support sustainable practices in ophthalmology.

Here is a sampling of the ASCRS discussions on the topic.

Greening eye care: reducing ophthalmology’s environmental footprint

The presenters, led by first author Sarishka Desai, BA, described the EyeSustain platform and its 5-pronged mission: educate the global ophthalmic community about more sustainable practices, collaborate with industry to reduce our carbon footprint and surgical waste, support research and innovative solutions that reduce ophthalmology’s environmental impact, support advocacy and education about the public health impact of climate change, and collaborate with industry to reduce our carbon footprint and surgical waste.

Desai, of the University of Connecticut School of Medicine in Farmington, and colleagues presented EyeSustain’s approach to reducing the ophthalmic carbon footprint. She was joined in the study by Nitya Devireddy, BS, MPH, of Penn State College of Medicine in Hershey, Pennsylvania; Sofia Miguez, BA, of Yale School of Medicine in New Haven, Connecticut; and Barbara Erny, MD, of the Department of Ophthalmology at Stanford University in California.

The greenhouse gas data associated with health care are startling. Health care is responsible for 4.4% of all global greenhouse gas emissions, 71% of which arise from the manufacturing, use, and disposal of medical supplies. Ophthalmology has the highest procedural volume of any surgical specialty, with 50 million cataract surgeries expected to be performed globally each year by 2050, Desai reported.

In light of the procedural data, the authors highlighted 6 areas that are currently undergoing research and quality improvement initiatives through the EyeSustain system.

 of cataract surgeons and nurses by David Chang and Cassandra Thiel found that 93% of respondents believe that the trash associated with OR procedures is excessive, and that methods to reduce waste should be identified and implemented.

 encouraged regulatory agencies to allow electronic instructions for use be disseminated in lieu of the traditional paper instructions included with each cataract pack.

Ongoing projects spearheaded by EyeSustain members, including medical students and ophthalmology residents, are taking a look at educating surgeons and surgical staff about sustainability and the impact of OR waste, OR water consumption, and evaluation of flash sterilization associated with cataract surgery.

In recognition of the fact that medications in the OR represent an estimated $560 million in waste annually, a multisociety position paper

 recently formulated 3 key recommendations: topical drugs in multidose containers can be used for multiple patients in surgical facilities if proper guidelines are followed; topical drugs in multidose containers can be used until the manufacturer’s labeled date of expiration if proper guidelines are followed; and, when applicable, patients should be able to take their partially used medication home for postoperative use.

The Aravind Eye Care system’s low-carbon model from Madurai, India, uses alternate energy sources, transport, infrastructure, and equipment maintenance.

 Studying global systems of eye care and waste produced can provide a deeper understanding of the impact of hospitals and providers on climate change, as well as ideas on how western eye care systems can proactively reduce carbon emissions.

The EyeSustain platform includes ophthalmology-specific action steps for greening offices and clinics in collaboration with the 

Partnerships can be established with large manufacturers to reduce packaging, make instruments reusable, and streamline the manufacturing and distribution processes.

In addition to the impact of practice waste on the environment, EyeSustain also recommends studying the effects of climate change on the incidence rates of ophthalmologic conditions, including cataracts, allergic disease, and glaucoma, among others.

Desai and her colleagues recommended that institutions take the following steps:

Conduct a waste audit to quantify the carbon footprint of an institution’s OR emissions. This includes using the EyeSustain-Zasti Carbon Footprint Calculator, using the Sustainability Index for Disposables in Cataract Surgery calculator for cataract packs to evaluate the item-by-item potential for carbon dioxide savings, and surveying clinical staff to identify areas of perceived excess waste.

Identify key stakeholders at an institution and an enthusiastic, multidisciplinary team and completing the OR Sustainability Pledge (

), which has been completed by ambulatory surgery centers/hospital outpatient departments from 9 countries thus far.

Implement best practices; multisociety recommendations for sustainability are easily accessible at eyesustain.org and My Green Doctor for outpatient/clinic resources and local legislation using the American Academy of Ophthalmology Topical Medical Waste Reduction Act legislative template.

Using phacoemulsification waste to guide changes in surgical sustainability

Adjustments to improve the sustainability of ophthalmic surgical practice can have a large impact when scaled to case volume, according to author Margaret Tharp, BSc, who described this study at the ASCRS meeting. She and her coauthors Stella Protopapas, BA, MPH, and Minka Gill, BSc, are from the Indiana University School of Medicine in Bloomington, whereas David J. Palmer, MD, ABO, is from the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

In their study, they sought to draw connections between results from a 24-hour waste audit at an outpatient surgical center and current resources available from EyeSustain to improve the sustainability of ophthalmic surgical practice.

The authors documented the extensive waste generated from 1 day of surgeries in an institution that included 13 phacoemulsification procedures, 5 plastic surgeries, 3 urologic surgeries, and 5 otolaryngologic cases. The waste products were sorted as medications (eg, propofol, eye drop containers), textiles (eg, surgical gowns, drapes), metals (eg, metal wiring, disposable instruments), and plastics (eg, hard, soft, wrappings).

When the amounts of the waste products were tallied, the authors found that “ophthalmology produced the greatest amount of waste in a single day relative to other operating specialties, despite producing the least amount of waste per case. Most ophthalmic waste was from textiles, hard plastics, and medications,” the authors reported.

The specific 13 phacoemulsification procedures resulted in 95.4 lb of waste broken down as follows: 18.5 lb of hard plastic, 5.5 lb of soft plastic, 8.3 lb of wrapping, 13.5 lb of medications, 41.2 lb of textiles, 6.7 lb of miscellaneous waste, and no metals. Compared with other operating specialties, ophthalmology produced the least amount of waste per case but the greatest amount of waste in total due to the relatively high case volume.

It has been reported that “discarded/unused pharmaceuticals from US cataract surgeries demonstrated waste of [approximately] $150 per case while generating carbon dioxide–equivalent emissions that approximated 25,000 to 100,000 flights from San Francisco, California, to Boston annually.

Small changes can have dramatic results. Tharp and colleagues suggested that the following would have positive consequences.

Revising the use of tetracaine bottles intraoperatively; for example, reusing the bottles between cases or sending the bottles home with patients

Optimizing packaging of surgical supplies and electronic instructions

Utilizing intravenous sedation to limit anesthesia gas carbon dioxide–equivalent emissions

Focusing on cutting waste also creates an opportunity to explore the practices of global leaders in sustainable eye care, such as the efforts of the Aravind Eye Hospitals, which provide similar surgical success rates at a fraction of the waste produced by US practices.

 A downside may be that such practices require significant reuse of materials, central sterilization, and stakeholder diligence, which can require complex interventions, according to Tharp. 

EyeSustain’s Surgical Facility Sustainability Pledge can serve as a guide for ophthalmologists to improve the sustainability of their practice in an approachable and lasting manner.

Factors contributing to the carbon footprint of cataract surgery

Omar Taboun, MSc, a medical student at Western University’s Schulich School of Medicine & Dentistry in London, Ontario, Canada, working under the direction of Netan Choudhry, MD, FRCSC, also described the negative impact of cataract surgery on the environment at the ASCRS meeting.

He commented, “We know that climate change can affect human health through various means, such as adverse weather events causing injury and exposure to pollutants [exacerbating] underlying health conditions. As health care providers, it is our responsibility to treat patients for their conditions that may ultimately be influenced by environmental factors. Counterintuitively, the health care sector is itself a greenhouse gas emitter,” Taboun said.

Surgery contributes significant emissions to the environment through the necessary materials and tools used during procedures. In addition, the need to maintain sterility increases waste.

The term footprint indicates the sum of all emissions direct and indirect resulting from this procedure, Taboun explained, the resultant value of which is typically reported in carbon dioxide equivalents

And although cataract surgery requires only a few minutes to complete, the procedural volume has increased exponentially over the past 2 decades,

Taboun and colleagues developed a 2-fold goal: they wanted to increase their understanding of the carbon footprint and waste accumulation to identify the primary contributors and pinpoint areas for improvement to enhance the sustainability of cataract surgery.

They conducted a literature search of PubMed, Google Scholar, and Medline to identify studies related to the carbon footprint and the elements of cataract surgery. The results yielded 6 studies, with 2 being the basis for this discussion,

He highlighted 3 main points extracted from the published data: the lowest footprint published was just under 6 kg of carbon dioxide equivalents; the highest published footprint was just over 180 kg of carbon dioxide; and the major factors contributing to the footprint include procurement of pharmaceuticals and materials, building and energy use, such as heating/cooling, lighting, electricity-powered tools, and travel by patients and staff to the location where the procedure is performed.

Taboun directed attention to centers that already have sustainable practices in place, such as the Aravind Eye Hospital, which reports the lowest footprint. These sustainable practices include the use of multiple operating tables in a single room; reusing gloves, gowns, and various medical equipment;

and using highly efficient autoclave settings.

Importantly, when these changes were implemented in the Aravind Eye Hospital,

 the rates of endophthalmitis remained comparable to other centers: 0.02% vs from 0.04% to 0.07% reported.

Taboun offered 3 ways that surgeons can offset the negative effects of cataract surgery on the environment—by focusing on procurement, energy use, and travel emissions.

Reduce emissions associated with procurement by collaborating with manufacturers to reduce packaging as much as possible and encouraging recycling in every OR.

Reduce building and energy use by incorporating renewable energy, such as solar panels, and more strategic lighting protocols and optimizing energy use within surgical centers.

Establish outreach clinics closer to more populous regions, whereby mostly staff members must travel, and patients less so, which will reduce travel emissions, along with performing bilateral procedures.

“Implementing sustainable practices, although challenging, will allow us to continuously provide this procedure and restore vision for millions of people at less of a cost to the environment,” Taboun said.

1. Chang DF, Thiel CL; Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste

. 2020;46(7):933-940.doi:10.1097/j.jcrs.0000000000000267

2. Schehlein EM, Hovasesian J, Shukla AG, Talley Rostov A, Findl O, Change DF. Reducing ophthalmic surgical waste through electronic instructions for use: a multi-society position paper. 

. 2024;50(3):197-200. doi:10.1097/j.jcrs.0000000000001381

3. Cleaning and Sterilization Task Force. Reducing topical drug waste in ophthalmic surgery: multisociety position paper

. 2022;48(9):1073-1077; doi:10.1097/j.jcrs.0000000000000975

4. Goel H, Wemyss TA, Harris T, et al. Improving productivity, costs and environmental impact in International Eye Health Services: using the ‘Eyeficiency’ cataract surgical services auditing tool to assess the value of cataract surgical services. 

. 2021 ;6(1):e000642. doi:10.1136/bmjophth-2020-000642. 2021

5. US EPA O. Greenhouse gas equivalencies calculator. United States Environmental Protection Agency. Updated January 2024. https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator

6. Gadani H, Vyas A. Anesthetic gases and global warming: [otentials, prevention and future of anesthesia. 

. 2011;5(1):5-10. doi:10.4103/0259-1162.84171

7. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. 

. 2017;43(11):1391-1398. doi:10.1016/j.jcrs.2017.08.017

8. Pandey D, Agrawal M, Pandey JS. Carbon footprint: current methods of estimation. 

. 2011 ;178(1-4):135-160. doi:10.1007/s10661-010-1678-y

9. Pandey D, Agrawal M, Pandey JS. (2011). Carbon footprint: current methods of estimation. 

. 2011;178(1-4):135-160. doi:10.1007/s10661-010-1678-y

10 Rachmiel R, Trope GE, Chipman ML, Buys YM. Cataract surgery rates in Ontario, Canada, from 1992 to 2004: more surgeries with fewer ophthalmologists. 

11. Morris DS, Wright T, Somner JEA, Connor A. The carbon footprint of cataract surgery. 

. 2013;27(4):495-501. doi:10.1038/eye.2013.

12. Latta M, Shaw C, Gale J. The carbon footprint of cataract surgery in Wellington. 

13. Ravindran RD, Venkatesh R, Chang DF, Sengupta S, Gyatsho J, Talwar B. Incidence of post-cataract endophthalmitis at Aravind Eye Hospital: outcomes of more than 42,000 consecutive cases using standardized sterilization and prophylaxis protocols. 

. 2009;35(4):629-636. doi:10.1016/j.jcrs.2009.01.002

14, Pershing S, Lum F, Hsu S, et al. Endophthalmitis after cataract surgery in the United States: a report from the Intelligent Research in Sight registry, 2013-2017. 

. 2020;127(2):151-158. doi:10.1016/j.ophtha.2019.08.026

Organization eyes green practices, shifting ophthalmology landscape.

Minimizing the carbon footprint of ophthalmic surgeries

Harrow has announced an initiative to expand access and affordability for its ophthalmic pharmaceutical products. This includes a program of targeted price reductions for several Harrow products and a strategic partnership with GoodRx.

A component of Harrow’s Access and Affordability Program is reducing the prices of several widely used eyecare products as a method of addressing cost barriers that limit patient access. The program began with price reductions for 2 of the company’s products, VIGAMOX and MAXIDEX, with the analysis of additional products underway.

Harrow’s new partnership with GoodRx will provide a cash-pay alternative for the purchase of select Harrow products, including FLAREX, ILEVRO, MAXIDEX, TOBRADEXST, VEVYE, VIGAMOX, and ZERVIATE. The GoodRx platform offers an alternative to traditional insurance allowing patients discounted pricing. This partnership may address the financial needs of those patients who may not have adequate insurance coverage for the eyecare medications they need.

Mark L. Baum, Chairman and Chief Executive Officer of Harrow, spoke to the mission behind these decisions and the benefit these programs may provide to patients, saying, “Our company was founded on a mission to help patients manage and preserve their sight by providing access to innovative and affordable medicines, and these initiatives are a significant step in advancing that mission. Patients often tell us that insurance co-payments can make their medications cost-prohibitive. By reducing prices and providing new access points, we’re creating a win-win: helping patients access critical sight-saving treatments while simultaneously delivering improved value to Harrow’s shareholders.”

, the company noted that patients can search for participating pharmacies and access discounts directly through the 

 website or mobile app to take advantage of this partnership.

Harrow Launches Access and Affordability Program with Price Reductions for Branded Products. Harrow, Inc. November 13, 2024. Accessed November 19, 2024. https://www.businesswire.com/news/home/20241113864368/en/Harrow-Launches-Access-and-Affordability-Program-with-Price-Reductions-for-Branded-Products

Harrow has initiated a program to enhance access and affordability for its ophthalmic pharmaceuticals, including price reductions for products like VIGAMOX and MAXIDEX. The initiative also involves a strategic partnership with GoodRx, offering a cash-pay alternative for select products, providing discounted pricing outside traditional insurance. This approach aims to alleviate cost barriers for patients lacking adequate insurance coverage. Harrow's CEO emphasizes the mission to make sight-saving treatments more accessible while delivering value to shareholders. Patients can access discounts through the GoodRx platform, enhancing affordability and accessibility.

The program aims to expand access and affordability for Harrow's ophthalmic pharmaceutical products through targeted price reductions and a strategic partnership with GoodRx.

Canonical

Harrow expands patient access to eyecare medications with price reductions and GoodRx partnership

A program from the National Health Service (NHS) England will bring 

 scans “closer to home” for thousands of patients. As part of an effort to improve outcomes for patients with diabetic retinopathy, OCT devices are rolling out in hospitals across the country, the NHS said in a news release. The NHS stated that around 4 million people are currently registered with the NHS Diabetic Eye Screening Programme. In addition, 3.3 million have routine digital screenings, at least every 2 years. “It is expected around 60,000 people who are already showing signs of eye disease will take part in OCT screening, which is offered to people at higher risk of diabetic retinopathy,” the news release read.

Previously, under a third of NHS eye care services were offering OCT imaging. There were disparities based on region, as well, according to the NHS news release. Now, all NHS staff are being trained in OCT screening. OCT devices are expected to be implemented into all eye care services by October 2025.

“Ophthalmology is one of the busiest outpatient specialities in secondary care,” the news release noted, with more than 7.5 million outpatient eye care appointments annually. Currently, eye care patients represent 8% of the entire NHS waiting list. The OCT initiative is expected to have a major impact on the backlog of patients waiting on eye appointments. “It is estimated that 120,000 hospital ophthalmology appointments are set to be saved through OCT,” the NHS added in its release, “and it is expected the number of hospital appointments saved will continue to rise.”

Steve Russell, NHS National Director for Vaccinations and Screening, said, “This technology will help us find and treat diabetic eye conditions early, helping minimise and prevent sight loss, and it also means that thousands of appointments in traditional hospital settings could be saved, which is great news for the NHS.”

Minister of State for Care, Stephen Kinnock, also provided a statement. “This is a great example of a small change that can make a big difference, giving diabetes patients more reassurance and freeing up thousands of hospital appointments,” he said. “Through our 10-Year Health Plan, we will shift care out of hospitals and into the community, easing pressure on our [accident and emergency departments] and enabling patients to get help closer to home.”

Mike Cypher, a Cheltenham resident with diabetes, also praised the effort to make OCT more accessible. He encouraged other people with diabetes to take a proactive approach in accessing care. “An OCT scan showed quite a major bleed in one of my eyes that could have badly affected my eyesight,” said Cypher, who is 56 and was diagnosed with diabetes in 1980. “I had laser treatment but if I hadn’t attended my routine appointments and had the treatment, my ophthalmologist told me my eyesight could have been irreparably damaged within a short space of time. So, if you’re offered screening, don’t hesitate to attend your appointment. OCT really could save your eyesight, as it’s done for me.”

Digital eye screening for people with diabetes could save hundreds of thousands of hospital appointments. News release. NHS England. Published 18 November, 2024. Accessed 18 November, 2024. 

https://www.england.nhs.uk/2024/11/digital-eye-screening-for-people-with-diabetes-could-save-hundreds-of-thousands-of-hospital-appointments/

The NHS England initiative aims to enhance diabetic retinopathy outcomes by deploying optical coherence tomography (OCT) scans nationwide, bringing them closer to patients' homes. With 4 million individuals registered in the NHS Diabetic Eye Screening Programme, the rollout targets 60,000 high-risk patients. Previously, less than a third of NHS eye care services offered OCT imaging, but by October 2025, all services will incorporate it. This initiative is expected to alleviate the backlog of eye care appointments, saving an estimated 120,000 hospital visits annually and improving early detection and treatment of diabetic eye conditions.

The NHS is expanding the use of optical coherence tomography to enhance diabetic eye care, aiming to improve early detection of diabetic retinopathy and reduce the backlog of hospital appointments.

NHS introduces OCT scans nationwide to improve diabetic eye care

One of the most common ocular pathologies, the cause of the onset and progression of myopia is not fully understood, but its prevalence is increasing globally. If the number of cases of myopia continues to rise at the current rate, it is estimated that by 2050 approximately 5 billion people will be myopic.

 As a result, myopia warrants national and international collaborative efforts as the cost and public health consequence are massive and frequently underrated in trends.

A retrospective study was conducted from 2019 to 2023 in accordance with the principles of the World Medical Association’s Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. The aim of the study was to assess the effectiveness of treatment and prevention of the progression of uncomplicated acquired myopia through physiotherapeutic methods. It was initiated only after obtaining informed consent from all participants, following an explanation of the applied methods and the consequences of the research.

The study included 80 participants, all of whom were aged 6 to 11 years. These participants were divided into 2 groups of 40 eyes each: the base group, which underwent physiotherapeutic treatment, and the control group, whose patients used single vision spectacle lenses. Furthermore, the eyes in each group were randomized into 2 subgroups based on the degree of myopia (low or moderate), and these subgroups were further divided into 2 groups, depending on the presence of a familial factor. For the comparative assessment of the dynamics of the studied indices, the clinical cases were evaluated before treatment, and after 1 and 2 years of treatment to align with the annual gradient of myopia progression.

 This method aims to stimulate the somato-vegetative functions of the body reflexively by applying transcutaneous electrical current to biologically active points (peripheral reflex zones) 

Low-intensity laser stimulation of the ciliary muscle:

 This method involves stimulating the ciliary muscle using low-intensity helium-neon laser radiation, employing infrared laser light. Low-intensity helium-neon laser radiation enhances biosynthetic and proliferative processes in the conjunctival tissue of the ciliary body, thereby improving the vascularization of the ciliary muscle, which positively influences the accommodation reflex 

 Electropuncture plus low-intensity laser stimulation of the ciliary muscle is a patented method.

Optical-reflex treatment of accommodation: 

Spherical positive lenses relax the ciliary muscle 

In the base group with low myopia and a family factor, after the first year, the annual myopia progression rate based on the spherical equivalent (AMPRS) value decreased from –0.68 plus or minus 0.05 diopter (D) to –0.18 plus or minus 0.01 D (with –0.50 D, 

Myopia is a growing global concern, projected to affect 5 billion people by 2050. A retrospective study from 2019 to 2023 evaluated physiotherapeutic methods for treating and preventing myopia progression in children aged 6 to 11. The study compared physiotherapy with single vision lenses, showing significant efficacy in reducing myopia progression rates. Physiotherapy was particularly effective in moderate myopia without familial factors, achieving an 86.3% reduction. Overall, physiotherapy reduced myopia progression by 69.7% in low myopia and 73.5% in moderate myopia groups.

Research explores innovative physiotherapeutic approaches to managing myopia progression, showing promising results in slowing its advancement over two years.

Steven J. Gedde, MD

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