Surgery in most high-income countries generates large quantities of waste. For instance, single-use disposable instruments are often used in a variety of surgery settings, but they also create large amounts of waste1,2 – and in today’s move toward “greening” facilities, ambulatory surgery centers and hospitals are becoming more aware of and evaluating the amount of waste surgery can generate. Ophthalmic practitioners are starting to take notice.
Hospitals generate 3.4 billion pounds of solid waste annually,2 5.9 million tons of which are due to disposable materials.3 Published green recommendations have identified operating room waste reduction and segregation and reprocessing of single-use medical devices as two of the top five areas that could improve.4
In the US alone, the healthcare sector produces 10% of the country’s total greenhouse gases and 9% of criteria air pollutants. In the UK, a single cataract surgery using phacoemulsification releases the equivalent greenhouse gases of driving a passenger vehicle nearly 700 km.1 (The UK averages around 300,000 phaco cases a year.)
But Cassandra Thiel, PhD, and colleagues analyzed the system in place at the Aravind Eye Care center in India and found phaco surgery there generated just 0.25 kg of solid waste and 6 kg of greenhouse gases (or driving a passenger vehicle 25 km).1 Aravind accomplished the feat “with no significant issues with safety and this decrease in waste generated with cataract surgery yielded comparable to better patient outcomes with less spending,” Nick Mamalis, MD, wrote in an editorial about the study.5
The Aravind Model
The Aravind system was set up with a goal of moving as many patients as possible through surgery as safely and as quickly as possible. The efficiencies implemented by Aravind have been documented in the literature, and include two beds per surgeon per room, which decreases surgical downtime and increases the number of cases that can be performed daily. Aravind staff reuse caps, masks, gowns, phaco wiring and tools, and stainless steel instruments.
Yet complication rates at Aravind, (including endophthalmitis) are 0.03%. When using intracameral moxifloxacin, the Aravind endophthalmitis rate was 0.01%; the current IRIS registry notes endophthalmitis rates of 0.07%. At Aravind, phaco tips are reused; sterilizing gel is used on gloves between cases; and cannulas, capsulotomy cystotomes, and irrigation solutions and tubing are all reused.1
In the US, regulations intended to enhance patient safety would prohibit implementing Aravind’s practices (e.g., flash sterilization techniques, reusing surgical gloves with antiseptic gel). But the US Government Accountability Office has found no evidence indicating that the use of reprocessed devices poses any health risk.4 Ophthalmic practices could save $20,000 by reprocessing commonly used devices. (To put this into perspective, orthopedic practices could save about $45,000, whereas urology would save about $2,000.)
Can Phaco Tips Be Reused?
Reusing phaco tips for the removal of the lens nucleus has been suggested as having potential to reduce spending and “go green-er.” But studies conducted with scanning electron microscopy at the far end of the phaco tip consistently find wear and evidence of debris,6 Dr. Mamalis wrote, as well as irregular and rounded cutting edges.
Further, the changes continued to deteriorate the tip and were more noticeable the more it was reused to the point where Paolo Cecchini, MD, and associates at the University of Trieste in Italy recommended single-use disposable phaco tips.6
But a separate study7 seems to contradict those findings, as ex vivo experiments performed at the Utah Nanofab Lab have found the reuse of phaco tips “did not cause significant structural microfracture, deformations, fissures, breakage, or failure as assessed using SEM analysis,” Dr. Mamalis wrote, and there were no differences between those tips labeled for single use or those labeled for up to 50 uses.5 Surgeons should be able to decide if they want to reuse phaco tips based on clinical observation and judgement, Dr. Mamalis said, especially as the labeling appears to be arbitrary at best.7
Other constraints for US facilities that Aravind (and other eye care facilities in India) do not have include donning new disposable masks for each case and using dilating drops from a new bottle for each case. There is simply no evidence that using disposable instruments is safer than reuse.
Call for Further Studies
Supporting that idea, last year the Ophthalmic Instrument Cleaning and Sterilization Task Force (comprising members from the American Society of Cataract and Refractive Surgery, American Academy of Ophthalmology, and Outpatient Ophthalmic Surgery Society) published new guidelines that support “the safety of common short-cycle instrument processing practices for sequential same-day anterior segment surgery.”8
The group recommended future studies “critically evaluate a variety of operating room protocols that may increase cost, waste, and carbon footprint, without any actual safety benefit.”8 Because both ASCs and hospital operating rooms are heavily regulated, it may fall on industry to allow the responsible reuse of instruments and products used in surgery through labeling and word choice.
Reducing carbon footprints (greenhouse gas emissions), increasing recycling of operating room waste, and transitioning to reusable materials has widespread potential and positive implications that go far beyond ophthalmology.
For questions about this article, please contact Michelle Dalton at firstname.lastname@example.org.
- Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391-8.
- Thiel CL, Eckelman M, Guido R, et al. Environmental impacts of surgical procedures: Life cycle assessment of hysterectomy in the United States. Environ Sci Technol. 2015;49:1779-86.
- Campion N, Thiel CL, Woods NC, Swanzy L, Landis AE, Bilec MM. Sustainable healthcare and environmental life-cycle impacts of disposable supplies: A focus on disposable custom packs. J Cleaner Prod. 2015;92:46-55.
- Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Arch Surg. 2011;146:131-6.
- Mamalis N. Reducing the environmental impact of cataract surgery. J Cataract Refract Surg. 2018;44:1-2.
- Cecchini P, D’Aloisio R, Antonuccio M, et al. Chemical and physical analysis of phaco tips surface before and after cataract surgery. J Cataract Refract Surg. 2017;43:1107–14.
- Tsaousis, KT, Chang, DF, Werner L, et al. Comparison of different types of phacoemulsification tips. III. Morphological changes induced after multiple uses in an ex vivo model. J Cataract Refract Surg. 2018;44:91-7.
- Mamalis N, Chang DF. Guidelines for the cleaning and sterilization of intraocular surgical instruments. J Cataract Refract Surg. 2018;44:6:675-6.