David F Chang
Few healthcare settings are as regulated as the operating room (OR). Whether cataract surgery is performed in an ambulatory surgery center or a hospital outpatient department, OR licensure, accreditation, and regulatory compliance entail enormous costs. Recent studies from the Aravind Eye Care System (AECS) in southern India demonstrate a significant reduction in the postoperative endophthalmitis (POE) rate following routine adoption of intracameral moxifloxacin prophylaxis.1 Excluding the manual, small-incision extracapsular cataract surgeries, the POE rate in more than 335,000 consecutive phacoemulsification patients receiving intracameral moxifloxacin was 0.01%. Interestingly, this is lower than the 0.04% POE rate in the United States, as calculated through the AAO’s IRIS Registry.2
Apart from the efficacy of intracameral moxifloxacin prophylaxis, what is equally striking is that the AECS reuses as many of their surgical and pharmaceutical supplies as possible. Maximizing volume, surgical efficiency, and cost effectiveness enables the AECS to perform approximately 60% of their surgical volume in charity patients for little to no cost. This requires critically assessing the necessity of every supply item and protocol, while monitoring quality through an electronic health registry that captures every operation and outcome. As a result, they simultaneously operate on multiple patients within a single large operating room, and do not change surgical gowns or gloves (which they rinse with alcohol and chlorhexidine) in between patients. They routinely reuse phacoemulsification tips and tubing, irrigating solution, metal blades, cannulas, sutures, viscoelastic, intraocular drugs, and perioperative drops. Despite regularly reusing items restricted to single use in the United States, their POE rate is no higher.
These compelling data suggest that many mandated practices in Western ORs may be unnecessary and of unproven benefit for ophthalmic surgery. Indeed, many OR regulations are based on the opinions of experts advising regulatory agencies and manufacturers. The AECS study suggests that big data registries could be used to generate more evidence-based, rather than eminence-based, recommendations. Ironically, no commercial intraocular antibiotic solution has been approved in the United States because of the lack of sufficiently large, randomized controlled trials. So while American patients have no access to the commercial intracameral moxifloxacin (costing $1 US per vial in India) that reduced POE at AECS by 3.5 times, rigidly enforced single-use mandates continue to generate excessive surgical waste at enormous cost without proven POE benefit.
The high and escalating volume of cataract surgery multiplies the economic impact of not reusing most surgical supplies, devices, and drugs. Recent studies show that this waste also entails considerable environmental impact by significantly increasing the carbon footprint of cataract surgery.3,4 A British study found that 1 phacoemulsification procedure in the United Kingdom generated the same carbon emissions (~130 kg CO2eq) as driving a car 500 km (310 miles).3 By comparison, phacoemulsification at AECS was found to generate the same carbon emissions (~ 6 kg CO2eq) as driving a car 23 km (14 miles).4 Compared with the United States and United Kingdom, AECS’s low POE rates with cataract surgery were achieved with much lower supply costs and one-twentieth the carbon emissions. The excessive economic and environmental costs of unnecessary surgical waste will not be sustainable as global cataract volume continues to increase. This challenge urgently merits further study and deliberation.
More than 90% of ophthalmologists agree that OR waste is excessive and concerning, according to a survey conducted by the Ophthalmic Instrument Cleaning and Sterilization (OICS) task force.5 Most respondents reported that surgical supply manufacturers play a substantial role in generating excessive waste. Roughly 95% consider single-use product packaging wasteful, want more reusable supply and device options, and believe that manufacturers favor single-use products to increase profit and limit liability. Most respondents believed that licensing and accrediting agencies (82%) and ASC/HOPD regulations (74%) that limit surgeon discretion over when and which supplies or drugs can be reused are also major contributors to surgical waste. At least 93% want regulatory agencies and product manufacturers to allow surgeons more discretion to reuse products labelled as single use.
Most respondents (87%) believed that their medical societies should advocate for reducing the OR carbon footprint; only 6% disagreed. This is consistent with 91% of respondents being concerned about global warming. After these results were shared with the ASCRS and AAO leadership, these 2 organizations became the first from ophthalmology to join 27 other major medical associations in the Medical Society Consortium on Climate and Health. The consortium was established in 2017 to inform policy makers and the public about the harmful health effects of climate change. Another goal of the consortium is to reduce the carbon footprint of the healthcare system.
It has been estimated that the healthcare sector accounts for approximately 10% of greenhouse gas emissions in the United States, with the operating room being a leading source.6 That the AECS has reduced the cost and carbon footprint of cataract surgery dramatically while achieving a lower POE rate than the United States average suggests that much of our surgical waste is excessive and unnecessary. Because ophthalmology has the highest surgical volumes in medicine, we have an exceptionally important opportunity to educate and work with regulatory agencies and the surgical manufacturing industry to reduce needless OR waste. The economic and environmental sustainability of cataract surgery worldwide may depend on our collaboration and leadership.
- Haripriya A, Chang DF, Ravindran RD. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from two-million consecutive cataract surgeries. J Cataract Refract Surg 2019; 45;1226-1233
- Pershing S, Lum F, Hsu S, Kelly S, Chiang MF, Rich WL 3rd, Parke DW 2nd. Endophthalmitis after cataract surgery in the United States: A report from the Intelligent Research in Sight Registry, 2013-2017. Ophthalmology 2020; 127: 151-158.
- Morris DS, Wright T, Somner JE, Connor A. The carbon footprint of cataract surgery. Eye 2013; 27: 495-501.
- 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; 43:1391-1398
- Chang DF, Thiel CL. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg 2020:46: (in press)
- Eckelman MJ, Sherman J. Environmental Impacts of the U.S. Healthcare System and Effects on Public Health. PLoS One. 2016;11(6):e0157014. Published 2016 Jun 9. doi:10.1371/journal.pone.0157014
Dr. Chang is co-chair of the multisociety Ophthalmic Instrument Cleaning and Sterilization Task Force.