April 15, 2025
11 min read
To tackle problems like sustainability and climate change, a lot of heads need to come together.
EyeSustain has been holding monthly meetings since its inception in 2022. Emily M. Schehlein, MD, said attendance is always significant.
“It’s important to make sure that everyone is an active part of the organization,” she said. “People are very dedicated, and everyone participates. It’s a structured meeting and a collaborative environment to come up with new ideas.”
Nearly 3 years into its mission, EyeSustain continues to find strength in a strong mix of experience and youthful exuberance. Aakriti Garg Shukla, MD, said David Chang, MD, EyeSustain’s chair and driving force, built the coalition from the beginning.
“Dr. Chang’s visionary idea was to have an advisory board made of more senior people who have been involved in this area for a long time as well as an editorial board made of early career people who are very passionate about this mission,” Shukla said. “These two groups of people have worked together to identify areas for change, whether that’s research projects or education. Climate change might impact younger ophthalmologists more, but our more experienced colleagues have seen these problems for a long time.”
EyeSustain has highlighted the topic of sustainability over the past few years. It has promoted a surgical facility pledge that asks institutions to evaluate potentially wasteful practices, educate their workforces and commit to more sustainable practices, and it has published several papers in scientific journals that bring hard evidence to commonsense sustainable practices, including policies that reduce wasteful use of eye drop medication and limit the inclusion of paper instructions for use in IOL packaging.
As the American Society of Cataract and Refractive Surgery annual meeting approaches, EyeSustain is gearing up for a full slate of activities to spread the word about its mission. In addition to its annual get-together, EyeSustain is hosting an industry workshop to continue to build relationships with partners outside of the clinical space.
“This is a time when many of our industry partners really come together and share their successes and strides they have made in reducing waste,” Schehlein said. “Historically, there has been a great discourse between the companies on different regulatory barriers and how some companies have been able to overcome them or pivot. It’s a unique meeting because we get to see our industry partners really working together and talking to each other even if they are competitive in the same space. It’s so encouraging to have all of these companies take an interest and participate in an active discussion for several hours on how they can help further the mission of EyeSustain and reduce waste in ophthalmology.”
Momentum
EyeSustain has spread the word about the work people are doing and provides examples of how surgeons can make adjustments to enact change. Schehlein said EyeSustain has been using its website as a central hub to showcase these efforts.
Emily M. Schehlein
“We are updating it real time with editorials and scientific articles,” she said. “There are meeting highlights up there, whether it’s from ASCRS or another meeting where they have covered a sustainability topic. Our goal is to highlight this great work that physicians are already doing, whether it’s via scientific studies or making changes in their OR, or if it’s our industry partners moving us forward in this space. We want people to see what their colleagues are already doing, how they can participate and the forward momentum that’s happening.”
The organization has also flexed its research muscles on topics such as waste in topical drugs and reducing paper consumption by encouraging electronic instructions for use in IOL packaging. Shukla said the organization’s position papers on these topics have been one of its biggest and most impactful efforts.
“The multi-society papers include the AAO, ASCRS, ESCRS and AGS, as well as other societies,” she said. “It becomes powerful when the leadership of multiple large ophthalmology societies come together and say, for instance, ‘We don’t actually need these giant pieces of paper to accompany the IOL box. We can just have a small QR code instead.’”
Several state societies have used EyeSustain’s 2022 position paper on ophthalmic topical drug waste to lobby for change in state policies to allow facilities to use eye drop bottles on multiple patients and to let patient bring partially used medications home with them. Shukla said sustainable practices like these are common in other parts of the world but are limited in the United States due to regulations and safety concerns.
“These are important statements that are not just opinion pieces,” she said. “They include evidence from all of the literature available on a given topic in one paper. We’ve been able to create and provide this online repository of all the educational materials about a given topic and also disseminate these papers that are now published in peer-reviewed journals like the Journal of Cataract & Refractive Surgery.”
Shukla said EyeSustain is using this experience and momentum to tackle other topics as well.
“Some institutions have faced regulations to shift toward more aggressive sterilization requirements for reusable tonometry tips or shift to disposable tips, which is a waste of plastic and reduces reliability of measurements,” Shukla said. “We’re putting together a position paper on that, as well as disposable gonioscopy lenses, and other areas of waste.
“The EyeSustain community has allowed like-minded people to come together to educate people who are educating other ophthalmologists, physicians in other specialties, regulators and other key stakeholders. It allows for these various initiatives to come together.”
Schehlein said one of the new initiatives she is excited about is the prospect of incorporating sustainability practices into ophthalmic training and board exams. She said EyeSustain is working in conjunction with the American Academy of Ophthalmology Committee on Sustainability and a liaison from the American Board of Ophthalmology to add sustainability educational content to the ophthalmology basic science curriculum and board exams.
“Last year, EyeSustain was able to meet with these partners, and we are going to be working with them to incorporate sustainability and reducing waste in ophthalmology board exams,” she said. “We already have material in the resident curriculum that trainees can study. This educational component has been really exciting because it shows that we have a lot of support from our sponsoring societies, the AAO and ASCRS, but also that the American Board of Ophthalmology understands and sees that this is an important part of a physician’s education, and every one of us should have a working knowledge of it so we can make changes in our own practices.”
Making changes
Shukla said there are small changes a surgeon can make right now. One is to use a micro dropper for topical medications.
Aakriti Garg Shukla
“That will make your eye drops last so much longer in the office,” she said. “The evidence shows that you probably don’t need a whole dilating drop. You can use a micro drop instead. Patients have told me it’s made a huge impact for them because they often have difficulty instilling drops, and they might accidentally put in multiple drops at a time. Then, they run out of drops sooner than when the refills are available.”
Shukla said surgeons can also evaluate their single-use items to try to cut back on what they do not use, asking themselves questions about what they actually need during a surgery.
“Do I need five different types of sutures to do a tube shunt? Can I do it with one or two?” she said. “Then, you reduce the waste that is associated with surgery and potentially save your OR valuable resources.”
Shukla said physicians can help cut back on emissions by considering same-day bilateral procedures when appropriate to reduce patient travel time. In her practice in New York City, she also accomplishes this by splitting up patient visits with their local ophthalmologist.
“People come in from all over to our offices in Manhattan, but they come once a year to us, and then see their local ophthalmologist twice a year,” she said. “It involves having good communication and personal phone numbers of their local doctors to make sure nothing is lost in translation. However, it is a great way to minimize patient transportation and make care more convenient for them while they are getting the same great care.”
Amy Mehta, MD, has been working within her practice to find small ways to reduce waste, particularly in the surgery center. One of the biggest efforts has been to reduce the drape size from a head-to-toe body drape to a half drape.
“We operate on 20,000 patients over the course of the year,” she said. “If we can reduce the number of full-length drapes, you’re basically cutting your trash in half and reducing cost to your practice.”
With this change, Mehta said her practice has gone from generating about two bags of trash per case to about one per case while also reducing the economic burden.
“It reduces the amount of packaging and the amount of transportation that goes into each case,” she said. “You can imagine the space it takes up on a truck to deliver them. It helps all parties involved, and when you’re doing eye surgery, you don’t really need to be covering below the waist.”
Mehta also leads the charge on sustainability efforts with the New York State Ophthalmological Society, where she is president-elect. Mehta and the society are learning lessons from David J. Palmer, MD, in Illinois and other efforts across the country to enact new legislation to allow for policy changes related to topical eye drop bottles.
“We are working hard to create legislation aimed at being able to use the same bottle of dilating drops and postoperative drops on multiple patients,” she said. “If you have a full bottle of medication, you shouldn’t be throwing it away after one patient, but that was the practice.”
Mehta said the AAO and ASCRS have provided a template for language that can be used for adoption in any state for legislation, which has been valuable in crafting a bill that can help all relevant stakeholders.
“It involves working back and forth with the different groups of people involved in any drug-related care,” she said. “A lot of other specialties have similar types of issues. There are ways to come together with your state medical society to also create more encompassing legislation. We haven’t gotten to that step yet, but it would be a good goal to find out how we can reduce other types of waste.”
Cataract surgery is one of the world’s most common surgeries, so any change an ophthalmologist makes to cut back on single-use items has the potential to make a big dent in plastic consumption.
In 2020, Kaiser Permanente was looking to make a change to its cataract surgery pack and enlisted Naveen Chandra, MD, to lead the charge. The item he was asked to target might not be the first thing that comes to mind when thinking about cataract surgery, but it has a big impact on sustainability — a plastic basin.
“Even though the eyeball is a tiny organ, the waste we create in the Western world is outsized, given all of the disposable instruments, drapes and supplies, including these plastic basins that hold our instruments or hold solutions to prep the eye during cataract surgery,” he said. “Even though they’re peripheral to the actual procedure, they’re the biggest solid plastic waste product that we generate.”
For 2 years, Chandra worked with NewGen Surgical to develop a plant-based alternative to the plastic basin. The basins are made out of sugarcane fiber, similar to what some restaurants use for to-go containers, Chandra said. These products were a good starting point, but he needed to ensure that they fit a cataract surgeon’s unique requirements.
“We wanted to make sure that there were no loose fibers that could come off,” he said. “In general surgery, it might not be a problem, but in the eye, it could be inflammatory or be a retained foreign body. We worked to create a polished edge so no fibers would come loose into our surgical field.”
Chandra also worked to create a version of the product that was covered inside and out with a waterproof coating. He said previous iterations were coated on only the inside and had the potential to release fibers that might cause issues during surgery.
“Another concern for ophthalmology is toxic anterior segment syndrome (TASS),” he said. “We wouldn’t want any new product in our surgical pack to trigger an immune response that could threaten the results of our surgery and the vision of our patients. We worked with experts to confirm that these biodegradable coatings and the plant fibers would not trigger TASS. We’ve been very happy to report that with more than 2 years of use, they have been inert in our surgical process, and we have had no problems from having adopted them in Northern California.”
After 2 years of work, Chandra landed on a product that seemed suitable. The basins were tested in the Kaiser Permanente system, and the surgical staff loved them. Staff use these basins to rinse off surgical instruments, and Chandra said the old plastic basins were unstable when they were filled with water, requiring two hands to carry them. The plant-based trays, however, are sturdy enough to carry with one hand when they are filled with water.
“It’s made their logistical maneuvers much simpler,” he said. “The staff in the OR are the ones handling the basins, but also, they’re the ones who see all the waste day in and day out. They are in the OR 5 days a week, whereas the surgeons come and go. The staff’s reception to these basins has been unanimous approval.”
Chandra is in charge of what goes into the surgical pack for 21 facilities and about 250 ophthalmic surgeons across Northern California. He said he was able to make the switch with one change order with the vendor once the new basin was developed.
“We made the change in 2022 and have completed over 2 years of cases,” he said. “For Northern California, that’s over 100,000 cases thus far. That means in these last 2 years, we’ve reduced our scope 3 CO2 emissions by 32 metric tons (which is equivalent to driving an average gasoline-powered vehicle 81,000 miles, according to the epa.gov calculator) . Our contribution within ophthalmology contributes to Kaiser Permanente’s overall goal to reduce our carbon footprint.”
With that mission in mind, Chandra said Kaiser Permanente is now expanding use of this plant-based basin to Southern California and other regions, including Washington, D.C., and other states. The product is not proprietary, so there is potential for other systems or facilities to make the switch as well.
“Once everyone within the Kaiser Permanente system pivots to this basin, we could more than double our impact,” Chandra said. “I was invited to share our innovation with our peers at EyeSustain. Meeting with the group has enabled other institutions to adopt these basins. As long as the pack manufacturer offers the product, anyone can pivot to these basins with a simple change order.”
Changing to plant-based basins is a good step in the right direction, but Chandra said there is potential to do more. Although the basins are designed to be compostable, Chandra said they are considered surgical waste and a biohazard. He said there is an effort to get the basins and other equipment that has not touched blood reclassified as compostable, with the hope that EyeSustain can help lead the charge to improve waste management practices across hospitals and surgical centers that are governed by local policy and regulation.
“For each individual surgeon or group of surgeons running a surgery center, it can be very intimidating to know how to start chipping away at the waste that we see and know is happening,” Chandra said. “EyeSustain is a great organization and shows people what’s available out there as resources to start addressing it. The more EyeSustain can promote innovations like the one we’ve created, the more people can adopt it.”
References:
For more information:
Naveen Chandra, MD, of The Permanente Medical Group, can be reached at naveen.chandra@kp.org.
Amy Mehta, MD, of SightMD in Rockville Centre, New York, can be reached at mehta.amy@gmail.com.
Emily M. Schehlein, MD, of Brighton Vision Center in Brighton, Michigan, can be reached at emschehlein@gmail.com.
Aakriti Garg Shukla, MD, of the CUIMC/Edward S. Harkness Eye Institute, can be reached at ag2965@cumc.columbia.edu.
Sources/Disclosures
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Disclosures:
Chandra, Mehta, Schehlein and Shukla report no relevant financial disclosures.
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