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Cover Stories | June 2024

Sustainability Made Easy

Strategies to reduce the environmental impact of ophthalmic practice.

Health care contributes 4.4% of total greenhouse gas emissions globally. With its high volume of consultations, ophthalmology plays a significant role in health care’s sustainability, and you can make a positive impact by implementing some small changes.1-7


Enable Ventilation 30 Minutes Before Surgery

Turning off OR ventilation outside of office hours instead of running it overnight and on weekends provides comparable infection control.8-10 This approach saves 50% on electricity costs and €2,000 annually per OR.

Use an Alcohol-Based Hand Rub

Compared to traditional scrubs, alcohol-based hand rub disinfectants or liquid preparations provide superior disinfection. Alcohol-based disinfectants act against a broader spectrum of microorganisms and offer a longer duration of action than traditional scrubs. The former are also less drying and irritating to the skin and cause fewer allergies.11,12 Additionally, the use of alcohol-based rubs reduces plastic and saves water and €1,600 annually (per 1,000 surgeries). The estimated water usage for a surgical scrub brush of 3 minutes is around 18.5 L per person.

Reduce Drug Waste

Preoperatively, topical drugs can be used safely on multiple patients. When appropriate, patients should be allowed to take their partially used medications home for postoperative use. The risk of endophthalmitis in cataract surgery is clearly reduced with asepsis and intracameral antibiotics. The benefits of topical antibiotics, however, are difficult to demonstrate. Intravitreal injections with topical antibiotics administered before and/or after the injection do not reduce the risk of endophthalmitis and may be counterproductive owing to the development of resistant microorganisms.13-20 Reducing drug waste decreases plastic and saves at least €6,000 annually (per 1,000 surgeries).

Reduce Packaging Waste

Replace the full body drape with a face drape. The latter is equally effective in preventing endophthalmitis and helps reduce patient claustrophobia, anxiety, and temperature-related discomfort.21-23 This change not only reduces waste, plastic, and costs but also saves at least €1,000 annually (per 1,000 surgeries).

Critically evaluate your custom packs to identify and eliminate unnecessary items that are often discarded unused. Utilize the ESCRS Sustainability Index for Disposables in Cataract Surgery, available at no cost on ESCRS.org (Figure; scan the QR code to access).

Figure. The ESCRS Sustainability Index for Disposables in Cataract Surgery.

Additionally, reducing items in intravitreal packs can maintain safety and quality of care while cutting waste, carbon emissions, and costs—potentially saving €2,000 annually (per 1,000 surgeries).23-28 This adjustment also minimizes plastic use.

Reduce Postoperative Visits

Postoperative visits after intravitreal injections, uncomplicated cataract surgeries, and vitreoretinal surgeries can be reduced safely, decreasing mobility-associated emissions and travel costs.

Immediately sequential bilateral cataract surgery, like bilateral same-day intravitreal injections, reduces patient travel and the number of postoperative visits. Also avoid using plastic shields.29-35 This approach saves at least €10,000 annually (per 1,000 surgeries).

Adopt More Sustainable Medicines and Instruments

Avoid using SF6 gas, one of the most potent greenhouse gases; it has a global warming potential 25,200 times higher than CO2. Consider alternatives such as C3F8 or air.36 Opting for sustainable medical equipment and instruments that are smaller, transportable, and reusable can significantly reduce environmental impact.


Improve the environmental impact of ophthalmic care by adopting practices of reducing, reusing, recycling, and rethinking.37 Share this article with colleagues, friends, and hospital management to enhance the sustainability processes in your environment. Create a team. Implement one change every month. Solicit feedback. Consider joining sustainability groups such as EyeSustain (eyesustain.org) to participate in the dissemination, research, and awareness of more efficient and ecological practices.

1. Wong YL, Noor M, James KL, Aslam TM. Ophthalmology going greener: a narrative review. Ophthalmol Ther. 2021;10(4):845-857.

2. Buchan JC, Thiel CL, Steyn A, et al. Addressing the environmental sustainability of eye healthcare delivery: a scoping review. Lancet Planet Health. 2022;6(6):e524-e534.

3. Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021;5(2):e84-e92.

4. Sherry B, Lee S, Ramos Cadena MLA, et al. How ophthalmologists can decarbonize eye care: a review of existing sustainability strategies and steps ophthalmologists can take. Ophthalmology. 2023;130(7):702-714.

5. Pichler P, Jaccard I, Weisz U, Weisz H. International comparison of health care carbon footprints. Environ Res Lett. 2019;14(6):064004.

6. Chang DF. Tackling the challenge of needless surgical waste in ophthalmology. J Cataract Refract Surg. 2023;49(4):333-338.

7. Delivering a net zero National Health Service. NHS England. Accessed April 25, 2024. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service

8. Dettenkofer M, Scherrer M, Hoch V, Glaser H, Schwarzer G, Daschner ED. Shutting down operating theater ventilation when the theater is not in use: infection control and environmental aspects. Infect Control Hosp Epidemiol. 2003;24(8):596-600.

9. Zarzycka A, Maassen WH, Zeiler W. Energy saving opportunities in operating theaters: a literature study. REHVA J. 2019;2019(2):25-31.

10. Lans JLA, Mathijssen NMC, Traversari AAL, et al. Capital and operational expenditures of different operating room air-handling installations with conventional or ultra-clean air supply systems. J Build Eng. 2023;78:107714.

11. Javitt MJ, Grossman A, Grajewski A, Javitt JC. Association between eliminating water from surgical hand antisepsis at a large ophthalmic surgical hospital and cost. JAMA Ophthalmol. 2020;138(4):382-386.

12. Jehle K, Jarrett N, Matthews S. Clean and green: saving water in the operating theatre. Ann R Coll Surg Engl. 2008;90(1):22-24.

13. Palmer DJ, Robin AL, McCabe CM, Chang DF; Ophthalmic Instrument Cleaning and Sterilization Task Force. Reducing topical drug waste in ophthalmic surgery: multisociety position paper. J Cataract Refract Surg. 2022;48(9):1073-1077.

14. Berkowitz ST, Finn A, Sternberg P Jr, Patel S. Potential cost savings associated with a multiuse preoperative and preinjection eyedrop protocol. Ophthalmology. 2022;129(11):1305-1312.

15. Råen M, Sandvik GF, Drolsum L. Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops. Acta Ophthalmol. 2013;91(2):118-122.

16. Chang DF, Rhee DJ. Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2021 ASCRS member survey. J Cataract Refract Surg. 2022;48(1):3-7.

17. Felfeli T, Miranda RN, Kaur J, Chan CC, Naimark DM. Cost-effectiveness of preoperative topical antibiotic prophylaxis for endophthalmitis following cataract surgery. Am J Ophthalmol. 2023;247:152-160.

18. Storey P, Dollin M, Pitcher J, et al; Post-Injection Endophthalmitis Study Team. The role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection. Ophthalmology. 2014;121(1):283-289.

19. Govindasamy G, Lim C, Riau AK, Tong L. Limiting plastic waste in dry eye practice for environmental sustainability. Ocul Surf. 2022;25:87-88.

20. March de Ribot F, Benitez Del Castillo JM, Geerling G, Messmer EM, Baudouin C, Alves M. Dry eye disease sustainability. Ocul Surf. 2023;30:104-106.

21. Sherry B, Lee S, Ramos Cadena MLA, et al. How ophthalmologists can decarbonize eye care: a review of existing sustainability strategies and steps ophthalmologists can take. Ophthalmology. 2023;130(7):702-714.

22. Schlager A. Accumulation of carbon dioxide under ophthalmic drapes during eye surgery: a comparison of three different drapes. Anaesthesia. 1999;54(7):690-694.

23. Schlager A, Luger TJ. Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under local anesthesia. Br J Ophthalmol. 2000;84(4):399-402.

24. Winklmair N, Kieselbach G, Bopp J, Amon M, Findl O. Potential environmental effect of reducing the variation of disposable materials used for cataract surgery. J Cataract Refract Surg. 2023;49(6):628-634.

25. Chang DF, Thiel CL; Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg. 2020;46(7):933-940.

26. Chang DF, Elferink S, Nuijts RMMA. Survey of ESCRS members’ attitudes toward operating room waste. J Cataract Refract Surg. 2023;49(4):341-347.

27. Hales S. Do you know where your cat pack comes from? Eurotimes. February 1, 2023. Accessed April 25, 2024. https://www.escrs.org/eurotimes-articles/do-you-know-where-your-cat-pack-comes-from

28. Gale J, Welch SH, Niederer R. Intravitreal injections with a low consumption technique have a low infection rate. Eye (Lond). 2024;38(4):811-812.

29. Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? Graefes Arch Clin Exp Ophthalmol. 2019;257:855-861.

30. Patel D, Borkar DS, Madhava M, et al; Wills Eye Retinal Detachment Study Group. Incidence of management changes at the postoperative day one visit after pars plana vitrectomy for retinal detachment. Am J Ophthalmol. 2021;222:271-276.

31. Spekreijse LS, Nuijts RMMA. An update on immediate sequential bilateral cataract surgery. Curr Opin Ophthalmol. 2023;34(1):21-26.

32. Malvankar-Mehta MS, Filek R, Iqbal M, et al. Immediately sequential bilateral cataract surgery: a cost-effective procedure. Can J Ophthalmol. 2013;48:482-488.

33. Power B, Brady R, Connell P. Analyzing the carbon footprint of an intravitreal injection. J Ophthalmic Vis Res. 2021;16(3):367-376.

34. Ruão M, Andreu-Fenoll M, Dolz-Marco R, Gallego-Pinazo R. Safety of bilateral same-day intravitreal injections of anti-vascular endothelial growth factor agents. Clin Ophthalmol. 2017;11:299-302.

35. Lindfield D, Pasu S, Ursell P. Shield or not to shield? Postoperative protection after modern cataract surgery. Eye (Lond). 2011;25(12):1659-1660.

36. Moussa G, Ch’ng SW, Park DY, et al. Environmental effect of fluorinated gases in vitreoretinal surgery: a multicenter study of 4,877 patients. Am J Ophthalmol. 2022;235:271-279.

37. Lam L, Bradbrook D, Gale J. Tracing the barriers to decarbonising ophthalmology: a review. Clin Exp Ophthalmol. 2024;52(1):78-90.

Sjoerd Elferink, MD, FEBOphth
  • Ophthalmologist and cataract surgeon, FlevoHospital Almere, Almere, Netherlands
  • sjoerd.elferink@gmail.com
  • Financial disclosure: None
Oliver Findl, MD, MBA
  • Director and Professor of Ophthalmology, Hanusch Hospital, Vienna
  • Founder and Head, VIROS, Hanusch Hospital, Department of Ophthalmology, Vienna
  • oliver@findl.at
  • Financial disclosure: None
Francesc March de Ribot, MD, PhD
Anna March de Ribot, MD, PhD
  • Ophthalmologist, University Hospital, Girona, Spain
  • Financial disclosure: None
Redmer van Leeuwen, MD, PhD
  • Ophthalmologist and vitreoretinal surgeon, University Medical Center Utrecht, Utrecht, Netherlands
  • r.vanleeuwen@umcutrecht.nl
  • Financial disclosure: None
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