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Evidence suggests that nitric oxide can modify both mechanical and vascular events in primary open-angle glaucoma pathogenesis.

Nitric oxide: A potential target for glaucoma treatment

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

Retina Society Dorga Borkar

Durga Borkar, MD, sat down with Sydney Crago of Modern Retina to discuss one of her presentations on the 12-month outcomes of the FARETINA and FARWIDE studies from the Retina Society meeting being held this year in Lisbon, Portugal. 

Editor's note: The below transcript has been lightly edited for clarity.

I'm Sydney Crago with Modern Retina, and I'm here today with Dr Durga Borkar to talk a little bit about her presentations at the upcoming Retina Society meeting. Dr Borkar, I understand you'll be presenting on 2 topics at this year's Retina Society meeting. Can you tell me a little bit about these?

Sure! The first presentation we'll be doing is on 12-month outcomes of the FARETINA and FARWIDE studies, which are real-world studies evaluating the efficacy, durability, and safety of faricimab in the real world, and then, I'll also be presenting the first time phase 2 clinical trial results for ONL-1204 for rhegmatogenous retinal detachment.

So turning over to the first one with the FARETINA study. Can you tell me a little bit about how this data was gathered?

Sure. So, this is a real-world study, there were 2 of them actually. One was done in the US and one in the UK. FARETINA is a US-based study, and that data is from the IRIS registry, which is the world's largest ophthalmology electronic health record registry. And so this study was done as a collaboration between Genentech and Verana Health. And for FARWIDE, this is a UK-based study. So these were sites from the NHS, and the data is also collected in the metasoft EHR.

What does this data tell us about these real-world cases?

So, both of these studies have been going on for some time, since faricimab first became FDA approved in early 2022, and so what the goal of the presentation at Retina Society is is to show really how the data set has matured and to show some 12-month outcomes. And in this presentation, we'll be focusing on treatment-naive patients. The analysis is a little bit cleaner, a little bit easier for us to compare to some of the clinical trial results, and what we see here is that faricimab works incredibly well in diabetic macular edema in treatment-naive patients. Patients gained about 3 letters of vision in the FARETINA study at 1 year or 6 injections and 8 letters of visual acuity in the FARWIDE study, which again, was the UK-based study. And when we look at the safety, you know, it's very comparable to the phase 3 clinical trials, which is great. And of course, the durability as well, we see that patients really have decreased treatment burden, particularly in the second half of the 12-month follow-up period with faricimab.

How can retina specialists who are treating DME patients, kind of, incorporate these learnings into their practice?

That's a good question. I think, in the past, when we've shown the FARETINA and FARWIDE results, we've really showed you know that a predominance of patients currently in the real-world are previously treated, so they are typically aflibercept 2 milligram switchers, and those patients do really well, as well. But in this analysis, we really focused on the treatment-naive patients, and the results are quite impressive, and so I think you know, one of the learnings from this is to consider faricimab earlier in the DME treatment paradigm, just because it does work really well, and it does potentially decrease treatment burden for patients.

Retina Society 2024: 12-month outcomes of FARETINA and FARWIDE studies

The FDA recently released a final guidance on the use of real-world data (RWD) for regulatory decision-making.

 represents a pivotal step forward for the eye care industry, promising to foster innovation in medical research and improve patient outcomes through more informed regulatory decisions.

Sujay Jadhav, CEO of Verana Health, provided an overview of the guidance. He told 

 the FDA is emphasizing the integration of real-world data and real-world evidence in regulatory decision-making processes. Additionally, the guidance outlines the standards and considerations for using data derived from real-world data sources like electronic health records (EHRs), medical and pharmacy claims, and patient-generated data from various apps and devices.

Jadhav said the guidance is “aimed to ensure the reliability and quality of real-world data, promoting its use and supporting regulatory submissions and decisions related to drug approvals, safety monitoring, and post-market surveillance.”

According to Jadhav, some of the benefits of integrating real-world data into regulatory decision-making are that it enhances decision-making and provides comprehensive insights into how drugs perform in broader populations beyond the controlled environment of clinical trials. Other benefits include increased efficiency and the ability to capture data from diverse patient populations, which Jadhav said are often underrepresented in traditional clinical trials and can now bring more awareness to equity issues in health care.

However, there are challenges to using real-world data in health care as well.

“Ensuring that real-world data is accurate, complete, and consistently formatted across different sources remains still a challenge,” Jadhav said. “Privacy and security, protecting patient privacy, and securing sensitive health data are critical concerns when handling large volumes of real-world data. Although there are improvements from a technology perspective, this is still an area that continues focus, which is needed. Integration and standardization, harmonizing data from various sources to create a cohesive data set that meets regulatory standards can be complex.”

The FDA will ensure the quality and reliability of data by making sure submissions they receive that use real-world data are aligned with the guidance.

For ophthalmologists, Jadhav says that they can contribute to the integration of real-world data by recording detailed and accurate patient data in EHRs, engaging in patient registries, and collaborating with research institutions by participating in studies that utilize real-world data to generate new insights and improve patient outcomes. Regarding the impact real-world data integration will have on practices, Jadhav is optimistic.

“I think one of the biggest impacts we'll be around helping streamline approval processes for new drugs and devices,” Jadhav noted. “Additionally, real-world data offers data-driven insights that can enhance patient care by improving patient management strategies, so these improvements collectively contribute to more effective and efficient ophthalmology practices.”

Additionally, Jadhav said real-world data could decrease the time it takes to bring new drugs to the market, making the trial process more cost-effective. Clinical trials could also transform their design by “providing a more comprehensive view of drug efficacy and safety.”

“This holistic approach I think will enhance the understanding of how treatments perform in a real-world setting,” he pointed out. “Additionally, real-world data can help support the development of adaptive trial designs that can adjust in real-time based on emerging insights, making trials more flexible and responsive to new information, which can improve their efficiency and outcomes.”

Looking ahead, real-world data could be expanded beyond regulatory decision-making, but also in post-market surveillance and health policy formation, which Jadhav said he believes can play a critical role in shaping the future of health care and improving patient outcomes by providing more.

Sujay Jadhav, CEO of Verana Health, a digital health company dedicated to revolutionizing patient care and clinical research through real-world data (RWD), provides an overview of new FDA guidance.

The implications of real-world data integration in health care and ophthalmology

The Retina Society is set to host their 57th annual Scientific Meeting in Lisbon, Portugal from September 11-15, 2024. The meeting will showcase a scientific program “designed to facilitate discussion and exchange of ideas and social functions which will allow [attendees] to reconnect with one another.”

Other than allowing attendees to reconnect, they will be able to hear updates on new and ongoing studies and data from leading companies across the world. With the meeting set to begin soon, companies have started to announce their participation in the meeting and what some of the data presented will focus on.

Below is a non-exhaustive list (in alphabetical order) of companies and the information surrounding their Retina Society presentations.

4DMT will present interim results from the PRISM phase 1/2 clinical trial evaluating intravitreal 4D-150. This potential treatment is being evaluated for adults with neovascular age-related macular degeneration (nAMD).

The presentation, titled “Interim Results from the PRISM Phase 1/2 Clinical Trial Evaluating Intravitreal 4D-150 in Adults with Neovascular Age-related Macular Degeneration” will take place on Sunday, September 15, 2024, at 8:34-8:39 am CEST. It will be presented by David Eichenbaum, MD, FASRS, director of research, Retina Vitreous Associates of Florida, St Petersburg, FL.

The Retina Society meeting will take place in Lisbon, Portugal from September 11-15, 2024.

Emmanuel Buys, PhD

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