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Botulinum toxin type A effect is usually seen 2 to 3 days following injection, with maximal effect at approximately 2 weeks. Touch-ups are not recommended until 2 weeks have passed.

Facial anatomy key to optimal use of botulinum toxin

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

Thyroid eye disease is a condition frequently associated with Graves disease that involves both acute and chronic inflammation of the orbit. Patients may experience ocular discomfort, appearance changes, and vision loss. In this podcast, an expert panel discusses diagnosing TED and providing appropriate pharmacologic and surgical treatments. 

In this PER On Air Ophthalmology Times podcast, an expert panel discusses diagnosing TED and providing appropriate pharmacologic and surgical treatments. 

Advancing the optimal diagnosis & treatment of thyroid eye disease

Myopia management options and knowledge have proliferated over the past decade. This pursuit of knowledge has been fueled by the understanding that the worldwide prevalence of myopia is increasing and that this spike in myopia cases may increase the population’s ocular pathology burden.

With this dynamic landscape and urgent need to curb the onset and progression of myopia, it is imperative that clinicians explore every avenue for improving myopic progression treatment outcomes. Although most studies have focused on evaluating monotherapy options, there is growing evidence suggesting that dual therapy may further slow myopic progression. Thus, the purpose of this literature review is to explore the current state of knowledge related to using a low-dose atropine as an adjunct therapy in patients who are also being treated with optical-based myopia management strategies.

Low-concentration atropine (0.1%-0.05%) has been demonstrated to be effective while having minimal adverse effects.

 Although atropine was once thought to exert its antimyopigenic effects as an antimuscarinic, its full mechanism is unknown.4 Orthokeratology and other optical-based clinically proven myopia management strategies are thought to reduce myopic progression by decreasing retinal peripheral hyperopic defocus.

 Thus, if a myopic patient were prescribed both atropine and orthokeratology, which appear to operate under different mechanisms, the atropine and orthokeratology might produce an additive treatment effect.

Kinoshita et al were some of the first investigators to report on this topic with their 2-year, parallel-group, randomized trial, which compared participants receiving combination orthokeratology with atropine (n = 43) with participants who were being treated with only orthokeratology (n = 37).

 The authors found that the combination group had a significant slowing of axial length elongation compared with atropine alone over the duration of the study. Kinoshita et al interestingly found that most of the added benefit detected with the combination occurred during the first 6 months of treatment.6 This result has since been corroborated by Yu et al and Tan et al.

Xu et al completed a 2-year, randomized trial comparing the efficacy of standard spectacles (n = 40), standard spectacles plus atropine (n = 42), orthokeratology (n = 40), and combined atropine and orthokeratology (n = 42) treatments.10 The authors found a significant treatment difference among groups with their pairwise comparison determining that the combined treatment was superior to atropine or orthokeratology treatment alone. Tan et al later conducted a 2-year, randomized trial comparing the combination of orthokeratology plus atropine (n = 45) to orthokeratology alone (n = 44) with the authors determining a similar conclusion.

Chen et al conducted a 3-year trial evaluating the effect of adding atropine for patients who were poorly responding to orthokeratology (≥ 0.30 mm of axial elongation after 1 year of treatment).11 The patients in this study were given the option to use atropine (n = 37) or not (n = 36) while continuing to use orthokeratology after 1 year of monotherapy. Chen et al determined after 2 years of combination treatment there were no additional benefits to adding atropine. 

Combination atropine and soft contact lenses

Multifocal, soft contact lenses (CLs) have demonstrated the ability to slow myopic progression,12-14 and there are emerging data regarding their usefulness in combination with atropine. Jones et al were among the first to evaluate atropine in combination with soft CLs with the authors performing an ancillary study to the Bifocal Lenses in Nearsighted Kids study (BLINK; NCT02255474).13,15 The BLINK study compared monthly, center-distance soft CLs with +2.50 D or +1.50 D adds to single vision CLs of the same brand. The authors found that the +2.50 add CLs but not the +1.50 D add CLs were able to significantly slow myopic progression compared with single vision CLs.

Jones et al compared a group of 46 patients being treated with atropine and +2.50 add soft CLs with age-matched +2.50 D add and single vision CL wearers from the BLINK study. The authors found that combination atropine and +2.50 D add CLs did not provide an additional treatment benefit. Erdinest et al has since implemented a 3-year, retrospective review, which compared patients who were treated with a daily disposable CL plus atropine (n = 26), atropine (n = 29), or with single vision spectacles (n = 30). Patients taking atropine were treated for 2 years with the drop. They then were tapered off the drop for 6 months and followed for an additional 6 months. Erdinest et al determined that there was no significant benefit to combination treatment over atropine treatment alone.

Although different spectacles designs have been evaluated as a means for slowing the progression of myopia for many years, these early investigations have failed to find a clinically meaningful effect.16 Nevertheless, more recent designs that promote the reduction of peripheral retinal hyperopic defocus across the full peripheral retina have been shown to significantly reduce myopic progression.17 Nucci et al were among the first investigators to tackle this topic. The authors completed a 1-year, unmasked study that compared patients treated with defocus incorporated multiple segments (DIMS) spectacles (n = 30), atropine (n = 53), DIMS plus atropine (n = 31), and single-vision spectacles (control; n = 32). The authors determined that all 3 treatments provided a significant reduction in myopic progression; the combination group also obtained a significantly better treatment effect than monotherapy for refractive error, but not for axial length.18

Huang et al have completed a retrospective study, which compared the treatment effect between patients treated with DIMS plus atropine (n = 40), DIMS (n = 49), or single-vision spectacles (control; n = 47). The authors found a difference between the treatment groups and the control group and a greater treatment effect with the combination group.19 Between-study differences could be attributed to Huang et al enrolling Asian patients and Nucci et al enrolling European patients.

Although the literature is still emerging, most studies suggest that 0.01% atropine in combination with optical interventions provides an additional treatment benefit, though this additional reduction in ocular growth may be limited to the first 6 months of treatment. More work is needed to understand whether slightly higher concentrations of low-dose atropine (0.05%/0.025 vs 0.01%) will provide a better treatment effect when combined with optical interventions and to understand whether subsets of patients may have better results.

1. Holden BA, Fricke TR, Wilson DA, et al. Global prevalence of myopia and high myopia and temporal trends from 2000 through 2050. 

2. Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia aetiology. 

3. Yam JC, Li FF, Zhang X, et al. Two-year clinical trial of the low-concentration atropine for myopia progression (LAMP) study: phase report. 

4. Zhao Q, Hao Q. Clinical efficacy of 0.01% atropine in retarding the progression of myopia in children. 

5. Smith EL 3rd, Hung LF, Huang J. Relative peripheral hyperopic defocus alters central refractive development in infant monkeys. 

6.Kinoshita N, Konno Y, Hamada N, et al. Efficacy of combined orthokeratology and 0.01% atropine solution for slowing axial elongation in children with myopia: a 2-year randomised trial. 

7.  Kinoshita N, Konno Y, Hamada N, Kanda Y, Shimmura-Tomita M, Kakehashi A. Additive effects of orthokeratology and atropine 0.01% ophthalmic solution in slowing axial elongation in children with myopia: first year results. 

8. Yu S, Du L, Ji N, et al. Combination of orthokeratology lens with 0.01% atropine in slowing axial elongation in children with myopia: a randomized double-blinded clinical trial. 

9.T an Q, Ng AL, Cheng GP, Woo VC, Cho P. Combined 0.01% atropine with orthokeratology in childhood myopia control (AOK) study: a 2-year randomized clinical trial. 

10. Xu S, Li Z, Zhao W, et al. Effect of atropine, orthokeratology and combined treatments for myopia control: a 2-year stratified randomised clinical trial. 

. Published online October 13, 2022. doi:10.1136/bjo-2022-321272

11. Chen Z, Zhou J, Xue F, Qu X, Zhou X. Two-year add-on effect of using low concentration atropine in poor responders of orthokeratology in myopic children. 

12. Walline JJ, Greiner KL, McVey ME, Jones-Jordan LA. Multifocal contact lens myopia control. 

13. Walline JJ, Walker MK, Mutti DO, et al; BLINK Study Group. Effect of high add power, medium add power, or single-vision contact lenses on myopia progression in children: the BLINK randomized clinical trial. 

14. Chamberlain P, Peixoto-de-Matos SC, Logan NS, Ngo C, Jones D, Young G. A 3-year randomized clinical trial of misight lenses for myopia control. 

Dual therapy may slow the progression of condition.

John R. Burroughs, MD

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