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RWO is hosting its 5th virtual, interactive conference titled “Top 10 Things I Wish I Knew Sooner” on Saturday September 30, 2023, from 8 am to 5:30 pm Central Time.

Bridging the gap: Real World Ophthalmology connects young ophthalmologists with invaluable knowledge and expertise

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

Alejandro Espaillat, MD, sat down to discuss his presentation on pearls for the anterior segment surgeon

Ophthalmology: Pearls for the anterior segment surgeon

Alejandro Espaillat, MD, sat down to discuss his presentation on pearls for the anterior segment surgeon at this year's ASCRS meeting held in Boston, Massachusetts. 

- This transcript has been edited for clarity.

I'm David Hutton of Ophthalmology Times, ASCRS is holding its annual meeting in Boston. At that event, Dr. Alejandro Espaillat is presenting "Ophthalmology: Pearls for the anterior segment surgeon." Thanks for joining us today. Tell us about this session.

Well, David, thank you very much for the opportunity to be here talking to your audience and readership, which I sincerely admire. This is going to be a very comprehensive level, instructive level, basic presentation on how artificial intelligence is implemented for the anterior segment surgeon. But we will start with a definition of artificial intelligence – what exactly that means. And the difference between artificial intelligence and human intelligence. And how artificial intelligence algorithms are created. And how do they work, particularly when they are implemented in healthcare, and specifically in ophthalmology, and for this particular meeting, particularly for the anterior segment surgeon and comprehensive ophthalmologist.

Ultimately, how can the use of AI help surgeons provide better outcomes for their patients?

It will completely change the way we practice medicine today and the way we get paid and the way we diagnose and treat the diseases. Just to give you an idea, there are published papers right now recently published in China, where a typical ophthalmologist nowadays even in the United States sees an average of about 4000 patients per year. With the proper implementation of artificial intelligence, a typical ophthalmologist will be able to – and this is not a misquote. From 4000 patients per year, you will be able to have access to 46,000 patients per year. When that implementation is done from the specialist all the way down to the primary care physician to the community physician. The eyecare provider will be able to increase the number of patients as well as to improve the diagnosis accuracy, assisting in the detection of eye diseases at much earlier stages and therefore preventing blindness.

Could this be something that could help access to ophthalmology care for patients who may live in rural areas and not have easy access?

Absolutely. Nowadays, we have what we called desert specialist areas. Areas where there just is lack of specialized eye care and specialized care in multiple specialties. So for patients, this will mean early diagnosis and early treatment and disease prevention. And so it will provide a much more personal care and recommendations and it will enhance the overall patient care through more efficient and streamline processes.

And lastly, what's the take home message of this presentation?

We have to be open to the new technology. Artificial intelligence is not here to replace doctors. It will enhance the way doctors practice and care for their patients. Be open about it and get ready to learn as much as possible and to implement these new changes that are coming very soon.

Alejandro Espaillat, MD, sat down to discuss his presentation on pearls for the anterior segment surgeon at this year's ASCRS meeting held in Boston, Massachusetts.

Videos

ASCRS 2024: Pearls for the anterior segment surgeon

Neda Gioia talks about her poster on multi-ingredient oral supplement on dry eye symptoms and tear volume from ARVO 2024

multi-ingredient oral supplement on dry eye symptoms and tear volume.

Neda Gioia, OD, sat down to discuss a poster from this year's ARVO meeting held in Seattle, Washington, from May 5 to May 9, on a multi-ingredient oral supplement on dry eye symptoms and tear volume.

I'm David Hutton of Ophthalmology Times. The Association for Research in Vision and Ophthalmology is holding its annual meeting in Seattle. Dr Neda Gioia is joining me today to discuss her presentation at the meeting titled, "Clinical Evaluation of a Multi-Ingredient Oral Supplement on Dry Eye Symptoms and Tear Volume." Thank you so much for being here. Tell us about your presentation.

Thank you so much, David, for having me here today. It's very exciting to be presenting at ARVO for these posters and talking about this very unique new oral supplement that is going to be in the hands of our doctors and patients soon.

So the posters, really there's 2 posters, but I'm going to talk about 1 more extensively, and that's the one about the multi-ingredient oral supplement on dry eye symptoms and tear volume. So the poster reflects a need right now, in terms of our dry eye toolbox and that's because over 150 million Americans are suffering from dry eye syndrome, if not more, and the incidence of this is increasing globally, not just in the US. And we can connect this to many different things: lifestyle factors, general health factors, digital use, etc. So we really need more expansion in terms of our options for our patients and it's nice to have something that is a prospective, randomized, double-blind, placebo-controlled study that features this oral supplementation as used to improve dry eye symptomology and improve dry eye tear volume.

So speaking about the poster, the objective is really to test the efficacy and the safety of this novel supplement. Now, just to kind of backtrack, what is the supplement made of? It's a proprietary blend of 20 milligrams of lutein, 4 milligrams of zeaxanthin isomers, alongside curcuminoids 200 milligrams, and vitamin D3 at 600 IUs, and this proprietary blend is tested against a placebo of 600 milligrams of soybean oil. So the eligibility criteria in these patients are roughly aged 18 to 65 and it's a 4 center test in the United States, with 116 subjects roughly split evenly between the placebo and the supplement group of neutral tears. And ultimately, the way that they accepted, the investigators, these subjects into the dry eye category is they assessed the OSDI scores, and a score of between 12 to 40, alongside a Schirmer's tear volume tests, which was assessed at less than an equal to 10 millimeters by a licensed optometrist really put everyone into that eligibility category to clinically say that these patients had mild to moderate dry eye. Now, these, the subjects were tested baseline and then at day 14, day 28, and day 56.

The primary endpoint of the OSDI as well as the Schirmer's tests were pretty remarkable. The OSDI scores at day 14 start to show statistically significant improvement, which is really, really amazing, knowing how nutraceuticals work, and that's going back to the formulation most likely and the bioavailability of that formulation. And that kept improving into day 56. Alongside that the tear volume also improved around day 28, again statistically significant. Now there were secondary endpoints that all showed improvement except for 1 which was not plus or minus, it was just the same and that was the artificial tear use. And those types of tests include MMP scores, TBUT scores, corneal and conjunctival staining, SPEED scores, again another subjective point for the test subjects. And these all showed improvement as well, statistically significant around that day 56. So in 2 months, we saw so many points of improvement in tear quality, tear volume. And even more importantly, the patient's report, right, because dry eye's also something alongside quality of life. So we see those quality of life scores improve.

And really the bottom line was this NutriTears formulation, this LCD formulation that we saw tested by these investigators, it really improved dry symptom relief, again, seen as little as 2 to 4 weeks. And the clinical data just really just shows the efficacy and the safety of this proprietary blend of the lutein, zeaxanthin isomers, curcumin, and vitamin D3 as a daily supplement to help with the signs and symptoms of dry eye. So having this therapeutic potential in a supplement form to help address the signs and symptoms of dry eyes in all these patients that we're seeing is going to really give us a lot of confidence to help add to our toolbox of treatments.

Now, the second poster emphasizes how the India study, which also was done a few years prior to the USA study, showed really similar results. Now the subject number was slightly smaller. Actually, if anything, the artificial tears usage, which seemed to be used less, as early as day 14 as well, again with statistical significance. It was a 1 center study, but in conjunction with the USA study, I think we really have 2 nice, solidified ways to show that this new novel, multi-ingredient oral supplement can help with dry eye symptoms and tear volume.

Well, what's wonderful is that this proprietary blend has also been investigated to come straight to the shelves, to basically be applicable to doctors to help recommend and also patients to basically use to help improve their dry symptomology. So, long story short, it's going to be accessible, most likely in the second half of this year.

ARVO 2024: A study on multi-ingredient oral supplement for dry eye symptoms and tear volume

Eric Donnenfeld gives updates on the Blink Triple Care

Eric Donnenfeld, MD, sat down to discuss presentations on the novel new artificial tear, Blink Triple Care, about its efficacy in a non-controlled trial as well as comparison to the Classic Blink at this year's ARVO meeting held in Seattle, Washington, from May 5 to May 9.

I'm David Hutton of Ophthalmology Times. The Association for Research in Vision and Ophthalmology is holding its annual meeting in Seattle. At that meeting, Dr. Eric Donnenfeld presented, "Clinical evaluation of a novel lipid-containing eye drop." Thank you so much for joining us today. Tell us about your presentation.

Hi, I'm Eric Donnenfeld, and I'd like to tell you about 2 different presentations that we're doing here at ARVO. These involving novel new artificial tear called, Blink Triple Care. Blink Triple Care is the first and only artificial tear that contains not only polyethylene glycolate as a lubricant, but also contains hyaluronic acid and has a nanoemulsion of lipid. It's transiently preserved. The first study just looked at the efficacy of this medication in a non-controlled trial, in which 77 subjects were enrolled, and of these, 75 completed the trial. We looked at baseline comfort and quality of vision, and we saw a statistically significant improvement in quality of vision at 7 days and again it 3 months later, tear breakup time, from a breakup was 8.8 seconds originally and 10.1 seconds on the third visit. The slit lamp findings showed a significant reduction in corneal staining. We follow this up with a second trial in which we compared Blink Triple Care to the Classic Blink, which was the first hyaluronic acid-based tear are used in the United States. What we found was a non-inferiority to Blink. What we looked at in this study was 158 participants enrolled, 130 completed the trial. We compared overall comfort scores from baseline to the 30-day follow-up. We show that this novel lipid-containing eye drop was similar to the Blink but was actually better in this non-inferiority comparison, looking at ocular comfort. There were no significant adverse events in the trial, and basically, the take home message from these 2 different studies are that this novel, new Blink Triple Care, which combines hyaluronic acid with nanotechnology lipid, is a very effective therapy in the management of dry eye disease. Thank you very much.

ARVO 2024: Clinical evaluation of a novel lipid-containing eye drop

post-hoc analysis of 2 FDA registration trials for perfluorohexyloctane

John Sheppard, MD, MSc, FACs, sat down to discuss post-hoc analysis of 2 FDA registration trials for perfluorohexyloctane, GOBI and MOJAVE, at this year's ARVO meeting held in Seattle, Washington, from May 5 to May 9.

Tianyi Wang

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