Single-use instruments in cataract surgery: Beyond the backup role

In the modern ophthalmic surgical centre, clinical efficiency, sustainability and economic viability often represent intertwined but diverging goals. Cataract surgery, the most commonly performed ophthalmic procedure globally, lies at the heart of these issues. Amid growing concerns related to clinical waste and carbon emissions, the question of whether to use reusable instruments (RUIs) or single-use instruments (SUIs) is more pertinent than ever.

This discussion must also be framed within a rapidly evolving macro context. The global volume of cataract surgery continues to increase, driven by ageing populations and expanding access to care. Office-based surgery models and operating rooms are under growing pressure to accommodate fluctuating surgical volumes, where the number of daily procedures may vary considerably from one day to the next. In contrast to the more predictable surgical schedules of the past, this variability demands a higher degree of organizational flexibility, placing strain on rigid instrument management systems. In this setting, flexible hybrid approaches combining RUIs and SUIs may provide value.

Although RUIs have traditionally been favoured for their perceived quality and lower carbon footprint, marked improvements in the performance, manufacturing efficiency and economic viability of SUIs have rendered their market position more competitive. These factors, combined with evolving clinical infrastructures, increasing demands on sterilization teams and global efforts to reduce surgical backlogs, are prompting many clinics to re-evaluate their instrument strategies. Despite this, comprehensive comparisons that account for indirect administrative costs and extended carbon footprints remain relatively scarce. Improved availability of such information would help ophthalmic centres select the most appropriate instruments for their individual clinical setting and needs.

To address this, we recently performed a multicentre study assessing the economic and environmental profiles of SUIs with respect to RUIs in six diverse surgical centres across Europe and the US.¹ The results, published in Clinical Ophthalmology, suggest that SUIs, far from being a niche or emergency-only option, can serve as a reliable and cost-effective choice for routine use, particularly in multi-specialty centres associated with high sterilization costs.

SUIs: A cost-effective solution in many settings

The study analyzed data from stand-alone surgical centres, private hospitals and university-affiliated institutions. The estimated cost of SUIs was based on the market average for a five-instrument cataract set, while RUI costs included sterilization, amortization over 4 years and annual replacement rates. Sterilization costs were particularly influential in determining overall cost-effectiveness, varying considerably among participating centres from €0.93 to €8.30 per instrument per sterilization cycle. High-volume centres with an internal sterilization system experienced better cost control with RUIs. However, in centres without internal sterilization capacity requiring external sterilization services—a scenario that may be encountered in certain multi-specialty centres—overall costs were higher, reducing the economic benefit of reusable instruments.

These findings align with prior studies performed in both general surgery and dental care settings, which have shown that SUIs can reduce both direct costs and administrative overhead, particularly when accounting for instrument turnover, maintenance and sterilization compliance.²⁻⁵

Practicality and predictability

Beyond their economic appeal in certain clinical settings, SUIs offer consistent, pre-sterilized instrument quality and eliminate variability caused by the wear and tear of reusable tools. This robustness can ensure more reliable surgical performance, simplify logistics and reduce risk for both patients and surgical teams. Historically, the quality of SUIs was a concern, as they were seen as a cheap, disposable alternative to be used only when necessary. Improvements in manufacturing quality for certain SUIs have helped shift this view.

From an operations perspective, the availability of sterile SUIs ensures uninterrupted surgical flow. This is particularly important in clinics facing staff shortages or turnover in central sterilization units. In rural or mobile settings, for example, SUIs simplify logistics and reduce the need for specialized reprocessing equipment. This is consistent with findings from a surgeon-based survey that showed high acceptance of SUIs in terms of safety, reliability and ease of use in cataract surgery.⁶ In the case of instrument malfunction or emergencies such as last-minute case additions, an SUI contingency stock may also eliminate dependency on instrument turnover, ensuring continuity of care and maximizing efficiency in time-sensitive environments.

Environmental impact: A complex comparison

While the cost benefits of SUIs are evident in certain contexts, their environmental impact is more complex. In our study, considerable differences were observed when comparing the overall carbon footprints of RUIs and SUIs:

• RUIs: 20.6 kg of carbon dioxide equivalent (kg CO₂e) per instrument over 5 years
• SUIs with recycling: 4,639.9 kg CO₂e over 5 years of usage
• SUIs without recycling: 5,478.2 kg CO₂e over 5 years of usage

In the case of SUIs, the carbon footprint was heavily influenced by inbound logistics and manufacturing (Figure 1).

Although these findings underscore the higher emissions profile of SUIs, they were calculated based on the assumption of global distribution logistics and minimal local recycling—variables for which strategies to counteract a significant portion of these emissions can be implemented. It has been highlighted that carbon emissions linked to inbound logistics can be significantly reduced by localising production or exploiting sea freight shipping.⁷⁻⁹ A gradual increase in the share of product shipped by sea instead of by air at a rate of 5% per year could potentially generate a 26%, or 0.49 kg CO₂e, reduction in carbon emissions per product by the end of a 10-year period (Figure 2).

As non-renewable energy sources are gradually phased out in favour of green energy production, this will also begin to produce considerable reductions in carbon emissions within the same time frame.

Cataract surgery often addresses one eye at a time, doubling patient travel and the use of resources, further elevating carbon costs. Innovations such as bilateral same-day surgery, smart supply chain planning and bulk packaging may further narrow the carbon gap between SUIs and RUIs.

A hybrid framework based on functional complementarity

To truly determine the environmental footprint of such medical instruments, it is necessary to reframe the discussion from a binary comparison towards a hybrid use perspective that more closely reflects real-world clinical practice. Accordingly, we also performed a study aimed at highlighting impact-reduction pathways applicable to a healthcare setting in which SUIs continue to represent a valuable component of clinical workflows.

The primary environmental optimization strategy remains the use of reusable instruments where efficient sterilization systems are available. However, our study highlighted that meaningful system-level improvements may be achieved through several actions. These include reducing emissions during the production of SUIs, using simpler packaging with less material and waste, improving transport and supply chain efficiency to avoid unnecessary deliveries, and introducing recycling and recovery programmes to reduce the volume of waste sent for disposal. The study also highlighted that innovation with reusable technologies may further reduce waste generation and material throughput without compromising clinical performance.

By leveraging these strategies, it is possible to reduce the impact of carbon emissions related to SUI use (Figure 3), further suggesting that recycling and improvements across the manufacturing, transport and disposal process may contribute to measurable reductions in overall environmental burden.

A strategic use of SUIs in clinical practice

Given the cost advantages and practical convenience that SUIs can offer in certain contexts, along with new strategies to reduce their environmental burden, many ophthalmic practices are adopting a hybrid model. In this approach, RUIs remain in primary use where feasible, but SUIs are employed selectively, particularly when significant strain is placed on the waiting list, when emergency surgeries are required or when sterilization resources are unavailable within a reasonable time frame.

SUIs also serve as a reliable backup for instruments that are particularly fragile and susceptible to wear, such as capsulorhexis forceps, where the performance of reusable instruments may degrade over successive sterilization cycles and potentially compromise procedural outcomes. More broadly, selective deployment of SUIs aligns with the increasing need for flexibility in modern operating rooms. As surgical volumes continue to rise, the ability to rapidly scale instrument availability without dependence on sterilization turnaround times represents a tangible operational advantage.

The findings from our study lend credence to the adoption of this mixed-use paradigm in centres with high sterilization costs or equipment limitations, where SUIs were generally more cost-effective. This is reinforced by broader surgical literature showing that hybrid instrument strategies can reduce the risk of infection and sterilization-related errors, improve operating room efficiency by shortening turnover times between cases and allow flexibility without significantly compromising sustainability.³⁻⁵

In teaching hospitals, the use of SUIs may also be beneficial when aiming to standardize the learning environment by ensuring instrument uniformity, highlighting that the strategic use of SUIs may be applicable across a wide array of operational and teaching settings. A hybrid strategy, using RUIs as the baseline approach but supported by the selective use of SUIs, is increasingly being considered a balanced approach and may be particularly advantageous in settings where high turnover or sterilization limitations make reusable-only strategies impractical.

Take-home message

The findings from our recent studies demonstrate that single-use instruments represent more than a contingency option. In specific hospital settings, particularly where sterilization costs are high, SUIs can reduce overall expenditure while ensuring a more efficient surgical workflow and improved quality control.

Although the environmental impact of SUIs remains a concern, it is important to contextualize this appropriately. A single SUI cataract set generates approximately 1.8 kg CO₂e, which, while not negligible, represents only around 1% to 2% of the total carbon footprint of a cataract procedure, estimated at approximately 182 kg CO₂e per patient.⁷ This highlights that instrument choice, whilst relevant, is not the primary driver of surgical emissions. The largest contributors to the carbon footprint of cataract surgery are energy consumption, particularly building and electricity use (approximately 36%), and procurement-related factors, including custom surgical packs (approximately 54%). Efforts to reduce environmental impact are therefore likely to be more effective when focused on energy optimization, improved pack design and enhanced recycling strategies.

Within this broader context, the selective use of SUIs becomes easier to justify, particularly when integrated into a well-designed hybrid model. By combining reusable instruments with targeted SUI use—supported by ongoing innovations in recycling, logistics and manufacturing—ophthalmic practices can achieve a pragmatic balance between efficiency, cost control and sustainability.

Ben LaHood, PhD, PGDipOphth, MBChB, FRANZCO

E: [email protected]

Ben LaHood, PhD, PGDipOphth, MBChB, FRANZCO, is an ophthalmologist and laser eye surgeon practising at both the Adelaide Eye and Laser Centre and ParkView Day Surgery in Adelaide, Australia.

References

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