In ophthalmology, cataract surgery is a major cause of carbon emissions and waste, from single-use disposable equipment to energy use in the facility itself. RHIANNON BOWMAN speaks to three surgeons who are implementing more sustainable practices.

For Dr Jesse Gale, decarbonising the healthcare system is not a matter of if, but when.

A general ophthalmologist with specialist expertise in cataract surgery, glaucoma and neuro-ophthalmology, Gale is a consultant at Capital Eye Specialists in New Zealand’s capital, Wellington, and a senior clinical lecturer at the city’s University of Otago campus. In 2021, he was appointed inaugural chair of RANZCO’s Sustainability Committee, formed following the launch of the college’s Sustainability Charter.

Prior to his appointment, Gale co-authored two papers, published in RANZCO journal Clinical and Experimental Ophthalmology on Australian and New Zealand ophthalmologists’ opinions on climate and sustainability.

“Around 65% of Australian and New Zealand ophthalmologists agreed that anthropogenic climate change is a public health issue requiring urgent mitigation,” Gale says.

“And a similar percentage agreed that public health systems should have sustainability as a performance indicator.”

Gale, who spoke on a sustainable future for ophthalmology at RANZCO’s virtual congress in February, is also part of a broader coalition striving for change.

The coalition includes Dr Cassandra Thiel of NYU, London ophthalmologist Dr Peter Thomas and Dr Andrew Cassels-Brown who also acts as medical director of the Fred Hollows Foundation.

They are jointly behind an app currently in development, known as Eyefficiency, designed to measure the triple bottom line.

“It collects data on throughput and efficiency, which is interesting to surgeons and managers, but has also been designed to collect and calculate information on travel, energy use, and procurement to provide a carbon footprint,” Gale says.

Gale recently led a project using the Eyefficiency methods to measure the carbon footprint of cataract surgery in six public and private hospitals in Wellington. The project’s outcomes were published in the New Zealand Medical Journal in September 2021.

“In healthcare, the biggest contributors to carbon emissions are energy (heating and cooling especially) and transport (of patients, staff and supplies). Wellington’s cataract carbon footprint was estimated to be 152kg of carbon dioxide equivalent (CO2e), and the great majority of that footprint was from procurement of surgical supplies and medications.”

By comparison, the carbon footprint of cataract surgery in Cardiff, UK, was estimated to be 182kg CO2e (measured in 2013, and including travel for postoperative visits), whereas the footprint at the Avarind Eye Care System of Southern India was only 6kg CO2e (in 2014).

“Wellington’s footprint now is roughly equivalent to Cardiff’s nearly 10 years ago but there is one main difference; New Zealand uses renewable energy. Our greatest source of emissions is procurement and the consumption of single-use supplies, and excessive packaging,” Gale says.

Renewable energy (predominantly hydro) accounts for 82% of New Zealand’s energy supply, compared to only 47% of the UK’s, according to Gale’s report. It named surgical supplies such as gauze, dressings, gowns and gloves, blades, lens implants, tubing and tips as contributing to emissions from procurement (83%).

Measuring the carbon footprint of cataract surgery in Wellington has helped Gale steer RANZCO’s Sustainability Committee’s Preferred Practice Guidelines for improved sustainability, launched on Earth Day (22 April 2022).

“Reducing carbon can save money and improve public health. The Preferred Practice Guidelines, which have been approved by RANZCO’s board, detail what ophthalmology operating theatres can implement immediately, such as stop administering unnecessary medications, without compromising patient care,” Gale says.

“Cataract surgery patients are often prescribed post-operative topical antibiotics as well as topical steroid, but some large registries have found the antibiotics makes no difference to the rate of serious infections, when antibiotics are given inside the eye during surgery.

“Each bottle of topical antibiotics costs only around $1. By ‘stopping the drop’, clinics can save on shipping and packaging costs too. It’s an important first step, even if it’s a small step. Our message to surgeons is to consider what you’re using, and don’t use what you don’t need.”

He says some of his colleagues on RANZCO’s Sustainability Committee were disappointed to discover that some ophthalmologists were using large and expensive single-use drapes to cover the patient’s whole body, for cataract surgery.

“We only need the drape to cover the face to prevent contamination of the field. We hope surgeons would consider using the smallest, lightest drape, or even a re-usable drape. Another waste-saving idea is to use a topical anaesthetic instead of injecting, to avoid using extra syringes and discarded pharmaceuticals,” he says.

Gale is now turning his attention to measuring the carbon footprint of intravitreal injections.

In a letter to the editor published in Clinical and Experimental Ophthalmology in January, Gale explained how he and three colleagues estimated the carbon footprint of 226 intravitreal injections at four public injection-only clinics in the Wellington region.

“Next we’re doing a survey of ophthalmologists across Australia on the equipment they are using for anti-VEGF injections. It seems there is quite a variety of techniques been used, ranging from minimalist injections in the clinic chair with very little equipment, to elaborate use of sterile supplies in the operating theatre.”

Gale hopes to use differences in techniques to guide the development of preferred practice guidelines to reduce waste in giving intravitreal injections.

Public health problem sparks opportunity

Further north in New Zealand, in the Waikato region, ophthalmologist Dr James McKelvie is following in Gale’s footsteps.

McKelvie is a consultant ophthalmologist with subspecialist fellowship training in cornea, anterior segment, cataract and refractive surgery. He is a consultant at Hamilton Eye Clinic, Waikato District Health Board, and the University of Auckland.

McKelvie is also CEO of CatTrax, an award-winning health IT company designed to improve visual outcomes following cataract surgery. The technology will soon be available in Australia.

“I’m interested in innovation. I attended RANZCO’s congress in Christchurch last year and heard Dr [Jesse] Gale speaking, and was inspired by his message of sustainability,” McKelvie says.

“Afterward, I spoke to co-ordinators in the Waikato region’s private and public hospitals because I wanted to measure the region’s carbon footprint. They were enthused for the first few weeks, contacting their suppliers as a first step. But I found that the more I asked, the less interested suppliers were. It soon fell into the ‘too hard’ basket and it came to a dead end for a number of suppliers,” he says.

That experience led McKelvie to reconsider his approach.

“I thought maybe I should start with only private clinics. I went back to smaller suppliers and said this – sustainability – will be a big issue in the future, so work with me. There are other benefits besides the obvious benefit to the environment, and I found the smaller players were motivated. We tried hard and did a lot of work on CO2 emissions associated with supply chains,” McKelvie says.

As he recalls, Gale’s report on the carbon footprint of cataract surgery in Wellington was published around this time. Inspired, he convinced his colleagues at Hamilton Eye Clinic to look at the clinic’s own carbon footprint.

Hamilton Eye Clinic has 10 consultants plus support staff, in a standalone building about 15-years-old, with two operating theatres and consulting rooms all housed in the same facility.

“Initially, we used Gale’s calculations, or metrics, and similar methods to him (although not the Eyefficiency tool). It was not perfect, but it was a start,” he says.

Instead, Hamilton Eye Clinic turned to Ekos, a New Zealand company that helps businesses measure and verify their carbon footprint, then use this footprint measurement to develop and implement a carbon reduction plan and offset carbon emissions that could not be reduced.

“Fortunately, my colleagues are progressive and supportive, and were on board with auditing the business from a sustainability standpoint and coming up with a strategy to reduce emissions. It was a detailed process, with a number of staff working on it,” McKelvie says.

Coincidentally, when Ekos delivered the report, a unique opportunity to test the clinic’s proposed carbon reduction plan arose.

“Waikato Hospital couldn’t perform all public cataract patients in-house and decided to outsource to Hamilton Eye Clinic, sending a cohort of 500 patients to us,” McKelvie says.

“We thought it was an ideal opportunity to try and do things differently, in a more sustainable way. We had developed a sustainable strategy around consumables and reducing use of disposables and medications, and removing anything we could without compromising patient outcomes.”

He continues: “The cohort meant Hamilton Eye Clinic had a specific contract with a set number of patients and could trial a protocol that reduces the carbon footprint of cataract surgery.”

Although the clinic had not completed surgery on all 500 cataract patients at the time of writing, McKelvie says the trial reduced the overall cost of surgery, and the clinic was able to invest the savings to offer cataract patients better quality lenses instead.

Ekos certified Hamilton Eye Clinic as carbon zero within 12 months.

“We’re seeing the trial as a new way of doing cataract surgery. We’re now carbon zero. I believe we’re the first carbon zero ophthalmology provider in New Zealand.”

McKelvie will present a one-year update on the clinic’s journey to carbon zero at RANZCO’s New Zealand branch meeting in 2023.

“With what we’ve achieved over this period of time, we hope will make it easy for others to follow,” he says.

“It’s a win-win-win situation. It requires bold steps and to challenge your thinking, and admittedly, not everybody was instantly on board, but implementing sustainability measures is beneficial for a number of reasons. We substantially reduced our carbon footprint with the help of Ekos. The clinic was over 200kg CO2e at baseline – we are significantly lower now.”

McKelvie says the surgeons involved in the trial of the 500 cataract patients – whose surgery had to be performed in a certain way in order to offset the carbon footprint – were incredibly positive about the experience.

“A lot of things were done differently for the 500 cohort. For example, we made the process of patient check-in fully digital, and we re-designed the custom pack of consumables that includes drapes, gowns, syringes and cannulas. We took out everything we didn’t feel was absolutely essential for routine cataract surgery,” he explains.

“We changed the type of anaesthetic we use, so all the patients in the cohort had a topical anaesthetic, which only requires one drop instead of a subtenons set that includes a syringe, and instruments that require sterilisation, and we eliminated most of the eye dressings following surgery.

“Having seen first-hand the benefits of the trial, one of the surgeons has told me they have changed the way they perform cataract surgery on their private list of patients, because it can be done environmentally sustainably in a structured and safe way, and still get great results.”

McKelvie says anyone wanting more information about how Hamilton Eye Clinic decarbonised cataract surgery can contact him at james.mckelvie@hamiltoneye.co.nz.

Dr Michael Loughnan, a surgeon at Eye Surgery Consultants in East Melbourne, has a long-standing interest in issues surrounding sustainability and the environment.

As a member of RANZCO’s Sustainability Committee, he believes enhancing the sustainability of ophthalmic practice can be best achieved through a strongly science-based approach.

He has previously presented at the RANZCO Annual Congress on ‘The Green Clinic’ and recently co-authored a manuscript on the views of RANZCO fellows and trainees on climate change and sustainability.

“The term ‘Green Clinic’ applied to a review of how our consulting clinic – Eye Surgery Consultants in East Melbourne – was run to reduce its environmental impact by reducing waste and greenhouse gas emissions, and to maximise recycling,” he says.

“As part of this, I employed a consultant who looked at energy consumption across the rooms and we then instigated changes to reduce energy consumption overall.”

Beyond the clinic, Loughnan and his wife Jacinta have been rehabilitating a previously drained wetland at Aireys Inlet along Victoria’s Surf Coast and revegetating the area to provide habitat for native animals.

Loughnan is also a visiting medical officer (VMO) with Cura, the largest group of private day hospitals in Australia, which performs 60,000 cataract operations per year across its 26 sites nationwide.

Loughnan is chairman of Cura’s Sustainability Committee.

“We’re trying to make surgery more sustainable. We want to reduce greenhouse gases, and reduce waste, particularly medical landfill, and cut the cost of surgery. Medical Consumer Price Index (CPI) runs several percentage points higher than general CPI. With wage increases, eventually surgery will be economically unsustainable,” Loughnan says.

He believes wasteful practices have become accepted as the norm in cataract surgery for two reasons.

“First, generally speaking, sustainability and cost has not been seriously considered. Second, there is the concept that ‘single-use’ surgery will be better and/or safer – but there is almost no evidence to support that,” he says.

Within Cura, three of the group’s 26 hospital sites have been reviewing their processes, including admissions, nursing, capital expenditure, and anaesthesiology, with an eye on sustainability.

“We’re looking to make it more sustainable, and we’re doing it in a collegiate manner. We don’t want a talkfest,” Loughnan explains.

“Each month or two we assess a practical item, this instead of that. For example, we’ve started using a sterile kidney dish, made of sugar cane, which is biodegradable, instead of a plastic kidney dish. We’re looking at practical, straight-forward measures that can be easily implemented and the quality of patient care is not compromised.”

The three Cura sites taking part in the review have also opted not to use an anaesthetic block for cataract surgery patients. Loughnan says that by eliminating the needle, they eliminate risk, as well as waste, which also strips cost.

“As James [McKelvie] demonstrates, the typical model for cataract surgery is notably wasteful. By controlling or reducing waste, you can reduce cost, and then invest money elsewhere,” Loughnan says.

He says RANZCO’s Sustainability Committee’s Preferred Practice Guidelines are designed to get ophthalmologists thinking about their systems and processes in terms of waste and recycling – and crucially, what they can easily change.

“We want surgeons to pause and ask themselves, do they need to open a single-use drape, for example. The guidelines are there for surgeons who wish to change their approach to surgery. It gives them guidance and support. It’s an evaluated policy of best-practice, for the patient and the environment, for the surgeon seeking to change but looking for evidence to go by,” he says.

“Change is challenging in our profession. We’re in a period when change is everywhere, it’s constant. RANZCO’s Sustainability Committee’s role is to make it easier for surgeons to adjust.”

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