Cataract surgeons on operating theatre waste: Less is often more

Ophthalmology Times Europe Journal, Ophthalmology Times Europe September 2021, Volume 17, Issue 07

Cataract surgeons and nurses would support having re-usable equipment and supplies to reduce operating theatre waste and carbon footprint.

Reviewed by Dr David F. Chang.

A recent survey1 of cataract surgeons and nurses found that most are concerned about operating theatre waste and believe that having more re-usable products in the operating theatre is a step in the right direction. The survey was developed by the Ophthalmic Instrument Cleaning and Sterilization Task Force, which has representatives from the American Society of Cataract and Refractive Surgery, the American Academy of Ophthalmology (AAO), the Outpatient Ophthalmic Surgery Society and the Canadian Ophthalmological Society. The survey was disseminated to the members of all four societies.

Some impetus for the survey came from two published studies from the Aravind Hospital System in India. The first report in 20172 found that their carbon footprint for phacoemulsification was one-twentieth of that in the United Kingdom and the United States, largely because they re-use as many surgical supplies and drugs as possible. A second study in 20193 found that despite such widespread re-use, the rate of endophthalmitis in the Aravind system was 0.01% – lower than that in the United States, with the AAO IRIS registry rate of 0.04%.

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“The results suggested that much of our surgical waste due to single use of everything is excessive and of unproven benefit for preventing endophthalmitis,” said Dr David F. Chang, clinical professor of ophthalmology, University of California, San Francisco, US. Dr Chang co-authored the survey report with Dr Cassandra Thiel, assistant professor, New York University School of Medicine, US.

What generates waste?

The respondents felt that the major factors accounting for operating theatre waste were wasteful packaging of single-use items (71%), hospital/regulatory policies (74% and 82%, respectively) that limit surgeon discretion in re-using supplies, manufacturer mandates in instructions for use (IFU) for single-use products to limit liability (70%) and manufacturers driving the market towards more profitable single-use products (77%). Surgeon or patient preference for single-use products was felt to be a driver by only 26% and 7%, respectively.

Support of re-use of devices and supplies

The surgeons strongly/somewhat agreed that manufacturers of devices and supplies should use recycled content in packaging of medical supplies (90%) and that they should consider the environmental/carbon footprint in product design (92%). “However,” Dr Chang said, “the real impact would be to offer more re-usable instruments and supplies as options (94%) and allow surgeons greater discretion within their IFUs for re-using supplies (93%).”

Other areas with which surgeons strongly/somewhat agreed were more surgical discretion in the re-use of supplies by regulatory bodies (95%) and advocacy by medical societies to reduce the carbon footprint in operating theatres (87%).

Regarding the use of topical pharmaceuticals and intra-ocular pharmaceuticals, 98% and 95%, respectively, would consider using them in multiple patients; there was also strong agreement for re-using compounded pharmaceuticals (86%). Most surgeons are or would consider sending pharmaceuticals home with patients from the operating theatre (93%).

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Surgeons were very willing to re-use phaco tips (92%), phaco tubing and irrigation bottles (77%), cystotomes (72%), single-use cannulas and metal blades (74%), iris retractors (72%) and the unused halves of sutures (59%). During cataract surgeries, 91% are or would consider using short-cycle sterilisation and 56% would consider simultaneous sequential bilateral cataract surgery, although 34% would not be willing to do so.

Among other conservation proposals, eliminating the full-body drape was supported by 95%, not having the patient wear a hospital gown was supported by 90% and operating theatre staff using the same surgical mask all day was supported by 95%. Two-thirds of respondents were open to not changing surgical gowns between every case, but 77% would not be willing to re-use surgical gloves. Endophthalmitis (48%) and toxic anterior segment syndrome (43%) risks and malpractice liability (51%) were factors that decreased willingness to use supplies and medications on multiple patients.

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Factors potentially driving single-use instruments included reduced staff processing requirements (45%) and improved operating theatre efficiency (37%). “However, the main factors driving manufacturers to promote single-use instruments were felt to be increasing profit (62%), reducing liability (66%) and an easier regulatory approval pathway (65%),” Dr Chang said.

According to Dr Chang, the findings showed that more than 90% of surgeons are concerned about global warming; excessive operating theatre refuse; the need for more re-usable and multi-use options; strong preference for re-usable over disposable instruments; discretion from regulatory agents and manufacturers in re-using materials; and greater manufacturer consideration of carbon footprint.

David F. Chang, MD
e: dceye@earthlink.net
This article is adapted from Dr Chang’s presentation at the American Academy of Ophthalmology’s 2020 virtual annual meeting. He has no financial interest in this subject matter.
References
1. Chang DF, Thiel CL. Ophthalmic instrument cleaning and sterilization task force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste.J Cataract Refract Surg. 2020;46:933-940.
2. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391-1398.
3. Haripriya A, Chang DF, Ravindran R. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45:1226-1233.

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