Sustainable Ophthalmology: Together We Can Make a Difference!

What sparked your interest in sustainable ophthalmology?

Years ago, as a young doctor, I had an incident in the operating room with a cannula. After a full day of operating, we wanted to identify the cannula, the culprit, in the waste. But we couldn’t: we didn't know which of the 13 cannulas in the waste it was. We reported this incident to the inspection and one of the suggested improvements was to keep the waste separate for each operation. Suddenly, I became painfully aware of the enormous amount of waste generated from placing such a small lens.

In my private life, I was already very concerned with sustainability. For example, I rode my speed pedelec to work instead of driving a car. At that time I came across a study by Dr. Morris (published in 2013) that calculated the environmental footprint of a cataract operation. When I extrapolated that footprint to one day of operating, the result shocked me. It meant one day of cataract surgery (15 surgeries) equaled a car drive from my hospital to Cape Town in South Africa! It didn't let go of me. I made all that effort to cycle to work (from Amsterdam to Almere (30 km, ed.) so I could leave the car behind. But meanwhile, the CO2 emissions from a day at work were almost a thousand times greater than the emissions from the car journey I wanted to save. That’s when I realized focussing on my professional life could have a much greater impact.

You actively seek cooperation with politicians, insurers and industry organizations. Why is cooperation in the chain so important?

The reason I am so focused on cooperation is that I discovered the theme of sustainability can bring people together in order to drive change.

I recently spoke to the Board of Directors of an Academic Hospital who had been discussing the topic of appropriate care - i.e. which care to provide or not to provide - solely from a cost perspective for some time. There was a lot of resistance from the shop floor, as they naturally wanted only the best for the patient. But sustainable care is simply appropriate care. Since this most sustainable approach is to provide necessary care and to leave out unnecessary care. By viewing appropriate care from a sustainability perspective, we suddenly got all hands together.

And consider the social urgency. People find the topic important and are looking for a way to give it meaning. It is also such a complex problem that it cannot be solved by healthcare professionals alone. Let this be the first theme that we can really cooperate on.

Isn't this a task to a large extent for politics? What do you expect from the authorities?

Of course, we are facing a megalomaniacal crisis. Read the IPCC reports. They are not lying. It's all evidence-based. Not just a little bit, but researched by tens of thousands of scientists. So how in the world is this not at the top of the agenda of every government in the world?

The recent global crisis of Covid was on top of the agenda because Covid visibly affected people directly. Climate change is a much worse global crisis. But its threat to human health is less visible and it is progressing much more slowly. Therefore it is also much slower to address. Besides, for Covid you can develop a vaccine, but for climate change there is not one single solution.

People often say that sustainability is about preserving the future of our children. But if you are currently under fifty, there is a significant chance that you could die from the consequences of the climate crisis, such as heat stress. The argument “I have to do this for my children”, is bullshit! Of course children matter because parents are role models to them. I want to show my children that I am not going to sit back and do nothing, but instead, I am going to fight for this.

What role can the industry play in promoting sustainable practices?

What I often hear is that the industry claims they do what the customer wants. So they bounce the ball back. Therefore I am trying, together with others, to shift our demand towards a more sustainable demand.

But it would show leadership if more people from the industry stood up and said, “This is going all wrong.” We are going to take a leadership role in this because we believe it is important. We are going to use our R&D for this, support research. Or make more knowledge available. In the short run it may cost us money, but in the long run it will also provide us a first mover advantage. I sincerely hope some industry will show this leadership.

One can also look at it more non-competitively. Why not really work together as an industry? For example: take the pizza industry. The manufacturers said a decade ago; “Hey, we have too much salt in our products. We know it's bad for people, so it has to go down. But if I'm the first one to reduce the salt, customers may stop buying my pizzas because they find them less tasty.” Therefore the manufacturers decided collaboratively to lower the salt levels bit by bit every year. The pizzas now contain much less salt than they did ten years ago. Together they made a significant impact.

What are examples of impactful initiatives in sustainable ophthalmology?

One notable initiative is the SIDICS (Sustainability Index for Disposables in Cataract Surgery) calculator developed by the ESCRS. This tool allows surgeons to assess the environmental footprint of their surgical products, encouraging more sustainable choices.

Note, many initiatives rely heavily on the voluntary contributions of individuals working in their own time. That’s special because it shows the intrinsic motivation and commitment of people on making a positive impact. But things move slowly. So, if we want to accelerate more, we need more time and resources. I have reduced my working hours myself to dedicate more time to this topic. With a team we were able to secure a grant for the Dutch Ophthalmic Society to develop a roadmap to reach the goals of the Green Deal.

Working on sustainability allows you to get a more broad view on your profession and connections with other fields of science. There is the whole technical aspect of calculating the environmental impact of products for instance. But it also touches on social, philosophical and ethical issues. And of course psychology; how are we going to change human behavior? You will have to engage with knowledge from various fields and collaborate with other people.

How do you view the relationship between sterility and sustainability? Are they in conflict with each other, or can they go hand-in-hand?

First and foremost, and this is really important, patient safety is just as important to us. We want to explore how we can operate just as safely while using fewer resources and reducing our environmental footprint. But I do think some of the current infection prevention measures are an overkill, at least in our field. This is understandable because formerly the only criterion for these measures was whether they could reduce infections. If we could afford it, we would do it. Meanwhile a lot of measures have been implemented that are not funded by evidence and aren’t sustainable at all. For instance the drape size during cataract surgery. Surgical drapes vary from 4 square meters to 1.2 square meters within the same country. And we know from research that these disposable drapes are a major contributor to the carbon footprint and to the amount of waste we produce during cataract surgery. It doesn’t make sense to cover up the entire patient with a full body drape when we make a 2mm incision. I am convinced that using a face drape instead of a full body drape does not jeopardize patient safety and it will have a huge impact on the environmental impact in our field if we would all apply this measure.

Collaborating with infection prevention specialists can be really tough from time to time. I understand that because their interest is to prevent infections. But I do notice they start looking at the greater picture as well. By delivering healthcare the way we are still doing nowadays, we are a major contributor to climate change and therefore we are in fact harming public health. That’s the paradox we must break through. Together.

Next to reducing the CO2 footprint, circularity is a big topic. What is the difference?

Note that CO2 emissions are difficult to calculate and the conclusions can vary largely between countries. Sometimes throwing away a product can have a smaller footprint than reusing it. In Australia, for example, using disposable gowns for the surgeons and scrub nurses can be more sustainable than reusing them. Why? A) In Australia they use a lot of brown coal for energy production, so washing reusable gowns would generate more CO2 emission than in a country with a greener energy mix. And B) The travel distances to laundries can be much greater. So a disposable option could be better in that case.

Next to CO2 emissions, circularity (i.e. minimizing your primary resources) is actually much simpler. If something is to be circular, it can never be linear. Throwing something away is, by definition, not circular. While the disposable gown in Australia may have a smaller footprint regarding carbon footprint, it’s not circular. Sometimes, carbon footprint and circularity don’t go entirely hand-in-hand.

So we all consider sterility and safety equally important. But we also need to think about how we can improve circularity and reduce our CO2 footprint.

Is that possible?

Yes, I think so. Look at all the disposables. They’ve been made so cheaply by the industry that they are affordable by most clinicians. Using common sense, you might think a brand new disposable item is safer than something that has been sterilized. And since we can afford it, we opt for the disposable option. Now, a new criterion is being added. It’s no longer just about cost. It’s also about CO2 emissions and circularity. When you reconsider things with that in mind, you might come to very different decisions.

There’s also a role for the industry here. There’s clearly a knowledge gap for us as customers. A manufacturer should be able to provide, for each product, the difference in price, footprint, and circularity, so that we can make the right choices. That should be the goal.

Do you see this overkill primarily in the safety measures overall, or also in value-based care, like deciding what treatments to perform or avoid?

An example of overkill can also be found in the surgeries themselves. You need to think carefully about indications and triage. Take outpatient visits as an example. The sum of pre- and postoperative patient visits for cataract surgery in Western countries varies greatly, between 3 visits to 9! It’s quite interesting—couldn’t we minimize that?

Do new digital technologies play a role in that?

Yes, definitely. Some visits can be replaced by telehealth. But improvement is also partly empirical. In the past, you’d always do a one-day post-op check after cataract surgery. And then you'd see that most of the follow-ups were fine. Eventually, a few daring people said, “I’ll just make a phone call.” It turned out that most follow-up calls were fine as well, which led to, “We’ll only call when necessary.”

Bilateral surgeries are becoming more common. How do you view that in terms of sustainability?

There are fewer patient trips involved, and that has a significant impact. As long as transportation hasn’t been fully electrified, this definitely makes a difference. It shouldn’t be the primary reason for performing bilateral surgeries, but it can certainly be one of the reasons.

What would you advise doctors or hospitals to do to further reduce their footprint?

With the ESCRS’ YOFS (Young Ophthalmologists for Sustainability), we’ve identified five easy initiatives under the theme “Start Next Monday.” These are things an ophthalmologist can start doing right away.

1)    Air handling

The first initiative is the least easy, but also has the greatest impact. It’s the air circulation in the operating room. In the Netherlands, the vast majority of operating rooms do 69 air changes per hour, while 20 is sufficient. That’s a factor of 3 (!). When considered that over 90% of the energy used in the operating room is for air handling, the savings potential becomes clear. Furthermore new studies show that decreasing the amount of outside air (which has to be heated and humidified) and increasing the recirculation air can significantly decrease the energy usage. Additionally, you can save even more by turning off the air handling outside working hours and adjusting the humidity. Humidity is often controlled using steam, which consumes a lot of gas. In the Netherlands, a humidity level between 50-65% is the guideline, but research shows that 30% is also sufficient. All these measures combined can lead up to more than 70% of energy savings.

For many ophthalmologists, this might feel like it’s beyond their control. You can't manage everything alone. You need someone motivated to contact facility management and say, “Look, I want to adjust this and this for these reasons.” We've made these changes in our hospital too. And guess what? You can save money as well.

2)    Surgical brushes

The second initiative is surgical brushes. For many of us, a day in the operating theater starts with the ritual hand washing that includes the disposable brush. It feels good to thoroughly scrub your hands. However, studies clearly show that there is no added value of using these brushes. In fact washing with the brush causes a higher bacterial load on the hands. The reason is that scrubbing with the brush can rub off bacteria that would otherwise have remained in place. Therefore, the use of the disposable brush is obsolete. It is only, and only then needed when your hands are visibly dirty. For instance, if the chain of your bicycle fell off (laugh, red.).

3)    Armrest covers

If you use armrests during surgery, you probably use disposable sterile armrest covers. There is a simple trick to prevent using those. A doctor in the Netherlands pointed out how odd it is that we wear sterile gowns and then sit down on a non-sterile chair. This makes our back immediately non-sterile. So, he said, “I’ll leave the back of the gown open since it’s not sterile anyway. When I sit down, I drape the gown over the armrests.” This way, fewer armrest covers are needed. It’s a great example of rethinking. And if you realize how significant the footprint of these covers is...

4)    Eye shields

Reduce the use of eye shields. These do not contribute to post-op recovery in uncomplicated cataract surgeries. Many clinics in the Netherlands and Scandinavia have already successfully stopped using them.

5)    Surgical drapes

As mentioned earlier, replace full-body drapes with face drapes. All these measures can be found on the ESCRS website: www.escrs.org/special-interest-groups/yos/yofs/

Do you see differences between countries? Are there leaders or guiding nations?

There are significant differences between countries. In the Netherlands, we’re really leading the way in ophthalmology, alongside gynecology and anesthesiology. Other champions are the UK, Australia and Scandinavian countries.

Was there anyone who inspired you to take this issue seriously?

The study by Dr. Morris that I mentioned earlier eventually triggered a snowball effect. It raised a lot of awareness and led to follow-up research. For me personally, if that article hadn’t been published, I would never have known about the environmental footprint of cataract surgery. I wouldn’t have been so committed to this cause.

But my greatest inspiration is David Chang. It was back in 2019 when an international colleague advised me to get in touch with David about the topic of waste and sustainability. At the time, I’d only been an ophthalmologist for two years in the little old Netherlands. To me, David Chang was like a Barack Obama figure. I wrote to David, with shaky hands, to explain what we were working on in the Netherlands and to emphasize the need for international collaboration to make a real impact. Within ten minutes, no kidding, I received a detailed reply. It started with the words, “Dear Sjoerd, I would be happy to collaborate with you on this important topic.”

Fantastic! That such a role model also recognizes the importance of this. His influence has been pivotal in making this a topic of discussion in ophthalmology. It’s fascinating to see the impact one person can have.

In turn, David Chang was inspired by India. Cataract surgeries in India are extremely high quality, with excellent patient safety. They’ve been dealing with resource scarcity for decades. Scarcity that we’re now facing globally and which will only become more urgent. What lessons can we, as so-called high-income countries, learn from low- and middle-income countries about resource conservation? Flipping the narrative is something I’d still love to do.

So, David Chang inspired you, and you’re now trying to inspire others. Are we moving fast enough?

In the Netherlands, there is a Green Deal for sustainable healthcare based on the European Green Deal. The Green Deal for healthcare has been signed by all relevant parties, including the government, insurers and care institutions. That’s unique because nowhere else in the world has one like it. The goals are very clear about where we need to go.

This issue is so urgent that, by definition, the answer to the question “Are we moving fast enough?” is “no”. We’re not moving fast enough because CO2 remains in the atmosphere for more than 120 years. Even if we stop all emissions today, warming will still continue. So the question isn’t whether the sea level will rise by three meters or not—the answer is yes. The real question is when. Will it happen before 2100 or in the 22nd century? That depends on how quickly we stop emitting.

So, are we moving fast enough? Look in the mirror. We all need to change—everyone. It’s such a complex issue that if you only focus on the end goal, you’ll feel disheartened. Draw energy from what can be done. Look at what you can contribute. For instance the Start Next Monday campaign I mentioned earlier are major successes. If we focus on those successes, we can make significant progress together.

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