Madiah Mahmood

The NHS accounts for approximately 4% of the country’s carbon emissions (1). Sustainability within ophthalmology is currently a trending topic however, like many other specialities, it is one that has significantly contributed to climate change because of the high energy consumption and waste generation for some time (2).

Why does ophthalmology have a high waste output?

Ophthalmology services receive a high volume of patients and in a document published by the Royal College of Ophthalmologists, it highlights, this specialty was the highest volume specialty resulting in 8.1% hospital outpatient visits nationally in 2018-2019 (3). Carbon emissions released when travelling to and from clinics and follow-up appointments, excess equipment in surgical packs, incorrectly disposed items also lead to high waste output. Within ophthalmology, there are numerous ‘single-use’ protocols required which ensure patient safety by avoiding cross-contamination, such as endophthalmitis (4).

How is the sky affecting the eye?

Climate change has a direct threat towards exacerbating many ocular pathologies, including but not limited to increasing the risk of severe allergic eye disease, dry eye conditions, glaucoma, accelerating the occurrence of cataracts because of increased UV exposure (3).

Extreme temperatures and weather events can result in the ocular surface being impacted, leading to an increased occurrence of conditions such as (5):

• Conjunctivitis
• Keratitis
• Dry eye disease

An increase incidence of ocular pathologies induced by climate change will not only negatively impact patients’ wellbeing, but will also increase attendance to eye-services, impacting service delivery and system burden (3).

How can we improve sustainability within ophthalmology?

The Royal College of Ophthalmologists highlight it is possible to tackle climate change using “sustainable, scalable and transferrable” interventions using the 5 Rs of sustainability (see Figure 1) (6).

Two principles which can be implemented nationally to encourage sustainable practice published by the college include (6):

1) “Reduce surgical waste”

• Consider requirement of patient and clinician drapes and gowns and materials of such items, choosing reusable clothing, equipment and multi-use droppers where appropriate is more sustainable
• Separate and dispose of medical and non-medical waste accurately to ensure recyclable materials are not sent to landfill

2) “Efficient models of care” – reducing energy and transport emissions

• Utilise appropriate methods of communicating with patients to reduce travel for patients and clinicians
• This may include telephone consultations, patient-initiated follow-up appointments

The ophthalmology department within Leeds Teaching Hospital Trust are utilising the Delphi method to “reduce carbon footprint of cataract surgery” and have found it to be an effective system to promote departmental engagement in ‘sustainable’ practices.  Some of the practices the LTHT team considered included (7):

• Asking manufacturers to reduce packaging
• Improve sorting of waste e.g. boxes into flatpacks
• Utilising paper or no aprons instead of plastic where appropriate

The team combined the most appropriate practices into an “eco-pack” intervention with suppliers, resulting in 675kg of waste and 350kg of CO2 equivalent being saved per annum.

Continued research needs to be dedicated to eco-sustainability within ophthalmology, Lee et al has found numerous areas areas where interventions could be adopted to improve sustainability which could be explored (8):

• Multidose eyedrops
• Adjusting Surgical packs
• Making package inserts available electronically
• Reusing surgical instruments

The road to reducing climate change is a long one, however, within our own departments, it is possible to improve sustainability. It requires multidisciplinary team engagement, innovation and adherence to better practice resulting in improving the quality of life and care for our patients, our environment and ourselves.

References

1. NHS England. 2022.  Home > Greener NHS > National Ambition. [Online] [DOA 15.01.25]. Available from: https://www.england.nhs.uk/greenernhs/national-ambition/
2. Leeuwen VR, Elferink S. 2022. Ophthalmology and the climate crisis: Time to take responsibility.  Ophthalmology Times Europe. [Online]. 18 (02) [DOA 15.01.25]. Available from: https://europe.ophthalmologytimes.com/view/ophthalmology-and-the-climate-crisis-time-to-take-responsibility
3. The Royal College of Ophthalmologists. Climate change and eye health. [Online]. 2024. [DOA: 15.01.25] Available from: https://www.rcophth.ac.uk/wp-content/uploads/2024/07/Climate-change-and-eye-health.pdf
4. Mensah-Hutton YE (American Academy of Ophthalmology). 2023. Sustainability in Ophthalmology: Network for Impact. [Online]. [DOA 15.01.25]. Available from:  https://www.aao.org/young-ophthalmologists/yo-info/article/sustainability-in-ophthalmology
5. Wong Y, Wong S, Ting SJD, Muralidhar A, Sen S, Schaff O, Istre-Wilz H, Erny B. 2024. Impacts of climate change on ocular health: A scoping review. The Journal of Climate Change and Health. [Online]. 15 (100296). [DOA 15.01.25]. Available from: https://www.sciencedirect.com/science/article/pii/S2667278223000950
6. The Royal College of Ophthalmologists. Sustainable Practice in Ophthalmology: General Principles and Decarbonisation Strategies. [Online]. 2024. [DOA 15.01.25].  Available from: https://www.rcophth.ac.uk/wp-content/uploads/2024/07/Sustainable-Practice-in-Ophthalmology_-General-Principles-and-Decarbonisation-Strategies.pdf
7. Malcom J, Dodd A, Shaikh M, Cassels-Brown A, Buchan JC. 2023. Reducing the carbon footprint of cataract surgery: co-creating solutions with a departmental Delphi process. Eye. [Online]. [DOA: 15.01.25]. Available from:  https://www.nature.com/articles/s41433-023-02902-4
8. Lee G, Matteo M, Williams BK, Nicola MD. 2024. Eco-sustainability in ophthalmology. Curr Opin Ophthalmol. [Online]. 1;35 (5): 403-408. [DOA 15.01.25]. Available from: https://pubmed.ncbi.nlm.nih.gov/38923880/