Eyeworld

20 | EYEWORLD | SEPTEMBER 2023 ASCRS NEWS Discussion Winklmair et al. provided an analysis of cataract surgical packages in three Austrian hospitals to highlight the wide variability of packages and elucidate potential best practices to address greenhouse emissions from cataract surgery. The authors proposed an "Austrian standard cataract package" based on the lightest third of packages by weight and found that ubiquitous adoption of these standards may reduce CO 2 emissions significantly by 34% in Austria. In a country with approximately 94,000 cases per year, this amounts to 134,586 kg CO 2 equiva- lents according to their analysis. If this were applied to the U.S., where cataract surgeries amount to approximately 3.7 million cases per year (40x higher), 9 the impact would be powerful. However, standardization of surgical packages may be more achievable in Austria where health policy is dictated by the European Medical Devices Directive. This recommen- dation may be difficult to achieve in a larger economy like that of the U.S. where healthcare regulations fall under the purview of both feder- al and state regulations. While there are three suppliers that represent more than 94% of pack- age sales in Austria, the diversity and number of manufacturers in the U.S. and worldwide is likely much greater. Thus, differences in the leg- islative landscape and economic scale may limit the generalizability of the present study. This study highlights the need for similar analysis in the U.S. and other large global economies to calculated for each product type, then multi- plied by sales figures from the three primary cataract package suppliers in Austria, which comprise 94% of the package sales in Austria. Because this study solely looked at cataract packages, factors such as electricity use, patient transportation, postoperative care, surgical gloves, phaco cassettes, individually packaged single-use surgical instruments, and viscoelas- tic device were not considered. The study also sent a survey on surgery waste disposal to every Austrian hospital and practice that performed cataract surgery; 25 sites participated and ac- counted for 77% of cataract surgeries in Austria. Results A total of 55 different cataract package com- positions were evaluated. The average weight of materials within cataract packages across three hospitals was 0.74 kg (range 0.5 kg to 1.2 kg), corresponding to 2.3 kg CO 2 eq per pack- age. On average, the product category "drapes and covers" accounted for 52% of weight per cataract package (0.4 kg), followed by "surgi- cal gowns" (0.2 kg) at 30%, "packaging" (0.1 kg), and the "other" category (0.04 kg), which included cannulas, syringes, and postoperative eye covers. Total package weight varied by up to 57%, and weights of drapes and gowns varied by 80% when comparing between the small- est and largest packages. Approximately 40% (0.3 kg) of cataract package materials were composed of fleece, and 50% (0.37 kg) were composed of plastics. Significant variation in both the quantity (counts between 2 and 9) and overall size of "drapes and covers" were appre- ciated. Measured sizing of various drape covers and gowns varied by 66% to 99% between different packages. When comparing the effects of waste disposal on the GWP, the authors found that CO 2 emission could be reduced by 13,576 eq or 6.5% assuming a 100% recycling rate over a 100% waste incineration rate (195,804 kg CO 2 eq with recycling compared to 209,380 kg CO 2 eq with incineration). In the survey on mate- rial management, approximately 20% of eye departments reported a lack of appropriate recy- cling containers in cataract operating rooms, and 52% reported separating operating waste. Of the departments that have proper recycling of surgical waste, 76% also reported separating paper from plastic waste. continued from page 18 References 1. Eckelman MJ, Sherman JD. Estimated global disease burden from US health care sector greenhouse gas emissions. Am J Public Health. 2018;108:S120– S122. 2. Eckelman MJ, et al. Life cycle environmental emissions and health damages from the Canadian healthcare system: an economic-environmental-epide- miological analysis. PLoS Med. 2018;15:e1002623. 3. Malik A, et al. The carbon footprint of Australian health care. Lancet Planet Health. 2018;2:e27–e35. 4. Nansai K, et al. Carbon footprint of Japanese health care services from 2011 to 2015. Resour Conserv Recycl. 2020;152:104525. 5. Bourne RRA, et al. Causes of vision loss worldwide, 1990–2010: a systematic analysis. Lancet Glob Health. 2013;1:e339–e349. 6. Morris DS, et al. The carbon footprint of cataract surgery. Eye (Lond). 2013;27:495–501. 7. Fontaras G, Samaras Z. On the way to 130 g CO2/km—estimat- ing the future characteristics of the average European passenger car. Energy Policy. 2010;38:1826– 1833. 8. Thiel CL, et al. Cataract surgery and environmental sus- tainability: waste and lifecycle assessment of phacoemulsifi- cation at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391–1398. 9. Rossi T, et al. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmol. 2021;6:e000464. continued on page 22 This study highlights the need for similar analysis in the U.S. and other large global economies to determine the impact of cataract surgical packages on the global carbon emissions.

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