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70 | EYEWORLD | SUMMER 2025 G UCOMA References (continued) 11. Nikita E, et al. Expansion of patient eligibility for virtual glaucoma clinics: a long-term strategy to increase the capacity of high-quality glaucoma care. Br J Ophthalmol. 2023;107:43–48. 12. Mercer R, Alaghband P. The value of virtual glaucoma clinics: a review. Eye (Lond). 2024;38:1840–1844. 13. Prea SM, et al. Uptake, persistence, and performance of weekly home monitoring of visual field in a large cohort of patients with glaucoma. Am J Ophthalmol. 2021;223:286–295. 14. Alawa KA, et al. Low-cost, smartphone-based frequency doubling technology visual field testing using a head-mount- ed display. Br J Ophthalmol. 2021;105:440–444. 15. Tsapakis S, et al. Home-based visual field test for glaucoma screening comparison with Humphrey perimeter. Clin Oph- thalmol. 2018;12:2597–2606. 16. Mudie LI, et al. The Icare HOME (TA022) Study: per- formance of an intraocular pressure measuring device for self-tonometry by glaucoma patients. Ophthalmology. 2016;123:1675–1684. Relevant disclosures Goldburg: None Li: None Qiu: None Robin: None Schehlein: None Shukla: None Contact Goldburg: samantha.goldburg@gmail.com Li: lucysfmatch@gmail.com Qiu: mary.qiu@gmail.com Robin: arobin@glaucomaexpert.com Schehlein: emschehlein@gmail.com Shukla: ag2965@cumc.columbia.edu in the U.S., and this rate is expected to grow 72% by the year 2036. 9 Procurement of pharmaceuticals is a large contributor to overall surgical emissions, and several glaucoma surgeries require the use of pharmaceuticals, such as MMC or 5-FU. Dispos- al of pharmaceuticals additionally contributes to the carbon footprint, as it requires incinera- tion, which releases greenhouse gases, leading to trapped heat and contributing to global warming. Single use of large eye drop bottles similarly contributes significantly to waste in the operating room setting. Another area where Dr. Robin sees waste is having an anesthesiologist for every surgery. Most patients are cooperative, healthy, and have minimal risks of systemic adverse events. Addi- tionally, there are risks to over sedating patients. Almost all patients who are healthy don't neces- sarily require an anesthesiologist, he said. Dr. Robin also noted water use during ophthalmological surgery as an area that could be improved. "I think all of us have learned to use scrubs that are based on water and either betadine or chlorhexidine before we start the day and in between all cases; a lot of glaucoma surgeons can do 10–15 cases, if not more, a day." He noted that alcohol-based scrubs, which are chlorhexidine alcohol, betadine scrubs are less wasteful of natural resources. He added that in many parts of the countries like Califor- nia and Arizona, there is a shortage of water. CDC guidelines say that you can use either alco- hol-based scrubs or water, and he suggested that an emphasis in training would help implement this in more areas. More sustainable practices in the OR and clinic To be able to implement new practices focused on sustainability, Dr. Robin said this would require data, adding that we need to reexamine the whole system. We need to figure out which steps are actually needed and eliminate unnec- essary steps. To implement change, Dr. Robin said it will be important to involve industry as well. You need to balance profit and the need for change, and many companies have been supportive so far. Drs. Goldburg, Li, Shukla, Qiu, and Sche- hlein said that in patients with open angle glaucoma, there is often a discussion regarding whether the patient should start treatment with drops or selective laser trabeculoplasty (SLT). Laser procedures may be a more sus- tainable way to treat glaucoma patients than alternative options. The energy used for SLT has been found to be negligible in terms of carbon emissions. Moreover, bilateral laser procedures should be performed, when possible, to de- crease the amount of patient transportation. "In the clinic, reusable tonometry tips and gonio- prisms should be used and disinfected properly rather than single-use items. Our goal should be to properly disinfect multiuse items to prevent patient infection while reducing the carbon footprint of our practice." Procedures such as suture gonioscopy-as- sisted transluminal trabeculotomy and bent ab interno needle goniectomy may be preferable to other MIGS from a carbon footprint standpoint, as they use readily available equipment in the OR and avoid waste from excessively large packaging and procurement of new devices. "In addition, autologous patch grafts such as scleral lamellar grafts or autologous capsular patch grafts may be considered to avoid the use of pre-made grafts that come in large, wasteful packages and require separate procurement," they said. Drs. Goldburg, Li, Shukla, Qiu, and Sche- hlein noted that early intervention in glaucoma may help to lessen the carbon footprint of care because it may decrease the number of follow- up visits associated with perioperative care if the patient were to require a surgery such as a trabeculectomy. "One strategy to help address sustainability in the care of glaucoma patients is to incorpo- rate more telehealth into our practice," they said. "Several studies have shown high adher- ence rates and patient satisfaction associated with virtual glaucoma appointments. 10,11 Virtual visits are most successful when done by glau- coma specialists and if moderate-to-severe or unstable glaucoma patients are excluded." 12 They also noted that there are a few visual field devices that can be used at home, including exams on a tablet, 13 a head mounted display, 14 a PC monitor, or virtual reality glasses. 15 There are also tonometers that patients can use at home, including the iCare HOME2; patients' IOP readings have been shown to correlate well with Goldmann applanation. 16 continued from page 69

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