Eyeworld

EW RESIDENTS 60 November 2017 by Sam Reiter, MD, Meron Haile, MD, Jayson Koppinger, MD, Ann Thomas, MD, Poorav Patel, MD, Maria Govorkova, MD, Jonathan Hernandez, MD, Michael Ang, MD operating rooms does not result in inferior outcomes for their patients. The authors analyzed input from all involved departments, such as lists of the materials used in sur- gery, their prices, quantities, estimat- ed lifespans and disposal routes, as well as information on sterilization processes and the hospital's over- all use of water and electricity. By matching the collected materials, energy, and water use data with Ecoinvent, an international emis- sions database, they performed a life cycle assessment (LCA) to quantify the environmental impact of each surgery. Emissions were character- ized and combined using the LCIA method (TRACI), the tool used by the US Environmental Protection Agency, 4 to standardize results with ongoing studies in the U.S. The authors report a small carbon footprint of 5.89 kg CO 2 per case on average, an impressive reduction from 130 kg CO 2 per case described in a similar U.K. study. 5 This difference is more staggering when CO 2 equivalents from each W e live in an era of rap- idly growing interest and investment in the sustainability of our transportation, hous- ing, and food as the human influ- ence on climate change has become an undeniable fact. 1 For the oph- thalmologist, one rarely explored area of environmental impact is the operating room. To give context to the issue, U.S. healthcare facili- ties are responsible for 10% of the country's greenhouse gas emissions and are the second leading contrib- utor of waste, producing more than 4 billion pounds of waste annually. Seventy percent of the waste stems from operating rooms and labor and delivery. 2,3 Many of us have a difficult time conceptualizing the environmental impact of each cataract surgery. In this article, we review a novel man- uscript by Thiel et al. that outlines a rigorous, systematic approach to reducing environmental emissions from cataract surgeries. Performed at two centers of the Aravind Eye Care System in southern India, the study also demonstrates that limiting the amount of waste generated by their case are converted into standard driving distance: 14.3 miles per Aravind case compared to 310 miles in the U.K. study. A vast majority of Aravind's emissions in nearly all categories is due to electricity used for sterilization of reusable mate- rials and, to a lesser extent, power air conditioning, lighting, and equipment. By decreasing surgery duration and OR turnaround time, they are able to perform more cases per day, and thus resources like electricity and reusable materials can be more optimally utilized. The authors note that since completion of the study, they have installed solar voltaic panels at Pondicherry to help mitigate electricity cost and emissions. Remarkably, each Aravind case generates only 250 g of waste production, two-thirds of which is recycled. This figure is kept low by reusing equipment for multiple cases, including caps, masks, gowns, phaco wiring and tools, and stainless steel instruments. If Aravind were to dispose of all equipment after each case, this would result in greenhouse gas emissions equivalent to 40 cases in the current Aravind model that embraces reuse of materials. In the U.S., surgeons and patients would likely raise concerns if supplies (such as the phaco fluid collection bag or the plastic protectors on the phaco machines) were not exchanged be- tween cases. It is therefore important to emphasize that complication rates including endophthalmitis (1/2942, 0.03%) were quite low and in line with previous Aravind studies. 6 Careful review of the paper re- veals areas for further reductions in emissions. Nearly half of Aravind's waste per case is comprised of the plastic face drape and IOL packag- ing. With the proper infrastructure, these products could be replaced with biodegradable materials with lower carbon footprints. Another notable contributor to each surgery's ozone depletion and cost is cotton gauze, used for drying and cleaning the ocular surface. Transitioning from traditionally grown gauze to either organically grown cotton or Reducing environmental impact of cataract Kasra Eliasieh, MD, program director, California Pacific Medical Center The trend toward using more and more disposable instruments and supplies for cataract surgery has some negative consequences in addition to cost. I asked the California Pacific Medi cal Center residents to review this article on the phaco carbon footprint in the November JCRS issue. —David F. Chang, MD, EyeWorld journal club editor California Pacific Medical Center residents and program director. Back row: Sam Reiter, MD, Poorav Patel, MD, Michael Ang, MD, Jonathan Hernandez, MD, Matthew Denny, MD, Kasra Eliasieh, MD. Front row: Maria Govorkova, MD, Meron Haile, MD, Ann Thomas, MD Source: California Pacific Medical Center EyeWorld journal club

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