Bouncing back better

One lesson to be learned from the COVID-19 pandemic is that ophthalmologists should be doing more to look after our planet

Sorcha Ni Dhubhghaill

Posted: Monday, February 1, 2021


Unless you’re in some particularly lone-wolf line of work (ski jumping maybe?) working with colleagues is an essential skill in any professional workplace. For us doctors, there’s even more to it as working with/for/under others is an integral part of our training.

It might seem almost predatory, but I think it’s common for young doctors to see their colleagues through training-tinted glasses: “What do I get out of this relationship?” for them means: “what can I learn from this person?”

As we get further along in our careers, that balance shifts as we more and more start to hand down what we’ve learned to more junior colleagues, and learn to relish the occasions we can work with colleagues who we are junior to. Everything is relative after all.

Recently I’ve been thinking that when we think about ‘what can I learn here?’ we’re perhaps a bit too focused on the medical side of things, when there are plenty of extra-curricular activities that our colleagues are engaged in and that can be thought-provoking too.

That thought came to me when working with one of my clinical fellows who, apart from an excellent doctor and colleague, is also — for lack of a better word — a bit of a tree hugger.

When she is not befriending the chickens that roam the hospital grounds (some of the lesser-mentioned benefits of a campus on the outskirts of the city), she reminds me that we should be doing more to look after our planet.

And she’s right, we should be. We all know this, but not all of us have this so ingrained that it’s front and centre in our attention span.

Cataract surgery is the most commonly performed surgery world-wide. Or at least it was until the pandemic led most of us to substantially cut down our clinical activities. In the face of an uncertain global pandemic, cataract surgery was not a high priority but at the world begins to adjust and heal we can look forward to getting back on track. One thing that we have noticed during the pandemic is how quickly the waste accumulates and while PPE is undoubtedly necessary, we can see the mountains of non-biodegradable trash that it generates. Our impact on the environment as a profession is already higher than you might think — the healthcare sector was responsible for 10% of total greenhouse gases and 9% of air pollutants in the US before the pandemic hit.

In the early phase of the COVID-19 pandemic, the lockdowns led to a reduction in the emissions from transportation. Air quality improved in China, India and Italy and the US Energy Information Administration predicted a reduction of 11.5% in emissions. We even saw images in the media of “nature healing”, as animals were seen wandering empty city streets. The chickens near our hospital had the run of the place. Unfortunately, these changes are almost certainly going to be temporary and the massive amounts of medical and hazardous waste generated by the healthcare industry will mitigate these environmental benefits.

Last year David Chang, in his keynote address at the ESCRS virtual meeting, said that one of the five lessons he wanted to share was about sustainability in cataract surgery and how we should look to India as a model. In 2017 Thiel and colleagues compared the waste and emissions generated by cataract surgery in two clinical centres in India to that produced in the United Kingdom and found that they generated only 5% of their carbon footprint but had similar clinical results.

So as European ophthalmologists, where can we make improvements? In the Aravind Eye Care System (AECS), great care is taken to resterilise and reuse as much material as possible. Many of use reuse surgical instruments but they reused gowns and gloves (after disinfecting of course), phacoemulsification tips, tubing and even blades. This sounds a bit bizarre to us but after data from more than two million cataract patients they could see that postoperative infections were even less common than in the United States.

I can’t really see reusing my surgical blades being received very well. I recently asked if I could use a bottle of balanced salt solution, that I had used less than a third of it, for a second patient. This was the irrigating fluid, connected to flow one-way to the phaco machine that had not had any direct contact with the patient. The first response I received was a questioning – why? We have plenty of fluid. This was followed by a comment that our hospital infection control would surely disimprove. In fact, when surveyed most cataract surgeons and nurses reported that much of the surgical waste was due to rigid regulation imposed by administrations as well as fear of product liability. This is a form of “defensive” medicine that can lead us to adopting disposable instruments when the evidence does not show that they are any safer their reusable counterparts.

As we start to get back to work, most of us will likely have quite a backlog of patients to treat. Maybe we can start looking more critically at each piece of plastic that ends up in the bin and see if perhaps we can be a bit more like the AECS. I don’t see my hospital approving reusing blades any time soon but I will keep fighting to stem the tide of disposable instruments taking over my surgical table. And I won’t be lazy and use the disposable plastic cups in the coffee room any more either – there are plenty of cups and a dishwasher. It’s only a small effort, and if nothing else, it keeps my fellow happy.

El Hamichi, S., Gold, A., Murray, T.G. et al. Pandemics, climate change, and the eye. Graefes Arch Clin Exp Ophthalmol (2020)

Chang DF. Needless waste and the sustainability of cataract surgery. Ophthalmology (2020)

Thiel, Cassandra et al Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility, Journal of Cataract & Refractive Surgery (2017)

Sorcha Ní Dhubhghaill is Professor of Anterior Segment Surgery at Antwerp University Hospital (UZA) and a Consultant Surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS)

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