The environmental and economic burden of surgical waste in ophthalmology operating rooms

Introduction

The last few years have brought about significant discussion regarding excessive and often needless surgical waste in ophthalmology. This was mainly amplified by the COVID-19 pandemic which led to thousands of tons of biomedical waste per day in the United States, India, and Brazil [1]. Previously seen as a necessity, in order to reduce the spread infection, now appears like a luxurious waste with an obscene amount of plastic packaging, instructions for use, and single use topical medications discarded during cataract surgeries. While this has been a topic of continued discussion, with over 90% of ophthalmologists in agreement that surgical waste is often excessive and unnecessary [2], there has yet to be any significant, systemic change in ophthalmology operating rooms. Our institution, Rutgers New Jersey Medical School, shows no exception to this result, often producing excessive surgical waste.

Surgical waste in ophthalmology operating rooms

The accumulation of surgical waste occurs quickly during a busy operating day, often reaching capacity before the surgical day has concluded (Fig. 1A). This waste includes mainly surgical drapes, tape, wrapping, encasing and packaging of disposable and non disposable equipment and instruments (Fig. 1B). In addition, a large amount of syringes, empty intraocular lens cartridges and boxes, needles and cannula wrappings, empty needle boxes, and single-use bottles and ointments for topical drug administration among others are disposed of (Fig. 1C). Marking pens, one example of a possibly obvious reusable surgical tool, is discarded after one mark is made. Certain types of gonioscopy lenses used in the operating room are disposed of after a single use, even though reusable lenses have been used previously and have shown no difference in deleterious outcomes when compared to disposable lenses [3].

Fig. 1. Surgical Waste in Ophthalmology Operating Rooms.

Surgical waste accumulating at the end of a routine surgical day (A). Surgical drapes (B) and other equipment including syringes, empty needle cartridges, single-use bottles and ointments (C) are often discarded after brief use as well.

Lack of change

As mentioned earlier, a majority of ophthalmic surgeons and surgical staff are in agreement that waste in operating rooms is excessive. Yet, many academic and private institutions have done little to make any significant change to the carbon footprint of ophthalmology. One possible detractor from making meaningful change in ophthalmology operating rooms is legal/professional liability. Endophthalmitis, among other infections, places significant pressure on institutions to mitigate risk by adopting an all-encompassing “one and done” policy on medications, instruments, and other operative tools to ultimately avoid medicolegal costs. Some of these policies may not be fully supported by existing medical literature [4].

The current practice puts ophthalmic surgeons in a difficult position in which they must balance compliance with policy and mitigating risk of infection with excessive surgical waste due to the precautionary practice of medicine. However, in other parts of the world, surgical waste in ophthalmology operating rooms is far less and often is associated with fewer post-operative complications. For example, the average waste produced per trabeculectomy in an eye care facility in Southern India was shown to be significantly less when compared to a hospital in Baltimore, Maryland (0.4 ± 0.2 kg vs. 1.4 ± 0.4 kg per trabeculectomy, p < 0.05) [5]. Furthermore, post-operative endophthalmitis rates were also compared showing a lower infection rate in the Indian hospital (0.27%) when compared to a U.S. hospital (1.1%) during the same study period.

Given this evidence, the discussion regarding surgical waste in ophthalmology operating rooms should be revisited. We provide several recommendations below that institutions and surgeons should consider in order to reduce their surgical waste burden.

Recommendations

Waste audits

In order to determine what waste can be reusable, recycled, or disposed of, there must be consensus amongst physicians, surgical staff, policy makers, and manufacturers. The American Academy of Ophthalmology (AAO) has already provided examples of reusable topical drugs with specific recommendations to avoid disposal after one time use [6]. Official, published recommendations should also be given to other surgical waste that should be recycled or even reused, such as instruments, marking pens, syringes, needle boxes, drapes, tape, wrapping, encasing and packaging amongst many more.

Local rather than national initiative for change

Even with the support of national organizations in ophthalmology, substantive change in ophthalmology practice is still lacking. The majority of institutions develop their own regulations based off their needs. Therefore, change is easier to implement on an institution-by-institution basis with the support of national organizations. Introducing new regulations (and new mentality) to curb excessive waste production, and institute policy on reusable and recyclable waste has to occur if we are to address the burden of surgical waste. Monitoring for post-operative or intra-operative complications will ensure the initial success of these changes while keeping patient safety at the heart of this initiative.

Residency education and reinforcement

Ophthalmology residents have the opportunity to engage in surgical education with experienced, board-certified attending surgeons. Resident surgeons have been shown to produce over 50% more clinical waste when compared to attending surgeons [7]. Therefore, emphasis on recognition and mitigation of wasteful practice, and the need for surgical waste reduction and reusability of certain medical equipment should be reinforced early on during residency training.

The need for further research

The development of new surgical techniques, tools and equipment requires a continuation of new research on the reusability and reduction of waste. This may occur at the manufacturer level, producing reusable medical equipment to supply to ophthalmology operating rooms. However, further research also needs to occur at the national, local, and institutional levels in order to monitor the environmental burden of surgical waste and to confirm the success of any newly imposed regulations.

Author contributions

ASK was responsible for study design. MO was responsible for literature review and drafting the report. Both ASK and MO edited and finalized the manuscript for publication.

Competing interests

Disclosures for ASK: Grant support: Allergan, NJ Health Foundation, Consultant: Glaukos, Bausch & Lomb, Speaker Bureau: Allergan, Bausch & Lomb. No conflicting relationship exists for the remaining authors.