From the Editor-in-Chief

Photo courtesy of Kevin Caldwell Photography.

To stand quietly in a northern forest in early spring, surrounded by melting snow, fallen trees, downed leaves, clinging mud, and courageous green shoots, is to witness a display of nature in balance. Everything has its place, from the salamanders and termites hiding under the leaves to the mushrooms and lichens relishing the moist earth and wood, all linked in a continuous cycle of decomposition and renewal.

This idyllic impression is often shattered, however, by a crushed beer can or plastic bottle on the trail, or by a garish, logo-labeled plastic bag snagged in the low branches of a tree. These intruders are also active in nature’s cycles now, but not as orderly participants; they demand their own terms.

The massive pine tree you clamber over on your hike will fully disappear and its components efficiently repurposed in no more than 100 years. However, the beer can might be around for 80 to 200 years, and various plastics may endure for 10 years to a millennium! Duration is just one part of the problem; although the aluminum in cans can be efficiently reclaimed, plastics typically break into simply smaller fragments of plastic, obstinate in their refusal to participate in sustainable global cycles.

Awareness of the substantial hidden costs in many human activities and commonly used products—ozone layer shrinkage from chlorofluorocarbon refrigerants (Freons), growing gyres of swirling plastic fragments in the oceans, and increasing carbon dioxide in the atmosphere—has sharpened thanks to our ever-growing ability to observe and detect disruptions in the global environment. Citizens in many industrialized countries now carry reusable shopping bags to the grocery store and dutifully separate and recycle their brown, green, and clear glass from plastics and corrugated cardboard.

Every day, we generate unimaginable quantities of trash and waste, and only a third of municipal solid waste is recycled or composted. Medical waste has exploded in the past year because of the understandable need for personal protective equipment (PPE) during the coronavirus disease 2019 (COVID-19) pandemic. For example, the common surgical mask is made with polypropylene mesh, and calculations suggest that trillions of these nearly impossible-to-recycle items will be added to the world’s landfills over the course of the pandemic.

The present issue of JVRD contains a unique study by Thomas Cameron, Loi Vo, Lily Emerson, Dr M. Vaughn Emerson, and Dr Geoffrey Emerson in which the medical waste associated with 337 consecutive intravitreal injections (IVIs) performed by a single retina specialist over a 2-week period was preserved, photographed, weighed, and categorized. These injections produced a total of 65.6 kg of waste, with shipping and packing waste by far the largest category at approximately 83%.

Nonhazardous waste (gloves, tissues, etc) was next at approximately 15%, and hazardous waste (syringes and needles) accounted for a little more than 1%. The authors discovered that the medical waste due to IVIs is most substantial. In addition to bringing attention to problematic shipping elements such as foam coolers, the authors explore the potential recyclability of various items, their environment impact, and carbon costs of IVIs.

This issue also contains several articles on endophthalmitis in various settings, a frightening case of bilateral central retinal artery occlusion in association with endocarditis, a thoughtful cost-and-outcomes analysis of treatment strategies for polypoidal choroidal vasculopathy, a contemporary reassessment of vitrectomy for visually significant vitreous floaters, extended follow-up and results for patients receiving aflibercept for radiation retinopathy, and many more scholarly contributions for your education and enjoyment.

IVI has rapidly become the most performed ophthalmic procedure and one of the most common in medicine overall. Estimates suggest more than 7 million are performed in the United States alone each year, ¹ lagging only such giants as vaccination and venipuncture but zooming past our former headliner of cataract extraction (approximately 4 million per year). Any reduction in medical waste generation from IVIs would be enormous and beneficial, but the issues are complex.

Remarkably, data regarding which elements (gloves, drapes, specula, etc) are essential for safe IVI performance are still surprisingly limited despite the vast numbers available for study. For perspective on just one aspect of the complexity, let’s take a closer look at glove use. (Note several caveats: First, I am speaking personally, not for the American Society of Retina Specialists; second, this analysis has a US physician perspective, because physicians in many other countries perform IVIs in an operating room with full sterile gear; and third, we are amid a pandemic with many overriding PPE practices and regulations.)

The rationale for glove use during IVIs includes consideration as well as some presumptions regarding their efficacy as a protection for the patient (endophthalmitis/disease transmission from the physician’s hands) and for the physician (disease transmission from the patient).

With regard to preventing disease acquisition by the physician, it is interesting to note that the Centers for Disease Control and Prevention (CDC), citing the regulations of the governmental agency regulating vaccinations (Occupational Safety and Health Administration or OSHA), does not require gloves for routine vaccinations but stresses the importance of hand washing in addition to hand sanitizer before and after each injection. ²

Gloves for vaccination are indicated only if there is “reasonable anticipation of employee hand contact with blood, other potentially infectious material, or mucous membranes.” While this certainly could be understood to include contact with patient tears during IVI, additional CDC guidance on blood-borne pathogen transmission indicates contact with low-risk fluids such as tears does not require reporting or special follow-up unless the fluid is visibly contaminated with blood. ³

We clearly have no data to quantify the presumably negligible risk of disease transmission to a physician during IVI, and certainly not to one who has applied hand sanitizer immediately before and after the procedure.

As for patient protection from endophthalmitis and disease acquired from the physician’s hands, it is interesting to recall that the US Food and Drug Administration labels both for Lucentis ⁴ and Eylea ⁵ specify the use of sterile gloves and a sterile drape (along with a sterile speculum!) for IVI. Yet a recent survey of 281 US retina specialists ⁶ found only 73% of physicians use any type of gloves, and one may extrapolate from earlier surveys that most select nonsterile disposables. (Drapes—of any type—are even more disdained; the same survey found only 7% of US physicians use them.)

Indeed, it is telling that this large, well-performed survey did not include glove sterility as a data point, and (pre-COVID) there is no mention of hand sanitizers at all. The CDC has identified the prioritization of gloves over hand hygiene during medical procedures as a substantial problem and misperception by providers.

One sobering study found that a box of nonsterile gloves becomes increasingly contaminated after being opened and accessed over several days. ⁷ Again, we have no data to assess the relative patient protection during IVI provided by nonsterile gloves or a sanitized hand. One could use both, but this dual option adds millions of gloves to the environment in the United States alone.

Additional complexities rapidly appear: What will patients think of the lack of glove use, and what about hospital and other regulations? And is there a risk of liability if an infection occurs and gloves were not used?

Solving the massive problem of medical waste in a responsible way will not be easy, and clearly everyone involved—including manufacturers, shippers, and providers— will need to contribute. The shared solution will begin with awareness, then data, then understanding the benefits and costs in their widest context.

Let’s be thankful to these authors for taking a first look at the medical waste generated by one of medicine’s most common procedures and highlighting a problem that retina specialists can play an important role in solving. It’s not going to be a walk in the park, but we can draw our resolve from a walk in the woods.

Donald J. D’Amico, MD
Editor-in-Chief
Journal of VitreoRetinal Diseases