Government and non-profit organizations have warned about the role the health-care system plays in climate change. In 2020, the U.S. health-care system attributed to 8.5 percent of greenhouse gas emissions nationally, rising approximately 6 percent between 2010 and 2018.¹ This was and continues to be impacted by hospital care, physician and clinical services and prescription drug usage in America.¹ A large contingent of physicians and companies are calling for sustainability efforts to be enacted to ensure the health and well-being of patients, especially in ophthalmology. Here, we’ll look at the shape these efforts are taking.

Ophthalmology’s Impact

Surgical procedures and treatments in ophthalmology require the use of multiple instruments, drugs and other surgical materials that ultimately contribute to the carbon footprint of a physician’s clinic. Due to differing surgical demands around the world, the carbon footprints of ophthalmology clinics will vary.

“When we think about ophthalmology, our most commonly performed surgical procedure is cataract surgery,” says Emily Schehlein, MD, an ophthalmologist at Brighton Vision Center in Michigan. “Carbon footprint is the emissions associated with the full life cycle of a product or event like, for example, cataract surgery, measured in carbon dioxide equivalents. There’s a great study that has been done that actually measured the carbon footprint of cataract surgery and compared India to the United Kingdom.² 

“In India, the carbon footprint was 6 kg CO₂ equivalents as compared to over 180 in the United Kingdom. What this equals is over 1.16 million kg CO₂ equivalents each year in the U.K., or 250,000 cars driven for one year. This is a really significant amount of waste. So, it’s really a responsibility of ophthalmology as an industry and surgeons to take steps to ensure that our surgeries and our clinics are more sustainable locally, and then of course nationally and globally as well.”

Surgical interventions and other treatments lead to biohazardous waste, which, when not properly disposed of, can impact the environment negatively. “Hazardous materials are regulated by state and federal law, such that they have to be disposed of in a careful manner and removed from the practice by a licensed company,” explains Todd Sack, MD, the executive director of My Green Doctor Foundation. “Hazardous materials can be minimized by putting them in a distinct bag and distinct disposal container and not putting non-hazardous stuff in those bags, because they’re very expensive to dispose of.”

What Dr. Sack pointed out about putting non-hazardous materials into the disposal bags is the issue that’s contributing greatly to waste buildup in clinics. Dr. Schehlein further explains, “This is a complex issue, but the most important part of managing biohazardous waste is properly segregating the waste. It’s believed that almost 90 percent of red bag, or hazardous waste, doesn’t meet the criteria for ‘hazardous waste.’ This may be in part due to lack of recycling bins, or bins placed in inaccessible locations.³ Much of the excessive waste in ophthalmology is from a mindset of single-use and a lack of awareness of where our waste goes and what’s being thrown away.”

“But it’s not the hazardous materials that physicians and nurses need to be so concerned about, because we’re going to have hazardous materials, and we can’t decrease those,” says Dr. Sack. “There’s going to be some materials that have blood and other secretions on them. It’s through the non-hazardous materials that we can minimize the waste by reusing them.”

“Across all ophthalmology, there’s many packing designs for materials and drugs that we could change to reduce waste,” says Dr. Schehlein. One concern in health care is the use of paper Instructions for Use and materials used for shipping and handling. “Intravitreal injections come with a paper IFU. They come with significant drug packaging for individual doses, the need for transportation, and the need for climate-controlled storage and disposal.”

Download the EyeSustain app for free from the Apple or Google Play stores to learn more about how to manage and improve ophthalmic sustainability. Simply create an account and stay informed on the latest news in sustainability. Photo: EyeSustain.

EyeSustain (a coalition of organizations working to make ophthalmic care more sustainable), the American Academy of Ophthalmology, the American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgery published a position paper on reducing ophthalmic surgical waste by implementing electronic IFUs.⁴ They conducted a survey to assess the pharmaceutical industry’s views on eliminating paper IFUs. A total of 32 manufacturers replied to the survey, with 95 percent of them agreeing that switching to electronic IFUs would be an acceptable alternative. However, only 30 percent of these manufacturers had made the effort to implement electronic methods. 

This joint paper led to the proposition from the AAO to pass the Prescription Information Modernization Act (H.R. 1503). This is a bipartisan legislation that would allow the U.S. Food and Drug Administration to propose a rule that would allow pharmaceutical companies the opportunity to transmit prescribing information electronically, instead of printing out the instructions, which is currently required. Physicians who want to support the act can visit the AAO’s website and fill out a form which will send a letter to their U.S. Representative.

Electronic IFUs may be a drop in the bucket for sustainability in ophthalmology, but other packaging designs are tougher to change. “Any packaging around a surgical product has to be validated for its ability to withstand mechanical trauma, temperature trauma and a variety of external factors that could compromise the product inside,” says John Hovanesian, MD, an ophthalmologist at Harvard Eye Associates in Laguna Hills, California.  “And if a package is changed, the manufacturer has to go through a lengthy validation process on any new packaging that really is a disincentive from streamlining packaging. And there are standards not just imposed by the FDA, but by groups like ISO, the International Standards Organization, or ANSI, the American National Standards Institute, that are imposed on manufacturers for validation of these packages. And so, for us to ask them to or for them to initiate downsizing of packaging is much more complicated than most of us know.” 

Industry Initiatives

Pharmaceutical companies have been putting in effort towards sustainability by implementing green initiatives and helping physicians and patients reduce, reuse and recycle. Here are how various companies are making an impact:

• Alcon. “Alcon has an organized effort toward what they call a ‘Greenest’ movement in the company, where for every new product that’s designed, one of the elements in consideration is environmental impact,” says Dr. Hovanesian. “And they’ve incorporated a lot of things to reduce packaging. They’ve moved to more sustainable packaging like a green cell foam that they’re using in some of their products.”

Alcon has been pushing for sustainability in ophthalmology with their Global Environmental Sustainability Strategy. This strategy focuses on sustainable products and services, energy efficiency and greenhouse gas reduction, operational waste and water stewardship.

According to Alcon’s 2023 Social Impact and Sustainability Report, they were able to continue their efforts towards reusing, recycling or donating medical equipment and reduce their greenhouse gas emissions. In 2021, Alcon was able to reuse, recycle or donate 108 kg of equipment. This continued through 2022 and 2023, with a total of 102 kg of equipment reused, recycled or donated last year alone. Additionally, their greenhouse gas emissions reduced from 309,083 kg CO₂ equivalents in 2021 to 233,482 kg CO₂ equivalents in 2023.

A part of Alcon’s sustainability strategy is to reduce 100 percent of non-hazardous waste generated at manufacturing sites by 2030. They were able to divert 95.9 percent of annual waste from landfills in 2023 and were able to reduce the amount of waste generated by approximately 956 kg.

Water is crucial for a sustainable environment and Alcon has implemented several projects to save on water. Last year, 12 projects were implemented globally, which led to Alcon saving over 110 megaliters of water. Their projects also focused on installing new water treatment systems and decommissioning old product lines for health-care facilities.

• Bausch + Lomb. “Bausch + Lomb, in the contact lens space, has put together a recycling program,” says Dr. Hovanesian. “So, both the packaging and the actual contact lenses themselves can be recycled.” Sustainability impact reports aside, Bausch + Lomb has created an initiative that both physicians and their patients can get involved with.

The Biotrue Eye Care Recycling program allows patients and physicians a way to recycle drop-bottle packaging and contact lens cases. Bausch + Lomb teamed up with TerraCycle, an industry leader in all things recyclable, to develop their program. TerraCycle works with businesses, government entities and individuals around the world to ensure proper recycling practices are being employed. Users of the service can recycle products at a TerraCycle recycling center or ship them to a TerraCycle facility where it can be processed properly rather than being wasted. 

As a part of the Biotrue Eye Care Recycling program, patients can go to the program’s website to get a step-by-step tutorial on how to recycle contact lens products. First, separate the products that can be traditionally recycled and the products that should be recycled with TerraCycle. For example, Biotrue Hydration Boost lubricant eye drops come in a plastic eye drop bottle with a plastic cap that’s placed into a cardboard box. The cardboard box can be traditionally recycled, while Bausch + Lomb’s bottle and cap are too small and must be sent to a TerraCycle facility. Also, single-use eye droppers and contact lens cases that come in the Biotrue packaging can be recycled with TerraCycle. Fortunately, this program isn’t limited to Bausch + Lomb’s products and they’ve opened it up to allow any brand’s packaging to be recycled.

The next step in the Biotrue Eye Care Recycling program is to create a TerraCycle account, which is free to do. After a patient creates an account, they can collect their recyclable items, place them into a recyclable box, and print out a shipping label on TerraCycle’s website to send the package to a recycling facility. 

The One by One Recycling program is another partnering program with TerraCycle, except only contact lenses and blister packs are accepted. Similar to the Biotrue Eye Care Recycling program, the One by One Recycling program allows for patients to recycle any brand’s packaging, so the program isn’t limited to Bausch + Lomb’s products. 

Although patients will need to create a TerraCycle account to recycle with the Biotrue Eye Care Recycling program, they won’t need to use it to recycle products with the One by One Recycling program. Instead, patients can visit the TerraCycle website, search for the One by One Recycling program and then plug in their location to find the nearest public TerraCycle facility. Here’s where physicians can get involved.

Ophthalmologists can play their part by adding a TerraCycle public drop-off point at their clinic. By doing so, this’ll allow for more accessible recycling options for patients willing to participate in the One by One Recycling program. Simply create an account with TerraCycle, request to join the One by One Recycling program, await for TerraCycle to review the request and then start recycling. According to their website, the address for the approved public drop-off point will appear on the TerraCycle public map. Once the location is set, patients can discard contact lenses and blister packs at the public drop-off. The last step is to take the recycled products and ship them to a TerraCycle facility, just like the Biotrue Eye Care Recycling program requires users to do.

• AbbVie. As a part of their sustainability efforts, AbbVie has created seven environmental targets that they outlined in their 2023 Environmental, Social and Governance Report. The first target is to reduce greenhouse gas emissions by 42 percent by 2030 from the baseline percentage of emissions recorded in 2021. As of 2023, they have reduced 26.4 percent of their emissions. The next target is to actively bring renewable electricity throughout the company to 100 percent by 2030 from 29.5 percent in 2021. In 2023, they increased their renewable electricity usage to 55.5 percent.

Additionally, AbbVie hopes to work with environmentally friendly suppliers for their products. One target that they aim to achieve is to increase the percentage of suppliers who produce emissions that are regulated by the Science Based Targets initiative, a corporate climate action organization who works with global companies and institutions to assist them in combating climate issues. AbbVie is working towards increasing climate-friendly supplier relationships to 79.1 percent by 2027. In 2023, AbbVie suppliers associated with the Science Based Targets initiative increased to 41.6 percent.

In 2025, AbbVie hopes to reduce their absolute water withdrawal and absolute total hazardous and non-hazardous waste generated during manufacturing by 20 percent compared to waste accumulated in 2015. They more than achieved their target of reducing hazardous and non-hazardous waste by achieving a 29 percent waste reduction in 2023. Furthermore, they are currently closing in on their goal for reducing water waste. In 2023, they reduced their absolute water withdrawal by 17 percent.

To continue their efforts into 2025, AbbVie is focusing on achieving and maintaining a combined recycling rate of 50 percent for hazardous and non-hazardous materials. As of 2023, they’ve increased their efforts by 40 percent. The final target in AbbVie’s plan is to achieve complete zero waste to landfill by 2035. This excludes leased office buildings. In 2023, they were able to achieve a 92-percent increase in their efforts towards their goal.

• Glaukos. “Glaukos has a strong internal team that’s very focused on sustainability through their products and packaging,” says Dr. Hovanesian. Currently, Glaukos is working towards establishing standard design guidelines for their latest facilities in order to evaluate energy efficiency and other environmental impacts. Along with this environmental effort, they’re also working towards maintaining ISO 14001 Certification, a voluntary standard on environmental management that organizations can certify to, for two of their business and manufacturing facilities.

In 2023, Glaukos established two new product distribution centers in which they were able to reduce costs and shipping travel. They were able to eliminate approximately 6.4 million miles of air travel, which led to an estimated 1,286-ton reduction in carbon emissions. 

In a company statement, Glaukos mentioned that they’re engineering biodegradable packaging solutions for preexisting products and are hoping to reduce waste even further by converting from paper IFUs to electronic IFUs.

• Johnson & Johnson. “Johnson & Johnson has reduced packaging around many of their commonly used surgical products,” says Dr. Hovanesian. Since Johnson & Johnson manufactures products for various medical specialties, their sustainable packaging efforts were focused on recyclable packaging for suture kits and self-injectable devices last year. However, according to their 2023 Health and Humanity Report, they’ve continued to transition to electronic IFUs for eligible J&J MedTech products.

To further product sustainability, J&J MedTech implemented a hospital recycling program for single-use medical devices. This program allows for physicians to recycle specific metal and plastic components from certain J&J MedTech instruments. For physicians who sign up for the program, Johnson & Johnson sends them the appropriate bin or collection option for the instruments being recycled. Additionally, they’ll work with hospital staff to ensure that they’re trained on how to properly recycle, handle and transport J&J MedTech instruments. According to the company, this program has diverted approximately 281,000 lbs. of waste from landfills and reduced CO₂ emissions by 171,000 lbs.

• Zeiss. In 2015, the United Nations Climate Change Conference established the Paris Agreement, a set of long-term goals to guide nations to adapt to the impacts of climate change. Now, Zeiss is attempting to achieve similar goals towards environmental sustainability by trying to be carbon neutral by 2025. They’ve created their own step-by-step process on how they intend to achieve the targets set by the Agreement.

According to the UN, the Paris Agreement set three goals: (1) Reduce global greenhouse gas emissions in order to hold the global temperature below 2°C in an attempt to reach a limited baseline temperature of 1.5°C; (2) Reassess the Agreement to ensure all goals are being met; and (3) Provide financial support to struggling and developing nations to assist in climate change.

Zeiss plans to implement more renewable energy resources, use natural resources in their products, maintain clean supply chains, offset their emissions and more all in an attempt to meet the Agreement’s standards. Since they hope to be carbon neutral by 2025, they have put in relative effort to reduce CO₂ emissions. They’ve noted online that they’ve successfully reduced 72 percent of CO₂ emissions compared to the 2018/2019 fiscal year.

• Sight Sciences. This year, Sight Sciences released their first Sustainability Report. Their report covered sustainability efforts from 2021 to 2023. In the report, they covered how they’ve transitioned to electronic IFUs for permitted medical products. Since beginning this initiative, they’ve saved approximately 2,000 lbs. of paper waste. Furthermore, they continued to reduce their environmental impact by consolidating shipments. Rather than shipping products weekly using air travel, they added monthly and bimonthly sea freight shipments. Due to the scope of their business, Sight Sciences noted in their report that they believe their overall environmental impact was small.

Sustainability in Practices

Pharmaceutical companies aren’t the only eye-care entities making an environmentally sustainable impact. Physicians are playing their part as well.

“For surgeons who wish to reduce their environmental impact in their surgical practice, they can go to the EyeSustain website and take the EyeSustain pledge,” says Dr. Hovanesian. EyeSustain is sponsored by ASCRS, ESCRS and the AAO. Dr. Hovanesian explains that the EyeSustain pledge is a great step-by-step guide to help begin a sustainability initiative for hospitals and institutions. 

“One of the examples [from the pledge] is to take a look at what’s in our surgical packs and evaluate whether all the products that are available are really used for the vast majority of surgeries or whether they’re rare items that don’t get used very often that get opened and thrown away,” mentions Dr. Hovanesian. “Another example is the size of the surgical drape. There are facilities and there are centers where it’s just a matter of their practice to fully drape the patient from head-to-toe for surgery. That’s not necessary for cataract surgery. It’s been shown in many cases that you can use a very small, short drape that adequately covers the area needed for sterility without compromising anything further. And you’re throwing a lot less material out when you do that.

The NanoDropper adaptor consists of a tip, base and cap. It’s shipped to the patient pre-sterilized, so it can’t be used for more than one medication. Additionally, the tip can get clogged which results in a loss of eye drop solution. Ensure that the eye dropper is properly stored in an upright position and expel the air from the dropper before each use to avoid clogging. Photo: NanoDropper.

“Another step is to evaluate reusable instruments as opposed to disposable instruments,” continues Dr. Hovanesian. “There are elements of our surgical pack that sometimes can be reused, like diamond blades instead of metal blades that are disposable with every case. Diamatrix makes reusable blades that are metal that can be used for a number of cases. Every time we reuse and sterilize, we reduce our [environmental] impact.”

Patients may want to put in their own effort towards sustainable eye care. Physicians can encourage their patients to recycle products, especially through the TerraCycle program, and assist them on reducing waste. For instance, patients can purchase a NanoDropper to reduce wasting eye drop solution. 

“The NanoDropper is an adapter that goes on top of the patient’s eye drop bottle,” explains Dr. Schehlein. “What it does is it reduces the eye-drop volume dispensed each time by about 62 percent.⁵ So, this will allow the bottle life to be increased by almost three times. The company hopes that this will help to reduce the carbon footprint associated with prescription medications. But also, when you look at the material that the NanoDropper adapter is made with, it’s made with #2 HDPE plastics, which can be recycled normally with other clean plastics.”

While the NanoDropper and TerraCycle program are ways in which patients can get involved with eye-care sustainability, they should try to focus their attention on their ocular disease and treatment regimen. “We as physicians have the responsibility to care for the whole patient,” says Dr. Schehlein. “They should focus on getting better. Individual sustainability and waste reduction is important for sure, but I think that physicians and medicine as a whole have more of an impact on climate change. It’s our responsibility to care for the patient in this space versus them contributing.”

Dr. Hovanesian is a consultant for Alcon, AbbVie, Bausch + Lomb and Johnson & Johnson. Dr. Sack and Schehlein have no financial interests to disclose.

^{1. How the U.S. health care system contributes to climate change. The Commonwealth Fund. https://www.commonwealthfund.org/publications/explainer/2022/apr/how-us-health-care-system-contributes-climate-change. Accessed June 11, 2024.}

^{2. Taboun OS, Orr S, Pereira A, et al. Factors contributing to the carbon footprint of cataract surgery. JCRS 2023;49:7:759-763.}

^{3. Kwakye G, Brat GA, Makary MA. Green surgical practices for health care. Archives of  Surgery 2011;146:2:131-136.}

^{4. Schehlein EM, Hovanesian J, Shukla AG, et al. Reducing ophthalmic surgical waste through electronic instructions for use: A multisociety position paper. JCRS 2024;50:3:197-200.}

^{5. St. Peter DM, Steger JS, Patnaik JL, et al. Reduction of eyedrop volume for topical ophthalmic medications with the NanoDropper bottle adaptor. Med Devices (Aukl) 2023;16:71-79.}