Sustainability

SUSTAINABLE OCULOPLASTIC SURGERY

Introduction

Cataract surgery is very standardised, as a rule. Each step is very predictable, and the surgeon knows the outcome of every step of the pathway. Outcomes are excellent, and complication rates are minimal (1, 2). Because the operation is standardized to a high degree, Life Cycle Analysis is straightforward. The NHS is committed to a net zero healthcare delivery (14), and oculoplastics has to contribute.

In contrast to cataract surgery, oculoplastic surgery is more diverse, with more procedures available for a particular clinical problem.
Entropion surgery, for example, has many different types of operations to solve the problem. (3, 4, 5, 6) as is ptosis surgery, anterior approach, posterior approach, white line advancement, Muller resection techniques (7, 8, 9).
Whereas there is a paucity of evidence at this point, in relation to the carbon footprint of oculoplastic care, there are some general principles that would help us reducing the carbon footprint in oculoplastics.
Despite various procedures being available for a particular problem, there are some general principles that would help us reducing the carbon footprint in oculoplastics.

Telemedicine

The main advantage in using remote consultations is in travel: both patient and healthcare professional do not need to travel. It can be done by phone or video consultation, and in doing so, reducing carbon emissions. (10, 11, 12, 13)

Areas of use:

• Diagnosis (lumps, entropion, ectropion, ptosis, dermatochalasis)
• Results of investigations (scans, histology)
• Post op
• Follow up

Place of surgery

Air handling systems account for more than 90% of the theatre’s energy use (15). Oculoplastic surgery does not require this level of sterility. Clean rooms are an appropriate place for oculoplastic surgery, and do not require an implant standard of sterility.

Instruments sets and material

• Refuse single use instruments
• Standardise sets
• Use a little sutures as possible
• Consider dissolvable sutures so that post op removal is not required, and virtual follow up is possible
• Use re-usable gowns instead of once-only use gowns (16)
• Markers: do they need to be plastic and single use, or can wooden markers be used, dipped in dye
• Masks are not required in all procedures, only in procedures where facial exposure to blood is expected.

Prophylactic antibiotic use

Great variation exists in use of post operative use of systemic antibiotics. Regular post operative use ranges from 2.9% (UK) to 86.7% (India). There can be no justification for such variation, and one has to ask if this prophylaxis is actually effective. (17)
Hunt followed this up with a study into the use of topical antibiotics following eyelid surgery. The authors found no statistically significant difference in patients treated with or without post operative topical chloramphenicol. (18)
There is therefore evidence that using the standard chloramphenicol ointment post op is not required.

1. The Royal College of Ophthalmologists national ophthalmology database study of cataract surgery: report 1, visual outcomes and complications. Day, AC et al. Eye 2015 (29), 552-560.
2. https://nodaudit.org.uk/data-and-reports/cataract-audit/adjusted-case-mix-surgeonspcr-funnel-plot
3. Transcanthal canthopexy for involutional lower eyelid entropion corrects horizontal laxity. Kono S, Kamei M . J Ophthalmol 2024 feb 13, 2024: 4694296.
4. Horizontal eyelid shortening alone versus combined procedures for the correction of involutional lower eyelid entropion. Auguste AL, Nghiem AZ, Vahdani K . Int Ophthalmol 2023 dec; 43(12):4979-4983
5. Anterior versus posterior retractor reinsertion with a lateral tarsal strip for involutional entropion repair: a multicentric experience. Mateos-Olivares et al. Eur J Ophthalmol. 2023 July; 33(4) 1733-1739
6. Success of nurse-led everting sutures for involutional entropion. Mohammed BR, Ford R . Eye 2017 (31): 732-735.
7. Outcomes for severe aponeurotic ptosis using posterior approach white-line advancement ptosis surgery Antus Z, Salam A, Horvath E, Malhotra R . Eye 2017 (32): 81-86
8. Open sky Muller’s muscle-conjunctiva resection for ptosis surgery Lake S, Mohammad-Ali FH, Khooshabeh R . Eye 2003 (17): 1008-1012.
9. Minimal incision posterior approach levator plication for aponeurotic ptosis. Ng S, Chan E, Ko ST. Eye 2015 (29): 483-491
10. Effectiveness of a telemedicine program for triage and diagnosis of emergent ophthalmic conditions. Eye 2022 (37): 325-331. Meshkin RS, Armstrong GW, Hall NE, Rossin EJ, Hymowitz Lorch A.
11. Assessing the carbon footprint of telemedicine: a systematic review. Casper van der Zee, Jennifer Chang-Wolf, Marc A Koopmanschap, Redmer van Leeuwen Robert L Wisse. Health Services Insights 2024 (17), 1-8.
12. Oculoplastic video-based telemedicine consultations: covid 19 and beyond. Eye 2020 (34) 1193-1195. Kang S, Thomas P, Sim D, Parker R, Daniel C, Uddin J.
13. Introducing the ‘Benign eyelid lesion pathway‘: 1 year experience of synchronous tele-oculoplastics in a tertiary hospital. Ah-Kye L, Butt A, Gupta A, Timlin H, Daniel C, Uddin J, Thomas P, Sim D, Ezra D, Kang S. Eye 2022 (37): 1458-1463.
    The carbon footprint of cataract surgery in Wellington. N Z Med J 2021 (134): 13-21. Latta M, Shaw C, Gale J.
14. Delivering a “Net Zero” National Health Service page 24. https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2022/07/B1728-delivering-a-net-zero-nhs-july-2022.pdf
15. The carbon footprint of the operating room related to infection prevention measures: a scoping review. Bolten A, Kringos DS, Spijkerman IJB, Sperna Weiland NH. J Hosp Infect 2022 (128): 64-73
16. A life cycle assessment of reusable and disposable surgical caps. Donahue L et al. Healthcare delivery, quality, and safety. 2024 (299), 112-119.
17. Multinational comparison of prophylactic antibiotic use for eyelid surgery. JAMA Ophthalmology 2015 (133): 778-784. Fay A, Nallasamy N, Bernardini F, Wladis EJ Durand ML, Devoto MH.
18. Bringing eyelid surgery in line with international guidelines regarding peri-operative antibiotic agents: a pilot study. Surg Infect 2022. 23(9): 834-840. Hunt S, Garrott H, Ford R.

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