EyeSustain is a global coalition of eye societies, organizations, and ophthalmologists collaborating to make ophthalmic care and surgery more sustainable

Introducing EyeSustain – What and Why?

In this video from the 40th Congress of ESCRS in 2022 in Milan, David Chang, MD, delivers a keynote lecture titled “Reducing Cost and Environmental Impact of our Highest Volume Procedure.” He discusses why we should care about cataract surgery’s carbon footprint - with guidance from the WHO, the Lancet, the Royal College of Surgeons, and other organizations. He mentions literature from the Aravind Eye Hospital, which has an astoundingly low endophthalmitis rate and carbon footprint of cataract surgery and compares these to statistics in the United States. He also describes a recent survey of cataract surgeons’ and nurses’ attitudes toward ophthalmology operating room waste, which demonstrates that 95% of individuals feel that the status quo is not adequate from an environmental and economic sense. He also mentions the impact of realities like general surgery’s rules being applied to ophthalmology and items like lengthy manufacturer instructions for use manuals increasing the size and weight of intraocular lens packaging. The talk also contains a tour of the EyeSustain website.

Who Can Take the Pledge?

Whether you operate at an ambulatory surgery center (ASC) or a hospital outpatient department (HOPD), have your surgical facility or department take the EyeSustain Pledge, which applies only to ophthalmic surgical cases. The pledge should be filled out by one designated representative per facility (e.g., administrator, nursing or medical director, head ophthalmic nurse, or head of the ophthalmology department). Be the ophthalmologist or nurse who champions sustainability to your operating room leadership and becomes the catalyst for change.

The Surgical Facility Pledge

We agree to promote sustainability of quality eye surgery through education and collaboration. To reduce unnecessary ophthalmic surgical waste, we specifically pledge to:

1. Educate surgeons and surgical staff about sustainability and the impact of O.R. waste

The ophthalmic nursing and surgeon staff can watch Dr. Chang’s 15-minute video presentation at “Introducing EyeSustain”. Along with his 2023 JCRS editorial, this video discusses the impact of, and ways to reduce ophthalmic surgical waste. It also provides a quick tour of the EyeSustain website.

Surveys on North American and European ophthalmologists’ and ophthalmic nurses’ attitudes regarding surgical waste can be downloaded and distributed.

Consider appointing a sustainability leader for ophthalmic ORs (e.g., MD or RN leader)

2. Regularly re-evaluate surgical pack standardization to minimize waste

Many standardized packs contain items that are frequently not used, and which could be separately opened when needed.

Surgeons should consult and collaborate with the nursing staff to update their custom packs on a regular basis.

Consider performing a 2-week challenge, by tracking which items in surgical packs go consistently unused over a 2-week interval. Surgeons can then evaluate whether these unused items can be packaged separately and opened only when necessary.

3. Use multidose bottles of topical medication and betadine on multiple patients when possible

Needless waste of ophthalmic surgical topical medication has a significant financial and environmental impact.

Four major American societies have endorsed and released a 2022 position statement supporting the use of multidose bottles of ophthalmic drugs on multiple patients until the bottle expiration date.

The statement also encourages allowing patients to take home a bottle of partially used medication, if appropriate, that was specifically opened for them.

Supporting resources and information are available in a section on reducing surgical drug waste on the EyeSustain website.

4. Assess the necessity for patient gowns and full body draping

In two surveys of ophthalmologists 47% of European surgeons and 44% of North American surgeons had eliminated full body draping (using only a face drape). Another 41% (European) or 51% (North American) would consider eliminating the full body drape.

50% of European surgeons and 56% of North American surgeons did not have patients change into gowns (wearing their own clothing instead). Another 27% (European) or 34% (North American) were willing to eliminate having patients change into hospital gowns for cataract surgery.

A registry-based retrospective study published in the BJO found no difference in endophthalmitis rates when patients were changed into hospital gowns, compared to wearing their own clothing into the operating room.

In many regions, large plastic eye drapes may be backordered, so this transition may take time to implement.

5. Regularly reassess options for reusable versus single-use products and instrumentation

In both the ESCRS and North American surveys, 8-10 times as many surgeons preferred reusable instruments over disposable instruments of equal cost.

Examples of reusable options include reusable metal or diamond blades, reusable phaco tips, etc.

6. Assess feasibility of alcohol-based surgical scrub for pre-surgical antisepsis

Alcohol-based surgical scrub is recommended for presurgical antisepsis by leading health organizations. One study modeled significant savings in cost, water, and scrub time by converting from water-based to waterless scrub techniques for ophthalmic surgery.

7. Institute or update recycling strategies


1. Chang DF. Tackling the challenge of needless surgical waste in ophthalmology. Editorial. J Cataract Refract Surg 2023; 49:333-338.

2. Chang DF, Thiel CL: Ophthalmic Instrument Cleaning and Sterilization Task Force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste. J Cataract Refract Surg 2020; 46:933-940

3. Chang DF, Elferink S, Nuijts RMMA. Survey report: survey of ESCRS members’ attitudes toward operating room waste. J Cataract Refract Surg 2023; 49: 3341-347.

4. Tauber J, Chinwuba I, Kleyn D, Rothschild M, Kahn J, Thiel CL. Quantification of the cost and potential environmental effects of unused pharmaceutical products in cataract surgery. JAMA Ophthalmol 2019;137: 1156–1163.

5. Berkowitz ST, Finn A, Sternberg P Jr, Patel S. Potential Cost Savings Associated with a Multiuse Preoperative and Preinjection Eyedrop Protocol. Ophthalmology. 2022;129:1305-1312.

6. Palmer DJ, Robin AL, McCabe CM, Chang DF. Reducing topical drug waste in ophthalmic surgery: multisociety position paper. J Cataract Refract Surg 2022;48:1073–1077.

7. Haripriya A, Ravindran RD, Robin AL, Shukla AG, Chang DF. Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery. Br J Ophthalmol 2022; doi: https://doi.org/10.1136/bjophthalmol-2021-320506. Epub ahead of print.

8. Javitt MJ, Grossman A, Grajewski A, Javitt JC. Association Between Eliminating Water from Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost. JAMA Ophthalmol. 2020;138:382-386.