The Environmental Sustainability of Oculoplastics and Reconstructive Surgery

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Article initiated by:

Sruti Rachapudi MD MBA, Lucy Mudie MD MPH

All contributors:

George Villatoro, Lacey Echalier, Leslie Neems, Kendall.Goodyear, Michael T Yen, MD, Sruti Rachapudi MD MBA, Lucy Mudie MD MPH

Assigned editor:

Michael T Yen, MD

Review:

Assigned status Up to Date

 by Michael T Yen, MD on July 31, 2025.

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Contributing Editors:	add

Original authors: Rachapudi S, Mudie LI, Villatoro G, Echalier LE, Neems LC, Goodyear K, Yen MT

Introduction

Due to the sheer volume of cataract surgeries performed every year, the consequential environmental burden has been well-documented. Oculoplastics is another high-volume, procedural subspeciality in ophthalmology, however, there have been sparse efforts to date to reduce waste and increase sustainability in oculoplastic surgery. Thus, there is unexplored potential for waste reduction in many oculoplastics procedures, such as blepharoplasty, entropion/ectropion repair, temporal artery biopsy, chalazion/hordeolum excision, tarsorrhaphy, and eyelid lesion excision.

Materials Waste

Cotton tips and gauze

The American Academy of Ophthalmology’s (AAO) recent Green Grant Program spurred several sustainability projects within oculoplastics, including a quality improvement study that conducted waste audits on over 100+ clinic procedures and operating room procedures. The most commonly observed procedures were eyelid lesion excisions, blepharoplasty/ptosis repairs, and botulinum toxin/filler injections. Gauze squares and cotton tip applicators were identified as the key targets for items that were opened but often unused and discarded. After meeting with clinical staff and surgical technologists to discuss these findings and address balancing pre-procedure preparation and limiting wasted disposable items, the decision was made to standardize pre-procedure setup in both the clinic and OR with fewer pre-opened cotton tips and gauze. These interventions significantly reduced waste, cutting unused cotton tips from 12 to 3 per procedure and gauze squares from 10 to 3 per procedure (unpublished). These findings underscore that small changes in supply management, such as tailoring pre-packaged items to procedural needs, can efficiently reduce waste without compromising preparedness.

Draping

A majority of landfill waste generated by oculoplastics procedures come from plastics, particularly nonwoven polypropylene. In one waste audit study of one office-based operating room blepharoplasty and one ambulatory surgery center (ASC) operating room (OR) blepharoplasty, the nonwoven polypropylene comprised 45% of office-based OR waste and 47% of ASC-based waste. Nonwoven polypropylene is often a single-use material in medical settings, contributing significantly to landfill waste. This plastic is commonly used in drapes. Therefore, reducing oculoplastic reliance on plastics can significantly decrease procedural environmental impact.

This study by Hu et al. noted that the ASC used a standardized surgical pack that was not specific for blepharoplasty, and was also used for more invasive ophthalmic and otolaryngologic surgeries- therefore, many excess materials and their associated plastic packaging were opened yet unused such as “table  covers, full-body drapes, gowns, gloves, sponges, cotton swabs, light handle covers, [and] plastic containers.” This study further highlighted the environmental impact through a life cycle analysis, which revealed that disposable supplies was a significant contributor. On average, each blepharoplasty generated 784 grams of physical waste at office-based ORs and 1323 grams at ASCs, corresponding to 6.42 kg of CO2 emitted and 7.78 kg of CO2 respectively. The reduction of single-use plastics and adopting reusable alternatives instead has significant potential for improved waste management practices and decreased landfill contributions from oculoplastics.

Initiatives in Oculoplastics

American Academy of Ophthalmology Green Grant

The American Academy of Ophthalmology (AAO) has demonstrated a strong commitment to enhancing sustainability within the field of ophthalmology. In 2023, the AAO initiated a task force on sustainability, which was further strengthened in 2024, by the Committee on Sustainability which focuses on education, advocacy, and collaboration with organizations like Eyesustain to promote environmentally responsible practices. To encourage innovation among young ophthalmologists, the AAO has sponsored “green grants” which support projects that have a significant impact on sustainability and the reduction of carbon footprint in ophthalmology. This grant has spurred many oculoplastic-specific projects, and has inspired others to pursue sustainable project ideas within oculoplastics. 

For the inaugural round Green Grant recipients in 2024, two projects focused on oculoplastics: 1) "Reducing Waste in Oculoplastics Procedures", and 2) "No Drape DCR".

Reducing Waste in Oculoplastics Procedures

This study identified key targets for items that were opened but often unused and discarded during common oculoplastic procedures. Meetings with stakeholders were held and standardized pre-procedure setups were created in both the clinic and OR with fewer pre-opened cotton tips and gauze. These interventions significantly reduced waste, particularly reduced unncessary usage of disposable single-use items.

No Drape DCR

This study investigated the use of a clean technique for endoscopic dacryocystorhinostomy (DCR), eliminating traditional sterile draping and gowning. Since endoscopic DCR is a clean-contaminated procedure performed entirely in the nasal cavity, it is inherently not sterile. In ENT practice, it is common to forgo prepping and/or fully draping these surgeries, and research on office-based endoscopic sinus procedures has shown that non-sterile techniques do not increase infection risk or worsen outcomes. By adopting this sustainable practice of forgoing unnecessary drapes, surgical waste may be reduced while also reducing operating room time and healthcare costs, without compromising patient safety.

Survey of American Society of Ophthalmic Plastic and Reconstructive Surgery

Upcoming

Current Regulatory Challenges

Electronic Instructions for Use (e-IFUs)

Most ophthalmic surgical supplies, including intraocular lenses (IOLS), botulinum toxins, and other devices, come with printed instructions for use (IFUs). These are often bulky and contribute significantly to waste, especially given the high volume of ophthalmic surgeries performed and botulinum toxin injections. These informational leaflets are also often in multiple languages, which is redundant as they are rarely, if ever, read by experienced practioners. Instead, many efforts within ophthalmology, particularly for cataract surgeries, have been made to advocate for the transition to electronic instructions for use (e-IFUs). Both the European Union Medical Device Regulation (MDR) and the U.S. Food and Drug Administration (FDA) allow for the use of e-IFUs, although the MDR does have certain restrictions for items such as machines, because they are not implants or permanently installed systems.  

In 2021, a European trade association for medical technology and devices surveyed over 800 participants of healthcare professionals and hospital administrators from 23 different countries regarding e-IFUs. 88% of healthcare professionals and 90% of hospital administrators preferred eIFUs notably due to ease of access and waste reduction. There is also currently no literature suggesting that e-IFUs are a safety threat to patient care. In fact, many argue that e-IFUs could be more safe due to the ease and speed of updating safety information electronically. Therefore, all ophthalmic devices, whether medical devices or surgical products and systems, should be allowed to have e-IFUs by regulatory bodies. An ongoing issue to widespread global adoption of e-IFUs is that many low and middle income countries do not have regulatory body approval of e-IFUs, unlike the FDA and MDR in America and Europe respectively.

Multi-use medications

Sending medications home with patients

A 2019 study in Illinois surveyed 73 ophthalmologists and revealed that only 40% of OR medications were allowed to be taken home, even if the medications were ordered by an on-site pharmacy. This study also surveyed ophthalmologists to identify barriers for patients taking home medications, and the most commonly cited reasons were hospital and state protocols not allowing OR drops to be dispensed as inpatient, and pharmacies not able to attach patient instruction labels for anti-inflammatory and antibiotic eyedrops. This is area for further advocacy for oculofacial plastic surgeons.

Conclusion

Oculofacial plastic and reconstructive surgeons have multiple opportunities to contribute to sustainability in ophthalmology. From communicating with clinic assistants and surgical technologists to avoid pre-emptitve over-opening of single-use supplies, to limited-area draping or no-draping for DCRs, landfill waste created by our subspecialty can be reduced. Of course, sustainability is more than just reducing landfill waste, to be sustainable we must also advocate for manufacturing processes that priortize products with longevity and enivronmentally responsible materials, as well as being efficeint with energy and water use. Through advocacy efforts, increased awareness and changing attitudes, its hoped our subspeciality can reduce its environmental impact across all stages.