Abstract
Purpose
To report the contribution to carbon dioxide equivalent mass [CO2EM] of various types of VR surgery performed across three tertiary referral centres, according to their indication and fluorinated gas used. We secondarily reported on the difference in tamponade choice, and CO2EM between the different centres.
Materials
Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital and Birmingham and Midland Eye Centre, and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire.
Results
Across 4877 procedures, the use of fluorinated gases produced 284.2 tonnes (71.2 tonnes annually) CO2EM; an annual consumption of 30,330 l of gasoline. Rhegmatogenous-retinal-detachment (RRD) and macular hole repair had the highest CO2EM by indication, accounting for 191.4 tonnes CO2EM (67.3%) and 28.6 tonnes CO2EM (10.1%); a mean 60.0 kg and 32.0 kg of CO2EM produced per surgery respectively. The use of fluorinated gases and their respective CO2EM contributions were significantly different across all three centres (p < 0.001) for all indications. SF6, despite being used in 1883 procedures (38.6%), contributed to 195.5 tonnes CO2EM (68.8%). Relative to C2F6, procedures using C3F8 and SF6 produced 1.9 and 4.4 times more CO2EM.
Conclusion
We demonstrated that SF6 causes significantly higher carbon emissions relative to C2F6 and C3F8 with RRD and macular hole repair having the greatest environmental impact. We also reported large variations between different large VR centres in fluorinated gas use, and therefore in carbon emission contributions depending on indications for surgery. Evidence-based protocols might help in making VR surgery “greener”.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
Data availability
The raw data are available upon reasonable request
References
IPCC. IPCC Fourth Assessment Report (AR4), Working Group 1. Chapter 2, Changes in atmospheric constituents and in radiative forcing. Intergovernmental Panel on Climate Change (IPCC); 2007.
IPCC. Climate change 1995: The IPCC Second Assessment Report. Intergovernmental Panel on Climate Change (IPCC);1995.
Moussa G, Ch’ng SW, Park DY, Ziaei H, Jalil A, Patton N, et al. Environmental effect of fluorinated gases in vitreoretinal surgery: a multicenter study of 4,877 patients. Am J Ophthalmol. 2021. http://www.ajo.com/article/S0002939421004773/fulltext.
UNFCCC. What is the Kyoto Protocol? United Nations Climate Change. 2020. https://unfccc.int/kyoto_protocol. Accessed 5 January 2022.
England N NHS becomes the world’s first national health system to commit to become ‘carbon net zero’, backed by clear deliverables and milestones. 2020. https://www.england.nhs.uk/2020/10/nhs-becomes-the-worlds-national-health-system-to-commit-to-become-carbon-net-zero-backed-by-clear-deliverables-and-milestones/.
Moussa G, Ch’ng SW, Park DY, Ziaei H, Jalil A, Patton N, et al. Environmental effect of fluorinated gases in vitreoretinal surgery: a multicenter study of 4,877 patients. American Journal of Ophthalmology. 2021.
IPCC. Climate change 2014: synthesis report. Contribution of Working Groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. IPCC; 2014.
EPA - United States Environmental Protection Agency. Greenhouse Gas Equivalencies Calculator. 2021. https://www.epa.gov/energy/greenhouse-gas-equivalencies-calculator. Accessed 21 February 2021.
Kıraç FS. Is ethics approval necessary for all trials? A clear but not certain process. Malecular Imaging Radionucl Ther. 2013;22:73–75.
Health Research Authority. Do I need NHS Ethics approval? http://www.hra-decisiontools.org.uk/ethics/. Accessed 29 May 2021.
Moussa G, Kalogeropoulos D, Ch’ng SW, Lett KS, Mitra A, Tyagi AK, et al. The effect of supervision and out-of-hours surgery on the outcomes of primary macula-on retinal detachments operated by vitreoretinal fellows: a review of 435 surgeries. Ophthalmologica. 2021. https://pubmed.ncbi.nlm.nih.gov/34818241/.
Moussa G, Kalogeropoulos D, Ch’ng SW, Lett KS, Mitra A, Tyagi AK. et al. Effect of deprivation and ethnicity on primary macula-on retinal detachment repair success rate and clinical outcomes: a study of 568 patients Khetan V (ed). PLoS One. 2021;16:e0259714. https://pubmed.ncbi.nlm.nih.gov/34752493/.
Moussa G, Mathews N, Makhzoum O, Park DY. Vitrectomy with air tamponade and cryotherapy for retinal detachment repair without perfluorocarbon use: a UK 12-month prospective case series. Eur J Ophthalmol. 2020. http://journals.sagepub.com/doi/10.1177/1120672120978884.
Tan HS, Lesnik Oberstein SY, Mura M, Bijl HM. Air versus gas tamponade in retinal detachment surgery. Br J Ophthalmol. 2013;97:80–82.
Chen QY, Tang YX, He YQ, Lin HM, Gao RL, Li MY, et al. Air tamponade in retinal detachment surgery followed by ultra-widefield fundus imaging system. Int J Ophthalmol. 2018;11:1198–203.
Lin Z, Liang QH, Lin K, Hu ZX, Chen TY, Wu RH, et al. Air tamponade and without heavy liquid usage in pars plana vitrectomy for rhegmatogenous retinal detachment repair. Int J Ophthalmol. 2018;11:1779–83.
Zhang Z, Peng M, Wei Y, Jiang X, Zhang S. Pars plana vitrectomy with partial tamponade of filtered air in Rhegmatogenous retinal detachment caused by superior retinal breaks. BMC Ophthalmology. 2017;17:64.
Zhou C, Qiu Q, Zheng Z. Air versus gas tamponade in rhegmatogenous retinal detachment with inferior breaks after 23-gauge pars plana vitrectomy: a prospective, randomized comparative interventional study. Retina. 2015;35:886–91.
Tetsumoto A, Imai H, Hayashida M, Otsuka K, Matsumiya W, Miki A, et al. The comparison of the surgical outcome of 27-gauge pars plana vitrectomy for primary rhegmatogenous retinal detachment between air and SF6 gas tamponade. Eye. 2020;34:299–306.
Martínez-Castillo VJ, García-Arumí J, Boixadera A. Pars plana vitrectomy alone for the management of pseudophakic rhegmatogenous retinal detachment with only inferior breaks. Ophthalmology. 2016;123:1563–9.
Martínez-Castillo V, Boixadera A, Verdugo A, García-Arumí J. Pars Plana Vitrectomy Alone for the Management of Inferior Breaks in Pseudophakic Retinal Detachment without Facedown Position. Ophthalmology. 2005;112:1222–26.e1
Martínez-Castillo V, Verdugo A, Boixadera A, García-Arumí J, Corcóstegui B. Management of inferior breaks in pseudophakic rhegmatogenous retinal detachment with pars plana vitrectomy and air. Arch Ophthalmol. 2005;123:1078–81.
Li Y, Cheung N, Jia L, Zhang H, Liu N. Surgical outcomes of 25-Gauge pars plana vitrectomy using air as an internal tamponade for primary rhegmatogenous retinal detachment. Retina. 2020;40:2077–82.
Mateo-Montoya A, de Smet MD. Air as tamponade for retinal detachments. Eur J Ophthalmol. 2013;24:242–6.
Ruamviboonsuk P, Limwattanayingyong J, Tadarati M. Sutureless 25-gauge vitrectomy for rhegmatogenous retinal detachment caused by superior breaks using air tamponade. Asia-Pac J Ophthalmol. 2015;4:92–96.
Eckardt C, Eckert T, Eckardt U, Porkert U, Gesser C. Macular hole surgery with air tamponade and optical coherence tomography-based duration of face-down positioning. Retina. 2008;28:1087–96.
Starup‐Hansen J, Dunne H, Sadler J, Jones A, Okorie M. Climate change in healthcare: Exploring the potential role of inhaler prescribing. Pharmacology Research & Perspectives. 2020;8.
Bali T, Flesher W. BET 1: The clinical impact of policies aimed at reducing the carbon footprint of emergency departments. Emergency Medicine Journal. 2020;37:170.2-171.
Wilkinson AJK, Braggins R, Steinbach I, Smith J. Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England. BMJ Open. 2019;9:e028763.
Author information
Authors and Affiliations
Contributions
All authors have made substantial contributions to the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted.
Corresponding author
Ethics declarations
Competing interests
All authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Moussa, G., Ch’ng, S.W., Ziaei, H. et al. The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures. Eye 37, 1405–1409 (2023). https://doi.org/10.1038/s41433-022-02145-9
Received:
Revised:
Accepted:
Published:
Version of record:
Issue date:
DOI: https://doi.org/10.1038/s41433-022-02145-9
This article is cited by
-
Sustainability practices made easy
Eye (2025)
-
Patients’ perspective on the environmental impact of the severe dry eye disease healthcare pathway
Eye (2025)
-
Sustaining Ophthalmic Practices for the Future: A High-Value Care Approach to Environmental Responsibility
Ophthalmology and Therapy (2025)
-
Schwefelhexafluorid (SF6) und Klimafolgen: Ist die medizinische Anwendung noch gerechtfertigt?
Die Ophthalmologie (2025)
-
Achieving net-zero in the dry eye disease care pathway
Eye (2024)
