Abstract
Healthcare services are significant contributors to climate change. Ophthalmology, by virtue of the volume of appointments and proceduresĀ it generates, is thought to play a major role in this regard. Intravitreal injections (IVI) are a commonly performed ophthalmological procedure to treat patients with conditions such asĀ macular neovascularisation secondary to neovascular age-related macular disease or myopia, diabetic macular oedema, and retinal vein occlusions. As IVIs become more ubiquitous, addressing their environmental impact and sustainability will become increasingly important. Strategies to tackle carbon emissions from IVIs may target the following areas which align with the Greenhouse Gas Protocol scopes: building energy; water consumption; travel to appointments; manufacture and procurement of the drug and other necessary materials; and waste disposal. We propose a path towards a more sustainable approach for IVIs, and discuss its potential safety as well as the patient experience.
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References
Lenzen M, Malik A, Li M, Fry J, Weisz H, Pichler PP, et al. The environmental footprint of health care: a global assessment. Lancet Planet Health. 2020;4:e271āe279.
NHS England. Delivering a Net Zero National Health Service, https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2022/07/B1728-delivering-a-net-zero-nhs-july-2022.pdf (2022).
NHS Digital. Hospital Outpatient Activity 2019-20. NHS Digital, https://digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/2019-20/summary-report---treatment-specialities (2020, accessed 27 May 2021).
Buchan JC, Thiel CL, Steyn A, Somner J, Venkatesh R, Burton MJ, et al. Addressing the environmental sustainability of eye health-care delivery: a scoping review. Lancet Planet Health. 2022;6:e524āe534.
Wong YL, Noor M, James KL, Aslam TM. Ophthalmology going greener: a narrative review. Ophthalmol Ther. 2021;10:845ā57.
Rossi T, Romano MR, Iannetta D, Romano V, Gualdi L, D'Agostino I, et al. Cataract surgery practice patterns worldwide: a survey. BMJ Open Ophthalmol. 2021;6:e000464.
Chopra R, Preston GC, Keenan TDL, Mulholland P, Patel PJ, Balaskas K, et al. Intravitreal injections: past trends and future projections within a UK tertiary hospital. Eye (Lond). 2022;36:1373ā8.
Hollingworth W, Jones T, Reeves BC, Peto T. A longitudinal study to assess the frequency and cost of antivascular endothelial therapy, and inequalities in access, in England between 2005 and 2015. BMJ Open. 2017;7:e018289.
Vision profile statistical commentary: September 2023. GOV.UK, https://www.gov.uk/government/statistics/vision-profile-september-2023/vision-profile-statistical-commentary-september-2023 (accessed 24 September 2023).
Power B, Brady R, Connell P. Analyzing the Carbon Footprint of an Intravitreal Injection. J Ophthalmic Vis Res. 2021;16:367ā76.
Cantanese L Second Geographic Atrophy Treatment Receives FDA Approval | BrightFocus Foundation, https://www.brightfocus.org/macular/news/second-geographic-atrophy-treatment-receives-fda-approval (accessed 30 September 2023).
Research News. FDA Approves First and Only Treatment for Geographic Atrophy, an Advanced Form of Age-Related Macular Degeneration | BrightFocus Foundation, https://www.brightfocus.org/news/fda-approves-first-and-only-treatment-geographic-atrophy-advanced-form-age-related-macular (accessed 30 September 2023).
Tennison I, Roschnik S, Ashby B, Boyd R, Hamilton I, Oreszczyn T, et al. Health careās response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021;5:e84āe92.
Psillaki M, Apostolopoulos N, Makris I, Liargovas P, Apostolopoulos S, Dimitrakopoulos P, et al. Hospitalsā energy efficiency in the perspective of saving resources and providing quality services through technological options: a systematic literature review. Energies. 2023;16:755.
Greener NHSĀ» Solar power sparks an electrical future for Milton Keynes University Hospital, https://www.england.nhs.uk/greenernhs/whats-already-happening/solar-power-sparks-an-electrical-future-for-milton-keynes-university-hospital/ (accessed 13 March 2024).
Sundar D, Das T, Chhablani J, Kumar A, Sharma N. All India Ophthalmological Society membersā survey: practice pattern of intravitreal anti-vascular endothelial growth factor injection. Indian J Ophthalmol. 2020;68:1095ā8.
Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The carbon footprint of surgical operations: a systematic review. Ann Surg. 2020;272:986ā95.
MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health. 2017;1:e381āe388.
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;138:382ā6.
Chandra P, Welch S, Oliver GF, Gale J. The carbon footprint of intravitreal injections. Clin Exp Ophthalmol. 2022;50:347ā9.
Elrod JK, Fortenberry JL. The hub-and-spoke organization design: an avenue for serving patients well. BMC Health Serv Res. 2017;17:457.
Borkar DS, Obeid A, Su DC, Storey PP, Gao X, Regillo CD, et al. Endophthalmitis rates after bilateral same-day intravitreal antiāvascular endothelial growth factor injections. Am J Ophthalmol. 2018;194:1ā6.
Emerson GG, Thompson JT, Vo LV, Mason R, Lee GD, Leder HA. Office examinationsādirected treatment paradigms reduce travel burden, decrease treatment cost, and improve quality-adjusted life-years for patients with exudative age-related macular degeneration undergoing antivascular endothelial growth factor therapy. J Vitreoretina Dis. 2020;4:472ā8.
Khanani AM, Patel SS, Ferrone PJ, Osborne A, Sahni J, Grzeschik S, et al. Efficacy of every four monthly and quarterly dosing of faricimab vs ranibizumab in neovascular age-related macular degeneration: the STAIRWAY phase 2 randomized clinical trial. JAMA Ophthalmol. 2020;138:964ā72.
Wykoff CC, Abreu F, Adamis AP, Basu K, Eichenbaum DA, Haskova Z, et al. Efficacy, durability, and safety of intravitreal faricimab with extended dosing up to every 16 weeks in patients with diabetic macular oedema (YOSEMITE and RHINE): two randomised, double-masked, phase 3 trials. Lancet. 2022;399:741ā55.
Brown DM, Boyer DS, Do DV, Wykoff CC, Sakamoto T, Win P, et al. Intravitreal aflibercept 8 mg in diabetic macular oedema (PHOTON): 48-week results from a randomised, double-masked, non-inferiority, phase 2/3 trial. Lancet. 2024;403:1153ā63.
Lanzetta P, Korobelnik J-F, Heier JS, Leal S, Holz FG, Clark WL, et al. Intravitreal aflibercept 8 mg in neovascular age-related macular degeneration (PULSAR): 48-week results from a randomised, double-masked, non-inferiority, phase 3 trial. Lancet. 2024;403:1141ā52.
Ranade SV, Wieland MR, Tam T, Rea JC, Horvath J, Hieb AR, et al. The Port Delivery System with ranibizumab: a new paradigm for long-acting retinal drug delivery. Drug Deliv;. 2022;29:1326ā34.
Sharma A, Khanani AM, Parachuri N, Kumar N, Bandello F, Kuppermann BD. Port delivery system with ranibizumab (Susvimo) recall- What does it mean to the retina specialists. Int J Retin Vitr. 2023;9:6.
Bjerager J, Schneider M, Potapenko I, van Dijk E, Faber C, Grauslund J, et al. Diagnostic Accuracy of the Amsler Grid Test for Detecting Neovascular Age-Related Macular Degeneration: A Systematic Review and Meta-analysis. JAMA Ophthalmol. 2023;141:315ā23.
Busquets MA, Sabbagh O. Current status of home monitoring technology for age-related macular degeneration. Curr Opin Ophthalmol. 2021;32:240ā6.
Balaskas K, Drawnel F, Khanani AM, Knox PC, Mavromaras G, Wang YZ. Home vision monitoring in patients with maculopathy: current and future options for digital technologies. Eye (Lond). 2023;37:1ā13.
Miller JRC, Patel PJ, Hanumunthadu D. Perspectives on the home monitoring of macular disease. Ophthalmol Ther. 2023;12:1ā6.
Birtel J, Heimann H, Hoerauf H, Helbig H, Schulz C, Holz FG, et al. Sustainability in ophthalmology: Adaptation to the climate crisis and mitigation. Ophthalmologie. 2022;119:567ā76.
Deutsche Ophthalmologische Gesellschaft (DOG), Berufsverband der AugenƤrzte Deutschlands e. V. (BVA) [Position paper and recommendations for action for ecologically sustainable ophthalmology: Statement of the German Society of Ophthalmology (DOG) and the German Professional Association of Ophthalmologists (BVA)]. Ophthalmologie. 2023;120:52ā68.
Birtel J, Hammer M, Feltgen N, et al. Intravitreal Injections: Improving Sustainability by Reducing Clinical Waste. Klin Monbl Augenheilkd. Epub ahead of print 4 April 2024. https://doi.org/10.1055/a-2184-9492.
van Leeuwen R, Elferink S Ophthalmology and the climate crisis: Time to take responsibility. Ophthalmology Times Europe; 18.
Gale J, Welch SH, Niederer R. Intravitreal injections with a low consumption technique have a low infection rate. Eye (Lond). 2023;38:1ā2.
Cameron TW, Vo LV, Emerson LK, Emerson MV, Emerson GG. Medical waste due to intravitreal injection procedures in a retina clinic. J Vitreoretin Dis. 2021;5:193ā8.
Vo LV, Mastrorilli V, Muto AJ, Emerson GG. Reuse of shipping materials in the intravitreal bevacizumab supply chain: feasibility, cost, and environmental impact. Int J Retin Vitr. 2023;9:34.
Schehlein EM, Hovanesian J, Shukla AG, Talley Rostov A, Findl O, Chang DF. Reducing ophthalmic surgical waste through electronic instructions for use: a multisociety position paper. J Cataract Refract Surg. 2024;50:197ā200.
Surgical hand preparation: state-of-the-art. In: WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. World Health Organization, https://www.ncbi.nlm.nih.gov/books/NBK144036/ (2009, accessed 3 October 2023).
Tanner J, Dumville JC, Norman G, Fortnam M. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2016;2016:CD004288.
Green-Simms AE, Ekdawi NS, Bakri SJ. Survey of intravitreal injection techniques among retinal specialists in the United States. Am J Ophthalmol. 2011;151:329ā32.
Huang K, Sultan MB, Zhou D, Tressler CS, Mo J. Practice patterns of ophthalmologists administering intravitreal injections in Europe: a longitudinal survey. Clin Ophthalmol. 2016;10:2485ā8.
Stem MS, Rao P, Lee IJ, Woodward MA, Faia LJ, Wolfe JD, et al. Predictors of endophthalmitis after intravitreal injection: a multivariable analysis based on injection protocol and povidone iodine strength. Ophthalmol Retin. 2019;3:3ā7.
World Health Organization, WHO Patient Safety. WHO guidelines on hand hygiene in health care. 2009; 262.
Li T, Sun J, Min J, Zhou S, Zhu X, Jia H, et al. Safety of receiving anti-vascular endothelial growth factor intravitreal injection in office-based vs operating room settings: a meta-analysis. JAMA Ophthalmol. 2021;139:1080ā8.
Lee MK, Mehta D, Welch SH, Gajus M, Gale J, Sandhu SS. The range of intravitreal injection practices in Australia and New Zealand. Clin Exp Ophthalmol. 2023;51:868ā70.
Benoist dāAzy C, Pereira B, Naughton G, Chiambaretta F, Dutheil F. Antibioprophylaxis in prevention of endophthalmitis in intravitreal injection: a systematic review and meta-analysis. PLOS ONE. 2016;11:e0156431.
Royal College of Ophthalmologists. Ophthalmic Service Guidance: Intravitreal Injection Therapy, https://curriculum.rcophth.ac.uk/wp-content/uploads/2018/02/Intravitreal-Injection-Therapy-August-2018-2.pdf (2018, accessed 23 March 2024).
The Royal Australian and New Zealand College of Ophthalmologists. Guidelines for Performing Intravitreal Therapy, https://ranzco.edu/policies_and_guideli/ivi-guidelines-for-performing-intravitreal-therapy/ (2020, accessed 23 March 2024).
Grzybowski A, Told R, Sacu S, Bandello F, Moisseiev E, Loewenstein A, et al. 2018 update on intravitreal injections: euretina expert consensus recommendations. Ophthalmologica. 2018;239:181ā93.
Merani R, Hunyor AP. Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review. Int J Retin Vitr. 2015;1:9.
Ong AY, Rigaudy A, Toufeeq S, Robins J, Shalchi Z, Bindra MS, et al. Intravitreal injections as a leading cause of acute postoperative endophthalmitisāa regional survey in England. Eye (Lond). 2023;37:163ā9.
Gragoudas ES, Adamis AP, Cunningham ET Jr, Feinsod M, Guyer DR, VEGF Inhibition Study in Ocular Neovascularization Clinical Trial G. Pegaptanib for Neovascular Age-Related Macular Degeneration. N. Engl J Med. 2004;351:2805ā16.
Munro M, Williams GR, Ells A, Fielden M, Kherani A, Mitchell P, et al. Lid splinting eyelid retraction technique: a minimised sterile approach for intravitreal injections. Br J Ophthalmol. 2018;102:1254ā8.
Fineman MS, Hsu J, Spirn MJ, Kaiser RS. Bimanual assisted eyelid retraction technique for intravitreal injections. Retina. 2013;33:1968ā70.
Shah CP, Garg SJ, Vander JF, Brown GC, Kaiser RS, Haller JA, et al. Outcomes and risk factors associated with endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmology. 2011;118:2028ā34.
MĆ©ndez PC, VĆ”zquez CM, Villar JO, Pazos JA. Assessment of the use of the speculum for intravitreal injections of anti-VEGF. Acta Ophthalmol. 2013;91:e244āe246.
Friedman DA, Mason JO, Emond T, McGwin G Jr. Povidone-iodine contact time and lid speculum use during intravitreal injection. Retina. 2013;33:975ā81.
Tailor R, Beasley R, Yang Y, Narendran N. Evaluation of patientsā experiences at different stages of the intravitreal injection procedure - what can be improved? Clin Ophthalmol. 2011;5:1499ā502.
Shrier EM. Cotton-tip applicator lid retraction technique for controlled intravitreal injection. Retina. 2014;34:1244ā6.
Raevis JJ, Karl MD, Parendo AM, Astafurov K, Dugue AG, Agemy SA, et al. Eyelid retraction discomfort with cotton-tipped applicator, unimanual and speculum intravitreal injection techniques: Eyelid retraction technique randomized comparison trial (Eyelid RETRACT). Indian J Ophthalmol. 2020;68:1593ā5.
Mason RWH. Use of a desmarres retractor for upper lid and lash isolation during intravitreal injections. Retina. 2013;33:2175ā6.
Dudani AI, Dudani AA, Dudani KA, Dudani AA. Unimanual upper and lower eyelid retraction for intravitreal injections. Indian J Ophthalmol. 2021;69:781ā2.
Rahimy E, Fineman MS, Regillo CD, Spirn MJ, Hsu J, Kaiser RS, et al. Speculum versus bimanual lid retraction during intravitreal injection. Ophthalmology. 2015;122:1729ā30.
Alattas K. Patientsā tolerance of bimanual lid retraction versus a metal speculum for intravitreal injections. Clin Ophthalmol. 2016;10:1719ā21.
Wasser LM, Roditi E, Weiss AR, Weill Y, Koslowsky M, Zadok D, et al. Anxiety and pain perception using a speculum-free eyelid retraction technique for intravitreal injection. Graefes Arch Clin Exp Ophthalmol. 2022;260:2023ā8.
Chaturvedi R, Wannamaker KW, Riviere PJ, Khanani AM, Wykoff CC, Chao DL. Real world trends in intravitreal injection practices among american retina specialists. Ophthalmol Retin. 2019;3:656ā62.
van Leeuwen R, Sustainable Ophthalmology Project Group. Best practice Intravitreal injections in a safe and sustainable way, https://www.eyesustain.org/-/media/eyesustain/pdfs/nog_best-practice-intravitreal-injection-english-version.pdf (2022, accessed 13 March 2024).
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This work was supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.
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AYO: Conceptualisation; Data curation; Investigation; Resources; Writingāoriginal draft, review, editing. JB: Resources; Writingāreview, editing. PCI: Conceptualisation; Writingāreview, editing.
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Ong, A.Y., Birtel, J. & Charbel Issa, P. Greener intravitreal injections: a narrative review. Eye 38, 2874ā2879 (2024). https://doi.org/10.1038/s41433-024-03185-z
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DOI: https://doi.org/10.1038/s41433-024-03185-z
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