Sustainability Made Simple in Retina

Think sustainability can’t mix with retina care? Think again. These clever tweaks prove you can cut waste, save cash and keep patient safety on beat. 

In a world where “reduce, reuse, recycle” rules the eco-conscious crowd, the medical field—and particularly ophthalmology—is finally spinning the same tune. Think of retina specialists as DJs of sustainability, remixing their clinical routines for a greener future without missing a beat in patient care. 

Medicine’s inconvenient truth

“The climate crisis is a great health threat of the 21st century,” warned Dr. Johannes Birtel (Germany) during his EURETINA 2025 lecture¹, noting that “about 5% of all global emissions are due to the healthcare sector.” It’s a stark reminder that while retina specialists work in one of the most resource-intensive corners of medicine, they also hold tremendous potential to drive meaningful change. 

And the data backs it up. Recent research shows that eye surgeons are becoming increasingly aware of their environmental footprint, and many are ready to do something about it.² 

The same could be said on the patient end. When those in injection clinics were surveyed, “patients really think that climate change is a significant issue and should be addressed by ophthalmologists,” Dr. Birtel pointed out. 

Starting small

Just like how a subtle bass line can completely change the mood of a song, a few simple tweaks in your practice can make a big impact on sustainability. Dr. Birtel offered several easy ways to go greener that don’t require reinventing the wheel:

Power down the OR. “You can reduce the ventilation of the OR…30 minutes before surgery, which actually offers as [good] infection control as 24-hour ventilation,” said Dr. Birtel. In other words, same safety, far less energy wasted. 

Water conservation. Evidence shows that “alkaline solutions are actually superior to surgical scrub brush,” Dr. Birtel noted, allowing surgeons to “save quite a lot of water, about 50 liters…for surgery.” Multiply that by 15 cataract cases a day, and surgeons can be saving the equivalent of “drinking water for a whole year in just one theater.” Not bad for a simple switch. 

Reduce drug waste. Major ophthalmology organizations like the American Academy of Ophthalmology (AAO) recommend that “eye drops should be used in multiple patients, also multiple dose containers, if actually proper guidelines are following this regard.” Medications should also be used until they expire. And if it’s appropriate, patients can take them home.³ Less waste, more sense. 

Intravitreal injections

For retina specialists, intravitreal injections are where sustainability can really hit its stride. With roughly 1.5 million injections performed every year in Germany alone—and even more across the United States—the environmental footprint adds up fast.⁴ 

Dr. Birtel’s research revealed that injection sets can range in weight from 90 grams to 280 grams. “Most of the material was plastic-based. So [with] 1,000,000 injections, [you create] around 165 tons of waste per year, which is equivalent to 302 tons of CO₂,” he explained, showing that small procedural choices can have massive environmental echoes. 

The Oxford model

The Oxford Eye Hospital (UK) offers a smart blueprint for easing into more sustainable injection practices, one small change at a time. 

“It was quite clever [how] a small reduction over time was performed,” Dr. Birtel said. “In 2017, topical antiemetic eye drops were omitted. Then in 2020, the drape was optional. In 2022, the lid speculum became optional. And now in 2024, injection packs have been omitted.”

By phasing in these changes gradually, the hospital could closely track outcomes, and the results speak volumes. Despite the scaled-back supplies, there was no rise in endophthalmitis rates, not to mention the environmental and financial payoffs (more on that later).⁵ 

The bare basics

When it comes to intravitreal injections, Dr. Birtel argued that we may be overcomplicating things. His research shows that a more minimalist, material-sparing approach can slash injection set waste by a whopping 99%, all without sacrificing patient safety.⁴ 

So, what does this pared-down process look like? It’s surprisingly simple: just a topical anesthetic followed by povidone iodine drops in the conjunctival sac.

Many injectors skip the lid speculum altogether, gently retracting the eyelids with their fingers instead. Even the injection site can be marked with the needle cap, no fancy calipers required. 

Beyond the injection suite

Sustainability extends outside of the injection room. Dr. Birtel encouraged a rethink of standard care, saying, “We should also ask…’Do we have to do all the checkups and follow-up examinations before and after surgery?’”

His research uncovered major variations in perioperative routines for cataract surgery, suggesting that there’s room to “streamline not only for cataract surgery, but also for retinal surgeons…to see how we can really focus on things which are important.” In other words, less busywork, more meaningful care. 

And then there’s the hidden culprit: travel. Patient transport adds up to a hefty chunk of emissions, contributing to an estimated 10.49 kg CO₂eq per injection—the single largest contributor to the injection carbon footprint.⁶ As Dr. Birtel noted, novel therapeutic agents that reduce treatment frequency could go a long way toward shrinking that number. 

Sustainable practices

For those ready to embrace sustainability in retina care, here’s a comprehensive playlist of changes to consider:

1. Optimize ventilation in operating rooms
2. Use alcohol-based hand rubs instead of water-based surgical scrubs
3. Reduce drug waste by using multi-dose containers appropriately
4. Minimize packaging waste by reviewing what’s truly necessary in surgical packs
5. Increase efficiency in patient care by reducing unnecessary visits
6. Consider same-day bilateral injections when appropriate
7. Eliminate topical antibiotics for intravitreal injections, as evidence suggests they’re ineffective in preventing endophthalmitis⁷
8. Adopt a minimalist approach to injection supplies
9. Evaluate the environmental impact when choosing between anti-VEGF agents

Going green saves green

Perhaps the most compelling argument for sustainability is also the simplest: it saves money. As Dr. Birtel puts it, “If you go for a sustainability approach, it can often also save a lot.” 

Take the Oxford Eye Hospital’s sustainable injection protocol, for example. It’s estimated to save £150,000 to £180,000 a year while cutting more than 3,000 kg of waste annually. That’s cash and carbon saved in one go, plus resources that can be reinvested into better patient care or new services. 

The sustainable future of retina care

Like a DJ who knows just when to drop the beat, the timing for sustainability in retina care couldn’t be more perfect. The climate crisis is calling for action, and ophthalmologists are in a prime position to make changes that benefit both their patients and the planet. 

When it comes to remixing your practice, start with the easy tracks first: tweak your OR ventilation, save some water and cut down on drug waste. Once you’ve got the rhythm, move on to the headliners: revamping injection protocols or rethinking perioperative care. 

The data speaks volumes. Sustainable practices in retina care can dramatically reduce environmental impact without sacrificing safety or outcomes. And just like a killer remix can breathe new life into a classic tune, these small shifts can energize your practice while helping to create a healthier world. 

So, grab your headphones, cue up that sustainability track and start remixing your retina routine. The planet—and your bottom line—will be dancing in gratitude. 

Editor’s Note: Dr. Johannes Birtel’s insights in this article are based on his Day 3 presentation at a session on sustainability in retinal health care at EURETINA 2025 Paris, titled “Sustainable Options Made Easy”. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore. A version of this article was first published in PIE Issue 37.

References

1. Birtel J. Sustainable Options Made Easy. Lecture at EURETINA 2025. Paris, France. September 6, 2025. 
2. Nanegrungsunk O, Kunavisarut P. Toward a greener vision: A review on advancing sustainability in ophthalmology. Asia-Pacific Journal of Ophthalmology. 2025;14(2):100182. 
3. Palmer D, Tauber J, Lee AG, et al. Sustainability and ophthalmology. AAO. October 6, 2025. Available at: https://eyewiki.org/Sustainability_and_Ophthalmology. Accessed on October 7, 2025. 
4. Birtel J, Hammer M, Feltgen N, et al. Intravitreal injections: Improving sustainability by reducing clinical waste. Klin Monbl Augenheilkd. 2024;241(10):1156-1162. 
5. Ong AY, Buckley TMW, Birtel J, de Silva SR, Stone N, Issa PC. Towards greener intravitreal injections: The Oxford Eye Hospital experience. Eye. 2025;39:2489-2491. 
6. Birtel J, Schellstede A, Pauleikhoff LJB, Spitzer MS, Yang-Seeger D. Travel-associated emissions of intravitreal injections. IOVS. 2025;66(8):4119. 
7. Hunyor AP, Merani R, Darbar A, Korobelnik JF, Lanzetta P, Okada AA. Topical antibiotics and intravitreal injections. Acta Ophthalmol. 2018;96(5):435-441.