In a world where healthcare’s environmental footprint is under growing scrutiny, VR surgeons are at the forefront of driving sustainability in ophthalmology.
On Day 1 of the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025), during the Sustainability Innovations in an Evolving Healthcare System symposium organized by the Philippine Academy of Ophthalmology (PAO), experts from the Philippines, India and Malaysia shared practical, evidence-based and forward-thinking strategies to reduce ophthalmology’s environmental footprint—without compromising clinical outcomes or slowing advancements in technology and quality of care.
Reusing supplies in VR surgery
Dr. Vivek Dave (India) opened the session with a compelling argument…that in a field as resource-intensive as vitreoretinal (VR) surgery, reusing supplies is no longer just an option—“it is a necessity.”
Citing a published paper from The Lancet Planetary Health1, Dr. Dave emphasized that “service provision must be environmentally sustainable” and that the true cost of clinical care must include its environmental burden. This is especially critical in ophthalmology, where complex surgeries and disposable-heavy workflows create huge amounts of waste.
To drive his message furthermore, Dr. Dave reminded the audience of the six R’s of sustainability—reuse, reduce, repair, refuse, recycle and reimagine. Among these, reuse carries transformative potential. “Around 78% of surgeons believe we should be reusing supplies more, and more than 90% want products that can be reused,” he noted, referencing a survey from the Ophthalmic Instrument Cleaning and Sterilization Task Force.2
For VR surgeons—who depend on intricate, expensive instruments—reuse directly translates to affordability. “Reusing instruments and supplies makes things economical…and leads to lesser waste and a lower carbon footprint,” Dr. Dave explained. In India, this practice has helped keep VR surgery accessible, with post-vitrectomy endophthalmitis rates remaining comparable to global standards.
However, Dr. Dave acknowledged the drawbacks, including rare risks of toxic anterior segment syndrome (TASS), prion disease and occasional instrument fatigue. He illustrated this with short surgical videos showing reused scissors or needles failing mid-procedure—very relatable moments that had the audience laughing in recognition. But these incidents, he noted, remain uncommon and, when they do occur, are manageable, especially with robust sterilization systems in place.
In conclusion, Dr. Dave called for institutional commitment: “Reusability should be a serious consideration in any big practice, especially in the developing world.” His recommendations include clear patient consent, dedicated reuse committees, strict processing protocols and annual sustainability audits.
In an era of rising costs and urgent climate demands, Dr. Dave believes that “reuse is not cutting corners. It is responsible, ethical and essential.”
READ MORE: To Reuse or Not to Reuse Disposables…that is the Question!
Greening the OR
“Why are we even thinking about going green?” Dr. Cesar Ramon Espiritu immediately addressed the elephant in the room, highlighting the issue from a hospital administration perspective. Dr. Espiritu is the President and CEO of The Medical City South Luzon, a leading hospital network in the Philippines.
“The healthcare sector accounts for about 10% of all greenhouse gas emissions. It’s a significant share. Operating rooms (ORs) are the most energy-intensive and waste-generating areas in a hospital,” he explained. According to Dr. Espiritu, ORs consume six times more energy than other hospital areas and generate 30% of the facility’s total waste.
So, what exactly is a green OR? “It’s an operating room designed and managed to minimize environmental impact,” Dr. Espiritu explained. “This includes implementing sustainable practices, optimizing efficiency and reusing instruments and products more effectively,” he added. At the same time, he emphasized, “you must also be conscious of maintaining patient care standards: balancing energy efficiency not just with surgical excellence, but also with quality outcomes.
When asked about the key features of a green OR, Dr. Espiritu emphasized efficiency as a primary focus and suggested the following measures, especially when building a new OR from the ground up:
- Reduce energy consumption with LED lighting
- Install occupancy sensors
- Switch to anesthetic agents with lower greenhouse gas emissions
- Purchase supplies in bulk to reduce costs
- Use gas-capturing technologies to minimize environmental impact
- Conserve water
- Install efficient fixtures
- Encourage best practices among staff
- Switch to reusable gowns, drapes and surgical trays
- Install recycling bins for specific OR waste streams
- Conduct regular waste audits to identify further reduction opportunities
- Use digital records to minimize paper use
Dr. Espiritu stressed that while fixtures and technologies are important, “the more crucial aspect is the discipline you instill in your staff to make sustainable practices routine.”
For example, and this is especially true in the Philippine setting: water conservation and staff engagement are equally vital, as sustainability relies on “discipline, training and cultivating habits until good practice [becomes] automatic,” Dr. Espiritu explained. Then the benefits—environmental, economic and social—are substantial.
Concluding his presentation, Dr. Espiritu noted that he is fortunate to implement greening initiatives in the OR from the top down. “It would be a far more difficult scenario if the demand were coming from the ground up,” he explained. “But every OR can really start small…building up to a total approach to energy conservation and creating meaningful, lasting impact,” he added.
Ultimately, according to Dr. Espiritu, success goes beyond green design. It depends on having the right people to monitor, teach and engage staff in sustaining these practices.
Community ophthalmology and sustainability
“Community ophthalmology, when done well, is one of the most effective ways to reduce environmental impact, reduce long-term healthcare resource use and ultimately achieve sustainability,” said Dr. Aramis Torrefranca, Jr.—a compelling message based on the real-world model developed in Bohol, Philippines, where he practices.
While sustainability in ophthalmology is often associated with operating rooms, equipment and hospital waste, Dr. Torrefranca challenged the audience to think beyond facility walls. “How about getting to the hospital? How about the patient’s individual situations before going to the hospital?” he asked.
Citing recently published data3, he noted that much of ophthalmology’s carbon footprint comes from patient travel and late-stage disease requiring repeated, resource-heavy interventions. “Every avoided trip to the main city [Tagbilaran, Bohol] saves patients money, time and reduces greenhouse gas emissions,” explained Dr. Torrefranca.
Bohol—a geographically fragmented island province with scattered barangays, mountains and transport barriers—illustrates this reality clearly, emphasized Dr. Torrefranca. “Many patients may not even afford to travel,” he said. Thus, such community-rooted challenges inspired the creation of Bohol’s pioneering Community Ophthalmology program, a section in the local government unit’s healthcare system designed not just for outreach but for long-term, replicable sustainability.
Their approach, reported Dr. Torrefranca, integrates several powerful strategies:
- Satellite eye centers placed closer to communities
- Barangay-level screenings using simple, reusable tools
- Mobile clinics and medical missions, each preventing dozens of individual trips
- Training local healthcare workers, enabling efficient triage and reducing unnecessary referrals
- Teleophthalmology, including remote diabetic retinopathy screening powered by AI
“Prevention saves eyesight, but prevention also saves carbon,” Dr. Torrefranca emphasized. He added that if there is early detection, then repeated imaging, injections and complex surgeries can be avoided more often.
Despite challenges such as limited specialists, costly equipment and weather disruptions, the Bohol team remains focused on building “a self-sustaining, evidence-based community ophthalmology program” that could be replicated nationwide.
Most importantly, Dr. Torrefranca closed his presentation with a powerful reminder: “Sustainability is not only about technology. It’s about people, pathways and partnerships. And in Bohol, this philosophy is already transforming eye care into a greener, more equitable system for all.”
READ MORE: NHS to Begin Shift of Eye Care from Hospitals to Communities in November
The Malaysian perspective
“Ophthalmology may save sight, but it also produces significant waste,” said Dr. Wee Min Teh, consultant ophthalmologist and vitreoretinal surgeon at the Oasis Eye Specialists in Malaysia.
It is common knowledge in the ophthalmic world that cataract surgery generates substantial waste. In Malaysia, with the country performing approximately 70,000 cataract surgeries annually, Dr. Teh emphasized the environmental burden. Furthermore, a study from the United Kingdom estimated each cataract procedure produces 183 kilograms of carbon dioxide equivalent, totaling 63,000 tons per year.4
In addressing the paradox of saving sight while generating substantial waste, Dr. Teh highlighted that the Malaysian Society of Ophthalmology (MSO; where he currently serves as Treasurer) has joined EyeSustain, a global coalition dedicated to promoting sustainable eye care.
Dr. Teh also highlighted interesting statistics that showcase ophthalmologists’ dedication to sustainability in their field: “Ninety-four percent of cataract surgeons are concerned about climate change and 89% want their societies to advocate for reducing the carbon footprint of surgery. Interestingly, 59% of surgeons in Asia Pacific are already reusing single-use instruments—far higher than in North America or Europe.”
Outlining practical steps to make ophthalmology greener, Dr. Teh believes that education is key, not just for surgeons, but also for staff.
Energy efficiency is another focus of Dr. Teh’s presentation. “Being near the equator, solar energy is a resource we can fully utilize,” he said, citing Malaysia’s renewable energy roadmap and government initiatives like net energy metering and large-scale solar projects.
To conclude, he encouraged the Philippine Academy of Ophthalmology (PAO) to take the pledge in EyeSustain and reflected on the personal responsibility required to spark change: “Sometimes you have to be the focus point, creating that initial ripple. The journey of a thousand miles usually begins with a single step. Climate change is real, so why aren’t we acting?”
Through advocacy, innovation and everyday action, Malaysian ophthalmologists are demonstrating that sustainable eye care is not only possible. It’s essential.
READ MORE: Dr. Caparas on Greener Cataract Surgery with Rayner’s Sophi
Philippine ophthalmology faces the green challenge
“Sustainability in healthcare is no longer optional. It is an ethical imperative.”
Dr. Sherman Valero, vitreoretina specialist at Makati Medical Center and The Medical City—two of the largest hospital groups in Manila, Philippines—closed the session with a call to action for Philippine ophthalmology.
Dr. Valero challenged Filipino ophthalmologists to rethink the environmental impact of their practice. “Developing countries like the Philippines bear a disproportionate health impact from environmental damage. It is our ethical duty to do no harm—not just to patients, but to the planet that sustains us,” he emphasized.
Echoing the insights of previous speakers before him, Dr. Valero reiterated that surgical services contribute up to 30% of hospital waste, and ophthalmology, with its high-volume, disposable-dependent procedures, plays a big role. He then shared sobering data from local audits at Makati Medical Center, noting that “for a third-world country hospital, our solid waste and greenhouse gas emissions per cataract surgery are shockingly high.”
But where do we start? Raising awareness is the first step toward change, noted Dr. Valero. “We cannot solve what we do not see,” he said, highlighting the fact that ophthalmologists often remain unaware of their environmental footprint because the impact is literally “invisible, unmeasured and distant,” simply because they have staff who take care of the actual disposal for them. “It’s very distant and silent. It’s not happening in front of our eyes. We’re not seeing waste being put in landfills. We’re not seeing waste being burned. So it’s something very distant to us,” he shared. Hence, mapping OR waste, engaging environmental experts and conducting local audits were suggested as practical interventions.
Dr. Valero also urged the audience for systemic reforms: “We need to review single-use versus reusable systems, implement green procurement, optimize OR energy use and streamline patient pathways.” Furthermore, he called for a national roadmap, proposing that the PAO establish a sustainability task force, integrate environmental considerations into CME programs and adopt international best practices. “We need to drive institutional change because sustainability does not always equal risk, you know, and it requires planning and not just compromise,” he said.
Ultimately, sustainability begins with engagement. “Track your OR waste, cluster appointments, demand greener products and engage with your profession. The health of our patients and the health of our planet are inseparable,” Dr. Valero concluded, issuing a clear call to action for PAO to lead by example.
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Editor’s Note: 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. Reporting for this story took place during the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025) from 12-14 December in Manila, Philippines.
References
- Buchan JC, Thiel CL, Steyn A, et al. Addressing the environmental sustainability of eye health-care delivery: a scoping review. Lancet Planet Health. 2022;6(6):e524-e534. [Erratum in: Lancet Planet Health. 2022;6(8):e644]
- 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(7):933-940.
- Zurl H, Qian Z, Stelzl DR, et al. Carbon Emissions From Patient Travel for Health Care. JAMA Netw Open. 2025;8(3):e252513.
- Morris DS, Wright T, Somner JE, Connor A. The carbon footprint of cataract surgery. Eye (Lond). 2013;27(4):495-501.