The Environmental Sustainability of Intravitreal injections

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Article initiated by:

Anna March de Ribot, MD, PhD, Francesc March de Ribot, MD, PhD

All contributors:

Anna March de Ribot, MD, PhD, Francesc March de Ribot, MD, PhD, Leo A. Kim, MD, PhD

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Introduction

In ophthalmology, intravitreal injections have become one of the most common procedures 5, with a significant increase in their numbers over the years. In the USA, an estimated 5.9 million intravitreal injections were performed in 2016, and this number continues to rise with the aging population. The UK also saw a substantial increase, accounting for up to 215% from January 2010 to May 2014, making it the most common invasive procedure in ophthalmology. However, this increase in intravitreal injections comes with environmental consequences. Each intravitreal injection, regardless of the anti-VEGF agent used, results in 13.68kg CO2eq. Patient travel was identified as the single largest contributor to the carbon footprint, accounting for 10.49 kg CO2eq, followed by the injection pack (2.54kg CO2eq). Additionally, the procurement of bevacizumab, ranibizumab, and aflibercept was found to produce approximately 20kg, 320kg, and 423kg CO2eq, respectively, per injection. Dispensable items implied an expenditure of €2.05 per pack, 0.56kg CO2eq per injection (4%), 240kg of plastic annually and 3.360kg CO2eq per annum based on their annual provision of 6,000 injections.

In a retina centre in the USA, it was seen that cold packs (62.5%), cardboard boxes (10.4%), foam coolers (8.4%), and nitrile gloves (6.0%) were the items that contributed the most to overall waste. Among these, the non-biodegradable foam coolers were considered the component of intravitreal injections with the greatest environmental impact, as the inexpensive manufacture promoted it to be single-used, they are bulky, persist in landfills for hundreds of years and imply high CO2 emissions.

Potential Solutions and Future Directions

Intravitreal injections timings

Intravitreal injections can be optimized, allowing patients to receive them on the same day as their clinic appointments and safe bilateral same-day injections. It is one of the more convenient approaches for both the patient and ophthalmologist.

Intravitreal injections follow-ups

Postoperative follow-ups after uncomplicated intravitreal injections can be safely reduced, decreasing mobility-associated emissions and travel costs. This change benefits the environment and improves access to healthcare for other patients.

Intravitreal injections packs

Intravitreal packs have items that are often opened and discarded unused, making changes to the material could significantly reduce carbon emissions. You can minimise the packs without compromising the safety or quality of care.

Splitting of vials

Bevacizumab, available in 100 mg/4 mL and 400 mg/16 mL vials, typically requires only 0.05 mL for intravitreal injection. This process can be done ideally by a compounding pharmacy with sterile precautions. However, when this is unavailable, alternative methods are used, such as aliquoting without the same standards or puncturing the rubber cap multiple times to use the same vial on the same day or over several days until it is finished.

Despite the ongoing debate about splitting vials, its potential environmental implications have not been thoroughly studied or demonstrated. Nevertheless, it is reasonable to expect that splitting vials could significantly reduce waste, lower the carbon footprint, and minimize chemicals released into the environment. Emphasizing these environmental benefits could further motivate healthcare facilities to adopt this practice.

Avoiding topical antibiotics

There is increasing evidence that topical antibiotics, given before and/or after intravitreal injections, are ineffective in preventing endophthalmitis and are possibly harmful. In addition to the lack of efficacy and increased development of resistant organisms, the use of topical antibiotics adds significantly to the cost of delivering intravitreal therapy.

See also

• Ophthalmology and Climate Change
• Sustainability practices implementation made easy
• The Environmental Sustainability of:
  • Cataract Surgery
  • Dry Eye Disease
  • Glaucoma
  • Retina/VR surgery
  • Eye Drops in Surgery