The Environmental Sustainability of Retina/VR surgery
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Introduction
In ophthalmology, retina surgery is one of the more complex operations requiring advanced material and toxic gases that generate significant waste and sustainability issues. More than 225,000 vitrectomies are performed annually in the United States, with increasing indications [1] [2] [3] [4]
Gas tamponade impact
SF6, hexafluoroethane (C2F6), and octafluoropropane (C3F8) are commonly used in vitrectomies and retina surgery.[5][6][7][8] As they persist in the atmosphere far longer than CO2, their global warming potential increases with time.[5][6][7][9] They are considered among the most potent GHGs, and SF6 is included in the Kyoto Protocol to be strictly regulated and limited in its use.[5][6][10][7] Global warming potential within 100 years is 23,900 for SF6, 9,200 for C2F6 and 7,000 for C3F8.[5]
These gases are used in cases of rhegmatogenous retinal detachment (RRD), macular hole, diabetic retinopathy (including segmentation, delamination, and diabetic vitreous haemorrhage), haemorrhagic posterior vitreous detachment, other causes of vitreous haemorrhage, epiretinal membrane peel, and sub-macular haemorrhage.[6] During surgery, the gases can be released into the atmosphere, eliminated from the body through respiration or the bloodstream, or disposed of as medical waste.[11]
Solutions using air tamponade
Alternatives have been tested by integrating air tamponade in RRD repair, lowering carbon emissions without compromising outcomes.[6] This highlights the potential of adopting more environmentally friendly practices in retina surgery. Nonetheless, air tamponade may not be suitable for all cases.
To be eligible for air tamponade, RD cases should fulfill certain criteria based on the Pneumatic Retinopexy versus Vitrectomy for Retinal Detachment (PIVOT) trial.[7] These criteria include a single retinal break or a group of breaks, no larger than one clock hour in the detached retina, all breaks in the detached retina to lie above the 8 and 4 o’clock meridian and breaks or lattice degeneration in the attached retina at any location when no proliferative vitreoretinopathy grade C found.[7] The proportion of cases eligible for air tamponade is estimated to be between 27% to 52.9%.[7]
Long-acting gas tamponades provide longer retinal support and are more beneficial for certain types of RD, such as inferior RD, large breaks and multiple breaks.[7] Considering the environmental impact, SF6, the most damaging and shortest-acting fluorinated gas, should be replaced with air whenever possible[7] or using lower concentrations of C2F6[5][6] or C3F8[6] as alternatives.[5]
References
- ↑ Novak MA, Rice TA, Michels RG, Auer C. The crystalline lens after vitrectomy for diabetic retinopathy. Ophthalmology. 1984;91:1480–1484. [PubMed] [Google Scholar]
- ↑ Scartozzi R, Bessa AS, Gupta OP, Regillo CD. Intraoperative sclerotomy-related retinal breaks for macular surgery, 20- vs 25-gauge vitrectomy systems. Am J Ophthalmol. 2007;143:155–156. [PubMed] [Google Scholar]
- ↑ Rizzo S, Belting C, Genovesi-Ebert F, di Bartolo E. Incidence of retinal detachment after small-incision, sutureless pars plana vitrectomy compared with conventional 20-gauge vitrectomy in macular hole and epiretinal membrane surgery. Retina. 2010;30:1065–1071. [PubMed] [Google Scholar]
- ↑ Vitrectomy with silicone oil or sulfur hexafluoride gas in eyes with severe proliferative vitreoretinopathy: results of a randomized clinical trial. Silicone Study Report 1. Arch Ophthalmol. 1992;110:770–779. [No authors listed] [PubMed] [Google Scholar]
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Moussa G, Ch'ng SW, Park DY, Ziaei H, Jalil A, Patton N, Ivanova T, Lett KS, Andreatta W. Environmental Effect of Fluorinated Gases in Vitreoretinal Surgery: A Multicenter Study of 4,877 Patients. Am J Ophthalmol. 2022 Mar;235:271-279. doi: 10.1016/j.ajo.2021.09.020. Epub 2021 Sep 26. PMID: 34587498.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Moussa G, Ch'ng SW, Ziaei H, Jalil A, Park DY, Patton N, Ivanova T, Lett KS, Andreatta W. The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures. Eye (Lond). 2023 May;37(7):1405-1409. doi: 10.1038/s41433-022-02145-9. Epub 2022 Jun 28. PMID: 35764874; PMCID: PMC10169801.
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Moussa G, Andreatta W, Ch'ng SW, Ziaei H, Jalil A, Patton N, Ivanova T, Lett KS, Park DY. Environmental effect of air versus gas tamponade in the management of rhegmatogenous retinal detachment VR surgery: A multicentre study of 3,239 patients. PLoS One. 2022 Jan 26;17(1):e0263009. doi: 10.1371/journal.pone.0263009. PMID: 35081126; PMCID: PMC8791455.
- ↑ Tavassoli S. Comment on: 'The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures'. Eye (Lond). 2023 Jun 24. doi: 10.1038/s41433-023-02651-4. Epub ahead of print. PMID: 37355757
- ↑ Lever M, Smetana N, Bechrakis NE, Foerster A. Erhebung und Reduktion der Abfallproduktion im Augenoperationsbereich [Survey and reduction of waste production from eye surgery]. Ophthalmologie. 2023 Sep;120(9):932-939. German. doi: 10.1007/s00347-023-01840-6. Epub 2023 Apr 13. PMID: 37052707.
- ↑ Birtel J, Heimann H, Hoerauf H, Helbig H, Schulz C, Holz FG, Geerling G. Nachhaltigkeit in der Augenheilkunde : Adaptation an die Klimakrise und Mitigation [Sustainability in ophthalmology : Adaptation to the climate crisis and mitigation]. Ophthalmologie. 2022 Jun;119(6):567-576. German. doi: 10.1007/s00347-022-01608-4. Epub 2022 Apr 22. PMID: 35451609; PMCID: PMC9024069.
- ↑ Chadwick O, Cox A. Response to Tetsumoto et al. regarding the use of fluorinated gases in retinal detachment surgery. The environmental impact of fluorinated gases. Eye (Lond). 2021 Oct;35(10):2891. doi: 10.1038/s41433-020-01197-z. Epub 2020 Sep 22. PMID: 32963309; PMCID: PMC8452693.
See also
- Ophthalmology and Climate Change
- Sustainability practices implementation made easy
- The Environmental Sustainability of:
