Eyes, economics and the environment: should green issues drive changes in ophthalmic care? –Yes

A cooling economy and a warming climate make this an opportune time to consider how ophthalmology might respond to the need to improve services while cutting costs. Although the NHS has enjoyed significant real growth in funding over the last decade, the King's Fund reports that the prospects for spending growth over the coming years look bleak.1 Meanwhile, climate change is now recognised as the biggest threat to global health in the twenty-first century.2

These trends are likely to impact on ophthalmic services. A reduction in available resources could affect the ability of the VISION 2020 resolution, and the UK vision strategy, to achieve their goals. Meanwhile, climate change may alter the epidemiology of diseases, such as cataract, trachoma, and fungal keratitis, and our ability to provide appropriate services.3

The UK Government has responded to these challenges by setting ambitious, legally binding targets to reduce CO2 emissions, and attempting to kick start the economy with ‘a green new deal’ designed to rescue us from climate and financial crises as Roosevelt's 1930's version did for America during the Great Depression. NHS England has a carbon footprint of over 18 million tonnes of CO2 and is responsible for 3.2% of all English CO2 emissions.4 In all, 16% of this is related to travel, 22% to building energy use, and 62% to procurement. If the NHS is to have its role in meeting the legislative targets, fundamental changes, not just to building energy use but also to the way that care is provided, will be required. Fortunately, adopting lower carbon care may offer opportunities to improve both the quality of patient care and the cost effectiveness of its delivery.

Four principles might guide us: disease prevention, patient empowerment, lean service delivery, and the preferential use of low carbon technologies. William Gibson famously noted ‘the future is already here—it's just unevenly distributed.’ Looking at some examples reveals the outlines of what higher quality, more resource-efficient ophthalmic care may look like in future.

Advances in technology have the power to transform5 and can contribute heavily to any solutions. Imaging technologies are increasingly used to improve referrals, aid triage, and reduce unnecessary visits by facilitating the sharing of digital images of cases of strabismus6 and anterior7 and posterior-segment8, 9 disease. This can enable more patient-centered care by allowing optometry services to provide more primary eye care through one-stop cataract clinics,10, 11 shared-care glaucoma clinics,12 and contributions to screening programmes for diabetic retinopathy and retinopathy of prematurity.

Personal computers can facilitate data management, education and, in the absence of appropriate vision charts, the measurement of visual acuity.13 Online video and image banks are already valuable learning resources and are being further developed. ‘Eye-Site’ (http://www.e-lfh.org.uk/projects/eyesite/index.html) is a collaborative development by the Royal College of Ophthalmologists and ‘e-learning for health,’ which will provide interactive knowledge sessions and a validated case archive to support the learning goals of the new curriculum. This builds on the new blended learning approach, which has improved the College's basic surgical skills course by allowing more time to be dedicated to practical tasks when visiting the skills centre. Other developments include new knowledge aggregators, such as NHS evidence, which improve access to the best sources of evidence, electronic patient records, which can facilitate audit, feedback and appropriate referral,14 and virtual reality simulation for surgical training.15 In future, perhaps, we will see live surgery16 demonstrated at virtual conferences,17 online decision aids,18 or self-tonometry for the monitoring of IOP in glaucoma.19

Simple, low-tech measures also have a role and can improve existing systems. For example, water-saving taps reduce the amount of water used when scrubbing,20 checklists reduce surgical complications,21 patients can be followed up by telephone consultation,22 and timely communication between primary and secondary care can be enhanced through electronic communication (perhaps reducing the risk of delay or inappropriate cancellation of a patient's follow-up leading to visual loss as highlighted in the recent NPSA report) (http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=61908).

Many of these innovations, both novel and established, are yet to be fully validated in both hospital and community settings, where their safety, acceptability, and cost-effectiveness must be assessed. However, it appears that the tools are available for ophthalmic care to be provided in better, cheaper, more sustainable ways and we might consider following the lead of our colleagues in renal medicine who are already embracing the sustainability agenda (http://www.greenerhealthcare.org/green-nephrology-programme). Some might argue that there is a moral dimension to this discourse, our legacy to future generations; however, more compelling are the immediate arguments for improved quality of care, better utilisation of scarce resources, greater patient safety, and wider adoption of truly innovative technologies and management systems. Perhaps it is time to leapfrog these twin crises by introducing sustainability criteria into procurement contracts for ophthalmic equipment and medicines, conducting more research on the safety, efficacy, and acceptability of low carbon care and developing and implementing the most promising of the innovative solutions, which abound in ophthalmology.


  1. 1

    Appleby J, Crawfor R, Emmerson C . How cold will it be?, Prospects for NHS funding: 2011–17 The King's Fund: London, 2009 Available at:http://www.kingsfund.org.uk/publications/how_cold_will_it_be.html. (accessed on 7 February 2010).

    Google Scholar 

  2. 2

    Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009; 373 (9676): 1693–1733.

    Article  Google Scholar 

  3. 3

    Johnson GJ . The environment and the eye. Eye (Lond) 2004; 18 (12): 1235–1250.

    CAS  Article  Google Scholar 

  4. 4

    NHS. NHS England carbon emissions: carbon footprinting report. SDC: NHS Sustainable Development Unit, England, 2008.

  5. 5

    White Jr L . Medieval Technology and Social Change. Clarendon Press: Oxford, 1962.

    Google Scholar 

  6. 6

    Helveston EM, Neely DE, Cherwek DH, Smallwood LM . Diagnosis and management of strabismus using telemedicine. Telemed J E Health 2008; 14 (6): 531–538.

    Article  Google Scholar 

  7. 7

    Kumar S, Yogesan K, Constable IJ . Telemedical diagnosis of anterior segment eye diseases: validation of digital slit-lamp still images. Eye (Lond) 2009; 23 (3): 652–660.

    CAS  Article  Google Scholar 

  8. 8

    Richter GM, Sun G, Lee TC, Chan RV, Flynn JT, Starren J et al. Speed of telemedicine vs ophthalmoscopy for retinopathy of prematurity diagnosis. Am J Ophthalmol 2009; 148 (1): 136–142.e2.

    Article  Google Scholar 

  9. 9

    Kennedy C, Van Heerden A, Cook C, Murdoch I . Utilization and practical aspects of teleophthalmology between South Africa and the UK. J Telemed Telecare 2001; 7 (1 Suppl): 20–22.

    Article  Google Scholar 

  10. 10

    Park JC, Ross AH, Tole DM, Sparrow JM, Penny J, Mundasad MV . Evaluation of a new cataract surgery referral pathway. Eye (Lond) 2009; 23 (2): 309–313.

    CAS  Article  Google Scholar 

  11. 11

    Gaskell A, McLaughlin A, Young E, McCristal K . Direct optometrist referral of cataract patients into a pilot ‘one-stop’ cataract surgery facility. JR Coll Surg Edinb 2001; 46 (3): 133–137.

    CAS  Google Scholar 

  12. 12

    Morley AM, Murdoch I . The future of glaucoma clinics. Br J Ophthalmol 2006; 90 (5): 640–645.

    CAS  Article  Google Scholar 

  13. 13

    Kumar S, Bulsara M, Yogesan K . Automated determination of distance visual acuity: towards teleophthalmology services. Clin Exp Optom 2008; 91 (6): 545–550.

    Article  Google Scholar 

  14. 14

    Imrie F, Blaikie A, Cobb C, Sinclair A, Wilson D, Dobson S et al. Glaucoma electronic patient record—design, experience and study of high-risk patients. Eye 2005; 19 (9): 956–962.

    CAS  Article  Google Scholar 

  15. 15

    Spiteri A, Aggarwal R, Kersey T, Benjamin L, Darzi A, Bloom P . Phacoemulsification skills training and assessment. Br J Ophthalmol 2010; 94 (5): 536–541.

    Article  Google Scholar 

  16. 16

    Hollick EJ, Allan BD . Live surgery: national survey of United Kingdom ophthalmologists. J Cataract Refract Surg 2008; 34 (6): 1029–1032.

    Article  Google Scholar 

  17. 17

    Viswanathan NP . Virtual congress of general practice is thriving. BMJ 2008; 337: a681.

    CAS  Article  Google Scholar 

  18. 18

    Evans R, Elwyn G, Edwards A . Making interactive decision support for patients a reality. Inform Prim Care 2004; 12 (2): 109–113.

    PubMed  Google Scholar 

  19. 19

    Liang SY, Lee GA, Shields D . Self-tonometry in glaucoma management—past, present and future. Surv Ophthalmol 2009; 54 (4): 450–462.

    Article  Google Scholar 

  20. 20

    Somner JE, Stone N, Koukkoulli A, Scott KM, Field AR, Zygmunt J . Surgical scrubbing: can we clean up our carbon footprints by washing our hands? J Hosp Infect 2008; 70 (3): 212–215.

    CAS  Article  Google Scholar 

  21. 21

    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360 (5): 491–499.

    CAS  Article  Google Scholar 

  22. 22

    Mandal K, Dodds SG, Hildreth A, Fraser SG, Steel DH . Comparative study of first-day postoperative cataract review methods. J Cataract Refract Surg 2004; 30: 1966–1971.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to J E A Somner.

Ethics declarations

Competing interests

The authors declare no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Somner, J., Connor, A. & Benjamin, L. Eyes, economics and the environment: should green issues drive changes in ophthalmic care? –Yes. Eye 24, 1309–1311 (2010). https://doi.org/10.1038/eye.2010.64

Download citation

Further reading