Survey examines the sustainability of cataract surgery within Morocco

Dr Safia Benamar recalls the ancient khettaras that wind their way through the streets in the oasis town where her grandmother grew up in Morocco.

In Figuig, this fragile, ingenious irrigation system is one of many aspects of traditional Moroccan life that is under threat by the climate crisis.

Evaporation means the spring water is saltier and less abundant, while date crops are also under threat from successive droughts. Benamar’s grandmother has observed how the palm groves have receded with the rising heat.

“I was sitting with my grandmother, and she told me, ‘I remember that this was once only green land’,” Benamar recalled.

As a third-year ophthalmology resident in Morocco, Benamar is endeavouring to play her part in mitigating the effects of climate change.

Benamar presented her survey examining the sustainability of cataract surgery in Morocco at the European Society of Cataract and Refractive Surgeons Congress (ESCRS) (11-15 September, Excel London).

“Climate change has become very difficult to ignore. It’s part of our daily lives,” Benamar told OT.

“Morocco has faced several years of drought, and it prompted me to reflect on my role as an individual and also as a trainee,” she said.

Climate change has become very difficult to ignore. It’s part of our daily lives

The environmental footprint of cataract surgery

Benamar highlighted that cataract surgery is the most common ophthalmology procedure performed globally – with around 30 million procedures performed each year.

“That volume matters because healthcare is responsible for 5% of the greenhouse emissions,” she added.

“What's also striking is how much this footprint varies between care models rather than by the procedure itself. A single phacoemulsification in the UK generates roughly 20 times the carbon emissions of the same procedure performed at the Aravind Eye Care System in India,” Benamar observed.

She added that the Aravind Eye Care System performs cataract surgery with reusable instruments and supplies while drawing from renewable energy sources.

Benamar shared that the hospital incorporates responsible water and waste management strategies, while maintaining safety and quality outcomes.

“Critically, this lower carbon model hasn’t come at the cost of safety because Aravind reported a postoperative endophthalmitis rate of 0.01% across more than a million consecutive procedures, which is actually lower than the rate reported by the US,” Benamar highlighted.

Benamar shared that while research has been conducted internationally on the environmental footprint of cataract surgery, no studies had been conducted within Morocco.

“The first step was to identify how people are practising, what they think about sustainability and where the pain points are,” Benamar observed.

She conducted an online questionnaire of 123 ophthalmologists and trainees working in Morocco.

The survey found that 81% of respondents used reusable instrumentation, while 75% reported reusing phacoemulsification cassettes.

More than three follow up appointments following cataract surgery were reported by 71% of respondents, while 68% of respondents reported prescribing three or more eye drops after cataract surgery.

Around one in three respondents (31%) agreed that cataract surgery generates excessive waste, with lack of training (43%) and infection concerns (48%) reported to be the main barriers to reducing waste.

Benamar noted that infection concerns relate to endophthalmitis – a potentially blinding infection that can develop after cataract surgery.

“Endophthalmitis is rare, but it can be blinding, so caution is instinctive. However, reducing waste is not simply a clinical question. The barriers are multifactorial, including regulatory constraints, industry and financial considerations, as well as perceptions and concerns around safety,” she said.

Dr Safia Benamar

Dr Safia Benamar, third-year ophthalmology resident

Reducing waste

Reflecting on the changes that she would like to see, Benamar emphasised the importance of working together to bring about change.

“We need to keep this conversation visible and active within the Moroccan ophthalmology community. Sustainability cannot move forward as an individual effort,” she highlighted.

The ophthalmology trainee added that she would like to see changes to the equipment that is used during cataract surgery.

“I would like to see cataract instrument trays optimised – stripping out redundant items that get opened but rarely used,” she said.

“On the prescribing side, reducing unnecessary post-operative eye drops and excessive post-operative visits is another concrete target. This is not only for environmental reasons, but because the evidence doesn’t consistently support that more drops or more visits improves outcomes,” Benamar emphasised.

As a next step in her research, Benamar is conducting an audit to establish the cost, carbon footprint and extent of packaging waste generated through cataract surgery across multiple public and private cataract surgery providers in Morocco.

“The goal is to demonstrate with local data where we are already doing well – for example, the use of multi-dose iodine bottles – and to quantify the environmental and economic burden of overprescribing eye drops,” she said.