Going Green in Ophthalmic Practice

Abstract

The healthcare sector has had a relatively late implementation of environmental thinking in its setup. “Green electronic technologies and go green healthcare system” has recently evolved to address the biodegradability and biocompatibility issues faced by inorganic electronics and non-biodegradable materials. Green healthcare has the capability to promote global health both directly and indirectly. With the rise in environmental degradation, utilizing innovative ‘Go Green’ strategies in ophthalmology is of utmost importance. It has been structured to imbibe environmentalism into healthcare. In this chapter, we have emphasized a few simple patient point of care (POC) innovations in the field of ophthalmology that could transform the future of disease management toward a much more sustainable model by reducing resource and energy consumption. We have discussed how we innovated the novel coronicle (corona + cubicle) during the COVID-19 era, which housed all the essential ophthalmic gadgets and was interconnected using the local area network (LAN) for data access in patient care. Turning to patient counseling, we have highlighted how our innovative and cost-effective 3D augmented reality, and 4D holographic diagnostics and counseling platforms are effective in replacing the conventional paper-based system.

1. Introduction

Environmental changes are considered by many as the major long-term threat to global health in the 21st century [1]. To keep an eye on that, worldwide communities, governmental agencies or international research programs like Green Program 2030 have made massive, concerted efforts to launch new visions in the economy, society, and healthcare sector such as green building, green cities and other go green initiatives, but, global environmental issues and its potentially catastrophic effects are accelerating faster than anticipated [2, 3, 4, 5, 6]. Healthcare services are more substantial contributors to climatic changes as it generates the most diverse both non-biodegradable and biodegradable biohazard waste materials in large quantities; compared to any other commercial sector. At least 15% of that are highly hazardous and not managed in an environmentally safe manner [7, 8]. In addition, the percentage of plastic in medical waste may be as high as about 20–30% [9]. Moreover, since the first outbreak of coronavirus disease (COVID-19) early in 2020, eight million tons of pandemic-associated waste (plastic) have been generated globally, contributing to environmental degradation and climatic change [10, 11, 12]. It is a known fact that healthcare services are significant contributors to total national greenhouse gas emissions, such as 10% in the United States of America (USA), 7% in Australia, 5% in Canada and Japan, 4% in the United Kingdom (UK) and 1.5% in India [3, 13, 14, 15, 16, 17].

Without question, modern eye care practice, as a high-volume service, generates an enormous amount of non-biodegradable trash regularly, and it all starts with any organization’s routine surgical and outpatient department (OPD) procedures, whether in private practice or academia or somewhere in between. For instance, ophthalmology is a high-volume speciality, accounting for 8·1% of hospital outpatient visits nationally in 2018–2019 in the UK [18]. Consequently, all eye healthcare centres in the world face numerous challenges, including inaccessibility of good services, rising costs, and an increase in environment-related pollution.

The adverse effects of ophthalmic healthcare delivery on the environment will probably increase daily. There are many innovations implemented to solve this problem, and demand is rising as the world population grows and ages. In this chapter, we have discussed one such emerging green concept; by embracing this concept, eye hospitals mainly benefit in terms of energy-saving, which can also lead to monetary savings. The green color is indicative of the effort taken to create an eco-friendly healthcare system. Going green involves waste reduction, and energy and resource conservation in the modern healthcare system, which requires expensive, energy-intensive processes in the use of water, lighting, heating, cooling, ventilation, and waste disposal [19]. As per estimates, 15 to 30% of energy and around 30% of water could be saved in this process. Usage of general lighting, compact fluorescent lamps (CFLs) and light-emitting diode (LED) lamps can reduce energy consumption by 15–30%, 30% and 45–50%, respectively [12]. The Indian Green Building Council (IGBC) and Green Rating for Integrated Habitat Assessment (GRIHA) are the green building rating systems that help review the requirements and aid in setting up goals for green projects by targeting elements of sustainability [12].

The medical community has already implemented green practices in various surgical units, such as in cataract surgery and surgical waste disposal. Still, the functioning of green teams should be beyond the hospital setting when involving long-term care or outpatient clinics [20]. In this chapter, we have discussed simple patient point of care (POC) innovations for diagnosing eye diseases and counseling platforms toward a much more environment-friendly culture in the OPD.

2. Green outpatient department and clinics

A healthy work environment is essential in healthcare not only to care for its own but to model for society at large the value of a healthy environment maintained according to principles of sustainability [21]. The essential principles of green clinics are to create a workspace that is safe and effective for both the patient and health workers and provides a sustainable model for long-term global health.

2.1 Coronicle (Corona +cubicle)

With the emergence of the COVID-19 pandemic, many drastic changes were made in the ocular healthcare system to provide quality healthcare without compromising safety and functionality, while also considering greener strategies [22, 23]. One such innovative practice pattern was the ophthalmic coronicle (cubicle) which was constructed to ensure safety for both healthcare workers and OPD patients in a high-volume urban private set-up [24].

2.1.1 Establishment of the Coronicle

During the COVID-19 pandemic, the pre-COVID waiting hall of approximately 450 square feet was converted into a state-of-the-art investigation coronicle of 256 square feet for comprehensive ocular examination (Figure 1). Dimensions of the coronicle were 16 feet in length, 16 feet in breadth, and 8 feet in height; since only a minimal area was utilized for patient examination, the usage of electricity was reduced greatly, contributing to environmental sustainability. Acrylic sheets, aluminum beading, fevicol, araldite paste, and a jigsaw cutting blade were used to build the coronicle in a do-it-yourself (DIY) template. A detailed cost analysis of the materials and the total cost of setting up the coronicle are provided in (Table 1) [24]. There are two slit lamps, two electronic medical records (EMR) computer systems, and one auto refractometer, lensometer, confocal fundus capture device, spectral-domain optical coherence tomography (OCT), optical biometer, manual keratometry, corneal topography, and non-contact tonometer (NCT) encompassed inside the coronicle (Figure 2), which were interconnected via local area network (LAN). The coronicle has proved to be effective over a period of two years (June 2020–July 2022) with the majority of the patients only needing the services available within the coronicle (p = 0.00). Table 2 provides the details of the number of patients requiring the services available within and outside the cubicle during this time period.

Figure 1.

Image showing the coronicle (corona + cubicle) in the pre-COVID waiting hall.

Materials	Dimensions	Price/unit (GBP)	Quantity	Amount (GBP)
Acrylic Sheet (8 mm thickness)	16*8 feet	4.61/square feet	4	2358.29
Aluminum Beading (4*4-inch thickness)	16 feet length		4	146.56
Aluminum Beading (2*2-inch thickness)	8 feet length		20	146.56
Screws, nuts, and bolts				18.84
Adhesives (fevicol + araldite)				26.17
Lock for sliders and door		8.37	9	75.37
Air Conditioner	2 tons	471.07	1	471.07
Labour charges		0.84/square feet		214.39
Cutting charges				39.78
Total				3497.03

Table 1.

Materials used for assembly the cubicle and their cost dynamics.

Figure 2.

All the essential ophthalmological instruments required for an eclectic setup inside the coronicle (a) optical biometry (b) optical coherence tomography, (c) corneal topography, (d) manual keratometry, (e) non-contact tonometer, (f) confocal fundus photography, and (g) slit lamp biomicroscopy.

Total patients
Month	Total OPD	Inside Cubicle						Percentage
		Slit Lamp	Lenstar	Sirius	Fundus	NCT	OCT
2020	19,181	19,101	3185	3185	14,207	13,910	1965	94.94%
2021	38,390	38,268	5221	5221	25,108	27,467	4328	96.50%
2022	27,564	27,502	4053	4053	12,359	20,242	4120	95.16%
Total	85,135	84,871	12,459	12,459	51,674	61,619	10,413	95.71%
Month	Total OPD	Outside Cubicle
		Synopto Phore	B-scan	Pachy Metry	Specular	Visual Field	IO
2020	19,181	30	720	6	9	60	2136	5.06%
2021	38,390	150	1330	32	256	218	1838	3.50%
2022	27,564	155	959	22	956	290	1300	4.84%
Total	85,135	335	3009	60	1221	568	5274	4.29%

Table 2.

Total number of ocular examinations at various stations performed inside and outside the cubicle.

2.1.2. Go green with Coronicle

As all the ophthalmic instruments need maintenance via good air conditioners for their longer sustainability, keeping each instrument in a different room ends up with a great amount of electricity consumption as well as a higher number of manpower, which is a major contributor to the carbon footprint. Air conditioners release potent greenhouse gases into the air causing insulation of our planet; it is a major contributor to global warming. Before the implementation of the coronicle, the total electricity consumption of the hospital was approximately 22,000 kilowatts per month, which has effectively reduced after the implementation of the coronicle to approximately 13,000 kilowatts per month. So, instilling all the gadgets in a single coronicle can effectively reduce the usage of the number of air conditioners as well as the number of tube lights, which in turn can reduce the consumption of electricity and can lead to a climate-friendly and energy-efficient healthcare facility. This way eye care hospitals can take initiative to address global environmental health for the future and present-day generations.

2.2 Local area network (LAN)

2.2.1 Features of LAN

Similarly, during the pandemic, along with the coronicle, we were able to optimally utilize LAN, which interconnects all the ophthalmic gadgets to the personal computer (PC) (Figure 3). As a result, it amplifies the functionality of holistic eye examination using a single internet connection [25]. In cases with multi-modal imaging and testing, LAN plays a vital role by not only connecting the devices but also providing in-depth data without compromising on quality.

Figure 3.

Image showing various devices linked via local area network (LAN) interconnectivity.

2.2.2 Setting up the LAN framework

The LAN networking is implemented by a sixteen-port switch (Figure 4a) present inside the coronicle which is connected to the CISCO (Commercial and Industry Security Corporation) switch (Figure 4b) inside the server room placed in a 6 U rack. CISCO allows the connected devices to share information and communicate with each other on the same network inside the building for high-security purposes. LAN also link wireless access points, printers, xerox machine, scanners and servers on the same network for extra facilities. Each ophthalmic gadget has a unique IP address; for example, 192.168.1.16 has been given to the fundus capture device, and its associated computer has an IP address of 192.168.1.15. An IP address can be set by following these three simple steps (Control Panel- > Network and Internet- > Network Connections- > Use the following IP address). In this example, we have assigned an IP address of 192.168.1.16. Once the IP address is allotted for that specific gadget, the same address is entered in the web browser of the PC desktop placed near the doctor’s slit lamp for activating the screen-sharing relay display from the machine (Figure 5).

Figure 4.

(a) Sixteen-port switch connections to/from various gadgets. (b) Commercial and industry security corporation (CISCO) switch (yellow arrow indicates the 28 ports in CISCO).

Figure 5.

Image showing LAN connection of fundus capture device after entering the IP address in the web browser.

All eye care professionals can invest in LAN, as it is relatively more cost-effective than a high-end EMR system. The costs of the CISCO server with the switch are approximately 1,00,000 INR/1046.82 GBP and approximately 10,000 INR/104.68 GBP for the sixteen-port switch. The wiring cost depends upon the area covered.

2.2.3 Role of LAN in go green ophthalmic practice

The reports of every patient can be accessed and viewed immediately after the completion of the full evaluation. Also, they can be compared side by side with their former baseline and other examinations. This aids as a smart time-saver. For instance, the time can be reduced considerably, as doctors need not visit each investigative machine to see the respective patient’s data and patients can be counseled by showing their image, sitting in one place. At last, the patient’s report can be sent by mail or WhatsApp, so they can carry the soft copy for future reference everywhere and anytime. EMR systems require huge storage servers which consume a significant amount of energy, whereas LAN provides better functionality without compromise.

Paperless billing, medical record filing and counseling are now possible with advanced practice management software systems [26]. Going paperless saves trees, which can be considered a direct or indirect way to protect the environment [27, 28].

3. Go green diagnosing and counseling stations

Practicing ophthalmology in a sustainable way begins with a focus on prevention and wellness. Considering the environmental consequences may need more commitment but can be initiated through innovative ideas. There are many creative ways to effectively counsel patients by conserving energy; we have discussed two such innovative ways for ophthalmic patients’ counseling and diagnostic procedures. They are three-dimensional (3D) augmented reality (AR) and four-dimensional (4D) holographic diagnosing and counseling platforms. During this fast-paced global era, face-to-face counseling with two-dimensional (2D) images has many challenges, and it is hard for the patients to comprehend their disease. At the same time, the impetus of 3D models in AR and 4D holograms will pay rich dividends (Figure 6). The use of such innovations helps reduce the need for conventional paper pamphlets and plastic eyeball models, which makes a significant reduction in the consumption of paper and plastic.

Figure 6.

Image showing (a) two-dimensional (2D), (b) three-dimensional (3D), and (c) four-dimensional (4D) TrueColor confocal fundus images used for patient diagnosis and counseling.

3.1 3D augment reality

AR has progressed from a science-fiction concept to a science-based reality [29, 30, 31]. It has slowly but surely become a significant aspect of modern life over the last decade with increasing applications in the field of medicine, especially in ophthalmology [32, 33, 34]. AR is a view of the real, physical world in which the elements are enhanced by computer-generated inputs and available on mobile handsets, which constitutes an essential patient e-counseling platform. During COVID-19, the impetus for AR in ophthalmology is stronger than ever. Recently, an AR program named “Eye MG AR” was innovated for diagnostic procedures and counseling patients by showing different anatomical and pathological structures related to the eye (Video 1, https://www.youtube.com/watch?v=LC7VMI56hLo). The patients’ own pathological real-time TrueColor confocal images have been used in 3D, with multiple customized angles of the viewer’s choice to simplify counseling procedures (Figure 7) [35, 36].

Figure 7.

Image showing the “Eye MG AR” app being used for e-counseling.

For immersive visual experiences, simple structures such as the eyeball and its parts and complex systems essential to the eye (cerebral and dural venous sinuses) were also constructed using advanced real-time 3D photo-real visuals. This app, built on an innovative interactive 3D touch interface, has a significant influence on improving ophthalmic diagnostic procedures, especially in patient counseling.

3.2 4D extended reality holograms

Extended reality (XR) is one of the leading futuristic concepts, which is still slowly evolving to set foot into the field of ophthalmology [37, 38]. What makes this device cutting-edge is the spatial recognition, eye-tracking, and hand-tracking concepts. Spatial recognition senses the world around the user, and eye-tracking recognizes where the user is seeing [39, 40, 41]. It also projects the holograms into the eyes of the user as light rays. The hand-tracking concept helps the user to touch, move, rotate, and scale the holograms. Using extended reality technology, especially in ophthalmic diagnostics procedures and counseling, will revolutionize the face of counseling on a whole new level. We have used this novel technology and have created holographic counseling platforms for various anatomical structures such as the eyeball, cerebral venous system, cerebral arterial system, cranial nerves and multiple parts of the brain in fine detail and diseases related to the eye (Video 2, https://www.youtube.com/watch?v=XkHYTzYRHYU). Suppose the patients can see the 4D holographic models related to ophthalmology right in front of their eyes; it can change the way of counseling to a whole new level (Figure 8). Ophthalmic institutes and practitioners can invest in this cutting-edge technology to provide their neophyte ophthalmic residents and allied ophthalmic personnel with a real-time understanding of the concepts involved in patient care and diagnosis.

Figure 8.

(a & b) Image showing doctor counseling a diabetic patient with the help of 4D hologram of TrueColor confocal fundus image and optical coherence tomography (OCT) image by using Hololens 2 before and after treatment, respectively.

3.3 3D and 4D holographic diagnosing and counseling workflows

The real-time TrueColor confocal images of each patient can be viewed immediately and simultaneously once the patient has completed the advised diagnostic investigations. Also, they can be compared side by side with their previous baseline and other analyses in 4D. This is less time-consuming, eco-friendly and patients can be counseled by showing their pathological images without plastic eyeball models.

After completion of each diagnostic procedure, the patient’s data will automatically get stored in the hospital database. Eye MG, the 4D Holographic translational software, will access this hospital database to take the patient’s scanned images and project them as 4D holograms (Video 3, https://youtu.be/xZ2b4d89ngk). These holograms can then be used for patient counseling. The whole process will take approximately 60 seconds (Figure 9). These holographic case sheets will be stored each time the patient visits. So, for every visit the patient makes after the first time, their condition can easily be matched with their previous hologram side by side.

Figure 9.

Image showing the 3D and 4D holographic diagnosing and counseling workflow.

4. Recommendation

Green practice patterns can start with small steps, which will create an impact in a big way.

• Place recycling bins in convenient locations throughout the hospital.

• Turning off lights and machines at night and setting electronic equipment to sleep mode while not in use saves energy and money.

• Follow the advanced digitalization system for reports to avoid excess paper use.

• Practicing greener surgical protocols to help reduce carbon footprint.

• Ophthalmic institutes and practitioners can invest in 3D AR and 4D holographic technology to provide better patient counseling than plastic eye models without affecting the environment.

5. Conclusion

Keeping in mind that certain current systems in place are not only harmful to the current generation but also have a potential impact on the health of the unborn generation, it is our ethical responsibility to bring change where possible. Though change is a necessity, it is not easy, especially in a large and complex system such as healthcare. So, every small innovation will have a significant role in paving the way toward a green healthcare system. These few easy and adaptable steps of structure-based (cubicle), function-based (LAN), and technology-based (3D and 4D counseling platforms) reforms have been able to pave a path toward sustainable healthcare by helping us reduce our carbon footprint.

Acknowledgments

We are grateful to Mr. Pragash Michael Raj - Department of Multimedia, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India, for his technical support throughout the making of this chapter.

Conflict of interest

The authors declare no conflict of interest.

3D models were created and used for AR simulations, virtual reality, and advanced mixed reality with Microsoft HoloLens 2 by us in this chapter. This includes the human eyeball with TrueColor confocal fundus image. These models help in better understanding of concepts and can be used in various fields of medicine. We have created models related to ophthalmology, which allows us to explain a disease or a condition with its pathophysiology, pathway, clinical features, tests, treatment and prognosis creatively and interactively.

We have created apps using these models, including the Eye MG AR (https://play.google.com/store/apps/details?id=com.EyeMG_AR) and Eye MG 3D (https://play.google.com/store/apps/details?id=com.EyeMG_3D) which are based on AR model of the eye and multimodal fundus imaging atlas, respectively. These are available for Android users and are free to download from Google Play Store. An app for iPhone users named Eye MG Max (https://apps.apple.com/in/app/eye-mg-max/id1607482649) is currently available in App Store. This application provides eyeball with TrueColor confocal fundus images and all structures related to ophthalmology with a user-friendly interface. In Eye MG Max, multiple views with transparency for viewing the structures passing through another model, free camera mode, annotated modes, customized zoomed views and videos related to any ophthalmic pathology are provided; thus, providing a 3D atlas at the user’s fingertip for better patient counseling. Usage of mixed reality in ophthalmology is only in the primitive stages.

The same 3D models used in the previously mentioned applications have been imported into Hololens 2 for holographic viewing by medical professionals and patients. When viewed through Hololens 2, the device tracks our hands, eyes and surrounding environment. This enables us to select different holograms just by looking at them (eye-tracking) and move the holograms around and enlarge/shrink using our hands (hand-tracking). This enables us to view the models in a 360-degree 3-Dimensional view. We can use this to counsel patients in a much more efficient and convincing manner, leading to better patient compliance. We can also add components such as Optical Coherence Tomography apart from TrueColor confocal fundus evaluation. Advancements such as holographic surgical simulative training will come out eventually in the near future.

Notes/thanks/other declarations

I (Dr Prasanna Venkatesh Ramesh) owe a deep sense of gratitude to my daughters (Pranu and Hasanna) and family (in-laws) for all their prayers, support, and encouragement. Above all, I extend my heartfelt gratitude to all the patients who consented for the images which are utilized for this chapter.

I (Dr. Shruthy Vaishali Ramesh) want to thank my partner (Arul) for his constant support and encouragement during the process of creating this chapter.

I (Ms. Prajnya Ray) would like to offer my special thanks to Mr. Deepak Kumar Panda for his constant support and never-ending encouragement, and my parents (Mr. Anil Ray and Mrs. Soubhagyabati Ray) for their support and motivation during the process of framing this chapter.

I (Mr. Aji Kunnath Devadas) want to thank my parents (Mr. Devadas K and Mrs. Sheeba Devadas) for their constant support and encouragement during the process of creating this chapter.

I (Akshay Surendran) want to thank my parents (Mr. Surendran P and Mrs. Lalitha K) and my sister (Anjana Surendran) for their constant support and encouragement during the process of creating this chapter.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the chapter. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Nomenclature

3D	Three-dimensional
4D	Four-dimensional
AR	Augmented Reality
COVID-19	Corona virus disease-19
CFLs	Compact fluorescent lamps
CISCO	Commercial and Industry Security Corporation Switch
DIY	Do-It-Yourself
EMR	Electronic Medical Record
GRIHA	Green Rating for Integrated Habitat Assessment
IGBC	The Indian Green Building Council
LAN	Local Area Network
LED	Light-Emitting Diode
NCT	Non-contact Tonometer
OCT	Optical Coherence Tomography
OPD	Outpatient Department
PC	Personal Computer
POC	Patient Point of Care
UK	United Kingdom
USA	United States of America
XR	Extended Reality