Speaker 1 (00:00): Support for this podcast comes from Bryn Mawr Communications. BMC produces a number of informative podcast series spanning a variety of topics in ophthalmology. Discover a new show at eyetube.net/podcasts.

Neda Nikpoor (00:25): Hi Neda.

Neda Shamie (00:26): Hi Neda.

Neda Nikpoor (00:27): I'm Neda. I'm here with Neda.

Neda Shamie (00:29): And I’m Neda. Welcome to Neda Squared.

(00:39): Well, everyone, welcome to another episode of Neda Squared. In this episode, I'm really excited to have a dear friend and colleague, Dr. Radhika Rampat, who is calling in here with us very early in the morning all the way from London. She and I got to know each other about three, four years ago when she started really thinking about a new initiative that we're going to talk about, and that is a green working group where she founded this initiative and has made some huge improvements in ophthalmology, but a lot of opportunity for continued change in our field. And Radhika is a cornea anterior segment refractive surgeon in London. She has her own practice and also, she's at the Royal Free London Clinic and truly is a superstar. Radhika, welcome to Neda Squared. We're so excited to spend this next half hour with you.

Radhika Rampat (01:35): Thank you so much for having me. This is honestly a huge honor because I listen to you guys all the time, so it's a pinch-me moment now.

Neda Shamie (01:43): You're very sweet. And by the way, my daughters follow your Instagram and they're like, "Mom, why can't your Instagram be like hers?" So pinch moment is for me. They may sneak in and want to– you're a superstar in our household.

Neda Nikpoor (01:58): Yeah, you're definitely a celebrity in ophthalmology. We love having you on here.

Radhika Rampat (02:02): Thank you so much. Thank you.

Neda Shamie (02:04): Tell us a little bit about your practice and then we can start chatting about what really draws at your heartstrings.

Radhika Rampat (02:12): Absolutely. So, I would describe myself, yes, as a vision correction surgeon, as many of us based in London. And as you said, I'm at the Royal Free. I'm also an honorary consultant at Moorfield's Eye Hospital, and then I have my own practice in Central London as well. And the other hat that I wear, I suppose, is that I am "the EyeFluencer" hoping to influence you all into doing good things within ophthalmology, whether it's telling patients about healthy eye habits or sharing the most recent conference or talking about sustainability and the things that I do within it. And then I'm the co-founder of the AECOS Green Working Group. And the truth is that it got inspired because of AECOS, which is the American European Congress of Ophthalmic Surgery. I got asked in 2022 to just– I was the new young ophthalmologist on the block and they said, "Why don't you arrange a sustainability session within AECOS?" And that was happening in Antwerp.

(03:15): And I said, "Yeah, sure." So, as I started to get this group of sustainability speakers together, both online and in person, I just started to understand the impact because till then it was all about clinical practice. But suddenly I was seeing all this information about waste in eye surgery and in eye care and it was just astounding. So, most people normally do sessions. They get on the stage, they do their thing, they moderate, and then you get off stage and you say, "Okay, see you next year." But something kind of struck me so much that when I got off the stage, I immediately said, "Something has to be done." And often you kind of think to yourself, "But somebody else is doing it or it's somebody else's thing." And I suddenly realized, no, we are the guys. We have to do this. And so, I just went home and just sat and read.

(04:13): There are so many amazing papers by people in sustainability, and I started just to read and read, and I had this whole folder of sustainability research papers. And in the end, we decided to go with– thankfully actually it was Sharaz Daya who really was my mentor at the beginning, and it sort of snowballed after that. And I co-founded this with David Shahnazaryan, who's a good friend and colleague here in London. And now of course we've snowballed to having expanded it into the US as well with Neda initially taking the baton and now it's gone on to Morgan Micheletti. And Kendall Donaldson has been so, so supportive as well. So, this has been kind of the core group that's been working together. So, the initiative that we started was that the logo and the motto of the AECOS Green Working Group was really to “ACT Locally and ImpACT Globally”.

(05:12): And when you see the “ACT”, the “ACT” is capitalized in both the “Act” and the “Impact”. And that's something that was so important to me because what I realized is we talk about sustainability all the time, but it doesn't really trickle down into our daily clinical practice. And I don't know if you both have experienced that as well. At least in the UK, one cataract surgery is equivalent of driving 500 kilometers or over 300 miles compared to Aravind Eye Care System, which I was fortunate to visit. They have about 5.9 kilograms of carbon emissions in comparison to 180 kilograms in the UK. I mean, the difference is astounding.

Neda Nikpoor (05:56): I love that you brought up that study because I was actually going to ask you about that because I know that was 2017 and UK compared to India. There are obvious differences in the way things are done and they showed that the outcomes are basically the same and ophthalmitis rates, all the things that people worry about when they talk about reusing instruments, they effectively proved in their Aravind trial that it was effective and had less carbon emissions. But we have a lot of regulations in the US that prevent us from doing things like using the same eye drop bottle even for multiple patients in some settings and some hospital settings. And so, I know David Chang and others are really involved, you guys are involved in trying to advocate for change in policy. So, I love the concept of act as an individual, but I'm curious if you can talk a little bit about, okay, what can people do as individuals versus what's being done on a broader scale to try to empower individuals to make decisions because so much of it is out of our hands.

Radhika Rampat (06:59): Yeah, no, absolutely. And that is what I thought as well. So, there's a whole other section about regulations and that's something that actually I started working on almost like a one-page draft because I feel like even as ophthalmologists, we don't even know what the regulatory issues are sometimes. And other times we'll try and make a change, and we'll come up against a barrier and then we often say, "Okay, well you know what? It's out of my hands. It's too big." And then I realized that yes, there's different subsections of things we can work on, but the fact is that just small things can have a huge impact and we kind of put that or brush that aside, but actually it's really impactful. And I didn't realize that until I started doing some projects locally and impacting nationally and internationally as well. The other thing is that there is a whole, at least in Europe, there's a whole med tech group and you need a few of the ophthalmology industry members to be in there, but it's very expensive to buy into that group to get a say on that.

(08:04): That's frustrating for all of us and I feel like that is going to be the end goal. And I think groups such as EyeSustain led by David Chang– we are part of EyeSustain as well, the AECOS Green Working Group. And we endorse EyeSustain and support it, but we carried on kind of chugging away ourselves because I felt like there were some changes that I wanted to make, as I said, locally. So let me give you an example, just a small example. One of the things where it was kind of regulation versus change was it was about scrub hats, so reusable scrub hats. So, I saw every day that we'd go to a hospital, put on a sort of throwaway scrub cap, put it on, not think about it, and then, oh, it falls on the floor or something happens, you get another one and then, oh, you've got five medical students coming.

(08:54): Okay. And then the theater nurse is circulating. Okay. So suddenly this is just building up, and most people would be like, "Oh, it's very light. It's very small. What's the big deal?" But then I said, "You know what? We should have reusable scrub caps." And there are plenty of places that do it. And I think in America you have reusable scrub caps. I see it quite often. Although sometimes you have to apparently put it on and then put another one on top as a throwaway, which again makes no sense.

Neda Shamie (09:20): That's again, one of those policies no one has really questioned. Do you need to do that? Yeah.

Radhika Rampat (09:25): Exactly. And of course, if you are sitting in, I don't know, a really gory vascular kind of surgery where blood is spraying everywhere, fair enough, maybe I can understand, but even then, we can wash it. But we use different reusable scrub caps between patients. I don't know because they're longer surgeries. But for us, we have quick, quick surgeries and if you go in and out and maybe you take it off, it's just such a waste. And so, when we started to talk about it immediately, infection control, no, you can't do that. And then we kept on coming back to them with data, studies, and then eventually we were like, oh, and the next-door hospital's already doing it and trialing and it's been successful. And we kept on going back, kept on going back. And then finally somewhere it must have clicked for somebody, and they said, oh, actually, yeah, in fact, another hospital within our group is also going to be trialing this.

(10:18): And suddenly it all came together. And the moment we got the yes from the infection control, they asked all the kind of questions, where are you going to wash it? How many times are you going to wash it? Do doctors really wash their caps? All these questions. And finally, we had a retort and an answer for everything to the point where they said yes. The moment they said yes, we had some charity money, and we got everybody scrub caps. And the amazing thing is that we had it with our names in the front and the green working group logo on the side. And that way, even for patients, they suddenly knew who's treating them. Sometimes they listen, but they don't know or it's overwhelming. So, there were multiple, and everybody in the group, even though we introduced ourselves at the team brief can understand, oh, I can just remember that person's name if you haven't worked with them.

(11:06): So, it really does have a huge impact. And that was just one of the things that we pushed back on that we could. And it's a small thing.

Neda Shamie (11:12): What was really impressive to me was those images of the trash that you described that we accumulate from just one 10-minute cataract surgery. Can you go over that and what changes you've implemented?

Radhika Rampat (11:24): Yeah. When I went to visit Aravind, the difference was astounding. And so, what I have realized is, for example, step by step, one of the papers that we published in JCRS was about the information for use-leaflets within all those boxes. And we looked at and named and shamed all the companies. They were already trying to make changes, but it really did, I think, catapult them into, okay, we really need to focus on this. And it was just looking at these information-for-use leaflets, and there'll be 12 empty pages. No one reads. No one reads, and it was IFUs for every single IOL implant, as if it's going to change the next time you open an implant. And so, it was all about changing it to electronic IFUs. And so, we equated it to the amount of trees wasted, et cetera. And we just named all the companies and weighed, physically weighed each and every IFU and put it into a table.

(12:26): And we said, "This is the worst, this is the best." And now I think that that has continued to impact, and I think companies are improving it all the time. Although the other day I did open a box of, I think it's like apraclonidine little sachets that you get, like single use drops. And there was a box, just a box with 12 of these sachets with 12 IFUs.

Neda Shamie (12:51): Oh my gosh.

Radhika Rampat (12:52): And I just emptied the box and I was like, "What is this? This is unacceptable." So, I took a photo, of course, and I will be writing to the CEO or something.

Neda Nikpoor (13:02): Thank you for doing that. When that happened, I was so grateful that somebody fought that fight. So, thanks for being the person and leading the charge to get that done.

Radhika Rampat (13:11): No, that was brilliant. That was with Benjamin Stern and Damien Gasnell and the group, and we collaborated on that. And interestingly, that led to a collaboration, not directly, but an impact by the Green Working Group because the Obs and Gyne Society looked at it and then they said, "Oh, all these contraceptive things have all these IFUs." So, they wrote a paper then on the back of that. So that was kind of cool, impacting other specialties, not just your own. And then I guess one of my other projects that I wanted to talk about really, which I felt has been locally most impactful and taught me how to go from an idea to actually execution, because there's a lot of things that you need to do to have that and the barriers that we get for that and to create a baseline for people to follow, like a structure.

(14:05): And so, it was all about single dose units. And my obsession was that there's all these single dose units that we use because it's preservative-free and it's better for the patient's ocular surface. But there's a ton of companies that are doing these preservative-free bottle drops now. And it's all come about in the last, I think, five, 10 years, but it's just not really come to the forefront of people's minds. And so, we're still using all these single-dose units. And so, I found all these alternatives and we looked at– so we did a whole review, and I think this is what every single ophthalmology unit should do. In fact, the first thing I said is that every single ophthalmology unit in the world, any eye clinic, private or public, should have a sustainability champion or sustainability warden. That's where we started. And we already have quite a few clinics around Europe that have this in place that are doing little projects on their own.

(15:01): And then the next thing was, okay, I told my pharmacy group, I said, "Please give me the list of every single ophthalmology drug that we have, what box it's in, is it preservative-free or not?" And create a table. And that took some time and it was almost a hundred drugs, and a lot of it was repeated and wasteful in the first place. So, we suddenly realized, why are we ordering five of these? And then I chose eight medications, which were some treating infections and some for glaucoma. And I said, "Let's pick these eight medications that are going to be the most impactful and look at their preservative-free bottled alternatives." And then we looked at just simple metrics. I took a high-quality measuring device, weighing scale, and I weighed personally in the pharmacy every box of the single dose units versus the box of the preservative-free that we got ahold of from different companies.

(15:58): And just the drug and plastic waste was like, if you switch from one to the other, it was like 70 to 90% reduction in plastic waste, and then 80% reduction or 60% reduction in drug waste. And then came the cost. The cost benefit was about 50%, sometimes 60%, even more. And so suddenly when I said the cost-waste benefit, all the managers stood up and said, "What?" And that's when the impact started. And so, we made this change within North Central London. So, we have five hospitals within Royal Free. And then of course I was working with Morefield as well, and we basically locally started making the change. And then suddenly the local community heard about it, then we got involved. And actually, they were faster at making the change than we were. And we said that, and it's now implemented within the local community. And they said that if we continue down this path within a year or two, we're going to save about half a million pounds just from those eight drops just in that area.

(17:08): In fact, I think it was only about five drops in the end in the community with it because the other two were infectious, anti-infection drops. So, it was astounding for me. And so, this is just one example of just having an idea and persevering. And now of course I'm supporting amazing people around the world, and everyone's been approaching me and now I've got a group, one individual in Morocco who's doing a great job and hopefully I'll support. And then we've got a group in Turkey. And then everyone's now starting to reach out and start to do these things. And for me, the most important thing is of course, supporting people and making it a sustainable thing because till now it's been very much myself and a small group of people, but what we need is everyone involved. And that's what I hope this discussion will kind of inspire people to do is just picking one pain point and then going with it.

Neda Shamie (18:08): So, I think with that, we're going to take a short break for our sponsors to share a few words, let your message and your inspiration settle in, and we'll be right back.

Speaker 1 (18:24): Support for this podcast comes from Bryn Mawr Communications. BMC produces a number of informative podcast series spanning a variety of topics in ophthalmology. Discover a new show at eyetube.net/podcasts.

Neda Shamie (18:42): So Radhika, now that we're back, and for those of our listeners who listened to the first part of this Neda Squared episode, we are feeling very inspired by not just your message, your commitment, your passion for sustainability, but just how you went from, like you said, an idea of just running an hour-long symposium, mini symposium, to now really making movements and making change in our field, not just locally, but really globally. I mean, you talk about how you have friends around the world who are implementing some of the changes that you have suggested. What is it going to take for one of our listeners who's in their practice, and hopefully this idea is really sparking an interest in them. What is it going to take for my practice, Neda's practice, to start some of these changes and really bring your message and your initiative to our local practices?

Radhika Rampat (19:43): Of course. I mean, I think I just want this to feel like a community. And the first thing is that if you're stuck and you're not sure where to start, just reach out. Drop me a line, get on my Instagram, drop me a DM, and tell me the thing that you have noticed is most painful or most wasteful in your practice that you see on a daily basis. And get your medical students involved, get your resident doctors involved, get them riled up about it because it just takes one small idea from any one of them. Maybe you are so entrenched in the practice that you don't see it. They come in, they're like, "Oh, why are we throwing all these single use instruments into the incinerator? Why don't we use recyclable single use instruments instead of that?" And obviously we always reuse first, reuse, reduce, recycle, but just get one of them involved in your practice and put forward a sustainability warden or champion and just get started.

(20:42): The first thing is to keep noticing the pain points, and you don't have to go for the biggest problem, you just have to go for the lowest hanging fruit. And that's where I would start. And then reach out, become part of our community, and I can then at least say, "Oh, I know this person, they can help you with this thing." And we're not alone. And actually, eye care, and as we know, is such a small community. We all know each other, and we can all help each other. And it's just starting with that low-hanging fruit. And the next thing is maybe if you imagine yourself, okay, you thought of the low-hanging fruit, you thought of a solution, but now you have a barrier. That's where you need to have a way to register your idea. Now you can go online, go to AI and ask them to create a project based on the idea.

(21:31): What are all the barriers that you're going to come across? Okay, write them down and then step by step say, well, for that barrier, this is the solution. Write it all down. And I think you could probably solve so many problems pretty quickly now.

Neda Shamie (21:45): Do you have a task list? Do you have a list of to-dos and then validating studies? Because you've done the work, you've done the work. Instead of having to reinvent what you've already done and how you have substantiated it for your own hospitals and such, do you have a way for us to be able to access that kind of, again, task list and support?

Radhika Rampat (22:11): Absolutely. I mean, I think I've written a few roadmaps where we've registered things, and we've got primary drivers and secondary drivers and endpoints and risks and mitigations of those risks. So, we have them for particular projects that we've done, and I'm more than happy to share that. And in fact, I've just been invited to write a 5,000-word review article on this, so I think that is where it's all going to come out. So, I'm really excited actually because there's going to be no gatekeeping. That is not the point here. The point is to literally share everything I learn with every project, and I'm going to put it all down. And I'm hoping that probably by early next year we're going to see that. But in the meantime, you've given me an idea to do something, maybe like a quick little summary or something that we can do to get started.

(23:01): But really, it's just a case of the number of people that I've helped already. I would say just reach out and give me your project. I'll give you a few quick pointers and get you started and we can work together on it.

Neda Shamie (23:14): I mean, you've already listed the scrub caps. I'm going to go back to the trash bin because we changed some of that. I remember you showing just the sheer mass of the trash we accumulate instead of just dumping everything into a giant yard bag essentially for every cataract case to really make it much smaller so it's much more compact. I mean, that's a simple task to do and you don't necessarily have to get permission from anyone to do that.

Neda Nikpoor (23:41): Can you talk more about that? You just took the same amount of trash and put it in smaller bags so it's more compressed.

Radhika Rampat (23:46): It's more just about looking at what you're throwing away and sometimes simple things like separating the paper from the plastic and saying, okay, this one can be recycled. So, we have two bags usually everyone does. One is a recycling, one is the throwaway, and it's just being really careful about what you throw away. And simple things like even the cataract surgery packs, they come in these kind of blue covers that you open up. And so, in our practice in the hospital, we keep those as we open them up on the side. And then we use that to cover a little box that we were going to throw away anyway. And then we chuck any kind of thing that we've used to wipe the patient's eye, the iodine, et cetera, we throw it in there. So little ways of reusing things and moving things around so that actually you don't open a new thing to do the same job.

(24:38): So yeah, you can just be a little bit more careful and ask because the scrub nurses do know how to separate things, but sometimes you get a little bit, if it's not at the forefront of your mind, you might get a bit lazy and just throw it in the normal trash bags.

Neda Nikpoor (24:55): You’re inspiring me to talk to one of my nurses, one of my lead nurses actually lives off the grid on the north shore and is super environmental. And I'm actually embarrassed to say, I'm like, "Wow, I can't believe we don't have a sustainability champion." Although I'm sure if you ask 99%, probably people don't, but that's such a great idea because they probably see it and they see we know what the infection protocols are, we know how to keep things sterile and clean for patients, but maybe there's things we can do to reduce what we're using and reuse certain things like you said, or even just taking things out of packs. I feel like we have so many things in the pack that don't get used, and that's such a big thing that I saw on your website and other places.

Neda Shamie (25:34): I mean, there's data that you don't need a full body drape for cataract surgery.

Radhika Rampat (25:39): Yeah, we've stopped using full body drapes. Yeah. We only have the small little plastic drape that goes around the face. That's all we use for us as well. And ESCRS has done great work as well. They have the whole SIDICS calculator and things like that. I would say EyeSustain, AECOS Green Working Group, and the ESCRS Sustainability Group, and the Aravind Eye Center. These are the four kind of reference points for me, and I just think we should all just be inspired by all of them. And I'm always collaborating with everybody just to make sure that I'm not trying to reinvent the wheel anywhere along the way. In fact, I had one idea which I'm still working on. I haven't kind of put it out there yet, but a board where everybody, it's like a Miro board kind of thing where everybody puts in what they're doing in which country they're in, what subsection.

(26:36): And it's going to be a bit of an undertaking, so I think I need a bigger team, but I just know that if I could put everything in one place, wouldn't it be cool that all of our eye community, if anybody says, "Oh, how can I get started?" I'd be like, "Well, look at the Miro board, have a look through, get inspired or put in your project." So that would be my ultimate goal, something that is accessible and refreshed every day online and just shows us what everyone's doing. But yeah, watch this space.

Neda Shamie (27:05): Well, I have to say that in the last, you started this in 2022, you have accomplished so much in a mere four years. I love when you say, “my ultimate goal”. I think that in the last four years you've accomplished more than many ophthalmologists do in an entire career. So, we're very excited to see where you take this, how your reach has already expanded and really inspired so many people. I agree with you. I think having wardens and having people who really champion this would be really important. And it's a really wonderful project for the nurses on your team, great project for younger associates in the practice, pre-med students. I mean, it was just right before this session, I was telling my daughter who is pre-med, listen, you really need to take notice of this because sustainability is going to be the way of the future. And I think medicine is behind the game.

(27:58): And so, you are definitely leading the way, and I cannot be more proud to know you as a friend and as a colleague, and I can't wait to see where you take this and count us on your team. We're definitely going to be working more with you.

Radhika Rampat (28:10): I'm so excited. Thank you so much. As you said, a medical student or anyone could do it. I had a medical student who just came over to my theater just on Monday and came to look at the water flow in the taps because we're trying to do the whole rub, don't scrub thing because at the moment we use water for every single case. We scrub for every single case and that's a standard in the UK. But there is a WHO whole thing about rub, don't scrub. And after the first case, you don't have to, you can just use alcohol rub basically between all the cases afterward, especially if there’s no infection, et cetera. And so, I got to look at the water flow rate, so that's another project that's incoming. But yeah, look, I'm inspired by you guys and all of you out there, and I love that I am in some way inspiring other people because for me, that will be the best thing.

(29:06): Just keep going. Don't ever think it's somebody else. It is you. You are the guy or you are the woman that's for the job. And just nothing is too small. Pick a pain point and just go for it. And if you're stuck, give me a shout. And I'm so, so excited to support everybody. And thank you so much for having me on Neda Squared.

Neda Nikpoor (29:29): Radhika, it's been such an absolute pleasure having you on Neda Squared. I feel like I am super inspired and I'm sure many of our listeners are inspired. You've given us some really great actionable things that we can do in our own practice to, like you say, think, what is it? Act locally and impact globally. Yeah. So, I think hopefully we're all going to start making these small changes that have a huge, huge impact globally. So, thanks for everything that you're doing. I love that it's a project that is not self-serving. It's something that's incredibly altruistic and you're so open and so generous with your time and with what you've learned, and it really helps make the entire world a better place for all of us. So, thank you, thank you, thank you. We really appreciate you. I'm looking forward to your roadmap. Yeah, and thank you to our listeners for tuning in for another episode of Neda Squared.