As eye care services expand to meet growing global demand, a paper in JAMA Ophthalmology highlights the need to consider environmental impact alongside patient outcomes and cost.

The Viewpoint article highlights a comparative unit, the ICFER, first proposed in 2024, that applies established health economic principles to environmental impact by measuring carbon emissions per quality-adjusted life year (QALY) gained. While cost-effectiveness analysis is widely used to guide clinical and policy decisions, the authors argue that integrating carbon alongside cost and outcomes is increasingly important as health systems respond to climate change.

The paper draws attention to large differences in the environmental footprint of similar procedures across settings. Cataract surgery, one of the most common and effective interventions in global health, can have substantially higher emissions and wastage in high-income settings compared with lower-resource systems, despite achieving similar visual outcomes. For example, a phacoemulsification cataract surgery in the UK produces 20 times more greenhouse gas emissions than the same procedure in India. This suggests that more resource-intensive care does not necessarily deliver greater patient benefit, and that opportunities exist to reduce emissions without compromising quality.

Although economic evaluations are often embedded in clinical trials and inform national policy decisions, carbon footprint data are rarely collected or reported, and there is no standardised approach to linking emissions with health outcomes in routine practice. The authors argue that using measures such as ICFER could help identify more sustainable approaches to delivering care, particularly in high-volume services.

For global eye health, the implications are significant. As countries scale up services, particularly cataract surgery, there is an opportunity to design systems that are efficient not only in terms of cost and outcomes, but also in environmental impact. This is especially relevant in low- and middle-income countries, where service expansion is ongoing and decisions made now will shape future delivery models.

The authors conclude that incorporating environmental considerations into research, planning, and policy will be important for delivering eye care that is both effective and sustainable. As health systems work towards global eye health targets, measures such as ICFER may help ensure that increasing access to care does not come at the expense of rising environmental costs.

Publication

Berkowitz ST, Buchan JC, Shukla AG. Incremental Carbon Footprint Effectiveness Ratio in Ophthalmology. JAMA Ophthalmology. February 2026. https://doi.org/10.1001/jamaophthalmol.2025.6322