Selective preoperative evaluation in cataract surgery reduces costs, carbon footprint and time burden: A triple bottom line analysis

Purpose To evaluate the economic, environmental and social impact of selective versus routine preoperative evaluation in cataract surgery using a Triple Bottom Line (TBL) framework, and to assess whether selective testing affects perioperative safety outcomes. Methods Observational comparative study including 1,519 patients (1,944 surgeries): a Routine Testing group (RT: 822 patients, 1,035 surgeries) and a Selective Testing group (ST: 697 patients, 909 surgeries). Preoperative evaluation in the ST group was reserved for patients with severe unstable systemic disease, inability to cooperate, or intolerance to the supine position. Economic, environmental and social outcomes were derived from hospital analytical accounting, a hybrid life cycle assessment, and a mobility survey. Results Intraoperative complication rates (2.71% vs 1.65%; OR 1.65, 95% CI 0.88–3.12) and surgical cancellations (1.83% vs 1.43%; OR 1.28, 95% CI 0.63–2.62) did not differ significantly between groups. The ST model reduced mean total cost per surgery from €101.71 to €46.88, carbon footprint from 33.92 to 15.63 kgCO 2 e, and preoperative time burden from 125.31 to 57.75 min, with an estimated productivity saving exceeding €33,000. Conclusions Selective preoperative evaluation was not associated with a statistically significant increase in intraoperative complications or cancellations while delivering meaningful economic, environmental and social benefits, supporting its broader adoption in line with current clinical guidelines.