Ophthalmologists are at an increased risk for musculoskeletal pain and injuries compared to other medical specialties, with significant repercussions. Inadequate ergonomics and limited postural awareness may exacerbate these issues, especially for retina specialists due to awkward patient examination positions and operating room maneuvers. This review delves into strategies within the clinic and the operating room aimed at reducing injuries, promoting career longevity, and evaluating innovative ergonomic solutions.
Key points
- •
Musculoskeletal pain affects many working ophthalmologists, due to the nature of repetitive and prolonged posturing both in the clinic and in the operating room (OR).
- •
Proper ergonomics may alleviate excessive bodily stress.
- •
New technologies such as the heads-up display may provide more comfort in the OR.
Introduction
Musculoskeletal (MSK) disorders are prevalent among ophthalmologists, with surveys finding that a majority of respondents report some degree of pain [ ]. Over 15% of ophthalmologists retire early due to these issues [ ]. A study comparing eye care providers to family medicine physicians found that ophthalmologists and optometrists had a higher prevalence of neck, hand/wrist, and lower back pain, likely due to working in awkward positions and performing repetitive motions [ ]. One of the reasons behind this disparity is that microsurgery contributes to MSK dysfunction and is associated with the degree of MSK dysfunction due to bodily stress and muscle fatigue during surgeries [ ]. The ophthalmologic examination in the clinic is also a major contributor to this issue, due to the ergonomic challenges of using equipment such as slit lamps and indirect ophthalmoscopes, which can lead to cervical spinal injuries [ ]. Concern exists that retina specialists may be at a particularly high risk of MSK injury, with one study reporting that during indirect examinations, vitreoretinal surgeons were found to have flexion of their spine for greater than 75% of the time, which was significantly greater than what was seen during slit lamp examinations and posed a higher risk of developing spinal pain [ ].
Prolonged poor posturing in the operating room (OR) also may contribute to and compound bodily stress. Common mistakes made by residents and fellows include not aligning their bodies properly to the microscope, bending to examine the patient without adjusting the patient’s body, leaning into the microscope, and excessively bending at the back and neck. This review aims to explore the importance of ergonomics in retina practice and describe strategies and emerging technologies that can be employed to help reduce MSK strain and improve career longevity.
Significance
Techniques to help improve ergonomics
Proper ergonomics in the clinic and OR can mitigate the risk of MSK injury [ ]. In a recent article published by the American Academy of Ophthalmology, key pillars to improving ergonomics included modifying elements of the working environment to improve them ergonomically, making time for physical activity and self-care, as well as prioritizing one’s comfort when appropriate [ ]. While at the slit lamp, it is crucial to align your head and spine vertically in a neutral position and minimize head tilting [ ]. A review article by Alrashed has further step-by-step instructions on maintaining the proper posture while at the slit lamp [ ]. A commonly cited, but an important fact, is that patients typically will only be seated at the slit lamp for a few minutes, once or twice annually, but ophthalmologists are there for their entire careers. A study evaluating the efficacy of an educational ergonomics course for ophthalmology residents found that it significantly improved the upright and neutral posture of residents when using the slit lamp [ ]. Making a conscious effort to maintain proper ergonomics will go a long way in improving the longevity of one’s career while minimizing the risk of developing MSK pain.
Retina specialists, in particular compared to other ophthalmology subspecialties, perform significant amounts of indirect ophthalmoscopy, whether it is for viewing the fundus or delivering laser therapies [ ]. During these examinations and treatments, retina specialists may contort their necks and bodies in uncomfortable positions ( Fig. 1 A, B ). Similar to the principles of the slit lamp examination, the key to maintaining good ergonomics during an indirect examination is maintaining a neutral neck and back. Methods to achieve this include elevating the patient’s chair to be eye-level with the examiner as well as reclining the patient back to 45° and tilting the patient’s head in different orientations to view the peripheral retina [ ].
In the OR, similar to in the clinic at the slit lamp, it is important to maintain a neutral spine with muscles relaxed while operating at the microscope [ ]. During procedures, it is important to be cognizant of how tightly instruments are being held, with a goal for a light grip; wrist rests can further improve stability and support to minimize the stress on the hand joints [ ]. It also is crucial for foot pedals to be level to distribute pressure evenly through the feet and for the chair to be at a comfortable height. A backrest can be helpful as well to improve support and attempt to minimize leaning forward to reduce muscular strain [ , , ]. Throughout the surgery, it is important to be mindful, take periodic breaks, and move around to help relax tension and reduce strain in the OR.
Yoga for musculoskeletal pain
Numerous studies suggest that practicing yoga can contribute to improved posture, flexibility, and core strength, factors crucial for individuals with physically demanding jobs [ ]. The combination of asanas (yoga postures) and mindful breathing exercises enhances body awareness, helping surgeons maintain a more ergonomic and comfortable working posture [ ]. Yoga’s emphasis on spine flexibility and alignment targets the MSK strain commonly experienced by retinal surgeons. Prolonged periods of sitting during retina surgery may increase MSK strain, and the stretches and poses involved in common yoga routines target large muscle groups, promote increased blood flow, and reduce stiffness [ ]. Studies show that yoga can lead to a significant reduction in pain intensity and improvements in functional mobility [ , ]. Yoga has the additive benefit of meditative states, which may contribute to stress reduction and additionally alleviate tension-related back discomfort. With its multifaceted benefits, yoga may be a holistic approach to improving the physical and overall health of retinal specialists.
New advances in the operating room to help improve pain
Viewing system
Heads-up display (HUD) surgery is an exciting development that changes the display of microsurgical procedures by viewing the microscopic image on a panel display sent from a three-dimensional (3D) camera, rather than requiring the surgeon to look through the eyepieces of the microscope ( Fig. 2 ) [ ]. Operating heads-up can alleviate some joint pressure and muscle strain in the neck and back by minimizing non-neutral hyperextensions and flexions required for microscope use [ ]. Not only have these systems been shown to be safe and effective for performing vitreoretinal surgery but also they have been shown to provide a more comfortable and efficient working environment while reducing physical strain [ ]. Although the literature has shown an initial increase in the duration of surgery associated with the use of HUD, this effect has been associated with a learning curve and has been shown to vanish after about 35 cases [ ]. In one study, 20 volunteers compared performing meticulous tasks using HUD compared to a traditional microscope [ ]. Tasks included stacking sequins, nails, and tying surgical knots. At least 90% of volunteers found HUD more comfortable than the traditional microscope during each task. A questionnaire answered by 64 surgeons (37 posterior segment, 25 anterior segment, and 2 mixed) found that HUD reduced the severity (64%) and frequency (63%) of pain and discomfort, improved posture (73%), and improved overall comfort (77%) compared to a conventional optical microscope [ ]. Forty-four percent of respondents with headaches, and 82% of respondents with pain and discomfort during operation, also reported a reduction in these symptoms since using HUD. Of note, these respondents had a mean of 14.9 years in practice and 2.3 years using HUD. Finally, those who used HUD for over half of their cases had about 5 times greater odds of reporting pain reduction [ ]. Interestingly, this analysis suggested surgeons of older age may have greater odds of reporting an improvement in pain-related issues after using HUD [ ].
Full access? Get Clinical Tree
