Working in pain is not comfortable for any individual; nor is it likely deliver optimal performance. It is true across many professions, and ophthalmology is no exception.

“We want to provide the best care at all times, and a hurting physician makes it difficult to sometimes provide the best care,” says Jeffrey Marx, MD, a professor of ophthalmology at Tufts University and ophthalmologist at Lahey Hospital and Medical Center in Burlington, Mass. Dr. Marx led an AAO task force in 2011 on the topic of ergonomics, which was mandated to identify the extent to which musculoskeletal disorders (MSDs), owing to long hours of practice in uncomfortable positions, plagued members of the Academy.

For several years, the AAO has held sessions on the subject of ergonomics at its annual meeting, with more and more surgeons recognizing its importance. “The room seems to get larger and larger year after year,” he says. “Discussions spill over into the hallway.”

Dr. Marx and colleagues have published two papers on the topic of MSDs in ophthalmology (in American Journal of Ophthalmology in January 2005 and Ophthalmology in February 2012). A survey they conducted found more than half (51.8%) of the 697 respondents reported that they have neck, upper extremity or lower back symptoms. The problem of MSDs in ophthalmology is not limited to the United States.

“It is a global problem,” says Dr. Marx. “We want to provide the best care available all the time, and a hurting physician makes it difficult to sometimes provide that best care.”

“It is probably rare to find a surgeon who has been practicing more than 5 years who has not had some type of (MSD) situation that did not arise during surgery,” adds Robert Weinstock, MD, of the Eye Institute of West Florida in Tampa, Fla.

Performing surgery during pain is more likely to detract from optimal surgical outcomes, he says. “If a surgeon is operating in pain because of the position their head and neck is in, the surgeon will rush through surgery and cause a complication. Eye surgery requires a tremendous amount of concentration. It does not take a scientific study to know that your concentration will not be 100%.”

EDUCATING FUTURE OPHTHALMOLOGISTS

Despite ophthalmologists and educators recognizing MSDs as a pervasive problem, the subject of how to prevent the onset of MSDs is virtually nonexistent in residency education, says Arsham Sheybani, MD.

“It comes up (ergonomics in ophthalmology),” says Dr. Sheybani, an assistant professor of ophthalmology and visual sciences at Washington University School of Medicine in St. Louis, Mo. “People talk about it, but there is no formalized training. It would be extremely powerful if we did (offer education about ergonomics in residency).”

For residents who are in their 20s, thinking about things like proper positioning at the slit lamp or doing regular stretching may not seem essential to clinical practice, but years of being hunched over will take a toll when they are seasoned in their careers, points out Davinder Grover, MD, MPH, attending surgeon and clinician, Glaucoma Associates of Texas in Dallas. “It is a big issue. I am seeing older colleagues who have these (MSD) issues and need surgery. I know surgeons who have had cervical fusions in the latter part of their career,” adding that this issue did not get as much attention as it does now.

PERSONAL CARE AND AWARENESS

Awareness about improper positioning is a first step to preventing an MSD or the exacerbation of one, according to Dr. Marx.

“Some things can be done that do not require a lot of money,” he said. “One physician told me having a back rest for his office chair has made a big difference. Raising the patient’s chair can also make a difference.”

Dr. Grover recalls he started paying closer scrutiny to his positioning at work when he began practicing and started seeing many more patients. “You go from seeing 10 or 20 patients in fellowship to seeing 40, 50 or 60 per day,” says Dr. Grover.

TECHNOLOGICAL INNOVATIONS

“While some technological advances are not necessarily designed only for ergonomics, they help with proper positioning and limiting pain,” says Pravin Dugel, MD, clinical professor, Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles.

The NGENUITY 3D Visualization System (Alcon) features a high-definition, 3D and heads-up display that offers digitally assisted vitreoretinal surgery (Figure 1). This system allows surgeons to be in a straight back position and see things in greater depth, says Dr. Dugel, who has used the system. “It provides a great depth of focus, a wide field, and a great amount of magnification. It also clearly helps with ergonomics.”

In addition, the system is safe. A retrospective review by Agranat et al published in Clinical Ophthalmology in October 2019 looked at 272 vitreoretinal surgeries involving the NGENUITY system and showed no complications that occurred were attributed to the visualization system.

Also available from Alcon is the new LuxOR Revalia Ophthalmic Microscope, which offers delivers enhanced visualization during all stages of cataract surgery and personalized LED illumination technology, the company says.

A similar advance is the Zeiss ARTEVO 800 (Figure 2). This device is a digital microscope that offers a heads-up display that allows ophthalmologists to look at a monitor instead of looking through a microscope. “It allows your body position to be more comfortable,” says Brandon Ayres MD, member of the Cornea Service at Wills Eye Hospital, Philadelphia, Pa. “You are not limited by the position of the oculars.”

With “DigitalOptics,” the ARTEVO 800 provides excellent depth of field, reduced light intensity requirements and real color impression for increased certainty, the company says.

Hi-R NEO 900 (Haag-Streit) is another ergonomic-focused surgical microscope intended to allow surgeons to operate with improved posture (Figure 3). Its vertiscope extends the binoculars to the surgeon, enabling him or her to maintain an upright and relaxed posture without sacrificing optical quality or workflow constraints, the company says.

In addition, the M822, M844 and Proveo 8 (Leica Microsystems) provide integrated TrueVision 3D visualization for anterior and posterior surgery. The high-definition screen delivers excellent depth perception and a large field of view and can be positioned to support a comfortable, upright position, the company says.

An up-and-coming technology is the Clarity Bionic Visualization Platform, a head-mounted display system being developed by Beyeonics, an Israeli medical device firm. The system’s viewing approach is based on technologies used in the cockpits of fighter planes. The augmented reality system is a huge leap forward, Dr. Dugel says.

“It allows for selected and enhanced viewing, so we can have information available as we need it projected onto our eyes, similar to how fighter pilots do (have images available to view),” Dr. Dugel says. “The main advantage is this augmented reality with informatics which can be scaled in and overlayed onto what we are seeing.”

The other advantage it offers: ergonomics. “We are wearing a headlamp, much like the headlamp that we wear when we examine patients,” Dr. Dugel says. “Because it is projected onto our eyes, the projection will remain. You can turn your body or head any which way, and you can still see the image. It is the ultimate advance in ergonomics.”

These technologies are part of a digital revolution, which includes the benefits of data integration and other features aimed to enhance clinical outcome. But, they also have a by-product of surgeons standing straighter and not being hunched over while they work.

Because there is no reimbursement for heads-up display surgical systems, physicians may be reluctant to shell out dollars for the systems, says Dr. Weinstock, but they “need to think big picture. Think about the income you lose if you have to end your career because of chronic neck and back pain or you have to take time away from work because of short-term disability. When you look at it from that perspective, (the purchase of heads-up surgical system) is probably the best money you could ever spend. It is almost like an insurance policy.”

CONCLUSION

Dr. Dugel says that qualified, experienced surgeons may discontinue practicing or work only half-time if head, neck and back pain persists.

“It is an ongoing problem, because we have to be in a position that is unnatural,” says Dr. Dugel. “Probably the place where it is most applicable is in surgery. Surgery is the first thing people give up because of that.”

It stands to reason that if physicians have to take time off because of MSDs or halt their careers altogether, patients may suffer as well.

“Will this become a resource staffing issue if surgeons only work half the time because they are in pain?” asked Dr. Weinstock. “There is a shortage of physicians now, relative to the needs of the population. If you have doctors taken out of the workforce because of work-related injuries, it is a natural link to say that this will ultimately affect patients not being able to access care.” OM