Musculoskeletal disorders are common among ophthalmologists.

The disorders develop slowly and progressively as a consequence of what may seem to be an innocuous routine: doing slit lamp examinations, laser treatments and gonioscopy, sitting on an operating chair and performing surgery. Early signs and symptoms are often overlooked, and structural changes happen silently, eventually leading to disabling or even irreversible damage.

“Many of us don’t seek treatment early enough and don’t make changes to our routine since we are so focused on patient care ” Deepinder K. Dhaliwal, MD, LAc, said. “In addition, we do very little for prevention. We are not taught, and neither teach our residents, about proper surgical and office ergonomics.”

In a 2005 survey published in American Journal of Ophthalmology, more than half of the respondents reported neck or back pain, and 15% had to curtail their work as a consequence. In 2018, a review and meta-analysis of surgical ergonomics published in Annals of Medicine and Surgery revealed that 68% of surgeons experience pain from operating. Minimally invasive surgeons were more likely to report pain, fatigue and numbness. Only 29% of surgeons reported seeking treatment for symptoms. Another paper published in the same year defined musculoskeletal disorders as “an impending epidemic,” leading to a loss of 12% of physicians through leave of absence or early retirement.

“Simple ergonomic and movement strategies and the use of ergonomically designed furniture and equipment may help reduce this risk and could spare us a lifetime of pain and discomfort,” Dhaliwal said.

Dhaliwal developed an interest in ergonomics through personal experience. In 2015, she slipped and fell in the operating room, developing a large L5 disc herniation. As a result, she had back pain and leg weakness that was so severe that she had to stop doing surgery and traveling. She consulted an orthopedic surgeon and two neurosurgeons who told her that the only way to avoid intolerable pain in the long term was to have an operation. Instead, after consulting with a physiatrist, she decided to try conservative therapy.

“I did physical therapy, acupuncture and meditation and made major modifications to my life, my home, the OR and office. As a result, I am now 90% recovered,” she said.

Similarly, from personal experience, Healio/OSN Board Member I. Paul Singh, MD, MPH, became aware of how fundamental a correct posture is to well-being and how small changes in the office and OR routine help decrease the chances of long-term issues.

In 2018, he fell off a ladder and hit his head. He was unconscious for a few seconds, and when he woke, he was paralyzed from the neck down for about 1 minute. He gradually regained motility over the next 5 minutes, and later, thorough MRI, he accidentally discovered he had significant spinal stenosis between C4/5 and C5/6.

“I was so stenotic in that area that, when I fell, the spinal column was momentarily compressed, which caused the transient symptoms. In a way, that fall was a blessing because otherwise I would not have known that I had severe level 3 disease because I had no warning symptoms,” Singh said.

To prevent further stenosis and collapse, he underwent anterior cervical discectomy and fusion. His late father, an ophthalmologist, also underwent the same procedure a few years before.

“If I had waited longer, there was a chance this could develop into permanent loss of function,” Singh said.

Since then, his life has changed. He has become passionate about ergonomics and is keen to raise awareness about it among colleagues.

Surgeons need to take care of themselves in order to properly take care of others, and they can perform at their best only in an environment that provides them the necessary comfort, according to Samaresh Srivastava, MD.

“It is very important to understand that with microsurgery becoming so competitive and result-oriented, every little detail matters in the final outcome, starting from the way the OR is furnished,” he said.

The most important and often underrated piece of furniture is the surgeon’s chair, particularly in a country such as India, where high volumes of surgery are performed every day.

“With our heavy routines, it’s easy to forget about ourselves, and after our 12th or 13th surgery, our back and neck start hurting a lot. In our OR, we switched from using stools to using proper chairs with good lumbar support to help us keep our spine in a neutral position. Height-adjustable chairs are a big advantage because you can align your eyes with the microscope without having to look up or down. I also use elbow rests because they give a lot of stability to my shoulders. They favor fine movements, and my wrists can move smoothly. The surgeon’s chair is one of the most vital investments,” Srivastava said.

Dhaliwal agreed that surgical stools are not ideal . Saddle stools are theoretically better, but surgeons, who use their hands and feet, need proper back support. After her injury, Dhaliwal carried a McKenzie lumbar roll everywhere she had to sit — in the office, in the OR, on the airplane and at meetings — and eventually this simple solution inspired her to suggest a pivotal modification to a specially designed surgical chair.

“I told Haag-Streit that something was missing, a lumbar support, when they were designing the CO:RE surgical chair. I use it when I am operating and feel my back supported. The lumbar support can be raised or lowered, and the whole chair is adjustable. You can personalize your settings of lumbar support so it is easy for the surgical staff to readjust prior to your surgical cases,” she said.

When looking into the microscope, it is important to avoid flexing the neck back or bending forward.

“Align your head above the spine, gliding your chin straight back, tucked to your neck. Even 1 day a week in the OR, with 6 to 8 hours of constant flexion looking into the microscope, can cause long-term changes in the spinal column over time,” Singh said. “Bring the microscope closer to you with your chair forward against the headrest of the patient.”

In the last decade, companies have placed a lot of attention on making surgery more ergonomic, and some of them have invested heavily on 3D systems and augmented reality.

“However, if you cannot afford that kind of setup, the thing to do is look for microscopes that have adjustable, tiltable eyepieces so that you don’t have to stoop up or down to see clearly. When choosing a microscope, one of the criteria should be ergonomic comfort,” Srivastava said.

For many years, Dhaliwal did not realize, while operating, how extended her neck was all the time to reach the oculars.

“Now I keep my shoulders down, my elbows in, and tilt the microscope,” she said.

Singh has a heads-up surgery system in three of the four surgical centers where he operates. He has been a big fan of 3D heads-up surgery from the start because it does not constrict the surgeon in one position.

“It gives you a lot of flexibility to move your head and change your positioning. It is a huge improvement for me, especially when I perform MIGS procedures, which force your neck and back in an awkward posture because the scope and patient’s head is turned, forcing you to turn your head to the microscope in an unnatural position. Now I can sit back, assume a natural posture and look at the big screen. When I do surgery in the one center that is not equipped with a heads-up system, by the end of the day, I have a tight neck and headache and feel very tired,” Singh said.

The first 3D heads-up system was the Alcon Ngenuity, which Singh tried and liked, but the system adopted by his clinics is the Zeiss Artevo, which has two cameras instead of one and works well with his digital alignment system and intraoperative OCT.

The advantages of operating heads-up with a 3D visualization system are multiple, but special attention must be paid to positioning the bed and the monitor so that the surgeon can maintain a comfortable position, looking straight ahead.

“You have to figure out the ergonomics and the setup of the room ahead of time. I have the screen in one place but move the bed depending on the eye I operate on. I have learned how to position my body and the screen so that I can look straight on, with the flexibility to move my head around and not be stuck with one position,” Singh said.

He said he also notices the entire staff is “on the same page,” more engaged and more proactive with handing instruments because they have the same view as the surgeon.

With the Beyeonics One (Beyeonics) digital visualization system, 3D video images are transmitted from the operating field directly to a head-mounted display as high-resolution augmented reality. Beyond the real-time video of the surgical field, the system provides easy access to preoperative data. The head-wearable device is lightweight and enables the surgeon to perform the entire procedure maintaining a neutral posture with full freedom of movement.

“It doesn’t matter how I hold my head. I can turn it, bend it, lean back, I can stand, look in all directions, and the image is always there. Specific movements of the head command zooming, magnification, focusing, and increasing or decreasing the light,” Anat Loewenstein, MD, MHA, said.

Operating rooms become a versatile, flexible space, she said. Surgeons can sit temporally at either side of the head or behind the head and change position during the procedure.

“You don’t need to change the structure of the OR. You can decide at any time where to sit, on which side of the eye, without losing visual contact with the operating field,” Loewenstein said.

She uses this system routinely for vitreoretinal surgery, and so do other surgeons in her team as well as her residents, also for cataract and corneal surgery.

“Last month, my cornea specialist did the first case of DSEK in the world with Beyeonics One, and he said that it was the first time he finished the transplant without back pain. That was very encouraging,” Loewenstein said.

Beyeonics recently started a collaboration with BVI to commercialize Beyeonics One in the U.S.

“This technology will push us forward to the next level,” Singh said. “I had a chance to try it in the showroom. It is a cool technology, very impressive, and hopefully should become available within the next few months. It allows you a lot of control, sitting in a comfortable position. There is a little bit of a learning curve, as there was for heads-up. With Artevo, I felt comfortable after 2 full days in the OR; with Beyeonics, it is probably a little more.”

Foot pedals play an important role in both cataract and vitreoretinal surgery. Srivastava recommended wire-free footswitches to avoid cluttering the operating room and to reduce the risk for tripping on wires while operating.

“Privilege switches that have no friction, that are light and have a wheel support that allows you to move them with small movements of your own feet,” he said. “Initially, when buying a machine, we may not pay attention to these subtle points, but as we start to operate, we wish we had these features.”

Tension in the feet and legs reflects on every part of the body, and the footswitch is therefore important for overall ergonomic comfort, he said.

Retina surgeons and brain surgeons operate not only with their hands, but with their legs, Loewenstein said. During the entire procedure, they need to coordinate fine control of both feet on the foot pedals.

“Most modern microscopes do have ergonomic foot pedals, where the leg rests comfortably,” she said.

During her fellowship in the U.S., Loewenstein learned to operate barefoot. She has introduced this habit in her department and recommends this to all vitreoretinal surgeons.

“With shoes, it is more difficult to feel the pedal, and this causes tension on your legs. Operating barefoot enhances tactile sensation, and you control the foot pedal better,” she said.

“In our part of the world, we always operate barefoot. Some of us use socks if they feel cold,” Samaresh said.

The slit lamp is the instrument that all eye specialists use most often and is “a huge problem,” according to Dhaliwal, because it is not ergonomically designed for both doctors and patients.

“The table is too long on either side, and we have to bend forward to reach the oculars. I ask patients to scoot forward in the chair toward me so that I don’t have to lean forward toward them,” she said.

“Keep your ergonomics consistent. Make the patient adapt with their chair. They will be there only for a few minutes. It will do them no harm,” Srivastava said.

Changes can also be made to the table, fixating the slit lamp closer to the edge on the doctor’s side.

“If you put the slit lamp right to the edge of the table, closer to you, you don’t have to hunch forward. You can also get oculars extenders so you can sit further back while examining the patient,” Srivastava said.

Some companies are working on 3D slit lamps. Srivastava said he has seen prototypes, and this will be a further improvement from the point of view of ergonomics.

3D systems are already available for diagnostic gonioscopy, a welcome alternative to standard methods, Singh said. For laser procedures, though, holding a gonioprism during selective laser trabeculoplasty, laser peripheral iridotomy or YAG capsulotomy forces the arm and shoulder to raise up, while the neck is pushed forward to the ocular of the microscope.

“For now, we are at the front edge of all this, but companies are aware. They do understand the difficulties we are facing and are working on a number of different technologies addressing ergonomic issues,” Singh said.

Incorporating good ergonomic techniques and stretching exercises into daily routines can greatly improve health and quality of life.

“Be mindful of your posture, and concentrate to create good postural habits, taking time to adjust your equipment,” Dhaliwal said.

She suggested a daily routine of core-strengthening exercises and microbreaks in between operating sessions to stretch the arms, legs, neck and back.

“Reverse the posture you had while operating, and be mindful of what you are doing. Meditation, yoga and deep breathing are very good techniques to help you stay centered and release stress,” she said.

Sitting puts 200 times more pressure on the discs than lying down and 100 times more pressure than standing. And eye surgeons spend a great part of their working day in a sitting position, Dhaliwal said.

“When we have a break, at work or at home, the last thing we should do is sit. Better stand up, lie down or, even better, exercise and walk,” she said.

“Yoga is a good approach because it normalizes your breathing and aligns your muscles. Half an hour a day is a good investment for the rest of your life. You can always find that time, even if you are busy or traveling,” Samaresh said. “I suffer from low back pain — it runs in the family — but I have learned that I can keep it under control if I look after myself in this way.”

It is never too early for surgeons to start looking after themselves and be proactive in preventing future problems, Singh said.

“Be aware now. Don’t wait until you have symptoms because by that time you’ll have significant structural changes to your spinal column and musculature that can cause problems later on in life,” he said. “Pay attention, think and act ergonomically now. That’s the key.”

Click here to read the Point/Counter to this Cover Story.

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