Take note of your posture as you read this: startling new statistics show the vast majority of ophthalmic professionals, including ophthalmologists, optometrists and orthoptists, suffer from musculoskeletal pain and injuries.
The physical demands of ophthalmology and other eyecare professions may seem minor to more labour-intensive careers on the face of it. But repetitive stress due to compromised body positions during precise tasks can culminate in insidious injuries to the neck, lower or upper back, wrist and hand.
Duty of care and accommodating the needs of the patient are the cornerstones of any health profession. Unfortunately, in these instances, the practitioner’s needs are often overlooked.
This is reflected in a recent study by Taison et al. (2023), published in Cureus, which found that up to 66.7% of eyecare professionals experience musculoskeletal pain and injuries.
It included 514 practising ophthalmologists, optometrists and orthoptists and, among the participants, 43.8% were younger than 30 years. More than half of ophthalmologists reported experiencing at least one type of pain, either in the lower back (39%) or neck (32.6%).
Furthermore, the study revealed the influence of age and gender, with 76.2% of women and 71.4% of those aged over 50 suffering from pain or injury and a high prevalence with existence of comorbidities – 92.2%. These injuries are also associated with low productivity, with correlations between back pain and work stress.
These statistics speak to the importance of ergonomics, which industry figures say is generally not reinforced during training or in the workplace. It also emphasises why correct posture and equipment setup shouldn’t be an oversight.
Melbourne-based ophthalmologist and director of educational platform GENEYE, Dr Jacqueline Beltz, is among the few eyecare professionals who have indoctrinated positive habits into their work routine. Having seen the majority of her colleagues suffer from musculoskeletal issues due to the demands of the profession, she uses her platform to drive awareness of the importance of ergonomics and physical health in her community.
“I personally know eight ophthalmologists that have needed to undergo neck surgery. Thankfully they are all doing well, and the injury or surgery has not been career-ending for any of them, but that number is extremely alarming,” Beltz says.
Ophthalmologist registrar Dr Rogan Fraser is among the many casualties of poor ergonomics. He recently underwent neck surgery to correct the cumulative impact of unaccommodating work environments.
“I had to have surgery on my cervical spine about halfway through last year, probably from a cumulative experience being both an optometrist and ophthalmologist. I got to the point where I couldn’t operate without having pins and needles in my left hand and intense pain in my elbow and eventually some weakness as well,” he says.
“I was left with this existential crisis of: can I continue doing the job that I love?”
Raising awareness of sustainable ergonomic setups is essential for maintaining quality-of-life. There’s also duty of care considerations for patients; it’s vital musculoskeletal fatigue does not impact results.
Beltz adds: “Stability during fine tasks is extremely important and can be compromised in the setting of discomfort. Most importantly though, injuries can lead to chronic problems such as headaches, musculoskeletal pain or neurological issues that not only can result in early end to careers, but in the worst cases, can reduce quality-of-life.”
Adelaide-based industrial physiotherapist Ms Lisa Harman has dedicated her career to physical longevity in the workplace through instilling manual handling principles into everyday life and works with eyecare professionals to ensure sustainable working conditions. Her ambitions as a physiotherapist are to identify her patients’ goals and help them to nurture that through targeted functional solutions. This includes working closely with eyecare professionals, where she optimises the way they work to ensure they employ neutral posture in their scope of daily tasks.
Key aggravating factors that contribute to musculoskeletal pain and injuries are sustained repetitive movement and awkward, or rigid positioning. These arise with continuous use of slit lamps, surgical microscopes, patient examinations and performing microsurgery.
“A lot of what they’re doing is with tools and with their hands, whether it might be using a slit lamp, changing lenses or operating on someone. This palm-down grip that they employ is leading to a lot of tennis elbow, and carpal tunnel injuries. They’re probably the more common injuries we tend to see in this population,” Harman says.
Neck and upper back issues can develop by looking through lenses or microscopes and not adjusting the height adequately to accommodate, resulting in forward neck posture.
“We’re also finding that people have musculoskeletal issues in their dominant shoulder from over reaching and we are finding they’re getting issues in their wrists from the repetitive wrist deviation when clicking different lenses. We definitely see a lot of forward head posture when they look into these lenses because there’s quite often a gap between the patient and the practitioner if the set up is not aligning to ergonomic principles,” Harman says.
The rigidity of clinical equipment contributes to the positioning of these items at incorrect height adjustments, so the worker’s posture is often altered to accommodate – instead of the equipment being suitable for the worker.
In Beltz’s experience, she finds correct posture more difficult to achieve at the slit lamp compared to the operating room.
“In general, in the operating room everything is adjustable and the first thing we do is set up the chair height, the table height and the microscope position and oculars to make sure that we can see well and stay steady, which basically correlates with being comfortable. But this can go wrong when the patient has musculoskeletal issues or discomfort,” she says.
“Whilst patient chair, doctor chair, table height and chin rest height are all adjustable, there are still some fixed variables and patients come in all shapes and sizes so sometimes we just have to be uncomfortable.”
The Cureus study showed that aggravating factors can include the number of consultations with patients, surgeries and laser treatment sessions. Others include how dynamic the surgeons are and if each specialisation requires sustained rigidity. Additionally, the type of equipment used in each specialisation, such as slit lamps and surgical microscopes, can be a contributing factor.
Of those who examined more than 150 patients per week, 72.4% experienced musculoskeletal pain and injuries, 85.7% of those performing more than 20 surgeries, and remarkably, 100% of those who performed more than 20 laser treatments.
Fraser cites laser eye surgery among the most notoriously strenuous procedures to perform in his discipline.
“The laser procedures are, personally for me, really awkward to perform. I’ve spoken to some of my colleagues who have really awful neck and back pain because their hands are outstretched and at the end of its range. And you have to keep your hands still because you’ve got something touching the patient’s eye and then of course, you’re operating an ostensibly dangerous piece of equipment. So again, there’s a little bit of tension in everything else as well,” he says.
General ophthalmologists, cataract, cornea, refractive and glaucoma surgeons and medical retina sub-specialists are more at risk to have back pain than paediatric ophthalmologists, neuro-ophthalmologists, oculoplastic surgeons and retina surgeons, as the latter disciplines are more dynamic in the clinic.
“We have all been brought up on patient-centred care and of course the patient’s comfort comes before ours, but sometimes this does lead to me having neck or back pain at the end of a case,” Beltz says.
Fraser adds: “I remember a doctor said to me once, ‘If the patient is uncomfortable, that’s a moment of discomfort for the patient while you’re examining them versus potentially a lifetime of discomfort for you. You have to get it right’.”
Preventative measures – the first line treatment
“The best treatment is prevention,” Harman says.
Surgical procedures require extensive, tailored planning for the best possible patient outcomes. This should also include making a conscious effort to adopt proper positioning of oneself and the patient to improve durability and prevent fatigue.
According to Harman, maintaining neutrality is crucial in avoiding awkward posture and mitigating neck and back issues. When treating a patient, whether in the clinic or operating theatre, it’s advised ophthalmologists avoid leaning into the patient via stooping through their spine and over-reaching. Instead, shoulders should be relaxed, scapulae engaged, tilt the pelvis in the direction of the task to get closer to the patient whilst aiming for relaxed forearms.
Harman suggests adopting an anterior pelvic tilt for seated tasks which a lot of people do not incorporate into their normal range of motion. This entails tilting the hips forward as opposed to planting hips and leaning forward with the upper back and neck – which is where she sees ‘stooping’ and unnecessary load bearing through the discs in the spine. Saddle seats are useful in promoting and maintaining this position.
Neutrality in the upper neck can also be achieved by performing chin tucks, which involves retracting the chin back to the neck without tucking the chin to the chest.
In the operating room, Beltz says it’s important to have both feet firmly planted on the foot pedals to balance properly.
“If this means changing the table height; just take the time to do it. I also recommend using the brake on the operating stool as this reduces musculoskeletal load required to keep yourself still. Think about the position and support of your arms as well as the tilt of the eye pieces. In general, we want to have our neck slightly flexed into a chin-tuck position, rather than extended or chin forward,” she says.
Harman suggests the use of makeshift ergonomic arm rests to prevent unsupported forward reaching, which has been employed by a number of ophthalmologists to stabilise the ‘reaching’ arm when utilising a slit lamp.
“We’ve had a few ophthalmologists get a foam yoga block made to the height they require. And then they’ve been able to rest through the length of that and then it’s only their wrist that’s changing things. They’ve found it makes them feel a lot more comfortable as they have an additional base of support and there is less scapula stabilisation required,” Harman says.
Experts recommend incorporating preventative measures into routines when they are examining patients and performing surgery early in their careers. Incorporating movement into their regime is a key mitigating factor, according to the Cureus study findings, which showed 68.3% who don’t do running exercises suffer from injuries.
As repetitive movements result in cumulative injuries, the key is to actively roster movement into the work schedules and break up the monotony of tasks to reduce likelihood of injury.
Beltz describes her movement regime: “I personally do physio-led Pilates as well as daily neck and back exercises to counteract the fixed postures that I employ during the day. I also see a myotherapist, have acupuncture and enjoy meditation and deliberate cold exposure.”
Rotating rosters is another strategy; injuries can be caused by completing clinical and operating work in succession, with no break in movement. Harman suggests reducing repetitive and sustained exposure through reduction of clinic and theatre shift times and alternating between the two to provide variation in movement.
“It’s not about not doing clinic and surgery work. It’s about rotating them as much as possible to avoid the exposure to prolonged levels of repetitive and sustained force,” Harman says.
The GENEYE Program and proactive ergonomics
GENEYE is an education platform that Beltz established on behalf of Eye and Ear Education in Melbourne 2019. The program uses modern educational strategies such as peer-to-peer learning, virtual reality simulation and coaching psychology for ophthalmologists striving for high performance, longevity, happiness and, consequently, excellent results.
It features an annual immersive workshop aimed at learners from all aspects of eye health. Topics vary each year, but always includes stations for surgical, mind and physical health training.
The immersive workshop in 2023 partnered with Harman, who guided the popular ergonomics station. It’s designed to educate on safe manual handling principles and ergonomics. Here, Harman and other expert physiotherapists, ergonomists and manual handling specialists demonstrated desk and slit lamp related strategies to prevent and manage musculoskeletal injuries, showing them sustainable posture and movements during their most-performed tasks.
“We’ve had some great follow up from those conferences as well. We quite often get ophthalmologists emailing us for information and we’re giving them resources that make such an impact in their day-to-day function. And every year that tends to change a little because the more we can understand about their role and the changes that they’ve been making, the more questions they have,” Beltz says.
In addition to the ergonomics station, GENEYE 2023 featured a station run by Fujitsu. The station showcased the company’s digital twin technology that collects data from the real-world using cameras and sensors, reproduces the real world in a virtual space, and then carries out precise simulations to provide data that might improve practice.
Applications of this technology thus far include its use in the manufacturing industry to improve safety at work. At GENEYE 2023, the technology was used to assess posture while sitting at the slit lamp. This tool can be used to initiate important conversations about ergonomics.
“Something that we can all do is have this conversation with colleagues, especially those that are junior to us, and have reminders to look after ourselves,” Beltz says.
The future of ergonomics for eyecare professionals
Technology, such as the Fujitsu digital twin, may one day start conversations, with Beltz and Fraser hoping that it will hold eyecare professionals accountable for their posture and positioning.
“Like how fitness trackers today remind us to get up and move, I would like to see slit lamps telling us to sort out our posture,” Beltz says.
Fraser adds: “What I’d love to see is slightly better technology. Whereby ergonomics can be more adaptable, certainly in the consulting room. I even think there’s more scope to individualise the ergonomics in the operating theatre.”
In other developments, 3D surgical visualisation surgical systems can offer intraoperative views, and with advancements, that may provide ergonomic advantages in future. In these systems – like the Alcon NGenuity system and ZEISS Artevo 800 – the surgeon wears 3D glasses and views the surgery on a high-definition screen instead of looking down a microscope.
“So far, physical limitations limit the ergonomic advantages a little bit, but as they improve, I think we will see benefits,” Beltz says.
“As these operating systems improve and then become normalised, I would like to see them extending into the clinic as well. Visualisation is better with digital systems anyway and, ergonomically, the advantage is massive.”
Looking ahead, Beltz says it is necessary for ophthalmologists to instil good habits as early as possible before growing accustomed to a particular way of working.
“In the shorter term, I hope to see education continuing from day one of ophthalmology and optometry training. There’s a bit of a learning curve when you switch from flat to tilted eyepieces on your slit lamp, but it’s definitely worth it. If you do it from day one that learning curve becomes irrelevant,” she says.
The GENEYE 2024 workshop will feature similar ergonomics stations as per previous years, with physiotherapists present to provide group based and individual level preventative strategies, postural suggestions, exercises and support.
“We also look forward to seeing how Fujitsu progresses their technology over the next 12 months. The digital twin technology is really exciting, and we expect further improvements and the ability to analyse angles, postures and suggest corrections,” Beltz says.
“At GENEYE we like to say that we look after ourselves and each other, so that we can adequately serve our patients.”