Health and Fitness Pearls for the Ophthalmologist

By Kelly Green, MD

Ergonomics

As ophthalmologists, we perform repetitive daily tasks that require a great deal of visual attention and musculoskeletal precision concurrently. Operating, examining patients at the slit lamp with a condensing lens, or performing binocular indirect ophthalmoscopy (BIO) are examples of tasks that we do many times in a day. Each of these activities is a task that demands coordinated movements of the examiner’s head, hands, arms, and sometimes the entire body. If we expect to be able to continue to do these critical tasks for 30 or more years, we must begin to examine HOW we do the tasks, to avoid injury and disability.

In a series of articles, KC Darwin and colleagues report on the importance of ergonomics for the eye doctor, including a summary of how various injuries occur, how frequently they occur (based on surveys), and methodologies for correcting the problem to avoid injury. Since our work requires high manual precision and elevated visual focus, this necessitates a great deal of stabilization of the head, neck, and upper extremity. This leads to increased muscle tension and other more serious problems. In the course of two surveys of ophthalmologists, the authors found that those more likely to have injury or complaint of pain were more likely to be female and younger, with increased reported work stress. The female preponderance may be attributed to shorter stature, but this has yet to be proven definitively. The overall prevalence of musculoskeletal disorders during the prior month was 51.8%. The complaints included lower back, upper extremity, and neck problems. A retina subspecialty survey found that 7.5% of physicians required surgery for neck or back problems, some of which are attributed to work-related injuries. Risk factors included BIO use, long surgeries, and poor posture.

Upper extremity neuropathies related to work in ophthalmology include carpal tunnel problems and rotator cuff tendonitis/shoulder impingement. Carpal tunnel injuries are acquired during repeated wrist extension and ulnar deviation at the slit lamp with the condensing lens. To avoid this error, we must relax the fingers, and try to have no wrist flexion or extension, and minimal forearm pronation. We should use a soft elbow support, and avoid using the metallic slit lamp track covers for elbow positioning. Rotator cuff and other shoulder problems can be due to unsupported flexion/abduction of the arm at the slit lamp while holding a lens. Therefore, we should instead support the upper extremity while examining patients.

The authors offer some tips to guide us as we try to become comfortable in the workplace. For operating room positioning, we should have lumbar padding, and keep the lumbar spine in contact with the backrest. We should rest the elbows at our sides, and wrists should rest on padded support. We should avoid elevating or abducting our arms. At the slit lamp and laser, we should adjust the seats/slit lamp to keep a neutral posture. The examiner’s seat should tilt anteriorly to maintain proper pelvis positioning. We should avoid reaching with unsupported upper extremities, and keep a neutral head posture. In order to protect lower cervical spine issues, we should avoid neck extension. When using the BIO, it is important to raise or lower the patient’s chair to prevent the examiner from having to flex his or her neck excessively. During cataract surgery, avoid neck flexion by tilting the microscope. For pictures of proper positioning, please see the cited articles.

I hope we can all enjoy long careers that are injury- and pain-free by following this simple set of ergonomic guidelines!

References

1. Dhmitir, KC et al. Symptoms of Musculoskeletal Disorders in Ophthalmologists. American Journal of Ophthalmology. 2005; 139 (1): 179-181.
2. Marx, JL et al. Work-related Musculoskeletal Disorders in Ophthalmologists. Techniques in Ophthalmology. 2005; 3 (1): 54-6