Back pain in ophthalmology: National survey of Indian ophthalmologists

Comparison of neck angle and musculoskeletal discomfort of surgeon in cataract surgery between three-dimensional heads-up display system and conventional microscope

The three-dimensional heads-up display system (3D HUDS) is increasingly utilized by ophthalmologists and suggested to offer ergonomic benefits compared to conventional operating microscopes. We aimed to quantitatively assess the surgeon's neck angle and musculoskeletal discomfort during cataract surgery using commercially available 3D HUDS and conventional microscope. In this single-center comparative observational study, the surgeon conducted routine phacoemulsification surgeries using Artevo® 800 and Opmi Lumera® 700 (both from Carl Zeiss Meditec, Jena, Germany). The surgeon's intraoperative neck angle was measured using the Cervical Range of Motion device. Postoperative musculoskeletal discomfort was assessed using the Visual Analog Scale (VAS) score after each surgery. A total of 80 cataract surgeries were analyzed, with 40 using Artevo® 800 and 40 using Opmi Lumera® 700. The neck angle was extended when using Artevo® 800 and flexed when using Opmi Lumera® 700 during continuous curvilinear capsulorhexis (CCC), phacoemulsification, and intraocular lens (IOL) placement (- 8.18 ± 2.85° vs. 8.27 ± 2.93° in CCC, - 7.83 ± 3.30° vs. 8.87 ± 2.83° in phacoemulsification, - 7.43 ± 3.80° vs. 7.67 ± 3.73° in IOL placement, respectively; all p < 0.001). The VAS score was significantly lower in surgeries performed with Artevo® 800 (1.27 ± 0.55 vs. 1.73 ± 0.64, p < 0.001). The findings suggest that 3D HUDS help reduce neck flexion and lower work-related musculoskeletal discomfort through ergonomic improvements.

Comparison of 3D heads-up display system with conventional surgical microscopy for minimally invasive glaucoma surgery on an artificial eye model

OBJECTIVE

To survey ophthalmic surgeons' opinions comparing a novel three-dimensional (3D) heads-up display system with a conventional surgical microscopy for minimally invasive glaucoma surgery (MIGS) on an artificial eye model.

MATERIALS AND METHODS

Twenty-one ophthalmologists at the 2021 Canadian Ophthalmological Society Annual Meeting in Halifax, Nova Scotia, underwent a 90-minute skills-transfer course on MIGS. Using an artificial eye model (SimulEYE iTrack Model; InsEYE LLC, Westlake Village, Calif.), participants engaged in hands-on practice of MIGS via both a 3D heads-up display system (3D HUDS) (Zeiss Artevo 800; Carl Zeiss Meditec, Jena, Germany) and a conventional surgical microscope. Following completion, participants and instructors answered a 16-question survey comparing the 2 systems (3D HUDS vs conventional surgical microscope). Survey responses were recorded on a 9-point double-headed Likert scale ranging from strongly favour 3D HUDS (1) to strongly favour conventional surgical microscopy (9). Mann-Whitney U nonparametric analysis was used to compare instructor versus participants and experts versus nonexperts.

RESULTS

Survey ratings favoured the 3D HUDS over the conventional surgical microscopy, with respondent ratings for all survey questions ranging from a response of 1 (strongly favour 3D HUDS) to 5 (equal). Mann-Whitney U statistical analysis revealed no significant difference between instructor versus participant as well as between expert versus nonexpert. Most ratings for the 3D HUDS were received for ergonomic setup of the surgical modality, depth of field (or) field of view, and usefulness in training residents for MIGS. Equal ratings for the 3D HUDS and conventional surgical microscope were received for system malfunctions and lag during surgery.

CONCLUSIONS

The 3D HUDS was favoured over conventional microscopy for the performance of simulated MIGS by ophthalmologists with varying levels of experience. The survey results suggest that the 3D HUDS in an artificial eye model is useful for teaching minimally invasive glaucoma surgery, particularly with the advent of competency-based ophthalmology education programs.

Digital Survey Assessment of Individual and Occupational Factors Associated with Musculoskeletal Disorders among Indian Ophthalmologists

Purpose

To study the prevalence of musculoskeletal disorder (MSD) and the associated occupational risk factors among Indian ophthalmologists, including residents and fellows.

Methods

A cross-sectional survey was conducted among ophthalmologists in India using a semi-structured questionnaire in a web-based survey. The questionnaire was prepared in English after extensive literature research and consulting with subject experts. It was pretested on ten ophthalmologists and after confirming that there were no ambiguities, the questionnaire was circulated. After providing informed consent online and ensuring the confidentiality of information, respondents could fill out the questionnaire containing questions to assess demographic details, risk factors, and musculoskeletal symptoms.

Results

We received 551 valid responses, out of which 74.77% reported musculoskeletal symptoms since starting practice in ophthalmology. We found a statistically significant association of work-related MSD with greater hours of practice, a higher number of hours of surgery, and a larger patient load. The self-reported symptoms were maximum in lower back (56.55%), followed by neck (49.03%), upper back (38.59%), and shoulder (23.79%). As a remedial measure, 58.98% resorted to rest while only 8.98% consulted orthopedist. Only 46% were aware of good ergonomic practices. Surgery (74.5%), indirect ophthalmoscopy (51.69%), and slit-lamp examination (50.73%) were reported as the major culprits. Respondents declared an interference with personal life (39.56%), with work (33.74%) as well as having caused psychological stress (43.2%) due to work-related MSD.

Conclusion

A vast majority of our respondents reported work-related MSD. Major risk factors were hours of practice, hours of surgery, higher body mass index, sedentary lifestyle, and higher patient load. The awareness of ergonomic practices was low.

Musculoskeletal Pain Among Eye Care Professionals

Purpose The purpose of this study is to investigate musculoskeletal pain among eye care professionals. Methods This cross-sectional study was conducted using an electronic detailed questionnaire through Google Forms. The structured questionnaire was distributed through various social media platforms targeting eye care professionals. The study included currently practicing ophthalmologists (Consultants, Specialists, Residents), optometrists, and orthoptists. Results A total of 514 eye care professionals participated in the study. The majority were younger than 30 years old (43.8%), with more than half being males (51.8%) and ophthalmologists (55.2%). The prevalence of eye care professionals who were suffering from musculoskeletal pain was 66.7%. The prevalence was significantly higher among females (76.2%) and those over 50 years old (71.4%). Sixty-eight point three percent (68.3%) of participants who don't do running exercises and 92.2% of those with comorbidities suffer from pain. The prevalence of pain among eye care professionals who every week examine more than 150 patients is 72.4%, perform more than 20 surgeries is 85.7%, and conduct more than 20 laser treatment sessions is 100%. Conclusion Musculoskeletal pain is highly prevalent among eye care professionals. This is especially true among females and older adults (>50 years). Among different exercises, running is most protective against musculoskeletal pain. Comorbidities contribute significantly to developing pain.

Impact of Heads-Up Display Use on Ophthalmologist Productivity, Wellness, and Musculoskeletal Symptoms: A Survey Study

Purpose

To explore how ophthalmologist productivity, wellness, and musculoskeletal (MSK) symptoms are affected by heads-up display (HUD) use.

Methods

A digital survey was emailed to the United States ophthalmologists. Questions covered topics including MSK health, surgical output, work hours, wellness hours, and factors related to HUD use.

Results

One hundred and forty-four ophthalmologists responded, and 99 completed all eligible questions. HUDs were utilized by 33 respondents, 29 of whom submitted complete surveys. HUD users worked 353 more hours annually (P = 0.01) and performed 673 more cases (P = 0.07) than nonusers. MSK symptom presence (P = 0.79), severity (P = 0.80), and frequency (P = 0.86) were independent of use. Over half (n = 16/29) of users identified symptomatic improvement attributable to the device, mostly in the cervical and lumbar regions. Mean job stress was moderate-severe for both users and nonusers (P = 0.10), and there was no significant difference in wellness hours (P = 0.44). Retina specialists (P = 0.02) and males (P = 0.03) were more likely to have operated with the technology. Nearly half of heads-up surgeons (n = 12/29) had obtained new equipment to target MSK symptoms, versus 1.4% of nonusers (n = 1/70; P = 0.0009). Most of those who operated with HUDs would recommend them to others (69.0%, n = 20/29), but 44.8% (n = 13/29) indicated ergonomic challenges. Primary concerns included awkward viewing angles, setup difficulties, and a lack of access.

Conclusions

HUD surgeons reported greater work output versus nonusers without significant compromises in wellness or MSK health. User feedback suggests that the technology may lessen neck and low back pains, but barriers including cost and system inconveniences may impede adoption.

Prevalence and risk factors of neck pain in spine surgeons - Are we our own patients?

Aim

This survey of spine surgeons aimed to determine the prevalence of neck pain and identify the associated risk factors. The prevalence of neck pain has been reported in various medical sub-specialities including laparoscopy surgeons, dentists, plastic surgeons, ophthalmologist, urologist and orthopaedic surgeons. However, the literature is lacking on prevalence and risk factors for neck pain in spine surgeons.

Methods

A survey questionnaire containing demographic, Neck pain and work practice details was administered to 300 spine surgeons (members of an online group) via text message and e-mail.

Results

One hundred and eighty surgeons responded to the survey (response rate, 60%). Three spine surgeons had previous cervical spine surgeries. The 1-month prevalence rate of neck pain was 74.4% (134/180 surgeons). One hundred and eighteen surgeons (88%) reported only neck pain, 16 surgeons (11.9%) had neck pain with radicular arm pain. Only 20.5% of surgeons used a loupe, 18% of surgeons used a microscope, and 24% of surgeons used operating table height at umbilicus during surgery. There was no significant difference between the mean age (p = 0.65), work experience (p = 0.8), time spent in surgery (p = 0.7), and operating table height preference (p = 0.4) when symptomatic and asymptomatic groups were compared. However, a significantly greater percentage of surgeons had a sedentary lifestyle (p = 0.002) & used loupes as compared to microscopes (p = 0.04) in the symptomatic group. There was significant correlation between the surgeon's lifestyle & use of loupe and the incidence of neck pain.

Conclusion

Spine surgeons have a higher prevalence of neck pain than general populations and surgeons from other specialties. Considering the high prevalence of neck pain, general health, work, and ergonomic guidelines and recommendations must be formulated to help prevent and decrease the burden of neck pain among spine surgeons.

Prevalence of low back pain in India: A systematic review and meta-analysis

BACKGROUND: Although many studies have investigated the prevalence of low back pain (LBP) among Indian subjects, no meta-analysis has been conducted to determine the comprehensive epidemiological point, annual, lifetime prevalence of LBP among Indian subjects. OBJECTIVE: The purpose of this systematic review and meta-analysis was to investigate the point, annual, and lifetime prevalence of LBP in the Indian population. METHODS: We searched PubMed, Embase, Science Direct, and Cochrane Library databases for relevant studies that reported point, annual, or lifetime prevalence of LBP among Indian subjects,. Pooled point, annual and lifetime prevalence rates were calculated. Meta-analysis, subgroup analysis, sensitivity analysis and publication bias assessment were performed. RESULTS: Ninety-seven studies were included in this review. Fifty-four studies included in the review (55.5%) were found to be of higher methodological quality. The pooled point, annual, and lifetime prevalence of LBP in India was 48% (95% CI 40–56%); 51% (95% CI 45–58%), and 66% (95% CI 56–75%), respectively. The pooled prevalence rates were highest among females, the rural population, and among elementary workers. CONCLUSION: The point, annual, and lifetime prevalence rates of LBP in the Indian population is higher compared to global and other ethnic populations affecting a large proportion of the population, especially among women, rural population and in elementary workers. The findings of this study can be the basis for formulating policy regarding the prevention and treatment of LBP in a large part of the global population.

Comparison of Surgeon Muscular Properties between Standard Operating Microscope and Digitally Assisted Vitreoretinal Surgery Systems

PURPOSE

To quantitatively analyze surgical ergonomics between standard operating microscope (SOM) and digitally assisted vitreoretinal surgery (DAVS) systems.

METHODS

The surgeon conducted procedures on 110 patients; 52 patients underwent a combined phacoemulsification and pars plana vitrectomy (Phaco-PPV group, 24 using SOM and 28 using DAVS), and 58 patients underwent phacoemulsification (Phaco group, 30 using SOM and 28 using DAVS). The surgeon's muscle tone and stiffness in the sternocleidomastoid (SCM) and the two positions of the upper trapezius (UT), which are 2 cm intervals along the UT muscle fibers, UT1 and UT2, were measured at preoperative, intraoperative, and postoperative time points.

RESULTS

In the Phaco-PPV group using the SOM, intraoperative muscle tone and stiffness were higher than pre- and postoperative values in the SCM (P<0.001, respectively), UT1 (P<0.001, respectively), and UT2 (P<0.001 and P<0.01, respectively). In the Phaco group using the SOM, intraoperative muscle tone and stiffness were higher than pre- and postoperative values in the SCM (P<0.001, respectively) and UT1 (P<0.001 and P<0.01, respectively). By contrast, when the surgeon used the DAVS, there were no differences in muscle properties at any measurement site or during any time point in the Phaco-PPV and Phaco groups (P>0.05).

CONCLUSIONS

This study provides quantitative measurement of retina surgeon ergonomics, suggesting that compared with a SOM, the DAVS can reduce intraoperative muscle fatigue.

Initial experience with three-dimensional heads-up display system for cataract surgery - A comparative study

Purpose:

To compare the complication rates, surgical time and learning curve using the 3-D Heads up display system in comparison with the conventional microscope for routine cataract surgery.

Methods:

Consecutive consenting adults with uncomplicated cataract were offered phacoemulsification using the 3-D Heads up display system (ARTEVO 800 Carl Zeiss Meditec) or the conventional microscope (Zeiss Lumera 700) by two experienced surgeons. Surgical time, measured from start of corneal incision to removal of microscope from the surgical field and complication rates were compared between the groups.

Results:

Of the 343 eyes enrolled, 100 (29%) underwent surgery using the 3-D Heads up display system. The surgical time for 3-D Heads up display system was significantly higher in the 3-D group (8.4 ± 2.1 vs. 6.5 ± 1.8 minutes, P < 0.001). There were no group differences in surgical complications (2% in 3-D vs. 2.5% in conventional microscope, P = 0.28). Comparing across 4 quartiles within the 3-D group, the mean surgical time was slightly higher during the 1^st quartile (n = 25, 9.1 ± 1.9 minutes) compared to the last quartile (n = 25, 8.2 ± 1.9 minutes) (p = 0.17). Complications in the 3-D group occurred only in the initial 50% of cases. Seven (7%) cases in the 3-D group were converted to conventional binocular microscope of which 3 each were due to difficulty in depth perception and low illumination while one was due to intraoperative pupillary constriction.

Conclusion:

Phacoemulsification with the 3-D Heads up display system takes longer time but offers excellent visualization, ergonomics and safety compared to conventional microscopes. Experienced surgeons should be able to adapt easily after their first 50 surgeries.

Heads-up 3D viewing system in rhegmatogenous retinal detachment with proliferative vitreoretinopathy - A prospective randomized trial

Purpose:

To compare the outcomes of vitreoretinal surgery in patients with primary and recurrent rhegmatogenous retinal detachment (RRD) with proliferative vitreoretinopathy (PVR) on 3 dimensional digitally assisted visualization system (3D-DAVS) and conventional analogue microscope (CAM).

Methods:

68 patients with primary (50) and recurrent (18) RRD with PVR > C1 were included. One group underwent surgery on 3D-DAVS while the other on CAM. The parameters studied included detachment rate, best-corrected visual acuity (BCVA), duration of surgery, mean endo-illumination levels of 23 G (Gauge) micro incision vitrectomy system (MIVS) and microscope and satisfaction of surgeon and observers based on a framed questionnaire. The mean duration of follow up was three months.

Results:

68 eyes of 68 patients with median age 52.5 (range 18–68) years were included. 50 had primary RRD and 18 had recurrent RRD. Detachment rate at the end of three months was comparable in both groups of primary (P > 0.99) and recurrent (P = 0.21) RRD. Mean duration of surgery in minutes for 3D DAVS and CAM group was 61.8 (±22.07) and 58.04 (±12.33), respectively, in primary RRD and 37.22 (±10.27) and 36.55 (±5.92), respectively, in recurrent RRD group. Mean endo-illumination in 3D DAVS (14.5%) group was half of that in CAM (34.17%) group. Surgeon and observer satisfaction scores were significantly higher for 3D DAVS group.

Conclusion:

3D DAVS is a safe and effective modality or performing VR surgery in RRD with PVR. 3D DAVS allows lower endo-illumination levels provides superior surgeon ergonomics and offers better learning opportunities to the trainees.

Can the Three-Dimensional Heads-Up Display Improve Ergonomics, Surgical Performance, and Ophthalmology Training Compared to Conventional Microscopy?

Purpose

To explore ophthalmic surgeons’ opinions regarding three-dimensional heads-up display (3D HUD) use and investigate musculoskeletal (MSK) complaints among ophthalmologists.

Methods

Physicians were invited to complete an online questionnaire. Musculoskeletal complaints and data of the HUD system use were correlated with demographic information. We explored surgeons’ feedback on image quality, depth perception, and the educational value of 3D microscopy.

Results

In this study, the prevalence of self-reported MSK pain was 82.6% (n=132). The pain started after joining ophthalmology practice and significantly improves on weekends and vacations. We found that the pain intensity in non-HUD users is higher than in HUD users, but this correlation was not statistically significant. Sixty-one (84.7%) of HUD system users were satisfied with depth perception, and 27 (37.5%) reported improvement in peripheral acuity. Thirty-seven (51.4%) of the participants believed they perform surgeries better through HUD; this was why most participants (83.3%) recommended its use in surgical training.

Conclusion

Heads-up display use provides more comfortable sitting positions for surgeons, superior depth perception, and serves as a better educational tool. We believe that adopting this technology may help improve career longevity and productivity.

Survey of musculoskeletal disorders among US ophthalmologists

Purpose

To characterize the prevalence of work-related musculoskeletal disorders (MSD), symptoms, and risk factors among ophthalmologists.

Methods

An online survey was distributed to ophthalmologist members of the Maryland Society of Eye Physicians and Surgeons. The survey consisted of 34 questions on respondent demographics, practice characteristics, pain, and effects of MSD on their practice patterns. Participants were excluded if they were not ophthalmologists or if they had MSD symptoms prior to the start of their ophthalmology career. Demographics and practice patterns were compared for those with or without MSD symptoms using the Welch t test and the Fisher exact test.

Results

The survey was completed by 127 of 250 active members (response rate, 51%). Of the 127, 85 (66%) reported experiencing work-related pain, with an average pain level of 4/10. With regard to mean age, height, weight, years in practice, number of patients seen weekly, and hours worked weekly, there was no difference between respondents reporting pain and those without. Those reporting MSD symptoms spent significantly more time in surgery than those who did not (mean of 7.9 vs 5.3 hours/week [P < 0.01]). Fourteen percent of respondents reported plans to retire early due to their symptoms.

Conclusions

A majority of respondents experienced work-related MSD symptoms, which was associated with time spent in surgery. Modifications to the workplace environment focusing on ergonomics, particularly in the operating room, may benefit ophthalmologists.

Ergonomics in the operating room: it doesn't hurt to think about it, but it may hurt not to!

Ergonomics has gained increasing recognition as an integral component of career longevity in ophthalmology. Residents and fellows may encounter unique ergonomic challenges when learning surgical techniques. A systematic review of the literature, specifically looking for recommendations on optimizing ergonomics in the operating room (OR) and articles that explicitly mentioned suggestions for trainees, was conducted. Of the identified 41 pieces of literature, 31 specifically mentioned ergonomics in the OR, 10 discussed vitreoretinal surgery, 2 mentioned strabismus surgery, and 2 described ergonomics in oculoplastics surgeries. Only 9 of the 41 articles explicitly mentioned either residents or fellows. Based on this review, as well as anecdotal experience, recommendations for residents, fellows, and staff ophthalmologists while working in the OR were compiled. To help offset risk for musculoskeletal injury, recommendations related to relaxation, movement, and maintenance of ergonomic focus are proposed. In addition, methods to optimize ergonomics for the patient, surgeon, surgical bed, foot pedals, surgeon's chair, and the microscope are identified. Trainees may be at particular risk for injury owing to their placement at the surgical bed, and the fact that they may be less likely to get set up ergonomically either owing to a lack of awareness and teaching on the subject, or secondary to perceived time pressures in the OR. Ergonomics should ideally be considered across all domains of life, including in the OR, clinic, and office and at home. The earlier proper positioning is adopted and becomes habitual, the less likely potentially career-threatening musculoskeletal disorders will develop.

Association between extremely long working hours and musculoskeletal symptoms: A nationwide survey of medical residents in South Korea

OBJECTIVES

It has been reported that South Korea ranked as one of the longest-working nations among OECD countries. This study sought to examine the association between long working hours and musculoskeletal pain among Korean medical residents.

METHODS

We analyzed a cross-sectional survey of 1,077 medical residents in South Korea. Working hours per week were categorized as follows: <60, 60-79, 80-99, and ≥100. Musculoskeletal pains (ie, upper limb, lower limb, and low back pain) over the past 3 months were categorized into three groups: no pain, pain without interfering with work, and pain interfering with work. Multinomial logistic regression was used to examine the association between long working hours and musculoskeletal pains after adjusting for covariates.

RESULTS

We found that the average working hours of medical resident was 85.6 hours per week in South Korea. Compared to the medical residents working <60 hours, those working ≥100 hours per week were more likely to have upper limb pain (PR: 1.77, 95% CI: 1.37, 2.30) interfering with work or low back pain (PR: 2.15, 95% CI: 1.51, 3.06) interfering with work, whereas no statistically significant association was observed in the analysis of lower limb pain.

CONCLUSIONS

This study suggests that extremely long working hours are associated with upper limb and low back pain interfering with their work among Korean medical residents.

Utility of digitally assisted vitreoretinal surgery systems (DAVS) for high-volume vitreoretinal surgery centre: a pilot study

AIM

To compare the surgical experience and preferred imaging platform, between digitally assisted vitreoretinal surgery systems (DAVS) and analogue microscope (AM), for performing various surgical manoeuvres.

MATERIAL AND METHODS

A questionnaire was used to evaluate the experience of surgeons who used DAVS for at least 6 months in the last 1 year.

RESULTS

Twenty-three surgeons, including 12 fellows, answered the questionnaire. Eighty-two per cent of surgeons got accustomed to DAVS in <10 surgeries. The higher magnification provided by DAVS was perceived as helpful by 87.0% surgeons. Seventy-eight per cent surgeons felt that DAVS provided a bigger field of view. Colours displayed on DAVS appeared unnatural to 39.1%. Difficulty using three-dimensional glasses over spectacles, asthenopia and dry eye symptoms while using DAVS were faced by 17.4%, 17.4% and 21.7% surgeons, respectively. Difficulty in frequent switching between DAVS and AM was faced by 30.4% surgeons. Difficulty in depth perception, hand-eye coordination and performance anxiety while using DAVS was faced by 43.5%, 21.7 % and 30.4 % surgeons, respectively. Majority consultants did not have any imaging platform preference for most posterior segment procedures, while majority fellows preferred DAVS. Majority surgeons preferred AM for anterior segment procedures and complicated situations like small pupil, corneal oedema and surgical surprise(s). Once the surgeons became accustomed to DAVS, none of them had to shift back to AM during any case.

CONCLUSION

It was easy to adapt to DAVS. DAVS was preferred for performing most posterior segment surgeries. Drawbacks like unnatural colours of the projected image and difficulty in performing anterior segment manoeuvres need to be addressed.