Article

THE EFFICIENT OPHTHALMOLOGIST

Oh, my aching back!

Our profession takes its toll on our bodies.

Repetitive motion syndrome has been discussed in our professional literature for years. In 2011, the Academy even formed its Ergonomic Task Force to study the nature, avoidance and potential treatment options for physicians at risk for these conditions. A recent JAMA Surgery study by Epstein, et al. found that the prevalence of work-related musculoskeletal disorders among at-risk physicians is comparable to those reported among high-risk workers (e.g., laborers).1 Many of our colleagues are forced to limit their clinic and/or surgery schedules, stop performing surgery or retire earlier than they’d planned as a result. A member of the Academy’s special task force informed me that disc surgery, spinal fusion and carpal tunnel repair are remarkably commonplace among our peers — and I could be another statistic.

The X-ray that led to my diagnosis of repetitive motion syndrome. Note the curvature it has caused in my spine.

IT HAPPENED TO ME

My symptoms of chronic low back pain began more than a decade ago. Of course the pain is exacerbated by long surgery days. Through the years, I have had multiple steroid injections at “trigger points” — with limited, temporary effect. The only treatment that has ameliorated my pain has been the use of tapering prednisone and, to a lesser degree, high-dose NSAIDs, neither of which I wish to use indefinitely.

Two years ago, a new and more severe pain developed in my right hip. This led to two MRIs (spine and hip), an EMG and three epidurals under fluoroscopy, which gave no benefit. I have several bulging discs, but apparently these are not the source of my symptoms. Recently, a neurosurgeon recommended a specific spinal injection around the facets of the lower spine. I am also investigating spun platelet and stem cell injection treatment. Understand that I hate going to doctors, so to take these extreme measures is an indication of the severity of my symptoms. They occur in motion and at rest.

After seeking the expertise of two orthopods, three physiatrists and two pain management specialists, my friend, Ron Wilds, a chiropractor, who examined me, shot an X-ray and diagnosed me immediately with repetitive motion syndrome. Dr. Wilds then found the mild scoliosis in my spine. In Dr. Wilds’ words: “As a chiropractor for 40 years, I see repetitive posture disorders daily. These negative postures get worse over time and become habits we ignore until more severe symptoms set in. The sooner the intervention, the easier the correction.”

WHY US?

I am an avid water and snow skier, and I love my work as an ophthalmologist, so I have no intention of cutting back on work or play. I have realized, though, that for 30 years, dozens of times a day in clinic, I have held the 20D indirect lens in my left hand and have bent to the right to examine the patient’s right eye, and then, even further away to look at the left eye. Same motions, same directions for my entire career. Men who tend to sit with their legs spread create an even further reach than women who tend to sit with their legs together or crossed. Looking at my posture at the slit lamp and the operating microscope, I finally can understand how poorly I have positioned myself. Now I constantly remind myself to sit up straight — not to slump or bend my neck/back at an unnatural angle upward or downward.

Our female colleagues may put themselves in an even more uncomfortable position when they wear a dress or skirt in clinic, which forces them to sit side-straddle to the slit lamp with their hips facing one direction and upper torso facing the patient.

Keep in mind that repetitive motion syndrome is not limited to the back, hips and neck. Ulnar nerve compression/carpal tunnel syndrome is common among surgeons.1

WHAT CAN BE DONE?

To avoid developing these problems, be aware of your posture at the slit lamp and operating microscope. Do not lean forward or slouch, and do not sit with your neck angling upward to approach the oculars. Use scopes with adjustable oculars to accommodate your height. Take the time to adjust your chair, the patient chair, OR bed and slit lamp before the exam or surgery. We often feel too hurried to do this properly.

Take action now to avoid painful problems

  • Stretch between every few surgeries or clinic patients.
  • Use autorefractors and push-button acuity charts instead of bending over standard phoropters and projectors — they can be a huge benefit.
  • Try yoga, swimming, massage and low-impact aerobics to help combat repetitive motion-related entropy.
  • Place EMR screens on a reticulating arm that swings into a position to improve your comfort as you view.
  • If designing a new workspace, be cognizant of the movements you make throughout the day — slit lamp, indirect, EMR, and discussion with the patient and family, who typically sit 90 to 180 degrees apart.
  • Do not lean on your elbows, as this can lead to further ligament, ulnar or median nerve pain.
  • Hire a physical therapist to observe you in clinic and surgery; it could be eye-opening.
  • Place a lower foot pedal on a platform under the OR bed, which allows both feet to remain at the same level throughout the case, so you do not compensate or rotate your hips to remain balanced.
  • Take your wallet out of your back pocket during the clinic day so that you do not unnaturally shift your hip to accommodate the bump on one side.
  • Consider a spectacle-mounted indirect to get the weight of the head-mounted indirect ophthalmoscope off your neck and shoulders.
  • Try physical therapy with a specialist in repetitive motion syndrome before undergoing surgery.
  • Place thick padding under carpeted areas (think of the booths at AAO and ASCRS, where the company reps stand all day).
  • Consider a soft back brace under your white coat to support your upper torso (we are not designed for long periods of sitting posture); think about the staff at Home Depot.

Support your upper body with core-strengthening activities and with a chair with a low, straight back that fits at the level of the lumbar spine. Consider arm rests on the chair in surgery to help stabilize the upper body, but be sure you can still move comfortably without awkwardly leaning forward when you or the patient move the head. This may be particularly important for our retina colleagues.

Consider more ergonomically designed OR and exam chairs, patient beds (especially temporally sitting cataract surgeons) and microscopes/slit lamps. (More tips are in the box, above.)

FINAL THOUGHTS

My brother, Bruce Silverstein, MD, a cornea specialist in northern California, has given up his desk chair for a treadmill. He does his computer work, dictations and e-mails walking at a gentle pace rather than sitting for long periods. He says doing so leaves him more refreshed after his busy day.

For years, I had a masseuse come to my ASC for a one-hour massage twice monthly in between morning and afternoon clinic; but no longer. Recently I made a wise purchase — a massage chair — that I use when I wish, much to the dismay of the now terminated masseuse! OM

REFERENCE

  1. Epstein S, Sparer EH, Tran BN, et al. Prevalence of work-related musculoskeletal disorders among surgeons and interventionalists: a systematic review and meta-analysis [published online Dec. 27, 2017]. JAMA Surg. doi:10.1001/jamasurg.2017.4947.