Microsurgical techniques transformed modern ophthalmic surgery.3 Operating microscopes were used widely initially until the introduction of good-quality loupe magnification with evidence supporting comparable outcomes when using either loupes or operating microscopes.3 Loupes are user-friendly, portable, and less expensive.3 In addition, closer access to the surgical field is possible with loupes.2 Despite their widespread use clinically, few papers have been published regarding patterns of use in practice and training in ophthalmic surgery, along with the perceived benefits and limitations of use.8 This study is the first to evaluate ophthalmic surgeons’ opinions on loupes, document their preferences, usage patterns, and their relation to the prevalence of work-related musculoskeletal disorders in Saudi Arabia.
This study established that about 55% of surgeons owned loupes, patterns of use varying depending on the subspecialty. Only a third of surgeons used loupes regularly. The main limitations were attributed to the limited field of vision, lack of comfort, and neck pain, including others. The prevalence of loupe usage in this study was lower than previously shown in literature (87% and 80.9%).7,8However, participants in previous studies were oculoplastic surgeons and did not include trainees. 7,8
Regarding the importance of loupes in surgical training, 62% agreed that loupes would be beneficial and required in training. There was a lack of consensus on whether residents should purchase loupes, with only 38% agreeing that it should be mandatory. More participants with shorter experience believed residents should not be required to purchase their loupes. Perhaps they could recall the financial difficulties residents face. Although the participants who owned loupes, 69% had purchased their loupe during residency training. Residency programs could offer to cover the cost of loupes in support of their trainees. Furthermore, the survey was distributed evenly among training program residents, Dammam residents were more interested in participating in the study. It could be because they are encouraged to buy and use loupes starting from their first year of residency by the oculoplastic attendings; this was not the case with other residency programs.
Approximately two-thirds (59%) of respondents thought loupe usage enhanced surgical outcomes. Therefore, the infrequent loupe usage could be related to the perceived limitations. The most common perceived limitation was the limited field of vision. Richards et al. showed that for every 30% increase in magnification, there was corresponding decrease by 2.5 cm in the depth and width of a user’s visual field.8,9 Lack of comfort and neck pain were the second most common limitations. Yet, a similar number of participants reported the opposite, indicating comfort and better ergonomics or posture as benefits (19% and 13%, respectively).
Whether or not loupes improve ergonomics remains a debate in literature. In dentistry, loupe use has been associated with reducing risks of musculoskeletal discomfort. A lower incidence of lower back pain was seen in the context loupe use that allowed for appropriate delineation angles resulting in optimal working postures. Therefore, surgical magnification without proper positioning may not have the same effect.4 These findings are supported by a systemic review, which concluded that the use of ergonomic saddle seats and magnification loupes improve working posture among dental care professionals. Additionally, the use of loupes appears to reduce shoulder, arm, and hand pain; the effect on neck pain is limited.8,10 This finding was replicated in a study by Aboalshamat et al., which demonstrated significantly lowered levels of musculoskeletal discomfort with the use of dental loupes (<0.05).11 Conversely, Burton et al. reported that static positioning associated with loupe use could cause dentists to experience back or neck pain.8
Our study showed that 82% of participants experienced musculoskeletal pain attributed to work in the operating room. The prevalence of pain was higher in participants who used loupes more frequently; however, this was not statistically significant. In contrast, 78% reported MSK pain related to work in the clinic. These rates are high and should be taken seriously, especially since 10% of musculoskeletal disorders have been reported to be career-ending among oculoplastic surgeons.5,7,8Another study reported 7% of plastic surgeons had to modify their practice, which is a direct consequence of MSD morbidity.12 Literature showed varying prevalence rates of MSK pain ranging from 46% to 90% across different surgical specialties.6-8,13-14
Diaconita et al. surveyed ophthalmologists and found that 46% experienced “neck pain” in the previous 12 months, 36% had “lower back pain,” while 28% had “shoulder pain.”15 These results are not similar to ours, which showed that 87% of ophthalmologists recalled suffering “neck pain” in the last 12 months, 81% experienced “shoulder pain,” and 73% “low back pain.” Like Diaconita et al., we noted lower rates reported for upper back, hand or wrist, and elbow pain by participants.15 Most participants chose to rest or self-medicate and did not seek professional help. It is important to note that none of the participants resorted to prescription opioids or surgical intervention. In contrast, Godwin et al. found that 4% of surgeons with neck pain required discectomy.12This could indicate that our physicians try to work through the pain, which could have more serious long-term sequelae. This is a critical issue to address, as injury rates among healthcare workers are estimated to be almost twice that of other service industries.16Alternatively, this could be related to a reporting bias with participants sharing coping mechanisms and treatments they underwent only in the past 12 months.
Our survey was based on the work of Diaconita et al. and Wei et al. Each tackled the topic from a different angle, one focusing on the prevalence of work-related MSK pain among ophthalmologists, the latter on patterns of loupe usage among oculoplastic surgeons.8,15 We aimed to determine the contribution of loupe usage to the prevalence of work-related MSDs. Although we established that ophthalmic surgeons with longer experience in the field, increased surgical volume, and prolonged operating times and loupe users had a higher prevalence of MSK pain, none of these associations were statistically significant. The results do not conclusively show that the high rate of MSK pain among ophthalmic surgeons is due to loupe use. Conducting the study with a higher number of participants could yield more significant results.Previous studies have studied this hypothesis across different surgical specialties with varying results (Table 5).6,7,11,12,17-19
Conversely, amount of exercise was associated with a lower prevalence of pain. Four or more days of exercise per week significantly reduced the likelihood of experiencing work-related MSK pain. Previous studies confirm these findings. One study established that exercise can improve neck-shoulder pain and function, targeting neck-shoulder muscle groups being very effective.20Other studies found resistance-based exercises to play a role in the prevention of neck-shoulder symptoms.20-22Sivak-Callcott et al. established that five hours of weekly exercise reduces the probability of modifying surgical practice among oculoplastic surgeons.7
Regarding workplace ergonomics, only 30% of participants were aware of the concept. This study showed that knowledge alone did not appear to be protective. Therefore, ophthalmic practitioners must be educated and encouraged to apply ergonomic principles to safeguard against injuries.16 Ergonomic improvements at the workplace aim to create a safer, healthy work environment.16Other benefits may arise. For example, productivity increases by 10-15%, with ergonomic improvements.16 The institute can note decreased levels of job stress, absenteeism, and mistakes (including medical errors).16
There are limitations to this study. First, a low number of participants, almost half of them below 30 years, so response and selection bias may have influenced the findings.The cross-sectional nature is another limitation.The questionnaire could have included more details regarding the long-term morbidity of MSDs by recording sequelae of the pain episode, past medical and surgical history, impact on work, and changes to work patterns. An ergonomic assessment would have helped evaluate the postural impact of wearing loupes while operating. A previous study demonstrated that oculoplastic surgeons wearing loupes adopted non-neutral posture 85% of their operating time, either bending or rotation >15°, along with flexion of >15°. Approximately 26% of their time in extreme postures with bending (>30°), rotation (>45°), and high flexion (>45°).5,7 Other reports found significant risk factors contributing to MSDs in the ophthalmic field include excessive static loading or exertion and repetition. 12,16In addition tothemental stress associated with operating.16 Most participants (32%) reported using front-lens-mounted loupes.While none of the available loupe systems provide neutral head posture, well-designed loupes should support a working posture of <25° of head flexion and <15° of head extension.16