Lecture: Eyeing Excellence: Igniting Passion and Safety through Ergonomics in Ophthalmology!

Discover the connection of passion and safety in ophthalmology with our webinar, “Eyeing Excellence.” Explore how ergonomic principles enhance precision and dedication in surgical practices. Learn the important role of ergonomic factors in creating a safer ophthalmic working environment. Gain practical insights into ergonomic design, optimizing workspaces, instruments, and techniques for maximum efficiency. Engage in an interactive Q&A session with expert panelists, transforming your approach to ophthalmic care. (Level: All)

Dr. Donny Suh, Ophthalmologist, University of California, Irvine’s Gavin Herbert Eye Institute, USA
Dr. Susan Ksiazek, Ophthalmologist, Marshfield Clinic, USA
Dr. Benjamin Young, Ophthalmologist, Oregon Health & Sciences University, USA


>> Our topic is on ergonomics in eye field, both in ophthalmology and optometry. It’s going to encompass the entire field of medical specialists. This is sponsored by Cybersight, which I’m proud to be a part of. It’s a free access educational platform for all the experts around the world. I think we’re almost at 100,000 members. So this is one of the largest medical platforms for the field of optometry and ophthalmology and anesthesia nursing and all the fields that are associated with the eye fields. We have free AI programs to help you to make a diagnosis of various retinal findings. We have free access to ophthalmology experts all over the world for your complex cases. We have online courses and libraries. So please, please, feel free to take advantage. Without further ado, I’m going to introduce our three amazing speakers. We have Dr. Benjamin Young who is at the CK Eye Institute in pediatric and adult retina. Is an excellent speaker and he’s been very active with AAO webinars. We have Susan Ksiazek. She is a double boarded neurology and ophthalmology and she has given numerous talks on this particular topic of ergonimics and she is currently in Wisconsin with Marshfield Clinic. And I am here at the University of California Irvine and I look forward to interacting with most of you here. Okay. First question, what do you do? I would like to have some background of your specialties. So let’s give, we’re going to just give five to ten seconds. And the answer to the first question is, most of us are optometrists and ophthalmologists and we have some students and surgical techs and some others. Okay. Next, how often do you experience back pain? One through six, never, rarely, occasionally, frequently, daily, only during certain activities. Okay. Occasionally to frequency. Perfect. Now we’re going to go to the next one. How often do you exercise. One through seven. Be very honest, please, we want to have the most accurate information. Daily, several times a week, once a week, several times a month, once a month, rarely, never. Hopefully none of you vote on never but we’ll see. Okay. I think there’s definite room for improvement. That’s great. Last question. This is an actual question that was brought up by Susan. Who may experience more pain? For those who practiced many years or for those busy surgeons or optometrists. And the answer is, most people think that it’s the people with higher volume. So Susan is going to demystify that. Sorry, one more question. What is poor ergonomics associated with? Back pain, headaches, carpal tunneling, musculoskeletal disorders, anxiety and depression, burnout, medical errors and wrong site surgery or all of the above. I’m going to tell you it’s all of the above. It can lead to anxiety and depression and burnout and medical errors. We’ll briefly touch on that later. I’m going to stop sharing my slides and we’re going to have Susan Ksiazek present her first talk. Thank you, Susan. >> Okay. Good morning. Or good evening as Dr. Suh said. We’re going to talk about the clinics and ergonomics in the office. I have no disclosures. We’re going to touch upon the chair and the patient’s chair and include wheelchairs in this. Often there are some patients that cannot transfer. We’re going to look at slit lamp positioning, indirect exam and also our workstation. Compared to family medicine, we’re more than two and a half times at risk for hand and wrist pain. Certainly we are at times, surgeons are contributing to that. But also we see a volume of patients that medicine doesn’t see. We probably see sometimes twice as many patients in a day as they do. We’re also three times more likely to get lower back pain. There’s a survey and there’s several of these we’re going to talk about. What I want you to notice, they’re all about 50 percent. Over 50 percent. But there are half of us working who are experiencing pain in some portion of the body. And they also, a certain percentage, 15 percent says it does effect their work. Maybe they cut back, take time off. This is personal for me. Six years after starting practice, I had neck surgery for a C5-6 radiculopathy and after that I became highly interested in how to take care of myself. And certainly some of the bad postures we’re going to talk about contributed to my injury. This is a question that Dr. Suh mentioned. Who has more pain. Certainly No. 2 won out. But the answer is No. 3. Is that we are not exempt as I said, it’s 6 years into practice I was relatively young, I had gotten several whiplash injuries. Was lifting poorly and contributed to using the slit lamp and the microscope. So seeing more than a hundred patients a week puts you at greater risk. Performing more than 4 surgeries a week. Or performing 6 lasers a week. Age was not a risk factor. Prevention is key. It’s an occupational risk. And remember we talked about the 50 percent. So it will surveys in 2004 as well as in 2005, over 50 percent of people had neck or back pain. Those are the bigger ones. And some had surgery. They noted back surgery, neck surgery. But back is more common. A more recent survey of plastic surgeons and this may relate to them bending over and I think Dr. Suh is going to cover some of that in his lecture with pediatric surgery. But the bending over may cause increased risk of neck and back problems. So in the office with a patient’s chair and the foot rest, you have them get in, you cannot get close enough to the patient because of your casters doesn’t fit under the foot rest. So the first thing I do is seat the patient, clean my hands and raise that chair up. I raise it up. I just do it, you do things by routine and you don’t even think about them. This enables you to get closer to the patient. In the first two a, you can see he is leaning in, extension of the neck and kyphosis of the back. In the second 2B, he is pulling the patient towards him. And sometimes the patients will complain a little bit but just think, they do it once and you do it 20 to 40 times or more in a day. Just say, please lean forward. In fact, you can see how raising the chair allows you to get the chair closer to the patient. I even have, when I’m checking APDs, if I don’t have the patient lean forward, I feel like I’m leaning on top of the patient. So again APDs. You need to check it. Your tech says no, I think I saw one, you go in. Have the patient lean forward. Often they will do so briefly and not complain. Here it is. You want to make sure your ear is over your shoulder, is over your hip. See that very nice posture in the first slide. You’re having the patient lean forward. And here I’m also having, I’m not making full use of my backrest. But if you have chairs with backrests, that’s another thing. You know when you lean off the backrest that you’re leaning forward. And you may consider getting some sort of cushion or pillow for the patient so they cannot have issues with leaning forward. Some of them, I don’t use one. I find I just ask them to lean forward and they do so for me. So some people have even gone to the extent of getting a custom table. If your table length is shorter, the width of it so to speak is shorter, there is less, you can lean in easier to the oculars. The other thing I would consider is making it wider and I’ll show you why in a minute. But custom tables is a way to go. The other thing when you use the slit lamp, this is a big no-no. And you sometimes see this in female physicians or optometrists where they’re wearing a skirt. So make sure you don’t do this. Not only are you leaning, you have torsion to your spine. This is really not very good at all. So don’t cross your legs. Put one on either side. Also, just a quick hint. If you are examining the right eye, you want to be to the left. When you examine the left eye, scoot your chair to the right. Avoid that torsion. Same thing with lasering. If you’re doing your right eye, put the foot pedal on the right. That way you balance your body opposed to leaning always way over with the hand and the foot doing both. Holding your wrist. He is leaning on the metal bracket of the slit lamp. Longhand. He is flexing. Not good. Just the opposite in the second picture. Hyperextending, not good. You want to be neutral. And notice there’s a cushion under his elbow. There are various cushions available. Don’t use the wooden one. The wooden one is out there, it’s too hard. The biggest problem I see is these cushions are too wide for a slit lamp so they often want to fall off. The one on the left doesn’t, it’s a little more narrow. You can find these, they are available. Or you can Jerry rig your own. A word about wheelchairs. So we talked about the slit lamp, the patient coming up. The chair, using a back, sitting straight. But what about the patient that comes in and can’t transfer. I transfer as many patients as possible. Wheelchair glides do not make this better. You’re leaning forward, again, your back is not in a good position. You’re not in alignment. The neck is hyperextending. Not good. I actually noticed just this past year when I was doing N I had a problem and my neck started acting up. It was every time I had a wheelchair patient. I had a retinal problem, they were bad diabetic and I had to do a very intense exam. So my manager, I give him credit. The problem with this is you need a dedicated room. You take the chair out, you raise the floor. Ours is a little over three inches and we have this lightweight plastic ramp which was reasonably priced. You wheel the patient up and instantly they’re at a higher position for you. Like as if you raised the chair. So you take the ramp away and then you can examine the patient easily. The biggest issue as I said is you have to have a dedicated room for this. You can put patients in regular chairs if you wish and examine them. But you don’t have your eye chair anymore. The indirect exam. This is terrible. This is something you see in the OR as well. Because you’re hunched over and leaning and also in the right picture, contorting your body. Not only leaning but twisting. This is not good for your body. If you’re not going to have a good career if you do that. Lessen your load on the neck. Raise the chair. Lie the patient down. In exam, go to the right side and go to the left side. This takes time and that’s the problem we have. Sometimes we want to be as efficient as possible and we hurt our body in doing so. What about your workstation and room? It’s better to excuse yourself, finish typing, and then turn and talk to the patient. Not like the doctor in the far right. That’s not good. Completely turn your chair around. So none of these pictures are ideal. In 1A, his chair is too low. His arms should be at 90-degrees. In 1B, he is turned. His spine is not straight. 1C is pretty good but he is not taking advantage of the back of the chair. For the keyboard, an articulated stand is nice if you want to swing it and talk to the patient. If you can’t, just excuse yourself, type, then turn and talk to the patient. I usually say first I’m going to examine you. Then I’m going to type, and then we’ll talk. So they don’t get upset while I’m quietly typing away. At your workstation, remember, 90 degrees, your ears above your shoulder above your hip. You can actually buy a cushion if you’re not right. So you can sit on something to raise you up. You might need a foot stool if you have short legs. You don’t want your mouse too far away. That reaching is very hard on your shoulder. Make sure your feet are not crossed. They’re straight and flat on the ground. There was a question early on about how do you set up your workstation. When you set up rooms, you don’t have an office yet. I would suggest for right-handed people, you put your workstation on the left as you walk in the room. That way you can turn to your right and vice-versa. But you should do all your rooms ideally the same. You shouldn’t have one room on the left and one room on the right. That’s when you’re going to run into problems. It’s the routine that helps you. Remember, during this webinar, I hope you leave with good ideas to prevent and treat your pain but you want to be in that good half. You don’t want to be in that 50 percent that has problems. And when it comes to long overtimes, make sure you take breaks. We tell patients 20, 20, 20 screen breaks. We need to take breaks. You need to stop and walk and stretch. Just stretching your arms and I think that Dr. Young will talk something about that. And somebody mentioned eye protection. I think of eye protection as something that I avoid sun or don’t let sun come into my eyes room. Room tap (ph) and sunglasses that’s my sunscreen. I take breaks, 20/20/20. Every 20 minutes look 20 feet away for 20 seconds. Remember, also, it’s not just at work. Maintain your good posture throughout your day. Remember your driving. Use your side mirrors. Lifting, that is how I got myself into trouble. I was lifting too much or lifting poorly. All of these things are important to consider as well. Those are my references. Thank you. >> Thank you, Susan, great, great talk. A lot of great tips. Next, it’s a great segue to Dr. Benjamin Young. He is going the talk about what are the things that are important outside of work, at home and a lot of the important habits that we should consider. So Ben? Please take it away. >> Thanks. I will just share the screen. There we go. Is that like a full screen share. >> Yes, perfect. >> Excellent. So Donny, thanks for inviting and Cybersight for hosting this. It’s a topic that I really care about and talk about. How do we improve ergonomics when not in the clinic or the OR. What can we do away from work. No financial disclosures. We just had this poll question come up and it looked like 94 percent of people had back pain at, with some frequency. It was only 6 percent never had back pain that were logged into this talk. So obviously this is a very common thing that happens. Just a little brief intro to myself. It’s a similar-ish story to Susan in terms of why I care and investigate this. You can probably tell from the video, I’m relatively young, early in my career. But early on I knew I wanted to manage retinopathy for maturity. That is not a picture of me. It’s a stock image. ROP exams along with peds and ophthalmology surgery and ROP exams and indirect laser, forces you into uncomfortable positions and you have to maintain your neck and back for long periods of time. In my residency, I was in my mid 20s and getting lower back pain. As Susan said, age is not really a factor. People at any age can get skeletal issues. Since that, I’m about 8 years or so beyond that. We’ll go on my evidence-based tour of what I’ve been trying to figure out so I can have a career that is more than a year or two and still be able to treat adults and babies. First, I want to review basics of the spine. I had a lot of misconceptions about what is important. So spine, we all should know is a column of bones separated by fibrocartilaginous discs. Intervertebral discs. The spine from an evolutionary perspective was designed to be good for rotational bending and lateral flexion. It’s good for when cats bend to clean themselves or when we evolved in the ocean and our back and forth movements with aquatic animals, that is what the spine is really good at. It’s not designed or was not evolved to tolerate compressive load. Even when we came to land, the spinal column was well designed to tolerate moment load. Like in the sheep on the left, the load from the weight of the gut pulling down, the spine is pretty good at tolerating that based on the arch and everything. But in terms of bipedal animals, it was not designed for that initially. As a result, if someone has back pain and they go see whoever and get an MRI scan, the majority of humans, something over 90 percent of humans will have some kind of degenerative change in their spine if they get imaging. Like mild herniations, thinning, bony spurs, et cetera. It’s just, that’s just a fact of life. Even if you have no back pain, you go in, you can still have these changes over time. That’s important to know from the out set. In other words, because our anatomy is likely not optimally designed to be in the position that we’re in, we’re constantly in a war against gravity. So the goal of what I’m going to talk about, really what all three of us are talking about, is to be able to generate force to maintain the appropriate intervertebral relationships so your spinal column can tolerate the compressive load it’s not designed to do well. In other words, that’s a lot of words, basically what I’m saying is a strong back is a healthy back. If your back is strong and able to isometrically contract and keep the spine in a neutral position, in a position that Susan just talked about and Donny will talk about how to maintain that neutral position. You will have a healthier back in general. I’m talking mostly about back pain. The strength that helps to protect your joints applies to all joints, not just your back, shoulder. But remember, strength, I’m going to talk about strength for a lot of this talk. I know, we’re not orthopedists. Classically, ophthalmologists are not into strength training or whatnot. Strength is the ability of your body to generate force against the outside world. That is important to protect your spine and other joints. So what’s the evidence behind this claim? Susan went through some with specific ophthalmology. But there are not a ton of huge studies that into this specific question. So I looked into other specialties. This is a big study of urologists. 700 urologists. It’s a summary of these graphs are that the statistically significant factor they found when they looked at age, duration of career, surgical volume and exercise is that exercise was protective. The rest, like Susan said, age, doesn’t have a strong factor. That was related to development of musculoskeletal pain, back and neck pain. This is, we get compared to dentists frequently for many reasons: But this was a nice study looking at the effects of resistance training for dentists and dental assistants. The summary is after a 20-week course of strength training, there were improvements in pain and all the joints of the neck, upper and lower back and shoulders. This was a nice literature review in occupational environmental medicine looking at not really specific to medicine but all occupational musculoskeletal disease. They found the strongest level of evidence of being able to develop an interventional program that was protective against musculoskeletal injury was resistance training. Other things were helpful like flexibility training and stress management, et cetera. You know, workstation adjustment all had moderate effects as well. The one that ran through many occupations is resistance training as be protective. This is just, like Susan mentioned, it goes beyond neck and shoulder pain if you are doing strength training. Headaches can be reduced with effective training programs. So I’m talking a lot about exercise programs. I’ve been talking about what those look like. Based on this literature, here are some things I would look for. All of us need something different. All of us have different equipment and such that are available. Here are some broad things that you should consider if you’re convinced by my pitch that we all should do some degree of strength training. Compound movements are better than single movements. Like a leg extension, it basically just works the quad muscles, compared to a leg press like on the right. It works across to joints, the hips and the knees. In part, this is good because we’re busy. All of us have busy people. And the fewer exercises you need to do, the more efficient your workout program will be. The other thing is you want to — if your goal is injury prevention, you want to balance out the muscles that are doing the different activities. If you’re only working your quadricep muscles and not the hamstrings, you might not have that balance and you may not be as effective in your prevention. Take that a step further, in general, free weight exercises appear to be better than machine exercises. Instead of a leg press, do a squat where you go up and again against gravity. The reason for that is when you do a machine restricted activity like the leg press depicted on the upper right, that doesn’t kick in the use of the smaller stabilizer muscles that you need to do in real life to do that activity. In real life we’re never making a more restrictive machine. You’re twisting. If you’re going to train your body to win the war against gravity, you need to be able to use all of the muscles in realistic situations. If you can use free weight activities compared to machine. Also, this is — this may be the first time you have heard something like this. I suggest avoiding exercises that induce spinal flexion. At least in the United States, we all learn to do sit ups and do them in grade school. The purpose of the spine — it can flex but the purpose of the spine, the core muscles, abs and back muscles should be isometric contraction to maintain the neutral intervertebral relationships. Like Susan was demonstrating in terms of keeping the spinal column neutral. That’s what you want to do. Doing sit ups to strengthen the core is not as effective for that. If you ever had back pain and I really suggest not doing it because you may have bony spurs or degenerative disc issues where you may exacerbate them with spinal flexions. You want to keep the spine neutral. Another thing that I would suggest is to look for something that involves progressive overload. The most distinct way to explain that is this cartoon depicts the myth of the Greek mist. A mist logical wrestler that did feats of strength. The story of how he got so strong is he had to carry a calf, like a baby wow when it was little. Carry it up a hill every day. And the cow got bigger and bigger and he was still able to carry it up the hill because your body will adapt to changing stress. Just like when we’re learning cataract surgery. If you do 100 routine surgeries, you’re probably not going to get better. It’s when you do more and more challenging cataract surgeries that your skills will improve. If you’re trying to train a muscle, don’t start off with the full size cow, you want to start with something light. And then progressively at a gradual rate increase the amount of stress your body is overcoming to be able to force it to adapt to increase strength and ability to exert force on the outside world. Look for something that involves that. If you’re doing ten sets of push ups every time, you’re not getting stronger, you’re maintaining strength. We don’t get stronger, our spines, and backs and necks don’t get stronger when we exercise. They get stronger when we sleep, hydrate, eat well and rest. It’s when our body adapts after the stress was applied to it. That o those are the most important things when exercising. Don’t overdo it and make sure you do the things in red. Okay. So the poll question we found that a lot of people, more than I was thinking were able to exercise routinely. I will tell you, I’m like early in my career and just had a baby, it’s hard to find time, I think a lot of us to exercise routinely. I searched for exercises that are the most efficient use of time so we can get in and out and accomplish our goals. My conclusion was that a barbell dead lift is probably the most efficient if your goal is ergonomics and injury prevention. If you’re looking for body building tips don’t ask me. I’m not the expert on that. But here is what a dead lift looks like. It’s taking the weight from a dead stop on the floor, that’s where the dead comes from, and bring it to standing height. Good technique is everything with this. If you can imagine, if you’re doing this wrong or the spine is not neutral or the technique is off, you can hurt yourself. I mentioned in the beginning, I had back pain very early on in my training. When I figured this out and started doing dead lifts regularly with progressive overloading and increasing strength over time, I haven’t had back pain since. Take that for what you will. I don’t have a large study to show that. There are smaller studies that suggest that is a common finding. That this technique can reduce things like back pain. This is what I found was helpful. Because, the R I don’t think I mentioned, a dead lift works the entire back. Basically the entire back muscles, the posterior muscles, forearms when you’re trying to strengthen your wrists, et cetera. Remember, doing any exercise according to the literature is better than nothing. If you don’t have the equipment for this, any kind of exercise is better. To be super clear, age is not a factor in whether you can do this or not. I know this technique may look scary. If you don’t know weights, this is more than I weigh, it’s 225 pounds or so. If you can walk, you should — and you don’t have serious prior back injuries or whatnot, you should be able to do this. Examples of training programs. This is like the most simple one. It doesn’t have to be a thousand different exercises. In this, like the thing called a press where you push away up or bench press when you push away forward, you can probably skip that if the goal is ergonomics. I don’t think anyone specifically studied this. It can be a couple exercises that you do two days a week. If you don’t have access to the more fancy equipment, home equipment are kettle bells. You can do a lot of free weight activities that can strengthen your core. Dumbbells. You can get adjustable dumbbells and vary the weight. If you want to do a body weight routine, there are a lot of versions out here. This follows the three principles I was talking about. I can’t go through all of these. Here is a QR code. Or you can search for McGill big three. That is one set of exercises that is recommended by physical therapists. The key to this is we’re not inducing repeated flexion. We’re keeping isometric contraction on the spine in different positions to strengthen and prevent injury. Conclusion, when you’re not at work, if you can find time a couple times a week, once or twice a week to do some resistance exercise. Any exercise is better than nothing. A lot of aerobic exercises will strengthen isometric contraction of the spine. And don’t forget sleeping and hydrating well are critical. That’s all I have. Thanks everyone. >> Thank you, Ben. That was awesome. Only thing that I’m doing that you have recommended is that I’m not doing any sit ups so I’m in good shape. Can you see it okay or no? Ben, can you see it okay? >> Yes. Yes. >> Perfect. Thank you very much, so for the next 15 minutes I’m going to give a talk on what are some of the things you can do in the operating room. I have no financial interest in any of the things I’ll be talking about. I have looked at different surveys and taken a survey from different sources of ophthalmologists and found the numbers were actually higher than Susan’s. It’s almost 80 percent of low back pain. And the numbers were higher among pediatric and plastic surgeons. Why is it so high? Ergonomic posture is not something that is natural. We have to consciously think about it. Just like what Susan and Ben talked about. Our instinct is to tilt our head to get close to what we’re doing. Unfortunately, we’re working on an organ that is very small. In order for us to see small items, we have to get close. That is human nature. We have to get close. As long as you can accommodate. If you can’t accommodate or need additional assistance, then we wear telescope mounted glasses, loops or use microscopes. And the ideal position just like Susan talked about, you want to have the shoulder in line with your ears. So your ear to your shoulder, you want that to be completely straight. You don’t want any forward or backward position. Also you want your arm to be at 90 degrees. But the ergonomics 101, jobs that require neck flexion greater than 15 degrees forward is associated with musculoskeletal disease. This has been well documented. In our field, it’s 45 degrees. Most of us spend, during surgeries, we typically lean forward for about 45 degrees if you’re not using a microscope. This is many of the pediatric ophthalmologists or the oculoplastics or retinal surgeons. Why is this important? Because today, we’re doing more number of surgeries than ever before in history. Because we have gotten efficient and our equipment is better. This means that we are spending even longer duration in the operating room. And then also to make things worse, the demand is growing. The population is growing. We don’t have the number of physicians that is growing in number proportionally. That’s why you see physicians — when I go to India or when I go to some of these countries, it’s not unusual for average surgeons to do — I’m not exaggerating, 80 to 90 surgeries a day. You can imagine the stress they’re putting on themselves. What happens when you’re leaning forward in the operating room to the lower back? If you can imagine, the disc that Ben talked about is like the shock absorber in your car. And the annular ligament is like the coiled spring that wraps around the shock absorber. When you’re leaning forward you are trying out the disc and shrinking it. The disc space is getting narrower and narrower and that induces bone spurs and tears in the annulus resulting in spinal stenosis with disc herniation and eventually irritating the nerve nearby. And Susan talked about this. The lateral flexion of the neck or back is even more dangerous because we don’t have — we don’t have an annular ligament that is significant enough to hold the spine in place laterally. So it’s mostly in the front and the back. But laterally, we don’t have much protection. So this type of movement for five to ten minutes, maybe you can endure. If you’re doing this for a prolonged period of time, this is going to cause significant strain on the disc. The lateral flexion is very common among the pediatric retinol gists and ophthalmologists because when we’re trying to look at the macula and look at the 270 degrees of the retina, you only have a few choices. You can rotate the eyeball, rotate the neck of the patient. But you’re going to have to tilt. You will have to tilt. So this is actually, we’re in a very difficult situation. So is there anything we can do? The answer is definitely yes. First, let’s talk about the surgical loops. This is something that I use on every case that I do. But most of the surgeons are using surgical loops that are not properly fitted. Please remember, I said this. They’re not properly fitted. You have this thing fitted when you’re a resident or 10 or 20 years ago. But your body changes, your body habitus changes and the optics change, the refraction changes. We are wearing glasses for most of us that are not properly fitted for us. It was at one point but not today. And also the telescopes are heavy. It’s putting a lot of pressure on the nose and ears. It’s uncomfortable. And then you can further and also these loops, the way it’s designed, it can furthered exacerbate the neck flexion and that’s the reason why many surgeons refuse to wear surgical loops and they’re just doing surgery without any glasses. Especially if they have the right optics. But, we have now recently, I’m going to say in the last two years or so, now the surgical loops companies have developed these special prisms that can bend the light. As you can see with this prism, it completely corrected my posture: It takes time to get used to but not much. I’ve been using this loops for 6 o’clock months and my posture is zero. There is no flexion whatsoever. This is something I would love to have you guys try: You can have these reps come to your office and you can try it. Make sure that you have the proper distance and working distance and wear the proper glasses. And also surgical instruments. Make sure it’s sharp and lubricated. If there are any instruments not working properly, send them back. And your future depends on it. Make sure these instruments are properly prepared. And try to avoid any type of flexion more than 15 degrees. The way you do that is you have to adjust a chair and bed and your microscope before the surgery starts. Don’t try to wiggle yourself and adjust after the surgery, because it’s too late by that time. It doesn’t work. Make sure you spend a couple of minutes, you sit comfortably, especially with the first case. That’s most important. Sit properly and make sure you’re completely comfortable and have someone else look at you and make sure that all the equipment is fitted to you, not the other way around. There are three dimensional display systems. I’m not going to talk about each individually. But they do have definite advantages. Here are three surgeons and a nurse looking at one small — they all have to look at one small organ and they have, someone has to flex, it’s going to be difficult to cram everybody together. This is me using the 3D system. You can have everyone looking at the big screens. We typically have two or three screens on the wall and you can be doing surgery, whether it’s cataracts or retinal or strabismus surgeries. There are many options out there but the problem is that they’re still pretty expensive and it does take up a lot of space in the operating room. So I do think there is a lot of potential for these technologies because it does, it does help me. So I’ve been pretty happy with it. But there are more and more companies that are coming out with better equipment. So I’m going to say four take-home messages. No. 1, have the OR staff take photos or videos of your posture during surgery. All athletes do this. For your profession, I think you owe it to yourself, have someone else look at you. There is no way you can look at yourself. And then review the videos. No. 2. Like Ben was talking about, most of us don’t have time to go to the gym, two or three times a week. So between surgical cases, instead of being on the phone and things like this, for two minutes between cases, make sure you stretch. So two minutes and let’s say you have ten cases, that is 20 minutes. That is pretty much what you need. Have some of these weights in the operating room and have them provided for you if they don’t. And do some to have exercises that Ben talked about and stretch. I think that’s extremely important. And then, of course, we talked about hydration. This disc needs to be hydrated. Third, consider prism surgical loops. There are — pretty much all companies have these prism surgical loops. They’ve been available for two years or so. It’s getting better and better and I’ve been pretty happy with it. Right now I’m doing an EMG and we’re doing a study trying to objectively quantify the muscle straining that we’re applying to different muscles. And hopefully next time I present this talk again, we’ll have that data available for you. And then also, you remember, your body is changing. Make sure you adapt to it. If your surgical loops are not designed for your body today, get it adjusted. And then No. 4. Pain, for us surgeons, it’s almost like considered a badge of honor. When I was in training, down at Baylor medical school, it was a surgeon’s mentality. You don’t complain. Pain is okay. No, it’s not okay. It’s not a badge of honor. If your body is telling you that you’re in pain, something is not right. You need to figure out what is causing the problem. I think making those small changes that we talked about today I think is truly critical. Charles Darwin, I was in the Galápagos. There is a huge sign and the sign says it’s not the strongest or the smartest that survive. Of course, it’s the most adaptable to change that will survive and out last you. Thank you very much. I’m going to — let’s go over some of these questions. I hope that was helpful. I tried to make this talk always under one hour. I know you all have busy schedules and I don’t want you to be sitting in an uncomfortable position for a long time. Susan, what are some of the suggestions for ophthalmic surgeons who are short? >> I would consider putting your foot pedals on risers. That is one thing. You want to keep your feet flat between the bed and the leg length. You need help there. >> Next question. I’m just going to ask Ben this question, for your retinal surgeries and cataract surgeries, what are some of the recommendations and I brought up some of the tips as well, but what are some of the tips that you can help you to make your posture better for your retinal or cataract surgeons using the microscope? >> For one, I learned early onto try to do everything under the scope. The biggest one is scleral buckles. It’s a learning curve. But that made my surgeons faster, a better view and made my posture better. I think what you said about spending, the more time you spend getting yourself set up properly at the beginning of the surgeon will save you time during the surgery. You’ll be more comfortable and your posture will be better. Setting up the foot pedals is huge. Not everyone has the same hip alignment. My hips are externally rotated compared to the mean person. I need my foot pedals 20 degrees out to be comfortable. And some people need it more in. I think you need to find out what is best for you and your posture. >> Okay. Thank you. Susan, do you have any other tips that you can share with us? You can unmute yourself, Susan. What are some of the tips that you have about positioning the bed and types of beds in the operating room? Any other tips you can share? >> The bed. The patient’s bed. I like the striker double angled head rest. It’s not just you. You have a patient that is kyphotic and you have to deal with it. You can put the patient in reverse Trendelenburg to get the head flat or the eye parallel to the floor before you start. You know, I think as far as short surgeons go, the risers are good. I always tilt my microscope because it brings the microscope to me, the oculars opposed to being up right. That way I don’t have to get as close to the bed. My back is not leaning in as much. Those are the tips that I would give. >> Okay. Thank you. Thank you very much for answering a lot of these questions. So Susan, since you’re — back issues what are some of the things — just unmute yourself, leave it unmuted — what is one or two things you have done that you think made the most impact that improved your ergonomics. If you say one or two things that made the most amount of impact that alleviated your back pain, what would that be? >> Raising the chair in the exam room. >> Okay. >> Not leaning in. Forcing the patient to come to me. Because you’re leaning in, mine was the neck issue and hyperextending my neck. If I can keep myself neutral and bring the patient towards me, I’m good. >> Okay. I’m a new ophthalmologist and have scoliosis. And thoracolumbar, since in med school. Do you have any tips for my back? So I can be in a good position and reduce my back pain? Thank you. Both of you, anybody. >> I would talk to your spine, who you see regularly as a physician and say what is the best position to keep me functioning for the rest of my life. And then try to adapt that posture in your work. I would say it’s going to be a form of neutral. But what’s neutral for you may have some curvature, obviously, there. And I bet there are exercises you can do as well. I agree with Ben, I would do my exercises, twice a week. >> I don’t know, I’m like not super comfortable knowing what scoliosis, I think talk to whoever does your spine for you. But in general, yes, strengthening it is probably a good idea but defer to your specialist. >> I feel very strongly about this. I’m just going to tell you, all athletes at a professional level have multiple coaches and multiple people that are constantly watching their posture. Golfers, even Tiger Woods, you can quote me on this, have multiple coaches that are constantly watching. These are people that are doing this repeatedly for million of times but they have coaches and they have trainers that are constantly watching. We’re all professionals. A lot of the recommendations that Ben made, I think they’re great. But I would highly recommend you have a trainer, a professional trainer or a physical therapist that works with you. At least initially. You may not have time to visit them on a regular basis but at least initially so you get the right technique. Some of the stuff, the exercises they recommend can be detrimental and hurt you. It can backfire. So please, please, get a professional, someone that — get a recommendation and talk to your doctors and get the professional physical therapists or trainers who deal with the — people in our specialties. Next, I had a whiplash injury. Being a pediatric ophthalmologist and do lasers. ROP lasers. And every patient now, when they’re treating, every patient, the person is having significant pain. Is neck collar, can you suggest in a collar can be helpful? Ben? >> Oh, man, I don’t believe that those tend to be helpful. I think, you know, when you have supportive device like that, I haven’t seen that looked at in the literature. But supportive devices can sometimes weaken the natural musculature. So when you don’t have it, that can lead to instability. I don’t think that’s recommended. >> I’m going to actually make a recommendation. First of all, I don’t think it’s a good idea. Because when you have a neck collar, it actually limits the area that you can visualize. So if you are in a significant discomfort or pain, let me just tell you, I would love to do everything that I can. Sometimes you may think about other options. So first, I would recommend if you’re in pain, do not ignore it. And second, I would get a physical therapist or talk to your doctors about your concerns and seek help. If they do not alleviate the discomfort, I would highly recommend you look for other things. And delegate the ROP treatment to someone else. That would be my recommendation. I actually had a partner, a colleague who had to retire early because of the ROP treatment with the lasers. But fortunately, these days we have other treatment modalities that are — that have been effective. So I think that’s great. What are the mattresses. Some of these practical questions. What type of exercise — okay, let me just say that the — this was a great comment. I would add avoid high heels and shoulder bags. What do you think about that, Susan? >> I think that’s a great idea. Backpacks are much better. They distribute weight. A shoulder bag is obviously very light. Or do your farmer carry. That is considered a good — you carry your bag in your hand and not on your shoulder. As long as you’re symmetric and well positioned, again, you can progressively load as Ben talked about. Put your stuff in a bag that you carry in your hand is better. High heels, yes, they’re hard. We can wear them for short periods of time. >> I definitely, when I see ladies in high heels, I just don’t know how they do it. If males, if men had to wear them, I don’t think anybody would. And then what strategies do you — these are a lot of great questions. I’m going to stop here because this is actually, this really is a topic that we can cover for — we can have a whole symposium on this particular topic. But I hope some of the tools that we talked about is helpful to you. And I’m hoping we can have another webinar on this topic next year. And hopefully all of you will join. Thank you very much everybody. I hope you have a wonderful, safe, ergonomic day today. Thank you. Thank you, everybody. >> Thank you.

Last Updated: June 21, 2024

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