Glaucoma
December 2021
by Ellen Stodola
Editorial Co-Director
When it comes to ophthalmic surgery, ergonomics play an important role. Manjool Shah, MD, and Xavier Campos-Möller, MD, discussed how they consider ergonomics in everyday practice, equipment and strategies to help, and its role in glaucoma surgery.
Improving ergonomics daily
According to Dr. Campos-Möller, the most important thing to understand is the alignment of the entire spine and the alignment of the shoulders and hips. He described it as a vertical line, which represents the spine, and two horizontal lines, which represent the shoulders and hips. “What’s important is making sure that the vertical line is always vertical and the two horizontal lines are always horizontal,” he said. If you drop your shoulder, this will cause one of the lines to be diagonal and would immediately put stress on the spine.
When you sit down for surgery, make sure your feet are level on the ground or level on the pedals, Dr. Campos-Möller said.
Another important consideration is the process of tilting the microscope toward you. This allows you to sit more upright because you don’t have to lean forward in order for your eyes to match the oculars, and you’re not leaning over the patient.
Make sure that your operating chair or stool is not too high, Dr. Campos-Möller said. One issue with the chair being too high is the feet are dangling, and you are no longer supporting yourself like a tripod. If you’re not properly supporting yourself, you’re compensating with core muscles to make sure you don’t fall off. When you lower the chair in conjunction with tilting the microscope toward you, Dr. Campos-Möller said you end up in an upright position that allows for your elbows to be below the patient’s eye level. This allows the elbows to be comfortably hanging by the side, relaxing the shoulders and neck and reducing the risk of tremors when operating.
“One of the most common errors in younger, less experienced surgeons is pushing the eye down when operating,” Dr. Campos-Möller said.
Another key consideration with the operating room chair is the positioning of your pelvis. The ideal position is to not hyperextend your spine; keep your back straight and make sure you don’t tuck your tailbone in when you’re sitting on the chair, Dr. Campos-Möller said.
Seat height and microscope adjustments should be made when different surgeons operate, such as trainees or fellows.
In clinic, Dr. Shah said he tries to remind himself to avoid leaning or hunching forward and compensating with neck extension. “Try to keep the shoulders back and chest up,” he said.
He will also try to encourage patients to come toward him, so he doesn’t have to hunch forward. He raises the patient’s chair as well as the slit lamp to facilitate an upright posture.
In the OR, he will tilt the operating room microscope about 10–15 degrees toward himself like Dr. Campos-Moller suggested and tilt the patient’s head toward him the same amount so a coaxial view is maintained.
“I think [ergonomics] has always been an issue; numerous studies have shown that ophthalmologists suffer chronic back or neck pain,” Dr. Shah said. “With increased volumes and efficiency, we are seeing more patients and doing more surgery, so the toll on our spines is that much more. The hope is increased attention to this problem will promote better habits and maybe even better designs for surgical and clinical tools.”
Recommended equipment
Dr. Shah said that a comfortable surgical chair with elbow and lumbar support is key.
Dr. Campos-Möller mentioned techniques he employs to improve ergonomics. Specifically, he tries to improve flexibility and body strength. He uses foam rollers to develop range of motion and weights and elastic bands to improve strength. “There’s no way you can perform at a high level unless you understand the mechanics of the motions you’re putting your body through and train your body to have flexibility, range of motion, and strength to be able to do what you need to do,” he said.
He mentioned some surgeons may use heads-up technology, which allows them to sit upright rather than bending over the patient.
Specific considerations in glaucoma surgeries
Dr. Shah said that glaucoma surgeries are often longer, so ergonomics is that much more important. “Complex anterior segment surgery is also often longer and requires particularly fine and sometimes awkward hand positions and maneuvers, so being comfortable, secure, and steady is paramount,” he said.
Dr. Shah said he has switched to a temporal approach for most surgeries as opposed to superior because he finds that having a single seating position enables him to be more efficient.
Dr. Campos-Möller said he thinks a lot of the understanding of the positions and postures comes from MIGS experience, where in order to visualize the angle, “we tilt the patient’s head away from us and tilt the scope toward us.”
“I think that’s where we started realizing that by tilting the scope toward you, you’re going to sit more upright,” he said.
It’s not just about being comfortable and pain-free, but proper ergonomics can also increase your performance, he said.
Dr. Campos-Möller mentioned the importance of range of motion and hand positioning in ergonomics, which also plays a major role in getting the technique right in MIGS procedures.
It is important to consider ergonomics in ophthalmic surgery, both to help optimize the surgery and to ensure physician comfort. Surgeons should be conscious of how they are positioning themselves in the OR and consider the use of tools and equipment to help with this.
About the physicians
Xavier Campos-Möller, MD
Head of Glaucoma and Advanced Anterior Segment Surgery
Western Health Eye Care Center
Corner Brook, Newfoundland, Canada
Manjool Shah, MD
Clinical Assistant Professor
Kellogg Eye Center
University of Michigan
Ann Arbor, Michigan
Relevant disclosures
Campos-Möller: None
Shah: None
Contact
Campos-Möller: xavocampos@yahoo.com
Shah: manjool@gmail.com
