The relationship between surgical loupes usage, workplace ergonomics, and musculoskeletal disorders among Saudi ophthalmologists

Abstract

PURPOSE:

To evaluate the knowledge, attitudes, and practices of surgical loupes among ophthalmologists and determine the relationship between this tool and musculoskeletal (MSK) disorders.

METHODS:

Between December 2020 and January 2021, ophthalmologists (trainees and consultants) working in Saudi Arabia received an anonymous, Internet-based survey through Google Forms.

RESULTS:

The total number of surveys completed was 93, and 82% reported pain with operating during the past 12 months; 87% reported neck pain, 81% reported shoulder pain, and 73% reported lower back pain. Sixty-eight percent chose to rest without seeking professional care. Forty-seven percent of participants exercise regularly. Sixty-nine percent attributed the pain to “bending or twisting your neck.” Fifty-five percent of surgeons owned loupes, and only a third used loupes regularly. Forty percent indicated a limited field of vision as the main limitation. The Chi-squared test showed that MSK pain is a risk among all ophthalmic surgeons (P = 0.348). It was more prevalent among surgeons with longer experience. Increased surgical volume and prolonged operating time were associated with higher rates of pain. In addition, more frequent loupe use was associated with an increased prevalence of pain. The study found no statistically significant association. Finally, the activity level was significantly associated with a lower prevalence of pain (P = 0.028).

CONCLUSION:

The majority of participants in this study experienced occupational MSK pain. Most participants owned loupes, and only a third used them regularly. Young ophthalmologists should be encouraged to apply ergonomic principles to safeguard against future MSK injuries.

INTRODUCTION

The use of magnification devices has contributed to the evolution of microsurgery.[1] Since their introduction in the 1960s, surgical success rates have increased.[1,2] They have become an essential part of several surgical fields, including ophthalmology.[1,2] Optical magnification is achieved using either loupes or operating microscopes.[3] Loupes are easier to use, less expensive, and offer better portability than surgical microscopes, making them more favorable.[2,3] Other benefits include a more detailed view of operative anatomy, translating into superior clinical work, and enabling the performance of procedures otherwise difficult with the naked eye.[3]

Improved intraoperative magnification can have ergonomic benefits due to a more comfortable working distance.[4] Although improper or prolonged use of these devices can have the opposite effect, studies have reported the association of neck pain and occupation-related musculoskeletal (MSK) disorders (MSDs) with surgical loupes.[5,6]

There is a strong correlation between cervical MSDs and static loads, awkward postures, excessive static contractions, and increased mental stress.[5,7] Ophthalmic surgeons encounter all of these factors while using surgical loupes, operating in prolonged nonneutral head–neck postures with the stressful nature of surgery.[5,7]

Previous studies have documented the prevalence of loupe usage between 80% and 87% among ophthalmic plastic surgeons.[7,8] There are only a few articles regarding surgical loupes use among ophthalmologists and their relationship with MSK pain, none in the Middle East. This study aims to assess surgical loupes usage, workplace ergonomics, and MSK pain among ophthalmic surgeons. Increasing awareness about MSDs will ensure early recognition of injury and implementation of strategies to prevent, manage, and promote safer use.

METHODS

An Internet-based survey [Appendix 1] was administered through Google Forms between December 2020 and January 2021. The survey questions were adapted from the literature and modified to assess usage and opinions on surgical loupes, knowledge of workplace ergonomics, and the prevalence of MSK pain among ophthalmic surgeons in Saudi Arabia. A few independent ophthalmologists reviewed the survey questions for applicability before distribution. The study participants included ophthalmologists from different hospitals [Table 1]. The survey link was distributed through E-mail or a direct invitation through text messages. A consent form appeared at the beginning of the survey. The institutional review board of King Fahd Hospital of the University approved this study (IRB-2021-11-191). This study is compliant with the tenets of the Declaration of Helsinki.

Table 1.

Characteristics of the study participants (n=93)

Characteristics	n (%)
Age (years)
23–29	43 (46.24)
30–39	35 (37.63)
40 and above	15 (16.14)
Gender
Female	57 (61.29)
Male	36 (38.71)
Nationality
Saudi	81 (87.1)
Other	12 (12.9)
Specialty
Ophthalmology resident	47 (50.54)
Pediatric ophthalmologist	16 (17.20)
Oculoplastic surgeon	15 (16.13)
Other	15 (16.13)
Training program (residents)
Dammam	30 (63.83)
Riyadh	6 (12.77)
Jeddah	5 (10.64)
Abha	2 (2.13)
Other	4 (8.52)
Level of training
Residency year 1	3 (6.38)
Residency year 2	12 (25.53)
Residency year 3	12 (25.53)
Residency year 4	20 (42.55)
Practice setting
Teaching hospital	60 (38.96)
Eye specialist hospital	54 (35.06)
General hospital	31 (20.13)
Private practice	9 (5.84)
Years in practice
<5	59 (63.44)
5–10	17 (18.28)
11 and more	17 (18.28)

The data obtained included demographics such as age, gender, and nationality. Participants were asked about their current subspecialty, years in practice, and practice setting. Ownership of loupes was determined and loupe owners were asked about the magnification, working distance, type, brand, frequency, and context of use, as well as the time of purchase. Participants who did not own a loupe were asked to clarify their reasons. Next, participants shared their perceptions of the limitations and benefits of loupe use, attitudes regarding the benefits of loupes during training and their effect on surgical outcomes, and whether loupe purchase should be required during residency [Tables 1 and 2].

Table 2.

Loupe specifications and usage patterns (n=93)

Specifications	n (%)
Loupe familiarity
Yes	87 (93.55)
No	6 (6.45)
Loupe ownership
Yes	51 (54.84)
No	42 (45.16)
Time of purchase
Residency year 1	11 (21.57)
Residency year 2	12 (23.53)
Residency year 3	9 (17.65)
Residency year 4	3 (5.88)
Fellowship	11 (21.57)
Upon practicing	5 (9.80)
Magnification
2.5	36 (38.71)
3.5	19 (20.43)
4.5	3 (3.23)
Don’t know	35 (37.63)
Type
Front-lens-mounted	30 (32.26)
Head-mounted	24 (25.80)
Through-the-lens	13 (13.98)
No preference	26 (27.96)
Brand
Designs for vision	12 (12.90)
Zeiss	12 (12.90)
Keeler	10 (10.75)
Hiene	1 (1.08)
Other	58 (62.37)
Frequency of usage
Always	10 (10.75)
Often	14 (15.05)
Sometimes	6 (6.45)
Rarely	40 (43.01)
Never	23 (24.73)

The last section, focused on MSK pain and asked participants if they had experienced MSK pain due to working in the clinic or operating room in the past 12 months. They were asked to identify perceived contributory factors. They were also required to identify the specific body site affected. For each location, they rated the pain severity and duration. Participants were asked about their pain management strategies. Treatment categories ranged from “rest” and “alternative medical practices” to “prescription medicine” and “surgery.” Finally, they were asked to determine the amount of physical activity performed per week.

Statistical analysis

The collected data were entered using Microsoft Excel software (Microsoft Corporation, Redmond, WA.) and analyzed using STATA software (StataCorp LLC, College Station, TX). Graphs were created in Excel. Pearson’s Chi-square test or Fisher-Freeman-Halton exact tests were used as appropriate to examine the associations between categorical variables (specialty, years in practice, length of individual cases, hours of surgery per week, weekly exercise), loupe usage, and pain experience. Significance was determined as: P < 0.05.

RESULTS

Ninety-three ophthalmologists participated in the survey [Table 1]. Of these, 57 were female (61%). Most participants were ophthalmology residents (n = 47 [51%]); other participants included pediatric ophthalmologists (n = 16 [17%]), oculoplastic surgeons (n = 15 [16%]), and other ophthalmologists (n = 15 [16%]). Most ophthalmology residents were from the Dammam training program (n = 30 [64%]). The most common practice setting reported was in a teaching hospital (n = 60 [39%]), followed closely by an eye specialist hospital (n = 54 [35%]). Forty-eight participants revealed multiple settings of practice. Two-thirds of participants had 5 years or less experience in ophthalmology.

Loupe ownership and use

About half of the participants (n = 51 [55%]) owned loupes [Table 2]. Those who did not own one, 15 cited they did not need it in their practice or had insufficient training and/or opportunities to try. Ten were not interested, ten said they were expensive, and the remaining seven stated discomfort. Most of the loupe owners (n = 35 [69%]) purchased it during residency. The majority (n = 58 [63%]) did not specify the brand of the loupe used; the two brands used by participants were designs for vision (n = 12 [13%]) and Zeiss (n = 12 [13%]), 2.5x was the most common magnification (n = 36 [39%]), and the front-lens-mounted loupe was most commonly used (n = 30 [32%]). Only 10 (11%) participants always used their loupes, whereas 63 (68%) rarely or never used them. Approximately two-thirds of those who rarely or never used loupes did not own one. Loupes were primarily used for lacrimal procedures (n = 70 [75%]), including dacryocystorhinostomy, jones tube placement, and other lacrimal surgery, followed by strabismus surgery (n = 48 [52%]). The least frequently reported use was for chalazion excision (n = 12 [13%]) [Table 3].

Table 3.

Loupe usage across various operations (n=93)

Operations of usage	n (%)
Lacrimal surgery	70 (75.27)
Strabismus surgery	48 (51.61)
Orbital tumor removal/biopsy	24 (25.81)
Enucleation/evisceration/exenteration	24 (25.81)
Blepharoplasty	21 (22.58)
Eyelid tumor removal/biopsy	21 (22.58)
Orbital decompression surgery	20 (21.51)
Ectropion/entropion repair	18 (19.35)
Ptosis repair	17 (18.28)
Injectables (Botox/fillers)	16 (17.20)
Orbital fracture repair	14 (15.05)
Chalazion excision	12 (12.90)
Other	1 (1.08)
None	9 (9.68)

With regards to loupe use, most of the participants (n = 77 [83%]) reported limitations, with a limited field of vision being the most common (n = 37 [40%]). Other limitations were neck pain (n = 31 [33%]) and lack of comfort (n = 31 [33%]). Others revealed headache (n = 27 [29%]), adjustment period (n = 24 [26%]), and limited depth of vision (n = 22 [24%]). The key benefits mentioned were magnification (n = 82 [88%]) and identification of anatomical structures (n = 65 [70%]). About a third of participants believed loupes improved the quality of patient care (n = 24 [26%]). Only a few believed they increased comfort (n = 18 [19%]) and provided better ergonomics (n = 12 [13%]).

Lastly, regarding the perceived advantages of loupes in practice and training, most participants considered loupes would be beneficial for surgical training during residency (n = 58 [62%]); 10 (11%) were against, and 25 (27%) were neutral. Fewer participants thought loupes improved the outcomes of surgery (n = 55 [59%]); 10 were against this (11%), while 28 were neutral (30%). Less than half believed that the purchase of loupes during residency should be mandatory (n = 36 [39%]), with an almost equal number that thought it should not be required (n = 35 [38%]); 22 were neutral (24%). There was no correlation between the frequency or duration (in years) of loupe use and whether they believed loupes should be incorporated into residency surgical training (P = 0.114 and P = 0.776, respectively). However, those with shorter experience of loupe use believed they were beneficial for training. In addition, most participants believe residents should purchase their loupes (P = 0.269); those who use them less frequently (<50% of their surgical cases) tend to have an inconclusive opinion in this regard. More participants with shorter experience believed that residents should not be required to purchase their loupes (P = 0.015). Furthermore, regardless of their frequency of loupe use and length of experience, participants believed loupe use improves surgical outcomes (P = 0.602 and P = 1.000).

Pain severity and location

MSK pain attributed to work in the operating room in the last 12 months was reported by 82%. In contrast, 78% experienced MSK pain in the previous 12 months related to work in the clinic. Neck pain was reported by 87% of participants; 47% described the pain as “moderate,” 31% as “mild” pain, and 9% as “severe” pain. This was followed by shoulder pain in 81%. The pain was described as “moderate” by 35% of participants, 32% reported “mild” pain, and 13% reported “severe” pain. Lower back pain was closely followed and reported by 73% of participants; 35% rated the pain as “moderate,” 34% as “mild,” and 3% as “severe.” Upper back pain, hand or wrist pain, and elbow pain had the lowest reporting rates at 59%, 30%, and 14%, respectively [Figures 1 and 2].

Figure 1.

Reported musculoskeletal pain duration according to location

Figure 2.

Reported musculoskeletal pain severity according to location

Pain coping mechanisms

Rest was the most common strategy for dealing with pain, as reported by 68% of participants. Massage therapy was the second coping modality mentioned by 43%, followed by paracetamol and hot or cold packs at 32% and 31%, respectively. Only 2% and 1% reported using acupuncture and occupational therapy, respectively. None mentioned prescription opioids or surgical intervention as a coping modality.

Most participants, (n = 55 [59%]), did not seek professional help for work-related MSK pain. Care was sought most by a “massage therapist” (n = 28 [30%]), followed by “personal trainer” (n = 13 [14%]), “physiotherapist” (n = 11 [12%]), and “orthopedic surgeon” (n = 11 [12%]). “Acupuncture specialist” (n = 3 [3%]), “chiropractor” (n = 2 [2%]), “family physician” (n = 1 [1%]), “neurologist” (n = 1 [1%]), “neurosurgeon” (n = 1 [1%]), and “rheumatologist” (n = 1 [1%]) were rarely sought.

Perceptions on the cause of work-related MSK pain

Varying causes were described as an association with work-related MSK pain, “bending or twisting your neck” being the most common (n = 64 [69%]). Other reported factors were “working in the same position for a long duration” (n = 52 [56%]), “reaching or working over your head or away from your body” (n = 37 [40%]), “working long or unusual hours” (n = 36 [39%]), “working in cramped or awkward positions” (n = 33 [35%]), and “insufficient breaks during the day” (n = 31 [33%]). Less reported factors were “performing the same task repeatedly” or “continuing to work when injured or sick” (n = 15 [16%]).

As for the specific tasks identified as contributing to work-related MSK pain, “height difference to the assistant surgeon” (n = 50 [54%]) and “length of the surgical case” (n = 49 [53%]) were the most likely factors. “Surgery with loupes” (n = 28 [30%]), “indirect ophthalmoscopy” (n = 28 [30%]), “slit-lamp examination” (n = 25 [27%]), “surgery without loupes or microscope” (n = 17 [18%]), and “surgery with a microscope” (n = 14 [15%]) were less commonly reported.

Risk factors for increased MSK pain among loupe users

The Chi-square test was used (Fisher’s exact tests whenever indicated) to identify factors associated with increased work-related MSK pain [Table 4]. There appeared to be no difference across the different ophthalmic subspecialties and the occurrence of pain (P = 0.348). Therefore, MSK pain remains a risk among all ophthalmologists. Increased prevalence of pain was associated with more frequent use of loupes (P = 0.735), longer experience (P = 0.156), increased surgical volume (P = 0.766), and prolonged operating time of individual cases (P = 0.551), although this was not statistically significant. Loupe ownership did not affect pain experience (P = 0.624), nor did the type of loupe (P = 0.252), meaning that the development of work-related MSK pain is a risk regardless. The level of activity (days of exercise per week) was found to be associated with a lower prevalence of pain. This was statistically significant and should thus be encouraged (P = 0.028). Finally, knowledge of workplace ergonomics alone did not appear to be protective, as there was no difference between aware and unaware participants (P = 0.103). These findings portray that work-related MSK pain is a genuine issue, and that knowledge alone is not enough. To prevent occupational hazards, ophthalmologists need the right tools.

Table 4.

Risk factors for musculoskeletal pain among participants

Characteristics	Total (n=93)	Yes (n=76), n (%)
Age (years)
23–29	43	31 (40.79)
30–39	35	30 (39.47)
40 and above	15	15 (19.74)
Gender
Female	57	47 (61.84)
Male	36	29 (38.16)
Specialty
Ophthalmology resident	47	37 (48.68)
Pediatric ophthalmologist	16	14 (18.42)
Oculoplastic surgeon	15	15 (19.74)
Comprehensive ophthalmologist	15	10 (13.16)
Years in practice
<5	59	46 (60.53)
5–10	17	13 (17.10)
11 and more	17	17 (22.37)
Surgical volume (h/week)
>6	16	14 (18.42)
4–6	30	27 (35.53)
1–3	13	8 (10.52)
<1	34	27 (35.53)
Length of individual case (h)
≥3	2	2 (2.63)
2	7	7 (9.21)
1	46	39 (51.32)
<1	38	28 (36.84)
Frequency of loupe usage
Always	10	10 (13.16)
Often	14	14 (18.42)
Sometimes	6	4 (5.26)
Rarely	40	33 (43.42)
Never	23	15 (19.74)
Loupe ownership
Yes	51	45 (59.21)
No	42	31 (40.79)
Type of loupe
Front-lens-mounted	30	27 (35.53)
Head-mounted	24	21 (27.63)
Through-the-lens	13	12 (15.79)
No preference	26	16 (21.05)
Activity level (days/week)
4–7	15	12 (15.79)
2–3	29	21 (27.63)
1	22	20 (26.32)
None	27	23 (30.26)
Knowledge of workplace ergonomics
Yes	38	30 (39.47)
No	55	46 (60.53)

DISCUSSION

Microsurgical techniques have transformed modern ophthalmic surgery.[3] The introduction of good-quality loupe magnification, with evidence supporting comparable outcomes when using either loupes or operating microscopes, led to their widespread use.[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 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 evaluated ophthalmic surgeons’ opinions on loupes and documented their preferences, usage patterns, and their relation to the prevalence of work-related MSK MSDs in Saudi Arabia.

The prevalence of loupe ownership in this study was about 55%, patterns of use varied depending on the subspecialty. Only a third of surgeons used loupes regularly. The main limitations included the limited field of vision, lack of comfort, and neck pain, among others. The prevalence of loupe usage in this study was lower than previously shown in the literature (87% and 80.9%).[7,8] However, 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 a 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 the literature. In dentistry, loupe use has been associated with reducing the risks of MSK discomfort. A lower incidence of lower back pain was seen in the context of 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 improves working posture among dental care professionals.[10] In addition, 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 lower levels of MSK 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 revealed that 82% of participants attributed their MSK pain to their work in the operating room, while 78% reported experiencing MSK pain because of their work in the clinic. Given that 10% of MSK MSDs have the potential to end a career, it is important to take these high rates seriously.[5,7,8] Another study reported that 7% of plastic surgeons had to modify their practice, which is a direct consequence of MSD morbidity.[12] The literature showed varying prevalence rates of MSK pain, ranging from 46% to 90% across different surgical specialties.[6,7,8,13,14]

Diaconita et al. surveyed ophthalmologists and found that 46% experienced “neck pain” in the previous 12 months, 36% had “lower back pain,” and 28% had “shoulder pain.”[15] These results are not like ours, which showed that 87% of ophthalmologists recalled suffering “neck pain” in the last 12 months, 81% experienced “shoulder pain,” and 73% experienced “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 a discectomy.[12] This 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.[16] Alternatively, 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 other 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 determined that ophthalmic surgeons with longer experience in the field, increased surgical volume, 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 larger number of participants could yield more significant results. Previous studies have studied this hypothesis across different surgical specialties with varying results [Table 5].[6,7,11,12,17,18,19]

Table 5.

Summary of previous publications and the risk factors of musculoskeletal disorders in the surgical work force among loupe users

Article	MSD	Respondents	Response rate	Prevalence of pain	Loupe use	Surgical intervention	Significant risk associations
Sivak-Callcott et al.[7]	Neck, back, and shoulder	Oculoplastic surgeons	21.5-28.2% (130 respondents)	72.5%	80.9%	7.6% spinal surgery	Operating <5 h of exercise per week
Farook et al.[17]	Neck and back	Dental trainers and trainees	153 respondents	47% dental trainers (loupe users and nonusers) 22%–27% dental trainees (loupe users and nonusers)	31% (62% were dental trainers)	-	-
Godwin et al.[12]	Cervical	Consultant plastic surgeons	81% (342/424) (329 usable responses)	32% (106/329)	99% (325/329)	6% steroid infiltration 4% discectomy	Duration of loupe use (hours worn) Older age
Howarth et al.[18]	Neck, back, and shoulder	Microsurgeons	16.7% (117/700)	50% acute pain 40% chronic pain	53% (MSD for surgery with loupes had a median pain level of 4/10 [10 worst pain])	5% surgery	-
Howarth et al.[6]	Neck and back	Craniofacial and maxillofacial surgeons	23.8% (95/400)	55% acute pain	MSD for surgery with loupes had a median pain level of 4/10 (10 worst pain)	-	Operating 3 days per week Operating >10 h
Meisha et al.[19]	General	Dentists	65% (239/360)	70%	23.9%	-	Wearing dental loupes Proper chair positioning Sufficient light at the workplace Having the instruments within hand’s reach Performing stretching exercises after clinical practice (decrease the odds of MSD)
Aboalshamat et al.[11]	General	Dental practitioners	80% (400/500)	8% loupe user versus 19% nonusers (pain in the last 7 days)	12.3%	-	Loupe use was associated with lower levels of MSD

MSD: Musculoskeletal disorder

More 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 reported that exercise could improve neck-shoulder pain and function, with targeting neck–shoulder muscle groups being very effective.[20] Other studies found resistance-based exercises to play a role in the prevention of neck-shoulder symptoms.[20,21,22] Sivak-Callcott et al. stated that 5 h 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. Ergonomic improvements at the workplace aim to create a safer, healthier work environment.[16] For e.g. productivity increases by 10%–15% with ergonomic improvements.[16] Additional benefits include decreased levels of job stress, absenteeism, and mistakes (including medical errors).[16]

There are limitations to our study. First, there was a low number of participants, almost half of them below 30 year old, 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 the 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 nonneutral posture for 85% of their operating time, either bending or rotation >15°, along with flexion >15°. They spend approximately 26% of their time in extreme postures, which include bending (>30°), rotation (>45°), and high flexion (>45°).[5,7] Other reports found significant risk factors contributing to MSDs in the ophthalmic field, including excessive static loading, exertion, and repetition,[12,16] in addition to the mental stress associated with operating.[16] While none of the available loupe systems provide a neutral head posture, well-designed loupes should support a working posture of <25° of head flexion and <15° of head extension.[16]

CONCLUSION

In summary, the goal of this study was to identify the prevalence of MSK pain among Saudi ophthalmic surgeons who use loupes. Our survey determined that work-related MSK pain remains a risk among all participants, although a direct relationship could not be established between loupe use and pain prevalence. To prevent MSK injuries, we recommend, at the ergonomic level, developing new loupe designs that minimize awkward body positions and reduce cervical load; creating specific exercise programs to strengthen neck-shoulder and lower back muscles; and stressing the importance of body-positive positions and active, healthy living among ophthalmic surgeons.

Conflicts of interest

There are no conflicts of interest.

APPENDIX

Appendix 1: Data collection sheet

1. Consent

   1. Do you agree to participate in this study?

      • Yes/No

2. Demographics

   1. Age (years)

   2. Gender

   3. Nationality

   4. Specialty

      • Oculoplastic Surgeon

      • Pediatric Ophthalmologist

      • Oculoplastics Fellow

      • Pediatric Ophthalmology Fellow

      • Ophthalmology Resident

      • Other

   5. Years in Practice

      • <5

      • 5–10

      • 11–15

      • 16–20

      • >21

   6. Practice Setting

      • Teaching Hospital

      • General Hospital

      • Eye Specialist Hospital

      • Private Practice

3. Ophthalmology Resident

   1. Training Program?

   2. Level of training?

4. Use of Surgical Loupes

   1. Are you familiar with surgical loupes?

   2. Do you own a loupe?

      • If yes, time of purchase?

      • If no, why?

   3. What loupe magnification do you use?

      • 2.5×

      • 3.5×

      • 4.5×

   4. What is your working distance?

      • <30 cm

      • 30–40 cm

      • 40–45 cm

      • >50 cm

      • Don’t know

   5. What type of loupe do you use?

      • Front-lens-mounted

      • Through-the-lens

      • Head-mounted

      • No preference

   6. What loupe brand do you use?

      • Designs for Vision

      • Zeiss

      • Keeler

      • Surgitel

      • Oculus

      • Don’t know

   7. What is the average number of hours you spend per week conducting surgery?

      • <1 h

      • 1–3 h

      • 4–6 h

      • 6–8 h

      • >8 h

   8. What is the average length of your individual cases?

      • <1 h

      • 1 h

      • 2 h

      • 3 h

      • >4 h

   9. Which of the following devices do you use most often when operating?

      • Loupe

      • Microscope

      • Loupe and microscope equally

      • Other magnification device

      • I don’t use a magnification device

   10. How frequently do you use a loupe when operating?

       • Never (none of the surgeries)

       • Rarely (<50% of surgeries)

       • Sometimes (50% of surgeries)

       • Often (75% of surgeries)

       • Always (100% of surgeries)

   11. For which operations do you prefer to use loupes?

       • Orbital tumor/biopsy

       • Orbital decompression surgery

       • Enucleation/evisceration/exenteration

       • Dacryocystorhinostomy

       • Jones tube placement

       • Orbital fracture repair

       • Other lacrimal surgery

       • Eyelid tumor removal/biopsy

       • Ectropion/entropion repair

       • Ptosis surgery

       • Blepharoplasty

       • Chalazion excision

       • Botox injection

       • Strabismus surgery

       • Filler injection

   12. For how many years have you used surgical loupes?

       • <5

       • 5–10

       • 11–15

       • 16–20

       • >21

   13. Do you use a headlight when operating with a loupe?

       • Yes/No

   14. If yes, for how many years have you used the headlight regularly?

       • <5

       • 5–10

       • 11–15

       • 16–20

       • >21

5. Attitudes Towards Surgical Loupes

   1. What are limitations for using loupes?

      • Lack of comfort

      • Limited depth of vision

      • Limited patient awareness

      • Limited field of vision

      • Neck pain

      • Headache

      • Fatigue

      • Eye soreness

      • Vertigo

      • Adjustment period

      • Possible contamination

      • Needle stick injuries

      • None

   2. What are the benefits of using loupes?

      • Magnification

      • Increased visual acuity

      • Identification of anatomical structures

      • Eye protection

      • Improved quality of patient care

      • Better ergonomics/posture

      • Comfort

      • None

   3. Do you think loupes are/would be beneficial for surgical training during residency?

      • Totally disagree/somewhat disagree/neutral/somewhat agree/totally agree

   4. Do you think residents should be required to purchase loupes during residency?

      • Totally disagree/somewhat disagree/neutral/somewhat agree/totally agree

   5. Do you think using loupes improves the outcomes of surgery?

      • Totally disagree/somewhat disagree/neutral/somewhat agree/totally agree

6. Ergonomics and Work-related MSDs

   1. Are you familiar with workplace ergonomics?

      • Yes/No

   2. In the past 12 months have you experienced musculoskeletal pain attributed to your work in the clinic?

      • Yes/No

   3. In the past 12 months have you experienced musculoskeletal pain attributed to your work in the operating room?

      • Yes/No

   4. What do you think the problem is?

      • Reaching or working over your head or away from your body

      • Bending or twisting your neck

      • Insufficient breaks during the day

      • Continuing to work when injured or sick

      • Working long unusual hours

      • Working in cramped or awkward positions

      • Working the same position for long periods of time

      • Performing the same task repeatedly

   5. What do you think is the cause?

      • Presbyopia/refractive error

      • Height difference to assistant surgeon

      • Surgery with loupes

      • Surgery with microscope

      • Surgery WITOUT loupes/microscope

      • Length of surgical case

      • Slit lamp examination

      • Indirect ophthalmoscopy

   6. Please specify the location and severity of the pain

      • Neck/Back/Shoulder/Elbow/Hand/Wrist/Upper back/Lower back

      • No pain/Mild/Moderate/Severe

   7. Please specify the location and duration of the pain.

      • Neck/Back/Shoulder/Elbow/Hand/Wrist/Upper back/Lower back

      • No pain/Few hours/Few days/Few weeks/Months

   8. How do you deal with pain?

      • Surgical intervention

      • Prescription opioids

      • NSAIDs

      • Paracetamol

      • Occupational therapy

      • Physiotherapy

      • Steroid injections

      • Acupuncture

      • Massage therapy

      • Hot/cold packs

      • Rest only

   9. Where did you seek help for the pain?

      • Family physician

      • Neurologist

      • Rheumatologist

      • Neurosurgeon

      • Orthopedic surgeon

      • Physiotherapist

      • Chiropractor

      • Acupuncture specialist

      • Massage therapist

      • Personal trainer

      • No one

   10. How many days per week do you spend exercising for at least 30 mins?

       • I don’t exercise

       • Once a week

       • Two to three times

       • Four to five times

       • Six to seven times

Funding Statement

Nil.