Frequency and Assortment of Self-Reported Occupational Complaints Among Iranian Ophthalmologists: A Preliminary Survey

Abstract

Background

Ophthalmology is unique in that its practitioners are exposed to a host of ergonomic (eg, indirect ophthalmoscopy), ergo-ophthalmologic (laser), infectious (adenovirus), and allergic (topical anesthetics) hazards. The purpose of this study is to provide a preliminary occupational health profile of Iranian ophthalmologists.

Methods

A comprehensive list of occupation-related entities was incorporated into a questionnaire, which was distributed among 350 ophthalmologist participants of the Annual Iranian Congress of Ophthalmology (November 2000, Tehran) and was mailed twice to the 1050 nation's registered ophthalmologists. Independent Samples t and chi-square tests were used to assess the relationships.

Results

One hundred sixty-two questionnaires were returned. The mean career time was 15.7 (range, 1-40) years. Twenty (12.3%) of the participants were women. The reported prevalences were as follows: history of infectious conjunctivitis, 49.4%; contact dermatitis, 43.2%; back pain, 80%; chronic headache, 54.9%; and laser or operating microscope-related visual disturbances, 15%. Psychological indispositions were reported by two thirds. Age and career time were inversely related to contact dermatitis, chronic headache, and stress-related problems (P < .05). Visual complaints were more prevalent in vitreoretina surgeons (P < .004). Psychosocial disorders were significantly more reported by women (P = .026; odds ratio = 4.4). Only 3% of participants reported to have none of the listed problems.

Conclusion

Our preliminary survey disclosed a high prevalence of diverse complaints from back and neck pain, contact dermatitis, visual disturbances, and infectious conjunctivitis to stress-related and psychosocial disorders among the participants. Younger age, being a woman, and vitreoretina practice were the complaints correlates. Due to the low response rate, uncertainty over the representativeness and coverage of the sample, and lack of control groups, the findings have to be interpreted conservatively.

Introduction

Medical practice, as with other professions, is associated with occupational hazards. The risks and the consequences are varied on the basis of the very situations of the practice. Ophthalmology is unique in that its practitioners not only share the hazards and risks common to all surgeons, but also have their own occupational exposures, such as laser radiation.

Ophthalmologists frequently manage patients affected with infectious conjunctivitis. Adenoviral conjunctivitis is especially contagious, and epidemic outbreaks with the involvement of ophthalmologists have been reported.[1-3] Although mostly a transient illness, it can be complicated by long-term disability. Moreover, ophthalmologists are exposed to needlestick-associated agents of HIV and hepatitis B virus.

Allergy to topical medications and chemical agents in the working environment (such as detergents and disinfectants in the operating room or topical anesthetics and fluorescent agents at the examination table) could be a major distress for the ophthalmologists and even may compromise their practices in some occasions. Reports of allergic contact dermatitis induced by proparacaine and proxymetacaine are some examples.[4-6]

The ophthalmologist must assume an awkward posture (at the slit lamp) and a long sedentary position (at the operating microscope) when operating on a patient, sometimes for several hours. A nationwide survey of British consultant ophthalmologists in 1994 showed that 54% of the respondents had significant attacks of back pain, with an increased incidence among the longest-serving consultants. More than half of the affected ophthalmologists made use of analgesics for pain relief.[7]

The risk of laser surgery has been argued in many ways.[8,9] Some studies suggest that a noticeable proportion of ophthalmologists have documented defects in visual functions, such as disturbances in color discrimination or contrast sensitivity, which can be related to their use of lasers and operating microscopes.[10,11] However, subsequent studies do not support this hypothesis.[12,13] This could be a consequence of enhanced adherence to safety precautions with ophthalmic surgery instruments and methods.

In addition to the aforementioned hazards, many occupational necessities and obligations, such as heavy workload and little free time, long-lasting training, costly instruments, early retirement, and the challenge of being up-to-date, could bring about psychosocial problems, such as insomnia, anxiety, depression, amnesia, and chronic headache, for all specialists.[14-16] Although these complaints are quite prevalent in the general population and not specific to ophthalmologists, we should suspect them as additional occupationally induced or exacerbated problems.

We conducted this survey to obtain some preliminary data on the self-reported frequency and extent of the conditions that seem to be occupationally induced or exacerbated in Iranian practicing ophthalmologists. Furthermore, we developed a framework for the occupation-related hazards in ophthalmology.

Methods

Initially, we carried out a comprehensive Medline and Embase search (with keywords: ophthalmologist, occupational disorder, laser, back pain, and psychological disorders); we reviewed some classic textbooks of clinical examination (content validity) and conducted some interviews with a number of experienced ophthalmologists, inquiring their opinions regarding other possible occupational affections (face validity). These yielded a comprehensive list of occupation-related entities (including symptoms, signs, and medical diagnoses), and an all-inclusive closed questionnaire was constructed. Presence and severity of the entities were questioned: if they have the problem or have had it during their careers (period prevalence). The questions were preceded with an introduction on the objectives of the study.

A total number of 350 questionnaires were distributed in the Annual National Congress of Ophthalmology (November 2000, Tehran) at the time of registration. Additionally, the questionnaires were mailed twice to 1050 of Iran's registered ophthalmologists to ensure coverage and to enhance the response rate.

Associations between demographic factors and disorders were evaluated by the Independent Samples t-test. The chi-square test was used to assess the relationship between visual complaints and subspecialties. The odds ratio was calculated to evaluate the role of sex in the prevalence of psychosocial complaints. Ninety-five percent confidence intervals (CIs) were calculated for the prevalence of several categories of diseases. P Values of less than .05 were considered significant.

Results

One hundred sixty-two questionnaires were returned. The mean age was 48.5 years with a standard deviation of 9.7 (age range, 33-76 years). The mean career time was 15.7 years with a standard deviation of 9.3 (range, 1-40 years). Twenty (12.3%) of the participants were women. Ophthalmologic inclinations among the surveyed ophthalmologists were general in 82 (50.6%), anterior segment in 42 (25.9%), posterior segment in 20 (12.4%), and others (including glaucoma, orbit, and strabismus) in 14 (8.6%) of the participants.

The prevalence and severity of several surveyed disorders are summarized in (Table 1). Back pain and neck pain were the most common reported complaints (80% and 69%, respectively). Affected ophthalmologists had attempted various treatments for pain relief ((Table 2)). Actually, the majority did not seek care.

Table 1.

The Reported Prevalence and Severity of Various Disorders Among the Participants

Complaint	Frequency (%)
Back pain	129 (79.6%)
Mild*	104 (80.6%)
Moderate	16 (12.4%)
Severe	9 (7.0%)
Neck pain	112 (69.1%)
Mild	83 (51.2%)
Moderate	22 (13.6%)
Severe	7 (4.3%)
Chronic headache	89 (54.9%)
Occasional	64 (71.9%)
Related to daily work††	21 (23.6%)
Constant	4 (4.5%)
Infectious conjunctivitis	80 (49.4%)
Only once	48 (62.5%)
2-3 times	26 (30.0%)
≥ 4 times	6 (7.5%)
Contact dermatitis	70 (43.2%)
Mild	38 (54.3%)
Moderate	23 (32.8%)
Severe	9 (12.9%)

*Definitions: Severe involvements impair daily living and function; moderate disorders interfere with daily living of persons but not their function; and mild disorders do not affect daily life or function.

^††Denotes periods of headache occurring in the office or hospital settings during or following patient visits or surgeries

Table 2.

The Variety and Frequency of the Treatments Sought for Back and Neck Pain by the Participants

Treatment	Frequency (%)
	Back Pain	Neck Pain
Pharmaceutical alone	17 (13.2%)	13 (11.6%)
Physiotherapy alone	22 (17.1%)	21 (18.8%)
Pharmaceutical and physiotherapy	13 (10.1%)	8 (7.1%)
Surgery	1 (.8%)	0 (.0%)
No treatment	76 (58.9%)	70 (62.5%)
Total	129 (100%)	112 (100%)

The agents causing contact dermatitis included surgical gloves, betadine, fluorescent strips, tetracaine, and others that, respectively, induced allergy in 28 (40.0%), 24 (34.0%), 8 (11.4%), 1 (1.4%), and 9 (12.9%) of the affected ophthalmologists. Nine of these (12.9%) had cross-sensitivity to both betadine and surgical gloves.

Twenty-five ophthalmologists (15%) reported visual disturbances, which they related to laser or operating microscope light. From all the studied ophthalmologists, 67 (41%) were practicing various kinds of posterior or anterior segment laser surgeries in their clinics, whereas 17 (25.4%) of them reported transient visual disturbances in the postprocedure period, and 3 (4.5%) pointed out decreased visual acuity after initiation of laser surgeries. Also, 7 (10.4%) of them mentioned recent dysfunction in their contrast discrimination and 3 (4.5%) in their color vision. Survey results of other potentially relevant conditions are listed in (Table 3).

Table 3.

The Frequency of Various Independent Medical Conditions Reported by Studied Ophthalmologists

Conditions*	Frequency (%)
Depression	47 (29.0%)
Anxiety	56 (34.6%)
Forgetfulness	32 (19.8%)
Insomnia	42 (25.9%)
Vertigo	15 (9.3%)
Chronic pruritus	24 (14.8%)
Urticaria or angioedema	15 (9.3%)
Peptic ulcer or dyspepsia	26 (16.0%)
Ischemic heart disease	10 (6.2%)
Hypertension	21 (13.0%)
Varicose veins	7 (4.0%)
TB or PPD	2 (1.2%)
Viral hepatitis	2 (1.2%)
Needlestick with HIV patient	0 (0%)
Abortion (in women)	1 (5.0%)

Age and career time were inversely related to contact dermatitis (P = .035), chronic headache (P = .003), and stress-related problems (P = .018). Contact dermatitis sufferers were about 3 years younger on average (46.6 vs 49.9, 95% CI for the difference of .2-6.2 years); the figure for chronic headache was about 5 years (46.3 vs 51.1, 95% CI for the difference of 1.7-7.8 years).

Visual complaints were more prevalent among vitreoretina surgeons (P < .004). Half of these surgeons (10 out of 20) reported postoperative visual disturbances, whether transient or permanent, and this group accounted for 40% of the affected physicians (10 of 25).

Psychosocial disorders were significantly more reported by ophthalmologists who were women (P = .026; odds ratio = 4.4 [95% CI 1.2-15.6]). Seventeen of 20 participants who were women (85%) reported some psychosocial complaints, whereas only 56% of men (76 of 135) protested this kind of disorder.

To organize the entities reported in our study as well as those reported in other reports, we developed a 6-pronged framework to categorize occupational hazards; in (Table 4), we further explain the disease conditions and the inciting agents. Respectively, 13%, 21%, 30%, 24%, and 9% of the participants had 5, 4, 3, 2, and 1 categories of involvement (ie, reported a complaint related to the corresponding categories). Only 3% of the participants reported to have none of the problems. Ergonomic disorders (back, shoulder, and neck pain) troubled 152 ophthalmologists (93.8%, with 95% CI of 90.1% to 97.5%) and accounted for the most frequent grouping. Self-reported psychosocial indispositions (the first 4 entities of (Table 3)) affected 108 of the participants (66.7%, with 95% CI of 59.4% to 73.9%). Stress-related disorders, such as dyspepsia, headache (constant or following surgeries), hypertension, and ischemic heart diseases, involved 110 ophthalmologists (67.9%, with 95% CI of 60.1% to 75.1%). Infectious events and allergic reactions were reported by 81 (50.0%, 95% CI 42.3% to 57.7%) and 84 (51.9%, 95% CI 44.2% to 59.5%) of the participants, respectively. In the Figures, we illustrate the relevant occupational contexts.

Table 4.

The Comprehensive Categorization of Occupationally Relevant Entities in the Participant Ophthalmologists^*

Number	Category	Disease Conditions††	Details/Agents
1	Allergic	Contact dermatitis, pruritus, urticaria, chronic cough, and asthma	Betadine, (Sagrosept), fluorescent strips, gloves, latex, topical anesthetics, tape
2	Ergonomic - mechanical	Neck, shoulder, and back pain; intervertebral disk diseases, and varicose veins	Operating microscope, slit lamp, indirect ophthalmoscope
3	Ergonomic - ophthalmologic	Transient visual disturbances, permanent diminished visual acuity (and contrast sensitivity), and ocular discomfort	Laser (and the aiming beam), exposure to dim and intense light
4	Stress -related	Peptic disease, Postoperative headache, irritable bowel syndrome, central serous chorioretinopathy, hypertension, asthma, and IHD	High workload, high demand for precision, intra- and postoperative complications
5	Infectious	HIV, HBV, HCV, and TB transmission; infectious conjunctivitis (especially adenoviral), and common cold	Close contact to the patients at examination, needlestick, contact with mucosal discharges, and contact with blood during operations
6	Psychosocial	Anxiety, depression, insomnia, amnesia, chronic headache, fatigue and eye strain, marital and parent-child conflicts, and suicide	High workload and less free time, costly instruments, lengthy training, lengthy operations, challenge of being a specialist of a rapidly developing specialty, early retirement
7	Miscellaneous	Abortion	Nitrous oxide in operating room?

TB = tuberculosis; PPD = purified protein derivative

IHD = ischemic heart disease; HBV = hepatitis B virus; HCV = hepatitis C virus; TB = tuberculosis

*This table is not intended to cover the conditions that are not specific to ophthalmology. Those in parentheses were not reported by our participants.

^††By the term "disease condition," we may mean just a symptom or a full-blown illness, such as major depression.

Figure 1.

Awkward position at slit lamp causes back, neck, and shoulder pain.

Discussion

Concerning the design of the study and lack of a comparison group, we are not able to draw a definite conclusion on the true significance of the disclosed prevalences and correlations. However, ophthalmologists seem to be at special occupational risk, as virtually all of the participants had some kinds of potentially occupation-related disorders (only 5 reported to be completely healthy).

The reported entities are quite varied. This may be attributed to the sophisticated and challenging nature of the specialty in terms of clinical examination, therapies, and technology. The comprehensive breadth of the survey prompted us to develop a framework to report the results ((Table 1)). The model is insightful and may be generalizable to other specialties -- even to healthcare providers in general -- and we propose its application in future studies.

In our study, neck pain and back pain were reported, respectively, by about 70% and 80% of the participants. According to a nationwide survey in France on 21,378 subjects, the prevalence of chronic neck pain was reported as 8% and 15% for workers who are men and women, respectively.[17] Our finding is just comparable to the prevalence of neck pain in some physically demanding occupations; a survey in Norway involving 109 farmers reported a prevalence of 74% for neck and shoulder pain during seasonal tractor work.[18] Also, in another study on 204 dentists and dental auxiliaries in Saudi Arabia, neck and back pain were reported by 54.4% and 73.5% of the subjects.[19] Back pain was quite more prevalent in our study than in the British ophthalmologists[7] (80% vs 54%); differences in the survey instruments may (partly) explain the discrepancy in the reported prevalences. Back pain should have functional significance, as it is evident from reports on the severity of the pain and the therapies sought ((Table 1) and (Table 2)).

The study identified younger age, being a woman, and laser exposure (vitreoretina inclination) as specific risk factors. We hypothesized that younger ophthalmologists may have relatively heavier workloads, may be less adapted, and may be more exposed to occupational allergens or adhere less to standards of practice (to explain higher incidences of chronic headache, stress-related problems, and contact dermatitis). Although less likely, a "healthy-worker effect" may also be considered as a possible explanation for the inverse relationship between age and the mentioned complaints. (Those who are healthier remain more functional, are more accessible, and respond better.) In the general population, women are twice as likely as men to experience depression.[20,21] In our study, ophthalmologists who are women had significantly higher rates of psychosocial problems relative to their colleagues who are men (4.4:1). Disproportionate responsibilities in the domestic duties and their more critical role in parenthood (especially in Iran) may impose additional stress on doctors who are women. Vitreoretina surgeons are naturally more exposed to lasers and report more visual complaints. They also perform relatively lengthier operations and are exposed to much more fluctuations in ambient light in the working environment.

Calculation of the response rates is not straightforward in this study, as we were not able to cover all of the nation's ophthalmologists because of the nonregistered colleagues and out-of-date status of a few of the ophthalmologists' addresses. The response rates were calculated as 45% and 15.5%, respectively, considering denominators of 350 (number of the congress participants) and 1050 (total number of the nation's registered ophthalmologists at the time of the survey).

As explained, the questionnaires were first distributed at the National Ophthalmology Congress; the Congress participants may not necessarily be representative of the target population. In general, we most likely surveyed the ophthalmologists who are occupationally more active. Also, it is very well possible that affected ophthalmologists were more likely to respond to the survey than healthy ones. So, all percentages based on persons who were accessed and responded could be overestimations. Additionally, we cannot confidently generalize these results to our foreign colleagues.

In the interpretation of the results, it should be kept in mind that what we report here is not the true prevalence of the diseases but the prevalence of the reported entities; however, as the surveyed subjects are themselves physicians, the reports should be largely valid. The entities were included in the survey questionnaire on the assumption that they are induced or exacerbated occupationally or may be linked to occupational exposures, but the distinction between occupational and nonoccupational entities is not clear-cut.

This study was not designated to delineate occupational disorders, and the scope of the study was exploratory and its purpose was comprehensive ascertainment of the problems. Although the report is a preliminary one, the authors believe that the crude prevalences, the identified associations, and the proposed occupational health model could be instrumental in guiding and designing independent studies (ideally with control groups) to quantify the specific problems and the role of the potential risk factors.

Conclusion

Ophthalmologists should be notified about the magnitude and impact of the occupational problems around them. Awareness over these potential occupational hazards may convince them to review their occupational lives and daily routines, and may prompt them to protect both themselves and their patients from various hazards. Development and dissemination of practice guidelines to outline sound practice habits for ophthalmologists can be helpful.

Figure 2.

Indirect ophthalmoscopy constitutes another cause for neck pain.

Figure 3.

Like general surgeon's oculoplastic, surgeons are at risk for varicose.

Figure 4.

Close contact with the patients facilitates transmission of adenovirus, common cold, and possibly tuberculosis and topical medications, such as tetracaine, are the inciting agents for fingers' contact dermatitis.

Figure 5.

Fluorescein strips are also capable of inducing hypersensitivity in prone cases.

Figure 6a.

Surgical gloves along with latex are some other sources for dermatitis; scrubbing can induce contact dermatitis to betadine and Sagrosept; and even the pieces of tape used to secure surgical masks have been reported to cause dermatitis.

Figure 6b.

Figure 6c.

Figure 7.

Operating room is an instance of extreme light intensity variation (being an eye specialist yet working in a non-ergo-ophthalmologically safe situation); it is physically demanding to sit for hours at the operating microscope; although ophthalmology is seemingly not a stressful specialty (probably due to its preoperative facet), intra- and postoperatively it has myriads, including vitreous loss, expulsive choroidal hemorrhage, endophthalmitis, diffuse lamellar keratitis, lost muscle, premature drainage, scleral perforation, shallow anterior chamber, optic nerve injury or globe perforation while performing retrobulbar injection, intraocular lens and nucleus drop, anterior segment ischemia, and retinal detachment.

Figure 8.

Refraction is said to be a tiresome, boring routine.

Figure 9.

Laser beam constitutes a unique occupational exposure especially for the vitreoretina surgeons who save people's sight but endanger their own.

Figure 10.

Like other surgery-related professions, needlestick is a risk.