Surgical loupe usage among oculoplastic surgeons in North America

Abstract

Objective:

To study the patterns of usage and perception among U.S. oculoplastic surgeons regarding surgical loupes.

Methods:

An anonymous 20-question survey was emailed out to the American Society of Ophthalmic Plastic and Reconstructive Surgery listserv. Data were compiled in Google Forms. SPSS was used for statistical analyses. This study was approved by the institutional review board.

Results:

Of the 609 members contacted, 239 (39%) completed the survey; 95% of respondents owned loupes and 78% regularly used them. No association was observed between frequency of loupe usage and sex or years in practice. The most common magnification and brand were 2.5× and Designs for Vision, respectively. The most common problems associated with loupes were limited vision (33%) and lack of comfort (24%), with 11% citing neck and cervical spinal disorders. The most common benefits were magnification (93%) and increased visual accuracy (68%). Of the respondents, 56% believed improved patient care to be a benefit and 76% believed that loupes enhance surgical outcome. With regard to training, 67% supported incorporating loupes into residency, 35% believed in mandating loupe purchase, and 25% wanted residencies to provide loupes at no cost. Respondent support for the use of loupes in practice and training was directly correlated with how frequently they used loupes.

Conclusions:

The vast majority of respondents owned loupes. Although most loupe owners used loupes regularly, a sizable proportion operated with limited vision and lack of comfort. Overall, just over half of respondents believed that loupes improve patient care and should be integrated into residency.

Surgical loupes, with the intraoperative magnification they provide to physicians, have revolutionized the field of surgery. Since their introduction, loupes have become widely used in medicine. In a study of loupe usage across various specialties, 100% of the cardiothoracic, plastic, and maxillofacial surgeons surveyed used loupes, followed by 83.3% of ophthalmologists and 75% of pediatric surgeons.¹ In terms of rates of usage across surgical specialties, cardiothoracic and plastic surgeons are reported to use loupes most frequently, followed by maxillofacial and pediatric surgeons.¹ Ophthalmologists are reported to use loupes less frequently, possibly because the field uses microscopes to provide the higher levels of magnification that are required for certain microsurgical procedures. Usage also varies considerably within specialties, such as oral and maxillofacial surgery, with 60% of surgeons regularly using loupes.² In recent years, there have been increased efforts to catalogue loupe usage in various surgical specialties, in part to push for increased use in fields such as emergency medicine and urology.^3,4 In oculoplastics, however, no studies have been done to investigate patterns of loupe usage. Indeed, to date, there is only one published statistic relevant to the topic, with one study reporting that 80.9% of oculoplastic surgeons use loupes.⁵

There is considerable evidence in support of the merits of using loupes, including increased visual acuity, ergonomics, portability, and greater precision in surgery.^3,6–9 This is countered by evidence suggesting that loupes may increase neck and back strain and limit depth of vision.^3,10–12 Additional limitations include vertigo, headaches, and vision dependency.^3,10 Overall, the literature across multiple fields of specialty remains divided on the relative effects of loupe usage on clinical outcome, with research on this topic being particularly scarce in the field of oculoplastics.^13,14

Given the paucity of research on loupes in oculoplastics, we undertook a survey to investigate and characterize patterns and perceptions of loupe usage among oculoplastic surgeons in North America. Specifically, we assessed physician preferences in purchasing and using loupes, both of which shed light on physician priorities in practice and provide valuable information for trainees. We also asked respondents about the policies of their respective residency programs regarding loupes, which may have influenced later usage patterns and perceptions in practice. Finally, we asked respondents for their opinions on the benefits and limitations of using loupes. It is our hope that these data and opinions will not only add to the current landscape of research on this topic, but also stimulate future discussions on the role of loupes in the field of oculoplastics.

Methods

A 20-question descriptive survey hosted on Google Forms was developed to assess usage and opinion on loupes among oculoplastic surgeons in the United States. An email containing a link to the survey was sent out to the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) listserv. A total of 609 oculoplastic specialists were reached. A follow-up email was sent 2 weeks after the first email as a reminder. The institutional review board of the Icahn School of Medicine at Mount Sinai approved this study (IF# 1802102). This study is HIPAA-compliant.

The demographic indicators that were collected include age, sex, number of years in practice, and practice setting. Participants were asked whether they owned loupes. Participants who answered no were asked to provide contributory reasons, and those who answered yes were asked about the magnification and brand of their loupes, the frequency of use, the specific operations and context of use, and time of purchase. Participants were asked whether specific rotations during residency required loupes, and if not, whether any encouraged the usage of loupes. The last section of the survey assessed the perceived benefits and limitations of using loupes. Here, participant opinion was also collected on the benefits of surgical loupes in surgery and training, whether they should be required during residency, and whether residency programs should provide loupes at no cost to trainees. The collected data were analyzed using Excel (Microsoft, Redmond, Wash.) and SPSS (IBM, Armonk, N.Y.). The graphs were generated in Excel.

Results

Of 609 physicians contacted, 239 completed the survey (39% yield) (Table 1). Of these, 179 were male (75%) and 60 were female (25%). The mean age was 50 years (standard deviation [SD] = 13 years), with a range of 29 to 87 years. The mean number of years in practice was 18 (SD = 13), with a range of 0 to 50 years. Most respondents reported working in private practice (n = 152 [64%]), followed by academic medicine (n = 87 [36%]). Sixty-one respondents indicated multiple settings of practice.

Table 1—

Physician characteristics (n = 239)

	Total (%)
Age, y
Mean ± SD	50 ± 13
Range	29–7
Sex
Male	179 (75)
Female	60 (25)
Years in practice
Mean ± SD	18 (13)
Range	0–50
Practice setting
Private practice	152 (64)
Academic medicine	87 (36)
Group practice	43 (18)
Hospital-based practice	36 (15)
HMO	4 (2)

SD, standard deviation; HMO, health maintenance organization.

Most respondents (n = 228 [95%]) owned loupes (Table 2). Of the 11 physicians who did not, 5 did not train with them and 3 said that they were not required in their practice setting. The remaining 3 cited either infrequent use, neck pain, or cost-to-benefit ratio as explanations. Among the physicians who owned loupes, 74% (n = 165) had purchased them during residency. To assess whether residency played a role in these purchases, we asked respondents about their respective residency programs’ policies regarding loupe use; 42% of respondents (n = 95) indicated that they were required to purchase loupes. The primary rotation that required loupes was pediatric ophthalmology (n = 79 [35%]), followed by oculoplastics (n = 70 [31%]), with some overlap among physicians. Four physicians indicated that loupes were purchased for them, and 72 physicians (32%) indicated that although it was not a requirement for them to purchase loupes, they were encouraged to buy them nonetheless. Oculoplastics rotations encouraged loupe purchase the most (n = 54 [24%]), followed by pediatric ophthalmology (n = 47 [21%]).

Table 2—

Loupe specifications and usage patterns

	Total (%)
Loupe ownership (n = 228)
Yes	228 (95)
No	11 (5)
Time of purchase (n = 224)
Internship	2 (1)
Residency year 1	114 (51)
Residency year 2	26 (12)
Residency year 3	25 (11)
Fellowship	38 (17)
Upon practicing	19 (8)
Magnification (n = 225)*
2.5	157 (70)
3.5	57 (25)
4.5	8 (4)
Don’t know	16 (7)
Brand (n = 226)*
Designs for vision	159 (70)
Zeiss	39 (17)
Keeler	15 (7)
Surgitel	13 (6)
Oculus	10 (4)
Other	18 (8)
Frequency of usage
Never	20 (9)
Rarely	23 (10)
Sometimes	7(3)
Often	20(9)
Always	158 (69)

Full sample size was 228. Sample sizes for individual questions vary as noted.

^*Some respondents owned more than 1 pair of loupes.

In terms of actual usage, the most popular brand used by respondents was Designs for Vision (n = 159 [70%]), followed by Zeiss (n = 39 [17%]), and 2.5× was the most common magnification (n = 157, 70%). Of the respondents, 158 (69%) always used their loupes, whereas 20 (9%) indicated that they never used them. There was no association between number of years in practice and frequency of loupe usage (ordinal regression; p = 0.185). Sex was also found to be uncorrelated with different levels of loupe usage (Pearson χ²; p = 0.64). Of the choices presented in the survey, physicians reported most frequent use of loupes in the context of orbital tumour removal/biopsy, followed closely by 9 other operations (mean = 85%), and least frequent for laser surgery (n = 51 [25%]) and injectables (n = 52 [25%]) (Table 3).

Table 3—

Loupe usage across various operations (n = 208)

Operations of Usage	Total (%)
Orbital tumour removal/biopsy	181 (87)
Dacryocystorhinostomy	179 (86)
Orbital fracture repair	177 (85)
Other lacrimal surgery	177 (85)
Ectropion/entropion repair	176 (85)
Ptosis repair	175 (84)
Eyelid tumour removal/biopsy	175 (84)
Orbital decompression surgery	174 (84)
Blepharoplasty	173 (83)
Enucleation/evisceration/exenteration	173 (83)
Jones tube placement	157 (76)
Trichiasis surgery	151 (73)
Chalazion excision	148 (71)
Injectables (Botox/fillers)	52 (25)
Laser surgery	51 (25)
Other	17 (8)

Regarding the costs and benefits of loupe usage, 57% of respondents (n = 136) reported limitations associated with using loupes, the most common of which was lack of comfort (n = 58 [24%]) (Fig. 1). Notably, 25 physicians mentioned that wearing loupes caused neck problems or cervical spinal disorders (11%), even though this had not been included on the list of answer choices. The second most frequently selected limitation was limited depth of vision (n = 54 [23%]). Many physicians also specified limited patient awareness (n = 11 [5%]) and limited field of vision as problems (n = 26 [11%]). Excluding overlap, a total of 79 physicians denoted problems with vision as a significant limitation (33%). The mean age of these physicians was 52 years (SD = 12 years), which is similar to the overall mean age (50 years; SD = 13 years) of the cohort. Other drawbacks included headaches (n = 35 [15%]) and fatigue (n = 28 [12%]).

Fig. 1—

Disadvantages of loupe usage, as perceived by respondents.

The primary benefits cited by respondents were magnification (n = 223 [93%]) and increased visual accuracy (n = 163 [68%]) (Fig. 2). Just over half of the physicians sampled indicated improved quality of patient care as a benefit (n = 133 [56%]). A minority of physicians viewed ergonomics (n = 54 [23%]) and comfort (n = 38 [16%]) as benefits.

Fig. 2—

Advantages of loupe usage, as perceived by respondents.

When asked about the perceived utility of loupes in practice and training, respondents had mixed opinions. The majority believed that loupes enhance surgical outcome (n = 182 [76%]), although 57 physicians disagreed or were neutral (24%) (Fig. 3). A smaller number of physicians supported incorporating loupes into residency training (n = 160 [67%]); 38 were against this measure (16%), and 41 were neutral (17%). Less than half of the physicians believed that residents should be required to purchase loupes (n = 84 [35%]), and a greater proportion of respondents believed that purchasing loupes should not be required (n = 101 [42%]); 53 were neutral (22%). A minority believed that residency programs should provide loupes to residents at no cost (n = 59 [25%]); 105 physicians believed that residency programs should not give out loupes free of charge (44%), and 75 were neutral (31%).

Fig. 3—

Respondent opinion, distributed across 5 levels of agreement, on the role of loupes in ophthalmology residency and their utility in practice.

There was a direct correlation between the frequency with which respondents used loupes and whether they believed that loupes enhance surgery and should be incorporated into residency training (multinomial logistic regression, p < 0.0005 for both). Furthermore, frequency of loupe usage was also correlated with whether respondents believed that residents should be required to buy loupes (ordinal regression, p < 0.0005) and whether residencies should provide loupes free of charge (ordinal regression, p = 0.014).

Discussion

The advent of loupe magnification has had a significant impact on many fields of surgical specialty, including oculoplastics. Despite their importance and prevalence in clinical practice, little research has been done on their role in practice and training in oculoplastics and the perceived benefits and drawbacks of their use. This study is the first to assess opinions of oculoplastic surgeons on loupes and catalogue their preferences and usage patterns. In this study, we demonstrated that the vast majority of oculoplastic surgeons owned loupes and had similar specifications and patterns of usage. However, almost a quarter of surgeons who owned loupes did not use them regularly, and many respondents noted limitations to their use, including limited vision and musculoskeletal pain, among others.

The prevalence of loupe usage in this study (87%) was higher, but comparable to that previously shown in the literature (80.9%).⁵ After adjusting for rare usage, the data indicated that 78% of respondents regularly used loupes—a clear demonstration of the high prevalence of loupe use but also drawing attention to factors that deter loupe usage in almost a quarter of respondents. Indeed, a similar percentage of respondents (24%) did not believe that loupes enhance surgery. Given the correlation between the frequency of loupe usage and respondent perception on whether loupes enhance surgery, the 22% of respondents reporting infrequent loupe usage may be inferred to overlap with the 24% of respondents who had negative opinions about loupes.

Although most respondents indicated that loupes were either mandated or encouraged during residency, with 42% specifying the former and 32% the latter (74% in total), the fact that more than a quarter of respondents (26%) had not been encouraged to purchase loupes also sheds light on the lack of consensus in the field on the relative importance of loupes in training. Indeed, only 67% of those surveyed supported incorporating loupes into residency training; 35% believed that residents should be required to purchase loupes, and only 25% believed that residencies should provide residents with loupes. As observed with respondent opinion on whether loupes enhance surgery, respondents who did not support active incorporation of loupes in residency training were also more likely to use loupes less frequently. Together, these associations highlight the conflicting opinions in the oculoplastics community regarding loupes. In particular, the first 2 statistics suggest that a significant portion of doctors believe that loupes are not essential to training, and the third reveals a general sentiment that the cost of loupes outweighs their potential return. To shed further light on these results, future studies should examine policies in residencies today and assess opinions among current residents and residency directors.

The most common limitations reported were limited depth and field of vision. One physician commented that wearing loupes can cause surgeons to “lose sight of the bigger picture,” which can detract from surgical outcome. Indeed, it is reported that every increase in magnification by 30% leads to a corresponding decrease in the width and depth of a user’s field of vision by 2.5 cm.¹⁵

Lack of comfort was the second most common limitation, with 24% of respondents selecting this option. Similar numbers of respondents thought the opposite, identifying comfort and ergonomics as advantages (16% and 23% of physicians, respectively). These contrasting viewpoints suggest that there is disagreement on the comfort of using loupes. As a qualification, however, the majority of respondents did not view lack of comfort as a disadvantage. Furthermore, omitting “comfort” as a benefit may not be equivalent to there being a “lack of comfort.” In the literature, whether or not loupes improve or reduce ergonomics remains a topic of debate. Hayes et al. showed that 66.6% of surveyed dental hygienists viewed ergonomics as an advantage of using loupes.¹⁰ However, Burton and Bridgman suggested that dentists can suffer from back or neck pain because of static positioning when using loupes.¹⁶

In this study, 25 physicians (11%) explicitly specified back or neck pain as a limitation of using loupes. In comparison, the literature reports that over half of oculoplastic surgeons experience neck or back pain.^17,18 A similar percentage believe that loupe use can lead to spinal disorders.⁵ Further research is necessary to ascertain whether there are true casual associations between loupe usage and these perceived drawbacks. There are a few explanations as to why the number we report is lower than that in the literature. First, we did not include back or neck pain as selection choices in the survey. The 25 physicians who reported back or neck pain selected “other” as an option and had to explicitly write in their complaint. Second, although over 50% of ophthalmologists experience back or neck pain, not all of them may associate that pain with using loupes. Regardless, the ergonomic limitations of loupes should be probed further, especially because 10% of musculoskeletal disorders are reported to be career-ending.¹⁹ This is particularly true for the field of oculoplastic surgery, as it has been reported that oculoplastic surgeons spend 85% of their operating time in non-neutral posture and 26% of their operating time in extreme postures characterized by high flexion (>45°), rotation (>45°), and bending (>30°).²⁰ Indeed, the same study demonstrated that mean cervical loading increased by 40% overall with the use of loupes and headlamps across all postures and cervical levels.²⁰ Efforts toward increasing awareness of these risks, as well as strategies to mitigate them among oculoplastic surgeons and trainees, may reduce the prevalence of these disorders in the field. To this end, previous reports have indicated that exercise and adjustment of posture can improve ergonomics and reduce the musculoskeletal complications that arise from surgery.^5,21,22

Limitations to this study include the following. First, our response rate was 39%, so respondent and selection bias may have been introduced. Although this may have resulted in the high mean age of respondents observed (50 years), our response rate was nonetheless comparable to that of previous studies on loupes and surveys of ASOPRS members. Sivak-Callcott et al.’s survey of ASOPRS members on loupes achieved a 25% response rate, and a recent ASOPRS survey study recorded a 41% response rate.^5,23 To bolster the methodology and response rate, members of the department were consulted in the design of this survey, and a reminder was sent out 2 weeks after the survey was first distributed. Second, further details about the musculoskeletal complications reported and the treatment surgeons received would have been helpful. Future studies should assess whether risk of musculoskeletal pain correlates with increased loupe usage. A retrospective cohort study with loupe usage designated as an exposure, and back or neck pain as an outcome, stratified by age, could provide this insight. A similar type of study could also be used to compare surgical outcomes with and without loupes. Surveys should also be expanded to increase power by including non-ASOPRS oculoplastic surgeons, otolaryngology surgeons, and plastic surgeons who perform periocular procedures.

This study demonstrated that while loupe usage is highly prevalent in the field of oculoplastics, there is a lack of consensus on the benefits and limitations of using loupes and their importance in training and in practice. Limited field and depth of vision as well as lack of comfort were identified as important limitations. It is our hope that the perspectives presented here will not only provide insight into the current outlook on loupes among oculoplastic surgeons, but also serve as a foundation for subsequent efforts toward further elucidation and mitigation of the risks associated with loupe use.