Issue #25 summary - GO BACK TO ARCHIVE

Ever-decreasing circles
The decline of vision with age is a universal complaint. Dr Glenn Carp explains how treatment techniques are turning back the clock on ageing eyes with presbyopia

Presbyopia will affect all of us at some point. The condition occurs as the eyes age, losing ability to change the focus of the eye to zoom from distance to near objects. It’s an entirely natural process resulting in gradual visual impairment, but one that ensures treatment is always in demand.  The process starts from birth as the crystalline lens grows in size and is an unavoidable part of ageing. While the progressive decline continues throughout a lifetime, the lessened capacity of the lens presents itself as a complaint around the mid-40s when it has a discernable impact on vision. At this stage, the eye has lost a noticeable ability to change from distant focusing to viewing a close-up object. The result is that the residual focusing power of the crystalline lens cannot provide sufficient near vision, and treatment becomes necessary, traditionally in the form of reading glasses or multifocal glasses.
     The ideal solution is to repair the ability of the crystalline lens to accommodate, but as yet no procedure has been able to reverse presbyopia and restore the natural focusing mechanism of the eye. There is ongoing research on techniques to achieve this, but clinical applications won’t be available for at least 10 to 20 years.
     Current treatments focus on compensating for the lack of accommodation by providing a different refractive power at distance and near. The challenge of such treatment options is to provide both distance and near vision while maintaining optical quality, with particular regard to contrast sensitivity and night vision preservation.  Traditional non-surgical methods of refractive correction for presbyopia include the use of dedicated reading glasses, bifocal, or varifocal glasses, monovision contact lenses or multi-focal contact lenses. But these treatments come with their own problems. Research studies have indicated that multi-focal glasses impair depth perception and edge-contrast sensitivity at critical distances for detecting obstacles in the environment.
     While in varifocal lenses, there is a corridor of continuously changing lens power and optimal vision is only obtained when looking though this corridor and directly facing the object of focus. Outside this corridor, the vision is distorted and peripheral vision is reduced. For these reasons, older people are more likely to fall when wearing multi-focal glasses.  Vision through bifocal lenses is the third greatest risk factor for falls in the elderly. This effect is more pronounced in high prescriptions, particularly for high astigmatism and so a number of patients are unable to adapt to this mode of correction.

Photoageing and uneven pigment
Laser and intense pulsed light can provide enviable results for patients with pigmented skin. Dr Peter Crouch discusses strategies for symptoms of photoageing and uneven pigment

Over the past five years, our NHS and private clinics have attracted a significant number of patients seeking a solution to the problem that is uneven and unwanted pigment. Often referred to simply as sun or age spots, these blemishes are treatable with either laser or intense pulsed light, with varying effectiveness across different skin types.  Experience teaches laser practitioners which patients will not benefit from intense pulsed light and laser treatment.  In conjunction with our technology providers, we have developed protocols to identify which remedial treatment paths are likely to assist and how best to predict and monitor treatment progress.
      Who is and isn’t a good candidate for laser and intense pulsed light (IPL)? For patients who approach with melasma, Intense pulsed light should be avoided, as unexpected hyperpigmentation may easily result. I am often asked why intense pulsed light is not a logical remedy for melasma and I simply reply that exposing a patient with a condition normally made worse by exposure to broadband sunlight to broadband intense pulsed light is unlikely to end in improvement of the condition.  All patients with pigmented skin (III. IV) must be treated with extreme caution as unwanted and unexpected hypopigmentation can result and the outcome may well be more distressing than the original condition. Patients with skin types V&VI should almost certainly completely avoid laser or IPL treatment in the 530nm wavelength range as there would be a very real expectation of hypopigmentation.
     Patients with a clear contrast between their pigmentation and their baseline skin pigment present as the best candidates for intense pulsed light and laser treatment. I choose laser for targeting of discrete lesions, which require precise targeting of energy, and intense pulsed light for addressing larger areas of uneven pigmentation such as the entire face.  The key to success is selective photothermolysis of pigment—specifically targeting pigment while leaving epidermis and blood vessels relatively unharmed.  Intense pulsed light devices produce a broad spectrum of incoherent light in a range of wavelengths. This light is highly controlled using filters and computer-adjustable pulse width and delay between pulses. We generally use wavelengths of 515-590nm. 
     In complete contrast, lasers produce a single wavelength of coherent energy and the ideal wavelength for targeting of brown pigment is usually around 540-560nm.  The machine that we use for this group is the Lumenis One intense pulsed light device. We apply a thin layer of treatment gel before typically treating with a single pass depending upon the skin type and depth of pigment. We employ contact cooling of the epidermis to reduce side effects (such as blistering) and the down time associated with postexposure bruising and oedema. Correct selection of filters, pulse durations and fluence can lead to steady clearance of pigment and comfortable treatments.

Making friends and influencing people
Building good relations with clients is essential to a successful practice. Mark Jeffries explains how this can benefit medical professionals

How much do your patients like you? If you’re aiming to achieve lasting success and a steady stream of clients, then the answer should be “a lot”.
     Establishing emotional bonds plays a vital part in boosting your reputation, and can be even more effective than technical excellence when it comes to word-of-mouth referrals.
In the business world, leading professionals know that networking and good relations are key. Whilst adapting to a customer’s needs by acting on their feelings and reactions creates a vital sense of trust and understanding.
     These soft skills are employed to great effect in sales-driven professions and can be just as effectively deployed in the medical world. So apart from your brilliant technical work, here are just a few ideas you can use to win and keep your valuable patients.
     As humans we like people who are similar to us, and in business the same thing is true. A way to achieve this is to discover a connection between you and your patient and use it to emphasise your similarities. Maybe you both support the same rugby or football team, have kids, dogs, or an obsession with Grey’s Anatomy. It doesn’t matter, but once you have a link you should subtly drop it into early conversations to create that allimportant bond. Matching your objectives to the needs of your patient then becomes a lot easier.
      A recent survey in the USA revealed that, in the event of malpractice, a physician was far more likely to be sued by the patient if he had been abrupt, arrogant or unfriendly during initial consultations.  At the other end of the scale, physicians who were deemed to be warm, open and pleasant experienced a far lower incidence of legal action.
     The moral of the story is you should always treat your patients like the valued clients they are. It protects you in tough times and, given that many medical referrals between friends are based not on your effective treatment but on how “lovely” you are, it will bring in more business

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