Intense Pulsed Light for the Treatment of Dry Eye Owing to Meibomian Gland Dysfunction
Summary
Dry eye disease is an increasingly common condition, which strongly impair patients' life quality. Recently, a new device employing intense pulsed light, specifically designed for the periocular area, has been shown to improve tear film stability and ocular discomfort symptoms in dry eye disease owing to meibomian gland dysfunction.
Abstract
Dry eye disease (DED) is an increasingly common condition and one of the most common complaints of patients. The vast majority of DED is caused by the so-called "evaporative" subtype, that is mainly caused by meibomian gland dysfunction (MGD). Intense pulsed light (IPL) devices employ high intensity pulses of polychromatic lights with a broad range of wavelength (515-1200 nm). IPL treatment has been utilized for years in the field of dermatology, and then its use was applied to ophthalmology for the treatment of MGD. Recently, a new device employing IPL was specifically designed for the periocular application. This procedure determines the thermal selective coagulation and ablation of superficial blood vessels and telangiectasias of the eyelids skin, reducing the release of inflammatory mediators and tear cytokines levels, and improving meibomian glands outflow. IPL treatment is noninvasive and easy to perform, lasts for only a few minutes and can be conducted in an office setting. In the present study, 19 patients underwent 3 sessions of IPL treatment. After treatment, both mean noninvasive break-up time and lipid layer thickness grade significantly increased, as a result of an improvement of tear film stability and quality, respectively. Conversely, no statistically significant changes were found for meibomian gland loss and tear osmolarity. Furthermore, the vast majority of the treated patients (17/19; 89.5% of the total) perceived an improvement of their ocular discomfort symptoms after IPL treatment. Although IPL treatment provides an improvement of both ocular surface parameters and ocular discomfort symptoms after one cycle of three sessions, regular repeated treatments are usually required to maintain the persistence over the time of its beneficial effects.
Introduction
Dry eye disease (DED) is an increasingly common condition and one of the most common reasons for clinical visits to an eye doctor1. The main symptom complained by patients affected by DED differs from various grades of redness and ocular discomfort to a chronic foreign body sensation, stinging, burning, itching, excessive tearing, pain, recurrent infections and transient visual disturbances2. The impact of DED on patients' quality of life has been compared to that caused by moderate to severe angina or dialysis treatment3, and is associated with a restriction in daily activities and a loss of work productivity4.The recent definition of dry eye disease formulated by the TFOS DEWS II highlights its multifactorial nature, since different complex and heterogeneous alterations play a significant role in the onset and the maintenance of the disease2.
The vast majority of dry eye is caused by the so-called "evaporative" subtype that is mainly caused by meibomian gland dysfunction (MGD), a condition that affects up to 70% of the population in particular regions of the world5. Meibomian gland dysfunction is caused by a chronic alteration of the meibomian glands that are located inside the upper and lower eyelids. The disease is characterized by hyperkeratinization of the external duct of the glands and the obstruction of the orifices with insufficient, not functional, production of the external lipid layer of the tear film, resulting in tear instability6,7,8.
Currently, several different therapeutic strategies are available aiming at interrupting the vicious spiral of dry eye, and consist mainly of antibiotics, anti-inflammatory drugs, eyelid hygiene, warm compresses and tear substitutes9. However, these therapies are chronic and provide often only partial or short-term relief of symptoms, with subsequent compliance issues. Therefore, novel treatments with high efficacy and tolerability are desirable. In recent years, intense pulsed light (IPL) therapy has been widely used in dermatology for the treatment of different skin diseases such as acne, rosacea, telangiectasias and vascular and pigmented lesion (e.g., hemangiomas, venous malformations, port-wine stains)10. When the light is applied to the skin, it is absorbed by pigmented structures, such as blood cells and teleangectasias, with subsequent heat production that coagulates and destroys the abnormal blood vessels11. Recently, this technique was applied to the ophthalmic field for the treatment of DED owing to MGD. Several mechanisms have been postulated to explain the therapeutic effect of the procedure. Firstly, IPL treatment acts inducing thermal coagulation and selective ablation of superficial blood vessels and telangiectasias of the eyelids skin. Furthermore, the procedure reduces the release of inflammatory mediators and the levels of tear cytokines, which may promote the keratinization of mebomian glands terminal duct12,13. Secondly, the light energy transformed into heat causes the warming and liquefying of meibomian glands secretions, with subsequent melting and improved outflow11,14. More recently, other mechanisms such as the enhancement in collagen synthesis and connective tissue remodeling, the reduction in skin epithelial cell turnover, and the modulation of cellular inflammatory markers have also been hypothesized15.
In this study, we describe the use and the therapeutic effects of a recently commercialized IPL device, developed specifically for the treatment of MGD, in which IPL emission has been "regulated" in a multiple polychromatic train of calibrated and homogenously sequenced pulses. Therefore, the aim of this study is to describe the treatment procedure in detail, in order to spread it to the scientific medical community, giving the opportunity to ophthalmologists to expand their current armamentarium for the treatment of MGD.
Protocol
Representative Results
Discussion
Intense pulsed light devices employ xenon gas-filled flash lamps to produce non-laser high intensity pulses of polychromatic non-coherent lights in a broad wavelength spectrum, from visible (515 nm) to infrared (1200 nm)18. The light energy pulse is released by the head of the handpiece by means of a sapphire or quartz block, and so directly applied onto the skin surface.
The mechanism of action of IPL systems is based on the principle of selective thermolisis, accordin…
Divulgations
The authors have nothing to disclose.
Acknowledgements
The authors have no acknowledgements to declare.
Materials
| I.C.P. Tearscope | SBM Sistemi, Turin, Italy | 1340864/R | Device for noninvasvive break-up time and lipid layer thickness evaluation |
| I.C.P. MGD | SBM Sistemi, Turin, Italy | 15006 | Device performing infrared meibomography and meibomian gland loss evaluation |
| TearLab Osmolarity System | TearLab Corporation, San Diego, CA, USA | 83861QW | Device for the measurement of tear osmolarity |
| E>Eye | E-Swin, Paris, France | Intense pulsed regulated light treatment device | |
| BM 900 Slit Lamp Biomioscropy | Haag-Streit, Koeniz, Switzerland | BM 900 | Slit Lamp Biomiscroscopy |
| Tobradex eye drops | Alcon Inc., Fort Worth, TX, USA | S01CA01 | Eye drops instilled immediately after the procedure in office |
References
- Schaumberg, D. A., Dana, R., Buring, J. E., Sullivan, D. A. Prevalence of dry eye disease among US men: estimates from the Physicians’ Health Studies. Arch Ophthalmol. 127 (6), 763-768 (2009).
- Craig, J. P., et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 15 (3), 276-283 (2017).
- Buchholz, P., et al. Utility assessment to measure the impact of dry eye disease. Ocul Surf. 4 (3), 155-161 (2006).
- Uchino, M., et al. Dry eye disease and work productivity loss in visual display users: the Osaka study. Am J Ophthalmol. 157 (2), 294-300 (2014).
- Schaumberg, D. A., Nichols, J. J., Papas, E. B., Tong, L., Uchino, M., Nichols, K. K. The international workshop on meibomian gland dysfunction: report of the subcommittee on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis Sci. 52 (4), 1994-2005 (1994).
- Baudouin, C., et al. Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction. Br J Ophthalmol. 100 (3), 300-306 (2016).
- Knop, E., Knop, N., Millar, T., Obata, H., Sullivan, D. A. The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland. Invest Ophthalmol Vis Sci. 52 (4), 1938-1978 (1938).
- Bron, A. J., et al. TFOS DEWS II pathophysiology report. Ocul Surf. 15 (3), 438-510 (2017).
- Qiao, J., Yan, X. Emerging treatment options for meibomian gland dysfunction. Clin Ophthalmol. 7, 1797-1803 (2013).
- Papageorgiou, P., Clayton, W., Norwood, S., Chopra, S., Rustin, M. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol. 159 (3), 628-632 (2008).
- Toyos, R., McGill, W., Briscoe, D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 33 (1), 41-46 (2015).
- Vora, G. K., Gupta, P. K. Intense pulsed light therapy for the treatment of evaporative dry eye disease. Curr Opin Ophthalmol. 26 (4), 314-318 (2015).
- Liu, R., et al. Analysis of Cytokine Levels in Tears and Clinical Correlations After Intense Pulsed Light Treating Meibomian Gland Dysfunction. Am J Ophthalmol. 183, 81-90 (2017).
- Goldberg, D. J. Current Trends in Intense Pulsed Light. J Clin Aesthet Dermatol. 5 (6), 45-53 (2012).
- Dell, S. J. Intense pulsed light for evaporative dry eye disease. Clin Ophthalmol. 11, 1167-1173 (2017).
- Pult, H., Riede-Pult, B. H. Non-contact meibography: keep it simple but effective. Cont Lens Anterior Eye. 35 (2), 77-80 (2012).
- Fitzpatrick, T. B. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 124 (6), 869-871 (1988).
- Raulin, C., Greve, B., Grema, H. IPL technology: a review. Lasers Surg Med. 32 (2), 78-87 (2003).
- Toyos, R., Buffa, C. M., Youngerman, S. Case report: Dry-eye symptoms improve with intense pulsed light treatment. Eye World News Magazine. , (2005).
- Jiang, X., et al. Evaluation of the Safety and Effectiveness of Intense Pulsed Light in the Treatment of Meibomian Gland Dysfunction. J Ophthalmol. , (2016).
- Albietz, J. M., Schmid, K. L. Intense pulsed light treatment and meibomian gland expression for moderate to advanced meibomian gland dysfunction. Clin Exp Optom. 101 (1), 23-33 (2018).
- Gupta, P. K., Vora, G. K., Matossian, C., Kim, M., Stinnett, S. Outcomes of intense pulsed light therapy for treatment of evaporative dry eye disease. Can J Ophthalmol. 51 (4), 249-253 (2016).
- Dell, S. J., Gaster, R. N., Barbarino, S. C., Cunningham, D. N. Prospective evaluation of intense pulsed light and meibomian gland expression efficacy on relieving signs and symptoms of dry eye disease due to meibomian gland dysfunction. Clin Ophthalmol. 11, 817-827 (2017).
- Vegunta, S., Patel, D., Shen, J. F. Combination Therapy of Intense Pulsed Light Therapy and Meibomian Gland Expression (IPL/MGX) Can Improve Dry Eye Symptoms and Meibomian Gland Function in Patients With Refractory Dry Eye: A Retrospective Analysis. Cornea. 35 (3), 318-322 (2016).
- Roy, N. S., Wei, Y., Kuklinski, E., Asbell, P. A. The Growing Need for Validated Biomarkers and Endpoints for Dry Eye Clinical Research. Invest Ophthalmol Vis Sci. 58 (6), BIO1-BIO19 (2016).
- Giannaccare, G., Vigo, L., Pellegrini, M., Sebastiani, S., Carones, F. Ocular Surface Workup With Automated Noninvasive Measurements for the Diagnosis of Meibomian Gland Dysfunction. Cornea. , (2018).
- Craig, J. P., Chen, Y. H., Turnbull, P. R. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 56 (3), 1965-1970 (1965).
- Meadows, J. F., Ramamoorthy, P., Nichols, J. J., Nichols, K. K. Development of the 4-3-2-1 meibum expressibility scale. Eye Contact Lens. 38 (2), 86-92 (2012).
- Finis, D., Hayajneh, J., König, C., Borrelli, M., Schrader, S., Geerling, G. Evaluation of an automated thermodynamic treatment (LipiFlow®) system for meibomian gland dysfunction: a prospective, randomized, observer-masked trial. Ocul Surf. 12 (2), 146-154 (2014).
- Yin, Y., Liu, N., Gong, L., Song, N. Changes in the Meibomian Gland After Exposure to Intense Pulsed Light in Meibomian Gland Dysfunction (MGD) Patients. Curr Eye Res. 43 (3), 308-313 (2018).
- Guilloto Caballero, S., García Madrona, J. L., Colmenero Reina, E. Effect of pulsed laser light in patients with dry eye syndrome. Arch Soc Esp Oftalmol. 92 (11), 509-515 (2017).
