Disclosures: Epstein reports he is a consultant for Lumenis Vision.
December 08, 2020
5 min read
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Real-world IPL results for MGD treatment

Disclosures: Epstein reports he is a consultant for Lumenis Vision.
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Every optometrist addresses ocular surface disease in some capacity and, driven by a growing body of compelling science, many have expanded the range of diagnostic and treatment options they offer as new technologies have emerged.

With a large practice limited to dry eye and OSD, I see patients from across the Southwest and beyond. I use a constantly evolving comprehensive approach that incorporates several treatment options. However, my nature is to take a conservative approach whenever possible.

I incorporated intense pulsed light (IPL) therapy in my practice about 2 years ago after considerable research. An increasing number of studies showing positive results and good scientific support were key to my decision. While I expected IPL to be helpful for patients primarily with ocular rosacea and rosacea-associated meibomian gland dysfunction (MGD), I quickly saw profound benefits for a much broader range of patients with MGD and dry eye than I initially anticipated.

IPL has literally transformed my practice and become an indispensable tool for managing my patients. Both clinical results and patient reaction have been extremely positive. As with many things involving patients and advanced technology, the devil is in effectively communicating the benefits patients can expect.

How does IPL work?

Arthur B. Epstein, OD, FAAO
Arthur B. Epstein

IPL technology has been used for many years in dermatology for treating a variety of skin conditions including rosacea. Its ability to stimulate fibroblast activity and collagen production has also made it useful for aesthetic treatment and photorejuvenation of the skin.

IPL uses carefully controlled pulses of noncoherent light generated by a Xenon flashlamp. Wavelengths typically range from 500 nm to 1200 nm and are filtered to control penetration and clinical effect. More advanced devices such as the Lumenis M22 Optima IPL that I use precisely control the waveform and incorporate cooling to improve comfort and protect the skin during treatment.

Among the many uses of IPL is treatment of the abnormal, telangiectatic blood vessels found with rosacea, an inflammatory condition of the skin’s sebaceous glands. The same telangiectatic blood vessels are present in the eyelids and periorbital area of patients with ocular rosacea and other types of inflammatory OSD. IPL reduces bacterial overpopulation and Demodex on the lids and induces an effect termed photobiomodulation, which has been reported to increase cellular activity and function in treated tissues (Giannaccare et al.). Inflammation is also reduced.

Although IPL uses intense light pulses to perform its clinical magic, the light is really an envelope for energy. For effective and safe treatment, several things must be calculated and controlled. The energy absorbed by the skin depends on skin pigmentation, so compensation must be made for that. Additionally, the fluence or the amount of energy per pulse is set along with the pulse waveform.

For MGD treatment, I use a triple pulse train with a rest between pulses. The rest period is very important to allow for tissue recovery between pulses. I also suspect that this pattern plays an important role in photobiomodulation effects.

The Lumenis M22 Optima IPL can precisely shape each pulse into square waves. Because square waves have no peaks, they have no hot spots — a significant safety advantage. There is virtually no chance of causing irritation or burning the skin. In hundreds of patients I’ve treated, I've never seen an adverse outcome from unexpected heating or burning. This is an important technological feature to consider because if waveforms are not uniform, it could result in hot spots.

The IPL procedure

I select IPL for patients who have ocular rosacea and associated MGD. I use a modified Toyos pattern, applying “shots” over the cheeks beneath the lower eyelids and nose, from tragus to tragus in two passes. For men, I avoid the sideburn area and may apply additional shots to the forehead to increase energy application depending on treatable surface area. In addition to setting fluence based on skin coloration and prior treatment response, I control energy application by the number of pulses and overlap. IPL-grade protective eye patches are placed over patients’ eyes during the procedure.

IPL is generally quite comfortable for most patients. Some patients experience a mild snapping sensation or momentary heating, usually on the left side of their face as it is most pigmented from sun exposure during driving. Most patients have four treatment sessions, spaced 2 to 4 weeks apart, followed by maintenance sessions spaced at 6 months to 1 year.

Symptomatic improvement with IPL increases over the course of treatment and persists for many months. Most patients show response by the second or third treatment. Very little warming occurs from IPL treatment, so post treatment expression is often uncomfortable, which is why I avoid it.

Photobiomodulation effects occurring in the glands and skin as well as reduction in abnormal blood vessels and resulting inflammation can be transformative. After treatment, we have observed physical changes in the meibomian gland structure, as well as some very significant changes in the meibum composition and quality (Yin et al). In some patients, the expressed meibum appears much less viscous after IPL. I have also observed increased meibomian gland function confirmed by higher lipid layer thickness measurements and increased noninvasive and fluorescein breakup time.

Additionally, IPL significantly decreases microorganism overgrowth, and that effect is rather long-lasting. The eyelids appear less red, which makes patients happy, and their dry eye symptoms are significantly improved (Toyos et al). It is evident that IPL technology can transform both structure and function.

Which patients need IPL?

I originally expected to use IPL primarily for patients with clearly evident ocular rosacea and comorbid MGD and dry eye. I found that ocular rosacea was more common than I had suspected, likely because I had attributed telangiectasia to inflammatory dry eye without recognizing the rosacea component.

Once I began using IPL, it quickly became apparent that effects go well beyond what I had expected. Patient response was over the top in terms of objective measures: 93% better tear breakup time (Dell et al.) and improved corneal staining (Rong et al.). Subjective symptom questionnaires improved more than 50%. I tried IPL on patients with MGD and mild signs of ocular rosacea for whom other therapies didn’t achieve the desired results, and they did remarkably well.

During this journey with IPL, I have gone from cautiously treating a small number of patients to filling nearly every Friday’s schedule with IPL patients. Driven by overwhelming patient acceptance, we were performing 25 to 35 IPL treatments a week within a few months. That would not have happened if the technology were not working so effectively.

For too many of us, dry eye patients have been a nuisance rather than an opportunity for both the patient and the practice. Admittedly, the dry eye space has been rather confusing; however, new diagnostic technologies and therapies, including IPL, can cut through the noise. Instead of feeling stymied by the learning curve or the sheer number of options, doctors should not hesitate to jump into OSD. Those of us who have done so no longer have patients returning over and over, telling us treatment isn’t working. We’ve embraced treatment technologies that work and can be life-changing for our patients.

References:

For more information:

Arthur B. Epstein, OD, FAAO, is head of the Dry Eye – Ocular Surface Disease Center and director of clinical research at Phoenix Eye Care – the Dry Eye Center of Arizona in Phoenix.