Perspective

Intense pulsed light treatment with meibomian gland expression relieves refractory dry eye

Refractory dry eye treated with a combination of intense pulsed light and meibomian gland expression resulted in a significant improvement in dry eye symptoms and meibomian gland function, according to a retrospective analysis of 35 subjects.

“For older patients with years of meibomian gland disease, automated thermal pulsation alone was not giving patients relief,” according to co-investigator Joanne F. Shen, MD, chair of the Department of Ophthalmology at the Mayo Clinic in Scottsdale, Arizona, which has a large referral practice of recalcitrant dry eye patients.

Shen and colleagues modeled the combination therapy of David R. Hardten, MD, who treats ocular rosacea dry eye with serial intense pulsed light (IPL)/meibomian gland expression (MGX). The protocol was originally designed by Rolando Toyos, MD.

In the study, which appeared in Cornea, patients received on average four monthly IPL treatments, ranging from one to four sessions, of roughly 30 pulses at a wavelength between 530 nm and 1,200 nm, spaced 4 to 6 weeks apart. Each light session was followed by MGX with a cotton tip applicator and digital pressure.

“The total time for hands-on treatment usually takes about 20 minutes,” Shen told Ocular Surgery News.

Significant improvements

In total, 89% of patients achieved a significant improvement in dry eye symptoms, with 71% of patients noting an improvement after only one session. Likewise, 77% of patients attained a significant improvement in at least one eye for meibomian gland function over the course of treatment, and 40% had improved meibomian gland evaluations bilaterally.

“I still am unclear about the exact mechanism of the treatment,” Shen said. “But I believe something is improving in the treated skin and eyelids. However, more studies are needed to elucidate the pathway.”

Patients are treated monthly with IPL/MGX until they experience relief. “After this plateau is reached, I see patients quarterly and re-treat usually every 3 to 6 months if they become symptomatic or if their expressible meibomian gland count drops,” Shen said.

Although Shen and colleagues are unaware of why the treatment protocol is effective, “we know that expression alone helps improve meibomian gland function,” she said. “The real question is, how does the meibomian gland respond to the IPL?”

Thermal pulsation

Because patients are concerned about potential damage to their eyes with IPL, “clinicians should ensure that they wear safety glasses and use adhesive shields to keep the eyelids closed during treatment,” Shen said. Also, “when conservative treatments are exhausted, consider automated thermal pulsation and IPL therapy.”

Nearly two-thirds of study patients had previously undergone thermal pulsation treatment, for which there was no improvement in symptoms after 3 months.

The study authors cautioned, however, that patients considering IPL/MGX should be counseled about the pain associated with MGX, which can be unbearable for some, as opposed to automated thermal pulsation, which is well tolerated by most patients.

The authors also noted that their study data do not shed light on ideal IPL/MGX candidates or who is likely to be a non-responder. The study found, though, that if a patient does not respond favorably after three treatments, a fourth session will probably not show any beneficial results.

Shen said the Tear Film and Ocular Surface Society Dry Eye WorkShop II (TFOS DEWS II) report is expected to become available in 2017, which will compile the current body of knowledge on dry eye disease.

Meanwhile, Shen and colleagues are expected to start a prospective pilot study examining microbial flora, impression cytology flow cytometry of conjunctiva cells and tear cytokine changes before and after treatment in patients undergoing IPL/MGX vs. MGX alone. – by Bob Kronemyer

Disclosure: Shen reports no relevant financial disclosures.

Refractory dry eye treated with a combination of intense pulsed light and meibomian gland expression resulted in a significant improvement in dry eye symptoms and meibomian gland function, according to a retrospective analysis of 35 subjects.

“For older patients with years of meibomian gland disease, automated thermal pulsation alone was not giving patients relief,” according to co-investigator Joanne F. Shen, MD, chair of the Department of Ophthalmology at the Mayo Clinic in Scottsdale, Arizona, which has a large referral practice of recalcitrant dry eye patients.

Shen and colleagues modeled the combination therapy of David R. Hardten, MD, who treats ocular rosacea dry eye with serial intense pulsed light (IPL)/meibomian gland expression (MGX). The protocol was originally designed by Rolando Toyos, MD.

In the study, which appeared in Cornea, patients received on average four monthly IPL treatments, ranging from one to four sessions, of roughly 30 pulses at a wavelength between 530 nm and 1,200 nm, spaced 4 to 6 weeks apart. Each light session was followed by MGX with a cotton tip applicator and digital pressure.

“The total time for hands-on treatment usually takes about 20 minutes,” Shen told Ocular Surgery News.

Significant improvements

In total, 89% of patients achieved a significant improvement in dry eye symptoms, with 71% of patients noting an improvement after only one session. Likewise, 77% of patients attained a significant improvement in at least one eye for meibomian gland function over the course of treatment, and 40% had improved meibomian gland evaluations bilaterally.

“I still am unclear about the exact mechanism of the treatment,” Shen said. “But I believe something is improving in the treated skin and eyelids. However, more studies are needed to elucidate the pathway.”

Patients are treated monthly with IPL/MGX until they experience relief. “After this plateau is reached, I see patients quarterly and re-treat usually every 3 to 6 months if they become symptomatic or if their expressible meibomian gland count drops,” Shen said.

Although Shen and colleagues are unaware of why the treatment protocol is effective, “we know that expression alone helps improve meibomian gland function,” she said. “The real question is, how does the meibomian gland respond to the IPL?”

Thermal pulsation

Because patients are concerned about potential damage to their eyes with IPL, “clinicians should ensure that they wear safety glasses and use adhesive shields to keep the eyelids closed during treatment,” Shen said. Also, “when conservative treatments are exhausted, consider automated thermal pulsation and IPL therapy.”

Nearly two-thirds of study patients had previously undergone thermal pulsation treatment, for which there was no improvement in symptoms after 3 months.

The study authors cautioned, however, that patients considering IPL/MGX should be counseled about the pain associated with MGX, which can be unbearable for some, as opposed to automated thermal pulsation, which is well tolerated by most patients.

The authors also noted that their study data do not shed light on ideal IPL/MGX candidates or who is likely to be a non-responder. The study found, though, that if a patient does not respond favorably after three treatments, a fourth session will probably not show any beneficial results.

Shen said the Tear Film and Ocular Surface Society Dry Eye WorkShop II (TFOS DEWS II) report is expected to become available in 2017, which will compile the current body of knowledge on dry eye disease.

Meanwhile, Shen and colleagues are expected to start a prospective pilot study examining microbial flora, impression cytology flow cytometry of conjunctiva cells and tear cytokine changes before and after treatment in patients undergoing IPL/MGX vs. MGX alone. – by Bob Kronemyer

Disclosure: Shen reports no relevant financial disclosures.

    Perspective
    David R. Hardten

    David R. Hardten

    Dry eye and meibomian gland dysfunction with evaporative dry eye are very common in the typical ophthalmology practice. These problems often complicate other eye diseases and surgical procedures. Shen and colleagues showed that the combination of intense pulsed light and meibomian gland expression can significantly improve symptoms in patients with this disease. For those patients who fail initial treatments with lid hygiene, artificial tears, nutritional supplementation or other traditional therapies, this may provide improvement in their disease state. We have been using this in our practice for the last 5 years and have also found that it has a role in treating these patients, with life-changing results in many patients.

    • David R. Hardten, MD
    • OSN Cornea/External Disease Section Editor

    Disclosures: Hardten reports no relevant financial disclosures.