Intense pulsed light therapy aims at underlying cause of dry eye

Arthur B. Epstein

Optometry is undergoing a tectonic shift, with online contact lens and eyeglass sales, telemedicine and equity capital group acquisitions all pointing to significant changes ahead. To prepare, we must identify unmet needs and expand our practices to meet them.

In my own typically competitive market, we focused on medical eye care, specifically dry eye disease, as a differentiator and protective strategy. Dry eye management is a gateway to a safer harbor for optometry as well as a means to add stability during tumultuous times to come. I urge all colleagues to embrace this growing opportunity before it is too late.

Treating dry eye opens the door to more patient visits as well as more paid procedures. About 6 months ago, after extensive research and considerable thought, we purchased a system for intense pulsed light (IPL) therapy (Optima IPL, Lumenis). The literature was overwhelmingly positive. IPL improves tear break-up time 93%, restores tear osmolarity and cuts symptoms by more than half (Dell et al.). It has also been shown to reduce MMP-9 levels (Liu et al.) and improve corneal staining (Rong et al.). In addition, unlike simple eyelid hygiene, IPL has been shown to actually improve the structure of the meibomian glands (Yin et al.).

How IPL works

Aimed primarily at patients who have ocular rosacea, IPL targets abnormal, leaky vessels that are thought to carry pro-inflammatory mediators to the glands. There also appears to be a photomodulatory effect that stimulates normalized gland function. Additionally, I have observed significant, nearly immediate changes in meibum consistency and clarity.

Perhaps most importantly, patients – whom I view as the most sensitive measures of treatment success – respond extremely well to IPL treatment. Unlike most current treatments that target signs or symptoms, IPL aims at the underlying cause.

The procedure

Patients with evidence of ocular rosacea such as telangiectatic vessels on the lid margins and related inflammation are offered IPL. We selected our IPL system because it is safe, comfortable and easily guided by the clinician. The handpiece’s shape, filters and adjustable spot sizes are designed to be used in close proximity to the eye. The instrument is state-of-the-art and widely considered the standard of care, which was key in selecting it.

After applying eye shields and coupling gel to the treatment area, light pulses are applied with the handpiece around the eyelids and surrounding area using a modified Toyos approach (Toyos et al.). Treatment is usually bundled as a package of four treatments, followed by periodic retreatment as necessary.

Return on investment

An IPL system is a significant investment, but ours will pay for itself in an unexpectedly short period. Our patients have embraced the technology. IPL is already familiar to many people through its use in aesthetics, where very little is covered by insurance, as well as through abundant discussion of IPL on social media. As a result of that familiarity, as well as patients’ eagerness to get relief from chronic dry eye disease, they have not hesitated to pay out of pocket.

When clinically appropriate, IPL can also be packaged with thermal pulsation (LipiFlow, Johnson & Johnson Vision) or personalized heated expression (Tear Care, Sight Sciences). Both work synergistically with IPL to clear meibomian gland obstructions.

Ultimately, I think many ODs will embrace dry eye and use technologies like IPL, pushing the envelope in medical eye care treatments that fit their practices.


References:

Dell SJ, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S130706.

Liu R, et al. Am J Ophthalmol. 2017;doi:10.1016/j.ajo.2017.08.021.

Rong B, et al. Photomed Laser Surg. 2018;doi:10.1089/pho.2017.

Toyos R, et al. Photomed Laser Surg. 2015;doi:10.1089/pho.2014.3819.

Yin Y, et al. Curr Eye Res. 2018;doi:10.1080/02713683.2017.


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. He can be reached at: artepstein@gmail.com.


Disclosure: Epstein reports he is a consultant for Alcon, Johnson & Johnson Vision, Lumenis and Sight Sciences.

Arthur B. Epstein

Optometry is undergoing a tectonic shift, with online contact lens and eyeglass sales, telemedicine and equity capital group acquisitions all pointing to significant changes ahead. To prepare, we must identify unmet needs and expand our practices to meet them.

In my own typically competitive market, we focused on medical eye care, specifically dry eye disease, as a differentiator and protective strategy. Dry eye management is a gateway to a safer harbor for optometry as well as a means to add stability during tumultuous times to come. I urge all colleagues to embrace this growing opportunity before it is too late.

Treating dry eye opens the door to more patient visits as well as more paid procedures. About 6 months ago, after extensive research and considerable thought, we purchased a system for intense pulsed light (IPL) therapy (Optima IPL, Lumenis). The literature was overwhelmingly positive. IPL improves tear break-up time 93%, restores tear osmolarity and cuts symptoms by more than half (Dell et al.). It has also been shown to reduce MMP-9 levels (Liu et al.) and improve corneal staining (Rong et al.). In addition, unlike simple eyelid hygiene, IPL has been shown to actually improve the structure of the meibomian glands (Yin et al.).

How IPL works

Aimed primarily at patients who have ocular rosacea, IPL targets abnormal, leaky vessels that are thought to carry pro-inflammatory mediators to the glands. There also appears to be a photomodulatory effect that stimulates normalized gland function. Additionally, I have observed significant, nearly immediate changes in meibum consistency and clarity.

Perhaps most importantly, patients – whom I view as the most sensitive measures of treatment success – respond extremely well to IPL treatment. Unlike most current treatments that target signs or symptoms, IPL aims at the underlying cause.

The procedure

Patients with evidence of ocular rosacea such as telangiectatic vessels on the lid margins and related inflammation are offered IPL. We selected our IPL system because it is safe, comfortable and easily guided by the clinician. The handpiece’s shape, filters and adjustable spot sizes are designed to be used in close proximity to the eye. The instrument is state-of-the-art and widely considered the standard of care, which was key in selecting it.

After applying eye shields and coupling gel to the treatment area, light pulses are applied with the handpiece around the eyelids and surrounding area using a modified Toyos approach (Toyos et al.). Treatment is usually bundled as a package of four treatments, followed by periodic retreatment as necessary.

Return on investment

An IPL system is a significant investment, but ours will pay for itself in an unexpectedly short period. Our patients have embraced the technology. IPL is already familiar to many people through its use in aesthetics, where very little is covered by insurance, as well as through abundant discussion of IPL on social media. As a result of that familiarity, as well as patients’ eagerness to get relief from chronic dry eye disease, they have not hesitated to pay out of pocket.

When clinically appropriate, IPL can also be packaged with thermal pulsation (LipiFlow, Johnson & Johnson Vision) or personalized heated expression (Tear Care, Sight Sciences). Both work synergistically with IPL to clear meibomian gland obstructions.

Ultimately, I think many ODs will embrace dry eye and use technologies like IPL, pushing the envelope in medical eye care treatments that fit their practices.


References:

Dell SJ, et al. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S130706.

Liu R, et al. Am J Ophthalmol. 2017;doi:10.1016/j.ajo.2017.08.021.

Rong B, et al. Photomed Laser Surg. 2018;doi:10.1089/pho.2017.

Toyos R, et al. Photomed Laser Surg. 2015;doi:10.1089/pho.2014.3819.

Yin Y, et al. Curr Eye Res. 2018;doi:10.1080/02713683.2017.


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. He can be reached at: artepstein@gmail.com.


Disclosure: Epstein reports he is a consultant for Alcon, Johnson & Johnson Vision, Lumenis and Sight Sciences.