Intense pulsed light and dry eye disease

IPL, once the province of dermatologists, is helping ophthalmic patients, but there is still much to learn.

By Joanne Shen, MD

Rolando Toyos, MD is an ophthalmologist who deserves credit for bridging dermatology and ophthalmology.¹ He worked with DermaMed Solutions to develop an intense pulsed light (IPL) handpiece with a footprint that would facilitate treating skin on the lower eyelid. At his clinic in Germantown, Tenn., he discovered that patients’ skin rejuvenated with IPL treatment. In addition to experiencing better-looking skin, their dry eye symptoms also improved. Consequently, he added an aesthetics clinic to his practice in 2002.

Dr. Shen administers IPL to a dry-eye patient. Note that the eyes of both physician and patient are protected.

Just why IPL helps mitigate dry eye symptoms is a bit of a mystery; Dr. Toyos told me he suspects thrombosis of the blood vessels, which minimize the skin’s redness, is involved.

Facial rosacea is a chronic, inflammatory condition that affects the skin on the face, nose and forehead. Many people with rosacea also develop ocular rosacea — usually in combination with skin symptoms, but sometimes in isolation. Many of my patients have only ocular rosacea, consisting of meibomian gland dysfunction and lid margin telangiectasias. When dry eye patients have facial rosacea, I find that improving the skin inflammation also improves their dry eye signs and symptoms. The IPL treatment indication is ocular rosacea, while the DermaMed system is FDA-labeled for rosacea.

The Centers of Excellence listed at www.toyosclinic.com include 39 nationwide groups that have been using IPL in their practice for at least six months. Here’s what we have learned about the efficacy of the treatment for dry eye disease.

How it works

I use the term “IPL/MGX” to better describe the treatment as I learned it in 2013 from Dr. Toyos. IPL is applied in two passes totaling about 30 pulses on the lower lid and cheek areas from one pre-auricular area to the other, with the eyelids masked. MGX —meibomian gland expression — refers to the manual expression of the upper and lower eyelid that follows. Because IPL is absorbed by pigmentation in the skin, only Fitzpatrick skin types I to IV can receive IPL treatment; so patients with darkly pigmented skin cannot receive it. Patients are instructed to wear sunscreen for three weeks after IPL treatment to avoid negating the IPL effect.

IPL/MGX is performed monthly for up to four treatments to control the ocular inflammation. After that, maintenance treatments every three to 12 months are needed to keep the symptoms and inflammation controlled. After each treatment, patients experience 24 to 36 hours of copious mucus production.

After the first IPL/MGX treatment, an early responder patient may experience five to seven days of symptomatic improvement followed by regression until the next treatment. After the second treatment, patients will again have about one day of mucus production followed by one to two weeks of improvement. Slow responders may not see improvements until after the second or third treatment.

After the fourth treatment, most patients have at least three months of sustained improvement.

Once regression occurs, the physician recommends a single IPL/MGX treatment that varies between patients: In my population, I’ve found that three to 12 months works best because sustained monthly IPL treatment could result in the skin thinning. The eyes of both patient and provider must be masked because of reports that IPL exposure to the iris can cause iris atrophy and permanent photophobia.² Both cases described in the reports were performed without eye masks when the IPL was used to treat pigmentation on the eyelid.

In my own practice

1. Does IPL/MGX help dry eye symptoms?

2. How does IPL improve dry eye symptoms?

To answer these questions, we conducted a retrospective review at our practice, examining severe dry eye patients who had exhausted conventional treatment and elected IPL/MGX. After four treatments, SPEED2 (a symptom scoring similar to OSDI) scores dropped by more than 50% in 27% of the patients. Additionally, 31% of the patients improved between 25% to 50%, and 27% of patients had minimal improvement of fewer than 25% in symptoms. Meibomian gland evaluations showed statistically significant improvements.

However, IPL/MGX is not a panacea: The remaining 15% of patients could not tolerate the treatment or did not improve.³ Despite this, my staff and I were pleased to see more smiling faces in the dry eye clinic. Many patients told us they felt better and could perform their daily activities without thinking about their painful, gritty eyes. Improved treated skin texture was an added bonus.

With the IPL/MGX, the physician can usually discontinue topical and systemic medications, but I do continue prescribing omega 3 fatty acids at 1200 mg daily. My philosophy has shifted over the past five years from handing out the latest tear substitutes to instead restoring the ocular surface, to performing without topical treatments that can wash out the “real” tears and add to inflammation with toxicity and allergy.

What IPL brings to treatment

Dr. Toyos theorizes that the light from the treatment is absorbed by the oxyhemoglobin in the skin’s surface blood vessels, which coagulates the cells leading to thrombosis of the blood vessels. This action minimizes redness and improves the look of the skin.

MGX by itself has been known to improve symptoms, yet so many people question the utility of adding IPL. To study the effectiveness of IPL alone, Jennifer Craig, OD, a dry eye specialist at the University of Auckland in New Zealand, performed a prospective, placebo-controlled IPL vs. masked treatment on 28 subjects with dry eye. She found an improvement in dry-eye symptoms, lipid tear thickness and tear break-up time even on the contralateral masked, untreated eye, without any meibomian gland expression.⁴

Dermatologists have long touted IPL’s efficacy in improving collagen synthesis. Musheera Ali, MBBS, a UK dermatologist, performed skin biopsies on affected backs of rosacea patients before and after IPL treatment. She found an upregulation of TGFB1 signaling after IPL was performed in the epidermis and sebaceous glands.⁵ TGFB1 is a member of a superfamily of cytokines involved in wound healing and regulation of growth and repair. It can induce other growth factors.

More information required

I suspect this upregulation of growth factors and cytokines suppresses the inflammatory cycle and influences the meibomian glands or the aqueous tear film or both. Further studies are needed. Designing a study, however, has been a challenge, for obvious reasons. We still don’t know which patients make good candidates for IPL/MGX or how frequently they would need treatments. I suspect the severity of inflammation and the individual visual demands would be contributing factors to future treatment guidelines.

In our practice in Arizona, we have benefited from Dr. Toyos’ discovery of the connection between IPL, rosacea and dry eye. The field of dry-eye treatments has become exciting as more investigators are working on this pervasive, growing problem. We look forward to the DEWS II results next year, which will summarize what we continue to learn about dry eye syndrome. OM

For a visual update of the first DEWS report, please turn to page 26.

REFERENCES

About the Author
	Dr. Shen is a cornea specialist at the Mayo Clinic in Arizona. She is also the chair of the Department of Ophthalmology and directs the Dry Eye Clinic and dry eye research projects. She can be reached at 480-301-8085 or shen.joanne@mayo.edu.