Because dry eye disease (DED) is a multifactorial disorder of the ocular surface — characterized by a loss tear film of homeostasis, accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and neurosensory abnormalities play etiological roles — traditional treatments such as artificial tears may provide temporary relief but do not address the underlying causes of DED. These include meibomian gland dysfunction (MGD) and ocular surface inflammation.
However, procedural treatments, including meibomian gland thermal expression therapy, intense pulsed light (IPL) therapy and lid margin exfoliation, target these underlying mechanisms. These procedures can improve tear film stability, reduce ocular surface inflammation and restore gland function, thereby enhancing the quality of life for patients suffering from dry eye. In this article, I will review the available procedural treatments available in the United States and offer some tips on patient selection that I’ve learned in my practice.
THERMAL MEIBOMIAN GLAND TREATMENTS
Thermal expression treatments utilize heat to liquefy meibum followed by manual or device-assisted expression to clear the meibomian gland obstructions. This method directly targets the root cause of MGD by promoting the natural flow of meibum, ultimately improving the health of the ocular surface and relieving dry eye symptoms.
The LipiFlow thermal pulsation system (Johnson & Johnson Vision) combines controlled heat application with simultaneous pulsatile pressure to the eyelids. The device was the first thermal meibomian gland treatment approved by the FDA in 2011. The procedure lasts for 12 minutes and involves applying targeted heat at 42.5°C to the upper and lower posterior eyelids with simultaneous pulsation. The treatment applicators are relatively easy to place and are comfortable for most patients.
However, in patients with very tight eyelids, placing the applicator can be more challenging. Conversely, in patients with loose lids, the applicators may not stay in place with proper apposition to the lids. The peak effect of the treatment typically occurs at 2 months, and the effect can last up to 12-15 months. A prospective study comparing LipiFlow and home warm compress mask b.i.d. showed increased gland secretion, improved tear break-up time, and improved symptoms at the 2- and 4-week endpoint. A cross-over group in the study showed similar improvement 2 weeks following LipiFlow.1
Another thermal treatment option is the iLux (Alcon) meibomian gland treatment system. This device is a handheld, battery-powered instrument with single-use patient interfaces. During treatment, heat application to the lids is maintained between 38 and 42° C. A randomized trial comparing iLux and LipiFlow showed an improvement in meibomian gland score, tear break-up time, and dry eye symptoms (OSDI score) at 4 weeks, with no significant difference between the two devices.2 A practical advantage of the iLux is its portability, given its handheld nature.
Yet another innovative approach to lid thermal expression is the TearCare system (Sight Sciences). Unlike other systems that apply heat with the eyelids closed, TearCare allows for an open-eye procedure, enabling patients to blink naturally during treatment. This feature potentially enhances comfort and the natural expression of meibum. TearCare delivers consistent heat to the eyelids for 15 minutes at a temperature of 45° C. After the heat application, the meibomian glands are manually expressed using a gland expression forceps. A randomized trial comparing TearCare and Lipiflow showed improved tear breakup time, meibomian gland secretion score and OSDI scores in both groups.3
In general, thermal meibomian gland treatments are more effective in patients with mild to moderate disease where gland atrophy has not yet occurred. Therefore, early intervention has proved to be a more successful strategy.
INTENSE PULSED LIGHT THERAPY
IPL therapy involves applying Xenon broad-spectrum wavelength light (400-1200 nm) to the periocular area. Originally used in dermatology for vascular lesions and skin hyperpigmentation, IPL therapy has several theorized mechanisms of action. These include reducing abnormal blood vessels that carry pro-inflammatory mediators, decreasing bacterial load and eradicating Demodex, and facilitating gland expression by liquefying meibum.
The typical IPL protocol consists of four initial treatments 1 month apart, followed by additional treatments every 6 to 12 months. It’s important to note that patients with dark skin pigmentation should not undergo IPL, with the ideal candidate having a Fitzpatrick skin type of IV or less. IPL can be particularly effective in patients with eyelid telangiectasias and ocular rosacea due to its potential to target abnormal blood vessels.
A prospective study evaluating IPL combined with manual meibomian gland expression in patients with moderate to severe MGD showed improved tear break-up time, corneal fluorescein staining, tear film osmolarity and dry eye symptoms (SPEED score) at
15 weeks after treatment.4
LID EXFOLIATION
Microblepharoexfoliation is an in-office procedure utilized for the treatment of dry eye disease and blepharitis. This technique involves the use of the BlephEx (BlephEx LLC), a handpiece that delicately spins a sponge along the margin of the patient’s eyelids. This motion effectively removes collarettes, scurf and crust, thereby improving the overall health of the lid margin. To enhance the procedure’s efficacy, an antimicrobial foam is often applied in conjunction. This combination serves to significantly reduce the microbial load on the lid margin, particularly beneficial for cases of Demodex blepharitis.
Numerous studies have highlighted the effectiveness of microblepharoexfoliation in treating this condition. For instance, a randomized comparative study compared the outcomes of patients undergoing one session of microblepharoexfoliation along with two weeks of tea tree oil scrubs vs patients receiving scrubs alone. The results demonstrated notable improvements in patient symptoms, as indicated by the OSDI score, and a reduction in Demodex count within the microblepharoexfoliation treatment group.5
Furthermore, microblepharoexfoliation aides in eliminating the biofilm produced by eyelid bacteria. This biofilm serves as a scaffold that promotes bacterial growth, contributing to inflammation along the lid margin. By removing this biofilm, it significantly reduces lid margin inflammation, showcasing its versatility and potential as a key component in a comprehensive treatment strategy.
CONCLUSION
DED is a complex condition of the eye’s surface characterized by an imbalance in tear film composition and function. As our understanding of DED evolves, it becomes increasingly clear that a comprehensive approach to diagnosis and management is important.
Procedural treatments, including meibomian gland thermal expression therapy, IPL and lid margin exfoliation play a crucial role in this approach. Their significance highlights the need for continued development in this area so that we can bring relief to our patients. OM
References
1. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012 Apr;31:396-404.
2. Tauber J, Owen J, Bloomenstein M, et al. Comparison of the iLUX and the LipiFlow for the treatment of meibomian gland dysfunction and symptoms: A randomized clinical trial. Clin Ophthalmol. 2020 Feb 12;14:405-418.
3. Gupta PK, Holland EJ, Hovanesian J, et al. TearCare for the treatment of meibomian gland dysfunction in adult patients with dry eye disease: A masked randomized controlled trial. Cornea. 2022 Apr 1;41:417-426.
4. Dell SJ, Gaster RN, Barbarino SC, Cunningham DN. 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. 2017 May 2;11:817-827.
5. Mohammad-Rabei H, Arabi A, Shahraki T, et al. Role of blepharoexfoliation in Demodex blepharitis: A randomized comparative study. Cornea. 2023 Jan 1;42:44-51.
