Glaucoma Today - by Rolando Toyos, 2016
Two decades ago, many doctors considered patients with dry eye disease (DED) a bother and did their best to weed these individuals out of their practices. Few physicians wanted to spend hours dealing with the most common cause of DED, meibomian gland dysfunction (MGD). The advent of LASIK and other refractive cataract procedures led ophthalmologists to realize that an unhealthy tear film can severely compromise the results of even the best surgeries. When the FDA approved cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan), the agency suggested to physicians that DED could be treated with more than just artificial tears, warm compresses, and lid scrubs. One such option is intense pulsed light (IPL) therapy.
In 2001, I began to incorporate aesthetics into my general ophthalmology practice. I used IPL to coagulate the abnormal telangiectasias of the skin seen in patients with rosacea and to perform facial rejuvenation. Some of my patients with MGD reported that IPL had not only improved their skin but also, surprisingly, their DED symptoms. As I studied their eyelids, meibomian glands, and tear film, I discovered that the IPL had indeed improved the signs and symptoms of DED as well as the health of the ocular surface. My colleagues and I began researching the causes of the improvement and how to optimize the effectiveness of IPL treatment for DED.
IPL uses a xenon flash lamp to produce light in the 500- to 1,000-nm wavelength range that can be pulsed and filtered to allow specific wavelengths of energy to be released. We discovered that specific wavelengths, fluences, and pulses improved meibomian gland function in DED patients. Over time, we became able to treat a wide range of MGD patients successfully by programming specific parameters and instituting a proven protocol with IPL (Figure)
PROTOCOL AND SYSTEMS
In my experience, the best protocol is for patients with MGD to receive IPL treatment from tragus to tragus, including the lids, a few times over the course of 4 months. Not all IPL technologies have the ability to deliver treatment around the lids, because the systems are unable to control the energy and pulses and are not ergonomically designed to maneuver around the lid margins. Also, most IPL technologies lose their ability to consistently provide the specific power programmed. For example, the operator may program an IPL system to deliver 14 J/cm2, but after several more uses, the energy level delivered is less than the programmed energy level. In my experience with other IPL systems, I would have to raise the programmed energy levels with increased use to achieve the desired outcome.
I use the Lumenis M22 with Optimal Pulse Technology (Lumenis), because I am confident that the energy level programmed will be the energy produced. The consistency of the system has allowed me to program parameters that I have found, with 15 years of experience, to work more than 95% of the time in select patients with DED. Surgeons whom I have trained have found similar success rates with my IPL parameters and protocols.
MECHANISMS OF ACTION
Understanding of the multiple mechanisms through which IPL benefits DED patients has evolved as knowledge of the disease and technology have advanced. One important characteristic of IPL is its ability to kill microorganisms. An IPL robot called the Xenex is now being used to disinfect ORs and hospitals and was a critical part of controlling the Ebola outbreak.1,2
Overgrowth of bacteria and Demodex is a hallmark of MGD, and studies show that IPL improves the signs of blepharitis. Also, IPL warms the dermis to temperatures up to 43º C, thus melting the thick secretions produced by patients suffering from MGD and allowing me to manually express the glands easily. I find that heat-assisted gland expression helps to relieve some of the signs and symptoms of DED but does not change the overall function of the glands.
Certain wavelengths of light at specific fluences can stimulate cells and glands to function normally. This process is called photomodulation. Importantly, several articles have demonstrated that IPL stimulates fibroblasts in skin to produce more collagen.3,4 I believe that the cells of meibomian glands are also stimulated by IPL. Over time, researchers and practitioners will learn more about all of the morphological changes that occur to the skin and glands of patients undergoing the procedure.
Last year, several published research articles demonstrated that IPL improves the signs and symptoms of DED.5,6 As the technology advances, so will the success rate and adoption of the procedure. In his book Transcend, futurist Ray Kurzweil, PhD, famously pointed out that it takes 15 years for a medical breakthrough to become the standard of care. I introduced IPL for DED in 2001. Perhaps the procedure is hitting Dr. Kurzweil’s tipping point.
AT A GLANCE
• After administering intense pulsed light (IPL) as an aesthetic treatment, Dr. Toyos discovered that the procedure also improved his patients’ signs and symptoms of dry eye disease.
• In Dr. Toyos’ experience, the best protocol is to apply therapy from tragus to tragus, including the eyelids, but not all IPL systems are capable of this approach.
• IPL’s mechanisms of action include killing microorganisms, heating the thick secretions characteristic of meibomian gland dysfunction to facilitate manual expression, and photomodulation.
1. Nagaraja A, Visintainer P, Haas JP, et al. Clostridium difficile infections before and during use of ultraviolet disinfection [published online ahead of print July 6, 2015]. Am J Infect Control. doi:10.1016/j.ajic.2015.05.003.
2. Martinez M, Vercammen P, Hannah J. Germ-zapping robot Gigi sets its sights on Ebola. CNN website. http://cnn.it/295d6VB. Updated October 18, 2014. Accessed June 30, 2016.
3. McDaniel DH, Weiss RA, Geronemus RG, et al. Varying ratios of wavelengths in dual wavelength LED photomodulation alters gene expression profiles in human skin fibroblasts. Laser Surg Med. 2010;42(6):540-545.
4. Wong WR, Shyu WL, Tsai JW, et al. Intense pulsed light effects on the expression of extracellular matrix proteins and transforming growth factor beta-1 in skin dermal fibroblasts cultured within contracted collagen lattices. Dermatol Surg. 2009;35(5):816-825.
5. Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 2015;33(1):41-46.
6. Vegunta S, Patel D, Shen JF. Combination therapy of intense pulsed light therapy and meibomian gland expression (IPL/MGX) can improve dry eye symptoms and meibomian gland function in patients with refractory dry eye: a retrospective analysis. Cornea. 2016;35(3):318-322.
Review of Ophthalmology by Christopher Kent, Senior Editor 2010
One key source of potential tear-film trouble is the meibomian glands. If the glands malfunction, the lipid layer may be reduced, allowing rapid evaporation of the tear complex. Furthermore, if the glands' secretions become trapped inside the glands, inflammation and bacteria can follow, worsening the problem.
For the past eight years, Rolando Toyos, MD, medical director and founder of Toyos Clinic in Memphis, has been refining a new approach to treating this problem, using intense pulsed light, or IPL, originally developed for use in dermatology. Brief, powerful bursts of light at specific wavelengths (in this case, between 500 and 800 nm) cause changes in blood vessels near the surface of the skin, raise skin temperature and eliminate problematic flora on the skin and eyes,1-5 all of which may have a beneficial effect on meibomian gland dysfunction.
Making The Discovery:
Dr. Toyos says he discovered this potential use of intense pulsed light by accident after opening an aesthetics clinic in his practice in 2002. "IPL is FDA-approved for patients with rosacea and acne," he explains. "The light that's emitted from the flashlamp is absorbed by the oxyhemoglobin in the blood vessels on the skin's surface; the absorption generates heat that coagulates the cells, leading to thrombosis of the blood vessels.1-4 This minimizes redness and improves the look of the skin. IPL is FDA-approved for patients with rosacea and acne. My rosacea patients who had the IPL treatment would return with their skin looking much better—but some also mentioned that their eyes felt better. On examination, their eyes really were better, even though the IPL treatment wasn't done directly on the glands.
"So, we began investigating this using different IPL instruments, none of which were designed to treat meibomian gland dysfunction," he says. "We got mixed results. Then in 2003 we received an ASCRS grant to pursue this, and we conducted a small study in which patients with MGD were treated with IPL on one side and nothing on the other side. We found that during some of the time points following treatment, their MGD was better; the lids looked clearer, there was less erythema, fewer blood vessels, thinner secretions, and most important, reduced symptoms."
However, the existing technology was inconsistent, and the bulb's intensity would diminish over time. Dr. Toyos worked with one of the companies, Dermamed, to solvethese problems. "Now, we have an instrument that's safe, with reproducible results," he says. (Dr. Toyos emphasizes that doctors should not attempt this using just any IPL equipment.)
Dr. Toyos says one immediate effect of IPL is that it acts like the "world's best warm compress."IPL acts like the world's best warm compress. "When the light is absorbed by the blood vessels, it generates heat in the dermal layer that melts the secretions and opens the glands," he explains. "So, immediately after treatment we express the glands. We can get out all of the secretions that were stagnating, so patients get some relief right away."
Research in the field of dermatology has uncovered several other relevant effects of IPL treatment. "For one thing, by closing off the blood vessels near the surface of the skin it decreases the inflammatory cytokines6 that contribute to meibomian gland dysfunction," he says. "In addition, IPL decreases the bacterial load on the skin, which is one of the reasons it helps with acne. There's also some evidence that IPL decreases parasites on the eyelash margin that can cause meibomian gland problems."
Performing the Procedure:
"When the patient comes in, we determine the skin type and how severe the meibomian gland dysfunction is," Dr. Toyos explains. "This treatment should only be used for patients whose skin is Fitzpatrick type four or below, to avoid causing lightening of the skin color. We then give the treatment from ear to ear; if we just treat the lid, the blood vessels grow back much sooner, requiring more maintenance treatments. Next, after putting an eye shield over the eyes we treat the lower lid."
Dr. Toyos notes that he doesn't directly treat the upper glands. "First of all, when you hit the side of the lid, you close off blood vessels that feed into the upper glands," he explains. "Also, once you get the lower glands working better, the lids appose each other better; as a result, the pumping mechanism that accompanies blinking is more effective in the upper glands. Younger patients need fewer treatments.Third, some of the heat is transferred from the side treatment and the lower lids, so you get the warm compress effect on the upper gland indirectly. We've found that the upper glands also open up, allowing us to express them.
Asked whether the results could be attributed largely to the medications, Dr. Toyos says he doubts it. "My initial studies were done without any medications, but patients reported improvement and I saw objective improvement," he notes.
"Also, many patients have come to me after using all of these medications without getting relief. Finally, some of our patients have not used the drops due to cost or allergy, and they still show positive results. But the medications do help to prolong the time between needed retreatments."
Dr. Toyos notes that it usually takes a minimum of four and an average of 5-6 treatments no longer than 5 weeks apart from each other to get the secretions thin and working correctly. "After the gland is normalized we do maintenance treatments every six months to a year," he says. "Younger patients need fewer treatments."
Other surgeons are getting positive results as well. David R. Hardten, MD, director of refractive surgery for Minnesota Eye Consultants and Regions Hospital, and adjunct associate professor of ophthalmology at the University of Minnesota, is one of several surgeons around the country who has recently begun using the IPL treatment. "We began offering IPL four months ago," he says. "The treated patients have improved both subjectively and objectively. In our hands, it appears to be an excellent treatment for the patient that wants an alternative to the typical medication regimens we've used for years."