Analysis of Cytokine Levels in Tears and Clinical Correlations After Intense Pulsed Light Treating Meibomian Gland Dysfunction

Caffeine's protective role in dry eye disease and meibomian gland Dysfunction: Insights from clinical and Experimental models

PURPOSE

Inflammation and apoptosis contribute to the development of dry eye disease (DED) and meibomian gland dysfunction (MGD). This study aimed to investigate the effect of caffeine on the ocular surface and tear inflammatory cytokines through clinical, in vivo, and in vitro experiments.

METHODS

In the clinical study, comprehensive ophthalmic examinations of participants in the control and the caffeine groups were compared, including ocular surface and tears inflammatory cytokines. For in vitro study, rat meibomian gland epithelial cells (RMGECs) and human corneal epithelial cells (HCECs) were pretreated with or without caffeine and then stimulated with lipopolysaccharide (LPS). Inflammatory responses, apoptosis, and differentiation in cells were analyzed. In vivo study, apolipoprotein E knockout (ApoE-/-) mice were given caffeine-diet or no caffeine-diet, and their meibomian glands (MGs) and cornea tissue were compared.

RESULTS

Participants in the caffeine group exhibited significantly healthier ocular surface, lower tears inflammatory cytokines and a reduced prevalence of DED compared to the control group. In vitro study, caffeine pretreatment attenuated inflammatory responses, apoptosis and differentiation in LPS-induced RMGECs. Meanwhile, caffeine also markedly suppressed inflammatory responses and apoptosis in LPS-induced HCECs. In vivo study showed that ApoE-/- mice with caffeine-diet had more normal morphology of MGs and corneas compared to those without caffeine-diet, along with reduced inflammatory responses, cells apoptosis and ductal keratinization. Both in vitro and in vivo studies indicated that caffeine treatment was observed to inactivate of unclear factor kappa B (NF-κB) phosphorylation.

CONCLUSIONS

Our study indicated that caffeine may be a protective potential of ocular surface, providing a new perspective on clinical treatment for DED and MGD.

Tear inflammatory cytokine profiles in orbital inflammatory disease

Tear inflammatory cytokines are a novel biomarker studied in a range of ocular surface diseases, periorbital and orbital conditions. This single-centre prospective study between 2022 and 2024 aims to characterise tear cytokine profiles (Interleukin-1β [IL-1β], IL-2, IL-6, Interferon-γ [IFN-γ] and Tumour Necrosis Factor-α [TNF- α]) in orbital inflammatory disease (OID). OID patients had pre-treatment tear collection via micropipette, and cytokine analysis via multiplex bead array analysis. Thirteen healthy controls with no prior ophthalmic history were enrolled for comparison. Eighteen tear specimens from seventeen OID patients (6 males; mean age: 52.1 ± 17.1-years-old), with one repeat tear sample taken for recurrent contralateral orbital inflammation. Diagnoses included non-specific orbital inflammation (47.1%), IgG4-related orbital disease (17.6%), orbital granulomatosis with polyangiitis (5.9%), giant cell arteritis (5.9%), herpes zoster ophthalmicus with orbital apex inflammation (5.9%), viral dacryoadenitis (5.9%), bacterial dacryoadenitis (5.9%) and orbital inflammation of uncertain cause (5.9%). Overall, OID patients, and specifically those with dacryoadenitis, had greater IL-6 levels compared to controls (P = 0.038 and 0.002, respectively). OID with dacryoadenitis had higher IL-1β levels compared to those without (P = 0.029). Higher IL-6 levels were observed in idiopathic dacryoadenitis compared to healthy controls (P = 0.008, respectively). There is significant variability in tear inflammatory cytokines profiles observed in OID. IL-1β and IL-6 levels may be non-specific markers of dacryoadenitis and may be particularly elevated in idiopathic dacryoadenitis. Tear cytokines may be affected by severity, localisation and pattern of inflammation. The utility of tear cytokines in the monitoring and prognostication of OID remains to be elucidated.

Treatment of Ocular Surface Disease in Ocular Cicatricial Pemphigoid

PURPOSE

While substantial research has focused on systemic immunomodulatory therapy for ocular cicatricial pemphigoid (OCP), limited data exist on managing associated ocular surface disease (OSD). This study evaluates treatments for OCP-related OSD at our institution.

METHODS

We conducted a retrospective analysis of patients diagnosed with cicatrizing conjunctivitis at the University of Colorado Hospital from January 1, 2013, to October 31, 2023. Patients with cicatrizing conjunctivitis due to non-OCP conditions were excluded, and disease severity was classified using the Foster Staging System.

RESULTS

Our review included 30 patients with OCP, all with at least six months of follow-up. The mean age of symptom onset (n = 19) was 62.2 years (SD = 16.4), while the mean age at diagnosis (n = 28) was 65.1 years (SD = 12.7). The most common OSD treatments at the last visit were preservative-free artificial tears (87%), topical corticosteroids (43%), autologous serum eye drops (40%), topical antibiotics (30%), and topical immunomodulators (23%). All patients used at least one treatment, with 83.3% on prescription therapies. Patients averaged 3.33 (SD: 1.4) treatments, with 1.7 (SD: 1.2) being prescriptions. Topical immunomodulators had the highest discontinuation rate at 73.1% (n = 19/26). Autologous serum eye drops and topical corticosteroids were the least discontinued treatments. Number of total treatments, prescriptions, and procedures sharply increased at stage three OCP.

CONCLUSIONS

The number of treatments and procedures increased with OCP severity, indicating that advanced OCP often necessitated more intensive OSD management.

Effects of combined intense pulsed light and cyclosporine 0.05% eyedrops in ocular surface matrix metalloproteinase-9 levels in patients with moderate-to-severe MGD

To investigate the changes in meibomian gland dysfunction (MGD) and tear matrix metalloproteinase-9 (MMP-9) levels in patients with moderate-to-severe MGD after combined treatment with intense pulsed light (IPL) therapy and cyclosporine 0.05%. Thirty-six patients concurrently treated with IPL and cyclosporine 0.05% ophthalmic drops were retrospectively enrolled. Tear break up time (TBUT), corneal and conjunctival staining scores, Schirmer test, and ocular surface disease index (OSDI) questionnaire responses were recorded. Meibum quality, consistency, and eyelid margin telangiectasia were evaluated. MMP-9 levels were examined by the positivity and signal intensity of red lines (scored 0-4). IPL was performed four times with a vascular filter at 2-week intervals, followed by a 1-month follow-up after treatment cessation. Immediately after each IPL treatment, gentle meibomian gland expression was performed in both the upper and lower eyelids using meibomian gland expressor forceps. TBUT (1.88 ± 1.02 s to 3.12 ± 1.08 s, p < 0.001), corneal and conjunctival staining (6.19 ± 2.11 to 3.12 ± 1.89, p < 0.001), Oxford staining grade (2.66 ± 0.89 to 1.35 ± 0.76, p < 0.001), and OSDI (52.97 ± 21.86 to 36.36 ± 22.45, p < 0.001) scores significantly improved after the combined treatment. Meibum quality, consistency and lid margin telangiectasia showed significant post-treatment improvement in both the upper and lower eyelids. MMP-9 positivity showed a significant decrease (97-69%, p = 0.026) with a reduction in signal intensity (2.72 ± 0.87 to 2.09 ± 0.95, p = 0.011). The combination of IPL therapy and 0.05% cyclosporine eye drops effectively treats moderate-to-severe MGD by reducing symptoms and signs of MGD and by decreasing ocular surface MMP-9-associated inflammation.

The photothermal effect of intense pulsed light and LipiFlow in eyelid related ocular surface diseases: Meibomian gland dysfunction, Demodex and blepharitis

The treatment and management of ocular surface diseases have shifted towards a co-treatment approach focusing on overall ocular surface homeostasis. When treating issues related to the eye, it is essential to not only focus on the damaged or disabled areas but also consider the larger picture. Meibomian gland dysfunction (MGD), Demodex infection, and blepharitis all interact at the eyelid site and can cause damage to the ocular surface to varying degrees. Palpebral lesions disrupt the balance of ocular surface homeostasis, leading to dry eye and keratitis. Traditional treatments, such as manual physical hot compress massage, have limited effectiveness due to the structure of the eyelid. However, intense pulsed light (IPL) technology uses penetrating light energy to generate heat energy, which can eliminate inflammation of capillaries or kill Demodex. Additionally, the LipiFlow thermal effect and physical compression provide a more vital and longer-lasting therapeutic effect on MGD by excluding other primary causes of ocular surface inflammation. Therefore, personalized treatment techniques based on photothermal effects may be effective. In the future, IPL and LipiFlow may potentially dismiss immune-inflammation factors causing ocular surface disease or block the delivery of systemic immune-related diseases.

Intense pulsed light treatment for the management of meibomian gland dysfunction

PURPOSE OF REVIEW

Meibomian gland dysfunction (MGD) is one of the most common disorders encountered by ophthalmologists, and its management can prove challenging for both clinicians and patients. Intense pulsed light (IPL), which has been historically used in the field of dermatology, has emerged as a tool to help improve meibomian gland function. The goal of this review is to assess the clinical efficacy, utility, and safety of IPL for the treatment of MGD.

RECENT FINDINGS

In recent randomized controlled trials, IPL has been shown to improve meibomian gland function, and subsequently tear film quality and dry eye symptoms. The mechanism of action still remains unclear. Recent literature suggests that IPL may also be used in conjunction with other therapies, such as meibomian gland expression, low-level light therapy, and thermal pulsation. Careful attention should be placed on each patient's Fitzpatrick skin type, as well as protecting the ocular structures to reduce the risk of adverse effects. Cost, accessibility, as well as a limited duration of efficacy may be drawbacks.

SUMMARY

There is significant evidence supporting that IPL may be used as a potential well tolerated and effective treatment for MGD, though there are certain caveats regarding its long-term efficacy, accessibility, and cost.

Efficacy and safety of intense pulsed light delivered by the C.STIM® for treatment of Meibomian gland dysfunction

INTRODUCTION

Intense pulsed light (IPL) appears to be a promising treatment for Meibomian gland dysfunction (MGD), the most common cause of dry eye disease. C.STIM® is a new IPL device. We report the first safety and efficacy study in clinical practice.

MATERIALS AND METHODS

Patients with moderate MGD treated with C.STIM® were included. Three IPL sessions were performed at D0, D15 and D45 with 4 shots per side (fluence of 8J/cm2). Clinical evaluation was performed at D0, D45 and M3 with several parameters: BUT, OSDI and Oxford scales, meibomian gland evaluation (morphology, quality and expressibility of meibum). The Lacrydiag® imaging device was used for objective evaluation of interferometry, meibography, tear meniscus height and NIBUT. The primary endpoint was the change in NIBUT between D0 and M3. Data collection was retrospective. Longitudinal analysis and a non-parametric linear mixed-effects model (R software) were used for statistical analysis.

RESULTS

Thirty-five patients were included. NIBUT increased significantly between D0 and M3, with a mean difference of 2.6seconds (95% CI 2.0; 3.1, P<0.001). The other parameters studied also changed significantly, except for meibography (percentage of loss and morphology) and tear meniscus height. No adverse event was noted.

CONCLUSION

C.STIM® appears safe and effective in the treatment of MGD, although a randomized controlled trial is needed to validate these results.

Efficacy and safety of intense pulsed light of upper and lower eyelids in Meibomian gland dysfunction: A prospective multicentric study

PURPOSE

To demonstrate that intense pulsed light therapy (IPL) of the upper and lower eyelids with meibomian gland expression (MGX) is effective in improving dry eye disease due to meibomian gland dysfunction (MGD).

METHODS

Patients with ocular discomfort (Ocular Surface Disease Index -OSDI- above 13) and signs of MGD were recruited. All patients underwent OSDI, visual acuity (VA), intraocular pressure, Schirmer test, meibography, non-invasive tear breakup time (NITBUT), slit-lamp examination (corneal and conjunctival staining, hyperemia, gland expressibility, and meibum quality), tear osmolarity and lipid layer thickness. IPL was performed with Optima IPL (Lumenis Ltd.) following a standardized protocol on upper and lower eyelids of both eyes, with inferior eyelid MGX. Patients received four sessions separated by two weeks each. Four weeks after, examinations were repeated.

RESULTS

160 patients (320 eyes) were included, of which 108 (67.5%) were women and mean age was 59.2 ± 15.08 (range 20-89). After four sessions, VA, OSDI, tear osmolarity, lipid layer thickness, NITBUT, hyperemia, corneal and conjunctival staining, gland expressibility, meibum quality, inferior eyelid Meiboscore and Schirmer test improved (all, p < 0.027). Changes in OSDI, initial and average NITBUT increased with dry eye disease severity (according to OSDI). Increased pre-treatment OSDI, hyperemia, corneal and conjunctival staining and Schirmer test were associated with an improvement in OSDI (all, p < 0.040). No adverse events were noted.

CONCLUSIONS

The combination of IPL on upper and lower eyelids with MGX is safe and effective for the treatment of MGD. Patients with severe dry eye disease present greater improvements.

Intense pulsed light therapy for ocular surface diseases

Intense pulsed light (IPL) is a non-laser, high-intensity light source that has been shown to play a valuable role in dermatology and has been adopted in ophthalmology for treating meibomian gland dysfunction (MGD). In this review, we discuss the mechanism of action of IPL, including its benefits in ophthalmology. IPL therapy has been shown to improve tear film stability, meibomian gland (MG) function, and subjective symptoms of ocular dryness in MGD patients. Moreover, emerging evidence suggests that IPL therapy is beneficial for other ocular surface diseases, such as blepharitis and chalazia. Hence, it can be inferred that IPL has potential as a therapeutic modality in future applications. Large clinical and experimental trials are needed to exploit the full potential of IPL as a treatment for recurrent chalazia, Sjögren's syndrome, and other causes of dry eye disease (DED). This paper reviews the published literature related to the application of IPL for treating ocular surface diseases.

Efficacy of far infrared functional glasses in the treatment of meibomian gland dysfunction-related dry eye

Meibomian gland dysfunction (MGD)-related dry eye disease (DED) is a significant subtype of DED. In this research, we investigate the effectiveness of far infrared (FIR) functional glasses in the treatment of MGD-related DED. According to the TFO DEWS II diagnostic criteria, 61 eyes with MGD-related DED were included. All participants wore functional FIR glasses throughout the day for a period of 4 weeks and were followed up three times during the treatment. All subjects were followed up thoroughly in accordance with the DED clinical examination procedure. Ultimately, the treatment's impact was assessed. We found the Visual Analogue Scale and Ocular Surface Disease Index scores after FIR treatment were significantly lower than the baseline values (p < 0.05). Compared with the baseline, fluorescein tear breakup time and corneal fluorescein staining score after FIR treatment were significantly improved (p < 0.05). The eyelid margin signs, meibum quality, and meibomian gland expressibility after the 4-week treatment were significantly better than those at baseline (p < 0.05). We can see that wearing the FIR functional glasses significantly relieves the symptoms and signs of patients. We believe FIR therapy could be considered as a new method of MGD-related DED.

Comparison of non-pharmaceutical treatments for evaporative dry eye: a randomised controlled study protocol

INTRODUCTION

The lipid layer of the tear film is critical to maintaining the integrity of the tear film and absence in the tear film lipid layer (TFLL) is one of the main causes of evaporative dry eye (EDE) in dry eye disease patients, resulting in excessive evaporation (so-called hyperevaporative dry eye). This study protocol will be designed to assess and compare the effects of intense pulsed light (IPL), heated eye mask (HEM), vectored thermal pulsation system (VTPS) and eyelid massage device (EMD) for improving signs and symptoms of EDE.

METHODS AND ANALYSIS

Patients with EDE will be randomly divided into IPL, HEM, VTPS and EMD groups and will be followed up for 6 weeks. The primary outcome measure will be non-invasive tear breakup time (NITBUT). The secondary outcome measures will include, TFLL score, meibomian gland quality and expressibility change from baseline conjunctivocorneal staining with fluorescein and lissamine, tear meniscus height, conjunctival hyperaemia (redness score) and ocular surface disease index questionnaire. Additionally, adverse events will be monitored and documented.

ETHICS AND DISSEMINATION

Ethics approval number: IRB(2023)K019.01. The findings will be shared regardless of the effect's direction.

TRIAL REGISTRATION NUMBER

NCT05923528.

Current application of intense pulsed light for the management of dry eye disease: A systematic review and meta-analysis

This review explored intense pulsed light (IPL) as an alternative treatment for dry eye disease (DED) symptom relief by correcting tear-film homeostasis. A systematic search was performed in March 2022 on five databases (Medline, Embase, SCOPUS, ProQuest, and EBSCO). Studies were extracted for the following outcomes of interest: standard patient evaluation of eye dryness questionnaire (SPEED), ocular surface disease index (OSDI), tear break-up time (TBUT), and corneal fluorescein staining (CFS). All studies published up to March 2022 were reviewed. Cochrane risk of bias tool (RoB 2) was used to screen studies for risk of bias where appropriate. A meta-analysis was done to quantify any reported quantitative data. Thirteen studies were included in this study. A total of 931 individuals and 1454 numbers of eyes were reviewed in this meta-analysis. Among studies that explored and reported the effect of IPL in individuals with DED, TBUT and OSDI improved significantly post intervention, with a standardized mean difference (SMD) of 1.02 [95% CI 0.41-1.64] and 0.28 [95% CI 0.04-0.52], respectively. CFS and SPEED scores, however, showed no statistically significant difference, with an SMD of 0.22 [95% CI -0.19 to 0.64] and 0.28 [95% CI -0.11 to 0.66], respectively. In conclusion, current evidence indicates IPL as a possible adjunctive treatment in individuals with DED in an otherwise limited treatment option. Further studies through more extensive trials are needed to validate this finding and elucidate its mechanism.

Evaluation of the Impact of Meibomian Gland Dysfunction Using a Novel Patient-Reported Outcome Instrument

Purpose: This study was intended to characterize the impact of meibomian gland dysfunction (MGD) on patients' quality of life. Methods: In this prospective, multicenter, noninterventional clinical study (NCT01979887), eligible individuals (age ≥40 years; absence of uncontrolled ocular/systemic disease) were categorized, based on composite grading of ocular symptoms, Schirmer score, and meibum quality, into (1) non-MGD, (2) mild/moderate MGD, or (3) severe MGD cohorts. The MGD Impact Questionnaire (MGD IQ), a 10-item patient-reported outcome measure, was self-administered at clinic visit on day 1, and readministered on day 22 to assess intervisit agreement regarding MGD IQ responses. Results: In total, 75 subjects were assigned to the study cohorts (25 per cohort). Across cohorts, MGD IQ item scores rose incrementally with increasing MGD severity. The severe MGD cohort experienced greater difficulty with reading and performance of leisure activities, greater time on eye care, and greater bother with eye care and eye appearance than the mild/moderate MGD cohort (all P < 0.05). Compared with the non-MGD cohort, the mild/moderate MGD cohort had greater difficulty working on computer, whereas the severe MGD cohort had greater difficulty reading, driving, and performing leisure activities, more frequent difficulty with outdoor activities, more time on eye care, and greater bother with eye care (all P < 0.05). Intervisit agreement between MGD IQ responses was fair to moderate (weighted kappa statistic 0.33‒0.58). Conclusions: Vision-related activities are negatively impacted by increasing severity of MGD. The MGD IQ instrument can help characterize disease severity and amplify the patient's voice in patient-centric clinical research. ClinicalTrials.gov NCT01979887.

Quality of life improvement in dry eye patients after intense pulsed light therapy compared to punctal plugs

PURPOSE

The purpose of the study was to evaluate the quality of life (QOL) improvement in evaporative dry eye patients after treatment with intense pulsed light (IPL) therapy compared to punctal plug insertion.

METHODS

A prospective comparative interventional study included 30 patients with moderate-to-severe evaporative dry eye. Patients' QOL affection before and after treatment was assessed by the Ocular Surface Disease Index (OSDI) questionnaire. Fifteen patients were treated with IPL therapy (Group 1). The other 15 patients were treated with silicone punctal plug insertion (Group 2).

RESULTS

Improvement of patients' QOL was noticed in all patients of Group 1, with significant improvement of OSDI score from a mean value of 56.9 to 22.9 (P = 0.001). Improvement was noticed in 80% of Group 2 patients (mean OSDI score pretreatment: 53.8 and posttreatment: 31.7, P = 0.017). The tear breakup time (TBUT) in Group 1 significantly improved from a mean of 3.2 s to 5.9 s (P = 0.001), whereas it showed no significant changes in Group 2 (mean TBUT pretreatment: 3.6 s and posttreatment: 3.9 s, P = 0.654). Complications occurred in 13.3% in Group 2, including punctal granuloma and proximal canalicular obstruction. No adverse effects were recorded in Group 1.

CONCLUSION

IPL therapy had better results with more improvement of patients' QOL compared to punctal plugs. It also showed a better safety profile with no reported complications.

Corneal Epithelial Dendritic Cells: An Objective Indicator for Ocular Surface Inflammation in Patients with Obstructive Meibomian Gland Dysfunction?

PURPOSE

To examine whether corneal epithelial dendritic cells (CEDC) could serve as an indicator to distinguish obstructive meibomian gland dysfunction (MGD) with or without ocular surface inflammation (OSI).

METHODS

We performed a case-control study on patients with diagnosed obstructive MGD between August 2017 and November 2019.

RESULTS

30 MGD cases and 25 healthy controls were recruited. The classification of MGD patients with and without OSI was based on the tear pro-inflammatory cytokine levels. Compared with the MGD without OSI and the control group, a higher CEDC density was detected in the MGD with OSI subgroup. The presence of >15.6 cells/mm2 CEDC had a sensitivity of 73% and specificity of 75% for the diagnosis of MGD with OSI.

CONCLUSIONS

OSI is not present in all patients with obstructive MGD. Evaluation of CEDC density in the central cornea may help identify whether MGD is concomitant with OSI.

Analysis of Treatment Efficacy of Intense Pulsed Light (M22) for Meibomian Gland Dysfunction with Demodex Mites

Objective

To investigate the effectiveness of intense pulsed light (M22) in treating patients with meibomian gland dysfunction (MGD) caused by demodex mites.

Methods

A total of 100 patients (100 eyes) diagnosed with demodex mites through microscopic examination at Shanxi Bethune Eye Clinic between June 2021 and May 2023 were selected using convenience sampling. The patients were randomly divided into two groups: an experimental group (n=50) and a control group (n=50). The control group received comprehensive treatment consisting of artificial tears, warm compress, anti-inflammatory eye ointment, hypochlorous acid cleansing, okra cotton pad, and meibomian gland massage. In addition to the comprehensive treatment, the experimental group received intense pulsed light (M22) therapy. After 8 weeks of treatment, the mite clearance rate and cure rate of dry eye were measured for both groups. The recurrence rate of dry eye was also observed 4 weeks after discontinuing M22 treatment.

Results

The experimental group achieved a mite clearance rate of 88.0%, while the control group had a rate of 58.0%, with a statistically significant difference (χ2 = 5.43, P = 0.017). Regarding the cure rate of dry eye, the experimental group showed a rate of 92.0%, while the control group had a rate of 82.0%, with a statistically significant difference (χ2 = 3.61, P = 0.021). In terms of the recurrence rate of dry eye, the experimental group exhibited a rate of 13.04%, while the control group had a rate of 26.83%, with a statistically significant difference (χ2 = 4.18, P = 0.016).

Conclusion

Intense pulsed light (M22) demonstrated superior efficacy in eradicating demodex mites, treating dry eye, and maintaining the treatment's effectiveness compared to comprehensive treatment with medication in patients suffering from meibomian gland dysfunction with demodex mites.

Composition and diversity of meibum microbiota in meibomian gland dysfunction and the correlation with tear cytokine levels

Meibomian gland dysfunction (MGD) leads to meibum stasis and pathogenic bacteria proliferation. We determined meibum microbiota via next-generation sequencing (NGS) and examined their association with tear cytokine levels in patients with MGD. This cross-sectional study included 44 moderate-severe patients with MGD and 44 healthy controls (HCs). All volunteers underwent assessment with the ocular surface disease index questionnaire, Schirmer without anesthesia, tear break-up time, Oxford grading of ocular surface staining, and lid and meibum features. Sample collection included tears for cytokine detection and meibum for 16S rRNA NGS. No significant differences were observed in the α-diversity of patients with MGD compared with that in HCs. However, Simpson's index showed significantly decreased α-diversity for severe MGD than for moderate MGD (p = 0.045). Principal coordinate analysis showed no significant differences in β-diversity in meibum samples from patients with MGD and HCs. Patients with MGD had significantly higher relative abundances of Bacteroides (8.54% vs. 6.00%, p = 0.015) and Novosphingobium (0.14% vs. 0.004%, p = 0.012) than the HCs. Significantly higher interleukin (IL)-17A was detected in the MGD group than in the HC group, particularly for severe MGD (p = 0.008). Although Bacteroides was more abundant in the MGD group than in the HC group, it was not positively correlated with IL-17A. The relationship between core meibum microbiota and tear cytokine levels remains unclear. However, increased Bacteroides and Novosphingobium abundance may be critical in MGD pathophysiology.

Dry eye disease: identification and therapeutic strategies for primary care clinicians and clinical specialists

Dry eye disease (DED) is a multifactorial disorder characterized by loss of tear film homeostasis with an estimated worldwide prevalence of 5% to 50%. In DED, dysfunction of the ocular structures that create and regulate the tear film components-including the lacrimal glands, meibomian glands, cornea, and conjunctiva-causes a qualitative and/or quantitative tear deficiency with resultant tear film instability and hyperosmolarity. This initiates a vicious cycle of ocular surface inflammation and damage that may ultimately impair the quality of life and vision of affected patients. Many factors can contribute to the development of DED, including ocular and systemic diseases, topical and systemic medications, and environmental conditions. Because DED is a chronic disorder, treatment is most often long term and may utilize both pharmacologic and nonpharmacologic interventions to address all etiologic components. The long-term management of DED can be challenging and most often should involve eye care specialist referral. However, primary care clinicians (PCCs) are often the first points of contact for patients with DED and importantly provide initial diagnosis and preliminary patient education about the disease process. Consideration of DED is also vital for the practice of various specialties due to the large number of comorbidities and medications that can contribute to DED pathogenesis and progression. Therefore, it is important that PCCs and clinical specialists be aware of the etiology of DED and its available therapeutic options. This manuscript provides an overview of DED pathophysiology and treatment and discusses specific considerations regarding DED management for PCCs and clinical specialists.Key messagesSuccessful management of dry eye disease often requires the use of various pharmacologic and/or nonpharmacologic therapies, as well as environmental and lifestyle modifications, to mitigate the underlying etiologies and restore tear film homeostasis.Primary care clinicians play an essential role in dry eye disease management by establishing a diagnosis, educating patients about the disorder, and providing referrals to eye care specialists for initiation of specialized treatment and long-term follow-up.Primary care clinicians and clinical specialists should consider prescribing medications with fewer ocular surface effects whenever possible in patients at risk for or with existing dry eye disease.

The Combined Impact of Intense Pulsed Light Combined and 3% Diquafosol Ophthalmic Solution on Evaporative Dry Eye: A Randomized Control Study

INTRODUCTION

The primary objective of this study is to assess whether the combination of intense pulsed light (IPL) with 3% diquafosol (DQS) ophthalmic solution is more effective than intense pulsed light in alleviating signs and symptoms of dry eye disease (DED).

METHODS

This randomized study included 66 participants with evaporative dry eye (EDE) who received IPL + DQS therapy (n = 44 eyes), IPL therapy (n = 44 eyes), or sham therapy (n = 44 eyes). All participants were examined at baseline (D0), day 14 (D14), and day 28 (D28) for non-invasive break-up time (NITBUT), tear-film lipid layer (TFLL), corneal conjunctival staining (CS), meibomian gland quality (MGQ), meibomian gland expression (MGEx), and ocular surface disease index (OSDI).

RESULTS

At day 28, comparison among the IPL + DQS therapy, IPL therapy, and sham therapy found significant differences in the mean NITBUT (12.03 ± 1.27 versus 10.47 ± 3.48 versus 4.57 ± 0.46; p < 0.001), TFLL (2.09 ± 0.29 versus 2.27 ± 0.45 versus 2.89 ± 0.65; p < 0.001), CS (1.43 ± 0.82 versus 1.93 ± 1.32 versus 3.52 ± 1.00; p < 0.001), MGQ (1.55 ± 0.66 versus 1.91 ± 0.77 versus 2.66 ± 0.53; p < 0.001), MGEx (1.27 ± 0.45 versus 1.75 ± 0.44 versus 2.41 ± 0.50; p < 0.001), and OSDI score (19.36 ± 7.01 versus 24.77 ± 4.68 versus 42.61 ± 7.49; p < 0.001); significant improvements in NITBUT, TFLL, CS, MGQ, MGEx, and OSDI were found in the IPL + DQS therapy and IPL therapy, while the sham therapy had no significant improvements.

CONCLUSION

Combining 3% diquafosol ophthalmic solution with intense pulsed light was superior to IPL therapy alone in relieving the signs and symptoms of patients with severe evaporative DED.

TRIAL REGISTRATION

Clinical Trials Identifier: NCT05694026.

Update on Dry Eye Disease Treatment: Evidence From Randomized Controlled Trials

ABSTRACT

Although the ultimate goal of dry eye disease (DED) management is to restore the ocular surface and tear film homeostasis and address any accompanying symptoms, addressing this is not an easy task. Despite the wide range of current treatment modalities targeting multiple aspects of DED, the available DED management literature is quite heterogeneous, rendering evaluation or comparison of treatment outcomes hard or almost impossible. There is still a shortage of well-designed, large-scale, nonsponsored, randomized, controlled trials (RCTs) evaluating long-term safety and efficacy of many targeted therapies individually or used in combination, in the treatment of identified subgroups of patients with DED. This review focuses on the treatment modalities in DED management and aims to reveal the current evidence available as deduced from the outcomes of RCTs.

Comparison Between Optimal Pulsed Technology and Meibomian Gland Massage Treatment for Contact Lens-Related Meibomian Gland Dysfunction

Objective: The purpose of this study was to compare the effectiveness of optimal pulsed technology (OPT) and meibomian gland massage (MGM) in alleviating the signs and symptoms of contact lens-related meibomian gland dysfunction (CL-MGD). Methods: This prospective, randomized, controlled study included 90 patients (180 eyes) diagnosed with CL-MGD and were assigned to the OPT group (n = 60 eyes), MGM group (n = 60 eyes), and control group (n = 60 eyes). All participants were examined at baseline (D0), day 21 (D21), and day 42 (D42) for the ocular surface disease index (OSDI), noninvasive tear break-up time (NITBUT), noninvasive tear meniscus height (NITMH), meibomian gland score (MGS), meibomian gland score (MGYSS), best-corrected visual acuity, and intraocular pressure. Results: The OSDI scores and NITBUT improved after treatment in all the three groups. The OSDI scores in OPT and MGM groups were significantly lower compared with that in the control group at D21 and further decreased at D42. The NITBUT in OPT and MGM groups increased compared with the control group at D21 and further increased at D42, and the NITBUT in OPT group increased compared with the MGM group at D21 and D42. The MGYSS both improved after treatment in the OPT and MGM groups, The MGYSS in OPT and MGM groups decreased compared with the control group at D21 and further decreased at D42, and the MGYSS in the OPT group decreased compared with the MGM group at D21 and D42. The NITMH and MGS had no differences after treatment. Conclusions: Results imply that OPT or MGM treatment can be safely used to relieve symptoms of CL-MGD. In addition, OPT treatment was found to be more effective in improving the general stability of the tear-film in CL-MGD.

Safety and efficacy of intense pulsed light in the treatment of severe chronic ocular graft-versus-host disease

OBJECTIVE

To investigate the safety and efficacy of intense pulsed light (IPL) in the treatment of severe chronic ocular graft-versus-host disease (coGVHD).

METHODS

A prospective cohort study. Seventeen patients with severe coGVHD were selected for inclusion in this study. All subjects were treated with IPL every fortnight together with conventional treatment, observation time points were pre-treatment (W0), 4 weeks post-treatment (W4), 8 weeks post-treatment (W8) and 12 weeks post-treatment (W12). Dry eye related examinations include Tear meniscus height (TMH), Non-invasive break-up time (NIBUT), Schirmer I test, Tear film lipid layer thickness (LLT), Ocular surface staining (OSS) and assessment of meibomian gland. Corneal epithelial cell morphology and inflammatory cell infiltration were analyzed by corneal confocal microscopy, while goblet cell density and squamous epithelial grade were assessed by conjunctival imprinted cytology.

RESULTS

Patients did not experience any adverse reactions during the follow-up period. All subjects showed significant improvement in clinical symptoms and most signs after IPL treatment. The corneal confocal microscopy showed that the number of dendritic cells infiltrates in the corneal stroma was significantly reduced after IPL treatment (p < 0.001). Conjunctival blot cytology suggested an increase in the number of conjunctival goblet cells from 5.12 ± 2.71 cells/mm2 before treatment to 22.00 ± 4.58 cells/mm2 after treatment, with a statistically significant difference (p < 0.001). An improvement in conjunctival epithelial cell morphology and a decrease in squamous epithelial grade was also observed.

CONCLUSIONS

IPL treatment can effectively increase tear film stability in patients with severe coGVHD without significant side effects.

Protocol for a parallel assignment prospective, randomised, comparative trial to evaluate the safety and efficacy of intense pulsed light (IPL) combined with 3% diquafosol (DQS) ophthalmic solution in dry eye syndrome

INTRODUCTION

Evaporative dry eye (EDE) is common and can lead to ocular pain, decreased visual quality and reduced quality of life. Intense pulsed light (IPL) and 3% diquafosol ophthalmic solution have been found to be beneficial in reducing signs and symptoms of dry eye.

METHODS AND ANALYSIS

A randomised clinical trial will be performed at He Eye Specialist Hospital in Shenyang. 360 dry eye disease patients will be equally divided randomly into the IPL group, DQS group (3% diquafosol ophthalmic solution eye-drops) and IPL+group (IPL combined with 3% diquafosol eye-drops). All groups will be followed up for 4 weeks. The primary outcome measures will be the non-invasive tear break-up time and the Ocular Surface Disease Index change from the baseline. The secondary outcome measures willincludeconjunctival and cornea staining with fluorescein and lissamine, meibomian gland function and secretion quality, tear film lipid layer score, tear meniscus height, conjunctival hyperemia (redness score) changes . Adverse events also will be monitored and documented.

DISCUSSION

This study aimed to assess whether the combination of IPL with 3% diquafosol ophthalmic solution (study group), IPL+ (study group), is more effective than IPL (active control group) or DQS (active control group) in participants with EDE.

ETHICS AND DISSEMINATION

Management of dry eye with IPL combined with 3% diquafosol ophthalmic solution, registered on 23 January 2023. Ethics approval number: IRB (2022) K029.01. The study's findings will be shared regardless of the effect's direction.

TRIAL REGISTRATION NUMBER

NCT05694026.

Comparison of clinical outcomes between intense pulsed light therapy using two different filters in meibomian gland dysfunction: prospective randomized study

Our study compared treatment efficacy between cut-off and notch filters in intense pulsed light (IPL) therapy for meibomian gland dysfunction (MGD) through a prospective, randomized paired-eye trial. Additionally, the efficacy of IPL treatment alone was investigated by restricting other conventional treatments. One eye was randomly selected for an acne filter and the other for a 590-nm filter. Identical four regimens of IPL treatments were administered. The tear break-up time (TBUT), Oxford scale, Sjögren's International Clinical Collaborative Alliance (SICCA) staining score, tear matrix metalloproteinase-9 (MMP-9) expression, tear osmolarity, and Ocular Surface Disease Index (OSDI) questionnaires were evaluated before and after IPL. Meibomian gland (MG) parameters were measured. When combining the results from both filters, the TBUT, SICCA staining score, OSDI score, and upper and lower lid meibum expressibility were improved after IPL. No significant differences were found between the two filters in the TBUT, Oxford scale, SICCA staining score, MMP-9 expression, tear osmolarity, and MG parameters. Although not significant, the acne filter showed better treatment efficacy than that in the 590-nm filter. IPL alone is efficacious in terms of ocular surface parameters, MG function, and subjective symptoms. Regarding filter selection, both acne and 590-nm filters are promising options for MGD treatment.

Intense Pulsed Light Therapy in the Treatment of Dry Eye Diseases: A Systematic Review and Meta-Analysis

BACKGROUND

Intense pulsed light therapy (IPL) is a recently developed way of treating dry eye disease (DED). During the last decade, there was a multiplication of trials studying IPL efficacy. The goal of this review is to summarize the most important and significant results of these trials estimating effect sizes.

METHODS

The PubMed and sciencedirect databases were searched using a PICO model-based approach. Randomized controlled trials including at least 20 patients with DED and no other eye condition, with a control group and break-up time or symptom scores data available for extraction were included in this review. Statistical analysis evaluated the tear break-up time (TBUT), non-invasive break-up time (NIBUT), ocular surface disease index (OSDI), and standard patient evaluation of eye dryness (SPEED). Three comparisons were carried on for each outcome: longest follow-up values vs. baseline in the treatment group, longest follow-up values in the treatment group vs. control group, and changes from baseline in the treatment group vs. control group. A subgroup analysis was carried on.

RESULTS

Eleven randomized controlled trials, published between 2015 and 2021 were included in this systematic review with 759 patients in total. The longest follow-up values vs. baseline in the treatment group analyses were significantly in favor of IPL for all the parameters studied for instance: NIBUT (effect size (ES), 2.02; 95% confidence interval (CI), (1.43; 2.62)), TBUT (ES, 1.83; 95% CI, (0.96; 2.69)), OSDI (ES, -1.38; 95% CI, (-2.12; -0.64)) and SPEED (ES, -1.15; 95% CI, (-1.72; -0.57)). The longest follow-up values in the treatment group vs. control group analyses, and, the change from baseline in the treatment group vs. control group analyses, were both significantly in favor of IPL for NIBUT, TBUT, and SPEED but not for OSDI.

CONCLUSIONS

IPL seems to have a positive effect on tear stability evaluated by the break-up times. However, the effect on DED symptoms is less clear. Some confounding factors such as the age and the IPL device used influence the results indicating that the ideal settings still need to be found and personalized for the patient.

Managing Severe Evaporative Dry Eye with Intense Pulsed Light Therapy

INTRODUCTION

This study assessed the efficacy and safety of intense pulsed light (IPL) therapy in participants with severe evaporative dry eye disease (DED).

METHODS

This randomized, controlled, single-center study included 49 adult participants (≥ 18 years) with severe evaporative DED who received either IPL therapy (n = 56 eyes) or sham therapy (n = 42 eyes) three times. The primary efficacy parameters were ocular surface disease index (OSDI) score, non-invasive tear breakup time (NITBUT), tear film lipid layer (TFLL), conjunctivocorneal staining score (CS), MG Score, meibomian gland (MG) quality, and MG expression score.

RESULTS

The mean ages for the IPL group and the control group were 28.05 ± 3.41 years (57.1% female) and 28.14 ± 3.53 years (52.4% female), respectively. Comparison between the IPL group and the control group found significant differences in the mean OSDI score (22.16 ± 6.08 vs. 42.38 ± 6.60; P < 00.01), NITBUT (6.27 ± 0.84 vs. 3.86 ± 0.68; P < 0.001), TFLL (2.14 ± 0.44 vs. 3.45 ± 0.50; P < 0.001), MG Score (1.34 ± 0.55 vs. 1.88 ± 0.33; P < 0.001), MG quality (1.59 ± 0.07 vs. 2.67 ± 0.08), and MG expression (1.54 ± 0.57 vs. 2.45 ± 0.55) at 12 weeks follow-up; however, there was no significant difference in CS (3.32 ± 1.11 vs. 3.74 ± 1.04; P = 0.063).

CONCLUSION

The findings suggest that IPL therapy is clinically beneficial in ameliorating the signs and symptoms of severe evaporative dry eye disease.

A Review of Applications and Intracellular Mechanisms of Intense Pulsed Light in Eyelid Inflammatory Diseases

Objective: To evaluate relevant clinical outcomes and conclude possible mechanisms of intense pulsed light (IPL) in eyelid inflammation. Background: IPL devices were primarily applied in cutaneous vascular malformations and have been used in ocular diseases for about 20 years, mostly including meibomian gland dysfunction (MGD), blepharitis, and ocular rosacea. Recent findings: Seventy-two original clinical researches were included, 57 for MGD, 4 for blepharitis or blepharitis-related keratoconjunctivitis, and 11 for rosacea. Dry eye symptoms, (tear) break-up time (BUT), and meibomian structure and/or functions were improved in most patients, but production of reactive oxygen species is an important link in the photobiomodulation mediated by IPL, which can influence numerous signal pathways to achieve anti-inflammatory, anti-infective, and prodifferentiation effects. Conclusions: The evidence suggests that IPL is an effective therapeutic tool for most patients with MGD, but more clinical evidence is needed for other indications.

Dry Eye Disease Associated with Meibomian Gland Dysfunction: Focus on Tear Film Characteristics and the Therapeutic Landscape

Meibomian gland dysfunction (MGD) is highly prevalent and is the leading cause of evaporative dry eye disease (DED). MGD is characterized by a reduction in meibum secretion and/or a change in meibum composition that results in the disruption of the tear film lipid layer and an increase in the tear film evaporation rate. Excessive evaporation causes tear film instability, desiccation, tear hyperosmolarity, inflammation, and apoptosis of ocular surface cells, resulting in a continuous cycle of DED. The primary treatment goal for DED associated with MGD is to restore the tear film lipid layer and decrease evaporation, thereby reducing ocular signs and symptoms. The management of MGD includes home care options (eyelid hygiene, warming eye masks, ocular lubricants) and office-based treatments (manual expression, microblepharoexfoliation, thermal pulsation, intense pulsed light, intraductal probing). Topical ophthalmic prescription medications attempt to alter various factors that may contribute to DED (e.g., inflammation, bacterial growth, inadequate tear production). In this review, clinical evidence regarding available treatments and emerging therapies from randomized studies in patients with DED associated with MGD is summarized. Although some treatment modalities have been evaluated specifically for DED patients with MGD, large-scale randomized controlled trials are needed to confirm efficacy and safety in this patient population. Currently, there are no approved prescription pharmacologic treatments specifically indicated for DED associated with MGD, and those medications approved for the treatment of DED do not target the key driver of the disease (i.e., excessive evaporation). NOV03 (perfluorohexyloctane; under review with the US Food and Drug Administration) is the most advanced emerging therapy for DED associated with MGD and has demonstrated statistically significant improvements in both signs and symptoms in randomized controlled trials. Development of novel pharmacotherapies will improve therapeutic options and allow for a more individualized approach for patients with DED associated with MGD.

Associations between Serial Intravitreal Injections and Dry Eye

PURPOSE

To investigate the effects of serial intravitreal injections (IVIs) on the ocular surface and meibomian glands (MGs) in patients treated with anti-vascular endothelial growth factor (anti-VEGF) for neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective, controlled, observational study.

PARTICIPANTS

Patients with nAMD receiving unilateral IVIs with anti-VEGF agents. The fellow eye was used as control.

METHODS

Tear film and ocular surface examinations were performed on a single occasion at a minimum of 4 weeks after IVI. A pre-IVI asepsis protocol with povidone-iodine (PVP-I) was applied.

MAIN OUTCOME MEASURES

Upper and lower MG loss, tear meniscus height (TMH), bulbar redness (BR) score, noninvasive tear break-up time (NIBUT), tear film osmolarity (TOsm), Schirmer test, corneal staining, fluorescein tear film break-up time (TBUT), meibomian gland expressibility (ME), and meibum quality.

RESULTS

Ninety patients with a mean age of 77.5 years (standard deviation [SD], 8.4; range 54-95) were included. The median number of IVIs in treated eyes was 19.5 (range, 2-132). Mean MG loss in the upper eyelid was 19.1% (SD, 11.3) in treated eyes and 25.5% (SD, 14.6) in untreated fellow eyes (P = 0.001). For the lower eyelid, median MG loss was 17.4% (interquartile range [IQR], 9.4-29.9) in treated eyes and 24.5% (IQR, 14.2-35.2) in fellow eyes (P < 0.001). Mean BR was 1.32 (SD, 0.46) in treated eyes versus 1.44 (SD, 0.45) in fellow eyes (P = 0.017). Median TMH was 0.36 mm (IQR, 0.28-0.52) in treated eyes and 0.32 mm (IQR, 0.24-0.49) in fellow eyes (P = 0.02). There were no differences between treated and fellow eyes regarding NIBUT, TOsm, Schirmer test, corneal staining, fluorescein TBUT, ME, or meibum quality.

CONCLUSIONS

Repeated IVIs with anti-VEGF with preoperative PVP-I application was associated with reduced MG loss, increased tear volume, and reduced signs of inflammation compared with fellow nontreated eyes in patients with nAMD. This regimen may thus have a beneficial effect on the ocular surface.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Artificial Tears: A Systematic Review

Artificial tears are the mainstay of dry eye disease management, but also have a role in corneal abrasion and wound healing, pain and inflammation management, conjunctivitis, keratitis, contact lens rewetting and removal, and foreign body removal. A systematic review of randomized controlled trials (PROSPERO registration CRD42022369619) comparing the efficacy of artificial tears in patients with dry eye to inform prescribing choices using Web of Science, PubMed and Medline databases identified 64 relevant articles. There is good evidence that artificial tears improve symptoms of dry eye disease within a month of regular use, applied about four times a day, but signs generally take several months to improve. Not all patients with dry eye disease benefit from artificial tears, so if there is no benefit over a month, alternative management should be considered. Combination formulations are more effective than single active ingredient artificial tears. Artificial tears containing polyethylene glycol are more effective than those containing carboxymethylcellulose/carmellose sodium and hydroxypropyl methylcellulose. Those classified as having evaporative dry eye disease, benefit from artificial tears with liposomes, especially of higher concentration. The data available is limited by the definition of dry eye disease applied in published studies being variable, as well as the disease severity examined and compliance with artificial tears being rarely quantified.

Intense pulsed light treatment of the upper and lower eyelids in patients with moderate-to-severe meibomian gland dysfunction

PURPOSE

We investigated the subjective and objective outcome after intense pulsed light (IPL) treatment and meibomian gland expression on the upper and lower eyelids compared with those after IPL treatment on the lower eyelid alone in patients with moderate-to-severe meibomian gland dysfunction (MGD).

METHODS

Patients who underwent four IPL treatment sessions with meibomian gland expression were divided into upper and lower treatment group and conventional treatment group treated with lower eyelid alone. All patients underwent an ophthalmologic examination and answered a symptom questionnaire before the first treatment and 1 month after the last treatment. An ophthalmologic examination included tear break-up time (TBUT), fluorescein staining score, Schirmer's test, matrix metalloproteinase-9 (MMP-9), meibum grade, color, consistency, and lid margin telangiectasia. Additionally, visual acuity and adverse effects were checked on every visit.

RESULTS

Of 115 patients, 75 in the upper and lower treatment group and 40 in the conventional treatment group were included. TBUT, fluorescein staining score, subjective symptom, and meibum grade were significantly improved in both groups. Additionally, meibum color and consistency of upper and lower eyelids significantly decreased post-treatment in both groups. The lid margin telangiectasia of the upper and lower eyelids significantly decreased post-treatment in the upper and lower treatment group. MMP-9 positivity and grading scores significantly decreased post-treatment in both groups, and no severe adverse effects occurred during the follow-up period.

CONCLUSION

Additional IPL treatment on the upper eyelid using a protective device was proven safe and provided an additive improvement in treating moderate-to-severe MGD.

Low-Level Light Therapy in Association with Intense Pulsed Light for Meibomian Gland Dysfunction

Purpose

To study the clinical benefit of low-level light therapy when associated with intense pulsed light for the treatment of meibomian gland dysfunction.

Methods

An observational study. Two groups of patients that were treated with IPL were considered: group 1 (31 subjects, 62 eyes), intense pulsed light followed by low-level light therapy and group 2 (31 subjects, 62 eyes) intense pulsed light alone. In both groups, treatments were performed in 3 sessions and subjects were evaluated at baseline and 3 weeks after the last treatment session. Values are shown as mean difference ± standard deviation.

Results

We observed a significant improvement in OSDI-12 score and lipid layer thickness, in both groups (-22.7±17.5, p<0.001 in group 1 and -23.6±23.8, p<0.001 in group 2 for OSDI and +18.6 ± 37.0, p<0.001 in group 1 and +19.9 ± 26.4, p<0.001 in group 2 for lipid layer thickness). Despite no differences between groups at baseline (p=0.469), only group 1 had a significant improvement in Schirmer test (+1.6±4.8, p=0.009 in group 1 and +1.7±6.9, p=0.057 in group 2). No significant side effects were noted. No patient in any group felt subjectively "worse" after the treatment.

Conclusion

Intense pulsed light seems effective and safe for the treatment of meibomian gland dysfunction, improving symptoms and the tear film lipid layer. This study shows no strong evidence of the benefit of low-level light therapy, but it shows weak evidence that it may further improve aqueous tear production.

Different Number of Sessions of Intense Pulsed Light and Meibomian Gland Expression Combination Therapy for Meibomian Gland Dysfunction

PURPOSE

To evaluate the effect of the intense pulsed light (IPL) and meibomian gland (MG) expression (MGX) combination therapy according to the total numbers of sessions in the meibomian gland dysfunction (MGD).

METHODS

Ninety patients with MGD were included. Patients had maximal five sessions of IPL (Aqua Cel, Jeisys Medical) and MGX combination therapy at 2-week intervals. The ocular surface disease index (OSDI) questionnaire score, MG profile grades, tear matrix metalloproteinase-9 (MMP-9), tear break-up time (BUT), tear osmolarity, tear secretion, and corneal erosions were evaluated.

RESULTS

The number of patients who had a total of one to five sessions (1S to 5S) was 10, 25, 17, 20, and 18, respectively. The time-serial decrease of OSDI scores was significant in patients who had three or more sessions (3S, p = 0.002; 4S, p < 0.001; 5S, p < 0.001). The MG expressibility grade decreased with two or more sessions (2S-5S, p < 0.001), but the meibum quality significantly improved with all sessions (1S, p = 0.012; 2S, p = 0.024; 3S, p = 0.015; 4S, p < 0.001; 5S, p < 0.001). Although tear BUT increased even in patients with one session (1S, p = 0.040; 3S, p = 0.005; 4S, p = 0.006; 5S, p = 0.021), tear MMP-9, osmolarity, Schirmer I, and corneal erosions were not improved in every number of sessions. The female sex was the sole contributor to the final symptomatic improvement (p = 0.042), and the MGD stages were not related to the final OSDI decrease.

CONCLUSIONS

The OSDI score, MGD grades, and BUT were improved after the IPL and MGX combination therapy in MGD patients. Unlike MGD grades and tear film instability might be improved just after a few sessions, the overall subjective relief was accomplished in three or more sessions.

Intense pulsed light-based treatment for the improvement of symptoms in glaucoma patients treated with hypotensive eye drops

Background

Ocular surface disease in glaucoma patients is a significant ocular co-morbidity that can affect 40% to 59% of these patients worldwide. The current study was aimed at evaluating the potential clinical benefit of an intense pulsed light (IPL)-based treatment in glaucomatous patients with ocular surface disease due to prolonged hypotensive eyedrop treatments. To our knowledge, this is the first series analyzing the therapeutic effect of this treatment option in this type of patients.

Methods

This non-comparative prospective case series study enrolled a total of 30 glaucoma patients ranging in age from 57 to 94 years old and treated with hypotensive eyedrops for years with dry eye symptomatology. All patients received four sessions of IPL treatment using the Optima IPL system (Lumenis, Yokneam, Israel) adjusted to the official optimized Lumenis setting. Changes in symptomatology, corneal staining, conjunctival hyperemia, non-invasive break-up time (NIBUT), tear osmolarity, tear meniscus height (TMH), meiboscore and meibomian gland expressibility was analyzed after treatment.

Results

Statistically significant reductions were observed after IPL treatment in the symptomatology scores measured with different questionnaires [ocular surface disease index (OSDI), standard patient evaluation of eye dryness (SPEED) and symptom assessment questionnaire in dry eye (SANDE)] as well as with the visual analogue scale (P < 0.001). Mean change in OSDI was − 15.0 ± 11.3. A significant reduction was found after treatment in the corneal staining score (P < 0.001). A significant reduction was found in tear film meniscus height (P = 0.012), as well as in tear film osmolarity (P = 0.001). A significant reduction was also found in meibomian gland expressibility (P = 0.003), changing the percentage of grade 3 eyes from 44.4% before IPL to 17.2% after treatment.

Conclusions

IPL therapy combined with meibomian gland expression (MGX) seems to be an effective option to improve symptomatology in glaucomatous patients with ocular surface disease due to prolonged hypotensive eyedrop treatments, with an additional improvement in clinical signs, such as tear osmolarity and corneal staining.

Pulsed Light Therapy in the Management of Dry Eye Disease: Current Perspectives

Purpose

To review the indications and efficacy of Intense Pulsed Light (IPL) application in the treatment of Meibomian Gland Dysfunction (MGD). Its main purpose is to describe its physiology, efficacy, indications, and adverse effects.

Patients and Methods

A two database (PubMed, EMBASE) search was performed from July 2017 to July 2022 using the MeSH terms ("Intense Pulsed Light" AND ("Meibomian Gland Dysfunction" OR "Dry Eye"). We included randomized studies and systematic reviews with meta-analysis. Exclusion criteria were non-randomized trials, studies enrolling non-MGD dry eye disease, and other works older than 5 years.

Results

Current literature shows that IPL is an effective and safe treatment modality for severe dry eye. Available evidence shows improvement of symptoms and objective indicators, such as noninvasive breakup time, thickness of lipid layer, and Schirmer test. However, our review concluded that the beneficial effects of IPL may lose some efficacy at 6-months after the initial session, and subsequent sessions may be required. Thus, IPL treatment should not be considered as first-line therapy for MGD but instead as an adjuvant option to the standard of care. The optimal treatment modality remains unknown and should be tailored according to each patient's phenotype, clinician's experience, and available technology. There is evidence that IPL treatment may down-regulate pro-inflammatory markers (such as interleukin (IL) 6, IL17a, IL-1) and Prostaglandin E2 (PGE2).

Conclusion

MGD is a multifactorial disease and IPL treatment seems a promising treatment modality. Despite this, more evidence is needed to study its benefits - since this is an emerging technology, it is expected an increase in comparative studies in the following years, with longer follow-up periods, which may enable more precise conclusions about this treatment modality.

Analysis of Cytokine Levels in Meibum and Clinical Correlations with Meibomian Gland Dysfunction

Objectives. This study is aimed at investigating the difference of meibum chemokines in MGD subjects with different degrees of MGD and the correlations of meibum chemokines with ocular surface parameters. Methods. Twenty MGD subjects (MQ $\text{score}>8$ ) and twenty MGD subjects (MQ $\text{score}\le 8$ ) were enrolled to examine ocular surface parameters, including meibomian gland function (MGE, MQ meibograde, and lid margin), tear stability (NIKBUT, FBUT, and LLT), tear secretion (SIT and TMH), OSDI questionnaire, and CFS. These subjects also obtained meibum samples, and then meibum chemokines (MIG, IFN-γ, IL-8, IP-10, and MCP-1) were examined and analyzed the correlations with ocular surface parameters. Results. MIG, IP-10, and MCP-1 were found clearly elevated in MGD subjects with higher MQ score than that in MGD subjects with low MQ score (MIG: $p=0.038$ , IP-10: $p=0.019$ , MCP-1: $p=0.040$ ). The meibomian function was found mostly positively correlated with level of MIG (MGE: $r=0.600$ , $p<0.001$ ; MQ: $r=0.579$ , $p<0.001$ ) and IP-10 (MGE: $r=0.719$ , $p<0.001$ ; MQ: $r=0.601$ , $p<0.001$ ). The tear stability was found negatively correlated with the level of MIG (NIKBUT: $r=-0.438$ , $p=0.005$ ; LLT: $r=-0.464$ , $p=0.003$ ) and MCP-1 (NIKBUT: $r=-0.425$ , $p=0.006$ ; LLT: $r=-0.761$ , $p<0.001$ ). The OSDI was positively correlated with IL-8, IFN-γ, and MIG. Conclusion. Chemokines in meibum were significantly evaluated in MGD subjects suffering from severe meibomian gland quality. These findings indicate that chemokines play roles in the pathogenesis of MGD, and molecules targeted by chemokines may develop as novel agents for MGD therapy, perhaps through inhibiting inflammation in meibomian glands and microvascular in the eyelid margin.

The Lowly Chalazion

Chalazia are localized cysts of chronic lipogranulomatous inflammation arising from the obstruction of sebaceous glands of the eyelid tarsal plate, including the Meibomian gland (deep chalazion) or Zeis gland (superficial chalazion). This disease entity is differentiated from the hordeolum (stye), an acute purulent localized swelling of the eyelid often associated with an eyelash follicle, Zeis gland, or Moll gland obstruction and infection. Ambiguously, the chalazion, hordeolum, and blepharitis are commonly categorized and described on a continuum in the literature. While it is one of the most common eyelid disorders across all age demographics, the chalazion remains largely understudied and pathophysiological, epidemiological, and therapeutic findings exist fragmented in the literature. We discuss current understandings of the chalazion and provide current best practice guidelines supported by clinical anecdotal evidence.

Case report: Immune-mediated meibomian gland dysfunction following pembrolizumab therapy for advanced urothelial carcinoma

Ocular immune-related adverse events are a relatively rare complication of immune checkpoint inhibitors. Common ocular toxicities range from dry eyes to inflammatory uveitis and ocular myasthenia gravis. Here, we present the case of a 55-year-old woman with recurrent urothelial carcinoma of the ureter after initially being managed with neoadjuvant cisplatin-based chemotherapy and surgical resection. She was treated with pembrolizumab which was complicated by immune-mediated pneumonitis after the eighth cycle, which was managed with a prolonged steroid course. The patient also developed red eyes along with recurrent styes. Eye examination revealed decreased tear breakup time, expression of thick and turbid meibum, and meibomian gland atrophy on infrared meibography. The patient was diagnosed with suspected immune-mediated meibomian gland dysfunction (MGD) as a result of pembrolizumab, a previously unreported complication of immunotherapy. The goal of MGD therapy is to stabilize the tear film and minimize evaporation with lipid-based lubricants and other conservative treatments.

Combined intense pulsed light and low-level light therapy for the treatment of refractory Meibomian gland dysfunction

PURPOSE

To evaluate the efficacy of combined Intense Pulsed Light (IPL) and Low-Level Light Therapy (LLLT) in treatment of Meibomian Gland Dysfunction (MGD).

METHODS AND ANALYSIS

In this prospective study, 70 patients with refractory MGD were enrolled; group 1 received 3 consecutive sessions of IPL + LLLT treatment using Eye-light® on day 1, day 15 and day 45; group 2 received hyaluronate sodium 2 mg/ml drops 3 times a day for 6 months. Patients underwent at baseline, and after 3 and 6 months Ocular Surface Disease Index (OSDI) questionnaire, Symptom Assessment in Dry Eye (SANDE), tear-film breakup time (TBUT), fluorescein ocular surface staining, meibum expressibility and quality evaluations. Keratograph 5M (Oculus, Germany) was used to assess NIBUT, tear meniscus height (TMH), meibography, and bulbar redness score.

RESULTS

At 6 months a significant improvement of OSDI (p = 0.03), SANDE (p = 0.02), NIBUT (p = p < 0.0001), TMH (p = 0.04), TBUT (p = 0.02), corneal-conjunctival staining score (p = 0.02), lid margin score (p < 0.0001), and bulbar redness score (p = 0.001) were recorded in group 1. Comparing the two groups, statistically significant differences were observed at 6 months in TBUT (p = 0.03), lid margin score (p < 0.001), Meibum expressibility (p = 0.03) and NIBUT (p < 0.001). No adverse events were recorded throughout the follow-up period.

CONCLUSION

This study confirmed the efficacy and safety of combined IPL and LLLT demonstrating its superiority compared to topical treatment.

Therapeutic Efficacy and Safety of Intense Pulsed Light for Refractive Multiple Recurrent Chalazia

To evaluate the efficacy and safety of intense pulsed light (IPL) combined with meibomian gland expression (MGX) for the treatment of refractory multiple and recurrent chalazia without surgery or curettage. This was a retrospective controlled study. Patients with multiple and recurrent chalazia, who had performed the conventional treatment at least 2 months without any surgery or curettage, were enrolled in this study. Twenty-nine consecutive multiple recurrent chalazia (12 patients) were assigned to receive either the combination of IPL and MGX or MGX alone as a control. Each eye underwent one to four treatment sessions with 2-week intervals. Parameters were evaluated before and 1 month after the final treatment session. Clinical assessments included symptom, size of each chalazion, lid margin abnormalities, corneal and conjunctival fluorescein staining, meibum grade, the number of Demodex mites, the Schirmer value and meiboscore. All parameters except meiboscore and the Schirmer value were significantly improved with IPL-MGX therapy, whereas only meibum grade was significantly improved with MGX alone. There were no adverse events which occurred in either group. IPL-MGX was safe and effective for multiple and recurrent chalazia without surgery or curettage by reducing the size of chalazion and improving lid margin abnormalities and meibum grade.

Clinical and Molecular Outcomes After Combined Intense Pulsed Light Therapy With Low-Level Light Therapy in Recalcitrant Evaporative Dry Eye Disease With Meibomian Gland Dysfunction

PURPOSE

Dry eye disease (DED) is a leading cause of ocular morbidity worldwide. This study evaluates the effects of combined light therapy [intense pulsed light (IPL) and low-level light therapy (LLLT)] on clinical and molecular outcomes in evaporative DED with meibomian gland dysfunction (MGD).

METHODS

This prospective study evaluated 94 eyes (47 subjects) with chronic MGD treated with combined light therapy. Patients underwent a detailed evaluation of MGD and DED using the Ocular Surface Disease Index, dry eye tests-tear breakup time and Schirmer test, ocular surface staining, meibomian gland expressibility scoring, and meibography. Patients underwent a single session of combined light therapy (IPL + LLLT treatment) using the Eye-light device. All these tests were repeated at 3 and 6 months after treatment. Tear fluid and ocular surface wash samples were collected from a subset of patients before and after treatment for cellular and secreted immune factor profiling by flow cytometry.

RESULTS

Combined light therapy (IPL + LLLT) demonstrated a marked improvement in the clinical metrics studied. Three months after treatment, Ocular Surface Disease Index showed a significant reduction in 95.6% ( P < 0.0001), tear breakup time increased in 72.3% ( P < 0.0001), and meibomian gland expressibility scoring increased in 80.8% ( P < 0.0001) of the eyes. These effects were observed to be sustained during the 6-month follow-up visit. Significant ( P < 0.05) reduction in tear fluid levels of interleukin-1β, interleukin-17F, and MMP9; MMP9/TIMP1 ratio; and ocular surface B-cell proportions was observed.

CONCLUSIONS

Combined light therapy shows promising results in patients with chronic MGD and DED, even in recalcitrant cases. Clinical and molecular factor alterations support the improved symptomatology and reduced inflammation.

The Efficacy and Safety of New-Generation Intense Pulsed Light in the Treatment of Meibomian Gland Dysfunction-Related Dry Eye: A Multicenter, Randomized, Patients-Blind, Parallel-Control, Non-Inferiority Clinical Trial

Introduction

This study aimed to evaluate the efficacy and safety of a new-generation intense pulsed light (IPL) device in improving the symptoms and signs of meibomian gland dysfunction (MGD)-related dry eye, and compare it with a traditional IPL device.

Methods

This multicenter randomized controlled trial enrolled 132 patients with MGD-related dry eye from two centers. Patients were randomly assigned into the new-generation IPL (Eyesis) group or traditional IPL (E-Eye) group, and then blinded to receive treatment on days 0 and 7. Ocular Surface Disease Index (OSDI), tear meniscus height (TMH), tear breakup time (TBUT), corneal fluorescein staining (CFS), Schirmer test, and meibomian gland signs were evaluated on days 0, 7, and 14. The primary outcome was defined as the effective rate of treating MGD at day 14. Any adverse events were recorded for safety assessment. Intergroup comparisons and non-inferiority analysis were performed. p values less than 0.05 were considered statistically significant.

Results

Basic information showed no significant difference between treatment groups. The intergroup difference of the effective rate was − 1.7% in the left eye and 1.6% in right eye, verifying the non-inferiority of the Eyesis device (p = 0.927). Significant improvements in OSDI, TBUT, Schirmer test, TMH, CFS, and meibomian gland signs were observed in Eyesis group on days 7 and 14 (all p < 0.05). Compared to the E-Eye group, the Eyesis group achieved more significant improvements in OSDI, TBUT, Schirmer test, TMH, and meibum quality (all p < 0.05). There was no significant difference in the incidences of adverse events between groups (p = 1.000).

Conclusions

The new-generation IPL was effective and safe in relieving the symptoms and signs of MGD-related dry eye, exhibiting a non-inferior effective rate compared to the traditional IPL. Additionally, Eyesis showed more clinical benefits over E-Eye in alleviating symptoms, increasing tear film stability and improving meibomian gland function.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00556-1.

A retrospective study of the efficacy of intense pulsed light delivered by the Lacrystim® for meibomian gland dysfunction therapy

Background

Meibomian gland dysfunction is the most common etiology of dry eye disease worldwide and intense pulsed light appears to be a promising treatment with encouraging results. Lacrystim® is a new IPL device (CE marking in 2019) and no studies have yet been published on it. We propose the first study on this device with an objective assessment of its efficacy and an extended follow-up over 6 months.

Methods

Patients presenting with a dry eye disease (DED) with stable mild to moderate MGD and having received Lacrystim® treatment between june 2019 and june 2020 were included. 3 IPL sessions were performed at D0, D15 and D45 with 4 shots per side at a fluence of 8 mJ/cm2. DED clinical evaluation was performed at D0, D15, D45, 3rd month and 6th month: Oxford scale and break up time, Schirmer test and Ocular Surface Disease Index (OSDI) questionnaire. Lacrydiag® imaging device carried out an objective examination of tear film: interferometry, meibography, tear meniscus height and non-invasive break up time (NIBUT). The primary endpoint was the evolution in NIBUT between the first visit D0 and 3rd month. Data collection was done retrospectively. Statistical analysis was done using a linear mixed-effects model and a non-parametric linear mixed-effects model (R software).

Results

Forthy five consecutive patients were included. NIBUT significantly increased between D0 and 3rd month: mean difference of 1.63 seconds, IC95% [0.51; 2.62], (p = 0.002) with a prolonged effect at 6th month. OSDI and OXFORD scores and interferometry were also significantly improved at 3rd month and 6th month. There was no significant change in BUT, Schirmer test and tear meniscus height. No adverse event was noted.

Conclusions

IPL delivered by Lacrystim® appears effective and safe to treat MGD although a randomized controlled trial is needed to validate its results.

Trial registration

This work was approved by a local ethics committee “Terre d’éthique” (institutional review board number: IRBN672019/CHUSTE) and registered on the clinicaltrial.gov website (NCT04147962, 01/11/2019).