Randomised double-masked placebo-controlled trial of the cumulative treatment efficacy profile of intense pulsed light therapy for meibomian gland dysfunction

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.

Predictive performance of corneal and lid margin sensitivity for dry eye disease: An investigator-masked, prospective, prognostic accuracy study

PURPOSE

To evaluate the prognostic ability of non-contact esthesiometry corneal and lid margin sensitivity measurements in detecting symptoms and signs of dry eye disease, as defined by the global consensus TFOS DEWS II criteria.

METHODS

A total of 87 community residents (58 females; mean ± SD age, 53 ± 16 years) were recruited in an investigator-masked, prospective, prognostic accuracy study. Dry eye symptomology, tear film parameters, and ocular surface characteristics were evaluated in a single clinical session, and non-contact esthesiometry corneal and lid margin sensitivity measurements performed by an independent masked assessor.

RESULTS

Overall, 49 (56%) participants fulfilled the TFOS DEWS II criteria for dry eye disease, while 57 (66%) exhibited clinical symptoms, and 67 (77%) had positive signs. The prognostic abilities of corneal and lid margin sensitivity measurements were significantly greater than chance for the detection dry eye signs (both p ≤ 0.03), but not for symptoms or overall disease diagnosis (all p > 0.10). The Youden-optimal prognostic cut-offs for corneal and lid margin sensitivity thresholds were both ≥0.8 mbar for the detection of clinical dry eye signs. Lid margin sensitivity demonstrated marginally higher predictive performance than corneal sensitivity (C-statistic, 0.688 versus 0.658), and was significantly correlated with tear film stability, corneal, conjunctival and lid wiper staining (all p < 0.05).

CONCLUSIONS

Corneal and lid margin sensitivity demonstrated moderate prognostic utility for detecting clinical dry eye signs. Future research is warranted to investigate the utility of incorporating non-contact esthesiometry in the workup for dry eye disease and neurotrophic keratopathy.

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.

Comparison of Intense Pulsed Light Treatments including Upper Lid or Lateral Canthus in Patients of Meibomian Gland Dysfunction

Background: To determine the differences in the effects of intense pulsed light (IPL) treatment when including the upper and lower lid or lateral canthus area in patients with meibomian gland dysfunction (MGD). Methods: Patients who underwent three IPL treatment sessions at 3-week intervals were divided into three groups according to the treatment sites: group A, lower lid; group B, upper and lower lids; and group C, lower lid and lateral canthal area. Before and after the IPL treatment sessions, we obtained the lid abnormality score (LAS), meibum expressibility (ME), meibum quality (MQ), lipid layer thickness (LLT), type I Schirmer test (ST), tear break-up time (TBUT) test, corneal fluorescein staining scores (CFSs), and Ocular Surface Disease Index (OSDI). Results: IPL treatment significantly improved LASs, ME, MQ, TBUT, CFS, and OSDI values in all groups. Differences in LAS values before and after IPL treatment were significantly greater in groups B and C than those in group A. Conclusions: IPL treatment encompassing the upper lid and lateral canthus together with the lower lid elicited additional improvement in patients with MGD. The additional effect on treating the lateral canthus was similar to the effect observed on the additional treatment of the upper lid.

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.

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.

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.

Treatment of Dry Eye Disease (DED) in Asia: Strategies for Short Tear Film Breakup Time-Type DED

Dry eye disease (DED) is a multifactorial disorder in which tear fluid homeostasis is lost, resulting in increased tear film osmolarity and ocular surface irritation. In Asia, the short tear film breakup time-type DED, which has become a global problem in recent years, is common. While the mainstay of DED treatment in the West is the suppression of inflammation, the first goal of treatment is the stabilization of the tear film in Asia. To date, artificial tears and steroid eye drops have been the main treatment for DED. However, artificial tears require frequent administration of eye drops and thus pose adherence problems, while steroids have problems with side-effects (cataracts, increased intraocular pressure). This review evaluates the new generation therapies in Asia based on what is known about them and demonstrates that they are more effective for DED than traditional therapies such as artificial tears and steroids. Based on considerations, it is proposed that the optimal treatment for the short tear film breakup time-type DED is the initial application of mucin-secretion-enhancing eye drops (long-acting diquafosol) and oral supplements; and if additional treatment is needed, cyclosporine eye drops and the adjunctive therapies presented in this review are added.

Novel treatment of chalazion using light-guided-tip intense pulsed light

We assessed the effectiveness of light-guided-tip intense pulsed light (IPL) with meibomian gland expression (MGX) in chalazion treatment. Ninety-five eyes with chalazion received a light-guided-tip IPL-MGX treatment (IPL-MGX group), and another 95 eyes with chalazion received incision with curettage treatment (Control group). Prior to IPL or incision, as well as 1 month after the final treatment, data were gathered pertaining to the lesion location and size, hyperemia, lesions regression or recurrence, and a comprehensive ophthalmic examination. The total size of the chalazia in the IPL-MGX group was significantly reduced after the final treatment, with an average resolution rate of 70.5%, which is comparable to excision surgery. A significant decrease in chalazion recurrence rate was apparent after treatment in the IPL-MGX group compared with control. Moreover, the IPL-MGX demonstrated significant advancements throughout noninvasive tear film breakup time (NIBUT) as well as meibum grade in comparison to baseline and those in the the Control group. The use of IPL-MGX was found to be an efficient therapy for reducing the size and recurring frequency of chalazia, as well as for improving the meibomian gland function. It may be considered as a first-line treatment for cases of primary or recurrent chalazia with inflammation.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

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.

The effect of non-ablative thermomechanical skin treatment (Tixel®) on dry eye disease: A prospective two centre open-label trial

PURPOSE

To determine the effects of a thermo-mechanical action-based peri-orbital fractional skin treatment (Tixel®) on dry eye disease.

METHODS

This prospective, controlled, open labelled study was conducted at two study centres: Midland Eye, Solihull, UK, and Vallmedic Vision, Andorra. Participants were screened at the baseline visit (visit-1), received three Tixel® treatments at 2-weeks intervals including further assessment (visits 2, 3 and 4). Participants were followed up for three months post-treatment (visit 5). Vision, intraocular pressure (IOP), dry eye symptomatology were assessed, including the Ocular Surface Disease Index (OSDI) questionnaire, non-invasive tear break-up time (NIBUT) and tear osmolarity as well as detailed ophthalmic assessments.

RESULTS

Seventy-four participants (41 in Birmingham and 33 in Andorra) with periorbital wrinkles and moderate to severe dry eye disease (DED) were enrolled. The mean age was 59.3 ± 13.3 years and 57 were females. No adverse events, no change in vision (p = 0.310) or IOP (p = 0.419) were observed. Tixel treatment was associated with clinically and statistically significant improvement in the DED symptoms, which was supported by a reduction of 21.40 ± 15.08 (P < 0.001) of the OSDI index. Non-invasive tear break-up time improved by 2.10 ± 0.91 s (p < 0.001) in the Birmingham cohort and 6.60 ± 2.13 s (p < 0.001) in the Andorra cohort. Tear osmolarity reduced from 299.8 ± 13.3 mOsm/L to 298.8 ± 15.6 mOsm/L following the Tixel treatment (p = 0.271).

CONCLUSIONS

Thermo-mechanical action-based peri-orbital fractional skin treatment Tixel® could be an attractive, safe and effective treatment for DED. This treatment is associated with high clinical and statistically significant improvement in DED signs and symptoms with no adverse events.

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.

The Approach of Intense Pulsed Light Treatment in Patients with Different Severities of Meibomian Gland Dysfunction

PURPOSE

To make appropriate therapeutic decisions of intense pulsed light (IPL) for meibomian gland dysfunction (MGD) patients.

METHODS

Sixty patients with MGD stage 2-3 were enrolled in IPL Group1 and Self-hygiene Group; 110 patients with MGD stage 3-4 were included in IPL + MGX Group and IPL Group2. Patients in IPL groups received IPL treatment once a month for three times. Meibomian gland expression (MGX) was combined with IPL treatment in IPL + MGX Group. Meibomian gland (MG) functions, MGD stage, associated ocular-surface indexes, and response rate were evaluated.

RESULTS

Population characteristics and clinical conditions were comparable between groups. In patients with MGD stage 2-3, both IPL Group1 and Self-hygiene Group improved in MG functions, ocular surface disease index (OSDI) and tear break-up time (TBUT). No statistical difference was found in improvements. Posttreatment response rate was 64.3-66.7% in two groups. In patients with MGD stage 3-4, IPL + MGX Group achieved better improvements in MG expressibility and higher response rate (75.5%) than IPL Group2 (63.3%). Referring to IPL treatment, no statistical difference in MG functions and OSDI improvements was found among MGD patients with different ages, genders, and IPL energy exposure. Patients with higher Fitzpatrick scale improved more in MG expressibility.

CONCLUSION

Self-eyelid hygiene is cost-effective for milder MGD stages. Combining MGX with IPL is necessary in more severe stages. Adult patients with all age and different genders can benefit from IPL treatment. Patients with darker skin can benefit more in expressiblity.

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.

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.

Effect of Intense Pulsed Light Therapy in Dry Eye Disease Caused by Meibomian Gland Dysfunction: A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to systematically evaluate the effect of intense pulsed light (IPL) therapy in patients harboring dry eye disease caused by meibomian gland dysfunction (MGD) based on qualified studies.

METHODS

The electronic databases, including PubMed, Cochrane, and Embase, were searched using keywords to identify available publications updated to November 2021. Relative risk or weighted mean difference combined with 95% confidence interval was used to synthesize the outcomes of included studies. The meta-analysis included 15 randomized controlled trials with 1,142 patients (2,284 eyes).

RESULTS

The results revealed that IPL could significantly decrease the ocular surface disease index (OSDI), standard patient evaluation of eye dryness (SPEED), artificial tear usage, tear film lipid layer, meibomian gland quality (MGQ), meibomian gland expression (MGX), and corneal fluorescein staining (CFS) while increase tear break-up time (TBUT) and noninvasive tear break-up time (NIBUT) compared with sham. Compared with MGX, IPL+MGX markedly decreased the SPEED, CFS, and tear meniscus height (TMH), but with increased TBUT. Compared with MGX, IPL showed significant effect in increasing the OSDI and TBUT, but decreasing the TMH and NIBUT. However, no significant differences were seen between IP+MGX and MGX in OSDI, MGQ, and MGX, nor between IPL and MGX in OSDI, SPEED, and TBUT.

CONCLUSION

We identified that the application of IPL alone or IPL combined with MGX elicited superior clinical effect for improving the eye function and symptoms in the treatment of MGD-related dry eye disease, which is considered available for wide clinical application.

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.

Investigation of Prognostic Factors for Intense Pulsed Light Treatment with a Vascular Filter in Patients with Moderate or Severe Meibomian Gland Dysfunction

We aimed to investigate the prognostic factors for, and treatment efficacy of, intense pulsed light (IPL) treatment with a vascular filter in patients with moderate or severe meibomian gland dysfunction (MGD). In this retrospective observational study, 58 moderate or severe MGD patients who underwent IPL treatment with a vascular filter were enrolled. IPL treatment was administered to the upper and lower eyelids four times at two-week intervals. At baseline, and four weeks after IPL, we evaluated the matrix metalloproteinase (MMP)-9 expression levels, tear break-up times (TBUT), ocular surface staining scores, lid margin telangiectasias, and meibomian gland characteristics. The subjective symptoms and adverse effects were reviewed and recorded. Regression analyses were performed to explore the prognostic factors affecting clinical outcomes. IPL treatment using a vascular filter led to improvements in the TBUT, ocular surface staining score, meibomian gland grade, meibum quality and consistency, lid margin telangiectasia, and symptom score (all p < 0.001). Furthermore, the positivity rate (90.2% to 70.6%, p = 0.013) and expression levels (1.92 ± 1.18 to 1.24 ± 1.18, p < 0.001) of tear MMP-9 improved after the IPL treatment. In multivariate logistic regression analysis, a young age (odds ratio = 0.867, p = 0.007) and a toothpaste-like consistency in the upper lid (odds ratio = 8.449, p = 0.046) were associated with improvements in the meibomian gland grade. No adverse effects were detected. IPL with a vascular filter is a safe and effective treatment for moderate and severe MGD. Age and the meibum consistency in the upper lid are important prognostic factors.

Placebo administration for dry eye disease: a level I evidence based systematic review and meta-analysis

Background

The efficacy of various common treatment options for dry eye disease (DED) has been investigated against placebo. However, the potential beneficial effect of placebo in the management of DED is still unclear.

Aim

This meta-analysis investigated the impact of placebo administration in DED in Ocular Surface Disease Index (OSDI), Schirmer I test (SIT), tear breakup time (TBUT), corneal staining, and complications.

Method

This meta-analysis and systematic review was conducted according to the 2020 PRISMA guidelines. In March 2022, Pubmed, Web of Science, Google Scholar, and Embase were accessed. All the randomised clinical trials which investigated any active treatment against a placebo control group were considered. The following data were extracted at baseline and at last follow-up: Ocular Surface Disease Index (OSDI), tear breakup time test (TBUT), Schirmer I test (SIT), corneal staining.

Results

Data from 56 studies (12,205 patients) were retrieved. Placebo administration is not effective in improving TBUT (P = 0.3), OSDI (P = 0.2), SIT (P = 0.1) and corneal staining (P = 0.1) from baseline to last follow-up. Active treatment led to a higher TBUT and SIT compared to placebo administration (P < 0.0001). The active treatment resulted in a lower OSDI compared to placebo administration (P = 0.0005). Five studies reported data on the corneal staining. No difference was found between placebo administration and active treatment (P = 0.8).

Conclusion

Placebo administration does not impact symptoms of DED and can be successfully employed to evaluate the efficacy of active treatments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01439-y.

Comparison of Intense Pulsed Light Therapy on Patients with Meibomian Gland Dysfunction Using AQUA CEL and M22 Devices

The purpose of this study was to compare the efficacy of Intense Pulsed Light (IPL) therapy for meibomian gland dysfunction (MGD) using the new AQUA CEL (AC, Jeisys) device and the traditional M22 (Lumenis) device. A total of 59 eyes of 59 patients with MGD (12 men and 47 women, mean age 49 ± 12 years) were enrolled. They randomly received four sessions of IPL therapy every three weeks either with AC (30 eyes) or M22 (29 eyes). Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire score, noninvasive breakup time (NIBUT), lid margin abnormalities, corneal and conjunctival fluorescein staining, fluorescein breakup time (FBUT), Schirmer’s test, meiboscore and meibum grade were evaluated before treatment and one month after treatment. Before IPL, no significant differences were seen in age, gender, or measured parameters between the AC and M22 groups (p > 0.05, respectively). SPEED score, NIBUT, lid margin abnormalities, fluorescein staining, FBUT, and meibum grade improved significantly in both groups after IPL compared to before IPL (p < 0.001, respectively). There were no significant differences in measured parameters between the two groups after IPL (p > 0.05, respectively). IPL therapy with AC and M22 devices has been shown to be equally effective for the treatment of MGD.

Bacteria and Dry Eye: A Narrative Review

(1) Background: Dry eye is a multifactorial disease of the ocular surface, the incidence of which has been increasing sharply. The pathogenesis of dry eye, especially in terms of the bacterial flora, has drawn great attention. Additionally, the potential treatment methods need to be explored. (2) Methods: We reviewed more than 100 studies and summarized them briefly in a review. (3) Results: We summarized the bacterial communities found on the ocular surface in the general population and patients with dry eye and found a relationship between dry eye and antibiotic therapy. We identified the possible mechanisms of bacteria in the development of dry eye by discussing factors such as the destruction of the antibacterial barrier, infectious diseases, microbiome homeostasis, inflammatory factors on the ocular surface and vitamin deficiency. (4) Conclusion: We systematically reviewed the recent studies to summarize the bacterial differences between patients with dry eye and the general population and brought up several possible mechanisms and possible treatment targets.

Indirect Application of Intense Pulsed Light Induces Therapeutic Effects on Experimental Murine Meibomian Gland Dysfunction

Purpose

To investigate the indirect effects of intense pulsed light (IPL) on morphological and pathological changes of the meibomian glands (MGs) in apolipoprotein E knockout (ApoE^–/–) mice and explore the underlying mechanisms.

Methods

ApoE^–/– mice were treated with or without IPL three times below the lower eyelids and MGs were not directly exposed to irradiation. The eyelids and ocular surface were observed under a stereoscope. The morphology of MGs was examined by photographing and hematoxylin and eosin staining. Lipid droplets in MGs were examined by Oil Red O staining. The ultrastructure of meibocytes and mitochondria was observed under transmission electron microscopy. The relative gene and protein expression in MGs of upper eyelids was determined by immunostaining, Western blot, and qRT–PCR.

Results

Three IPL treatments decreased the toothpaste-like plugging of orifices and thickening and irregularity of the upper and lower eyelid margins in ApoE^–/– mice. The morphology of some MGs improved after IPL treatments, accompanied by increased proliferation of acinar basal cells and decreased ductal keratinization. Furthermore, the accumulation of hyperchromatic lipid droplets in the acini increased, and the lipid droplets distributed in the cells around the acini were round and small. Compared with untreated ApoE^–/– mice, oxidative stress and apoptosis were downregulated by IPL treatment, accompanied by the improvements in mitochondrial structure. Further research showed that IPL treatments reduced the levels of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-17A, IL-6 in MGs and inactivated nuclear factor kappa B (NF-κ B).

Conclusion

Collectively, the results demonstrate that indirect effects of IPL can improve the structure and function of MGs and mitigate the progression of MGD, which may be related to the indirect effects of photobiomodulation.

Safety and Feasibility of Low Fluence Intense Pulsed Light for Treating Pediatric Patients with Moderate-to-Severe Blepharitis

To explore the safety and feasibility of low fluence intense pulsed light (IPL) for treating pediatric patients with moderate-to-severe blepharitis and to analyze potential factors associated with the recovery of meibomian glands (MG) dropout, a retrospective, noncomparative study, including 17 blepharitis patients (33 eyes) aged between 5 and 16 years old was conducted. All of the participants were given 4 continuous sessions of low-fluence (9−12 J/cm2) IPL at 3−4 week intervals. Corneal fluorescein staining (CFS), tear breakup time (BUT), inferior tear meniscus height, Demodex presence, and MG morphology were examined before and after the treatment. Results indicated that CFS, BUT and MG morphology (central/total gland area ratio and gland signal index) had significantly improved (p < 0.05). Symptoms and signs such as severe corneal neovascularization, limbal pannus and conjunctival congestion also subsided. Among age, gender, presence of Demodex and interval before diagnosis, age initiating the formal treatment was confirmed as a negatively correlated factor of the recovery of MG dropout (p = 0.032, B = −1.755). No notable adverse events were reported. In conclusion, low fluence IPL seems to be a safe and effective alternative for moderate-to-severe pediatric blepharitis, and MG dropout is prone to recover in younger patients.

Safety and efficacy of a low-level radiofrequency thermal treatment in an animal model of obstructive meibomian gland dysfunction

This study aimed to evaluate the safety and efficacy of a low-level radiofrequency thermal treatment in an obstructive MGD rabbit model. Meibomian gland orifices of the central two-thirds of the upper and lower eyelid margins were coagulated twice at 2-week intervals using a 5-MHz high-frequency electrosurgical unit. Sixteen eyes of eight rabbits were treated with one session of radiofrequency thermal treatment (radiofrequency group) and eight eyes of four rabbits were followed up without treatment (control group). Lid margin abnormality and corneal staining scores, histologic examination of the eyelids and meibombian gland, and meibography imaging were evaluated just before and 4 weeks after meibomian gland orifice closure and 4 weeks after radiofrequency thermal treatment. Lid margin abnormality score improved significantly for the upper and lower eyelids after radiofrequency thermal treatment (P < 0.001 for both eyelids). Corneal staining score remained unchanged in the radiofrequency group; however, the control group saw an increase at final follow-up. There was a significant improvement to almost baseline levels in the mean area of secretory acini in the radiofrequency group (P = 0.004). Additionally, meibography indicated an improvement in meibomian gland loss rate in the radiofrequency group. Low-level radiofrequency thermal treatment heating the inner and outer eyelid surfaces is safe and effective to treat obstructive MGD in a rabbit animal model of MGD.

Lipidomics Profiles Revealed Alterations in Patients With Meibomian Gland Dysfunction After Exposure to Intense Pulsed Light

So far, intense pulsed light (IPL) has been widely used in the treatment of meibomian gland dysfunction (MGD), but there was still a lack of research on its specific mechanism. Determining whether there was a correlation between liposome changes and remission of clinical signs in patients with MGD treated with IPL was of great significance in the clinical evaluation of efficacy in patients with MGD. Our study enrolled the 10 healthy subjects and 26 adult patients, who were diagnosed with MGD and had not received any alternative treatments for at least 3 months. Each patient received a series of three treatments at 3-week intervals. The meibum was collected before the first treatment (T0) and the third treatment (T2). The significant changes in ocular surface parameters before and after IPL treatment were analyzed. The results showed that IPL significantly improved the symptoms of MGD, including ocular surface disease index (OSDI), tear breakup time (TBUT), redness of conjunctival (CR), corneal fluorescein staining (CF), the meibomian gland expressibility (MGE), and meibum quality (all p < 0.05). Lipidomics analysis of the meibum characterized the changes in lipid profiles induced by IPL. A total of 323 lipid species compounds were identified in the spectrum. A total of 41 lipid species were significantly different in patients with MGD (T0) vs. healthy controls. Following IPL treatment (T2), 24 lipid species were significantly different compared with T0: TG (10 lipid species), LPC (6 lipid species), OAHFA (4 lipid species), Cer (2 lipid species), SM (1 lipid species), and PE (1 lipid specie). Among these lipids, 4 of the lipids was a high correlation with TBUT, 5 was TH, 6 was CR, and 11 was meibum quality. In a ward, IPL treatment can achieve the therapeutic effect by changing the alternations of tear film lipids in patients with MGD. The changes in lipid expression profiles are potential indexes to evaluate the therapeutic effectiveness of IPL treatment or other treatments on MGD.

Efficacy of Intense Pulsed Light Combined Blood Extract Eye Drops for Treatment of Nociceptive Pain in Dry Eye Patients

Purpose: To investigate the efficacy of intense pulsed light (IPL) combined with deproteinized calf blood extract (DCBE) eye drops for dry eye disease (DED) patients with nociceptive ocular pain. Methods: In this prospective, one-center, interventional study, 23 subjects with DED and ocular pain were treated with a combination of IPL and DCBE eye drops for four sessions at a four-week interval. Subjective and objective assessments on nociceptive pain and dry eye were examined and analyzed. Results: The visual analog scale (VAS), ocular surface disease index, ocular pain assessment survey (OPAS), patient health questionnaire-9 items, generalized anxiety disorder (GAD-7), Athens insomnia scale, corneal fluorescein staining score, meibomian gland secretion quality, and expressibility scores were significantly reduced after the treatment. Tear break-up time and Schirmer I test increased significantly. The brand density of corneal nerves and neuropeptide substance P also significantly increased. OPAS, GAD-7, meibomian gland secretion quality, and expressibility scores were essential factors affecting the VAS changes. Conclusions: IPL combined with DCBE drop therapy was effective for DED patients with ocular pain. With such treatment, both DED symptoms and the sensation of ocular pain may be improved.

Effect of intense pulsed light using acne filter on eyelid margin telangiectasia in moderate-to-severe meibomian gland dysfunction

Evaluate the improvement in clinical signs and symptoms in patients with moderate-to-severe meibomian gland dysfunction (MGD) treated with intense pulsed light (IPL) using an acne filter. A retrospective chart review of 70 eyes of 35 patients with moderate-to-severe MGD treated with IPL using the acne filter was performed. IPL treatment was administered using the acne filter four times at 2- to 3-week intervals to upper and lower eyelids. We evaluated tear break-up time (TBUT), matrix metalloproteinase (MMP)-9, Sjögren's International Clinical Collaborative Alliance (SICCA) staining score, and Oxford staining grade. We performed Schirmer's test I without topical anesthesia, slit-lamp microscopic examination of lid margin and meibomian gland, and patient's symptom score assessment and evaluated the incidence of adverse effects in the ocular and periocular areas at baseline and 30 days after the final treatment. Significant improvements (P < 0.001) were observed in TBUT, SICCA staining score, Oxford staining grade, quality of meibum, consistency of meibum, lid margin telangiectasia, MGD grade, and patient's symptom scores after acne filter IPL treatment. Furthermore, the positivity (100 to 71.43%, P = 0.002) and level (2.43 ± 0.98 to 1.14 ± 0.78, P < 0.001) of MMP-9 significantly decreased after treatment. However, there was no significant improvement in Schirmer's test I (P = 0.224). No systemic or regional adverse effects were observed in any patient. IPL treatment using the acne filter is an effective and safe therapeutic modality for treating moderate-to-severe MGD, especially for lid margin telangiectasia and MMP-9.

Response of tear cytokines following intense pulsed light combined with meibomian gland expression for treating meibomian gland dysfunction-related dry eye

PURPOSE

This study compared the changes in tear inflammatory cytokine levels after intense pulsed light (IPL) combined with meibomian gland expression (MGX) (IPL group) and instant warm compresses combined with MGX (physiotherapy group) as treatments for meibomian gland dysfunction (MGD)-related dry eye disease (DED) to explore their similarities and differences in therapeutic mechanisms.

METHODS

This study was a post-hoc analysis of a randomized controlled trial. Thirteen patients with MGD-related DED were enrolled in each group and received three treatments correspondingly with 3-week intervals. The levels of 20 tear cytokines, namely, TNF-α, IL-6, MMP-9, CXCL8/IL-8, CXCL10/IP-10, IL-10, EGF, IL-6R, IL-1β, IFN-γ, lactoferrin, Fas ligand, IL-17A, LT-α, S100A9, LCN2/NGAL, IL-13, IL-12/IL-23p40, Fas, and CCL11/Eotaxin, were measured at baseline, before the second and third treatments, and 3 weeks after the third treatment. The primary outcome was the difference in cytokine levels between baseline and the last measurement, and the trends were analyzed at each measurement point.

RESULTS

At the last measurement, a significant decrease was observed in all tear cytokines for both IPL and physiotherapy groups compared with baseline. The IPL group showed greater reductions in IL-6, IL-6R, IL-1β, IL-13, and CCL11/Eotaxin than the physiotherapy group. TNF-α, CXCL8/IL-8, CXCL10/IP-10, IL-10, EGF, IL-1β, IFN-γ, and Lipocalin-2/NGAL levels continued to decrease with treatment time. Important interactions were found in the changes of IL-6 and IL-13 levels, where the levels first decreased and then slightly increased in the physiotherapy group after treatment, while they continued to decrease in the IPL group.

CONCLUSIONS

The mechanisms of IPL and physiotherapy in treating MGD-related DED were both associated with reducing inflammation, and the superiority of IPL could be attributed to its better inhibitory effect on inflammatory cytokines like IL-6. In addition, several cytokines were on a downward trend during treatment, suggesting that the vicious cycle of DED was suppressed.

Efficacy of Intense Pulsed Light Treatment in Patients with Sjögren’s Syndrome Associated with Meibomian Gland Dysfunction

Purpose: To investigate the efficacy of intense pulsed light (IPL) treatment in patients with meibomian gland dysfunction (MGD) associated with Sjögren’s syndrome.Methods: This study included 43 patients with MGD and Sjögren’s syndrome. Patients received either IPL with meibomian gland expression (IPL/MGX) (n = 22) or MGX only (n = 21). Treatments were administered three times at a 3-week interval. Patients were followed up 6 weeks after the end of the treatment. Ocular Surface Disease Index (OSDI), tear film breakup time with fluorescein dye (FBUT), non-invasive tear breakup time, tear meniscus height (TMH), Schirmer test, SICCA ocular surface staining score, meibum quality score (MQS), and meibum expression score (MES) were evaluated at each visit. Meibomian gland dropouts (meiboscore) and tear film lipid layer grade were measured using keratography.Results: OSDI, FBUT, corneal surface staining score, MQS, meiboscore, and tear film lipid layer grade improved after IPL/MGX treatment (p < 0.05). In both treatment groups, MES significantly improved (p < 0.01 and p < 0.05 for IPL/MGX and MGX groups, respectively). The Schirmer test score, conjunctival surface staining score, and TMH after treatment were not significantly different between the groups. After treatment, the IPL/MGX group had significantly lower OSDI, FBUT, corneal staining score, MQS, and MES, but higher FBUT, compared with the MGX group (p < 0.05).Conclusions: IPL treatment effectively improved tear film, ocular surface parameters, meibomian gland function, and lipid layer grade in patients with Sjögren’s syndrome and MGD.

Factors influencing the clinical outcomes of intense pulsed light for meibomian gland dysfunction

To observe the clinical outcomes of intense pulsed light (IPL) for meibomian gland dysfunction (MGD) and identify its influencing factors.Forty-eight eyes of 48 patients with MGD were included. Subjects were followed up 5 times on day 1, day 15, day 30, day 45, and day 120, and underwent 3 sessions of the IPL treatment on day 1, day 15 and day 30. Gender, age, duration of MGD, time of video display terminal usage, and severity of MGD were recorded at baseline. At every visit, Ocular Surface Disease Index (OSDI), eyelid margin abnormality score, tear film breakup time, Schirmer I test (S ɪ t) and corneal fluorescein staining were recorded. The clinical parameters before and after 3 IPL treatments were compared. Univariate and multivariable logistic regression analyses were performed to explore influencing factors.Compared with baseline, the tear film breakup time was increased and the corneal fluorescein staining score and OSDI were significantly decreased on day 45 and day 120 (all P < .001). In univariate analysis, among the patients with a younger age (18-39 years), moderate MGD, higher baseline S ɪ t and higher baseline OSDI, the IPL treatment had a higher effective rate (P = .032, .004, .024, and .014 respectively). The MGD severity was strongly associated with effective IPL, and patients with moderate MGD had an OR of 22.454 compared with the severe MGD patients (OR = 22.454, 95% CI: 2.890-174.436, P = .003).IPL effectively improves clinical symptoms and some signs in MGD patients. Age, MGD severity, baseline S ɪ t and baseline OSDI are potential factors that may influence the clinical outcomes of IPL. MGD severity is an independent influencing factor.

The Effect of Meibomian Gland Dysfunction Treatment on Sleep Quality

Purpose

To assess the therapeutic efficacy of a combinational therapy, including conventional treatment and intense pulsed light (IPL) technique on sleep quality of patients with meibomian gland dysfunction (MGD).

Methods

Fifty participants with a clinical diagnosis of MGD were enrolled in this study. Participants underwent three sessions of IPL therapy. There was a 2-week interval between IPL sessions 1 and 2 and 1 month between sessions 2 and 3. Treatment was supplemented with conventional home-based therapy (including lid hygiene, warm compress, eyelid massage, and lid margin scrub) for MGD. Dry eye symptomatology, tear film, and ocular surface parameters were evaluated at baseline (day 0) and days 15, 45, and 75. Sleep quality was assessed before and after the study using Pittsburgh Sleep Quality Index (PSQI).

Results

PSQI components improved significantly at day 75 in comparison with the baseline (all P < 0.05). Ocular Surface Disease Index (OSDI) score, noninvasive Keratograph tear break-up time (NIKBUT), fluorescein tear break-up time (FTBUT), meibomian gland expressibility, meibum quality score, and tear osmolarity improved at follow-up visits (P < 0.05). Younger patients showed more improvement in NIKBUT, sleep quality, and duration (P = 0.024, P = 0.047, and P = 0.008). Sleep latency decreased with increased NIKBUT and FTBUT and decreased OSDI score (P = 0.001, P = 0.005, and P = 0.041).

Conclusions

The treatment of MGD is effective for improving sleep quality. Younger patients may preferentially benefit from the treatment.

Safety and Efficacy of BroadBand Intense Pulsed Light Therapy for Dry Eye Disease with Meibomian Gland Dysfunction

Background

BroadBand light intense pulsed light (BBL-IPL) therapy has shown to reduce hordeolum and blepharitis frequency. This study aims to evaluate the efficacy and safety of BBL-IPL therapy in patients with dry eye disease (DED) from meibomian gland dysfunction (MGD).

Methods

This is a retrospective, consecutive case series of 48 patients with DED from MGD who underwent BBL-IPL therapy from October 2016 to January 2019 at a single, outpatient clinic in Ontario, Canada. Clinical outcomes included first and average non-invasive keratograph tear break-up times (NIKBUT), bulbar redness (BR) scores, tear meniscus heights (TMH), visual acuity (VA) and meibograph grades. Patient-reported outcomes included the Canadian dry eye assessment (CDEA) questionnaire and patient subjective assessment (PSA) scores. Outcomes were measured at baseline and after completion of 4 monthly BBL-IPL sessions.

Results

The mean severity of dry eye symptoms as measured by the CDEA and PSA decreased significantly from 19.78 ± 9.62 to 12.08 ± 7.40 (p<0.001) and from 7.65 ± 1.74 to 4.77 ± 2.03 (p<0.001), respectively. Twenty-five percent of patients reported no dry eye symptoms after treatment. The meibograph grade improved significantly in both eyes (p<0.001). Approximately 71.0% and 80.1% of patients had an improved meibograph grade in the right and left eye, respectively. Near-significant improvements were observed for BR scores and VA. There was also a trend towards improved first/average NIKBUT and TMH scores. No adverse events were noted.

Conclusion

BBL-IPL appears to be an effective and safe treatment modality in improving dry eye symptoms and meibomian gland function in patients with DED from MGD.

Efficacy of five-flash intense pulsed light therapy technique in patients with meibomian gland dysfunction

CLINICAL RELEVANCE

Meibomian gland dysfunction is the main cause of evaporative dry eye disease and can lead to ocular discomfort and ocular surface damage. Early diagnosis and management of this condition can prevent its impact on patients 'visual health and quality of life.

BACKGROUND

In the last decade, intense pulsed light therapy (IPL) has been introduced as a therapeutic option for patients with meibomian gland dysfunction (MGD). Various treatment modalities and protocols have been reported to increase the efficacy of this technique. This study aimed to assess the efficacy of a novel five-flash IPL technique in combination with home-based therapy and to compare it with conventional home care alone in patients with MGD.

METHODS

In a randomised controlled trial, 100 symptomatic MGD patients were enrolled. The treatment group underwent three sessions of a five-flash IPL therapy. For all participants, eyelid warming, lid hygiene and lubricant therapy was prescribed. Ocular surface parameters were compared for control and treatment groups.

RESULTS

Ocular Surface Disease Index (OSDI), non-invasive keratograph tear break up time (NIKBUT), fluorescein TBUT, MG expressibility, meibum quality and tear osmolarity were improved at follow up visits in both groups (p < 0.05). On day 75, NIKBUT was significantly higher in the IPL group (p = 0.045). The IPL treatment effect was not statistically significant (p > 0.05), except for bulbar and limbal hyperaemia (p = 0.02 and p = 0.02). In both groups, younger patients showed more improvement in NIKBUT (p = 0.02, r = -0.32; p < 0.001, r = -0.52).

CONCLUSION

IPL therapy combined with conventional home-based therapy, and home care alone are both effective for patients with MGD. IPL may have an additional role in the improvement of ocular hyperaemia.

Annual direct economic burden and influencing factors of dry eye disease in Central China

PURPOSE

To study the direct economic burden of dry eye diseases (DED) on Chinese residents and analyze the influencing factors of the direct economic burden of patients with DED.

METHODS

Two hundred and twenty-one Chinese adults with DED who underwent treatment in Wuhan Aier Hankou Eye Hospital were enrolled in this health economics research from January 2018 to August 2018 and followed for at least 1 year. Examination, pharmacological therapy, and nonpharmacological therapy costs were collected to calculate the annual direct economic burden of DED on patients through the outpatient medical record system.

RESULTS

Annual direct economic burden caused by DED on each patient was $465.54 ± 303.08. The direct economic burden of female patients in the 40-49 years group was significantly higher than that of male patients (P < .05). Age, number of hospital visits and severity of DED were showed a significant influence on the direct economic burden both in univariate linear regression analysis and multiple linear regression analysis. Subtype of DED was showed a significant influence on the direct economic burden in multiple linear regression analysis after eliminating confounding factors.

CONCLUSION

This study preliminarily analyzed the direct economic burden of Chinese DED patients. Age, number of hospital visits, severity of DED, mixed and evaporative dry eye (EDE) subtypes are shown to be the significant influencing factors of the direct economic burden and sex is a potential influencing factor.

Prospective trial of a 2940 nm Er:YAG laser for the treatment of meibomian gland dysfunction

PURPOSE

The primary objective was to evaluate the efficacy and safety of Er:YAG laser treatment for meibomian gland dysfunction (MGD) in a prospective study.

METHODS

A total of 128 eyes from 64 patients with MGD were enrolled to receive either three Er:YAG laser treatments with meibomian gland expression (MGX) or MGX-alone treatment sessions at 3-week intervals. The Standard Patient Evaluation of Eye Dryness (SPEED) validated questionnaire; fluorescein breakup time of the tear film (FBUT); corneal fluorescein staining (CFS); lid margin abnormalities; meibomian gland morphology (meiboscore); lower tear meniscus height (TMH); and assessment of 15 meibomian glands in the lower eyelids, including total meibomian gland secretion quality (TMGS), the number of glands secreting any liquid (GSAL), and the number of glands yielding optimal clear liquid secretion (GYCL), were assessed at day (D)0, D21, D42, and D63 for the Er:YAG-MGX group and D0 and D63 for the MGX group.

RESULTS

At D63, significant decreases in SPEED scores and lid margin abnormalities as well as significant increases in FBUT, TMGS, and GSAL were observed in both groups (all p < 0.05). The Er:YAG-MGX group showed a significantly better improvement in SPEED scores, TMGS, and GYCL than the MGX group (all p < 0.05).

CONCLUSION

Although preliminary, the study results of Er:YAG laser treatment for dry eye syndrome caused by MGD are promising. Er:YAG laser treatment may be a new direction for managing MGD.

TRIAL REGISTRATION

The study was registered at www.chictr.org.cn : ChiCTR1900026004.

Effects of lid debris debridement combined with meibomian gland expression on the ocular surface MMP-9 levels and clinical outcomes in moderate and severe meibomian gland dysfunction

Background

To evaluate the effects of lid debris debridement and meibomian gland expression (MGX) on extracellular matrix metalloproteinase-9 (MMP-9) levels and clinical outcomes of moderate and severe MGD.

Methods

In this retrospective case series study, a total 48 eyes of 24 patients with moderate and severe MGD underwent one session of lid debris debridement using the BlephEx combined with MGX. We evaluated the tear film break-up time (TBUT), corneal and conjunctival fluorescein staining scores, Schirmer 1 test, biomicroscopic examination of lid margins and meibomian gland (MG), ocular surface disease index (OSDI) questionnaire score, and extracellular MMP-9 levels using a point-of-care MMP-9 immunoassay device before and 4 weeks after lid debris debridement and MGX. Linear mixed model and generalized estimating equations model were used to evaluate possible differences.

Results

There were significant improvements in the TBUT (P = 0.002), SICCA and Oxford staining scores (all P < 0.001), lid margin telangiectasia (P < 0.001 for upper and lower eyelids), lid thickness (P < 0.001 for upper and lower eyelids), MG orifice plugging (P < 0.001 for upper and lower eyelids), meibum color (P = 0.026 for upper eyelid, P < 0.001 for lower eyelid), meibum consistency (P < 0.001 for upper and lower eyelids), meibum grade (P < 0.001), MGD stage (P < 0.001), and OSDI score (P = 0.002). MMP-9 immunoassay positivity rate significantly decreased from 83.3 to 50.0% 4 weeks after treatment (P = 0.014).

Conclusions

In patients with moderate to severe MGD, lid debris debridement using the BlephEx combined with MGX improved clinical findings, subjective symptoms, meibomian gland function, along with ocular surface MMP-9 level. We hereby suggest lid debris debridement using BlephEx combined with MGX as an effective clinical strategy for treatment of moderate to severe MGD.

Prospective evaluation of a new intense pulsed light, thermaeye plus, in the treatment of dry eye disease due to meibomian gland dysfunction

PURPOSE

This study aims to estimate the efficacy and safety of a new intense pulsed light (IPL) Thermaeye Plus for dry eye disease (DED) secondary to meibomian gland dysfunction (MGD).

PATIENTS AND METHODS

This is a prospective, longitudinal study of patients with moderate to severe MGD. Treatment consisted of 4 consecutive IPL sessions, 12 flashes with the same energy 8J/cm² on the periocular area at days 1, 14, 28, and 49. All patients were evaluated before each IPL sessions and 1 and 4 months after the last session. Measuring: Symptoms score and OSDI questionnaire, Non-invasive tear meniscus height (NITMH), Non-invasive break up (NITBUT), Tear osmolarity (TO), Corneal fluorescein staining (CFS) and Eyelid margin and Meibomian gland assessment. The adverse effects on the eye, periocular area, and systemic complications were evaluated. All types of skin pigmentation (Fitzpatrick scale I to VI) were included.

RESULTS

The study included 44 consecutive patients (88 eyes), 40 males and 48 females, with a mean age of 52.5±13.6 years, ranging from 22 to 78 years. Significant improvements were observed in single and total signs and symptoms. The most significant changes were observed in dryness, foreign body sensation (p<0.001), and pain (p<0.005). The OSDI questionnaire showed a significant decrease in total symptoms (p<0.003). The percentage of patients with a normal index <13, improved from 23.8% (10 patients) at baseline to 80.9% (34 patients) at last visit, after 23 weeks. Clinical sings also improved, more than 90%, stand out telangiectasia and blepharitis (p<0.002, and p<0.0005, respectively). No statistical differences between age (<40y, 40-60y, and >60y) and gender were observed. The clinical improvement began after the second and third week after the first IPL session, until the end of the IPL treatment (D49). After that, the results maintained stable until the last visit, after 11 weeks. No complications were reported locally, nor in the periocular area as well as systemically.

CONCLUSION

Thermaeye Plus, a new IPL for ophthalmic use, is a safe and effective treatment in patients with DED due to MGD, showing improvement from the second week of treatment and maintaining until the last visit, 4 months after the last IPL session (23 weeks of total follow-up). Patients with pigmented skin (Fitzpatrick V or VI) have been treated with no side effects. It is relevant, especially to apply in brown-dark skin populations since complications with other IPL devices have been reported.

Modern approach to the treatment of dry eye, a complex multifactorial disease: a P.I.C.A.S.S.O. board review

Dry eye disease (DED) is a growing public health concern affecting quality of life and visual function, with a significant socio-economic impact. It is characterised by the loss of homoeostasis, resulting in tear film instability, hyperosmolarity and inflammation of the ocular surface. If the innate immune response is unable to cope with internal bodily or environmental adverse conditions, the persistent, self-maintaining vicious circle of inflammation leads to the chronic form of the disease. Treatment of DED should be aimed at the restoration of the homoeostasis of the ocular surface system. A proper diagnostic approach is fundamental to define the relevance and importance of each of the DED main pathogenic factors, namely tear film instability, epithelial damage and inflammation. Consideration also needs to be given concerning two other pathogenic elements: lid margin changes and nerve damage. All the factors that maintain the vicious circle of DED in the patient's clinical presentation have to be considered and possibly treated simultaneously. The treatment should be long-lasting and personalised since it has to be adapted to the different clinical conditions observed along the course of the disease. Since DED treatment is frequently unable to provide fast and complete relief from symptoms, empathy with patients and willingness to explain to them the natural history of the disease are mandatory to improve patients' compliance. Furthermore, patients should be instructed about the possible need to increase the frequency and/or change the type of treatment according to the fluctuation of symptoms, following a preplanned rescue regimen.

Comparative Evaluation in Intense Pulsed Light Therapy Combined with or without Meibomian Gland Expression for the Treatment of Meibomian Gland Dysfunction

OBJECTIVE

To determine whether the combination of meibomian gland expression (MGX) with intense-pulsed light (IPL) has a better efficacy to treat meibomian gland dysfunction (MGD) than IPL alone.

METHODS

One hundred patients with MGD were randomly divided into three groups: MGX, IPL, and IPL+ MGX. Clinical parameters included the Ocular Surface Disease Index (OSDI), tear meniscus height (TMH), noninvasive keratograph tear breakup time (NIBUT), redness, meibomian gland dropout, tear breakup time (TBUT), corneal fluorescent staining (CFS), eyelid margin score, meibomian gland secretion function, and Schirmer I tests were collected before treatment and at 1 and 3 months after treatment. Compare the indexes of each group before and after treatment and also compare the differences of each group on follow-up.

RESULTS

Compared to the baseline, OSDI, TBUT, and meibomian gland secretion function in IPL group improved throughout the follow-up period (all P < .05) and part of the meibomian gland secretion function increased continuously. OSDI, TBUT, lower eyelid margin scores, and meibomian gland secretion function in IPL + MGX group improved at the both follow-up visits (all P < .05), and continued improvement in meibomian gland secretion function can be observed. Lower meibomian gland dropout and CFS reduced at 1 month and 3 months respectively in IPL ± MGX group (P = .001,P = .001).Compared to IPL group, only CFS has reduction in IPL + MGX group at 1-month (P < .001), CFS, upper and lower MGYCS were improved at the 3 months (P = .037,P = .014, P = .049).

CONCLUSIONS

MGX may have synergistic effect when combined with IPL therapy, and the effect can last at least 3 months.

[Efficacy of intense pulsed light therapy in the treatment of Meibomian gland dysfunction-related severe dry eye]

INTRODUCTION

Dry eye syndrome caused by Meibomian gland dysfunction (MGD) is a common disease in the general population and impairs quality of life. Intense Pulsed Light (IPL) has mainly been used in dermatology for the treatment of skin disorders, and more recently for MGD-related dry eye. The objective of our study is to evaluate the efficacy and tolerability of IPL with the E-Eye® device (E-Swin, Houdan, France) in severe MGD-related dry eye patients.

MATERIALS AND METHODS

This non-comparative study included 20 patients with MGD-related dry eye with a Break-Up Time (BUT)<10seconds, dry eye symptoms >30mm on a Visual Analog Scale (VAS), and failure of lid hygiene and artificial tears. Treatment consisted of 3 sessions of IPL on D0, D15, and D45 (5 flashes of 13J/cm² per eye). The following parameters were assessed at each visit and at D75 : symptoms graded with a VAS and the Standard Patient Assessment of Eye Dryness questionnaire (SPEED), BUT, corneal fluorescein staining, Meibomian gland expression score, meibography, tear film lipid layer thickness by interferometry and the ocular scattering index by double-pass aberrometry (OQAS). Statistical analysis was performed on the eye most affected at baseline.

RESULTS

We included 40 eyes of 20 patients, 15 female and 5 male, mean age 47±15 years (24 to 74 years). The symptoms rated by VAS were severe, averaging 69±25mm. After treatment, there was a statistically significant decrease in symptoms, with a 14mm VAS decrease (55±29mm at D75 versus 69mm at D0, P=0.048) and SPEED score of 3.4 (19.0±6mm versus 22.4±4.6, P=0.03). The number of expressible Meibomian gland ducts increased significantly (from 5.9 to 8.1, P=0.04), lid redness decreased (from 1.4 to 0.6, P=NS) and BUT improved (from 4.2 to 5.9, P=NS). Other parameters remained unchanged. Three patients (15%) complained of transient ocular burning after each treatment.

CONCLUSION

IPL appears to be effective in improving signs and symptoms in patients with severe MGD-related dry eye, with a good safety profile. Its exact mechanism of action remains to be elucidated.