Meibomian Gland Dysfunction: Intense Pulsed Light Therapy in Combination with Low-Level Light Therapy as Rescue Treatment

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.

[Role of neodymium laser in surgery: stimulation of postoperative surgical wounds healing. Results of clinical studies]

OBJECTIVE

To prove the effectiveness of the low-intensity laser radiation application in the treatment of wounds of different origin.

MATERIAL AND METHODS

The clinical study involved 110 persons, divided into 55 subjects in both the study and control groups. The patients of the study group were exposed to the long-wave short-pulse neodymium laser immediately and within 35 days after interventions with a skin incision using it, in a way that wound treated with laser received low-level laser therapy. The control group patients' wounds were treated with standard methods by the means of topical drugs corresponding to the clinical manifestations of the wound process in each particular case. The study was carried out in the hospital of the department of maxillofacial and plastic surgery of the dental complex of the «Russian University of Medicine» from 2019 to 2022, and further conservative treatment was conducted in the department of dermatology and cosmetology of the University Hospital of the Medical Graduate School (Institute) of the RSSU. All wounds were classified into three groups for the convenience of systematization and formation of a generalized treatment protocol for postoperative surgical wounds.

RESULTS

The objectivity and optimality of the chosen by us actions were confirmed in the conducted work. The formed scars were visually assessed on the POSAS scale at the end of the treatment by patients and 4 independent doctors, as well as each scar was visually assessed by four independent doctors and patients. At the end of the study we formed and proposed an algorithm for the treatment of surgical wounds of various origins. The parameters of the Aerolase Neo Light Pod neodymium laser for the treatment of patients with different types of skin wounds were clinically determined. Experimentally proven properties of the Aerolase Neo Light Pod neodymium laser on accelerating the healing process of surgical wounds through photobiomodulation mechanism support their regeneration with the formation of negligible normotrophic scars, as well as reduce the length of patients' treatment in surgical hospitals, as compared to patients receiving standard external drugs.

Comparison of Light-Based Devices in the Treatment of Meibomian Gland Dysfunction

PURPOSE

To compare different light-based devices, namely, intense pulsed light (IPL) and IPL with low-level light therapy (LLLT), in the treatment of meibomian gland dysfunction (MGD).

METHODS

This was a prospective, observational study that included patients with MGD. Group 1 included 58 eyes treated with IPL (eye-light®, Espansione Marketing S.p.A., Bologna, Italy), followed by LLLT (my-mask®, Espansione Marketing S.p.A., Bologna, Italy); Group 2 included 60 eyes treated with IPL (E>Eye®, E-Swin, Houdan, France); and Group 3 included 58 eyes treated with IPL (Thermaeye Plus®, OptiMed, Sydney, Australia). The presence of symptoms (Ocular Surface Disease Index (OSDI)) and ocular surface changes were evaluated at baseline, three weeks, and six months after treatment.

RESULTS

At week three, there was an improvement in the OSDI in all groups (p<0.001), without differences among them (p=0.339). The lipid layer thickness (LLT) increased in Groups 1 and 2 (p<0.001), with a similar variation (p=0.144). Patients with superior OSDI and lower LLT at baseline had the greatest improvement in the respective parameters (p<0.001). The basal tear flow increased in Group 1 (p=0.012). Corneal staining (CS) significantly decreased in Groups 2 (p<0.001) and 3 (p<0.001). At six months, compared to three weeks, there was further improvement in the OSDI (p<0.001) and the LLT (p=0.007), in Group 1, and an increase in the presence of CS in Group 3 (p=0.011).

CONCLUSION

IPL treatment led to a sustained decrease in patients' symptoms, even after six months. Different IPL devices seem to have different beneficial effects. Adding LLLT to IPL appears to have an additional long-term beneficial effect as well as positive effects on the lacrimal gland.

A comparative review of evaporative dry eye disease and meibomian gland dysfunction in dogs and humans

Dry eye disease is a complex ophthalmic disorder that consists of two main subtypes, aqueous deficient dry eye (ADDE) and evaporative dry eye disease (EDED). Due to the complex underlying physiology, human dry eye disease can be difficult to model in laboratory animal species. Thus, the identification and characterization of a spontaneous large animal model of dry eye disease is desirable. Dogs have been described as an ideal spontaneous model of ADDE due to the similar pathophysiology between dogs and humans. Recently, EDED and meibomian gland dysfunction (MGD) have been increasingly recognized and reported in dogs. These reports on EDED and MGD in dogs have identified similarities in pathophysiology, clinical presentations, and diagnostic parameters to humans with the comparable disorders. Additionally, the tests that are used to diagnose EDED and MGD in humans are more easily applicable to dogs than to laboratory species due to the comparable globe sizes between dogs and humans. The reported response of dogs to EDED and MGD therapies are similar to humans, suggesting that they would be a valuable preclinical model for the development of additional therapeutics. Further research and clinical awareness of EDED and MGD in dogs would increase their ability to be utilized as a preclinical model, improving the positive predictive value of therapeutics for EDED and MGD in both humans and dogs.

Serial Sessions of a Novel Low-Level Light Therapy Device for Home Treatment of Dry Eye Disease

INTRODUCTION

This study aimed to evaluate the changes that a recently developed at-home device using low-level light therapy (LLLT) produced in signs and symptoms of patients with dry eye disease (DED) owing to meibomian gland dysfunction (MGD).

METHODS

In this prospective study, patients with DED owing to MGD not successfully responding to first-line therapy (tear substitutes and eye lid hygiene) were treated with four serial sessions (every other day) of mask based on LLLT technology and dedicated for home use (my-mask^®, Espansione Marketing S.p.A., Bologna, Italy). Non-invasive ocular surface examination was carried out by means of Keratograph 5M (Oculus, Wetzlar, Germany) before and after four mask sessions for the evaluation of (i) tear meniscus height (TMH); (ii) first and average non-invasive Keratograph breakup time (NIKBUT); (iii) meibomian gland loss (MGL). Ocular Surface Disease Index (OSDI) questionnaire was used to assess ocular discomfort symptoms.

RESULTS

Overall, 17 patients (3 male, 14 female; mean age 61.47 ± 11.93 years) were enrolled and all of them regularly completed the entire cycle of four sessions without reporting any adverse event. The mean values of NIKBUT first and NIKBUT average increased significantly after treatment (from 5.29 ± 2.60 at T0 to 9.04 ± 3.49 s at T1 [P = 0.001] and from 9.40 ± 3.81 to 11.28 ± 2.81 s [P = 0.017]); in parallel, the mean value of TMH increased significantly from 0.27 ± 0.06 to 0.32 ± 0.09 mm (P = 0.029). Conversely, there were not statistically significant differences for MGL (P = 0.346). In addition, the mean value of OSDI score decreased after treatment (from 32.00 ± 7.96 at T0 to 20.71 ± 8.03 at T1; P < 0.001).

CONCLUSIONS

One week of serial sessions of a newly developed LLLT device for home use significantly improved tear film production and stability along with ocular discomfort symptoms in patients with DED owing to MGD. These findings open up a new scenario for patients with MGD who can enjoy the unique benefits of LLLT at home.

Low-Level Light Therapy Versus Intense Pulsed Light for the Treatment of Meibomian Gland Dysfunction: Preliminary Results From a Prospective Randomized Comparative Study

PURPOSE

The purpose of this study was to evaluate and compare the safety and efficacy of low-level light therapy (LLLT) and intense pulsed light (IPL) for the treatment of meibomian gland dysfunction (MGD).

METHODS

Forty eyes of 40 patients with MGD were randomized to receive either LLLT or IPL. Four weekly sessions of LLLT (MY MASK-E, Espansione Marketing S.p.A., Bologna, Italy) and IPL (Eye-light device, Espansione Marketing S.p.A., Bologna, Italy) were performed. The following parameters were evaluated before and 2 weeks after the last session for each treatment: Standard Patient Evaluation of Eye Dryness questionnaire, noninvasive break-up time, tear meniscus height, redness score, meiboscore, and meibomian gland loss.

RESULTS

All patients completed regularly all the scheduled sessions, and no adverse events were reported in any of the groups. The Standard Patient Evaluation of Eye Dryness score significantly decreased after both LLLT and IPL (P < 0.001) although the improvement was significantly greater in the LLLT compared with the IPL group (-9.9 ± 3.2 vs. -6.75 ± 4.5; P = 0.014). Patients in the LLLT group showed a significantly higher increase in tear meniscus height compared with those in the IPL group (0.06 ± 0.10 mm vs. -0.01 ± 0.014; P = 0.040). In both groups, the noninvasive break-up time, redness score, meiboscore, and meibomian gland loss did not vary significantly after treatment (all P > 0.05).

CONCLUSIONS

Both LLLT and IPL were safe and effective in improving ocular discomfort symptoms in patients with MGD; however, the former determined a greater improvement in symptoms and an improvement of tear volume.

Intense Pulse Light Combined With Low-Level Light Therapy in Dry Eye Disease: A Systematic Review

OBJECTIVES

To evaluate the improvement in symptoms and signs associated with intense pulse light (IPL) combined with low-level light therapy (LLLT) in the treatment of dry eye disease (DED).

METHODS

A systematic review of full-length original studies reporting the effects of IPL combined with LLLT for DED in two databases, PubMed and Scopus, was performed according to the PRISMA statement. The quality assessment tool for case series studies from the National Heart, Lung, and Blood Institute was used to analyze the quality of the studies selected.

RESULTS

The search provided a total of 393 articles, of which six were included. Significant decreases in the Ocular Surface Disease Index (OSDI) score, meibomian gland dysfunction (MGD) score, MGD grade, and meiboscore and increases in tear film stability, lipid layer thickness, and loss area of the meibomian gland have been reported. Concerning tear volume, tear meniscus height, and Schirmer test remained unchanged. In relation to tear osmolarity and corneal fluorescein staining, contradictory outcomes were found.

CONCLUSIONS

Intense pulse light combined with LLLT for the treatment of dry eye improves OSDI, tear film stability, and meibomian gland function; thus, this treatment may be recommended for DED patients due to MGD.

Eyelid Warming Devices: Safety, Efficacy, and Place in Therapy

Meibomian gland dysfunction (MGD) is characterized by the obstruction and/or inflammation of the meibomian glands that result in decreased and altered meibum secretion. This results in deficiencies in the tear film lipid layer which contributes to increased evaporation and destabilization of the tear film. One of the mainstay therapies for MGD is medical devices that apply heat and/or pressure to the eyelids and promote the liquification and outflow of meibum into the tear film. Over the past two decades, there have been a surge of interest in diagnosing and managing MGD. As a result, numerous medical devices have been developed and each have their own unique approach to treating MGD. This narrative review was conducted to summarize the current state of knowledge on eyelid warming devices, specifically warm eye coverings, devices that direct heat and/or pressure to the eyelids, moisture chamber goggles, and light-based therapy. This review summarized 58 human clinical studies and found that most eyelid warming devices were efficacious in improving signs and symptoms in a wide range of MGD severities and were generally safe to use.

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.