Is intense pulsed light (IPL) therapy a light at the end of the tunnel for dry eye disease (DED) patients? I would argue that it’s definitely worth considering for these patients.

So, how does this previously primarily dermatologic and aesthetics treatment work on DED, who are the patient candidates, and how can you explain it to them?

How does it work?
IPL delivers light energy (non-laser) in different wavelengths to targeted tissue. These different wavelengths are then absorbed at different levels of the tissue, which may be used to treat pigmented structures within the skin, including melanin and hemoglobin.^1,2,3 

The exact wavelengths utilized by a particular IPL unit may vary among manufacturers, but the higher the wavelength, the deeper the treatment target is within the skin. Inversely, the lower the wavelength, the shallower the treatment target within the skin.³

When it comes to DED, IPL helps address inflammation at its root by improving meibomian gland function, ocular rosacea, and both bacterial and Demodex blepharitis. Additionally, it aids in decreasing the release of pro-inflammatory molecules and increasing the release of anti-inflammatories in tears.⁴ The outcome is improved meibomian gland function and structure, which creates improved meibum quality. This is, in theory, related to a photochemical process from the IPL’s light energy liquifying meibum within the glands. By helping to remove obstruction, it improves the structure of the meibomian glands.

Patient candidates
Because of how IPL works and melanin is one of its targets, skin typing patients, using the Fitzpatrick Scale (left), is important prior to initiating treatment.

Patients with pre-discussed issues, including rosacea, meibomian gland dysfunction, and blepharitis, who are Fitzpatrick skin type from I to IV would benefit from IPL.

On the other hand, patients with deeply pigmented skin and Fitzpatrick skin type V and VI are at high risk for burns and blistering and, therefore, not your typical IPL candidates. However, more research and protocols are currently being developed to help address IPL use in these patients. Additionally, patients who have active sunburn, healing wounds, or active herpetic infection should not undergo the treatment. We also want to avoid treating direct areas of facial melasma and scarring, as well as facial and eyeliner tattoos. Similarly, if the patient has any suspicious pre-cancerous lesions, uncontrolled immunosuppressive disease or ocular infections in the last 6 months, treatment should be postponed. Lastly, if the patient is actively using any photosensitive medications, such as doxycycline, or is planning to receive radiation therapy or chemotherapy to the area, be aware of increased risk for burns, and consider appropriate adjustments or a washout period.

Explaining it
When discussing MGD with the patient, I recommend talking about the underlying causes, including bacteria, Demodex, and inflammation and then, how, specifically, IPL can help. An example script: “Ms. Smith, to help improve the function of your meibomian glands and decrease your symptoms, we need to perform IPL. This is a light therapy that has been used safely in dermatology and for nearly a decade in eye care to treat MGD. It will target the bacteria, decrease the inflammation, and help to improve the expression of your meibomian glands. We will do an initial 3 to 4 sessions, 4 to 6 weeks apart with manual gland expression at each appointment. We will likely need to perform touch up treatments every 3 to 6 months depending on how you respond to the treatment.”

Cecelia Koetting, OD, FAAO is a clinical instructor at the University of Colorado School of Medicine. She is a fellow of the American Academy of Optometry, diplomate of the American Board of Optometry, an active American Optometric Association member, and she consults for multiple companies. Email her at Dr.CeceliaKoetting@gmail.com.

References
1. Toyos R, Toyos M, Willcox J, Mulliniks H, Hoover J. Evaluation of the safety and efficacy of intense pulsed light treatment with meibomian gland expression of the upper eyelids for dry eye disease. Photobiomodul Photomed Laser Surg. 2019;37(9):527-531. doi:10.1089/photob.2018.4599

2. Dell SJ. Intense pulsed light for evaporative dry eye disease. Clin Ophthalmol. 2017;11:1167-1173. doi: 10.2147/OPTH.S139894.

3. Schroeter CA, Haaf-von Below S, Neumann HA. Effective treatment of rosacea using intense pulsed light systems. Dermatol Surg. 2005;31(10):1285-1289. doi:10.1111/j.1524-4725.2005.31204.

4. Suwal A, Hao JL, Zhou DD, et al. Use of intense pulsed light to mitigate meibomian gland dysfunction for dry eye disease. Int J Med Sci. 2020;17(10):1385-1392. doi:10.7150/ijms.44288.