IPL for the management of MGD/DED Dr. Jeffrey Judelson, FRCSC
IPL presentation Introduction to IPL Clinical evaluation of DED/MGD Overview of management multifaceted approach
DED/MGD basics Prevalence in a variety of populations between 7-33% Two major types 1. aqueous deficient and 2. evaporative dry eye caused by MGD Majority of patients seen clinically with DED suffer from MGD and evaporative dry eye
Meibomian gland review 20-30 glands lower and 30-40 glands upper lids Superficial lipid layer consists of all lipid classes. Waxy esters, triglycerides, cholesterol esters, hydrocarbons, free fatty acids, free cholesterol and phospholipids. Thickness varies between 0.1 to 0.2u. (Aqueous layer 6.5 to 10u and Mucin layer 0.02 to 0.04u thick)
Meibomian gland review Movement of lipid along the duct to the surface facilitated by contraction of the orbicularis muscle. Normal lid function required Lipid layer thickens with a narrowed palpebral aperture Uncertain whether under sympathetic or parasympathetic control PH about 7.4 (7.3-7.7). Osmotic pressure about 305 mosm/kg.
Lipid layer function Retard tear evaporation Assist in uniform tear spreading by lowering surface tension Dysfunction leads to an unstable tear film/ decrease TBUT
IPL Xenon flash lamp generates a broad wavelength of light Filters used to allow treatment with specific wavelengths approx. 550nm Parameters include energy (fluence) and adjustment for pulses in milliseconds Wavelength absorbed by the skin, blood cells, gland and pigment
Lumenis M22 Most sophisticated IPL unit Self calibrating no loss of power with treatment Customize treatment for skin type Painless procedure due to water cooling as apposed to other IPL units Preset with Toyos treatment parameters
Proposed mechanisms of action: 1. Close abnormal blood vessels/telangiectasis Longstanding treatment for Rosacea Light from IPL absorbed by oxyhemoglobin generating heat and closing of abnormal blood vessels Closing of telangiectasis improves inflammation by reducing inflammatory cytokines Rosacea usually associated with MGD
2. Photomodulation Light may stimulate the cellular process like mitochondria May stimulate fibroblasts to produce collagen skin changes Specific wavelengths/parameters may stimulate meibomian glands
3.Heat Generation Eyelid temperature is normally 33 degree C Abnormal meibum has a higher melting temperature than 33 degrees Warm compresses can raise temperature to 38 degrees Lipiflow heats inner lids to 42.5C IPL heats from dermal to epidermal layer (opposite to warm compressors). Makes manual expression easier.
4. Photodynamic toxicity oxidative damage Ability to kill bacteria and demodex Overgrowth of bacteria/demodex in MGD Staph epidermis and Aureus, P. Acnes and Corynebacterium Overgrowth of bacteria can lead to inflammation and blepharitis Release lipases which breakdown normal fatty acids in tear film. Increased inflammatory cytokine release IPL robots Xenex used to disinfect surgical/hospital facility
IPL treatment protocol Require multiple treatments. Recommended 4 procedures 4-6 weeks apart. Toyos protocol with Lumenis M22 Energy parameters based on skin type (Fitzpatrick scale). Treat patients with type 4 or lower. Lower energy settings with increasing pigmentation of skin due to greater absorption of energy
Fitzpatrick scale
Treatment protocol Approximately 10-15 treatment spots placed on each side then repeat for two passes. Do not treat upper lids risk of iris damage/uveitis Require protective IPL eye shields prevent iris damage/uveitis On completion of IPL aggressive expression of meibomian glands Topical corticosteroid BID or TID for a few days Skin protection with sunscreen. May continue with other dry eye therapies
Eye protection avoid damage to iris/uveitis
IPL treatment
Evaluation of DED/MGD Screening with the OSDI or Speed questionnaire (Standard patient evaluation of eye dryness) Both validated although Speed simpler /quicker to complete Evaluates both the frequency and severity of symptoms 8 simple questions Score 0-28 Questions about symptoms in the present to past three months due to variability of symptoms Score > 8 may need to re evaluate for better control
Screening for DED/MGD Schirmer score (mm/5min) may be variable but less than 10 abnormal Tear meniscus TBUT (sec) less than 10 abnormal. Should be longer than the interval between blinks Corneal conjunctival staining Fluorescein and Lissamine green
Fluorescein staining
Lissamine green
Lid margin/meibomian glands Big picture look at the face Rosacea Margins telangiectasia and inflammation. Lashes as well Meibomian glands expression at slitlamp for oil quality and quantity Quality: 1. normal oil 4. solid inspissated meibum Quantity: 0. no flow 4. maximal free flow with digital pressure
Rosacea
Lid margin
MG expression manual or forceps (Tearse)
MG expression quality grade3
MG expression: quality grade 3
MG expression- meibum quality grade 4
Meibography
MGD a multifaceted approach Heat/hot compresses Hot compresses usually recommended BID Bruder or similar masks may raise temperature to 38 degrees C Normal eyelid temperature 33 degrees C Abnormal meibum higher melting temperature Lipiflow may raise inner lid temperature to 42.5 degrees IPL heats from deeper dermal layer.? Temps as high as 62C
Supplements Omega 3s (PUFA) ALA in plants and EPA and DHA in fish Reduce inflammation Triglyceride and Ethyl Ester forms Ethyl Ester has less absorption and bioavailability Recommended brands: PRN, Nordic naturals.
Omega 3 index
Antibiotics MGD and Rosacea Doxycycline 50-200 mg/day. GI side effects Minocycline 50 to 200mg BID PO Azithromycin. Better tolerated. Cycle treatment 5 days per month. 500mg day one then 250mg for four days.
Literature summary Longstanding history for treatment of Rosacea Overall has not been well studies and currently limited studies in the literature Recent study: Outcomes of IPL therapy for the treatment of evaporative dry eye disease. CJO August 2016. Preeya K. Gupta et al. Multicentre study. Statistical improvement in a number of parameters including: Facial/lid margin telangiectasia, OSDI score, oil flow and decrease meibum viscosity. Improved TBUT.
Summary of IPL therapy Safe and effective for evaporative eye disease Another option for a difficult to treat pathology with compliance issues Needs to be combined with other traditional therapies Not all patients candidates Fitzpatrick score >4 Cost may be an issue with some patients
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