Evolving eye care with light therapy, part 2: Intense pulsed light therapy

(Image credit: Adobe Stock / ©Michael)

The utilization of light therapy is an evolving science in eye care. Our ability to manage ocular surface disease has evolved because of our additional knowledge of light therapy. In my last article, I discussed low-level light therapy and its beneficial role in ocular surface disease management. In this article, I will discuss intense pulsed light (IPL) therapy and its role in managing ocular surface disease.

How does it work?

As its name implies, IPL is light that is pulsed at the surface of the skin, and components in the skin called chromophores absorb the light energy. Various chromophores are sensitive to different light wavelengths, which are applied to the area of the skin being treated. Shorter wavelengths of light typically penetrate the skin at shallower depths than longer wavelengths of light.¹

Light is applied to the surface of the skin in those wavelengths that will optimize the desired clinical outcomes. IPL has been utilized to minimize vascular and pigmented lesions and remove unwanted hair.^2,3 In eye care, we leverage our understanding of IPL’s ability to reduce inflammation in the skin to improve ocular surface outcomes.

Why is it used for dry eye?

Meibomian gland dysfunction (MGD) plays a significant role in dry eye disease. Estimates place MGD as having a role in 86% of cases of dry eye.⁴ So improving meibomian gland functionality is critical to effectively managing dry eye disease. Additionally, it is well documented that the inflammation is elevated in the tear film and ocular surface of patients with dry eye disease.^5,6 Understanding these underlying pathophysiological ocular characteristics helps us target treatment to alter them to promote a healthy ocular surface state.

Inflammation in the skin creates visible telangiectatic blood vessels, which cause the dilation and superficial migration of blood vessels. Because the blood supply for the face includes the blood supply for the eyelids, inflammatory conditions that affect the skin can also affect the eyelids.⁷ This can affect the health of the meibomian glands.⁸ When MGD is associated with rosacea, we refer to this as ocular rosacea.^7,8 Leveraging the power of IPL can help us both promote improved meibomian gland functionality and reduce inflammation.

IPL’s activity

Although the exact mechanism of action of IPL in improving dry eye signs and symptoms is not known, IPL treatment has been shown to provide clinical benefits. Chromophores in the skin allow the absorption of light energy and can cause direct changes to the structures in the tissues. Specifically, hemoglobin located in the telangiectatic vessels in the superficial layer of the dermis absorbs light, which produces localized heat and closes these superficially located blood vessels.^1,9 This reduces inflammation in the tissue.¹⁰ Because these blood vessels are not separate from the vascular supply feeding the eyelid margin, the beneficial effects of IPL will be carried to the eyelids and eyelid margins, directly affecting eyelid function and the meibomian glands.¹¹

Additionally, IPL improves the synthesis of collagen, elastin, and other supporting structures in the dermis, supporting IPL’s role in collagen remodeling.¹⁰ Reduced integrity of the extracellular matrix of the skin causes a loss of elasticity. At the level of the eyelids, this can lead to poor lid apposition and incomplete blinks, which can lead to less efficient meibum secretion from gland orifices.¹¹

Scientific evidence

Several studies have demonstrated the benefits of IPL therapy for those with dry eyes.^11-13 IPL therapy has been shown to improve ocular surface disease index (OSDI) scores, noninvasive tear film break-up time (NITBUT), tear film lipid layer (TFLL) thickness, meibomian gland score, and meibomian gland expression.^14-16 Several other studies have explored the benefits of IPL therapy.

Contact lens discomfort is an important consideration for dry eye treatments. When contact lens designs and materials have been optimized to maximize the comfort of the lens, it is important to treat any underlying ocular surface disease to optimize the ocular surface that will support comfortable contact lens wear. A recent study examined IPL treatment for patients experiencing contact lens–related dry eye for at least 1 year. They randomized groups to receive either 2 IPL treatments 3 weeks apart or 2 sham treatments. The IPL group had improved NITBUT, TFLL thickness, OSDI, and meibomian gland expressibility.¹⁷ This demonstrates benefits for contact lens wearers.

Other specific populations have been studied to determine the potential benefits of IPL therapy. Patients who had post-LASIK refractory dry eye who did not respond to traditional dry eye treatments were randomly assigned to receive 2 IPL treatments 2 weeks apart or sham treatments as the control group. In the treatment group, improvements were noted in NITBUT, OSDI, TFLL thickness and meibomian gland expressibility. Additionally, the frequency of artificial tear use was significantly less in the treatment group.¹⁸ This clearly demonstrates the benefits of IPL therapy in patients with post-LASIK dry eye.

IPL therapy has also been evaluated with other treatments. Another study looked at 3 arms: patients randomly assigned to receive IPL for 3 treatments, each 3 weeks apart; a second group of patients who received the same IPL treatment and a heated eye mask (HEM) to be used daily for 20 minutes; and a third group of patients, the control group, who received neither treatment. Final clinical measurements were taken 6 weeks after the last IPL treatment. At that time, significant improvements in TFLL, NITBUT, corneoconjunctival staining, meibomian gland quality, meibomian gland expressibility, and OSDI were seen in the IPL and IPL plusHEM groups but not in the control group. Additionally, there were significant improvements in the IPL plus HEM group compared with the IPL treatment only group.¹⁹ This study clearly demonstrates the benefit of IPL with or without supplemental heat mask therapy.

IPL therapy has also been studied with supplementary expression. A study examined patients receiving 4 IPL treatments every 2 weeks followed by immediate meibomian gland expression (MGX) compared with a group that had a sham IPL treatment followed by MGX. Several ocular surface measurements were analyzed prior to starting treatment and 1 month after the last treatment. Ocular findings that were significantly improved in the IPL plus MGX treatment group compared with the MGX group included the following: TBUT, meibomian gland score, eye dryness score, and number of expressible glands in the lower and upper eyelids.²⁰ Other studies have further supported these findings.²¹

Clinical considerations

It is important to consider several things before proceeding with IPL therapy. A full medical history should be completed so that you are familiar with all medications that the patient is taking. Patients undergoing IPL therapy shouldn’t be on any photosensitizing medications, eg, retinoids (including isotretinoin), tetracyclines, and anticoagulants. Additionally, those undergoing chemotherapy should not be treated with IPL.²²

Also, be cognizant of the history of the area being treated. Patients should avoid significant ultraviolet exposure approximately 1 month prior to treatment. Also be cautious of keloid scars or a history of skin cancer in the area being treated with IPL. Any type of skin treatment such as chemical peels should be avoided 2 weeks prior to treatment. If the patient has an active herpetic infection, treatment should be delayed. If the patient has a history of herpetic infections, they may need to take a prophylactic antiviral medication. Patients who have a history of seizures also may not be ideal candidates for IPL therapy because the flash from the treatment may trigger a seizure.

Skin typing is also important when performing IPL therapy. The chances of skin depigmentation increase with the darkness of a patient’s skin tone. Prior to treatment, a questionnaire should be completed to determine the patient’s Fitzpatrick skin type. This is based on their genetic disposition, reaction to sun exposure, and tanning habits. Based on these factors, the patient is given a Fitzpatrick skin type score,²³ which is graded from I to VI. A lower score typically indicates fairer skin that is highly likely to burn when exposed to ultraviolet radiation. A higher score indicates dark pigmented skin that does not have the same predisposition to burning.²³

The Fitzpatrick score helps clinicians determine which individuals are the most appropriate candidates for IPL therapy and also provides guidance on the proper fluence (energy per unit area) to be used in treatment. Typically patients with Fitzpatrick scores of V and VI are not treated with IPL. IPL energy is absorbed by melanin so those with a lower Fitzpatrick score can be treated with higher energy levels. Once the Fitzpatrick score is established, the fluence level can be determined.²⁴

In preparing the patient for IPL treatment, it is important they come into the office not wearing any makeup, creams or sunblock. Eye shields are placed over the eyes. Prior to the application of ultrasound gel, the patient’s face is cleaned with makeup remover and then with an alcohol wipe. The face is allowed to dry and a thin layer of ultrasound gel is applied to the area that will be treated. At that point, the area is ready to be treated, and there are usually 2 passes that are performed over the treatment area. The most common protocol performed for dry eye is a tragus-to-tragus pass over the nose. There are usually 2 to 4 weeks between treatments for a total of 4 treatments.²⁵ There are now procedures for IPL treatment that involve the direct application of IPL therapy to the eyelids and require the application of eye shields between the eyelids and the ocular surface.²⁶

After the treatment, the gel is cleaned off the patient’s face, and they should not put anything on their face for a few hours. After that, moisturizing agents may be used. Additionally, the patient should be encouraged to use sunblock SPF 30 when outside for extended periods. If the patient experiences any skin sensitivity, they can take ibuprofen or acetaminophen as needed.

Case in point

Figure 1. Eyelid margin in hyperemia in the presence of meibomian gland dysfunction.

Figure 2. Corneal staining before treatment. (Images courtesy of Mile Brujic, OD, FAAO)

A 48-year-old White woman was seen for a dry eye evaluation. Her entering complaints weresignificant ocular dryness that caused her to use artificial tears 6 to 8 times a day. It was clear from the clinical examination that the majority of her symptoms were secondary to meibomian gland dysfunction (Figure 1). Additionally, the patient had significant corneal staining as well (Figure 2). The patient’s entering Standardized Patient Evaluation of Eye Dryness (SPEED) score was 20.

We discussed treatment options and the patient decided to proceed with IPL therapy. We asked her to start using warm compresses twice a day for 10 minutes at a time and also had her start utilizing preservative-free artificial tears. We scheduled her for 4 IPL tragus-to-tragus pass treatments 2 weeks apart. I saw the patient again 4 weeks after the final treatment. The patient’s SPEED score at that time was 4. Her eyelid margin had markedly less hyperemia along with improved meibomian gland secretion. Her corneal staining at this visit was negligent.

IPL provides a viable opportunity to help patients with dry eye disease. Understanding its science along with its clinical applications will ultimately provide the most appropriate approach to utilizing IPL to help patients achieve positive clinical outcomes.

References

1. Ash C, Dubec M, Donne K, Bashford T. Effect of wavelength and beam width on penetration in light-tissue interaction using computational methods. Lasers Med Sci. 2017;32(8):1909-1918. doi:10.1007/s10103-017-2317-4

2. Arminda A. Intense pulsed light (IPL) for the treatment of vascular and pigmented lesions. J Cosmet Dermatol. 2024:23(suppl 1):1-6. doi:10.1111/jocd.16281

3. Babilas P, Schreml S, Szeimies RM, Landthaler M. Intense pulsed light (IPL): a review. Lasers Surg Med. 2010;42(2):93-104. doi:10.1002/lsm.20877

4. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. doi:10.1097/ICO.0b013e318225415a

5. Bhujbal S, Rupenthal ID, Steven P, Agarwal P. Inflammation in dry eye disease-pathogenesis, preclinical animal models, and treatments. J Ocul Pharmacol Ther. 2024;40(10):638-658.doi:10.1089/jop.2024.0103

6. Periman LM, Perez VL, Saban DR, Lin MC, Neri P. The immunological basis of dry eye disease and current topical treatment options. J Ocul Pharmacol Ther. 2020;36(3):137-146. doi:10.1089/jop.2019.0060

7. Tavassoli S, Wong N, Chan E. Ocular manifestations of rosacea: a clinical review. Clin Exp Ophthalmol. 2021;49(2):104-117. doi:10.1111/ceo.13900

8. Machalińska A, Zakrzewska A, Markowska A, et al. Morphological and functional evaluation of meibomian gland dysfunction in rosacea patients. Curr Eye Res. 2016;41(8):1029-1034. doi:10.3109/02713683.2015.1088953

9. Schoenewolf NL, Barysch MJ, Dummer R. Intense pulsed light. Curr Probl Dermatol. 2011:42:166-172. doi:10.1159/000328446

10. Papageorgiou P, Clayton W, Norwood S, Chopra S, Rustin M. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol. 2008;159(3):628-632. doi:10.1111/j.1365-2133.2008.08702.x

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

12. Tashbayev B, Yazdani M, Arita R, Fineide F, Utheim TP. Intense pulsed light treatment in meibomian gland dysfunction: a concise review. Ocul Surf. 2020;18(4):583-594. doi:10.1016/j.jtos.2020.06.002

13. Lei Y, Peng J, Liu J, Zhong J. Intense pulsed light (IPL) therapy for meibomian gland dysfunction (MGD)-related dry eye disease (DED): a systematic review and meta-analysis. Lasers Med Sci. 2022;38(1):1. doi:10.1007/s10103-022-03690-1

14. Qin G, Chen J, Li L, et al. Managing severe evaporative dry eye with intense pulsed light therapy. Ophthalmol Ther. 2023;12(2):1059-1071. doi:10.1007/s40123-023-00649-5

15. Pac CP, Sánchez-González JM, Rocha-de-Lossada C, et al. Intense pulsed light therapy for dry eye disease: analyzing temporal changes in tear film stability and ocular surface between IPL sessions. Healthcare (Basel). 2024;12(11):1119. doi:10.3390/healthcare12111119

16. Yurttaser Ocak S, Karakus S, Ocak OB, et al. Intense pulse light therapy treatment for refractory dry eye disease due to meibomian gland dysfunction. Int Ophthalmol. 2020;40(5):1135-1141. doi:10.1007/s10792-019-01278-3

17. Yang L, Pazo EE, Zhang Q, et al. Treatment of contact lens related dry eye with intense pulsed light. Cont Lens Anterior Eye. 2022;45(2):101449.doi:10.1016/j.clae.2021.101449

18. Pazo EE, Huang H, Fan Q, et al. Intense pulse light for treating post-LASIK refractory dry eye. Photobiomodul Photomed Laser Surg. 2021;39(3):155-163. doi:10.1089/photob.2020.4931

19. Li L, Chen J, Qin G, et al. Tear film lipid layer changes following combined effect of heated eye mask with intense pulsed light therapy for evaporative dry eye: a randomized control study. Photobiomodul Photomed Laser Surg. 2023;41(8):435-444. doi:10.1089/photob.2023.0051

20. Toyos R, Desai NR, Toyos M, Dell SJ. Intense pulsed light improves signs and symptoms of dry eye disease due to meibomian gland dysfunction: a randomized controlled study. PLoS One. 2022;17(6):e0270268. doi:10.1371/journal.pone.0270268

21. Suwal A, Hao J, Liu X, et al. Effect of intense pulsed light to mitigate meibomian gland dysfunction for dry eye disease. Klin Monbl Augenheilkd. 2023;240(2):163-168. doi:10.1055/a-1942-2007

22. Srinivas CR, Kumaresan M. Lasers for vascular lesions: standard guidelines of care. Indian J Dermatol Venereol Leprol. 2011;77(3):349-368. doi:10.4103/0378-6323.79728

23. Sharma AN, Patel BC. Laser Fitzpatrick skin type recommendations. In: StatPearls. StatPearls Publishing; updated March 6, 2023. https://www.ncbi.nlm.nih.gov/books/NBK557626/

24. Thaysen-Petersen D, Erlendsson AM, Nash JF, et al. Side effects from intense pulsed light: importance of skin pigmentation, fluence level and ultraviolet radiation-a randomized controlled trial. Lasers Surg Med. 2017;49(1):88-96. doi:10.1002/lsm.22566

25. Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 2015;33(1):41-46. doi:10.1089/pho.2014.3819

26. Kim M, Min J. Effect of intense pulsed-light treatment using a novel dual-band filter in patients with meibomian gland dysfunction. J Clin Med. 2022;11(13):3607. doi:10.3390/jcm11133607