IPL: The science of comfort and safety

For years, dermatologists have used intense pulsed light (IPL) to treat a variety of skin conditions as well as for aesthetic enhancements. IPL has several mechanisms of action. On the skin, it stimulates both collagen production and activity in the fibroblast cells that make up connective tissue, improving the skin’s structure and smoothing the surface. IPL can reduce the population of demodex and bacteria on the skin. It also helps seal abnormal telangiectatic blood vessels—a common inflammatory finding of rosacea facies, ocular rosacea, and other related inflammatory ocular surface disease. These mechanisms also explain the decreased presence of pro-inflammatory mediators in the ocular surface environment.1,2

In 2005, Rolando Toyos, MD, first reported the effectiveness of IPL for symptomatic relief of dry eye disease in addition to its dermatologic and esthetic benfits.3 It has since become evident that the therapy’s ability to enhance cellular function, seal abnormal blood vessels, reduce overpopulation of microorganisms and decrease inflammation make it a transformative treatment for dry eye disease with associated meibomian gland dysfunction (MGD).6

Related: Offer IPL as a treatment for MGD and dry eye disease

ODs considering offering IPL to their patients must know what to expect from the procedure and what features to look for in today’s systems.

IPL procedure and results

The 10-minute IPL procedure is easy to conduct. A technician places IPL-grade protective eye shields on the patient, applies ultrasonic gel to the treatment area. The doctor administers IPL in two passes from tragus to tragus, over the cheeks and under the lower eyelids (generally following what is called the Toyos pattern). Depending on the patient severity of disease and skin pigmentation, I fine-tune application through fluence (energy) setting, number of “shots applied, and shot overlap.

Patients typically have a series of 4 sessions, 2 to 4 weeks apart, followed by maintenance sessions every 6 months to 1 year. My patients generally begin to feel the effects of IPL after 2 or 3 sessions.

ODs can expect patients with dry eye related to MGD and ocular rosacea to show improvements in both structure and function after IPL therapy is complete. Positive changed include:

• 93 percent improvement in tear break-up time4

• Less staining5

• Lower bacterial and demodex load1

• Over 50 percent symptomatic improvement from subjective questionnaire evidence4

Related: IPL treats rosacea and meibomian gland dysfunction

In addition, structural improvement to the meibomian glands can be observed after IPL therapy.1 The quality of meibum generally progresses to a thinner, healthier composition, evidenced in my own patients by higher objective measurement of lipid layer thickness. Overall, the vast majority of my patients report a significant benefit, and in some cases the results have been life changing.

To ensure ODs achieve results like these from IPL, begin by reading about various systems and becoming familiar with the features that optimize outcomes.

Mechanisms of comfort and safety

As ODs investigate IPL, keep in mind that both comfort and efficacy are essential for this procedure. The sensation of having IPL applied to the eye area must be comfortable enough for patients to remain calm during the procedure and feel willing to complete a full series of 4 IPL treatments. Likewise, precise energy control and shot application is key when treating the eyelids using laser-grade eye shields and the periorbital area, especially for patients with rosacea, who require higher fluence levels.

Related: 3 steps to getting started with dry eye treatment

Although the eye and surrounding area are more sensitive than other regions targeted with IPL by dermatologists, today’s IPL technology can provide the necessary level of comfort and effectiveness using advanced technological features:

• Controlled pulses. IPL systems direct light from a xenon flashtube in a rapid series of pulses. Those pulses must be controlled to apply the energy safely and effectively. When I perform IPL, I carefully calculate and control the amount of energy per pulse, the number of pulses, and how those pulses overlap. My typical setting for treatment of dry eye is a train of 3 pulses with a rest between pulses, which gives the tissue an opportunity to recover. I set the pulse power based on skin pigmentation, which affects energy absorption. I also factor in the patient’s response to previous treatment. Controls vary from instrument to instrument; some are more easily set than others.

• Filtered wavelengths. In IPL, most energy wavelengths are 500 cm to 200 nm. ODs can control the wavelength and filter the waves to compensate for skin tone, as well as to achieve the right penetration and efficacy. For example, darker skin tones require lower levels of energy. When uncertain, test shots can help guide appropriate settings.

• “Square” waveforms. Peaks in IPL energy waves represent “hot spots” with the potential to cause discomfort or even irritate or burn the skin. For example, if I set the device to 12 J/msc2, the pulse might range from 10 to 14 J/msc2—ineffective at the low end and potentially unsafe at the peak. It is possible to avoid peaks like this and make the IPL procedure safer, more comfortable, and more effective by creating a square wave pulse. This waveform delivers consistent energy throughout the pulse rather than in a peak and fall.

• Cooling tip. IPL produces heat, so IPL devices must mitigate heat at the skin’s surface for both comfort and safety. Systems can have a fan-based cooling mechanism or a water-cooled tip. In my experience, a water-cooled system allows for use of higher energy levels without affecting safety or comfort, which in turn allows ODs to optimize results as well as safely treat darker skin tones per the Fitzpatrick classification scale.

Related: The dropless future: SLT as a first-line treatment for glaucoma

Almost all of my patients say that IPL is comfortable, with some exceptions for a minor “snapping” feeling or temporary heat. The safety has been exceptional, with no burning or other incidents over the course of more than 1,200 sessions.

IPL in my practice

Having offered patients IPL (M22 Optima IPL, Lumenis) for nearly 2 years, some of my perceptions of the procedure have changed. Initially, I thought that candidates would be limited to those with ocular rosacea, and I questioned the cost effectiveness of incorporating IPL. I soon saw its value for a broad range of patients with MGD and dry eye, including those for whom previous treatments were not completely successful. Rapid growth in IPL volume paid for the device within 3 months, validating my belief in the technology.

Clinical results have been profound for my patients, many of whom have suffered for years, dropped out of contact lenses, and routinely experienced dry eye symptoms that interfered with their lives. It has changed my practice as well. With a highly predictable procedure, measurably good results, and enthusiastic feedback from my patients, my use of the IPL procedure has grown to include an average of 24 IPL sessions each Friday. IPL for dry eye is a safe, effective, and essential therapy in my practice.

Related: Why ODs should treat dry eye

References

1. Liu R, Rong B, Tu P, Tang Y, Song W, Toyos R, Toyos M, Yan X. Analysis of cytokine levels in tears and clinical correlations after intense pulsed light treating meibomian gland dysfunction. Am J Ophthalmol. 2017 Nov;183:81-90.

2. Yin Y, Liu N, Gong L, Song N. Changes in the meibomian gland after exposure to intense pulsed light in meibomian gland dysfunction (MGD) patients. Curr Eye Res. 2018 Mar;43(3):308-313.

3. Toyos R, Buffa C, Youngerman S. Case report: Dry–eye symptoms improve with intense pulsed light treatment. EyeWorld News. September 2005.

4. Rong B, Tang Y, Tu P, Liu R, Qiao J, Song W, Toyos R, Yan X. Intense pulsed light applied directly on eyelids combined with meibomian gland expression to treat meibomian gland dysfunction. Photomed Laser Surg. 2018 Jun;36(6):326-332.

5. Dell SJ, Gaster RN, Barbarino SC, Cunningham DN. Prospective evaluation of intense pulsed light and meibomian gland expression efficacy on relieving signs and symptoms of dry eye disease due to meibomian gland dysfunction. Clin Ophthalmol. 2017 May 2;11:817-827.

6. Dell SJ. Intense pulsed light for evaporative dry eye disease. Clin Ophthalmol. 2017 Jun 20;11:1167–1173.