A dermatologic treatment for patients who have rosacea and other skin conditions increasingly will find use as an ophthalmologic treatment for patients who have dry eye as a result of meibomian gland dysfunction and blepharitis.
Dr. Toyos, medical director and founder, Toyos Clinic, Jackson, TN, said he performs intense pulsed light (IPL) therapy for dry eye as an elective procedure in his practice. "I think [the profession is] going to be using it more and more," he said.
Dr. Toyos said he first suspected that IPL could address dry eye in 2003.
"We opened up an aesthetics clinic right next to our ophthalmology clinic, and one of the things we were offering was IPL. In the aesthetic world, the dermatology world, IPL is used for patients with rosacea, to take care of telangiectasias," he said.
"What would happen was, in my eye clinic, I was seeing patients with dry eye, and I said, 'You know, we have this treatment called IPL next door for your blood vessels,' and I sent them over. They would come back and say, 'I love the way my skin looks, and my dry eye has been taken care of, too.' And I'd look at their lids, look at their lid margins, look at the meibomian gland, and it looked so much better than when I first started," Dr. Toyos added.
How IPL works
The meibomian glands are responsible for secreting the lipid layer of the tear, which prevents the premature evaporation of the tear complex. When the gland is blocked, meibum accumulates, the gland becomes inflamed, and bacteria infiltrate. The bacteria contain lipases that change the polarity of the tear and the tear film. The altered secretions tend to solidify, further blocking the glands.
In IPL, a xenon flashlamp emits energy in wavelengths ranging from 400 to 1,300 nm through a crystal to the intended tissue, Dr. Toyos said, adding that a wavelength of 500 to 800 nm is used to treat dry eye. The device has a filter that controls the amount of energy emitted, to protect the non-targeted tissue.
With the patient's eyes shielded and ultrasound gel applied to the area of the face to be treated, the light is pulsed at speeds of 10 to 40 milliseconds and travels through the epidermis to target the hemoglobin in red blood cells. The hemoglobin absorbs the energy and then coagulates in the small vessels, occluding them.One of the reasons IPL may be successful against dry eye is that, with the blood vessels closed, inflammatory mediators no longer can reach the gland, Dr. Toyos said, but further research is needed to determine the exact mechanism of action.
"You get rid of the blood vessels and, for dry eye, you get rid of all of those telangiectasias around the lid margin" because blood flow is decreased, he said. IPL also addresses erythema and swelling in the gland, Dr. Toyos added.
He said he varies the intensity of the millijoules, starting at a low level and then increasing the intensity. He makes two passes with the device, from one ear tragus to the other. The upper lids can be treated only indirectly through maximization of exposure to the lower lids, Dr. Toyos added.
The sensation of the treatment can be pleasing to patients, he said. "One of the things I tell people is, 'This is like the best warm compress you'll ever have.' The pulsed energy is giving heat to the meibomian gland." That heat liquefies toothpaste-like secretions in the gland to unplug it, Dr. Toyos added.
He said he prescribes one drop of nepafenac (Nevanac, Alcon Laboratories) for patients to use postoperatively for 2 to 3 days and advises patients to wear sun block and avoid sun exposure for a week.
"After two or three treatments, you start to see fewer and fewer telangiectasias around the meibomian gland, and then all of a sudden, these glands are working better," Dr. Toyos said. "It takes three to four treatments for 90% of the glands to be working," which he said is his treatment goal.
Patients visit the clinic as needed every 3 to 12 months for maintenance therapy.
The treatment is appropriate for patients whose facial skin pigmentation falls between type 1 and type 4 on the Fitzpatrick scale, Dr. Toyos said. "In somebody whose skin is darker pigmented, you'll lighten the skin, so you really want to stick to those patients who are in that Fitzpatrick-type-4-and-below range," he said.
In addition to addressing the symptoms of dry eye, IPL also improves the anatomy of the lid, which can be of particular benefit to older patients with evaporative dry eye-of which meibomian gland dysfunction is the leading cause-whose skin is starting to sag, Dr. Toyos said. IPL initially was used-and still is used-to perform "photo facials," he pointed out. With improvement of lid apposition comes improvement in the pumping mechanism of the gland during blinking, Dr. Toyos added.