Understand the expanding role of IPL in dry eye disease

Intense pulsed light therapy
Understand the expanding role of IPL in dry eye disease

Intense pulsed light (IPL) treats the fundamental root cause of dry eye, not just the downstream consequences.

Editor’s Note: Welcome to “Let’s Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. “Let’s Chat” continues with this blog by Richard Adler, MD. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or MJH Life Sciences.

Watery Dry Eyes

Inflammation is widely understood to be an integral component in chronic dry eye disease (DED). More than two decades of research has helped elucidate the role of inflammation in instigating and perpetuating chronic dry eye.

It is now considered an accepted fact that chronic dry eye is a cyclical inflammatory process: Even short-term desiccating stress at the ocular surface increases osmolarity, causing an outflux of intracellular fluid, and thereby yielding cell shrinkage that leads to the release of inflammatory mediators (such as interleukin-6 and -8).

These mediators further decrease tear production while increasing osmolarity—which then restarts the cycle that culminates in hallmark symptoms of ocular surface discomfort and fluctuating visual acuity.

Related: IPL + thermal pulsation: A thorough approach to dry eye 

Meanwhile, a host of pro-inflammatory cytokines, chemokines, and their receptors have been implicated in playing a central role in disease progression.

Khanna Institute Of Lasik and Refractive Surgery
Khanna Institute Of Lasik and Refractive Surgery

It seems that inflammatory processes are also relevant in the earliest stages: the prevailing theory at the current time regarding the initial cause of dry eye is that dysregulated immune system responses—in reaction to environmental or physiologic stressors—initiate and sustain the abnormal inflammatory cycle inherent to dry eye.

What those of us who manage patients with dry eye can take away from all of this is that inflammation plays a key role in initiating, perpetuating, and causing dry eye progression.

As a result, if ophthalmologists are not treating the inflammation, we are not treating this disease.
 

Why IPL makes sense
The classic thinking around the use of intense pulsed light (IPL) in treating dry eye is that active signs of inflammation (such as facial and/or ocular rosacea and telangiectasia) or meibomian gland dysfunction (MGD) indicate the treatment might be successful.

While true, there is a wide range of patients for whom IPL is a good option. As has been learned over the past two decades, inflammatory processes are a common factor in all forms of dry eye—evaporative, and aqueous deficient alike.

In short, IPL works for dry eye because it has multiple mechanisms of action, many of which are important regardless of etiology:

• Light energy from IPL warms the meibomian glands, thereby facilitating expression of meibum. There is evidence that IPL helps restore the function and morphology of the meibomian glands.2

• The wavelength of light used in IPL is selectively absorbed by telangiectatic blood vessels, which coagulates them. This has a dual outcome, both destroying blood vessels that perpetuate inflammation and decreasing the levels of pro-inflammatory mediators that contribute to dry eye.2-5

IPL reduces the load of demodex mites that stimulate infection.

• The light energy in IPL is absorbed by cytochrome C within the mitochondria, which is active in the electron transport chain (ETC). In turn, this improves adenosine triphosphate (ATP) production, which facilitates important cellular functions such as collagen synthesis in fibroblasts and motility in immunoregulatory cells.

As an additional note, IPL treatment also indirectly interrupts the dry eye inflammation cycle by reducing the osmolarity of the tear film to normal levels.7,8

Technology
I have been using IPL with my dry eye patients since around 2010. I currently use the Optima IPL (Lumenis).

Over the past decade, clinical studies have demonstrated the effectiveness of Lumenis’ IPL platforms for treating DED.9-11

In my view, using Lumenis IPL technology has several advantages:

First, the company has been in the space for decades. There are no click fees or disposables associated with performing the treatment.

For those interested in using IPL in applications outside of eye care—including medical aesthetic—the Optima IPL is part of the modular aesthetic laser multi-application platform (M22), which allows a user to select and use different wavelengths of light.

With regard to the Optima IPL, specifically, the platform permits higher energy levels for effective treatment of inflammation while maintaining patient comfort with a unique cooling system. Individual pulses have higher energy as well.

A 10 J/cm2 setting is three pulses of 3.33 J/cm2, rather than five 2 J/cm2 pulses, as with other systems. The energy can also be lowered to treat fragile or sensitive skin, and is compatible with a wide range of tip sizes that allow ease of access around the tricky periocular anatomy.

Some of the features noted above speak to the broad applications of IPL in treating the skin on the face and around the eye, as well as for treating the ocular surface.

Related: Treating chalazion with IPL therapy 

Choosing patients
But even within the category of ocular surface disease (OSD), there is wide range of patients for whom IPL makes sense. Generally speaking, patients who have tried traditional therapies and are still struggling may get relief from their dry eye symptoms with IPL.

On the other end of the spectrum, I have found that many newly diagnosed patients simply do not want to use pharmacotherapy, and so a device-based treatment offers a different yet equally effective approach.

Of course, there are myriad opportunities in between those two extremes.

The fundamental reason IPL is successful for dry eye is that it treats the upstream inflammatory root cause of DED— not just the downstream consequences, as its multiple mechanisms of action collectively interrupt the vicious inflammatory cycle that instigates and perpetuates dry eye.

It is an effective standalone procedure for patients suffering with aqueous deficient, evaporative, or mixed modal etiology dry eye.

But it can also easily be added to pharmacology or other device-based treatments in a multimodality approach to treating the multifactorial entity of DED.

RECOGNIZE THE INCREASING ROLE OF IPL IN DRY EYE DISEASE

Image result for exclusive pic on ROLE OF IPL IN DRY EYE DISEASE



Extreme pulsed light (IPL) deals with the fundamental source of dry eye, not just the downstream consequences.


Swelling is extensively comprehended to be an important part in chronic dry eye disease (DED). Greater than twenty years of research has assisted illuminate the function of inflammation in instigating as well as bolstering chronic completely dry eye.
It is currently considered an accepted reality that chronic dry eye is an intermittent inflammatory procedure: Even temporary desiccating anxiety at the ocular surface increases osmolarity, causing an outflux of intracellular fluid, as well as therefore producing cell shrinkage that causes the launch of inflammatory arbitrators (such as interleukin-6 and -8).
These mediators reduce tear production while enhancing osmolarity – which after that reboots the cycle that finishes in marked signs of ocular surface pain as well as varying visual acuity. 

Meanwhile, a host of pro-inflammatory cytokines, chemokines, and their receptors have actually been linked in playing a central role in condition development. It appears that inflammatory procedures are likewise relevant in the earliest stages: the prevailing theory at the present time regarding the preliminary root cause of dry eye is that dysregulated immune system responses – in response to environmental or physiologic stress factors – initiate and also suffer the abnormal inflammatory cycle intrinsic to dry eye.


What those people that manage patients with dry eye can eliminate from every one of this is that inflammation plays a vital role in launching, bolstering, and also creating dry eye progression.


Consequently, if ophthalmologists are not dealing with the inflammation, we are not treating this illness.

Why IPL makes sense
The classic thinking around using intense pulsed light (IPL) in treating dry eye is that active signs of swelling (such as facial and/or eye rosacea and telangiectasia) or meibomian gland disorder (MGD) indicate the therapy might be effective. While real, there is a wide variety of patients for whom IPL is a good choice. As has actually been found out over the past twenty years, inflammatory procedures are a common consideration in all kinds of dry eye – evaporative, and also liquid deficient alike. Simply put, IPL works for completely dry eye since it has several devices of action, much of which are important regardless of etiology:


Light energy from IPL heats the meibomian glands, thereby facilitating secretion of meibum. There is proof that IPL helps recover the function and morphology of the meibomian glands which secrete or produce meibum.
The wavelength of light used in IPL is uniquely absorbed by telangiectatic blood vessels, which coagulates them. This has a double outcome, both ruining the capillary that perpetuates inflammation and decreasing the levels of pro-inflammatory moderators that contribute to completely dry eye.


IPL reduces lots of demodex termites that stimulate infection. 


The light energy in IPL is taken in by cytochrome C within the mitochondria, which is energetic in the electron transport chain (ETC). Subsequently, this enhances adenosine triphosphate (ATP) production, which assists in crucial mobile functions such as collagen synthesis in fibroblasts and mobility in immunoregulatory cells. As an added note, IPL treatment likewise indirectly interrupts the dry eye swelling cycle by decreasing the osmolarity of the tear film to regular degrees.

Technology
Ophthalmologists have actually been making use of IPL with dry eye patients given that around since 2010, I presently utilize the Optima IPL (Lumenis). Over the past years, clinical researches have actually demonstrated the effectiveness of Lumenis’ IPL systems for treating DED.


In doctor’s view, making use of Lumenis IPL innovation has a number of advantages:

First, the business has remained in the room for decades. There are no click charges or disposables related to doing the therapy. For those thinking about utilizing IPL in applications outside of eye treatment – including medical visual – the Optima IPL is part of the modular aesthetic laser multi-application system (M22), which allows a user to select as well as utilize different wavelengths of light, which might then be used for different purposes.
When it come to the Optima IPL, especially, the system permits higher energy levels for efficient treatment of inflammation while preserving client comfort with a unique cooling system. Private pulses have higher energy as well. A 10 J/cm2 setting is 3 pulses of 3.33 J/cm2, rather than 5 2 J/cm2 pulses, as with various other systems. The energy can likewise be lowered to deal with vulnerable or sensitive skin, and also works with a wide range of suggestion sizes that permit ease of accessibility around the challenging periocular anatomy.
Some of the functions noted above, talk about the broad applications of IPL in dealing with the skin on the face as well as around the eye, in addition to for dealing with the eye surface area.

Choosing clients
But even within the classification of eye surface area disease (OSD), there is wide range of patients for whom IPL makes sense. Usually talking, patients who have tried typical therapies and also are still having a hard time might get a remedy for their completely dry eye symptoms with IPL. On the various other end of the ranges, it has been discovered that many newly detected patients merely do not intend to make use of pharmacotherapy, and so a device-based therapy uses a different yet equally reliable method. Obviously, there are myriad opportunities in between those two extremes. The essential factor in IPL that achieves success for completely dry eye is that it treats the upstream inflammatory origin of DED – not simply the downstream consequences, as its numerous devices of activity collectively disturb the savage inflammatory cycle that instigates and leads to completely dry eye.
It is an effective standalone treatment for patients suffering with liquid lacking, evaporative, or blended modal etiology dry eye. But it can also be added to pharmacology or other device-based treatments in a multimodality approach to treating the multifactorial entity of DED.

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