80% of dry eye patients have a poor quality oily layer to their tear film. The function of this layer is to reduce evaporation of the watery layer of the tears. Excess evaporation of the water from the tear film results in the remaining tears becoming hypertonic or “too salty” These excessively salty tears suck moisture from the glands and cells covering the eye surface by osmosis resulting in dehydration damage to the cornea and mucous secreting goblet cells on the conjunctiva, the membrane covering the white of the eye.
IPL Photo-Biomodulation is a new exciting treatment option for patients with Evaporative Dry Eye, Blepharitis and Rosacea. We offer this procedure, using the advanced Lumenis M22 device. This delivers scientifically controlled pulses of intense red and infra-red light of only a few milliseconds duration which are applied to the eyelids and upper face. The M22 uses a band wavelength filter set at 590nm for Dry Eye treatment. In the following image of a patient who has had IPL Photo-Biomodulation you can see the improved clear secretions from the meibomian openings.
IPL has been used since 1995 to treat abnormal blood vessels and inflammation in diseases such as Acne Rosacea. Later, in 2001, the machine and its treatment parameters were modified specifically to treat dry eye. Its use was pioneered by US ophthalmologists, Rolando and Melissa Toyos, in Nashville.
The “Photo-Biomodulation” mechanism is due to the red visible and the infra-red invisible IPL light which improves functions at a cellular level, by
- Improving mitochondrial function, potentially “activating” or “energising” the meibomian glands
- Improving calcium channel flow
- Reducing the secretion of inflammation products
- Suppressing MMP proteolytic enzymes thereby improving the extracellular matrix
All the above effects help normalise the tear film and reduce dry eye irritation.
In other specialities, similar wavelength Photo-Biomodulation is used to treat dry macular degeneration, and diverse conditions such as psoriasis and skeletal problems.
In addition to Photo-Biomodulation it is thought to exert its effects by several additional mechanisms:-
- The abnormal blood vessels in the inflamed lid margin are thrombosed as the IPL light coagulates the oxy-haemoglobin flowing through them. This stops the vessels releasing inflammatory mediators into the meibomian glands in the lid margin.
- Improved nerve function around the meibomian glands
- The IPL flash heats up and melts the meibum secretions blocking the glands, improving the tear lipids and reducing evaporation
- Demodex mites living in the meibomian glands are destroyed(a chromophore in the exoskeleton of the mite absorbs IPL energy). By eradicating Demodex, IPL reduces the consequent bacterial load on the eyelids, which in turn reduces chronic inflammation and the conversion of normal melting point meibum to high melting point lipid, thereby improving the fluidity of the lipids secreted and the quality of the lipid layer.
- Skin tightening – as we age, the collagen and elastin fibres relax, reducing skin rigidity and elasticity. IPL stimulates the fibroblasts and up-regulates the synthesis of collagen and elastin fibres
In MGD, a inflammatory cycle is created, leading to the development of abnormal blood vessels or telangectasia, which in turn release pro-inflammatory mediators that cause dilation of the blood vessels and yet further escalated inflammation. Demodex mites and bacteria flourish in the inflamed tissue, leading to clogging of the glands and further irritation and damage to the corneal surface. As evaporation increases as the lipid layer continues to fail, osmolarity increases damaging the goblet cells and reducing the quality of the all important mucous layer that helps maintain the aqueous component in place. So the downward spiral increases. Restoring the lipid layer with omega 3 supplements, lid hygiene and IPL treatment helps to arrest and reverse this process.
The IPL treatment area includes the skin overlying the cheeks and nose in addition to the eyelids, as the minute broken blood vessels in these areas can feed the inflammation in the eyelids. Cosmetically many patients are pleased with the reduction in thread vessels, skin blemishes and wrinkles, which often occur as a beneficial side effect.
Contraindications include systemic use of drugs causing photo-sensitivity, history of high sun or artificial tanning treatment, conditions such as lupus, and adnexal ketosis, melanin aggregation and tattoos. Examples of medication that might photosensitise are the tetracycline family of drugs that are sometimes used for patients with Blepharitis and acne.
Patients should not wear face make-up for at least 1 day before treatment. They should especially avoid products containing retinoids (retinal, retinol etc). After treatment moisturiser cream is advised as the skin can be a bit sensitive at this stage. High factor sunscreen should be worn afterwards for a few days for the same reason.
Treatment spans four to 5 sessions scheduled two to four weeks apart. Maintenance treatment normally consists of one treatment per year. Because IPL is used to treat facial Rosacea as well, treatment of lower face telangiectasia can be combined with dry eye treatment.
In addition, the Optima IPL’s OPT feature ensures that the pulses of light are uniform and repeatable. Because the thickness of the skin is so thin close to the lower eyelids, ensuring that the light energy is delivered in a reliable manner is key to safety.
In the photo below you can see a patient having the IPL procedure performed. In most cases a series of 4 treatments is required, spaced 2-3 weeks, no more than 5 weeks apart apart. With IPL for dry eye we treat across the lower eyelids and bridge of the nose. This protocol allows us to address a large portion of blood supply to the lower lids as well as some of the upper lids (coming from the lateral part of the eyelid skin).
The procedure consists of the following steps
- The patient signs a consent form
- Protective IPL eye patches are applied
- Optometrist wears the appropriate protective eye wear.
- Apply IPL transmission buffer gel is applied to areas to be treated
- The power setting, pulse duration and pulse frequency is set
- A temporal cheek area is tested to confirm setting levels correct
- The basic treatment involves approx 3 sweeps from ear to ear of about 14 treatment areas. Leaving delay time of 20-60 seconds between each sweep.
- The treatment gel is removed
- Heat expression of meibomian glands
- Apply moisturiser to cheeks
During consenting, the patient is counseled and signs to say that they understand that there is a possibility of rare side effects, none of which have occurred in our clinics. Possible complications include pain, reddening, burning, swelling, discoloration and temporary bruising of the skin. Color changes, such as hyper-pigmentation (brown/red discoloration) or hypo-pigmentation (skin lightening), may occur following treatment. Unprotected sun exposure in the weeks before and following treatments is contraindicated as it may cause or worsen this condition. A blue- purple bruise (purpura) may appear on the treated area. This can last a couple of weeks up to a several months to completely resolve. Scarring and burns can occur but is very uncommon. Top up treatments may be needed at a future date. Careful titration of the power and pulse characteristics usually avoids complications occurring.
It is important that the pulse type, flash duration and power settings are tailored to the patients skin colour. Ironically the darker their skin colour, the lower the treatment power settings need to be. The initial setting is based on their Fitzpatrick skin type (see table below). I usually test a relatively non visible bit of skin near the tragus at a low setting and work up the power settings till a medium to hot tingle is felt. As the inflammatory vessels recede with each subsequent treatment the power settings can be gradually increased. The higher the power, the better the effect on the meibomian glands, but the greater the chance of skin irritation.
The Fitzpatrick Skin Type Scale
Protective IPL patches are applied to protect the eye itself, because, in addition to oxy-haemaglobin, melanin is also heated up by the IPL wavelengths and so the iris theoretically can suffer heat damage from the light used. This could result in intra-ocular inflammation and iris depigmentation. The protective shields are placed just below the lower lash root line or just above the upper lash line, depending on the area being treated. As well as protecting the eye itself, this ensures that the eyelashes are not accidentally burned away by mistake.
The purpose of the treatment gel is to protect the skin from the heating effect and also to ensure that the light reaches the haemoglobin in the telangetatic vessels located just below the skin surface without excess pressure flattening the vessels thereby occluding the blood flow. It is important that the gel used is clear, not coloured as colouring would affect the light transmission of the IPL treatment. The treatment head on the M22 is refrigerated to increase patient comfort and reduce the possibility of thermal skin damage.
Patients should be aware that they may smell burning during the process. This is not the skin getting cooked, merely the downy facial hair going up in smoke. I ensure that in males, I avoid the moustache and beard area during IPL treatment as it may interfere with future intentional facial hair growth.
The M22 has 3 different sizes of treatment head to improve access to difficult areas. The fluence emitted has the same energy density, whichever head is used.
IPL treatment is also used for hair removal, thread vein removal, treatment for hyper-pigmentation (freckle and age spot removal), Photo rejuvenation (i.e. the treatment of sun damaged skin) and acne treatment using the M22 device. The melanin in “age-spots” and freckles is heated up by the IR light and they usually fade with repeated treatments.
As you see from the diagram below variable treatment depths can be achieved by selecting different treatment wavelengths.
Standard IPL with the M22 device can elicit mild skin tightening and hair removal. Female patients are often very pleased with these “bonus” benefits. It is wise to warn them that they may smell burning hair during the process, and not to worry. Similarly, we do not treat the lower face and upper lip with male patients as it may interfere with beard growth at a future date.
During hair removal, the IPL light energy is absorbed by pigment within the hair follicle, heating it up and permanently damaging it so that the hair doesn’t grow back.
IPL needs to target the hair follicles during a specific part of their life cycle (during the growth, or ‘anagen’ phase). Not all of the hairs will be in the anagen phase at the same time, so multiple treatments are needed in order to get long-lasting results.
The M22 can also be used to treat conventional Acne, which affects over 80% of the population between the ages of 14-30, most prevalent in the teenage years. Often patients with teenage acne are left with disfiguring facial scarring. The main bacterium involved is Propionbacterium Acnes. Although in vitro, blue light of 400nm is most effective at destroying P Acnes, due to its poor penetration depths in skin, it has been found that the 590nm broadband IPL provides more effective penetration into deep blocked skin pores. In addition, it is thought that the thermal effect on the sebaceous glands can result in long term remission from acne. The thermal stimulation of fibroblasts and collagen production can reduce mild acne scarring and accelerate healing.
Using the advanced Lumenis M22 device scientifically controlled pulses of intense red light of only a few milli-seconds duration are applied to the eyelids and upper face.
