Intense pulsed light treatment for the management of meibomian gland dysfunction.

PURPOSE OF REVIEW: Meibomian gland dysfunction (MGD) is one of the most common disorders encountered by ophthalmologists, and its management can prove challenging for both clinicians and patients. Intense pulsed light (IPL), which has been historically used in the field of dermatology, has emerged as a tool to help improve meibomian gland function. The goal of this review is to assess the clinical efficacy, utility, and safety of IPL for the treatment of MGD. RECENT FINDINGS: In recent randomized controlled trials, IPL has been shown to improve meibomian gland function, and subsequently tear film quality and dry eye symptoms. The mechanism of action still remains unclear. Recent literature suggests that IPL may also be used in conjunction with other therapies, such as meibomian gland expression, low-level light therapy, and thermal pulsation. Careful attention should be placed on each patient's Fitzpatrick skin type, as well as protecting the ocular structures to reduce the risk of adverse effects. Cost, accessibility, as well as a limited duration of efficacy may be drawbacks. SUMMARY: There is significant evidence supporting that IPL may be used as a potential well tolerated and effective treatment for MGD, though there are certain caveats regarding its long-term efficacy, accessibility, and cost.

Intense pulsed light therapy for ocular surface diseases.

Intense pulsed light (IPL) is a non-laser, high-intensity light source that has been shown to play a valuable role in dermatology and has been adopted in ophthalmology for treating meibomian gland dysfunction (MGD). In this review, we discuss the mechanism of action of IPL, including its benefits in ophthalmology. IPL therapy has been shown to improve tear film stability, meibomian gland (MG) function, and subjective symptoms of ocular dryness in MGD patients. Moreover, emerging evidence suggests that IPL therapy is beneficial for other ocular surface diseases, such as blepharitis and chalazia. Hence, it can be inferred that IPL has potential as a therapeutic modality in future applications. Large clinical and experimental trials are needed to exploit the full potential of IPL as a treatment for recurrent chalazia, Sjögren's syndrome, and other causes of dry eye disease (DED). This paper reviews the published literature related to the application of IPL for treating ocular surface diseases.

Models for Meibomian gland dysfunction: In vivo and in vitro.

Meibomian gland dysfunction (MGD) is a chronic abnormality of the Meibomian glands (MGs) that is recognized as the leading cause of evaporative dry eye worldwide. Despite its prevalence, however, the pathophysiology of MGD remains elusive, and effective disease management continues to be a challenge. In the past 50 years, different models have been developed to illustrate the pathophysiological nature of MGD and the underlying disease mechanisms. An understanding of these models is crucial if researchers are to select an appropriate model to address specific questions related to MGD and to develop new treatments. Here, we summarize the various models of MGD, discuss their applications and limitations, and provide perspectives for future studies in the field.

First-in-human Clinical Trial of a Novel Eyelid warming Device in Meibomian Gland Dysfunction.

BACKGROUND: Meibomian gland dysfunction (MGD) causes significant patient morbidity as well as economic burden. OBJECTIVES: To evaluate a novel eyelid warming and a neuro-stimulating device that delivers heat via low-level infrared radiation to the eyelids of patients with MGD. METHODS: In this prospective interventional study, patients with MGD were recruited at a single medical center. The main outcome measures included changes in tear break-up time (TBUT), Schirmer's test, and Ocular Surface Disease Index (OSDI), overall satisfaction, and corneal signs of dry eye. Patients were instructed to use the device twice daily for 5 minutes on each eye for a total of 14 days. Follow-up assessments were performed after the 2-week treatment. RESULTS: A total of 10 patients were included; mean age was 67 ± 16 years; six males (60%). Changes in pre- vs. post-treatment TBUT (5.0-6.11), OSDI (28.1-23.9), and Schirmer score (8.67-7.11) were not statistically significant. Over a course of 243 treatments, 131 (54%) demonstrated improvement in symptoms, 40% found no change, and 6% experienced worsening of symptoms. General satisfaction was observed overall in 80% of the patients. No adverse events were observed. CONCLUSIONS: In this first study of a novel eyelid warming device, overall subjective satisfaction was reported in 80% of patients. Potential advantages of this user-friendly device include its ability to improve MGD and tear film stability, as well as symptomatic relief, while allowing the user to continue with normal daily functioning while undergoing treatment.

Factors affecting long-term changes of meibomian gland in MGD patients.

PURPOSE: To explore the long-term course of patients with meibomian gland dysfunction (MGD), and to analyse potential factors affecting the recovery of meibomian gland (MG) dropout. METHODS: Seventy-nine MGD patients (79 eyes) aged 36.03±15.78 years old who underwent more than one year of follow-up were enrolled in this retrospective study. Corneal fluorescein staining (CFS), tear meniscus height (TMH), noninvasive breakup time (NIBUT), and noncontact meibography at baseline and last visit were collected and analysed. Then an automatic MG analyzer was used to measure the morphological and functional parameters of MGs, including their area ratio (AR), tortuosity index (TI), and signal index (SI). The patients whose AR increased by more than 5% were defined as MG improvement, and AR decreased by more than 5% was MG worsening. RESULTS: A total of 79 patients (79 eyes) were assessed with at least 1-year of follow-up. More than 1/3 of MGD patients (27 eyes, 34.2%) underwent MG improvement, and 30.4% of MGs became worsened. Age (P=0.002), gender (P<0.001), IPL treatment (P=0.013), the change of CFS (P=0.0015), and the recovery of SI (P=0.035) showed significant differences among different recovery groups. Age(P<0.001), female sex (P=0.003), ΔCFS (P<0.001), AR at baseline (P<0.001) were negative correlation with AR recovery, and the change of SI (P=0.003) and IPL treatment (P=0.003) had a positive correlation with it. Among them, age (P=0.038), the change of CFS (P=0.004), and AR at baseline (P=0.007) were confirmed as negatively correlated factors predicting the long-term change of the MG. CONCLUSION: Although the MGD treatment has continued for more than 1 year, only 34.2% of MGD patients were observed to undergo MG improvement. Younger patients and patients with better CFS recovery seem to have more opportunities to improve their MGs.

Evaluation of the Impact of Meibomian Gland Dysfunction Using a Novel Patient-Reported Outcome Instrument.

Purpose: This study was intended to characterize the impact of meibomian gland dysfunction (MGD) on patients' quality of life. Methods: In this prospective, multicenter, noninterventional clinical study (NCT01979887), eligible individuals (age ≥40 years; absence of uncontrolled ocular/systemic disease) were categorized, based on composite grading of ocular symptoms, Schirmer score, and meibum quality, into (1) non-MGD, (2) mild/moderate MGD, or (3) severe MGD cohorts. The MGD Impact Questionnaire (MGD IQ), a 10-item patient-reported outcome measure, was self-administered at clinic visit on day 1, and readministered on day 22 to assess intervisit agreement regarding MGD IQ responses. Results: In total, 75 subjects were assigned to the study cohorts (25 per cohort). Across cohorts, MGD IQ item scores rose incrementally with increasing MGD severity. The severe MGD cohort experienced greater difficulty with reading and performance of leisure activities, greater time on eye care, and greater bother with eye care and eye appearance than the mild/moderate MGD cohort (all P < 0.05). Compared with the non-MGD cohort, the mild/moderate MGD cohort had greater difficulty working on computer, whereas the severe MGD cohort had greater difficulty reading, driving, and performing leisure activities, more frequent difficulty with outdoor activities, more time on eye care, and greater bother with eye care (all P < 0.05). Intervisit agreement between MGD IQ responses was fair to moderate (weighted kappa statistic 0.33‒0.58). Conclusions: Vision-related activities are negatively impacted by increasing severity of MGD. The MGD IQ instrument can help characterize disease severity and amplify the patient's voice in patient-centric clinical research. ClinicalTrials.gov NCT01979887.

Comparison Between Optimal Pulsed Technology and Meibomian Gland Massage Treatment for Contact Lens-Related Meibomian Gland Dysfunction.

Objective: The purpose of this study was to compare the effectiveness of optimal pulsed technology (OPT) and meibomian gland massage (MGM) in alleviating the signs and symptoms of contact lens-related meibomian gland dysfunction (CL-MGD). Methods: This prospective, randomized, controlled study included 90 patients (180 eyes) diagnosed with CL-MGD and were assigned to the OPT group (n = 60 eyes), MGM group (n = 60 eyes), and control group (n = 60 eyes). All participants were examined at baseline (D0), day 21 (D21), and day 42 (D42) for the ocular surface disease index (OSDI), noninvasive tear break-up time (NITBUT), noninvasive tear meniscus height (NITMH), meibomian gland score (MGS), meibomian gland score (MGYSS), best-corrected visual acuity, and intraocular pressure. Results: The OSDI scores and NITBUT improved after treatment in all the three groups. The OSDI scores in OPT and MGM groups were significantly lower compared with that in the control group at D21 and further decreased at D42. The NITBUT in OPT and MGM groups increased compared with the control group at D21 and further increased at D42, and the NITBUT in OPT group increased compared with the MGM group at D21 and D42. The MGYSS both improved after treatment in the OPT and MGM groups, The MGYSS in OPT and MGM groups decreased compared with the control group at D21 and further decreased at D42, and the MGYSS in the OPT group decreased compared with the MGM group at D21 and D42. The NITMH and MGS had no differences after treatment. Conclusions: Results imply that OPT or MGM treatment can be safely used to relieve symptoms of CL-MGD. In addition, OPT treatment was found to be more effective in improving the general stability of the tear-film in CL-MGD.

[Acaricidal therapy in chronic demodex blepharitis and meibomian gland dysfunctions]. / Akaritsidnoe lechebnoe vozdeistvie pri khronicheskom demodekoznom blefarite i disfunktsii meibomievykh zhelez.

PURPOSE: The study comparatively evaluates the effectiveness of various approaches to acaricidal treatment in patients with chronic demodex blepharitis and meibomian gland dysfunctions. MATERIAL AND METHODS: The study included 40 patients with chronic blepharitis (CB) of demodicosis etiology in conditions of meibomian gland dysfunction (MGD) and dry eye (DE). The 1st group of patients (20 people) received acaricidal treatment as part of therapeutic eyelid hygiene (TEH; 2 times a day) involving the use of «Blefarogel ochishchenie¼, «Blefarolosion¼, «Blefarogel forte¼ (contains sulfur and metronidazole). Acaricidal treatment in the patients of the 2nd group involved applications of a product containing metronidazole (2 times a day) without TEH. Control points: 1) at inclusion in the study; 2) after a course of therapy (45 days). Evaluation included: patient acarograms, symptoms and signs of CB (points); OSDI; tear film break-up time (TBUT, sec), severity of meibomian gland dysfunction (S-MGD, points). Statistical analysis: calculation of M±SD, Mann-Whitney, and Wilcoxon tests. RESULTS: Acaricidal treatment was effective in both groups (reduction in demodex population, which was more pronounced in the 1st group). Symptoms and signs of CB were significantly less pronounced in the patients of the 1st group after therapy. The patients of the 1st group showed a significant decrease in S-MGD, OSDI and an increase in TBUT, the 2nd group - a significant decrease in OSDI and an increase in TBUT at the second control point. The positive OSDI and TBUT trends were significantly more pronounced in the 1st group. CONCLUSION: Acaricidal treatment as part of TEH showed a significantly more pronounced reduction in demodex population, relief of CB symptoms and sign, OSDI decrease and TBUT increase, compared to the 2nd group. Apparently, this was associated with combined acaricidal effect and significant S-MGD decrease in the patients of the 1st group.

Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the literature to determine the efficacy and safety of thermal pulsation technologies in improving signs or symptoms of meibomian gland dysfunction (MGD) and dry eye compared with no therapy or with conventional warm compress therapy or eyelid hygiene. METHODS: A literature search was conducted in the PubMed database in June 2022 and again in March 2023 to identify all studies in the English language on the use of thermal pulsation to treat MGD or dry eye. The search yielded 59 citations, and 11 articles met all of the inclusion criteria. The panel methodologist then assigned a level of evidence rating for each study; 8 studies were rated level I evidence and 3 studies were rated level II evidence. RESULTS: All included studies evaluated a single 12-minute session using the LipiFlow automated thermal pulsation system (TearScience, Inc, or Johnson & Johnson). Improvements were detected in subjective and objective metrics of MGD or dry eye in patients within 1 to 12 months of thermal pulsation treatment compared with nontreatment. Most of the studies (9/11) reported greater efficacy with thermal pulsation than with standard warm compress therapy and eyelid hygiene. Four of these studies showed relevant industry conflicts of interest. Two of the 4 level I studies without direct industry participation concluded that thermal pulsation treatment was not significantly different from conventional hygiene or warm compress therapy control treatments (in symptoms in one of the studies and in objective findings in the second study). No serious adverse events were reported in any of the 11 studies. CONCLUSIONS: According to the current literature, a single thermal pulsation session may improve subjective or objective parameters of MGD and dry eye safely. However, industry support and participation were present in 4 of the 8 level I studies. The durability beyond several months and cost efficacy remain uncertain. Because the inclusion parameters of this assessment captured only the LipiFlow system, the conclusions are limited to that product. High-quality independent studies are needed to assess the long-term benefits of this intervention. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Meibomian gland dysfunction and blepharitis: A common and still unsolved ophthalmic problem.

Blepharitis and meibomian gland dysfunction (MGD) are very common, usually underdiagnosed and underappreciated diseases. More than 50% of patients seeking ophthalmologic consultations have symptoms and signs indicating one or both entities. We summarize the key points of diagnosis and management of both diseases, comparing the work of Dry Eye Workshop II (2017) with the dry eye blepharitis syndrome unification theory. The impact of MGD/blepharitis on ocular surgery also is described. Although MGD and blepharitis seem to be uncurable, most of the time they can be successfully controlled. Different management options are available, but the key to success remains simple-routine eyelid hygiene and moisturizing with the use of preservative-free lubricants.

Intense pulsed-light treatment improves objective optical quality in patients with meibomian gland dysfunction.

BACKGROUND: To evaluate changes in objective optical quality following intense pulsed light (IPL) treatment combined with meibomian gland (MG) expression (MGX) in patients with MG dysfunction (MGD). METHODS: This retrospective cross-sectional study included MGD-related dry eye disease (DED) patients who received IPL treatment between March and December 2021 at Kim's Eye Hospital, Seoul, Republic of Korea. Each patient underwent four sessions of IPL treatment using Lumenis M22 (Lumenis Ltd., Yokneam, Israel) and MGX at three-week intervals. RESULTS: This study included 90 eyes from 45 patients with MGD. The mean age was 52.3 ± 16.1 years (range, 20-75 years), and 53.3% (24/45) of patients were female. Compared with the baseline, all clinical symptoms and signs significantly improved after IPL treatment combined with MGX. All optical quality parameters obtained with an optical quality analysis system (OQAS: Visiometrics, Castelldefels, Spain) have improved significantly over the baseline (p < 0.001). CONCLUSIONS: In patients with MGD, IPL treatment combined with MGX improved the objective optical quality and clinical signs and symptoms of DED.

3-month post-procedural evaluation of a combined intense pulsed light and photo-biomodulation system in the treatment of meibomian gland dysfunction.

PURPOSE: Meibomian gland dysfunction (MGD) is the leading cause of dry eye syndrome. It is a frequent and underdiagnosed condition with a significant socioeconomic impact. We propose here the evaluation of a platform combining intense pulsed light and photo-biomodulation in the treatment of Meibomian gland dysfunction. METHODS: We conducted a retrospective study at Brest University Hospital analyzing a cohort of 74 eyes (37 patients) at 1 month and 3 months after a protocol of 3 Eye-Light® (Espansione Group, Italy) sessions 14 days apart between January 2019 and April 2020. The primary outcome was the change in OSDI quality of life score. Secondary outcomes were the SPEED questionnaire score; tear break-up time (BUT), Oxford score, non-invasive break-up time (NIBUT), lipid layer thickness, lacrimal meniscus height and Meibomian gland atrophy rate. Tolerance of the treatment was also evaluated. RESULTS: We found a significant improvement in OSDI scores at 1 month (-17.32; 95% CI (-25.84; -8.79), P<0.0001) and 3 months (-16.95; 95% CI (-25.26; -8.64), P<0.0001). The SPEED score, BUT, Oxford score, Meibomian gland atrophy and NIBUT were also statistically significantly improved. Tolerance to treatment was very good despite two cases of herpetic keratitis, which resolved on treatment. CONCLUSION: Treatment with the Eye-Light® in three sessions every two weeks significantly reduced symptoms and ocular surface damage in patients with MGD. This data suggests that the use of Eye-Light® may represent a good option for patients with MGD.

Evaporative dry eye disease due to meibomian gland dysfunction: Preferred practice pattern guidelines for diagnosis and treatment.

Evaporative dry eye (EDE) due to meibomian gland dysfunction (MGD) is one of the common clinical problems encountered in ophthalmology. It is a major cause of dry eye disease (DED) and of ocular morbidity. In EDE, inadequate quantity or quality of lipids produced by the meibomian glands leads to faster evaporation of the preocular tear film and symptoms and signs of DED. Although the diagnosis is made using a combination of clinical features and special diagnostic test results, the management of the disease might be challenging as it is often difficult to distinguish EDE from other subtypes of DED. This is critical because the approach to the treatment of DED is guided by identifying the underlying subtype and cause. The traditional treatment of MGD consists of warm compresses, lid massage, and improving lid hygiene, all measures aimed at relieving glandular obstruction and facilitating meibum outflow. In recent years, newer diagnostic imaging modalities and therapies for EDE like vectored thermal pulsation and intense pulsed light therapy have emerged. However, the multitude of management options may confuse the treating ophthalmologist, and a customized rather than a generalized approach is necessary for these patients. This review aims to provide a simplified approach to diagnose EDE due to MGD and to individualize treatment for each patient. The review also emphasizes the role of lifestyle modifications and appropriate counseling so that patients can have realistic expectations and enjoy a better quality of life.

A randomized controlled study evaluating outcomes of intense pulsed light and low-level light therapy for treating meibomian gland dysfunction and evaporative dry eye.

Purpose: This randomized, controlled, blinded study evaluates the efficacy of intense pulsed light (IPL) therapy with low-level light therapy (LLLT) in the treatment of meibomian gland dysfunction (MGD) and evaporative dry eye (EDE) compared to a control group. Methods: Hundred patients with MGD and EDE were randomized into control (50 subjects, 100 eyes) and study group (50 subjects, 100 eyes). The study group underwent three sittings of IPL with LLLT 15 days apart and were followed up 1 month and 2 months after the last treatment sitting. The control group underwent sham treatment and was followed up at the same intervals. The patients were evaluated at baseline and 1 month and 3 months (post 1st treatment) for dry eye. Schirmer's test and tear breakup time (TBUT), OSDI, meibomian gland expression, and meibography. Results: The study group showed significant improvement in OSDI scores (P < 0.0001) compared to the control group and a significant improvement in TBUT (P < 0.005) compared to the control group. There was no change in schirmer's test and an improvement in the meibomian gland expression but not significant. Conclusion: The results show that a combined therapy of IPL with LLT is effective in treating MGD with EDE compared to controls, and repeated treatment sessions have a cumulative effect on the disease outcomes.

A Review of Applications and Intracellular Mechanisms of Intense Pulsed Light in Eyelid Inflammatory Diseases.

Objective: To evaluate relevant clinical outcomes and conclude possible mechanisms of intense pulsed light (IPL) in eyelid inflammation. Background: IPL devices were primarily applied in cutaneous vascular malformations and have been used in ocular diseases for about 20 years, mostly including meibomian gland dysfunction (MGD), blepharitis, and ocular rosacea. Recent findings: Seventy-two original clinical researches were included, 57 for MGD, 4 for blepharitis or blepharitis-related keratoconjunctivitis, and 11 for rosacea. Dry eye symptoms, (tear) break-up time (BUT), and meibomian structure and/or functions were improved in most patients, but production of reactive oxygen species is an important link in the photobiomodulation mediated by IPL, which can influence numerous signal pathways to achieve anti-inflammatory, anti-infective, and prodifferentiation effects. Conclusions: The evidence suggests that IPL is an effective therapeutic tool for most patients with MGD, but more clinical evidence is needed for other indications.

Efficacy of vector thermal pulsation treatment in reducing postcataract surgery dry eye disease in patients affected by meibomian gland dysfunction.

PURPOSE: To evaluate the effect of a single LipiFlow vector thermal pulsation treatment performed before cataract surgery in reducing signs and symptoms of postoperative dry eye disease (DED) in patients with mild-moderate meibomian gland dysfunction (MGD). SETTING: Eye Clinic, Careggi Hospital, University of Florence, Florence, Italy. DESIGN: Prospective unmasked randomized controlled clinical trial. METHODS: This study included patients affected by age-related cataract and mild-moderate MGD, who were randomized into 2 groups: (1) a single LipiFlow treatment performed at 5 preoperative weeks and (2) warm compresses and eyelid massages twice a day for 1 preoperative month (control group). Noninvasive break-up time (NI-BUT), Schirmer test, Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and MG functionality parameters were evaluated at visit 0 (5 preoperative weeks), visit 1 (1 preoperative week), and visit 2 (1 postoperative month). Confocal microscopy of the MG of lower eyelids was performed at visit 0 and visit 2. RESULTS: A total of 46 patients (46 eyes) were enrolled. In the LipiFlow group (n = 23), NI-BUT, SPEED questionnaire, and MG functionality parameters significantly improved at visit 1 ( P < .05) and visit 2 ( P < .05) compared with baseline and remained stable postoperatively. In the control group (n = 23), they did not significantly improve after treatment, while worsened postoperatively. Moreover, the changes in all parameters from baseline were significantly different between the 2 groups. Confocal microscopy imaging highlighted lower postoperative MG alterations in the LipiFlow group. CONCLUSIONS: A single preoperative LipiFlow treatment was effective in preventing postcataract surgery DED in patients with mild-moderate MGD. Postoperatively, treated patients displayed a better ocular surface status compared with warm compresses.

Meibomian gland dysfunction patients benefit in ocular parameters and tear chemokines after thermal pulsation treatment.

Objectives: To investigate the effect of thermal pulsation treatment on meibomian gland function, ocular parameters and tear inflammatory cytokines compared with the warm compress group. Methods: Twenty-five participants with MGD underwent a 12-minute thermal pulsation treatment, while 25 participants with MGD underwent manual warm compress treatment. MGD related parameters, including meibomian gland function (MGE, MQ and lid margin), tear stability (NIKBUT, FBUT and LLT), tear secretion (SIT, and TMH), were examined and OSDI questionnaire was also obtained. Tear chemokines (MIG, IFN-γ, IL-8, IP-10 and MCP-1) were examined and analyzed the correlations with MGD related parameters and OSDI. Results: Compared with warm compress subjects, OSDI, lid margin and tear stability were found improved more in thermal pulsation treatment at 3 months (OSDI: *p = 0.014, lid margin: *p = 0.021, LLT: **p = 0.008, CFS: *p = 0.028). The level of IP-10 and MIG decreased more in thermal pulsation group than in warm compress group (IP-10: *p = 0.021, MIG: *p = 0.039). IP-10 was positively correlated with MQ (r = 0.522, *p = 0.037) and negatively correlated with tear stability (r = -0.613, **p = 0.002), and OSDI was only positively correlated with IL-8 (r = 0.679, ***p < 0.001). The decrease of MIG was positively correlated with less corneal epithelium injury (r = 0.557, **p = 0.006) and meibograde (r = 0.49, *p = 0.019). Conclusions: Thermal pulsation treatment obviously improved MGD probably by attenuating tear CXCL chemokines in ocular surface of MGD patients, which demonstrated an efficacy and well-tolerated therapy in clinical.