Photo courtesy of Craig Thomas, OD.
For years I have been treating dry eye and feeling like there was something . . . missing. I knew there was more I could be doing for more dry eye patients. Turns out – it was as simple as light all along! And it’s finally here! Can you feel my excitement?
(Side note – for those of you who want the science behind all of this, feel free to click on the links I’ve provided to review the papers in more depth from which this information comes from).
There are currently 2 types of photobiomodulation aka “light” therapies being used in eye care to treat dry eye. One of them is Low Level Light Therapy (LLLT) delivered via medical grade masks, and the other is Intense Pulse Light (IPL) therapy. Both of them treat evaporative dry eye – the type of dry eye that results from poor quality oil secretions coming from the glands in our eyelids. If we don’t have enough of the top oil layer of our tear film, our tears will evaporate too easily. This comprises 86% of dry eye, so chances are pretty high that if you have dry eye, you will benefit from these therapies. Did I mention that their major side effect is a collagen tightening, anti-aging effect? More on this later . . .
At the Siepser Dry Eye Center, we will use LLLT masks that come in 2 different wavelengths of light – one red mask and one blue mask. The red mask will be our work horse for treating evaporative dry eye – it works at the level of the mitochondria to improve cellular metabolism, giving it a long lasting benefit. There is not a single evaporative dry eye patient who does not need improved cellular metabolism. In the process of improving ATP production, LLLT produces enough internal heat to melt poor quality, pasty oil gland secretions which can then be easily cleared out. And yes it does have that fun, anti-aging benefit as well!
The blue LLLT mask is mainly anti-microbial by releasing perforins which will kill their targets by binding to their cell membranes and basically punching holes in it. This will be very beneficial for patients with eyelid inflammation (blepharitis), demodex (a mite that commonly lives in eyelashes and oil glands), and ocular rosacea. Both mask treatments will typically last 15 minutes each – so you get to come in, relax in a large comfortable chair, and close your eyes for 15 minutes. Doesn’t sound so terrible does it?
The great thing about the evolution of dry eye diagnosis and treatment over the last decade plus is that we now have lots of new technologies to image and measure dry eye. We have validated symptom questionnaires that are repeatable and have been used in a number of studies. We can easily measure things such as the tear break up times, inflammation, and salt content in the tears. We can image the oil glands with infrared technology – something we do routinely at the Siepser Dry Eye Center. So the bottom line is we have reliable ways of measuring whether or not someone’s dry eye is improving both in the office and in academic settings. In recent studies, they have been able to measure “significant” improvements in dry eye patients who have undergone LLLT, with some reporting more than 90% improvement.
For IPL, this is like having the benefit of the blue mask and the red mask on steroids. The absolute simplistic beauty of it is it is also nothing more than incoherent light – no toxins, no chemicals, just all natural light therapy. Multiple wavelengths of light in the visible spectrum, typically between 400 and 1200 nm, are delivered in short pulses to the skin via a handheld device by a trained professional. These wavelengths of light are absorbed by 3 different types of chromophores in the skin – water, hemoglobin, and melanin – giving it a number of applications. It can diminish the appearance of dark spots (think freckles and age spots), tighten up collagen (yet again, that fun anti-aging effect!), and eliminate vascular lesions such as the fine telangiectasia that are the hallmark of rosacea (this will be its main dry eye application). IPL is also antimicrobial, so it will have all of the same benefits as the blue LLLT mask such as being able to kill the demodex mite on contact.
IPL first got FDA approval for removal of telangiectasia (fine, leaky, inflammatory blood vessels) as a treatment for facial rosacea in 1995, so it has been used by dermatology for years. In the world of dry eye, IPL really shines as a treatment for ocular rosacea, which has plagued ocular surface disease specialists such as myself for years.
It was probably about 10 years ago when I first heard about IPL as potentially having applications for ocular rosacea – which is when those pesky telangiectasia affect the eyelid. It is estimated that 1 in 10 people have rosacea. 20% of cases of rosacea begin with the eyelids before affecting the rest of the face, and up to 90% of people with rosacea have ocular involvement. It has also been noted that often times patients who have rosacea have a higher percentage of the demodex mite than those without rosacea.
Telangiectasia are fine blood vessels that leak inflammation onto the lid margin and into the meibomian (oil) glands in ocular rosacea
In 2017 a few important papers were published that provided us with pretty solid evidence that IPL was in fact a very effective therapy for evaporative dry eye. In a nutshell, telangiectasia are not good blood vessels. As I mentioned, they are weak, leaky blood vessels. And they leak inflammation. All over the lid and right into those meibomomian (oil) glands in the eyelid. This in turn clogs them and contributes to turning that clear oil white and pasty. Next thing you know you don’t have enough of that top oil layer of your tear film, and you are left with an evaporative dry eye.
Evaporative Dry Eye
So the bottom line is, if you remove the source of the inflammation (the telangiectasia/leaky blood vessels) via IPL, you are really removing the root cause of the problem.
People who have ocular rosacea have probably the most recalcitrant form of evaporative dry eye that there is. It is so hard to treat those patients! My usual tricks will get them happy . . . for a few months. Then they are right back in my chair with symptoms 3-4 months later. If those blood vessels aren’t removed and just continue to leak inflammation into the glands, it makes sense that things such as in-office heat treatments such as Miboflo that keep your “typical” dry eye patient comfortable for a year or more only keep an ocular rosacea patient comfortable for a few months. So these people in particular really need a little light therapy in their lives to get rid of those leaky blood vessels.
And oh my goodness do I see ocular rosacea at Siepser Eyecare. All. Day. Long!
Additionally, it turns out that we have learned through studies that IPL suppresses several important anti-inflammatory mediators on the ocular surface, so it is not just for rosacea and ocular rosacea patients. In fact, another study identified 6 interrelated mechanisms of dry eye that need to all be addressed if we are to effectively treat dry eye – the bacterial burden and demodex along the lid margin, enzymatic compromise, inflammation, stasis in the glands, increased melting temperature of the glands, and obstruction in the glands. Turns out IPL tackles nearly all of these in one fell swoop.
It is through these many mechanisms that eye doctors have been turning to light therapies as an alternative means to treat chalazia or “styes.” IPL can be used to treat chalazia rather than performing an excision or doing an injection. We also now have evidence in the literature that LLLT via the red mask can treat recalcitrant chalazia as well. In one study, 46% of eyes improved after one 15 min red mask treatment, and 92% of eyes improved after two 15 min mask treatments My colleagues have used these masks in young children with chalazia whose parents have opted for LLLT rather than surgical excision for very obvious reasons!
Just like we need to get our teeth cleaned every 6 months, these stronger in-office treatments will need to be repeated periodically. Everybody’s dry eye is different, so I will be determining individual treatment and maintenance routines on a case-by-case basis. Some patients may need 2-4 red mask only treatments, some may need a few blue mask only treatments, others may need a red mask followed by a blue mask, others may need a combination of the above plus IPL. All I know is I have been watching, studying, and waiting on this for years, and I cannot wait to finally get these technologies into the Siepser Dry Eye Center and start recommending them to my patients. And if we all get to walk around looking a little bit younger – hey, I’m bound by HIPAA, I won’t reveal any of your beauty secrets. I hope after reading this you are just as excited as I am!