SkyVision joins team IPL
An expert explains the possible science behind intense pulsed light and why his practice is finally using it for dry eye.
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Well, you have to give me credit for being consistent.
Years ago, I balked at adding thermal pulsatile treatment using LipiFlow (now owned by Johnson & Johnson Vision) because I hated the early business model so much. Once the good folks at TearScience made a few changes (that I may or may not have suggested), even the attempted panel ambush at Caribbean Eye was not enough to scare me off. The science was good, and LipiFlow (as well as meibomian gland imaging and tear lipid analysis) has performed as predicted. Credit for the wider use of LipiFlow should go to Frank Bowden (with an assist to his administrator Patti Barkey). While others such as Cliff Salinger were early adopters, Dr. Bowden was a pioneer in every way when it came to LipiFlow.
Now I am later to the game with another technology than I probably should have been. Intense pulsed light (IPL) is another highly effective technology that has been adapted for use in the treatment of dry eye disease. When you think about IPL in ophthalmology, there is really only one name that comes up in a search for early adopters and developers of this technology: Rolando Toyos, MD. Again, others have made significant contributions over time, but Dr. Toyos is arguably the single biggest factor in the widespread use of IPL both in the U.S. and around the world. You could spend hours on his YouTube channel watching all things IPL. As a matter of fact, if you are the least bit inclined to bring IPL into your practice, you probably should.
I sure did.
There is some robust science behind the “why” of IPL. Let us step back for a moment and consider why meibomian gland inflammation is key to so may different aspects of DED. We know from experience that blurred vision from DED is associated with a decreased tear breakup time. This, in turn, is routinely seen in all types of meibomian gland dysfunction, especially obstructive MGD with or without gland destruction. A bedrock principle of modern DED care is that inflammation on the surface of the eye is responsible for tear dysfunction, which may eventually lead to destruction of other elements of the lacrimal functional unit such as goblet cells. Whether the meibomian glands are the primary source of inflammation, as we surmise in seborrhea and rosacea, or simply a reservoir of inflammatory cytokines and chemokines deposited from the tears, inflammation in meibomian glands is a significant contributor to damage on the ocular surface.
In a landmark study published in 2015 in Photomedicine and Laser Surgery, Dr. Toyos demonstrated improved signs (87% of subjects had an increase in tear breakup time) as well as symptoms (93% of subjects reported a decrease in DED symptoms) after a series of IPL treatments. How does it work? Steve Dell, MD, published a comprehensive review in Clinical Ophthalmology in which he cites the many ways in which pulsed light in the infrared and near red wavelengths affects the tissues around the lids. The mechanism of action is complex, comprising some or all of the things that IPL does at the tissue, cellular and molecular level.
Light energy is absorbed by hemoglobin, causing thrombosis and destruction of telangiectatic blood vessels near the surface of the lids. These vessels are felt to be a reservoir of inflammatory mediators. It is entirely possible that this alone is sufficient to reverse inflammation in the meibomian glands. However, Laura Periman, MD, has written that light energy as used in IPL also has an anti-inflammatory effect of its own. This may have a direct effect on the inflammation seen on the ocular surface. IPL treatments upregulate anti-inflammatory cytokines such as IL-10, while at the same time inhibiting the activity of pro-inflammatory cytokines such as IL-6 and matrix metalloproteinases, specifically MMP-9. These effects are strikingly similar to those of corticosteroids when they are used to treat DED. (One wonders if IPL might also upregulate mucin production.) Note that I have not mentioned heat or the possibility that IPL works in DED simply by melting solid oil clogging meibomian glands. Here I fall firmly in line with Dr. Periman who feels that it is not the thermal but rather the anti-inflammatory effects of IPL, as well as the destruction of abnormal blood vessels, lying behind the success of IPL.
After all of this science (two citations!), you are probably wondering who is really writing this column. I have to admit, the science is pretty cool. So cool that your very practical “who cares how it works, just tell me how to do it” scribe got deep into those woods for a bit. Which brings us up to why IPL at SkyVision, and more specifically, why now? Well, there was not any kind of public ambush story like the LipiFlow thing this time, but I did get a bit of good-natured ribbing and a fair amount of semi-public shaming at the hands of several of my DED comrades. Have you ever been on the receiving end of a Laura Periman “knowledge bomb”? The only way to get Dr. Periman to accept your “uncle” plea is to agree to try whatever she is teaching. But the final credit goes to my good friend Alice Epitropoulos, MD, in Columbus, Ohio. I had been sending patients who needed IPL to Dr. Epitropoulos. Each time they came back, she sent a note teasing me for making my patients drive 2.5 hours. Ouch.
So, how has it gone? I would love to tell you that we are now 4 months into our experience, but our IPL project was blasted off schedule by COVID-19, just like everything else. Our fancy M22 from Lumenis sat in a corner for 3 months, waiting for us to get going. Thankfully, we are now up and running; all of our trial patients sailed through their experience without complications and with an early improvement in their symptoms. I owe a huge debt of gratitude to Cynthia Matossian, MD, for holding my hand through the process of putting our practice protocols in place. There are now 40 patients lined up and ready to rock, all of whom have significant lid disease and associated DED.
If nothing else, I am consistent when it comes to adopting DED technology. SkyVision is usually first off the block when it comes to pharmaceutical innovation, but for whatever reason, it takes a bit more to get us off the schneid with device-driven treatments. If our LipiFlow experience is any indication, our patients will love having IPL available where they obtain the rest of their DED care.
And Dr. Epitropoulos will stop making fun of me!
- References:
- Dell SJ. Clin Ophthalmol. 2017;doi:10.2147/OPTH.S139894.
- Toyos R, et al. Photomed Laser Surg. 2015;doi:10.1089/pho.2014.3819.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
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