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Dry-eye syndrome is one of the most commonly diagnosed ophthalmic conditions in the general U.S. population. Estimated frequency of dry-eye syndrome ranges from 11% to 17% in the general U.S. population.i,ii
Certain autoimmune diseases, medications, environmental factors, smoking, diabetes, increased age and menopause have been associated with dry-eye syndrome.
Common symptoms of dry-eye include dryness, grittiness, burning, ocular fatigue, redness, soreness and foreign body sensation.
Current treatment options for dry-eye patients include artificial tears, medicated ophthalmic drops, oral antibiotics and punctual occlusion.iii
However, these therapies may not alleviate symptoms in some patients.
Due to the considerable population affected by this condition, identifying novel and successful treatment options is critical for improving the quality of life for dry-eye patients.
Dry-eye disease involves both inflammatory and vascular components. Common vascular and inflammatory dry-eye symptoms include ocular erythema and telangiectasia, which are also characteristics of both cutaneous and ocular rosacea.
Several studies have identified successful pulsed light treatment of rosacea associated facial erythema and telangiectasia.4-6
We have observed similar results in rosacea patients treated with intense pulsed light for facial erythema and telangiectasia.
We have also observed improvement of dry-eye symptoms in these laser treated patients.
We present one such dry-eye case to demonstrate the prospective benefits of intense pulsed light therapy for dry-eye patients.
Case study
Figure 1. IPL treatment areas.
Source: Rolando Toyos, M.D.
The patient had a history of hypothyroidism controlled with oral medication. The patient presented with primary open angle glaucoma and had been prescribed latanoprost ophthalmic solution (Pfizer, N.Y.) for seven years.
During initial examination, the intraocular pressure was 16 mm Hg in the right eye and 16 mm Hg in the left eye.
The patient wore soft contact lenses with BCVA 20/20 in the right eye and 20/20 in the left eye.
The patient reported “unbearable dry-eye symptoms” that were unresponsive to artificial tears and punctal plugs.
Throughout the course of 13 months following the initial visit, the patient visited our office five times and exhibited repeated bilateral punctate epithelial erosions, allergic conjunctivitis, and meibomian gland disorder.
These conditions were unresponsive to treatment with artificial tears, cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan, Irvine, Calif.), brimonidine tartrate ophthalmic solution 0.15% (Alphagan, Allergan), epinastine HCl ophthalmic solution 0.05% (Inspire Pharmaceuticals, Durham, N.C.), and 30 days of oral doxycycline (100 mg, b.i.d.).
The patient’s IOP remained below 16 mm Hg for both eyes, and BCVA with soft contact lenses remained 20/20 for both the right and left eyes for the entire 13 months.
To note, the patient discontinued use of latanoprost ophthalmic solution (Xalatan, Pfizer) began travoprost ophthalmic solution 0.004% (Travatan, Alcon, Fort Worth, Texas) five months after the initial visit.
Treatment
In October 2004, the patient returned to our office and exhibited bilateral punctate epithelial erosions and meibomian gland disorder.
Baseline Schirmer’s test with anesthesia results were 8 mm OD and 0 mm OS, and tear break up time was four seconds OD and five seconds OS.
The patient received consecutive intense pulsed light treatments over a four-month period on their facial area (Fig. 1) using Quadra Q4 Intense Pulsed Light Source (DermaMed, Lenni, Pa.).
Four treatment areas were defined as:
1) Inferiorly: From the base of the nose laterally to the tragus of the ear;
2) Superiorly: From the lateral point of the eye shield to the hairline, and from the medial point of the eye shield to the bridge of the nose;
3) Medially: From the mid-saggital line along the length of the nose; and
4) Laterally: The hairline and the tragus of the ear.
Treatments consisted of removing excess dirt or makeup on the patient’s face with a clean washcloth and gentle cleanser. Then, the face was cleaned with a witch-hazel/alcohol solution and a cotton round.
Thermal spring water was then applied to the patient’s face.
External stick-on IPL shields were applied to the patient’s eye area. Cold ultrasound gel was applied to the treatment area. The patient was treated with the IPL using a double pass technique.
Treatment setting ranged from 12-14 J/cm2 with a pulse width of 20 ms. Treatment goal was uniform, mild erythema of treatment area without blistering or edema.
Following completion of treatment, the gel was removed with a clean towel, the patient’s face was cleaned with witch hazel solution and cotton round, and SPF 25 sunscreen (Genesis Pharmaceuticals, Hazel Park, Mich.) was applied to the whole face.
Treatments were repeated once a month for four consecutive months OU. Schirmer’s test with anesthesia and tear break up time was performed prior to each treatment session to assess the quality of the patient’s tear film.
Results
The patient’s IOP was monitored throughout the four month treatment period and remained below 16 mm Hg both OD and OS.
The patient’s OU BCVA with soft contact lenses remained 20/20 throughout the treatment period.
Schirmer’s test with anesthesia and tear break-up time results are illustrated in (table 1).
We observed continual or maintained improvement of both eyes with TBUT and Schirmer’s test, with the exception of the third time point for the Schirmer’s test OU and TBUT OS.
Both eyes exhibited decreased improvement prior to the third treatment.
However, both Schirmer’s and TBUT tests OU were improved prior to the fourth time point. Schirmer’s test with anesthesia and TBUT tests were performed OU one month following the fourth treatment.
We observed increases in Schirmer’s test with anesthesia (OD: +11 mm; OS: +8 mm) and TBUT (OD: +8 mm; OS: +3 mm) for both eyes when comparing initial pretreatment baseline results and results one month following the fourth treatment.
Discussion
These preliminary results indicate a potential use for intense pulsed light treatment for dry-eye.
Our initial use of intense pulsed light for dry-eye patients began when a patient rosacea indicated improvement of dry-eye symptoms since receiving IPL treatment.
We suspect IPL treatment improved meibomian gland production due to either meibomian gland stimulation or effectively decreasing telangiectasia.
However, additional investigation is necessary to determine the exact effects of the IPL on surrounding tissue.
We recently received an American Society of Cataract & Refractive Surgery Foundation Research Grant to help further our study comparing dry-eye symptoms pre-and post treatment with broadband intense pulsed light. We look forward to sharing our results in the near future.
Table 1. Schirmer’s test with anesthesia and tear break up time results for each time point.
Tests were performed and recorded prior to each IPL treatment.
| |
OD |
OS |
| Treatment |
Schirmer’s with anesthesia (mm) |
TBUT (sec) |
Schirmer’s with anesthesia (mm)
|
TBUT |
| 1** |
8 |
4 |
10 |
5 |
| 2 |
14 |
6 |
10 |
6 |
| 3 |
10 |
6 |
7 |
4 |
| 4 |
19 |
8 |
18 |
8 |
| 1 month after 4th treatment |
19 |
12 |
18 |
8 |
IPL=intense pulsed light; TBUT=tear break up time
**baseline pretreatment measurements
Source: Rolando Toyos, M.D.
Editors’ note: Dr. Toyos has no financial interests related to his comments.
Contact Information:
Toyos: 731-660-3937, rostar80@aol.com
References
i Reddy, P, Grad, O, Rajagopalan, K. (Review) The economic burden of dry eye: A conceptual framework and preliminary assessment. Cornea. 2004. 23(8) 751-761.
ii Schein, OD, Tielsch, JM, Munoz, B, et al. Relation between signs and symptoms of dry eye in the elderly: a population-based perspective. Ophthalmology. 1997. 104: 1395-1401.
iii O’Brien, PD, Collum, LMT. (Review) Dry Eye: Diagnosis and Current Treatment Strategies. Current Allergy and Asthma Reports. 2004. 4:314-319.
4 Mark, KA, Sparacio, RM, Voigt, A, Marenus, K, Sarnoff, DS. Objective and quantitative improvement of rosacea-associated erythema after intense pulsed light treatment. Dermatology Surgery, 2003. 29(6): 600-604.
5 Clark, SM, Lanigan, SW, Marks, R. Laser treatment of erythema and telangiectasia associated with rosacea. Lasers in Medical Science, 2002. 17(1): 26-33.2
6 Tan, ST, Bialostocki, A, Armstong, JR. Pulsed dye laser therapy for rosacea. British Journal of Plastic Surgeons, 2004. 57: 303-310.
ABOUT THE PHYSICIAN
 Rolando Toyos, M.D., is medical director and founder of the Toyos Clinic, Tenn.
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