The multifactorial disease known as commonly as “dry eye”, occurs by a loss of hemostasis of the tear film from instability, ocular surface inflammation and damage including neurological and morphology changes. Meibomian gland dysfunction or “MGD” is a chronic abnormality of the oil producing glands of the eye. MGD occurs when the oil glands become clogged and meibum cannot be released with each blink; this reduces the volume they produce and creates chemical changes in secretions. Periocular rosacea, exacerbates MGD, more on that in a minute.
Regardless of how much of the water component of your tears you produce (it makes up ~90% of the volume normally), without an oily layer on the surface of your eye, the tear film will evaporate quicker than a normal blink occurs. This instability leads to inflammation and mild damage. Without fixing the source of the problem, over time this negative feedback loop leads from mild symptoms. These range from intermittent blur to devastatingly severe symptoms of constant ocular discomfort, redness and irritation (burning, stinging, foreign body sensation). The earlier in this chronic process we treat the underlying cause, the better the outcomes and the less involved your treatments need to be. That’s where IPL or intense pulse light therapy comes in.
Meibomian glands impact on dryness symptoms
MGD is not only the leading cause of evaporative dry eye. It also makes up the majority of dry eye cases overall. Regardless of how much of the water component of your tears you produce (it makes up ~90% of the volume normally), without an oily layer on the surface of your eye, the tear film will evaporate quicker than a normal blink occurs. This instability leads to inflammation and mild damage. Mild symptoms include intermittent blur. Severe symptoms include constant ocular discomfort, redness and irritation (burning, stinging, foreign body sensation). The earlier we treat the underlying cause, the better the outcomes and the less involved your treatments need to be.
Where to start
One of the first things we recommend to improve the MG secretions is what is considered “conservative” treatment. It’s only effective when the disease is very mild, often before many people notice symptoms. These treatments include using hot compresses and introducing an increased amount of Omega 3s into the diet. Both of these aim to increase meibum volume, Omega 3s help increase volume by providing the proper building blocks to create meibom (namely DHA) and hot compresses express the oil near the gland’s opening removing any obstructing that might be beginning to form. Patients spend on lot on these treatments and often doesn’t help their symptoms.
The Meibomian Gland Game Changer
When inflammation is limited to the ocular surface, medications that treat inflammation can significantly help restore a healthy tear film. Things like cyclosporine (Restasis) or lifitegrast (Xiidra) address this. However, not everyone benefits from these medications, nor do most of us want to be a medication indefinitely. For many people who have cloudy meibum* these options don’t help much; inflammation from outside the eye needs to be stopped before the tear film can reestablish a homeostatic ocular surface environment.
(*Cloudy meibum-chemical change in the oil from translucent olive-oil color to a milky white one. This cloudy oil doesn’t spread over the eye with blinking; instead, it clumps together and sticks to the eyelid or anything else in the eye include eyelashes or contact lenses.)
The Trouble with Leaky Blood Vessels
Inflammation of the peri-ocular region (aka the skin around the eyes, including the cheeks, upper and lower eye lids and brows), can leech through the thin skin of the lids and affect the function of the meibomian glands. The most common sign we see around the lids are dilated blood vessels call telangiectasia. Those with facial rosacea know this effect well; it’s the reason for the red patches on their cheeks, nose or other areas of their face.
Intense pulse light treatment is a game changer for dry eye. Studies have shown over and over that IPL is a treatment amplifier for dry eye: It more then doubled the effect of the meibomian gland expression alone.
~Dr. Laura Nennig
These superficial blood vessels not only look bad (cosmetically), but they are poor quality and leaky. Slowly leeching inflammatory irritants into skin, leads to a poorly functioning skin barrier, leading to dry, thickening skin over time. This same thing happens to the eye lid. Not only do meibomian glands produce poorer quality oil, these leaky vessels also thicken the tissue along the lid margin. This makes what oil they do produce a challenge to get out of the pore when you blink. (I think of this like a pimple you picked on and can’t get to pop; swollen skin blocks pores and nothing expresses out until the inflammation quiets down.)
The best way to improve function to these glands is to treat the source of the problem: the superficial blood vessels. A light therapy was developed many years ago for use on the face to treat rosacea. It’s only been applied to dry eye treatment for a few years. IPL for dry eye was just approved in early 2021 for treatment of these vessels around the eye and results have been striking.
Study Results for Intense Pulse Light Treatment
One study found when comparing Meibomian gland expression* alone and with IPL treatment:
- Patient’s subjective symptoms improved more when adding IPL compared to expression alone (all patients started around with moderate dry eye score of ~13-15, and improved by 9 points w/ IPL vs 3.5 with expression alone about 3 months since last treatment)
- Tear break up time (TBUT) or the measure of how quickly the tear film evaporates was significantly and consistently improved over the expression alone
- Superficial vascularity improved significantly after a few treatments and results remained for at least 3 months after last treatment (expressing miebomian glands doesn’t impact this one way or the other)
- Improved conjunctival staining and plugging of MG, signs that high levels of inflammation are present and the benefit remained unchanged for at least 3 months after last treatment. These improved slightly with expression, but not near as much
- IPL makes the expression procedure more comfortable by softening the meibom through the thin lid skin
- 66% of patients saw improvements in signs and symptoms after 4 treatments. And over 90% of patients saw improvement after 8 treatments. This improvement remained unchanged through the end of the study about 3 months after last treatment.
- Symptoms start to improve after only 2 treatments!
*Meibomian gland expression or thermal pulsation: heat applied to the lids to melt thickened secretion; examples of this treatment are LipiFlow, iLux and to a lesser extent, hot compresses.
The Lumenis OptiLight IPL for dry eye is a game changer. Studies have shown over and over that IPL is a treatment amplifier for dry eye. It more then doubled the effect of the meibomian gland expression alone. After using this technology for the last 2 years, Dr. Foster findings support that also. Read our updated article about intense pulse light.
How OptiLight Treatment Works
There are several ways researchers think ILP helps Meibomian gland dysfunction:
- IPL warms the MG through the thin eyelid skin and melts the secretions within the glands
- IPL emits energy absorbed by chromophores in the hemoglobin. This closes abnormal vessels in the lid margin and adjacent conjunctiva, this prevents release of inflammatory factors into the tears
- ILP may relieve inflammatory or neurogenic pain
- IPL results in an immediate reduction in bacterial load at the lid margin and surrounding skin; an external source of inflammation.
The exact reason may be unknown, but 5+ years of results from this technology is exceedingly positive without additional medications. No other MGD option treats a root cause like IPL, effectively halting the disease process. Go-to treatments, like Restasis, make you less susceptible to inflammatory irritants, IPL treats the source.
If you’re interested in this treatment and want to know what to expect, read this blog about the treatment process. Want the latest info? Read an updated article here.
If you think you have meibomian gland dysfunction (it makes up 85% of dry eye sufferers)? Please call or text us at 816-524-8900 and get scheduled with our dry eye specialist Dr. Alyssa (Sherwood) Foster.
Posted updated June 2022 by Laura Nennig, OD; she specializes in contact lens fittings, with advanced training with scleral lenses including those used for dry eye treatment. She works closely with our resident dry eye specialist, Alyssa (Sherwood) Foster, OD.
