Dry Eye Disease Technology
FDA Approved for Dry Eye - From Idea to Approval
Intense Pulsed Light for Dry Eye (IPL)
With over 25 years of initial and ongoing contributions to research in dry eye, IPL treatments for dry eye were FDA approved in the spring of 2021 to treat the signs and symptoms of dry eye. IPL machines use visible and infrared light to kill Demodex, reduce inflammation, close abnormal lid margin blood vessels, and help return meibomian glands to their natural state. Dr. Rolando Toyos discovered and perfected the IPL treatment for dry eye. He also developed the Toyos Protocol used to treat dry eye by doctors and other researchers around the world - the ONLY peer-reviewed published IPL protocol. Doctors can be trained and certified at the Toyos Centers of Excellence to offer their patients this revolutionary treatment.
The Q
The Q is light technology that patients can utilize at home and on the go called, The Q, short for the Quantum. The Q complements the in office IPL treatments and can be used to extend time between IPL treatments, to treat dry eye flares and to maintain IPL results.
Safe enough to use every day on every skin type, the Q offers low energy light at a safe wavelength to stimulate the glands that produce our tears with a fraction of the energy used for in office IPL treatments. This can also be used to treat or prevent styes.
Dr. Toyos has patented this technology that is only available at selected doctors office. Results from treatment research were presented at the Ocular Surgery News International meeting in Italy. The prospective study showed increase in tear production and over a 90% satisfaction rate by patients. The 2023 new and approved Q device is now available for purchase on www.teamtoyos.com
Dry Eye Measuring Devices
Toyos Clinic has tried several technologies to objectively measure dry eye disease severity. Nothing can replace listening to the patient and an experienced dry eye specialist examining the patient at the slit lamp (exam microscope). We utilize the Oculus 5M Keratograph to document severity of dry eye by taking photographs of the Meibomian Glands.
We also have a Heidelberg confocal microscope to examine, live, the presence and health of corneal nerves, inflammatory cells and specific ocular diseases.
Dry Eye Research
Toyos Clinic is committed to continuing to pursue solutions for our toughest dry eye patients including moderate to severe dry eye, neurotrophic keratitis, Sjogren’s and other autoimmune patients. If you are interested in learning more about your options, please contact Sarah at 615.327.4015 or email her at SSmith@toyosclinic.com
Dr. Toyos has written a book, Dry Eye Disease Treatment in the Year 2020, that discusses all the new and future technologies that they are using to improve the signs and symptoms of the disease. The book is written specifically for the patient but we are already finding it out it is a favorite of specialists internationally. The book opened number two in best sellers on Amazon.com. You can purchase the book here.
Intense Pulse Light for Treating Dry Eye Disease is a treatment discovered and pioneered by Dr. Rolando Toyos.
Article Published in the Ocular Surface Disease Issue of Glaucoma Today 2016
Two decades ago, many doctors considered patients with dry eye disease (DED) a bother and did their best to weed these individuals out of their practices. Few physicians wanted to spend hours dealing with the most common cause of DED, meibomian gland dysfunction (MGD). The advent of LASIK and other refractive cataract procedures led ophthalmologists to realize that an unhealthy tear film can severely compromise the results of even the best surgeries. When the FDA approved cyclosporine ophthalmic emulsion 0.05% (Restasis; Allergan), the agency suggested to physicians that DED could be treated with more than just artificial tears,warm compresses, and lidscrubs. One such option is intense pulsed light (IPL) therapy.
Discovery
In 2001, I began to incorporate aesthetics into my general ophthalmology practice. I used IPL to coagulate the abnormal telangiectasias of the skin seen in patients with rosacea and to perform facial rejuvenation. Some of my patients with MGD reported that IPL had not only improved their skin but also, surprisingly, their DED symptoms. As I studied their eyelids, meibomian glands, and tear film, I discovered that the IPL had indeed improved the signs and symptoms of DED as well as the health of the ocular surface. My colleagues and I began researching the causes of the improvement and how to optimize the effectiveness of IPL treatment for DED.
IPL uses a xenon flash lamp to produce light in the 500- to 1,000-nm wavelength range that can be pulsed and filtered to allow specific wavelengths of energy to be released. We discovered that specific wavelengths, fluences, and pulses improved meibomian gland function in DED patients. Over time, we became able to treat a wide range of MGD patients successfully by programming specific parameters and instituting a proven protocol with IPL (Figure)
Protocol and Symptoms
Dr. Rolando Toyos writes the first case report demonstrating that Intense Pulse Light can improve Dry Eye Disease 2003.
In my experience, the best protocol is for patients with MGD to receive IPL treatment from tragus to tragus, including the lids, a few times over the course of 4 months. Not all IPL technologies have the ability to deliver treatment around the lids, because the systems are unable to control the energy and pulses and are not ergonomically designed to maneuver around the lid margins. Also, most IPL technologies lose their ability to consistently provide the specific power programmed. For example, the operator may program an IPL system to deliver 14 J/cm2, but after several more uses, the energy level delivered is less than the programmed energy level. In my experience with other IPL systems, I would have to raise the programmed energy levels with increased use to achieve the desired outcome.
I use the Lumenis M22 with Optimal Pulse Technology (Lumenis), because I am confident that the energy level programmed will be the energy produced. The consistency of the system has allowed me to program parameters that I have found, with 15 years of experience, to work more than 95% of the time in select patients with DED. Surgeons whom I have trained have found similar success rates with my IPL parameters and protocols.
Mechanisms of Action
Understanding of the multiple mechanisms through which IPL benefits DED patients has evolved as knowledge of the disease and technology have advanced. One important characteristic of IPL is its ability to kill microorganisms. An IPL robot called the Xenex is now being used to disinfect ORs and hospitals and was a critical part of controlling the Ebola outbreak. (1,2)
Overgrowth of bacteria and Demodex is a hallmark of MGD, and studies show that IPL improves the signs of blepharitis. Also, IPL warms the dermis to temperatures up to 43º C, thus melting the thick secretions produced by patients suffering from MGD and allowing me to manually express the glands easily. I find that heat-assisted gland expression helps to relieve some of the signs and symptoms of DED but does not change the overall function of the glands.
Certain wavelengths of light at specific fluences can stimulate cells and glands to function normally. This process is called photomodulation. Importantly, several articles have demonstrated that IPL stimulates fibroblasts in skin to produce more collagen. (3,4) I believe that the cells of meibomian glands are also stimulated by IPL. Over time, researchers and practitioners will learn more about all of the morphological changes that occur to the skin and glands of patients undergoing the procedure.
Conclusion
Last year, several published research articles demonstrated that IPL improves the signs and symptoms of DED.(5,6) As the technology advances, so will the success rate and adoption of the procedure. In his book Transcend, futurist Ray Kurzweil, PhD, famously pointed out that it takes 15 years for a medical breakthrough to become the standard of care. I introduced IPL for DED in 2001. Perhaps the procedure is hitting Dr. Kurzweil’s tipping point.
At a Glance
After administering intense pulsed light (IPL) as an aesthetic treatment, Dr. Toyos discovered that the procedure also improved his patients’ signs and symptoms of dry eye disease.
In Dr. Toyos’ experience, the best protocol is to apply therapy from tragus to tragus, including the eyelids, but not all IPL systems are capable of this approach.
IPL’s mechanisms of action include killing microorganisms, heating the thick secretions characteristic of meibomian gland dysfunction to facilitate manual expression, and photomodulation.
Footnotes
Nagaraja A, Visintainer P, Haas JP, et al. Clostridium difficile infections before and during use of ultraviolet disinfection [published online ahead of print July 6, 2015]. Am J Infect Control. doi:10.1016/j.ajic.2015.05.003.
Martinez M, Vercammen P, Hannah J. Germ-zapping robot Gigi sets its sights on Ebola. CNN website. http://cnn.it/295d6VB. Updated October 18, 2014. Accessed June 30, 2016.
McDaniel DH, Weiss RA, Geronemus RG, et al. Varying ratios of wavelengths in dual wavelength LED photomodulation alters gene expression profiles in human skin fibroblasts. Laser Surg Med. 2010;42(6):540-545.
Wong WR, Shyu WL, Tsai JW, et al. Intense pulsed light effects on the expression of extracellular matrix proteins and transforming growth factor beta-1 in skin dermal fibroblasts cultured within contracted collagen lattices. Dermatol Surg. 2009;35(5):816-825.
Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 2015;33(1):41-46.
Vegunta S, Patel D, Shen JF. Combination therapy of intense pulsed light therapy and meibomian gland expression (IPL/MGX) can improve dry eye symptoms and meibomian gland function in patients with refractory dry eye: a retrospective analysis. Cornea. 2016;35(3):318-322.