Do results of IPL treatment vary by technique and by the filters used? (& does it regenerate withered glands?)

Do results of IPL treatment vary by technique and by the filters used?

 I often get asked this question as patients may find me after getting multiple treatments elsewhere and they wonder if my treatments will be different. I have a lot of older, relevant posts on IPL for dry eye treatment, including this one: https://www.eyethera.com/blog/more-on-ipl but will add some updated information and share some thoughts below.

The short answer is yes and yes. In fact, not all IPL technology is the same, either. The two types of IPL are “Broad Band” (BB) vs “Selective Filtering.” (SF) Major companies have good reasons to produce one or the other, as each has strengths and weaknesses. The strength of BB is that a broad range of light energies will accomplish a broad range of treatment - mostly tailored towards aesthetic purposes, when a single pulse of BB will affect pigment (irregularities of skin color is referred to as dyschromia and can make skin appear older - like age spots - and therefore appear less attractive, as well as affecting vascular issues or hair reduction, all at the same time. Dr. Steve Mulholland refers to this as the “grenade effect.” The SF type of IPL uses a narrow (as opposed to broad) range of light by employing a very selective filter. This can approximate the effect of a laser, which is all of one “color” (or wavelength). Dr. Mulholland refers to this as a “sniper” that can knock out a single target. In the world of dry eyes, there are specific targets that appear to be most related, so the SF IPLs are tailored to that treatment. While BB IPL can cover the same wavelengths, using multiple wavelengths can be like using a sledgehammer when a smaller hammer would do. Assuming different doctors use the exact same machine, results can vary.  (SF IPL is what Lumenis was able to convince the FDA as being safe and effective for dry eye treatment, so is the type used by myself and, I believe by Dr. Periman, though I should also add, after getting FDA clearance, Lumenis has since developed a smaller handpiece that they call Optilight and claims it can treat around eyes more precisely). Understanding how light works to treat different types of skin and eye conditions is as important as the equipment used. Treating ocular rosacea (a common form of dry eye disease) means treating abnormal blood vessels. Too much pressure on the handpiece can compress the blood vessels and make them less visible to the light (so affecting them less). Tipping the handpiece at an angle can scatter the light, making it less effective. Cooling the skin too much can also shrink the vessels (like compression does), but not enough cooling can be uncomfortable for the patient and may result in surface burns. I could go on and on, but the key is to understand that Drs like Dr. Periman (and Dr. Toyos, who pioneered/invented IPL for this treatment) literally wrote the book on much of this, so I think her patients can expect the highest levels of care (apart from her being an excellent doctor). So, the equipment, the technique and the filters all are important parts of the equation. THIS IS NOT TO SAY THAT THERE ARE NO OTHER QUALIFIED DOCTORS (& related staff) WHO CAN PROVIDE EXCELLENT CARE. Many have been trained and/or influenced by Dr. Periman and/or Dr. Toyos (I’ll count myself as lucky among them) and some come from other walks of careers that might bring other talents to their practice (I like to count myself in this boat as well, having used dermatology lasers to treat skin for aesthetic purposes for many years as well as pioneering/inventing RF for dry eye care). In general, those practitioners have gone out of their way to get better training and experience than the average professional, so don’t be afraid to ask questions about their experience. All should have a minimum of a day of training from a nurse representative of the company making the IPL, but may will have taken extra courses and/or spent time with leaders (like Dr. Periman and Dr. Toyos) who have shared their knowledge and best practices with them.

Second: Does IPL regenerate withered Meibomian Glands?

Numerous reports (many anecdotal) show visible improvement in these critical glands with repeated treatments over time. There are several problems when it comes to clearly documenting visible improvements.

1) the technology for imaging is prone to errors as the angle and degree of light, rotation of the lid and focus will all affect how the glands are perceived.

2) it typically takes years for glands to “go bad” and years to see them “go good.”

3) infrared cameras tend to capture the “active” portions of the glands. As the glands become more active, they can appear to “regenerate.” How much actually regenerates is a matter of some debate. However, many of us are finding this for many of our patients. At least one clinical study found this likely to be true…

– excerpted from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802620/

“Yin and collaborators analyzed the effect of IPL on two indexes describing the meibomian gland microstructure: the acinar longest diameter and the acinar unit density. Both these parameters showed a significant improvement after treatment.27 Authors speculated that the changes in gland microstructure were induced by the photomodulation effect of IPL on acinar cell activity.27” (Incidentally, this article has a good review of the use of IPL in dry eye treatments, ut shies away from use directly over lids - which is a common part of the “Periman Protocol” that I and many other IPL practitioners find most helpful to our patients - and involves use of expensive metal eye shields under the lids, to effectively protect the eyes during the treatment).

Fortunately, following the gland function is usually easier to monitor than their anatomy (Tear Break Up Time, results of expression at the slit lamp (amount and quality), Tear Osmolarity are all useful tools in evaluating improvement). Ultimately the subjective dry eye questionnaires (SPEED, OSDI, etc) may give a good clue, too, as they allow the patient to indicate to us the type and amount of improvement they sense as a result of the treatments.