Segment 12. IPL for dry eye - common concerns and questions
Does IPL hurt? The key to IPL treatments is to adjust the frequency of the light to the target you want to treat. Because inflammation is carried by blood in blood vessels, the typical wavelength we chose for dry eye treatments is directed to that. The vessels can be thought of as a “tree of inflammation” where the roots are where all the vessels should be and the trunk, branches and twigs are reaching up to the surface and into the tear glands. The first treatment targets what the light can “see” - largely the twigs on the surface. Lots of red = lots of target (& relates to degrees of discomfort - more target = more discomfort). These vessels will “regress” or shrink, after a good treatment. This leaves a layer of skin that becomes clear over the next, “branch level” of vessels. Waiting an appropriate time allows the next treatment to reach through the less red skin, down to the next red level (of branches). Each treatment can clear more redness. Less redness means less target, less inflammation (& less discomfort). However, it can be useful in many cases, to increase the power, so as to reach the lower levels of red - so subsequent treatment may be as - or more - uncomfortable- than the first. While we can adjust settings to be less uncomfortable, we try to balance this with what is more likely to work best in clearing more redness and inflammation. Usually this is at least 4 consecutive treatments (typically 3-5 weeks apart, though that can vary with clinical findings and treatment objectives). Experienced specialists will be able to guide you.
Why is IPL alone, not sufficient for clearing obstructed tear-oil glands? IPL’s major shortcoming is that despite a variable degree of MG heating (depending on the device and protocols used as well as the skin type being treated), by the time the MGs are expressed (which can be significantly delayed after removing the ultrasound gel and positioning at a slitlamp) - and some IPL protocols don’t include any expression- the waxy clogs may be too solid to respond to expression pressures. Lots of technology has evolved to help address this issue. Lipiflow was the first in-office device, but has limitations on the amount of heat, pressure and surface area it covers. TearCare can provide more uniform heat, but can also suffer from a time delay to expression. iLux is more customizable but can be a bit tricky for upper lid treatments. I prefer off label use of radio frequency (RF) for full customization (with the unique “side effect” of leaving skin looking a bit younger, with fewer fine lines and wrinkles). As a part owner of eyeThera, (my financial disclosure), I find the thermashields I helped devise for expression with RF can also be a benefit for other heated expression (TearCare and Mibo to name two). If you and your provider wish to try a shield for this purpose, I try to do most of my expression in the final minutes of Mibo or TearCare heating, by moderate digital pressure (or QTip pressure) over the lid and against the “backstop” of a thermashield. This can be quick, comfortable for the patient - and therefor, more effective - in my limited experience - as I still use RF for most. eyeThera can provide a single shield if your provider will order through their website. I also find it critical to take excellent Omega 3 oils but not to neglect the Omega 6&9’s. I generally advocate some high-quality Fax Seed Oil in addition to the Fish Oil supplements, (or to take a good combination supplement like the MaxiTears Dry Eye Formula) though each case is different and best to check with your provider.
Can IPL cause loss of lashes? Lash loss is a frustrating problem that can have a complex list of causes. One of the most common causes is also one of the most common indications for RF - which is blepharitis (inflammation and irritation of the lids and lid margins, including the lashes and lash follicles). Lashes grow in a cycle that can take about 6 weeks from falling out to fully return, under ideal circumstances. Inflammation can interrupt this cycle. When we use IPL to treat blepharitis and related dry eye issues, we typically use a wavelength best suited (590nm). While this wavelength can temporarily affect the lash cycle, it commonly takes a wavelength closer to 755nm to more permanently affect or damage the lash follicle - so “permanent hair removal” would target that 755 wavelength. Some IPL machines have a broad band of light that could include a higher wavelength that could damage lash follicles, but the majority of dry eye specialists (myself included) use Lumenis’ technology (M22 or Optilight units), which can selectively target the lower 560-590 range for dry eye treatments that was FDA approved for this purpose. We also don’t aim the light directly over the lashes, so permanent loss of lashes is rare.
How long does it take for IPL to work? (1), it is not for everyone (can't treat skin of darker color), (2), it rarely has lasting or significant benefit before the 3rd to 4th treatment - so generally needs to be prescribed as a series of 4 treatments, (3), it requires maintenance treatments which varies depending on the patient. Those with larger numbers of blood vessels near the surface of the skin (which bring inflammation to the lids and eyes), those with more sensitive skin, those with more advanced degrees of dryness, those who don't do their "homework" (generally not taking good oils, not keeping lids and lashes clean, don't do good blinks or hot compresses) and those with "bad" genes (innately programmed to progress towards inflammation and dry eyes) may all need more treatments up front and more frequent maintenance. Most need 1 treatment every 6-12 months (some more and rarely less). As also stated above, the type of machine used along with the protocols and skills of the treating physician will also play a role (not all machines are equal). I find IPL a very effective tool (among others) for treating dry eye, rosacea and a variety of cosmetic and medical skin problems. The best treatment can only come from having a good exam and doing the "homework" the doctor prescribes.