More on IPL:
I’ve had several good questions raised about the efficacy and safety of IPL in various patient skin types and skin problems lately. I’m posting my replies for you here.
How dark can skin be and still be safely treated with IPL?
It depends on how much pigment (largely based on Fitzpatrick skin type). Fitzpatrick describes his skin types (1-6) I-VI, based on the amount of pigment and the way skin reacts to the ultraviolet light in sunlight. Some borderline (5’s) V’s can be brought down to IV’s or even III’s with careful sun protection and sometimes bleaching agents like topical hydroquinone (strongest) or other weaker, more natural products. All skin types can benefit from heated expressions (I like off label RF, but there are many others), if there are signs of obstruction. Lid hygiene helps a lot, too. Check with your dry eye specialist for their recommendations and good luck. If you are interested in learning your Fitzpatrick skin type, you can find it through a variety of online quiz’s, but it often helps to have an experienced clinician help “steer” your answers, as I find many of us can over or under estimate some of the questions and can help us get a more refined starting point for IPL treatments. One useful online quiz is here: https://www.proprofs.com/quiz-school/story.php?title=fitzpatrick-scale-quiz
How do we determine when to do more IPL treatments?
In my dry eye and rejuvenation center, another round of testing for tear volume and quality is generally done a month or so after the 4th treatment. If results are sub-optimal but substantial, then “stay the course” with the ongoing “homework” (typically oral Omega supplements, lid hygiene and warm, moist eyelid compresses with blink exercises) and retest 3 months later. Anytime results stop short of adequate, more IPL (& heated expression if indicated) can be considered. If the MGs are significantly short (or other evidence of being “choked” by scarring or deeper clogging), then Maskin probing may be considered. Each case is different, so check with your dry eye specialist.
Is treatment over eyelids necessary and – if so - how close to the lash line do we need to treat?
While there continues to be some debate among IPL using doctors as to whether to treat over lids or not, like Dr. Periman, (and a great many more) I find best results by treating over lids. As to how close to get to the lash line, since the blood vessels (feeding the inflammation to the tears) course through the outer to inner margins, I find that treating 1-2mm away from the lash line to be very effective, while taking less risk of diminishing the lashes whose growth bulbs are in that 2mm fringe. The IPL filters we use also make damage to lashes less likely and treating close to the lash line has the added advantage of heating the area where the oil producing glands most often clog up - so you can soften that waxy clogging, too. That the light appears to also stimulate the cells making the tears and knocking off some of the germs that eat those tears - are yet other reasons to treat as much of the active oil gland area (so over more lid area) as is safely possible.
When do you only treat with heat and when with IPL? Is a combination of both always necessary?
If your only problem is obstructive MGD (clogged oil glands), then any good, heated expression can be helpful - from Lipiflow, TearCare or iLux - to my preference of off label use of RF (radio frequency). However, if there is some related inflammation or severe MGD, then adding IPL can be a huge extra benefit. Each case is different, but my general protocol is to do IPL followed immediately by the RF heated expression in cases of obstructive MGD and concurrent lid inflammation. My experience-led rationale:
- blockages are generally of a wax-like nature, with a high melting point. Though IPL may heat enough in some cases to melt those plugs, the lids cool so quickly that the waxy oils can congeal back to thicker “toothpaste-to-macaroni” consistency that is hard to effectively and efficiently express. The lids are still warm, but not hot enough, so the RF can reheat quickly and efficiently to allow effective expression.
- one of the values of IPL is to slightly (on purpose) “injure” the abnormal blood vessels that are close to the surface and are delivering inflammatory cells and proteins to the lids, tears and therefore the eyes. Adding more heat at a juncture where they are still warm appears the better timing, as once the session is over, the healing and vessel regression (shrinking) can begin. Adding heat (without IPL) later will dilate those vessels we want to shrink, but dilation can encourage them to carry more blood and to grow back. (This can be one of the paradoxes of applying hot compresses to eyelids with active Rosacea when the clogging plugs are absent. non-obstructive MGD may occur after effective expression or in cases where inflammation is the principal problem), or when those plugs are so waxy and “hard” that the heat applied with home tools can’t melt them (so you only foster more inflammation without helping the obstruction).
- IPL alone typically takes 3-4 treatment sessions before patients experience significant relief. Adding RF expression at the outset of IPL treatment can help “jumpstart” the relief.
- MGs are often so “dysfunctional” from clogging and withering, that they may require multiple sessions of expression and since IPL also requires multiple treatments, the ability to pair IPL with RF is more cost effective and more efficient (I can reduce costs in such “packages” since I can spend less time with better efficiency).
Why is IPL not working?
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 than but can be a bit tricky for upper lid treatments. I prefer off label use of radio frequency (RF). 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 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 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. It is also important to be taking excellent Omega oil supplements to “nourish” these oil glands with the building blocks they need to make good oils. Omega 3 is good oil (and usually supplied from a refined fish oil) but diets may still be lacking in the Omega 6&9’s. I generally advocate some high-quality Flax Seed Oil to the Fish oil supplements (or – better – a combination 3-6-9 supplement with all the above), though you might check with your provider. Strong, regular blinking (often coupled with hot moist compresses) and good lid hygiene complete the “support system” that most oil glands need to do their best. IPL is a jumpstart (often coupled with a good, heated expression of clogging) but without good, ongoing support, the glands may not be able to work up to their potential. Major withering of these glands may need a prolonged course of IPL (and expression) treatments and sometimes may need added interventions like Maskin Probing (more on this in future postings).
Again, each case is different, so best to go with the recommendations of your dry eye specialist.