Low-Level Light and Intense Pulsed Light Therapy combo effective for Dry Eye in Sjogren's
Dry eye disease (DED) is a multifactorial disorder involving different components of the tear film and the ocular surface. It provokes discomfort and visual acuity alterations and, in the absence of adequate treatment, can lead to ocular surface damage.
In most cases, DED is due to functional alterations of the Meibomian glands. When this occurs, the lipid component of the tears decreases, resulting in excessive lacrimal evaporation.
Sjogren's syndrome (SS) is a systemic chronic autoimmune inflammatory disease. It is characterized by lymphocyte infiltration into exocrine glands, especially lacrimal and salivary glands. SS can occur as a primary disease or be associated with other autoimmune diseases. The factors most strongly associated with impaired health-related quality of life (HRQoL) in patients with SS were patient-reported symptoms, especially the dry eye severity.
Up to date, the first line of treatment for DED in SS has been the topical application of lacrimal substitutes. Second line approaches include autologous serum eye drops, corticosteroid, and cyclosporin A topical therapies, while the occlusion of lacrimal puncta, resulting in increased tears permanence in the eye, and oral administration of pilocarpine, that increases the secretion of the aqueous components, are indicated as rescue therapies.
Intense pulsed light (IPL) is a technology based on a polychromatic light (wavelength spectrum between 500–1200 nm, modulated through a filter) that induces a selective photothermolysis of the irradiated tissue. The thermal impulses stimulate the Meibomian glands to restart their normal activity. Applied on the periorbital region and cheekbones, the light stimulates the contraction of the glands, thereby increasing the lipid flow and its liquefaction. The lipid compartment stabilizes the aqueous component with consequent reduction of the lacrimal evaporation.
The low-level light therapy (LLLT) is a particular type of photobiomodulation, based on light-emitting diodes. An athermal and atraumatic cellular photoactivation leads to a significant improvement in tear breakup time (BUT). Moreover, LLLT therapy has proven effective in patients affected by Meibomian gland dysfunction.
Marino et al carried out a study to evaluate the effects of combined intense pulsed light therapy (IPL) and low-level light therapy (LLLT) in dry eye disease (DED) in patients affected by Sjogren's syndrome. This was a monocentric, prospective, interventional study. At baseline, all the study patients (n = 20) were on tear substitute therapy and underwent Schirmer type-1 test and breakup time (BUT) test. After baseline measurements, tear substitute therapy was suspended, and patients underwent IPL and LLLT. The same investigations were carried out at one (T1) and at three (T3) months after treatment. The Ocular Surface Disease Index (OSDI) survey was used to measure the severity of DED.
Diagnosis of SS was made according to 2016 EULAR/ACR classification criteria, including BUT <10 s, Schirmer I (no anesthesia) <5 mm of the paper after 5 min, and ocular surface assessment by staining (Oxford scale grade ≥2, Van Bijsterveld score ≥4 in both eyes).
BUT test showed an increase in tear film breakup time in patients with DED evident at 1 month (T1) after the beginning of the treatment (T0 vs T1: p =0.01). This decrease was even more statistically significant after 3 months of the treatment (T0 vs T3: p < 0.0001)
Schirmer test values increased too, but there was no statistically significant difference between values at T0 and T1 or T3. Patients perceived an amelioration in their condition upon the combined treatment, which resulted in a lower score at the OSDI survey. The OSDI score associated with the symptoms was decreased immediately after the end of the treatment (T0 vs T1: p = 0, 0003), while it tended to increase again after 3 months although it was lower compared to baseline (T0 vs T3: p = 0.02). There were no reported facial or ocular side effects.
Based on the OSDI evaluation, at the baseline (T0), 2 patients revealed a moderate DED (10%), while 18 (90%) showed a severe disease. At T1, 2 patients showed mild DED (10%), 8 a moderate DED (40%), and 10 (50%) a severe disease. At T3, 6 subjects (30%) reported mild DED, 2 a moderate form (10%), and 12 (60%) a severe disease.
The dual stimulation of the Meibomian glands with both IPL technology and LLLT aims at reducing the evaporative component of DED. The authors tested their combined efficacy on a group of SS patients and observed both objectively measurable and patient-perceived improvements. BUT test showed an increase in the lacrimal film stability while OSDI survey revealed a decrease of the subjective discomfort complained by the patients. In these patients, the lacrimal composition was clearly improved after IPL and LLLT therapy, probably due to the increase of the lipidic component.
In this study, the Eye-light instrumentation has been proven safe and effective. DED patients often perceive the multiple daily administration of artificial tears as tedious, time-consuming, and cost-ineffective, and this may decrease both the quality of life and the compliance to the therapy. With a reduction in the number of therapeutic sessions and of the associated costs, the IPL therapy could thus represent a viable therapeutic option in the treatment of DED patients. The use of this new technology could be effective in the co-treatment of complex pathologies such as SS, in which the amelioration of the evaporative component of the dry eye could improve patient's quality of life.
Although the number of patients and the follow-up time are limited, these preliminary results suggest a clear benefit that can be obtained in treating the evaporative component of the dry eye with the IPL and LLLT stimulation of the Meibomian glands in these patients. Randomized controlled trials are necessary to better elucidate the role of combined techniques to optimize patient management.
Source: Matteo Di, Marino Paola Conigliaro, Francesco Aiello et al; Hindawi Journal of Ophthalmology