CLINICAL SCIENCE Multicenter Study of Intense Pulsed Light Therapy for Patients With Refractory Meibomian Gland Dysfunction Reiko Arita, MD, PhD,*† Takanori Mizoguchi, MD,†‡ Shima Fukuoka, MD,†§ and Naoyuki Morishige, MD, PhD†¶ 07/15/2018 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+33yPZHZnd1ltCeBinjI0EbPIxIV3FUx46YDB8E8QFs= by https://journals.lww.com/corneajrnl from Downloaded Downloaded Conclusions: IPL-MGX ameliorated symptoms and improved the fi Purpose: To evaluate the ef cacy of intense pulsed light (IPL) condition of the tear film in patients with refractory MGD and is therapy combined with meibomian gland expression (MGX) for from therefore a promising treatment option for this disorder. refractory meibomian gland dysfunction (MGD) in a prospective https://journals.lww.com/corneajrnl study conducted at 3 sites in Japan. Key Words: meibomian gland dysfunction, meibomian gland, intense pulsed light Methods: Patients with refractory obstructive MGD were enrolled and underwent 4 to 8 IPL-MGX treatment sessions at 3-week (Cornea 2018;0:1–6) intervals. Clinical assessment included the Standard Patient Evalu- ation of Eye Dryness questionnaire; noninvasive breakup time of the by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3+33yPZHZnd1ltCeBinjI0EbPIxIV3FUx46YDB8E8QFs= tear film and interferometric fringe pattern as determined by tear eibomian gland dysfunction (MGD) is a chronic abnor- interferometry; lid margin abnormalities, fluorescein breakup time of Mmality of meibomian glands characterized by terminal the tear film, corneal and conjunctival fluorescein staining (CFS), duct obstruction or qualitative or quantitative changes in the and meibum grade as evaluated with a slit-lamp microscope; glandular secretion of meibum.1 Individuals with MGD thus meibomian gland morphology (meiboscore); and tear production manifest an imbalance in components of the tear film because as measured by the Schirmer test without anesthesia. of a deficiency of the lipid layer. The goal of MGD therapy is to provide long-term and stable amelioration of the symptoms Results: Sixty-two eyes of 31 patients (17 women, 14 men; mean of this condition by improving the quality of meibum or age 6 SD, 47.6 6 16.8 years) were enrolled. The Standard Patient increasing meibum flow, thereby normalizing the balance Evaluation of Eye Dryness score (P , 0.001), noninvasive breakup between the lipid layer and the aqueous and mucin layers of time (P , 0.001), and interferometric fringe pattern (P , 0.001) the tear film and enhancing tear film stability, as well as by were significantly improved after therapy, with 74% of eyes showing reducing inflammation. Common therapies include applica- a change in the interferometric fringe pattern from 1 characteristic of tion of a warm compress; practice of lid hygiene; dietary lipid deficiency to the normal condition. Meibum grade, lid margin supplementation with omega-3 fatty acids; forced meibum abnormality scores, fluorescein breakup time, and CFS were also expression2; intraductal probing3; automated thermal pulsa- significantly improved (P , 0.001, P , 0.001, P , 0.001, and P = tion4; and administration of topical steroids, topical and oral 0.002, respectively) after treatment, whereas the meiboscore and antibiotics including topical cyclosporine and azithromycin, Schirmer test value remained unchanged. preservative-free artificial tears, lipid-containing eye drops, and topical diquafosol.5,6 Despite the variety of treatment Received for publication April 27, 2018; revision received May 21, 2018; options available, however, many patients with MGD are accepted May 23, 2018. refractory to treatment and thus do not experience complete or From the *Department of Ophthalmology, Itoh Clinic, Saitama, Japan; †Lid long-term relief of symptoms. ‡ and Meibomian Gland Working Group (LIME), Tokyo, Japan; Mizoguchi Intense pulsed light (IPL) therapy is widely adopted on Eye Clinic, Sasebo, Japan; §Omiya Hamada Eye Clinic, Saitama, Japan; 07/15/2018 and ¶Division of Cornea and Ocular Surface, Ohshima Eye Hospital, cosmetically and therapeutically for removal of hypertricho- Fukuoka, Japan. sis, benign cavernous hemangiomas or venous malforma- R. Arita holds patents on the noncontact meibography technique described in tions, telangiectasia, port wine stains, and other pigmented this article (Japanese patent registration no. 5281846; US patent lesions.7 A systematic review found that IPL is an effective publication no. 2011-0273550A1; and European patent publication no. 2189108A1), is a consultant for Kowa Company (Aichi, Japan) and and well-tolerated treatment option for a range of dermato- Lumenis Japan (Tokyo, Japan), and has received financial support from logic conditions, having been shown to result in reduction in TearScience (Morrisville, NC). The remaining authors have no funding or the extent of telangiectasia and the severity of facial conflicts of interest to disclose. erythema.8 The efficacy of IPL therapy for patients with dry Correspondence: Reiko Arita, MD, PhD, Department of Ophthalmology, Itoh Clinic, 626-11 Minami-Nakano, Minumaku, Saitama, Saitama 337-0042, eye due to MGD was discovered serendipitously during IPL 9 Japan (e-mail: [email protected]). treatment of facial rosacea. Subsequent studies found that Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. IPL is effective for improvement of subjective symptoms and This is an open-access article distributed under the terms of the Creative objective findings in patients with mild to moderate MGD or Commons Attribution-Non Commercial-No Derivatives License 4.0 10–21 (CCBY-NC-ND), where it is permissible to download and share the dry eye. Indeed, the combination of IPL and meibomian work provided it is properly cited. The work cannot be changed in any gland expression (MGX) was found to ameliorate dry eye way or used commercially without permission from the journal. symptoms and to improve meibomian gland function in Cornea Volume 0, Number 0, Month 2018 www.corneajrnl.com | 1 Arita et al Cornea Volume 0, Number 0, Month 2018 patients with refractory dry eye, a cohort that included not and 4 weeks after the final treatment. All patients were asked only individuals with MGD but also those with graft-versus- to continue their current ocular medications. No patient was host disease or Sjögren syndrome.13 The efficacy of such allowed to initiate therapy with a new topical or systemic combination treatment in patients with moderate to advanced agent for dry eye or MGD during the treatment course. MGD was also recently demonstrated in a single-center study.21 The purpose of this study was to evaluate the efficacy of Clinical Assessment IPL combined with MGX for patients with refractory MGD, The noninvasive breakup time (NIBUT) and the interfer- including those with the most severe stage of the condition, in ometric fringe pattern of the tear film were determined with a 3 centers in Japan. Refractory MGD was defined as that DR-1a tear interferometer (Kowa, Nagoya, Japan), as described which had failed to respond to at least 3 types of conventional previously.25 Lid margin abnormalities (plugging of meibomian therapy prescribed in Japan including topical or systemic anti- gland orifices and vascularity of lid margins),26 breakup time inflammatory therapy, topical or systemic antibiotic therapy, [fluorescein breakup time (FBUT)] of the tear film and the topical lubricant eyedrops or ointment, automated thermal corneal and conjunctival fluorescein staining score (CFS, 0–9)27 pulsation treatment, and intraductal probing over the course based on fluorescein staining, and meibum grade (0–3)23 were of at least 1 year. Given that most patients with MGD have evaluated using a slit-lamp microscope. Morphological changes applied a warm compress or practiced lid hygiene at home in the meibomian glands were assessed on the basis of the regardless of disease severity, these home-care remedies were meiboscore (0–6)28, as determined by noninvasive meibography. not included as failed therapies in this study. Tear fluid production was measured by the Schirmer test, as performed without anesthesia.29 Symptoms were assessed with the Standard Patient Evaluation of Eye Dryness (SPEED) PATIENTS AND METHODS validated questionnaire (0–28).30,31 The study was approved by the Institutional Review Boards of Itoh Clinic, Mizoguchi Eye Clinic, and Ohshima Eye Hospital, and it adhered to the tenets of the Declaration of IPL-MGX Procedure Helsinki. The study was performed at each of the 3 Before the first treatment, each patient underwent participating centers from March to September 2017. Fitzpatrick24 skin typing, and the IPL machine (M22; Informed consent to study participation was obtained from Lumenis, Yokneam, Israel) was adjusted to the appropriate each patient. setting (range, 11–14 J/cm2). At each treatment session, both eyes of the patient were closed and sealed with IPL-Aid disposable eye shields (Honeywell Safety Products, Smith- Patients field, RI). After generous application of ultrasonic gel to the Individuals with refractory MGD attending Itoh Clinic, targeted skin area, each patient received ;13 pulses of light Mizoguchi Eye Clinic, or Ohshima Eye Hospital were (with slightly overlapping applications) from the right enrolled in the study. Inclusion criteria included the follow- preauricular area, across the cheeks and nose, to the left ing: 1) an age of at least 20 years; 2) a diagnosis of preauricular area, reaching up to the inferior boundary