Dry eye disease (DED) is one of the most prevalent eye conditions, affecting millions of people globally. The worldwide prevalence is estimated to be between 5–50%, depending on geographic location. DED is multifactorial, however, this article concentrates on those with meibomian gland dysfunction (MGD). Patients with MGD and DED are quite often debilitated by symptoms and finding the right topical regime can be difficult.
Dr Nisha Sachdev writes that in her experience, a novel, office-based treatment for patients with DED from MGD, which is both non-invasive and painless, has provided excellent results.
Low level light (or laser) therapy (LLLT) has only recently been adapted for use in ophthalmology. However, it has been well established for years in other medical disciplines. LLLT was discovered in 1967 by Endre Mester at the Semmelweis Medical University in Hungary. When attempting to cure a malignant skin tumour in mice following a fellow US scientist’s laser formula (McGuff ), Mester unfortunately (or fortunately) and unknowingly, used laser settings that were only a small fraction of McGuff ’s laser power. This resulted in unsuccessful tumour regression, however, Mester observed an unusual, heightened rate of hair grown and wound healing compared with McGuff ’s laser treatments. This led to the discovery that ‘lower powered’ lasers were indeed beneficial on a molecular cellular level and ultimately led to what we now know as photobiomodulation (PBM). This unique discovery led to the introduction and invention of photobiomodulation therapy (PBMT).
What is Photobiomodulation Therapy?
PBMT or LLLT is a non-invasive, atraumatic, non-thermal technique that has been used by dermatologists for many years. LLLT uses low levels of red and near-infrared light to reduce pain and inflammation, promote regeneration of different tissues and nerves, and prevent tissue damage. It is termed ‘low level’ as the energy or power densities are much lower compared with other forms of laser therapy that we commonly use, such as thermal coagulation and ablation, which in essence induces disruption to tissue.
The exact biological mechanism is thought to be the stimulation of cytochrome c oxidase (CCO) within mitochondrial chromophores, following absorption of red and NIR (near infra-red) light. This stimulates a cascade of events, ultimately causing upregulation of adenosine triphosphate production, leading to activation of certain intracellular signalling pathways that ultimately alters the affinity of transcription factors concerned with cell proliferation, survival tissue repair, and regeneration.
LLLT has been used in many medical disciplines, but mainly in dermatology for treatment of skin rejuvenation, acne, photoprotection, vitiligo, hypertrophic scar and keloid scar formation, and psoriasis. The Ophthalmic community recently adapted LLLT with a gentler wavelength, as a novel office-based device that penetrates the skin to reach the meibomian glands.
PBMT and Eye Disease
LLLT, a form of PBMT, has been adapted by the ophthalmic industry, to treat patients with ocular surface disorders. PBMT stimulates protein synthesis, which enhances and stabilises the lipid tear film layer. The delivery of LLLT is through a mask that sits on the patient’s face, covering the forehead, eyelids, and maxillary sinuses. The Espansione system also releases endogenous heat that is created to 42°C. The NIR light penetrates the eyelid tissue to a degree that is unable to be accessed with warm compresses.
In the ophthalmic world, the technology can be used for a variety of ocular conditions, but mainly dry eye from MGD, contact lens discomfort, pre- and post-cataract surgery, blepharitis, rosacea, Sjögren’s syndrome, and chalazion/meibomian gland cysts.
For the purposes of this paper, I will discuss the use of LLLT for dry eye disease and MGD.
LLLT and Dry Eye Disease
The use of LLLT in DED, is primarily for MGD, which results in a reduction of the lipid layer of the tear film.
The invisible light is applied directly to the eyelids, providing heat to the meibomian glands. This improves the function of the glands by secreting more meibum and replenishing the tear film, which subsequently reduces inflammation. This results in a healthier, more stable tear film, and provides significant symptomatic relief.
Benefits
The main benefits of this treatment are that it is office-based, non-invasive, painless, and can be done with minimal preparation. The patient does not have any ‘downtime’ and it is very convenient. Additionally, it can be used on any skin type and on children.
Treatment Process
The treatment is very simple. The duration of treatment is dependent on the severity of the MGD and ranges from 12–17 minutes.
The severity of the MGD is assessed and graded clinically, via objective meibography and on the slit lamp. An ocular surface disease index (OSDI) questionnaire is completed for subjective assessment of symptoms.
The patient sits in a chair with a face mask on (Figure 1), which applies heat and light directly to the eyelids and surrounding tissues. The heat zones span from the frontal sinuses (forehead) around the periorbital area, and down to the superior border of the maxillary sinuses (cheek).
This form of therapy requires multiple sessions of LLLT. I usually do these five to 10 days apart, with the initial three treatments in close succession. The number of treatments depends on the severity of the condition, based on the OSDI questionnaire score and MGD score as assessed on slit lamp examination. A minimum of three treatments is recommended, however, more can be administered if needed, according to patient symptoms.
Treatment Preparation
In my experience, the simplicity of this treatment is great. No specific preparation is needed from the patient or clinician. I usually advise no makeup (skin foundation) or eye makeup to be worn for the treatment, however, there are no studies stating that this is a contraindication. Contact lenses should be removed for this treatment and the treatment occurs with eyelids closed.
Post Treatment
I usually examine the patient immediately following treatment to assess the tear film and surrounding tissues. There are no known side effects demonstrated from this treatment, however, it is recommended that the patient should stay out of direct sunlight for the initial few hours following treatment.
I always recommend the treatment at least 10–14 days prior to any form of intraocular surgery; it is a great treatment prior to cataract surgery for patients with any dry eye.
Non-Surgical Treatment of Chalazia/Meibomian Gland Cysts
Due to the stimulation of meibomian gland function, the other best utility of this technology is as a non-surgical treatment for chalazia or meibomian gland cysts.
If I see a superimposed cellulitis on initial examination, I usually treat this first with either topical or systemic antibiotics. Once the cellulitis has cleared, I treat the cysts with three treatments of LLLT, one week apart.
The cyst usually resolves one month after the third treatment, negating the need for surgical incision and curettage, and preventing other cysts from forming.
I have had great success with this approach in both adults and children.
Case One
Ms Smith,* a 54-year-old woman with chronic MGD and DED, has been my patient for eight years. She has used multiple combinations of topical preparations, including preservative free lubricating eye drops, topical steroids, and topical immunosuppressants (ciclosporin). She was non-compliant with warm compresses and lid hygiene for her MGD and could not tolerate a home face heat mask. She had no other ocular sequelae. Her OSDI score was 86.78 (severe dry eye) and she had an MGD score of two.
After stopping her topical steroids and ciclosporin for two days, LLLT with the Espansione meibomask was administered for 12 minutes for her first session. Five days later she was only using topical lubricants and her OSDI score was 13.64.
Her lids were clean, and her tear film was clear.
Her second session of LLLT was 17 minutes, which she tolerated well. Seven days later her OSDI score was 6.82 and she was only using lubricating eye drops twice daily and a drop gel at night. She had her third session of LLLT that day for 17 minutes duration. At the time of publishing, I can report that for the past five months, she has only needed topical lubricants twice daily and is a changed woman.
Case Two
A 10-year-old girl presented with a chalazion on her left upper eyelid, having had a superimposed cellulitis treated by her general practitioner.
I saw her and commenced LLLT; three sessions, one week apart, with parental supervision. Her cyst resolved eight weeks following the third treatment of LLLT and she did not require surgical intervention
(Figures 2 and 3).
Figure 2. Chalazion prior to treatment.
Figure 3. Patient post- treatment with LLLT.
Conclusion
LLLT an innovative non-contact, nonthermal, atraumatic, and effective system that uses heat production and photobiomodulation to treat MGD, DED, and ocular surface disorders.
This office-based system is non-invasive, easy to use, painless and can be administered with minimum preparation. I’ve found it provides excellent objective and subjective results in patients suffering from chronic DED, and can be used as a non-surgical treatment of chalazia in both adults and children.
Dr Nisha Sachdev PhD FRANZCO is an ophthalmologist based in Sydney. She is a general ophthalmologist with subspeciality training in paediatrics. Her PhD was in visual optics using wavefront aberrometry to analyse aberrations induced by cataracts and intraocular lenses. She works in both public and private practice in Sydney and has multiple RANZCO affiliations.
No financial disclosures.
*Patient name changed for anonymity.
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