| Background:Dry Eye Disease(DED)is a common ocular condition that needs prompt diagnosis and careful treatment interventions.If left untreated,it can lead to numerous sight-threatening complications,including ulceration of the cornea,blepharitis,alterations of the tear film,conjunctivitis,and in severe cases,significant drying of the eye may lead to scarring,thinning,and even perforation of the cornea.Henceforth,early diagnosis and proper treatment are necessary to prevent further complications and to restore the vision as well as to maintain the integrity of eyelids.The cause of dry eye varies from obstructive such as age-related disorder to evaporative such as meibomian gland dysfunction(MGD).Meibomian glands are large sebaceous glands situated in the eyelids,which secrete lipids that form the superficial layer of tear film to protect the evaporation of the aqueous phase.There are about 25-40 glands in the upper eyelid and about 20-30in the lower eyelid with measurements of about 5.5 mm in upper eyelid versus 2 mm in the lower eyelid.Each gland consists of sets of about 10-15 secretory acini in the upper eyelid,which drain into a central duct through smaller ductulus.Each gland opens into the lid margin secreting lipids to form tear film.Meibomian gland dysfunction(MGD)is a chronic,diffuse abnormality of the meibomian glands,commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion.MGD is one of the most common causes of dry eye.An intense pulsed light device is a non-laser high-intensity light source that uses a high-performance flash lamp to produce a non-coherent light output of large wavelength,usually,in the range of 500 to 1200 nm.Light pulses generated by most modern devices are produced by bursts of electrical current passing through a xenon gas-filled chamber.IPL use in the medical field relies on the basis that specific targets for energy absorption(chromophores)are capable of absorbing energy from this broad spectrum of light wavelength(absorptive band)without exclusively being targeted by their maximum absorption peak.The working principle of the IPL is based on selective photo thermolysis,in which thermally mediated radiation damage is limited to chosen epidermal and/or dermal pigmented targets at the cellular or tissue structural levels.The initial report of the use of an IPL device in medicine dates back to 1996 when it was effectively utilized to treat a cohort of 80 patients with treatment-resistant facial port-wine stains in Germany.IPL uses heatwaves of desired wavelengths to dilate the capillaries,causing them to involute.This results in the suppression of the leaked inflammatory mediators,which interrupts the vicious cycle of inflammation and improving symptoms of dry eye.It also works with the help of thermal pulsation for many patients.In the incidence of chronic inflammation,the meibum's composition changes to include more monounsaturated fats.Those fats have a significantly higher melting point of close to 45?C–warmer than body temperature.This meibum does not melt into the tear film's lipid layer as it should,and it clogs the glands.Thermal pulsation therapy combines sustained heat and pressure to liquefy the meibum and clear the glands.Manually expressing glands is less effective,uncomfortable for patients,and potentially scarring.Thermal pulsation is gentle and effective.With these mechanisms,we have come to an understanding that IPL helps relieve the symptoms of dry eye.In this dissertation,we demonstrated the mechanism of action of IPL,including its benefits on DED by comparing results of NIBUT,meibomian gland dropouts,the height of tear film,and NIBUT grades with before and after the IPL treatment.The emerging evidence shows that the role of IPL in DED is novel and therapeutic.These results direct us to conclude that IPL is a potentially beneficial tool and essential future therapy for DED.Objective:This retrospective study aims to evaluate the effect of single IPL treatment combined with meibomian gland expression in treating MGD related dry eye disease patients.Methods:A total of 31 MGD related dry eye patients were managed by IPL-MGX from October 2018 to December 2019 in The First Hospital of Jilin University and were included in the study.Those 31 patients had single IPL-MGX treatment with one follow-up visit,and no tropical eye drops used were included in the study.General patient checkup and data collection helped in determining the age,sex,diagnosis,status of the meibomian gland,1~stt NIBUT,average NIBUT,the height of Tear film and additional medical history,and was recorded accordingly.Dry eye associated with MGD was diagnosed based on the criteria recommended by the Diagnosis Subcommittee of the TFOS Dry Eye Workshop II:Executive Summary.Presence of one or more Ocular Comfort Index(OCI)symptoms of ocular surface irritation such as dry,gritty,stingy,tired,painful and itching along with poor measurements from Keratograph 5M(OCULUS,Wetzlar,Germany)constitute DED.Tear film instability was also measured by Keratograph 5M.Reported values were<5 seconds for 1~stt BUT and<7 seconds for average BUT to be considered as dry eye.A camera image is taken with either infrared or white illumination allowing measurement of the height of tear film.Generally,the height of tear film is measured in line with the pupil center.It is measured with a built-in ruler.The normal value of the height of tear film is more than 0.25mm.The height of tear film less than 0.25mm is suggestive of a dry eye.Irregular height of tear film can be evaluated along the lid margin.Additional evaluations included an MGD grading scale and MG dropouts based on the quality and quantity of the meibum.The inclusion of infrared diodes in the hardware of the Keratograph 5M makes it possible to trans-illuminate the upper and the lower eyelid and helps to observe and evaluate the morphological changes in the meibomian glands.Eversion of the lids is necessary to record the MGs.IPL treatments were performed using the OPTIMA m22 IPL device.After the IPL treatment,1~stt NIBUT,average NIBUT,NIBUT grade,MG dropout,and height of tear film of both the eyes were measured using OCULUS Keratograph 5M.Superior and inferior MG expression was done using the expressor paddle.Collected data were analyses were conducted using SAS software(version 9.4,SAS Institute,NC,USA).Continuous variables were described as mean±standard deviation,and categorical variables were represented as frequency(percentage).Continuous measurements were compared using paired t-test.Categorical measurements were compared with the Cochran-Mantel-Haenszel test.Secondly,a comparison of measurements before treatment and after treatment was further performed using the generalized estimating equation to accommodate the correlation between eyes of the same person,and the upper eyelid and lower eyelid of the same eye.Statistical tests were two-tailed,and P-values<0.05 were considered statistically significant.Results:A study on the 31 patients that had at least two clinical visits was done.For the right eye,the difference between the mean height of tear before and after the treatment was 0.0345±0.1299(P=0.1496).Similarly,the difference between the mean value of 1~stt NIBUT before and after the treatment was 0.2396±1.7178(P=0.4668).The difference between the mean value of average NIBUT before and after the treatment was 0.7057±1.5901,which was statistically significant(P=0.0264).For the right upper eyelid,a total of 11 patients(36.7%)showed a significant decrease in the meibomian gland dropouts after treatment,18 patients(60.0%)remained the same and only one patient(3.3%)showed an increment in the meibomian gland dropouts.The P value indicated that the treatment was effective(P=0.0047).For the right lower eyelid,a total of 11 patients(36.7%)showed a significant decrease in the meibomian gland dropouts after treatment,19 patients(63.33%)remained the same,and no patients(0%)showed an increment in meibomian gland dropouts.The P value indicated that the treatment was effective(P=0.0017).A total of 8 patients(28.57%)showed improvement in the NIBUT grade after treatment,18 patients(64.28%)remained the same,and only two(7.14%)showed worse NIBUT grade(P=0.0578).Similarly,for the left eye,the difference between the mean height of tear before and after the treatment was 0.0239±0.1459(P=0.3697).The difference between the mean value of 1~stt NIBUT before and after the treatment was 0.0514±2.3786(P=0.9098).The difference between the mean value of average NIBUT before and after the treatment was 0.2664±2.1925(P=0.5256).For the left upper eyelid,a total of 11 patients(36.7%)showed a significant decrease in the meibomian gland dropouts after treatment,18 patients(60.0%)remained the same,and only one(3.3%)showed an increment in the meibomian gland dropout.The P value indicated that the treatment was effective(P=0.0158).Similarly,on the left lower eyelid,a total of 13patients(43.3%)showed a significant decrease in the meibomian gland dropouts after treatment,16 patients(53.33%)remained the same and only one(3.3%)showed an increment in the meibomian gland dropouts.The P value indicated that the treatment was effective(P=0.0027).A total of 6 patients(21.42%)showed improvement in the NIBUT grade after treatment,21 patients(75%)remained the same,and only one(3.57%)showed worse NIBUT grade(P=0.0588).Using the generalized estimation equation,after considering the individual differences between patients and the relevance of each person's left and right eyes,six indicators were compared and found that there was a significant decrease in the meibomian gland dropouts of the upper eyelid of both eye(P=0.0007)and lower eyelid of both eye(P=0.0006)between the right eye and left eye of the same person.However,there were no significant changes in the height of tear(P=0.1129),1~stt NIBUT(P=0.3589),average NIBUT(P=0.0808),and NIBUT grade(P=0.0652)after the IPL-MGX treatment.Using the generalized estimation equation,after considering the individual differences between patients and the correlation between the left and right eye and upper and lower eyelids of each person,the difference between the MG dropout index between the first and second times was compared.While there was no difference between the comparison of the upper eyelid and lower eyelid(P=0.4262)and right eye and left eye(P=0.2256),there was a definite change between the comparison of diseased meibomian gland before and after the treatment(P=0.0003).Conclusion:The result of this dissertation suggests that there are advantages to the use of IPL-MGX on ophthalmic cases such as MGD related DED.The reduction in symptoms of DED,as well as MGD in conjunction with an improvement in living conditions,has been widely documented throughout the literature.These all lead to the conclusion that the use of IPL-MGX shall provide vital effectiveness in the field of DED.These findings highlight the potential of IPL-MGX as a novel therapeutic procedure in MGD related DED. |
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