Intense Pulsed Light: A Therapeutic Option for Patients With Rosacea-Related Dry Eye and Blepharospasm

Clinical Correspondence Section Editors: Robert Avery, DO Karl C. Golnik, MD Caroline Froment, MD, PhD An-Guor Wang, MD Intense Pulsed Light: A Therapeutic Option for Patients With Rosacea-Related Dry Eye and Blepharospasm Anna N. Monterastelli, Lucy A. Bailey, MD, MPH, Kimberly Cockerham, MD D ry eye syndrome is the most common reason that patients visit an eye care specialist in the United States. It is associated with decreased tear production and is most prevalent in patients 50 years of age or older. There are currently about 5 million affected patients across the United States. (1). It can be caused by certain medications, progressive aging, rosacea, and hormonal changes in women. Symptoms include itching, burning, discharge, pain, redness, and may even cause blurred vision (2). Standard therapy includes artificial tears, prescription medications including Restasis and Xiidra, and punctal closure with cautery or punctal plugs (3). Blepharospasm occurs in a subset of dry eye patients with overlapping demographic. Treating the dry eye syndrome can help improve comfort and duration of botulinum toxin activity (2). We describe a patient with rosacea-related dry eye syndrome and severe blepharospasm who was helped with intense pulsed light treat- ments (Table 1). A 38-year-old Caucasian woman presented with approximately 4 years of progressively worsening bilateral essential blepharospasm, photophobia, and eye discomfort. On examination, she was found to have severe dry eye associated with facial rosacea with a visual acuity of 20/25 OU. She had low basal tear production as measured by Schirmer’s testing with topical proparacaine (1 mm in the right eye and 2 mm in the left eye), no visible tear lake on slit-lamp examination, and superficial punctate keratitis diffusely on both corneas. She had normal appearance of her meibomian glands with no evidence of blepharitis or Demodex infestation of the eyelashes. Her external examination was remarkable for mild rosacea of her cheeks. She had visible blepharospasm of the upper and lower eyelids. She was using preservative-free artificial tears every 2 hours, gel at bedtime, and had a history of punctal plug placement in upper puncta. She had also failed a trial of both TABLE 1. Patient’s dry eye findings over the course of her IPL treatments IPL Treatments (Time from Baseline) Baseline 3 months 6 months 8 months 12 months 14 months 17 months 20 months 24 months 30 months Schirmer’s Testing OD OS 1 4 7 16 13 5 7 14 12 10 2 3 12 3 17 2 5 10 8 9 Tear Lake Tear Break up SPK Low Low Normal Normal OD/low OS Normal Low Normal Normal Normal Normal Abnormal Abnormal Normal OD/abnormal OS Normal Normal Normal Normal Normal Normal Normal 2+ diffuse 1+ None None None None None None None None IPL, intense pulse light; SPK, superficial punctate keratitis. Loyola Marymount University (ANM), Los Angeles, California; Central Valley Eye Medical Group (LAB, KC); Stockton, California; and Stanford Department of Ophthalmology (KC), Palo Alto, California. The authors report no conflicts of interest. This report was in compliance with the Health Insurance Portability and Accountability Act and the tenants of the Declaration of Helsinki. Address correspondence to Kimberly Cockerham, MD, Central Valley Eye Medical Group and Stanford University Department of Ophthalmology 36 W Yokuts, Suite 2, Stockton, CA 95207; E-mail: [e-mail] e494 Restasis and Xiidra as well as oral doxycycline. She was receiving therapeutic botulinum toxin injections (50U) every 3 months, but the spasms were reduced for only 6– 8 weeks. Work-up for Sjogren disease by a rheumatologist was negative–she had no evidence of dry mouth and negative antibodies. With recalcitrant dry eye disease and worsening blepharospasm symptoms, an alternative treatment option was pursued. Intense pulse light (IPL) therapy has been reported to be useful in meibomian Monterastelli et al: J Neuro-Ophthalmol 2022; 42: e494-e496 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence FIG. 1: Mechanisms of action of IPL. Source: Steven J. Dell.5 IPL, intense pulse light. Adaptations are themselves works protected by copyright. So to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. gland dysfunction and dry eye dysfunction (4). The exact mechanism of action of IPL on the cheeks improving dry eye is not entirely understood; however, it is hypothesized that, after the mechanism for improvement of facial rosacea, the treatment closes abnormal blood vessels/telangiectasias surrounding the malfunctioning meibomian glands which secrete inflammatory mediators, thereby resulting in decreased inflammation (Fig. 1). The patient underwent IPL treatment on her cheeks and nose with Lumenis M22 for 2 and a half years, with treatments continued to keep her rosacea under control (Fig. 2). Although these treatments were not covered by insurance, the patient considered the out-of-pocket cost of these treatments to be comparable with her previous costs or preservative-free artificial tears, Restasis, and Xiidra. Over the course of the IPL therapy, her rosacea, blepharospasm, photophobia, superficial punctate keratitis, and ocular comfort improved (Table 1). The blepharospasm was less severe after therapies were performed, and it was eliminated entirely with her quarterly therapeutic Botox injections. We believe this is the first report of IPL use for the management of blepharospasm. Our patient had both subjective and objective improvement of her rosacea-related dry eye and blepharospasm with IPL treatments, and therefore, this therapy should be considered in these patients (Fig. 2). FIG. 2. Treatment area in IPL of MGD. IPL, intense pulse light. Monterastelli et al: J Neuro-Ophthalmol 2022; 42: e494-e496 e495 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: A. Monterastelli and K. Cockerham; b. Acquisition of data: A. Monterastelli and K. Cockerham; c. Analysis and interpretation of data: A. Monterastelli, L. Bailey, and K. Cockerham. Category 2: a. Drafting the manuscript: A. Monterastelli; b. Revising it for intellectual content: L. Bailey and K. Cockerham. Category 3: a. Final approval of the completed manuscript: A. Monterastelli, L. Bailey, and K. Cockerham. 2. 3. 4. REFERENCES 1. Rolando T, William M, Dustin B. Intense pulsed light treatment for dry eye disease due to meibomian gland e496 5. dysfunction; A 3-year retrospective study. Photomed Laser Surg. 2015;33:41–46. Craig E, Bao JB, Powers AS, Kassem IS, Schicatano EJ, Henriquez VM, Peshori KR. Dry eye, blinking, and blepharospasm. Mov Discord. 2002;17(Suppl 2):S75– S78.Accessed July 7, 2020. Choi M, Han SJ, Ji YW. Meibum expressibility improvement as a therapeutic target of intense pulsed light treatment in meibomian gland dysfunction and its association with tear inflammatory cytokines. Sci Rep. 2019;9:7648. Vegunta S, Patel D, Shen JF. 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