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Method Article

Clinical Application of Intense Pulsed Light Therapy and Radio Frequency for Treatment of Ocular Surface Diseases

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DOI:

10.3791/68377

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July 3rd, 2025

 ,  , 
1Indiana University School of Optometry, 2Uptown Eye Associates, 3Periman Eye Institute

In This Article

Summary

Intense pulsed light with the Optical Pulse Technology platform has US Food and Drug Association approval for the management of Meibomian Gland Dysfunction (MGD)-associated Dry Eye Disease (DED) by improving meibomian gland function and reducing inflammation. Radiofrequency treatments result in meibum melting. Combination therapy may offer superior outcomes for DED and MGD.

Abstract

Dry eye disease (DED) is a multifactorial condition in which tear film instability and inflammation play important roles in its etiology. DED can cause symptoms of pain, burning, grittiness, and decreased vision, which, if left untreated, can become increasingly more severe, resulting in damage to the ocular surface. Intense pulsed light (IPL) therapy and radio frequency (RF) treatments have emerged as important modalities for managing DED, particularly in patients with underlying meibomian gland dysfunction (MGD) and rosacea. Both conditions contribute significantly to ocular surface inflammation, tear film instability, and symptoms of DED. Traditional therapeutic methods are often not effective at treating MGD-associated DED as they fail to target the underlying pathophysiology. IPL therapy targets inflammatory pathways by emitting broad-spectrum light that absorbs into the skin, targeting chromophores such as abnormal telangiectatic vessels. The mechanism of action of IPL in DED includes modulation of inflammatory cytokines in the tear film, reduction of meibomian gland inflammation, and improved meibum quality, all promoting enhanced tear film stability.

Radio frequency therapy uses electromagnetic current to generate thermal energy to promote skin tightening and rejuvenation. This current generates heat in the skin, thereby stimulating the production of collagen and improving tissue tone. RF treatments work well for MGD as the heat liquefies meibum within the eyelids, thereby enhancing meibomian gland secretion. Clinical studies support the combination of IPL and RF therapies as an effective, adjunctive treatment approach for DED associated with MGD. Treatment typically involves multiple sessions with maintenance treatments required to sustain therapeutic effects, and both therapies are generally well-tolerated. This paper will describe recommended treatment protocols to begin standardizing clinical guidelines for the use of these therapies. The synergistic effect of IPL and RF offers a promising non-pharmacological alternative for patients with DED.

Introduction

Dry eye disease (DED) is a multifactorial condition characterized by tear film instability, hyperosmolarity, and inflammation, which can lead to loss of ocular surface homeostasis and ocular damage1. DED affects millions in the United States (US)2,3 and worldwide4,5,6 and results in chronic eye discomfort7, reduced vision8, and decreased quality of life9. The prevalence of DED among US adults aged 50 years and up may be as high as 75%, with higher frequencies in women and older individuals10. Female sex is a known risk factor for DED, and women tend to have more severe disease compared to men11. Other risk factors include lifestyle factors such as screen time use12, contact lens wear13, and smoking14, and medical conditions, including autoimmune diseases, diabetes, thyroid disease, and depression13,15.

DED is a chronic condition necessitating treatments that target the underlying mechanisms and the vicious cycle of inflammation16. Meibomian gland dysfunction (MGD), defined as a "chronic, diffuse abnormality of the meibomian glands characterized by terminal duct obstruction and/or qualitative/quantitative changes in glandular secretions"17, contributes to tear film instability and is found in 86% of dry eye patients18. The associated mechanisms of MGD, including inflammation, microbial factors, and lipid deficiencies19, can result in increased tear film evaporation, desiccating stress of the ocular surface, and subsequent ocular surface inflammation20,21,22. Thus, using a treatment that can target both inflammatory cycles of DED and MGD would prove beneficial to patients.

Intense pulsed light (IPL) therapy has been increasingly used to treat MGD-related to DED and ocular rosacea23. IPL is a non-laser technology that employs pulses of polychromatic light, which can be absorbed by chromophores in telangiectatic blood vessels, inducing intravascular damage and coagulation, thereby reducing the abnormal telangiectasias (a clinical endpoint over the treatment series). IPL has been used in dermatology for the treatment of rosacea-a cutaneous neurovascular inflammatory disorder characterized by erythema and telangiectasias24,25. As up to 80% of rosacea patients have MGD, IPL is beneficial for both rosacea and MGD26,27. Studies have shown that IPL can significantly reduce inflammatory cytokines such as interleukin (IL)-6, IL-17A, and tumor necrosis factor (TNF)-α in the tears, which correlates with improving both clinical signs and symptoms of MGD28,29,30.

Ideal candidates for IPL therapy are symptomatic patients with DED due to MGD and chronic ocular surface inflammation. During slit lamp evaluation, these patients will present with signs such as telangiectasia of the lid margin and inspissated meibomian glands. Patients with fair to medium skin tones (Fitzpatrick I-IV) and no contraindications such as active infections, photosensitivity disorders, or recent isotretinoin use are appropriate for IPL treatment. An IPL treatment regimen consists of multiple treatment sessions spaced 2-4 weeks apart, dependent upon the treatment protocol being used-usually at least three or four treatment sessions are recommended, but some patients may benefit from five or six treatment sessions. Successful IPL treatments will result in tear film stability and meibomian gland function improvements28,31. Clinical endpoints used to measure treatment success include patient symptom assessment with a standardized questionnaire, meibomian gland secretion score, and ocular inflammation (see Representative Results).

Radio frequency (RF) therapy for the face is a non-invasive procedure that uses electromagnetic current to generate thermal energy to promote skin tightening, rejuvenation, and improvement of skin laxity32,33,34,35. As the skin is heated, collagen fibers undergo remodeling and new collagen is formed, resulting in an improvement in tissue tone36. RF also has a role in pain relief via improving nociceptive pain signaling37. Monopolar and bipolar RF devices are commonly used for treatment application. Monopolar RF devices penetrate deeply into the skin, with the current returning via a grounding electrode often placed on the patient's back when treatment is applied to the face38. Bipolar RF has a more superficial effect, with the current flowing between the two electrodes placed on the skin. The frequency for skin RF treatments can range from 1 MHz, which penetrates more deeply into the skin, to 6 MHz, which penetrates less deeply and is more superficial35. RF treatments work well for MGD39 as the generated heat is safely kept at 41 °C, which liquefies meibum within the eyelids, thereby enhancing meibomian gland secretion and improving meibomian gland function40. The treatment protocol for MGD begins at 1 MHz, which stimulates neocollagenesis and liquefication of meibum in the dermis32,41, and switches to 4 MHz, which improves skin laxity and texture in the upper dermal layers42.

Ideal candidates for RF therapy will have signs of evaporative dry eye related to MGD, including poor lipid layer quality and reduced expression of meibum from the meibomian glands. Since chromophores are not targeted, RF is a treatment option for patients of all Fitzpatrick skin types. Since the downstream effects of MGD can contribute to inflammation19, Chelnis et al. explored the combination of IPL and RF therapies, showing enhanced efficacy in reducing patient symptoms and improving meibomian gland secretion compared to IPL alone43. This combination therapy appears to offer a synergistic effect, providing more substantial and sustained relief for patients from DED symptoms. In this paper, we describe the treatment protocols and clinical outcomes of a commercially available IPL device indicated for the treatment of DED that uses the Optimal Pulse Technology (OPT) platform. The aim of the study is to provide standardized procedure protocols for treating patients with DED and rosacea using IPL and steps for pairing IPL with RF therapy.

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Protocol

NOTE: Photos were printed with written permission and release from patients.

1. Intense pulsed light (IPL) therapy treatment

  1. PreIPL treatment preparation
    1. Assess the patient's Fitzpatrick skin type by administering the Fitzpatrick skin type questionnaire. The IPL energy level will be set based on the skin typing score. When in doubt, or this is the patient's first treatment, always start at the next higher Fitzpatrick level.
      NOTE: The Fitzpatrick skin type score is based on the amount of pigmentation in the patient's skin, its reaction to UV exposure from the sun, and ethnic background (Table 1).
    2. Prepare the patient's face. Clean the patient's face of all makeup and tinted creams using an unscented commercial makeup remover wipe, eyelid wipe, or facial cleansing cloth.
    3. Protect the patient's eyes with one of the methods listed below.
      1. Use Cox II metal laser corneal eye shields if treatment will be applied directly on the eyelids. Place 1 drop of anesthetic eye drop in each eye followed by 2-3 drops of a thick artificial tear. For each eye, insert a metal shield under the eyelids, lifting away from the globe, avoiding contact between the shield and the cornea.
      2. Place commercial grade light-blocking stickers or goggles over patient's closed eyes if treatment will not be applied directly on the eyelids.
    4. Apply a 2 mm-thick layer of clear ultrasound gel over the face from tragus to tragus, including the nose, forehead, and chin, using a tongue depressor or similar tool. If treating directly on the eyelids, place a thin layer of clear gel over the upper, closed eyelids, taking care to avoid gel getting into the eyes.
      ​NOTE: All personnel present in the room when IPL is being performed must wear safety eye protection with optical density 3 tinted lenses.
    5. If the patient has significant facial rosacea, start with the Rosacea treatment protocol and then move on to the Dry eye treatment protocol. If no facial rosacea is present, perform the Dry eye treatment protocol.
    6. Confirm the water-cooling reservoir is filled on the IPL device and turn it on by pressing the green button.
  2. Rosacea treatment protocol
    1. Consider applying 1-2 test spots on the lateral malar region before applying a rosacea treatment, especially for Fitzpatrick skin types 4 and higher. If the Fitzpatrick skin type is unclear, or ultraviolet (UV) exposure has been recent, perform a few test pulses and assess the tissue reaction 24-48 h later. Reduce the fluence if tissue reaction is excessive. Lengthen the pulse width and interpulse rest to titrate to tolerability and melanocyte safety.
    2. Press the IPL button on the touchscreen of the device after turning it on and unlocking the touchscreen with a passcode if needed.
    3. Select the Skin Treatments option under Application.
    4. On the Skin Treatment preset window, select the following based on the treatment to be applied:
      1. Select the patient's skin type based on the Fitzpatrick questionnaire.
      2. Select the patient's primary condition to be treated. In this case, it will be either Rosacea/Telangiectasia or Erythema of Rosacea.
      3. Select Lesion Depth. This will typically either be Shallow or Medium. Preprogrammed presets will display on the screen.
    5. Ensure the large rectangular lightguide and the recommended light filter based on the selected Skin Treatment settings are inserted into the device handpiece. Clean the lightguide with an alcohol wipe.
    6. Press the ready button on the touchscreen and remove the device handpiece from the holder.
    7. Gently applanate the rectangular applicator on the skin, starting either on the patient's right or left side of the face near the tragus in the lateral malar area.
    8. Press a yellow button on the device handpiece to apply the first treatment pulses and lift off the skin immediately after. Check the skin response after 1-2 treatment applications for the appearance of a very slight flush. Adjust the fluence up or down to achieve the appropriate skin response.
    9. Apply the next application adjacent to the previous area on the face with ~10% overlap. Continue applying the pulses using the device handpiece, moving towards the nose but staying below the orbital rim. Apply additional pulses along the jaw line and across both the chin and forehead on the same side so that the entire side of one face has received pulses but avoid facial hair growth zones in men. Repeat on the other side of the face so that the entire face receives one full pass of pulses.
    10. Repeat treatment application with the lightguide starting at the initial lateral malar region selected and moving towards the opposite tragus including the nose, overlapping application areas by ~10% (Figure 1). Ensure the light guide is well approximated with the skin, as planar and parallel with the contours of the face as possible.
    11. Perform the Dry eye treatment protocol.
  3. Dry eye treatment protocol
    1. Select the OptiLight treatment on the touchscreen of the homescreen.
    2. Select the patient's skin type based on the Fitzpatrick questionnaire. These presets are based on recommended settings for treating DED (Table 2).
    3. Ensure the large rectangular lightguide and the OptiLight filter are inserted into the device hand piece.
    4. Press the ready button on the touchscreen and remove the device handpiece from the holder.
    5. Gently applanate the rectangular lightguide on the skin, starting either on the patient's right or left side of the face in the lateral malar region near the tragus. Lightly apply the lightguide as flat as possible on the skin without pressure.
    6. Test Pulse: Press a yellow trigger button on the device handpiece to apply the first treatment pulses and lift off the skin immediately after.
    7. Inspect the skin for response to the energy. If red or the patient reports an intolerable sensation, reduce the Joules or go up one Fitzpatrick level. Repeat the test application until patient tolerability and normal skin response are achieved.
    8. Apply the next application with 10% overlap from the area of prior pulse delivery. Continue applying the pulses using the device handpiece, moving across the nose below the orbital rim towards the opposite lateral malar area near the opposite tragus (Figure 1). Ensure the light guide is well approximated with the skin, as planar and parallel with the contours of the face as possible.
    9. Repeat the application of pulses tragus to tragus, including the nose for a total of two passes. Apply both passes in the same direction (i.e., left to right for first and second pass or right to left for first and second pass to allow for dermal cooling).
    10. Press standby on the touch screen. Pull out the rectangular lightguide, wipe off the gel with a tissue, and insert the rectangular pen attachment to the handpiece with a fresh tip.
    11. Press ready on the touch screen after connecting the pen attachment to the device.
    12. Beginning near the lateral canthus of either the right or left eye, touch the tip of the pen to the skin and press a yellow button to deliver pulses.
    13. Continue applying pulses with the pen moving along the infraorbital rim and ensuring that applications are applied 3 mm away from the eyelashes.
    14. Repeat this treatment pattern for a total of two passes. Apply both passes in the same direction.
    15. Apply additional pulses directly on top of the eyelids to cover the area if corneal shields are in place. Repeat for a total of two passes per upper eyelid.

2. Radio frequency treatment

  1. Pretreatment preparation
    1. Clean the patient's face with an unscented commercial makeup remover wipe, eyelid wipe, or facial cleansing cloth.
  2. RF protocol
    1. Select Start Treatment after turning on the device.
    2. Select the size of electrode that is preferred (10 mm or 20 mm) and insert it into the handpiece.
    3. Apply the manufacturer's recommended RF cream to the treatment area.
    4. Place the handpiece on the skin in the treatment area and press the Play button on the touch screen. The preset treatment designed for dry eye will begin, which includes 3 min of 41 °C at 1 MHz and 3 min of 41 °C at 4 MHz.
    5. Continuously move the electrode in a curvilinear racetrack type C-shape on the treatment area, which is from the supraorbital foramen to the anterior lacrimal crest along the orbital rim. Keep the movements continual (turn the corner instead of stop/reverse directions). Do not treat within the orbital rim.
    6. Always maintain full contact between the handpiece and the patient's skin when delivering RF. Heating will be faster when the handpiece is moved more slowly.

3. Post-treatment meibomian gland expression

  1. Position the patient within the slit lamp with forehead against the forehead rest and chin in the chin rest.
  2. Perform expression of the lower eyelid by tethering the lid with a cotton swab in the non dominant hand and gently squeeze the eyelid in the gland clearance forceps with a bottom of the gland to the top motion (like the bottom of a tube of toothpaste), continually expressing from temporal to nasal, the lid constantly held taut with the swab.
  3. Evaluate five meibomian glands in each region of the eyelid (temporal, central, and nasal), as well as the central eight meibomian glands in both eyelids44, and record the number of glands yielding secretion and grade the quality of secretions from each gland. Grade each gland based on quality using the following scale by Bron et al: 0 = clear, 1 = cloudy, 2 = granular, and 3 = toothpaste/opaque45.
  4. Repeat for the upper and lower eyelids of both eyes.

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Results

The purpose of this paper is to provide a detailed protocol for IPL and RF therapies used to treat MGD-associated DED and ocular rosacea that can be adopted by eye care providers. After undergoing IPL and RF treatments, the primary outcomes evaluated for effectiveness should include both subjective and objective measures. Subjectively, patients should report an improvement in DED related symptoms, which can be evaluated using a validated questionnaire such as the Ocular Surface Disease Index (OSDI)46

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Discussion

Intense pulsed light and radio frequency therapies are both effective treatments for DED due to MGD and provide a synergistic effect when used in combination due to their differing mechanisms of action. Intense pulsed light uses pulses of polychromatic light to reduce inflammation and improve meibomian gland function. Clinical outcomes include improved OSDI score46, TBUT, and increase in the number of meibomian glands yielding liquid secretion52. Radio frequency therapy use...

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Disclosures

AT received a KOL honorarium from Lumenis for a single event in 2024, while LP is a Lumenis principal investigator and speaker. LZ has no conflicts of interest to declare.

Materials

List of materials used in this article
NameCompanyCatalog NumberComments
Alcohol wipesAny
Clear ultrasound gelAquasonic 
Cox II metal corneal shieldsAmbler Surgical21-264EMedium size works well for most patients
Doctor/Staff IPL glassesInnovative Optics8x2.Pi14Intense pulsed light (IPL) Shade 3 Glasses
Eyelid wipes or makeup removal wipesAny
Light blocking eye stickersInnovative Optics816009IPL Vee-Shield, Disposable Patient Eye Protection
OptilightLumenisIntense pulsed light therapy device
OptiplusLumenisRadiofrequency device
Proparacaine 0.5% ophthalmic anestheticAny
Refresh celluvisc artificial tearAllergan

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