From the start of my ophthalmic career, I have approached dry eye disease (DED) with an interventional, science-based strategy. For too long, DED was not treated as a true disease, with little interest or competition, and treatment was often limited to providing patients with whatever artificial tears were available. The unmet need for effective care inspired the creation of a DED centre of excellence focused on interventional therapies.

Intense pulsed light (IPL) therapy was among the first cornerstones, and nearly 18 years and 13,000 treatments later, it still is a central component of DED treatment offerings. As the technology becomes even more refined, comfortable and accessible to practices and patients, it continues to fit smoothly into recommended treatment protocols.

Why IPL?

In the beginning, I had a healthy scepticism of IPL, so I asked for a demonstration from Rolando Toyos, MD, the first to describe IPL’s value for meibomian gland dysfunction (MGD) and ocular rosacea.¹ The immediate and measurable results, also appreciable to patients, were enough to start the journey.

For ophthalmologists who may be considering integrating IPL into clinical practice, some considerations include the following:

The scientific data behind IPL is strong. In the past decade, several studies have elucidated IPL’s mechanisms of action and clinical results.^2-6 The primary mechanism of action, by neuromodulation of the parasympathetic nerve pathway, drives secretion of both meibum and tears. The treatment also photocoagulates telangiectasias, heats the meibomian glands and has antibacterial, antiparasitic, and anti-inflammatory effects.

We can see and quantify the clinical results IPL delivers for patients. I coauthored a double-blind, randomised, controlled prospective study with Toyos and Steven Dell, MD, in 2022 that showed IPL followed by meibomian gland expression reduces eyelid edema, facial telangiectasia and eyelid vascularity, while improving meibomian gland scores and tear break-up time and raising the Ocular Surface Disease Index score by nearly 10 points.⁷

IPL technology has improved while becoming more affordable. I have owned and used nearly every IPL device commercially available for MGD, with a broad range of capital costs, perceived efficacy and patient comfort. I now use E-Eye (E-Swin), which employs intense regulated pulsed light (IRPL) to deliver consistent energy. Each flash comprises a differential pattern of 8 subpulses within a spectral range of 580 to 1200 nm, based on a proprietary algorithm designed to reach different tissue depths for maximum effect and a better patient experience.⁸ Patients who have experienced IPL with other devices report that E-Eye is more comfortable, with nearly 100% of patients returning for all sessions compared with 80% with previous technologies. Its cost point compares favorably with that of other devices, making it more accessible for both practices and patients.

Patients want interventional treatment. Patients prefer interventional therapies that may reduce some of the burdens associated with time to effect, effort, cost and adverse effects of conventional therapies. We also explain that interventional treatments can relieve obstruction, inflammation and the vascular component of ocular rosacea and MGD-driven DED better than topical therapies. The eagerness of patients to return for maintenance treatments underscores the value of the approach, demonstrating that the benefits to their quality of life justify the cost.

I can prepare the ocular surface for surgery faster. Most patients referred for cataract surgery have DED.⁹ They are eager to achieve the best possible vision without glasses, but biometry and surgery cannot proceed until the ocular surface is optimised. Topical therapies require weeks to months, even with perfect adherence, whereas interventional treatments can avoid significant delays. Patients often experience visual improvement of 1 to 2 lines before surgery, which contributes to better surgical outcomes. An additional, often overlooked benefit is that establishing robust ocular surface stability expands the option of advanced technology IOLs to more patients.

Interventional treatment protocol

Interventional therapy can turn DED around, followed by a schedule of simple at-home care and two or three maintenance visits per year. The process begins with a treatment-forward diagnostic approach. Rather than collecting a detailed history of past therapies and performing an exam with the intention of compiling a list of diagnoses and then creating treatments for each—an approach that can be inefficient—the starting point is the full range of known available treatments and their indications.

A focused exam is used to look for pertinent positives that confirm the indications for those treatments. This method allows a treatment plan to be implemented more quickly without becoming bogged down in what has failed in the past. Patients are reminded that, as in life, achieving something never experienced before often requires being willing to do something never attempted before.

The basic components of my interventional approach include
the following considerations:

IPL treatment. IPL treatment is highly efficient, requiring approximately 3 to 5 minutes per session to treat from tragus to tragus. Patients typically undergo three or four IPL treatments that are spaced 2 to 4 weeks apart. At each session, cold expression of the meibomian glands is performed before treatment and hot expression afterward, allowing progress to be tracked and confirmed with the patient.

Heat treatment. IPL is combined with targeted advanced thermal gland expression (TearCare; Sight Sciences) for most patients to relieve the obstructive component of MGD. Patients receive the 15-minute heat treatment immediately before the first IPL treatment.

In addition to the clinical benefits, the instant results are encouraging to patients. With prior forms of IPL alone, patients may not have noticed any benefit until the third or fourth treatment. When IRPL is coupled with induction therapy with a TearCare treatment, patients notice a more immediate effect.

Maintenance IPL and heat. Patients receive maintenance treatments every 4 to 6 months, alternating between IPL and thermal expression therapy. They are encouraged to adjust the treatment cadence based on their symptoms—spacing visits closer together or farther apart as needed—to maximise treatment durability. Most patients appreciate this treat-and-extend strategy that aligns with their individual best interests.

Punctal occlusion. Lacrifill Canalicular Gel (Nordic Pharma, Inc) has become first-line therapy for nearly all patients with DED, as it benefits both evaporative and aqueous-deficient forms. The cross-linked hyaluronic acid provides immediate comfort. The therapy takes 1 to 2 minutes to instill and lasts 3 to 6 months.⁹

Nutritional supplements. The science behind nutritional support for DED has advanced towards such a level that I consider it a major part of addressing the DED process. Patients use HydroEye (ScienceBased Health), a clinically validated supplement that contains gamma-linolenic acid, a fatty acid from black currant seed oil and a precursor to prostaglandin E1 that supports tear production and reduces inflammation on the ocular surface.^10,11 The MGD benefits in particular stem from its strong anti-inflammatory effects,¹² which also help patients with ocular rosacea.

Maintenance and self-care. Patients maintain the effects of interventional treatment with nightly use of a heat mask (Bruder). Preservative-free artificial tears can help patients manage challenging situations such as long-term screen use. To ensure they avoid confusion and get a beneficial tear, I recommend 2 specific products (Refresh Optive Mega-3; AbbVie, and Retaine MGD; OCuSOFT). I also prescribe perfluorohexyloctane (Miebo; Bausch + Lomb), especially in the context of preoperative surface optimisation, as this can make a significant difference in the quality of biometry and ultimate refractive outcome accuracy.¹³

Patients with severe DED or concomitant conditions such as Sjögren syndrome benefit from the addition of an immunomodulator, while interventional therapies and at-home maintenance allow many individuals to reduce their use of topical prescription and OTC agents. Many patients prefer allocating resources towards occasional interventional treatments rather than carrying the long-term financial and practical burdens of conventional therapies. Even those who arrive eager for cataract surgery and must first undergo treatment for DED often become strong advocates of this approach, helping build a community reputation for prioritising not just efficiency, but the appropriate steps needed to achieve visual goals with comfort and precision.

Neel R. Desai, MD

E: [email protected]

Desai is a cornea, cataract, and refractive surgeon at The Eye Institute of West Florida in Largo, Florida, USA.

Desai is a shareholder of BioTissue and DefEYE (Verséa Ophthalmics Inc) and a speaker and consultant for AbbVie, Alcon, Bausch + Lomb, DefEYE (Verséa Ophthalmics Inc), E-Swin, ScienceBased Health, Sight Sciences, and Sun Pharma.

References

1. Toyos R, McGill W, Briscoe D. Intense pulsed light treatment for dry eye disease due to meibomian gland dysfunction; a 3-year retrospective study. Photomed Laser Surg. 2015;33(1):41-46. doi:10.1089/pho.2014.3819

2. Dell SJ. Intense pulsed light for evaporative dry eye disease. Clin Ophthalmol. 2017;11:1167-1173. doi:10.2147/OPTH.S139894

3. Shergill M, Khaslavsky S, Avraham S, Kashetsky N, Zaslavsky K, Mukovozov I. A review of intense pulsed light in the treatment of ocular rosacea. J Cutan Med Surg. 2024;28(4):370-374. doi:10.1177/12034754241254051

4. Liu R, Rong B, Tu P, et al. Analysis of cytokine levels in tears and clinical correlations after intense pulsed light treating meibomian gland dysfunction. Am J Ophthalmol. 2017;183:81-90. doi:10.1016/j.ajo.2017.08.021

5. Li H, Huang L, Fang X, et al. The photothermal effect of intense pulsed light and LipiFlow in eyelid-related ocular surface diseases: meibomian gland dysfunction, Demodex and blepharitis. Heliyon. 2024;10(13):e33852. doi:10.1016/j.heliyon.2024.e33852

6. Somboonna N, Wongsaroj L, Watthanathirakawi A, Wanumkarng N, Iam-A-Non A, Pongpirul K. Potential impact of ocular intense pulsed light on eyelash microbiome in severe meibomian gland dysfunction: report of 2 cases. Front Ophthalmol (Lausanne). 2023;3:1240627. doi:10.3389/fopht.2023.1240627

7. Toyos R, Desai NR, Toyos M, Dell SJ. Intense pulsed light improves signs and symptoms of dry eye disease due to meibomian gland dysfunction: a randomized controlled study. PLoS One. 2022;17(6):e0270268. doi:10.1371/
   journal.pone.0270268

8. Flashing a light on dry eye. I-MED Pharma. October 1, 2022. Accessed November 13, 2025. https://imedpharma.com/blog/flashing-a-light-on-dry-eye/

9. Packer M, Lindstrom R, Thompson V, et al. Effectiveness and safety of a novel crosslinked hyaluronate canalicular gel occlusive device for dry eye. J Cataract Refract Surg. 2024;50(10):1051-1057. doi:10.1097/j.jcrs.0000000000001505

10. Sheppard JD Jr, Singh R, McClellan AJ, et al. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: a randomized double-blind clinical trial. Cornea. 2013;32(10):1297-1304. doi:10.1097/ICO.0b013e318299549c

11. Kapoor R, Huang YS. Gamma linolenic acid: an antiinflam­matory omega-6 fatty acid. Curr Pharm Biotechnol. 2006;7(6):531-534. doi:10.2174/138920106779116874

12. Pinna A, Piccinini P, Carta F. Effect of oral linoleic and gamma-linolenic acid on meibomian gland dysfunction. Cornea. 2007;26(3):260-264. doi:10.1097/ICO.0b013e318033d79b