TREATMENT WITH A POLYCHROMATIC PULSED LIGHT DEVICE FOR A DYSFUNCTION

DESCRIBED AS “DRY EYE” IN THE FORM OF A CORNEAL CONDITION ASSOCIATED

WITH A DEFICIENCY IN THE LIPID LAYER
Dr Christian MALBREL, Ophthalmologist

Anatomical review Current treatments

The lachrymal film, which is necessary for the functioning A variety of therapeutic treatments are available, according to
of the eye, is comprised of three layers: the severity of functional symptoms and the daily discomfort
experienced by patients:
 a mucus layer in contact with the eyeball, secreted by
the conjunctival mucus cells  lachrymal substitutes, in the form of eye lotions or creams
 an aqueous layer, secreted by the lachrymal glands  occlusion of the lachrymal points
 a lipid layer, secreted by the intratarsal Meibomian  moisture chamber spectacles
cells  treatment by antibiotics – local and general
 treatment by cortisone cream
The Meibomian cells, approximately 80 in number, are  treatment by cyclosporin
arranged in the tarsus of the upper and lower eyelids, and  treatment by dietary supplements
discharge at the level of the grey line, behind to the lashes.  cleansing treatments
These cells secrete a lipid phase, the function of which is - Lachrymal substitutes are easily obtainable and available
to prevent the evaporation of tears, to adapt to surface at any time, and provide immediate relief; however, their
changes associated with blinking, and to deliver an optical effectiveness is often short-term, requiring the frequent
function by the maintenance of a perfectly convex diopter. application of treatments. Their administration may be
more difficult for older patients, or for those whose manual
The lipids are comprised of polarized fatty acids, the dexterity is impaired (where arthritis in the hands prevents
fluidity of which is maintained by the body temperature, the squeezing of the bottle, or rheumatism in the shoulders
and unpolarized at the surface, thereby maintaining the prevents the lifting of the arms).The cost of these
stability of the lachrymal fluid and ensuring the lubrication treatments will rapidly become substantial, as they are
of the palprebal conjunctival surface. The contraction of subject to only limited reimbursement, if any.
Riolan’s muscle ensures the spreading of the lachrymal
film.
- Meatic plugs can be used for the occlusion of the inferior
lachrymal point, and deliver an improvement associated
Dysfunction of the Meibomian glands with the reduction of the consequences of evaporation. For
some patients, they have the disadvantage of a permanent
Impairment of the lipid phase secreted by these cells will irritation associated with rubbing contact on the conjunctiva
result in the excessive evaporation of tears, instability in of the eyeball each time the eye is closed. They are easily
the lachrymal film and an inflammatory reaction of the lost, and cost in the region of 130 euros per pair, subject to
conjunctiva. 65% reimbursement.

The result will be an increasing visual impairment during - Moisture chamber spectacles can theoretically eliminate
prolonged tasks involving close-up vision (work on VDUs), evaporation and improve the quality of the lipid fraction.
with sensations of burning or the presence of foreign However, they cannot be worn for more than a few minutes
bodies which will oblige the sufferer to interrupt the task in at a time and cost 220 euros per pair, which is not subject
progress. to reimbursement.
If this process accelerates, the resulting discomfort will
become permanent, leading to paradoxical watering which - Treatment with local and general antibiotics can combat
will make it impossible to wear contact lenses. the secondary infection which is frequently associated with
this type of pathology. This treatment can relieve the
Anatomical changes may occur in conjunction with the symptoms associated with rosaceous acne. However, this
atrophy of the outlet ducts of the Meibomian glands, is a complementary treatment only. Severe allergic
punctuated by infectious episodes – stys, chalazions, reactions are frequently encountered.
secondary conjunctival infections – and, in the most
severe cases, damage to the cornea.

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- Local and, in some cases, general corticotherapy can
relieve the inflammatory element of the condition, and is
For optimum sequencing, following the first treatment
frequently effective in application. As a result of side
session, a second session should be administered two weeks
effects – secondary infections, can occur such as ocular
later, followed by one session per month thereafter until the
hypertonia, cataracts – therefore this is not a long-term
symptoms are cleared.
treatment solution.
Protection and safety
- Cyclosporin is highly effective for the most severe forms
of the condition. Cyclosporin is not commercially
The skin is protected by the application of a thick pad of cold
available, and is difficult to obtain. Tolerance of
hydrogel.
cyclosporin is mediocre.
The eyeball of the patient under treatment is protected by a
- Dietary supplements are useful for patients who suffer
metal eye shield. The operator must also wear appropriate
from a deficiency of essential fatty acids. These
eye protective equipment, as must any other person presents
supplements are not subject to reimbursement.
in the treatment room.
- Cleansing treatments are essential. Their effectiveness
Ideally, the patient should be reclined on a treatment table.
is limited and they are not subject to reimbursement.
This will ensure the greater comfort of the patient, and will
facilitate the administration of treatment by the practitioner.

Treatment of dry eye using PPL Results of E-EYE PPL treatment

Device used PPL stimulation induces the restoration of the normal activity
of the Meibomian glands, with a very rapid subjective
The device used, the E-EYE model produced by the improvement for the patient in the hours following treatment.
company E-SWIN, generates a polychromatic pulsed light. This improvement lasts for approximately one week following
the initial treatment, for two to three weeks after the second
Forms of treatment and third treatments, and thereafter for several months, in
response to the cumulative effects of treatment.
In the majority of cases, treatment application is
straightforward. The effectiveness of treatment is virtually constant for all
conditions affecting the Meibomian glands – this is not true of
Treatment of the tarsal element of the lower eyelids, conditions associated with an isolated impairment of the
applied to the cutaneous flank, is the basic option for aqueous phase or the mucus phase, or in case of an
treatment: associated secondary infection, which must be treated
beforehand.
4 charges are applied, sweeping the lower eyelid from the
outer canthus to the inner canthus, at a power rating of 13 Perceived effectiveness
joules.
Results obtained for a cohort of 80 patients aged between 21
For the treatment of skins with a high phototype (4 and 5, and 90 years, with an average age of 67, with no preselection
according to the Fitzpatrick classification system), or if the and representative of the “standard” patient register of an
patient is deeply tanned, the flux density should be independent practice, show a significant subjective
reduced by 1 to 3 J/cm2, in order to avoid any deleterious improvement, with satisfaction of the order of 90% following
effects upon melanocytes. the first two treatment sessions.

This improvement is established on the basis of the patient’s

In the most severe cases, however, it may be necessary to opinion of the discomfort experienced before and after the
treat all four eyelids simultaneously. In this case, following application of treatment and the associated focusing time,
local anaesthesia by the administration of Tetracaine®, whether for reading or for work on a VDU. After the first
metal shells, previously coated with an ophthalmic gel, will treatment, this improvement is experienced for a number of
need to be placed upon the eyeball. These shells are days, and will only become more prolonged after the second
removed subsequently using a ventouse. and subsequent treatments.
Accordingly, the patient must be warned of a temporary
disturbance of vision associated with the gel, will need to
be accompanied upon their departure from the surgery,
and will be prohibited from driving for one hour thereafter.

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 - 23%, or 18 patients, are classified at stage 1:
Quantitative results
 10 from group 1
For objective assessment, the Oxford classification may be  8 from group 2
appropriately applied, with five levels for fluorescein
instillation: There was no variation in either group 3 or group 4.

For this examination, the natural surface condition of the No patient had deteriorated.
patient’s cornea and conjunctiva will be observed, followed
by the instillation of one drop of fluorescein, with no If we consider only those patients who, prior to treatment,
associated anaesthesia. were classified at stages 1 and 2 and who represent the
target population for this type of treatment, the development
Excess tears are removed, and the dye is allowed to observed was as follows:
spread for one minute – the break-up time of the lachrymal
film is then observed, together with the appearance of Upon initial Upon final
micropunctuations which are coloured by fluorescein under examination examination
blue light. Stage Patients % Patients %
0 – a number of punctuations on the outer edge: minor 0 - 27 44%
discomfort for the patient 1 31 50% 18 29%
2 31 50% 17 27%
1 – micropunctuations on the lower part of the cornea:
difficulty in reading for long periods Total 62 100% 62 100%

2 – micropunctuations on the lower quarter of the cornea: - 45% of stage 2 patients improved by one or more grades.
difficulty in focusing - 81% of stage 1 patients improved by one grade.
3 – micropunctuations on the visual axis and the horizontal
edge: permanent discomfort It should be noted that patients initially classified in group 0,
and who could not be subject to any objective improvement
4 – micropunctuations over the entire corneal surface: after treatment – as the Oxford classification does not include
disability. any stage lower than 0 – all reported an improvement in their
In the group of patients studied, after the passage of more perceived discomfort.
than two months and a number of treatment sessions
equal to or greater than three, observations were as
follows: Glare test

Upon initial Upon final The object of this test is the quantification of the improvement
examination examination in visual function after treatment by more extensive
Stage Patients % Patients % documentation than that associated with the grading of
corneal punctuation of the perceived improvement of the
0 6 08% 33 41% patient.
1 31 39% 18 23%
2 31 39% 17 21% This test has numerous clinical applications: the early
3 7 09% 7 09% detection of cataracts, determination of the pre-surgical and
4 5 06% 5 06% post-surgical refractive index, evaluation of aptitude for night
driving, etc.
Total 80 80
For the execution of this test, a stimulator is equipped with
Development: lateral sources of glare on either side of the screen. The
result is delivered in the form of a score, which corresponds
Upon final examination: to the number of letters which are correctly identified by the
patient. The sensitivity of the test can be particularly
- 33 patients, or 41%, are classified at stage 0: enhanced by the use of optotypes with a low level of
luminance on a dark background. Provision is made for three
 6 from group 0 levels of luminance: 1 cd/m2, 5 cd/m2 and 100 cd/m2. The 1
 21 from group 1 cd/m2 level is intended for normal subjects, while the 5 cd/m2
 6 from group 2 and 100 cd/m2 levels are intended for subjects with impaired
vision.

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The lateral positioning of a source of glare in relation to the
eye tested increases the difficulty of the reading test and Conclusions and recommendations
simulates conditions encountered in everyday life, such as
the night-time driving of a vehicle, where the driver will be From these results, the effectiveness of the E-EYE treatment
exposed to the glare of headlights coming in the opposite is clear, with a rapid return to the least disabling clinical
direction. In this test, the discomfort described by patients forms. Although there is little impact upon the most severe
suffering from ocular dryness is associated with a very forms, this is not the principal intended purpose of the
clear impairment of performance, in relation to the testing treatment.
of visual acuity under normal conditions.
Accordingly, this treatment should be accessible to the
It will be seen that this test is more sensitive, as patients of maximum number of patients in France, estimated at around
the type represented by cases 1 and 2 below show a one million.
significant improvement in visual function, whilst remaining
at the same stage of corneal punctuation:

Cornea: grade 1 og Cornea: grade 1, 3 weeks after a single treatment

Impaired glare test Improvement in glare test for the left eye
Patient 1 Patient 1

Initial test for right eye, average impairment Test one month after a single treatment, cornea still grade 1
Cornea: grade 1 Return to normal
Patient 2 Patient 2

The process is easy to use, and avoids any endangerment to

the vision of the patient, provided that the eyeballs and skin
are correctly protected.

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The machine is straightforward to operate, and the read-
outs from the various windows are easily comprehensible.
The service frequency is satisfactory. An attempt should
ideally be made for the reduction of noise during cooling,
particularly where the hand-held component is resting on
its base.

The gel for application to the skin should ideally be

provided in the form of a disposable pad, to be refrigerated
where applicable, of sufficient thickness to adapt to the
contours of the zone treated and be substantially stable
under pressure, in order to ensure the effective application
of treatment and to avoid any cutaneous damage
associated with the emission of heat.

Finally, particular attention will need to be paid to the

ocular protection system, in the form of a pair of metal eye
shields which are easy to use, adaptable to the
morphology of the patient, and easy to disinfect.

°°°°°°

Study undertaken by Dr Christian MALBREL,

Ophthalmologist

Former director of studies at the Reims Faculty of

Medicine
Former senior clinical assistant at the Reims Faculty of
Medicine
Inter-university graduate in morphological and anti-ageing
medicine from the Bobigny Faculty of Medicine