More eye clinics are elevating their dry eye service by investing in an intense pulsed light system. An Australian optometrist and ophthalmologist discuss adopting the Thermaeye Plus IPL in their respective practices with some key differences.
Optometrist Mr Raj Maiti has experience running dry eye clinics for anterior segment surgeons in one of New Zealand’s most prestigious private ophthalmology groups, Eye Institute. So, when he embarked on independent practice ownership 18 months ago in Brisbane, he was well-equipped to offer an adjunct dry eye service. But there was a key ingredient missing.
Feeling limited with his current treatment regime of eye drops, lid scrubs, eye masks and eyelid-warmers, he was also concerned about the compliance factor when patients were sent off with home-based therapies. Seeking a longer-lasting approach that could also cater for his most extreme cases and rosacea, he went in search of an intense pulsed light (IPL) system.
Today, there’s an expanding suite of IPL systems designed specifically for dry eye and related ocular conditions. After some trial and error, he landed on the Thermaeye Plus system – becoming the first optometrist in Queensland to install the device at his practice, Eyecare Plus Nundah. Versatility and affordability were key factors in his decision.
“I found the system provided greater control because of the five different filters that offer varying wavelengths allowing me to treat at different depths and skin tones,” he says.
Optometrist Raj Maiti, owner of Eyecare Plus Nundah, says versatility and affordability influenced his IPL purchase.
“I can also easily select the duration and energy of each individual pulse, as well as the pulse interval. But I had to be mindful of the budget as well – I found this to be one of the more affordable IPLs available in Australia. For a new optometrist starting out, Thermaeye Plus was giving me all the control I needed, but yet at a more attainable price – and having the longer wavelength to treat meibomian gland dysfunction (MGD) in darker skin types is a useful option.”
Maiti trialled the system with his patients with good results: seeing a 75% improvement in meibomian gland function on average. One of those was a pharmacist, a highly analytical patient who was suffering from recurrent conjunctivitis and irritation for few years.
“She was given a quantifying DEQ-5 questionnaire before we started and then afterwards. After the third session – because we still had one left – I asked how uncomfortable are your eyes in terms of zero to five (five being most uncomfortable)? She remarked they were infinitely better. So that was a positive early impression of the instrument,” he says.
“But it’s important to note for me that IPL isn’t a one-hit-fix. I prescribe a combination of anti-inflammatories and lubricants at the beginning of the treatment to take care of the dry eye until the IPL starts working. I squeeze the eyelids and have a good technique of extracting the meibum. Manual expression is crucial to get the most out of the IPL treatment.”
In terms of patient comfort and safety, Maiti has had no complaints. A key feature of the system is an integrated skin cooling system within the handpiece that works to prevent excessive temperature increases to the epidermis, reducing the risk of thermal damage.
Maiti plans to complement his dry eye service with purpose-built diagnostics, investing in a S390L (Firefly) Slit Lamp Microscope, also available through OptiMed. The system offers several dry eye tools, including meibomian gland observation, tear film breakup time, red eye analysis and keratopathy exposure, and tear meniscus height.
“Having the right imaging tools so people can better understand their condition is important. The great benefit with this digital slit lamp is that it has meibography built-in, so there’s no requirement to move the patient to another instrument. They are already sitting against the chinrest, and I can quickly take an infrared photo of the meibomian glands and pull it up on the big screen and show why they might want to consider IPL in future,” he explains.
The introduction of an IPL system has helped differentiate Maiti’s practice compared with corporates located in proximity. He is providing the IPL service for $600 for four sessions as an introductory offer. But he recommends IPL as a second line treatment. Patients are sent home with a home-based treatment as a first line treatment and scheduled for a follow up within four weeks. They are given a blepharitis pamphlet and advised of the IPL clinic-based treatment as a potential next step when symptoms are no better with home-based treatments.
“The chair time is currently around 20 minutes, so it’s not going to be the primary source of income, but it’ll be an additional service that will help address the needs of local community with an ageing population,” he says.
“It’s very important, being a small independent, to provide more than what the box retail optical stores do.”
With some optometrists, especially in the US, adding skin rejuvenation to their dry eye service, Maiti anticipates this will be a trend that catches on in Australia – and having the Thermaeye Plus IPL is a way of preparing for this, if the opportunity presents.
In the ophthalmology setting
Meanwhile, in the ophthalmology setting, the Thermaeye Plus IPL has contrasting objectives.
Dr Gayatri Banerjee, from Nepean Valley Eye Surgeons in Sydney, first had the system installed two years ago. While she does see patients seeking standalone dry eye care, often it’s about treating the ocular surface to optimise cataract surgery outcomes pre- and post-operatively.
There’s also other patients to consider, such as those with a compromised ocular surface due to ongoing use of glaucoma eye drops, or patients receiving intravitreal anti-VEGF injections where the use of disinfectants can strip the ocular surface or highlight underlying issues.
“IPL is not my first line treatment – I would categorise this as one of the later stage therapies, partly because of the fact that it is a procedure and more expensive for patients because they don’t receive a Medicare rebate for it,” she says, noting that patients undergo four treatments as part of the initial IPL treatment program.
In a busy private ophthalmology clinic, Banerjee is mindful of the extra chair time IPL can create, but she views it as an investment, avoiding larger issues in future when a patient may return with complaints due to a sub-optimal ocular surface.
“My main objective is a quick, effective treatment that’s going to minimise my chair time. If I have a good ocular surface, it means I can achieve an ideal post-operative result, avoiding issues later down the track. I’m not looking to spend extended amounts of time with the patient repeatedly.”
Dr Gayatri Banerjee.
When first acquiring the Thermaeye Plus IPL, Banerjee thought it principally had a role in rosacea. She was surprised to hear about the applications it potentially had in the dry eye space, so she began attending talks and conducting her own research before expanding its use.
“Patients are equally as mystified by this business of IPL, but it’s been through my own observations of their symptoms through OSDI scores and SPEED scores that we are objectively able to say they have improved,” she says.
“Between 50-70% of patients are improved and that’s partly to do with my patient selection and management of their expectations. Over time I have started integrating other functions such as rosacea management. One of the benefits of the Thermaeye Plus is that it has different filters that you can use for various conditions.”
Banerjee continues: “But ultimately cost and comfort were the biggest factors when considering which IPL to purchase. Some of the older generation IPLs could burn and hurt patients, but the newer generation systems don’t, and they can be used on many skin types, including Fitzpatrick type V. I tested it on my own skin, and it has been comfortable for patients. In terms of cost, we analysed what was available, and determined this offered the best value for our practice.”
