One-year outcome of intense pulsed light therapy for refractory meibomian gland dysfunction in patients continuously exposed to hypotensive agents: a comparative study

doi:10.21203/rs.3.rs-3340966/v1

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One-year outcome of intense pulsed light therapy for refractory meibomian gland dysfunction in patients continuously exposed to hypotensive agents: a comparative study

https://doi.org/10.21203/rs.3.rs-3340966/v1

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Background: To compare the one-year effect of intense pulsed light (IPL) for refractory meibomian gland dysfunction (MGD) between patients treated with and without topical hypotensive agents.

Methods: This comparative retrospective cohort study included 41 MGD eyes of glaucoma patients (age, 67.59±11.12 years) and 41 MGD eyes of non-glaucoma patients (age, 62.73±15.97 years). Both arms received a course of IPL with meibomian gland (MG) expression (MGX). Baseline characteristics were matched by propensity score test. Standard evaluation including eye dryness (SPEED) questionnaire, tear breakup time (TBUT), lid telangiectasia, corneal fluorescein staining (CFS) score, meibum quality and expressibility were assessed at baseline, 3, 6, 9 and 12 months after treatment.

Results: No baseline intergroup heterogeneity was detected after matching. Both groups demonstrated significant improvements in SPEED score (-6.37 vs -3.23), lid telangiectasia (-0.62 vs -0.60), MG expressibility (-0.66 vs -0.93) and meibum quality (-0.83 vs -0.84) at 6 months (all p < 0.01), with a sustainable effect up to 9 months in glaucoma group and 12 months in non-glaucoma group in terms of SPEED score and MG expressibility. Both arms showed significant improvements in TBUT and meibum quality at 12 months (p < 0.01). CFS significantly decreased in the non-glaucoma group at 6 months while there was no significant change of CFS in glaucoma group over the follow-up period.

Conclusions: IPL with regular MGX exerts a promising sustainable effect in ameliorating symptoms and signs of MGD patients treated with topical hypotensive agents, but the effect lasts shorter than that in non-glaucoma patients.

Health sciences/Diseases/Eye diseases/Corneal diseases

Health sciences/Health care/Therapeutics/Biological therapy

Intense pulsed light

Meibomian gland dysfunction

Glaucoma

Meibomian gland expression

Meibum

Ocular hypotensive eye drops

As the leading cause of irreversible blindness worldwide, glaucoma is a globally-concerned disease.¹ More than 100 million people are predicted to be afflicted with glaucoma by 2040 which causes substantial burden on public health.² The only well-established treatment for glaucoma is through the control of intraocular pressure (IOP), which is achieved by long-term topical hypotensive agents in the majority of patients. While topical medical therapies effectively halter progressive visual loss and prevent blindness, the components and the preservatives of these medications inevitably cause ocular surface problems, with reported prevalence ranging from 37 to 91%.^2,3 Of note, meibomian gland dysfunction (MGD) is a commonly reported cause of ocular surface discomfort in patients treated with topical hypotensive medications.⁴ Numerous studies have shown that hypotensive eye drops have a negative impact on the meibomian glands (MG), being highly associated with depletion and impaired function of MG,^5,6 rendering treated glaucoma patients more vulnerable to evaporative dry eye disease.⁷ Specifically, the prevalence of MGD was reported to be up to 82% in the glaucoma group, while it was 52.5% in the normal group.⁸ The ocular symptoms caused by MGD substantially affect life quality as well as reduce medication adherence, leading to less effectiveness of antiglaucoma treatments, thus increasing the likelihood of blindness.^2,7,9 Therefore, it is crucial to explore an effective and sustainable treatment for glaucoma patients with MGD.

The management of MGD involves multimodality treatment options such as lifestyle modification, lubricants, warm compression, topical anti-inflammatory agents, topical mucin stimulator via P2Y2 receptor agonist, punctal plugs, intraductal probing, thermal pulsation, systemic antibiotic and oral supplements.^10,11,12,13 However, limited response with significant ocular discomfort was present in a considerable proportion of MGD patients despite of the above treatments.^11,14 In recent years, the combination of intense pulsed light (IPL) and meibomian gland expression (MGX) has been established as an effective and safe approach to mitigate symptoms and signs of MGD. ^15,16 The treatment can have a lasting effect up to 9 months.^11,17,18 However, clinical trials studying the impact of IPL on MGD often exclude subjects using ocular hypotensive agents, leaving the effect of IPL on glaucoma eyes uncertain. ^{19,20,21,22,23} A non-comparative retrospective study analyzing the IPL effect in patients using ocular hypotensive agents reported short-term (4 weeks) results, revealing significant improvements in subjective symptoms, ocular surface staining, MG expressibility, tear osmolarity and tear meniscus height.²⁴ Given that exposure to glaucoma medications may counteract the endurable effect of IPL, it is a pressing need to conduct a study to observe the effects of IPL over a longer follow-up period to validate the clinical value of adopting IPL in glaucoma patients who require long-term topical hypotensive medications to control their IOP.

The study included patients diagnosed with symptomatic MGD and received IPL at a tertiary referral center from January 2019 to August 2022. Before IPL, these patients had limited response to conventional treatments, such as lubricants and warm compression. Patients were divided into two groups: concurrent use of topical glaucoma medication before and after IPL (glaucoma group) and those without glaucoma eye drops (non-glaucoma group). The study complied with the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board of Taipei Veterans General Hospital. Patients with the following conditions were excluded: (1) acute ocular inflammatory or infectious disease (eg, allergic conjunctivitis, acute viral conjunctivitis, corneal melting, and corneal ulcer) (2) eyelid abnormality (eg, ectropion, lagophthalmos, blepharospasm) or facial paralysis (3) periorbital pathology like skin cancer or pigmented lesions (4) ocular trauma, major surgery or glaucoma filtering surgery prior to baseline evaluation (5) exposure of photosensitive drugs/foods (6) systemic inflammatory disease or critical illness (7) skin Fitzpatrick scale V/VI (8) contraindications to IPL therapy.

2.1 Treatment protocol

Each patient was treated with three- to four-time IPL sessions using a hand-held IPL device (E > Eye, ESwin, Paris, France) which emitted 5 flashes of intense pulsed regulated light (IRPL®) over lower periorbital area in the setting of 12–13 J/cm2 depending on the skin type, with a therapy scheme of 2-week interval between initial 2 sessions and 1-month interval between the following sessions. For each treatment session, protective eye shields were placed to cover the eyes and coupling gel was applied to the treated regions. The procedure was repeated for the opposite eye. MGX over the upper and lower eyelids were applied with a meibomian gland expressor forceps immediately after IPL treatment and at each 3-month follow-up visit after IPL (Fig. 1). All the IPL therapies and MGX were performed by a single cornea specialist (N.-W. Fan). The patients were instructed to avoid sunlight exposure and keep the installation of topical fluorometholone 0.02% for 14 days after IPL therapy. The informed consents were obtained from all the patients before this procedure.

2.2 Baseline and outcome assessment

Clinical parameters associated with MGD were evaluated at baseline and 3, 6, 9 and 12 months after the first IPL session by a single cornea specialist (N.-W. Fan). The frequency and severity of dry eye symptoms were assessed using SPEED questionnaire. Tear breakup time (TBUT) was recorded as the average of 3 measurements after instillation of fluorescein. Corneal fluorescein staining (CFS) scores was quantified using the National Eye Institute (NEI) grading system, giving a score from 0 to 3 for each of the five areas of the cornea.²⁵ To avoid the influence of fluorescein drops on tear film, LipiView interferometer (Johnson & Johnson, New Brunswick, New Jersey) was arranged at different clinic to evaluate lipid layer thickness (LLT), MG structure, blink dynamics, and MG morphology. Loss of MG was graded as followings: grade 0: 0–25% loss, grade 1: 26–50% loss, grade 2: 51–75% loss, grade 3: 76–100% loss, which was evaluated by a single investigator who was masked to the grouping. The score of meibograde was the sum of grading results of upper and lower eyelids.²⁶ Lower eyelid margin was observed for telangiectasia, as grade 0 for no telangiectasia, grade 1 for mild telangiectasia, grade 2 for moderate telangiectasia and grade 3 for severe telangiectasia. MG expressibility and meibum quality were measured from the central lower 5 glands (grade 0: all glands expressible, grade 1: 3–4 glands expressible, grade 2: 1–2 glands expressible, grade 3: no gland expressible; grade 0: clear meibum, grade 1: cloudy meibum, grade 2: cloudy particulate meibum, grade 3: toothpaste like meibum).

2.3 Statistical analysis

SPSS statistical software (IBM SPSS, Version 26, NY, USA) was used to conduct descriptive analysis, chi-square, t-test and propensity score matching, which matched the glaucoma and non-glaucoma group to minimize intergroup heterogeneity and thus reduce the impact of confounders. Categorical variables were presented as numbers with proportion. Continuous variables were reported as mean with standard deviation (SD). A P value < 0.05 was considered to indicate statistical significance.

The construction of diagram and statistical analysis were carried out with GraphPad Prism version 8.3.0 for Windows, GraphPad Software, San Diego, California USA. Repeated analysis of outcome measurements (mixed model) was performed to examine whether there was significant difference of outcome variables across five different follow-up time points.

3.1 Demographics and baseline characteristics

A total of 220 eyes (110 patients) received IPL therapy, and 87 eyes were excluded due to incomplete treatment courses (2 eyes due to the COVID-19 pandemic), phthisis (1 eye), or loss of follow-up (84 eyes). The final analysis included 133 eyes of 67 patients (glaucoma group: 41 eyes, non-glaucoma group: 92 eyes). After matching the glaucoma group and non-glaucoma group in terms of age, diabetes mellitus, hypertension and severity of lid telangiectasia with propensity score, 41 eyes in each group were included for further analysis, and there was no intergroup heterogeneity detected regarding the severity of MGD at baseline (Table 1) and thus comparative analysis was allowed.

Table 1

Demographics and clinical characteristics of study subjects (133 eyes)
	Non-matched			Propensity score-matched
	Glaucoma group N = 41	Non-glaucoma group N = 92	P value	Glaucoma group N = 41	Non-glaucoma group N = 41	P value
Age (year)	67.59 ± 11.12	56.36 ± 13.95	< 0.001***	67.59 ± 11.12	62.73 ± 15.97	0.115
Gender (male)	18 (44%)	27 (29%)	0.101	18 (44%)	12 (29%)	0.169
Laterality (OD)	22 (54%)	45 (49%)	0.613	22 (54%)	20 (49%)	0.659
Systemic disease
DM	15 (37%)	9 (10%)	< 0.001***	15 (37%)	9 (22%)	0.145
Hypertension	27 (66%)	22 (24%)	< 0.001***	27 (66%)	20 (49%)	0.118
Hyperlipidemia	18 (53%)⁺	39 (46%)⁺⁺	0.486	18 (53%)⁺	24 (69%)⁺⁺⁺	0.184
GvHD	0 (0%)	2 (2%)	1.000	0 (0%)	0 (0%)	N/A
Sjögren's syndrome	4 (10%)	2 (2%)	0.073	4 (10%)	2 (5%)	0.675
Rumatoid arthritis	0 (0%)	4 (4%)	0.311	0 (0%)	3 (7%)	0.241
Associated factors of dry eye
History (year)	4.50 ± 3.26	3.57 ± 3.84	0.181	4.50 ± 3.26	3.28 ± 3.47	0.105
Screen time (h/day)	3.86 ± 2.67	6.35 ± 4.25	0.002**	3.86 ± 2.67	5.79 ± 4.22	0.098
Smoking	8 (20%)	8 (9%)	0.089	8 (20%)	5 (12%)	0.364
TBUT (sec)	2.81 ± 1.53	3.05 ± 1.85	0.498	2.81 ± 1.52	3.33 ± 2.23	0.239
Schirmer test (mm)	14.29 ± 9.82	15.67 ± 10.35	0.473	14.29 ± 9.82	15.09 ± 9.82	0.716
Severity of MGD
SPEED score	12.37 ± 5.33	13.17 ± 5.44	0.428	12.37 ± 5.33	12.05 ± 4.38	0.769
Expressibility	1.34 ± 0.94	1.32 ± 1.13	0.909	1.34 ± 0.94	1.54 ± 1.12	0.396
Meibum quality	1.58 ± 0.76	1.21 ± 0.59	0.015*	1.58 ± 0.76	1.33 ± 0.48	0.129
Lid telangiectasia	1.68 ± 0.98	1.11 ± 0.78	0.002**	1.68 ± 0.98	1.34 ± 0.85	0.096
Ant. displacement of MCJ	24 (59%)	47 (51%)	0.426	24 (59%)	22 (54%)	0.656
MG plugging	18 (44%)	45 (49%)	0.593	18 (44%)	23 (56%)	0.269
MGD stage	3.49 ± 0.55	3.34 ± 0.60	0.206	3.49 ± 0.55	3.44 ± 0.55	0.690
LipiView Meibography
Meibograde (total)	2.88 ± 1.44	2.52 ± 1.66	0.240	2.88 ± 1.44	2.59 ± 1.76	0.423
Upper lid	1.66 ± 0.85	1.31 ± 0.90	0.038*	1.66 ± 0.85	1.41 ± 0.91	0.212
Lower lid	1.22 ± 0.85	1.26 ± 0.94	0.809	1.22 ± 0.85	1.24 ± 1.07	0.909
LLT (nm)	64.68 ± 22.59	62.99 ± 22.12	0.686	64.68 ± 22.56	66.37 ± 21.23	0.729
Partial blink (%)	62 ± 38	58 ± 36	0.653	62 ± 38	64 ± 38	0.815
DM (diabetes mellitus), GvHD (graft versus host disease), TBUT (tear breakup time), MGD (meibomian gland dysfunction), SPEED (Standardized Patient Evaluation of Eye Dryness), MCJ (mucocutaneous junction), MG (meibomian gland), LLT (lipid layer thickness), N/A (not available), ⁺denominator: 34, ⁺⁺denominator: 85, ⁺⁺⁺denominator: 35 P value < 0.05, < 0.01, < 0.001** Continuous variables are expressed as mean ± standard deviation while dichotomous variables as number (proportion).

Table 2

Outcomes in the glaucoma and non-glaucoma group across the follow-up period
		0M	6M	9M	12M	6M-0M	P	9M-0M	P	12M-0M	P
SPEED	Glaucoma	12.37 ± 5.30	6.00 ± 3.57	7.14 ± 5.26	8.84 ± 4.39	-6.37	< 0.0001	-5.23	< 0.01	-3.52	0.18
SPEED	Non-glaucoma	12.05 ± 4.38	8.82 ± 3.37	7.38 ± 3.77	8.21 ± 3.65	-3.23	< 0.01	-4.67	< 0.0001	-3.84	< 0.01
TBUT	Glaucoma	2.81 ± 1.53	5.57 ± 1.83	5.73 ± 2.21	5.00 ± 2.03	2.75	< 0.0001	2.92	< 0.0001	2.19	< 0.001
TBUT	Non-glaucoma	3.33 ± 2.23	5.03 ± 2.71	5.53 ± 2.81	4.45 ± 1.53	1.17	0.07	2.20	< 0.01	1.12	< 0.05
Lid telangiectasia	Glaucoma	1.62 ± 0.83	1.00 ± 0.67	1.15 ± 0.75	1.37 ± 0.94	-0.62	< 0.001	-0.47	0.12	-0.25	0.43
Lid telangiectasia	Non-glaucoma	1.34 ± 0.85	0.74 ± 0.81	0.46 ± 0.59	0.41 ± 0.50	-0.60	< 0.0001	-0.88	< 0.0001	-0.93	< 0.0001
MG expressibility	Glaucoma	1.34 ± 0.94	0.68 ± 0.75	0.77 ± 0.69	0.74 ± 0.65	-0.66	< 0.01	-0.57	< 0.05	-0.60	0.09
MG expressibility	Non-glaucoma	1.54 ± 1.12	0.61 ± 0.72	0.59 ± 0.61	0.83 ± 0.76	-0.93	< 0.001	-0.94	< 0.0001	-0.71	< 0.001
Meibum quality	Glaucoma	1.58 ± 0.76	0.75 ± 0.61	0.70 ± 0.73	0.74 ± 0.64	-0.83	< 0.01	-0.87	< 0.01	-0.84	< 0.05
Meibum quality	Non-glaucoma	1.33 ± 0.48	0.50 ± 0.63	0.57 ± 0.49	0.64 ± 0.68	-0.84	< 0.0001	-0.77	< 0.0001	-0.70	< 0.001
CFS score	Glaucoma	0.95 ± 2.01	0.59 ± 1.45	0.85 ± 2.33	0.26 ± 0.81	-0.36	0.55	-0.11	1.00	-0.69	0.22
CFS score	Non-glaucoma	0.65 ± 1.46	0.16 ± 0.63	0.87 ± 1.31	0.46 ± 1.07	-0.49	< 0.05	0.22	0.55	-0.19	0.79
Outcome assessment at baseline, 6, 9 and 12-month visits are displayed in the left column (mean ± standard deviation). Changes of outcome measurement with adjusted P value are demonstrated in the right column. SPEED (Standardized Patient Evaluation of Eye Dryness), TBUT (tear breakup time), MG (meibomian gland), CFS (corneal fluorescein staining)

The glaucoma patients in our study averagely received 2 to 3 different classes of pressure-lowering drops (2.34 ± 1.09) for 4.90 years, including alpha agonist (23 eyes, 56%), beta blocker (29 eyes, 71%), carbonic anhydrase inhibitor (14 eyes, 34%), prostaglandin analog (30 eyes, 73%).

3.2 SPEED

As shown in Fig. 2, the glaucoma group experienced significant improvement of symptoms as shown by the change of SPEED score at 3, 6 and 9-month visits compared to baseline (P value 0.0017, < 0.0001, 0.0013 respectively). The non-glaucoma group showed significant reduction of SPEED score over the one-year follow-up-period (3 to 12-month visits). The most significant change occurred at 6-month visit in the glaucoma group whereas 9-month visit in the non-glaucoma group.

3.3 TBUT

As illustrated in Fig. 2, both arms showed significant improvements of TBUT at 9 and 12-month visits (P value: glaucoma group < 0.0001, 0.0004; non-glaucoma group 0.0043, 0.0350). Additionally, TBUT significantly increased at 3-month and 6-month follow-up in the glaucoma group. The greatest change was observed at 9-month follow-up in both groups (glaucoma group: mean difference 2.92, 95% CI 1.51 to 4.32; non-glaucoma group: mean difference 2.20, 95% CI 0.57 to 3.83).

3.4 Lid telangiectasia

The severity of lid telangiectasia significantly decreased at 3 and 6-month follow-up in both arms (P value: glaucoma group 0.0002, 0.0003; non-glaucoma group 0.0035, < 0.0001). However, the effect lasted for 6 months in the glaucoma group, while the effect lasted for 12 months in the non-glaucoma group (Fig. 2).

3.5 MG expressibility and meibum quality

Both arms showed significant improvements at all timeframes in meibum quality (Fig. 2). But the effect on MG expressibility improvements lasted shorter in the glaucoma patients (9 months) than non-glaucoma patients (12 months). The degree of the expressibility improvements peaked at 6-month visit (mean difference: -0.66, 95% CI -0.24 to -1.09) in the glaucoma group and peaked at 9-month (mean difference: -0.94, 95% CI -0.53 to -1.36) in the non-glaucoma group.

3.6 CFS score

There was no significant improvement of CFS in the glaucoma group. In contrast, the non-glaucoma group showed a significant improvement of CFS score at 6-month visit (Fig. 2). Both groups demonstrated a trend of improved CFS at 6 months, followed by a rebound to the baseline level thereafter.

By means of a comparative analysis of matched glaucoma and non-glaucoma patients, our study reports the one-year effect of IPL + MGX treatment and confirms the promising effect of IPL in improving both the symptoms and signs of MGD in patients treated with hypotensive eye drops, but the effect lasted shorter than non-glaucoma patients.

The results of our study are in line with a previous noncomparative retrospective study, which evaluated short-term (2.5 months) results of IPL + MGX in 30 eyes treated with hypotensive eye drops,¹⁹ showing significant improvements in SPEED and meibum expressibility. Our study evaluated additional parameters, such as lid telangiectasia and meibum quality, showing sequential changes of these parameters to understand the durability of the benefit in this specific population. The MG expressibility, meibum quality and tear film stability are indicators of MG secretory function, being critical for maintaining ocular surface health. Our study reveals the lasting effects of IPL therapy in both glaucoma and non-glaucoma patients, particularly in terms of the meibum quality and TBUT, which improved till the end of one-year observation. However, in glaucoma patients, the beneficial effects of IPL in amelioration of lid telangiectasia, SPEED, along with meibum expressibility are less persistent compared to that in non-glaucoma patients. Specifically, the beneficial effect of IPL on lid telangiectasia was not observed after 6 months post-treatment. This may be ascribed to the long-term and concurrent use of hypotensive eye drops, which has been linked to ocular surface inflammation and eyelid margin abnormalities,²⁷ and may counteract the anti-inflammatory effect of IPL therapy.²⁸

The reported durability of IPL in MGD patients is dependent on the observation periods of studies. One randomized controlled trial (RCT) conducted by Arita et al which studied the effect of a series of 8 treatment sessions (IPL + MGX) in 45 patients with 8-month follow-up period showed that IPL + MGX significantly improved LLT, TBUT, eyelid margin abnormalities, meibum grade and SPEED score at final visit.¹⁰ By directly applying IPL over both upper and lower eyelids for a total of 12 pulses in each eye with a follow-up of 12 months, Rong et al reported that TBUT and meibomian gland yielding secretion score of upper and lower eyelids improved by 6 months after IPL.²⁹ In our study, which observed the effects of IPL for a duration of 12 months, we found that the non-glaucoma patients experienced a longer effect of up to 12 months compared to the aforementioned studies. The extended duration of beneficial effects in our study may be attributed to the application of MGX not only at each IPL treatment session but also at every 3-month returning visit after IPL therapy. Therefore, the regular performance of MGX following IPL may contribute to the continual improvement of MG function.

Our study observed differences in demographic and clinical characteristics between the general population with MGD and MGD patients treated with topical glaucoma medication. We found that there was a greater proportion of patients with elder age, diabetes mellitus and hypertension in the glaucoma group than non-glaucoma group before matching. The parameters mentioned above also serve as risk factors for glaucoma and thus it could explain the varied distribution among the 2 groups before matching. In addition, MGD patients with hypotensive eye drops presented with higher degree of lid telangiectasia, more MG loss in the upper eyelids, less favorable meibum quality, which may be related to the side effects of hypotensive eye drops.²⁷ This finding was compatible with that in Arita 2012, which concluded that glaucoma patients exhibited greater severity of eyelid margin abnormality, superficial punctate keratopathy, along with worse morphology and function of meibomian gland compared to healthy subjects.³⁰

In addition to the inherent limitation of a retrospective study, there were some limitations. First, our study lacked more objective and molecular-based outcome parameters such as tear osmolarity or cytokine level in tear film. Second, we did not analyze the impact of different categories of hypotensive eye drops on the effects of IPL due to small sample size.

Our study shows that improvements of tear film stability and meibum quality after IPL therapy are sustainable over time, whereas the improvements in lid telangiectasia, dry eye symptoms and meibum expressibility in medicated glaucoma patients are relatively short-lived compared to non-glaucoma patients. This phenomenon is probably ascribed to the concurrent hypotensive eye drops which preclude the treated eyes from escaping the vicious cycle of proinflammatory mediators and reactive oxygen species after IPL.^27,28,31 Nevertheless, given that at least 6-month improvements in all parameters except for CFS score were detected after IPL in both arms, our study suggests that IPL with regular MGX could serve as a propitious treatment option for patients with MGD, including chronically medicated glaucoma patients who are more vulnerable to the development of MGD-related ocular surface diseases.

Acknowledgements and financial disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. No financial disclosures.

IPL, intense pulsed light; MGD, meibomian gland dysfunction; MGX, meibomian gland expression; MG, meibomian gland; SPEED, Standard Patient Evaluation of Eye Dryness; TBUT, tear breakup time; CFS, corneal fluorescein staining; LLT, lipid layer thickness; PSM, propensity score matching

Acknowledgements and financial disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. No financial disclosures.

Conflict of Interests

The authors declare that they have no conflict of interest.

Author contribution statement

NWF contributed to designing and guiding the study, performing IPL and clinical examinations for patients, interpreting results and editing the draft. MJC assisted in collecting and extracting data. YCK provided feedback on the research. CCY was responsible for chart review, data extraction, statistical analysis, preparation of the figures, tables and draft.

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Editorial decision: revise
12 Mar, 2024
Reviewer #1 agreed at journal
17 Oct, 2023
Reviewers invited by journal
03 Oct, 2023
Editor assigned by journal
29 Sep, 2023
Submission checks completed at journal
11 Sep, 2023
First submitted to journal
09 Sep, 2023

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One-year outcome of intense pulsed light therapy for refractory meibomian gland dysfunction in patients continuously exposed to hypotensive agents: a comparative study

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Version 1

Abstract

Figures

1. Introduction

2. Methods

2.1 Treatment protocol

2.2 Baseline and outcome assessment

2.3 Statistical analysis

3. Results

3.1 Demographics and baseline characteristics

3.2 SPEED

3.3 TBUT

3.4 Lid telangiectasia

3.5 MG expressibility and meibum quality

3.6 CFS score

4. Discussion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1