Analysis of the Results of Intense Pulsed Light Treatment Previously to Laser Refractive Surgery

Analysis of the Efficacy and Safety of Intense Pulsed Light Treatment for the Ocular Surface in Patients Who Will Undergo Laser Refractive Surgery

Dry eye is often reported as the most common complication after a laser refractive surgery. Any refractive procedure can lead an impact on the corneal surface and the tear film.

The main cause of this dry eye is the corneal denervation caused by the destruction of the anterior stromal nerves during the ablative procedure. This loss of corneal sensitivity leads to a decrease in the blink reflex, a decrease in the secretion rate of the meibomian glands and finally an evaporated dry eye. There is also a chronic inflammation at the corneal surface that produces an increase of inflammatory cytokines and a dysfunction of the meibomian glands.

Yu et al have described incidences of dry eye closed to 60% after the first month of LASIK. Hovanesian et al have observed dry eye symptoms in 50% of patients 6 months after surgery. Donnenfeld et al describe 15% of moderate dry eye in the following 3 months and 5% of severe dry eye in the first 6 months. A small number of patients will present with chronic dry eye symptoms for more than 1 year. Bower et al analyzed its incidence in 0.8% Alterations in the tear film also decrease the quality of the retinal image and produce greater number of high-order due to the irregular.

Pulsed light therapy (IPL) applied preoperatively in patients who undergo a laser refractive surgery may prevent the post-surgical dry eye and improve the refractive results. The aim of our study is to evaluate the usefulness of the applied therapy for the prevention of dry eye in patients that undergo a corneal refractive procedure.

Study Overview

• Status: Recruiting
• Conditions: Meibomian Gland Dysfunction; Blepharitis
• Intervention / Treatment: Device: Study group; Other: Control group

Detailed Description

1. Design Clinical experimental controlled trial, double-blind in which participants will be randomized into 2 groups: a study group (IPL + laser refractive surgery) and a control group (laser refractive surgery without IPL).

   The study will be conducted in accordance with Law 14/2007 of 3 July, on Biomedical Research, the Declaration of Helsinki (October 2013 version), standards of Good Clinical Practice and legislation in this area.

   All participants included in the study should read the Information Sheet and sign the informed and voluntary consent.

2. Participants Participants from Vissum Clinic that present the inclusion criteria and none of the exclusion criteria.

   The investigators will start the study with a preliminary project and depending on the results obtained, the investigators will apply these values to calculate the final sample size using the T-student-Fischer test for unilateral hypotheses and for a type 1 or α error of 5%. and a type 2 or β error of 20%.

3. Parameters evaluated Primary measures: age, sex, skin phototype, visual acuity with and without correction, refraction, cycloplegic refraction, OSDI and VAS questionnaire, use of artificial tears, oxford scale, lacrimal meniscus height, tear break-up time, conjunctival hyperemia, meibography and slit lamp examination.

   Secondary measures: corneal topography and tomography (MS-39, CSO, Italy), corneal aberrometry (MS-39, CSO, Italy), ocular aberrometry (Osiris, CSO, Italy), analysis of contrast sensitivity (CSV-1000, Vector vision), photographic capture of the epithelial defect in PRK, pre-surgical and postsurgical photographic capture of the eyelid changes in PRK.

   The measurement of the different objective variables will be carried out in the clinic. The measurement of the subjective variables will be carried out by two ophthalmologists, both masked.

4. Surgery and follow-up Participants who are candidates for a LASIK or SMILE procedure will receive, after randomization, IPL treatment in both eyes (experimental group) or sham IPL (control group). In the case of participant candidate for a PRK procedure, an intra-subject control group will be used, where one eye will receive the IPL treatment (right eyes) and the left contralateral eye the sham IPL treatment (control).

   Refractive surgeries will be performed exclusively two ophthalmologists following the same surgical protocol.

   IPL therapy (M22, Lumenis LTD, Israel) will be performed following the same protocol (standardized facial and periocular application with automatically adjusted energy according to Fitzpatrick skin classification). Three IPL sessions will be applied (simulated in the case of the control group): 7 days before the intervention, 7 days after the intervention, and 30 days after the intervention. The total postsurgical follow-up will be 6 months.

5. Statistical analyses All demographic and clinical data will be collected in a database and analyzed with the SPSS statistical package for Windows version 22.0. A p <0.05% will be considered significant.

• Study Type: Interventional
• Enrollment (Anticipated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Jorge Alió del Barrio, MD, PhD; Phone Number: +34 965154062; Email: jorge_alio@hotmail.com
• Study Contact Backup: Name: Alejandra Rodriguez, MSc, PhD; Phone Number: +34 965154062; Email: clinicaltrials@vissum.com

Study Locations

• Spain
  • Alicante, Spain, 03016
    • Recruiting
    • Alicante Vissum Miranza
    • Contact: Alejandra E Rodriguez, MSc, PhD; Phone Number: +34 965154062; Email: clinicaltrials@vissum.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 60 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients over 18 years of age who are undergoing a corneal laser refractive surgery after a medical indication by the Vissum ophthalmologist

Exclusion Criteria:

• Pregnancy
• Piercings
• Fitzpatrick skin classification V and VI
• Autoimmune diseases
• Epilepsy
• Previous history of herpes or ocular pathology
• Pathological or suspicious corneal topography
• Treatment in the previous month with corticosteroids, antihistamines or topical vasoconstrictors.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Study group; IPL + laser refractive surgery	Device: Study group; The IPL therapy consists in a polychromatic pulses of light not coherent and not collimated. The therapy leads to a series of processes such as the destruction of superficial blood vessels and thus the reduction of local inflammation, the liquefy of the meibum and an antimicrobial, anti-inflammatory and antioxidant effects. The therapy is performed over the cheeks, nose and upper eyelids.; Other Names: Intense pulsed light therapy (Lumenis M22)
Placebo Comparator: Control group; Laser refractive surgery without IPL	Other: Control group; Same procedure but without energy

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
OSDI questionnaire	It measures the severity of ocular surface symptoms and includes 12 items organized into 3 subscales; eye discomfort, functionality and environmental factors. After completing the questionnaire, a final score is obtained that when it is higher than 13 indicates ocular surface pathology.	0 day
Change from Baseline OSDI questionnaire	It measures the severity of ocular surface symptoms and includes 12 items organized into 3 subscales; eye discomfort, functionality and environmental factors. After completing the questionnaire, a final score is obtained that when it is higher than 13 indicates ocular surface pathology.	7 day
Change from Baseline OSDI questionnaire	It measures the severity of ocular surface symptoms and includes 12 items organized into 3 subscales; eye discomfort, functionality and environmental factors. After completing the questionnaire, a final score is obtained that when it is higher than 13 indicates ocular surface pathology.	30 day
Change from Baseline OSDI questionnaire	It measures the severity of ocular surface symptoms and includes 12 items organized into 3 subscales; eye discomfort, functionality and environmental factors. After completing the questionnaire, a final score is obtained that when it is higher than 13 indicates ocular surface pathology.	90 day
Change from Baseline OSDI questionnaire	It measures the severity of ocular surface symptoms and includes 12 items organized into 3 subscales; eye discomfort, functionality and environmental factors. After completing the questionnaire, a final score is obtained that when it is higher than 13 indicates ocular surface pathology.	180 day
Lacrimal meniscus height	Measured in millimeters by Ocular Keratograph 5M, a value greater than 0.20 mm is considered normal	0 day
Change from Baseline Lacrimal meniscus height	Measured in millimeters, a value greater than 0.20 mm is considered normal	7 day
Change from Baseline Lacrimal meniscus height	Measured in millimeters, a value greater than 0.20 mm is considered normal	30 day
Change from Baseline Lacrimal meniscus height	Measured in millimeters, a value greater than 0.20 mm is considered normal	90 day
Change from Baseline Lacrimal meniscus height	Measured in millimeters, a value greater than 0.20 mm is considered normal	180 day
Tear Break-up-time	Time elapsed from the last blink to the appearance of the first tear discontinuity measured by Ocular Keratograph 5M. A title longer than 5 seconds is considered normal.	0 day
Change from Baseline Tear Break-up-time	time elapsed from the last blink to the appearance of the first tear discontinuity measured by Ocular Keratograph 5M. A title longer than 5 seconds is considered normal.	7 day
Change from Baseline Tear Break-up-time	time elapsed from the last blink to the appearance of the first tear discontinuity measured by Ocular Keratograph 5M. A title longer than 5 seconds is considered normal.	30 day
Change from Baseline Tear Break-up-time	time elapsed from the last blink to the appearance of the first tear discontinuity measured by Ocular Keratograph 5M. A title longer than 5 seconds is considered normal.	90 day
Change from Baseline Tear Break-up-time	time elapsed from the last blink to the appearance of the first tear discontinuity measured by Ocular Keratograph 5M. A title longer than 5 seconds is considered normal.	180 day
Conjunctival and ciliary hyperemia.	Grade of red eye measured by Ocular Keratograph 5M. Jenvis ranking from 0 to 4 (normal, mild, moderate, severe)	0 day
Change from Baseline Conjunctival and ciliary hyperemia.	Grade of red eye measured by Ocular Keratograph 5M. Jenvis ranking from 0 to 4 (normal, mild, moderate, severe)	7 day
Change from Baseline Conjunctival and ciliary hyperemia.	Grade of red eye measured by Ocular Keratograph 5M. Jenvis ranking from 0 to 4 (normal, mild, moderate, severe)	30 day
Change from Baseline Conjunctival and ciliary hyperemia.	Grade of red eye measured by Ocular Keratograph 5M. Jenvis ranking from 0 to 4 (normal, mild, moderate, severe)	90 day
Change from Baseline Conjunctival and ciliary hyperemia.	Grade of red eye measured by Ocular Keratograph 5M. Jenvis ranking from 0 to 4 (normal, mild, moderate, severe)	180 day
Upper and lower meibography	Measured by Oculus Keratograph 5M. Observes and evaluates morphological changes of the meibomian glands Meiboscore classification; Grade 0: no loss of meibomian glands.; Grade 1: loss of less than 1/3 of the total surface of the meibomian glands.; Grade 2: loss of 1/3 to 2/3 of the total area.; Grade 3: loss of more than 2/3 of the surface.	0 day
Change from Baseline Upper and lower meibography	Measured by Oculus Keratograph 5M. Observes and evaluates morphological changes of the meibomian glands Meiboscore classification; Grade 0: no loss of meibomian glands.; Grade 1: loss of less than 1/3 of the total surface of the meibomian glands.; Grade 2: loss of 1/3 to 2/3 of the total area.; Grade 3: loss of more than 2/3 of the surface.	7 day
Change from Baseline Upper and lower meibography	Measured by Oculus Keratograph 5M. Observes and evaluates morphological changes of the meibomian glands Meiboscore classification; Grade 0: no loss of meibomian glands.; Grade 1: loss of less than 1/3 of the total surface of the meibomian glands.; Grade 2: loss of 1/3 to 2/3 of the total area.; Grade 3: loss of more than 2/3 of the surface.	30 day
Change from Baseline Upper and lower meibography	Measured by Oculus Keratograph 5M. Observes and evaluates morphological changes of the meibomian glands Meiboscore classification; Grade 0: no loss of meibomian glands.; Grade 1: loss of less than 1/3 of the total surface of the meibomian glands.; Grade 2: loss of 1/3 to 2/3 of the total area.; Grade 3: loss of more than 2/3 of the surface.	90 day
Change from Baseline Upper and lower meibography	Measured by Oculus Keratograph 5M. Observes and evaluates morphological changes of the meibomian glands Meiboscore classification; Grade 0: no loss of meibomian glands.; Grade 1: loss of less than 1/3 of the total surface of the meibomian glands.; Grade 2: loss of 1/3 to 2/3 of the total area.; Grade 3: loss of more than 2/3 of the surface.	180 day

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Visual acuity	Visual acuity with and without correction, measured on a decimal scale, determined by the Snellen panel, placing the examined person at a distance of 6 meters, will be collected by an optician.	0 day
Change from Baseline Visual acuity	Visual acuity with and without correction, measured on a decimal scale, determined by the Snellen panel, placing the examined person at a distance of 6 meters, will be collected by an optician.	180 day
Corneal topography	Performs an analysis of the cornea, which allows evaluating the shape and quantifying the power of the different curvatures	0 day
Change from Baseline Corneal topography	Performs an analysis of the cornea, which allows evaluating the shape and quantifying the power of the different curvatures	180 day
Corneal aberrometry	Technique that analyzes complex systems of light waves to quantify the set of optical aberrations that exist within the ocular structure.	0 day
Change from Baseline Corneal aberrometry	Technique that analyzes complex systems of light waves to quantify the set of optical aberrations that exist within the ocular structure.	180 day
Analysis of contrast sensitivity	Contrast Sensitivity is a test that assesses a person's ability to identify an object and separate it from the background Contrast sensitivity is evaluated with charts that can be used as projected or wall acuity charts.	0 day
Change from Baseline Analysis of contrast sensitivity	Contrast Sensitivity is a test that assesses a person's ability to identify an object and separate it from the background Contrast sensitivity is evaluated with charts that can be used as projected or wall acuity charts.	180 day
VAS questionnaire	investigates the intensity of the ocular surface symptoms from 0 to 100 (normal- severe)	0 day
Change from Baseline VAS questionnaire	investigates the intensity of the ocular surface symptoms from 0 to 100 (normal- severe)	180 day

Collaborators and Investigators

• Sponsor: Vissum, Instituto Oftalmológico de Alicante
• Investigators: Principal Investigator: Jorge Alió del Barrio, MD, PhD, Vissum Miranza; Study Chair: Maria Martinez Hergueta, MD, Universidad Miguel Hernández; Study Chair: Maria A Amesty, MD, PhD, Vissum Miranza; Study Chair: Mario Cantó Cerdan, MSc, Vissum Miranza; Study Chair: Alejandra Rodriguez, MSc, PhD, Vissum Miranza; Study Chair: Jorge L Alió y Sanz, MD, PhD, Vissum Miranza

Publications and helpful links

General Publications

• Solomon R, Donnenfeld ED, Perry HD. The effects of LASIK on the ocular surface. Ocul Surf. 2004 Jan;2(1):34-44. doi: 10.1016/s1542-0124(12)70022-8.
• Toda I. Dry Eye After LASIK. Invest Ophthalmol Vis Sci. 2018 Nov 1;59(14):DES109-DES115. doi: 10.1167/iovs.17-23538.
• Ge J, Liu N, Wang X, Du Y, Wang C, Li Z, Li J, Wang L. Evaluation of the efficacy of optimal pulsed technology treatment in patients with cataract and Meibomian gland dysfunction in the perioperative period. BMC Ophthalmol. 2020 Mar 18;20(1):111. doi: 10.1186/s12886-020-01357-5.
• Jung JW, Han SJ, Nam SM, Kim TI, Kim EK, Seo KY. Meibomian gland dysfunction and tear cytokines after cataract surgery according to preoperative meibomian gland status. Clin Exp Ophthalmol. 2016 Sep;44(7):555-562. doi: 10.1111/ceo.12744. Epub 2016 May 1.
• Yu EY, Leung A, Rao S, Lam DS. Effect of laser in situ keratomileusis on tear stability. Ophthalmology. 2000 Dec;107(12):2131-5. doi: 10.1016/s0161-6420(00)00388-2.
• Hovanesian JA, Shah SS, Maloney RK. Symptoms of dry eye and recurrent erosion syndrome after refractive surgery. J Cataract Refract Surg. 2001 Apr;27(4):577-84. doi: 10.1016/s0886-3350(00)00835-x.
• Nettune GR, Pflugfelder SC. Post-LASIK tear dysfunction and dysesthesia. Ocul Surf. 2010 Jul;8(3):135-45. doi: 10.1016/s1542-0124(12)70224-0.
• Cote S, Zhang AC, Ahmadzai V, Maleken A, Li C, Oppedisano J, Nair K, Busija L, Downie LE. Intense pulsed light (IPL) therapy for the treatment of meibomian gland dysfunction. Cochrane Database Syst Rev. 2020 Mar 18;3(3):CD013559. doi: 10.1002/14651858.CD013559.
• Rong B, Tang Y, Tu P, Liu R, Qiao J, Song W, Toyos R, Yan X. Intense Pulsed Light Applied Directly on Eyelids Combined with Meibomian Gland Expression to Treat Meibomian Gland Dysfunction. Photomed Laser Surg. 2018 Jun;36(6):326-332. doi: 10.1089/pho.2017.4402. Epub 2018 Apr 24.

Study record dates

Study Major Dates

• Study Start (Actual): February 15, 2021
• Primary Completion (Anticipated): April 15, 2023
• Study Completion (Anticipated): August 15, 2023

Study Registration Dates

• First Submitted: November 4, 2021
• First Submitted That Met QC Criteria: November 17, 2021
• First Posted (Actual): December 1, 2021

Study Record Updates

• Last Update Posted (Actual): October 18, 2022
• Last Update Submitted That Met QC Criteria: October 17, 2022
• Last Verified: October 1, 2022

More Information

Terms related to this study

• Keywords: Intense pulsed light; LASIK / SMILE
• Additional Relevant MeSH Terms: Eye Diseases; Eyelid Diseases; Meibomian Gland Dysfunction; Blepharitis
• Other Study ID Numbers: IPL-2020

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No
• IPD Plan Description: Data will be anonymized by assigning a code file and only authorized personnel will have access to personally identifiable data. The highest levels of professional conduct and confidentiality will always be maintained, complying with Organic Law 3/2018, of December 5, on the Protection of Personal Data and guarantee of digital rights.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No