The Ultimate Guide to OptiPLUS with OptiLIGHT for Dry Eye

Dry eye disease (DED) is one of the most routinely encountered conditions in eye care, with an estimated 38 million people affected by the condition in the U.S., although the true number of those suffering from DED is likely even higher.¹ Dry eye disease is a multifactorial condition, with numerous contributory factors that disrupt and destabilize the tear film, ultimately leading to a loss of ocular surface homeostasis.²

Traditionally, DED has been classified into two categories: aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE). ADDE refers to cases of DED caused by a lack of aqueous tear production. In contrast, EDE is characterized by premature evaporation of the tear film primarily due to poor tear quality.³ In actuality, many cases of DED exist on a continuum with a mixture of elements of both ADDE and EDE,³ with nearly 86% having an evaporative component.⁴ This premature evaporation of the tear film typically stems from meibomian gland dysfunction (MGD).

MGD itself is a multifactorial condition that leads to underproduction of meibum or production of poor-quality meibum that fails to prevent tear film evaporation adequately.⁵ Other common ocular surface diseases can contribute to DED and MGD, such as Demodex and bacterial blepharitis, which can destabilize the tear film and obstruct and damage the meibomian glands and lid margin,^6-10 as well as ocular rosacea, which causes the development of proinflammatory telangiectatic blood vessels and also disrupts the function of the meibomian glands.¹¹ Additionally, physical changes to eyelid architecture and blinking mechanics can impede proper tear secretion, which can also impact DED.¹² Each of these conditions can contribute to DED, as can many others, which makes it a particularly complex condition to manage (Figure 1).

The loss of tear film homeostasis associated with DED can result in numerous signs and symptoms, including erythema, feelings of dryness, burning, stinging, itching, foreign body sensation, fluctuating vision, epiphora, and general irritation.³

There are numerous treatment options available for DED. These include primarily palliative OTC treatments like artificial tears and warm compresses, which largely “kick the can down the road” by allowing an eye to feel better but do not necessarily improve the ability of the tear apparatus to make a better tear, lid hygiene (lid scrubs, foams, and sprays) and dietary supplements (omega-3 fatty acids, antioxidants). Prescription therapies such as immunomodulators, neurostimulators, and tear film stabilizers, and advanced in-office procedures such as microblepharoexfoliation, ocular surface lavage, thermal treatments and expression, intense pulsed light, and radiofrequency all share the purpose of improving tear quality and/or production through various mechanisms of action.

Given the multifactorial nature of DED, most patients will require multiple treatments from several of the categories to manage their condition fully.^30,31 However, in more severe cases of DED or in cases where a patient simply wishes to reduce the number of treatments needed on a day-to-day basis, advanced treatments such as (on-label) intense pulsed light (IPL) and/or (off-label) radiofrequency (RF) can be excellent or even necessary therapeutic options to manage the disease.

OptiLIGHT is a light-based therapy that delivers intense pulsed light to target tissues in the periocular region to address DED and MGD.³² Intense pulsed light utilizes a xenon flash lamp to produce wavelengths in the range of 400 to 1200 nm.^33-35 By its very nature, the light produced is not a laser, as it is polychromatic and noncoherent.³³ The intense pulsed light produced by OptiLIGHT is absorbed by pigmented structures within the target tissue, with the resulting effects determined by the specific wavelengths of light produced and the areas treated.^33,36-39

Longer, lower energy wavelengths penetrate more deeply, whereas shorter, higher energy wavelengths of light do not penetrate as deeply and therefore deliver energy more superficially.^33,40 For this reason, the different wavelengths of light produced by OptiLIGHT will be absorbed by pigments, or chromophores, at varying tissue depths in the periocular area.^33,40 Therefore, cutoff filters are used to produce specific wavelengths that will penetrate to the desired depths and target tissues.³³ A 590 nm high pass cutoff filter is commonly used in the treatment of DED and MGD, as it produces wavelengths of 590 nm and above, corresponding to yellow, orange, red, and near-infrared light, while attenuating shorter wavelengths.^36,41-44

Once the light energy is absorbed by chromophores contained within the target tissues, it produces its therapeutic effects through several processes, including photobiomodulation (PBM). Photobiomodulation refers to the delivery of energy to tissues in the form of visible and infrared light, which stimulates intracellular biological processes through photochemical reactions that can have effects at the protein and gene levels.^{36,37,41,45,46} Ultimately PBM is thought to target cytochrome c oxidase (COX), which is a chromophore contained in the mitochondria of cells that absorbs the light energy produced by OptiLIGHT.^37,47,48

COX is also an enzyme that is responsible for producing adenosine triphosphate (ATP) as part of the electron transport chain (ETC).^37,47-49 When COX absorbs the light energy produced by OptiLIGHT, it causes photoexcitation of the enzyme, which increases the function of the ETC, and, ultimately, increases production of ATP.^37,47-49 ATP provides a form of cellular energy and enhances the function of intra- and extracellular exchange structures, including pumps and transporters, which results in an increase in free intracellular calcium.^37,47,48,50 It has also been proposed that, as a separate or complementary mechanism, the light energy produced by IPL may cause physical vibrations of cellular calcium channels, increasing their permeability and consequently increasing levels of free intracellular calcium.⁴⁶

Regardless of its source, calcium acts as a key signaling molecule that can stimulate cell proliferation, migration, and differentiation, in addition to cellular repair and healing.^36,51-53 Therefore, PBM is thought to stimulate tissue repair and regeneration through action on multiple cell types, including fibroblasts, keratinocytes, T cells, and macrophages.^36,54-56 There are multiple beneficial effects to activating these cells, as fibroblasts stimulate cell proliferation and collagen synthesis,⁵⁷ keratinocytes regulate epithelial wound healing,⁵⁸ T cells control immune and inflammatory responses,⁵⁹ and macrophages clear dead cells and proinflammatory debris.⁶⁰

Photobiomodulation is also thought to produce anti-inflammatory effects, including an increase in antioxidants and a decrease in stress-related genetic material that is associated with cell death.⁶¹ Local blood flow may also be increased by PBM, which aids in healing and tissue repair, either through enhanced production of nitric oxide, a potent vasodilator, via increased activity of nitrite reductase, or through the dissociation of nitric oxide from COX upon photoexcitation.⁶²

Additionally, OptiLIGHT has general anti-inflammatory effects, as it increases the production of anti-inflammatory molecules, such as IL-10, and decreases the levels of proinflammatory factors like IL-6.37,^63-65 Other factors that influence T cell production on the ocular surface include TGF-β,^66,67 TNF-α,⁶⁸ and MMPs.^69,70 TGFβ can be both pro- and anti-inflammatory and can also be modulated by OptiLIGHT.⁶⁷ The use of OptiLIGHT can decrease TGF-β levels when using low fluences and vice versa,⁶⁶ whereas TNF-α, which is involved in acute inflammation, is decreased by IPL.⁶⁸ This decrease in TNF-α has the downstream benefit of decreasing MMP levels, as TNF-α is involved in MMP production.^68,71 Additionally, MMP production is reduced by IPL at the mRNA level as well.⁶⁹

OptiLIGHT also appears to influence the levels of reactive oxygen species (ROS), or free radicals, present in the tear film following an Arndt-Schultz curve.^72,73 According to this model, ROS increases when low energy levels of IPL energy are utilized, whereas higher energy levels have antioxidative effects.³⁷ A decrease in ROS would be beneficial as free radicals can create damage through oxidative stress,⁷⁴ whereas an increase may also be beneficial in terms of ocular surface disease, as the increase in free radicals may potentially have antimicrobial effects that could reduce the bacterial burden on the lids and lashes.³⁷

In terms of clinical application, the effects of OptiLIGHT confer several potential benefits for dry eye patients as it has been shown to address DED by improving meibomian gland structure and function,^32,37,75-79 destroying proinflammatory telangiectatic vessels associated with ocular rosacea,^36,38,63,80 decreasing inflammation,^{37,63-66, 68,69,81-83} and reducing the microbial burden on the lids.^37,36,84,85

Although IPL has been shown to improve meibomian gland structure, function, and meibum quality,^32,75-79,86 the mechanisms by which these improvements occur may differ. The light energy produced by OptiLIGHT is thought to liquify stagnant meibum, thereby improving meibum quality and clearing obstruction from the glands.^75-77,86 However, it is controversial as to whether this process is due to “true” thermal melting of the oil or through a photochemical process, as the heat produced by the light rapidly dissipates and consequently may not be sustained for an adequate duration to result in melting of the meibum.^37,87-90 Additionally, MGD may improve due to the effects of PBM, as enhanced cellular activity can potentially increase meibocyte proliferation. Meibocytes are cells that are produced by the meibomian glands that ultimately break down and form meibum,^91-93 so by increasing meibocyte proliferation, meibum production may be enhanced as well.

Another major benefit of OptiLIGHT is its impact on the proinflammatory telangiectatic vessels that are associated with ocular rosacea. Hemoglobin found in red blood cells is a chromophore and selectively absorbs light energy produced by OptiLIGHT, which results in rapid heating that causes the blood to coagulate and the vessel to involute.^36,80 Destroying these abnormal vessels reduces inflammation as they can secrete proinflammatory factors.^38,80,87 The destruction of the vessels may also improve cosmetic appearance by reducing associated erythema.³⁸

An overpopulation of the microbes of our skin’s natural microbiome, especially staphylococcal bacterial species and Demodex mites, is a common cause of blepharitis and can act as a contributory factor to DED and MGD.^{6-8,10,94-100} Waste products and digestive enzymes produced by these microbes can destabilize the tear film and cause chronic inflammation.^8,9,95-97 Demodex mites also harbor bacteria on and inside their bodies, which can contribute to an overabundance of bacteria.^101-104 OptiLIGHT can help address these issues as light energy is absorbed by chromophores in the chitinous exoskeleton of Demodex, causing rapid heating and coagulative necrosis of the mites, thereby reducing the microbial burden around the ocular surface.⁸⁴

Lumenis’ IPL technology demonstrated its safety and efficacy in the improvement of signs of dry eye due to MGD in a multicenter, double-blinded, randomized controlled clinical trial.³² There are numerous other studies demonstrating the benefits of Lumenis IPL with Optimal Pulse Technology (OPT) as well, including a clinical study by Dell et al that showed improvement in meibomian gland function and meibum quality after IPL treatment in addition to a significant impact on tear breakup time, with TBUT nearly doubling after a full series of treatments.⁸⁶ The use of Lumenis’ light technology has also been shown to decrease inflammation,^63,77 improve meibomian gland structure,^77,105 destroy pro-inflammatory telangiectatic blood vessels,^38,80 and decrease the microbial load in the periocular area, including Demodex mites.⁸⁵

Although there are other IPL devices that are FDA-cleared, Lumenis’ IPL technology is currently the only IPL treatment FDA-approved for MGD and dry eye.⁷⁹ This means that Lumenis’ IPL technology has specifically demonstrated safety and efficacy for the management of MGD and dry eye, which is backed by clinical studies. Conversely, FDA-cleared devices have shown their technology to be “substantially equivalent” or similar to another device without having to demonstrate their safety and efficacy in clinical studies directly.^106,107 Practically, this means using OptiLIGHT to treat dry eye and MGD is an on-label indication, whereas the use of an FDA-cleared device to treat these conditions is technically off-label if that device does not carry the specific indication for the treatment of dry eye and MGD.¹⁰⁸ Additionally, FDA approval can potentially confer medicolegal benefits as the device is being used for its intended purpose. Therefore, Lumenis’ light technology’s FDA approval provides users with confidence when managing dry eye and MGD, as the technology they are using is backed by clinical data and supported by a specific indication for use in these conditions.

OptiLIGHT has several key features that make it an ideal choice when using IPL for the management of MGD and dry eye disease. It utilizes SapphireCool technology in which a sapphire crystal lightguide is actively cooled, which allows for safe, comfortable treatment. In addition to the standard rectangular lightguide, OptiLIGHT also includes the OPT handpiece that consists of a smaller cylindrical lightguide and Opti-Tip disposable tip that are ideal for treating delicate or hard-to-reach places. Additionally, the delivery of light energy itself is unique with OptiLight as it employs Optimal Pulse Technology (OPT) that uses a triple-pulse pattern to emit three pulsed flashes of light of a duration of 4-20 ms per pulse with a 5-150 ms relaxation time between pulses with each “shot,” allowing for optimal, consistent delivery of energy that avoids spiking between shots. OptiLIGHT also has built-in settings based on validated data from hundreds of patients to ensure safe and effective treatment. This is in significant contradistinction from common “broadband” IPL devices, which deliver a wide spectrum of light in pulses that, according to some analogies, can make a filtered Lumenis OptiLIGHT akin to a “sniper rifle” specifically targeting the wavelengths found to be at the heart of dry eye disease, as compared to the “hand grenade” of the broadband devices which spew a wide spectrum of light onto the surface, attempting to bludgeon all targets in a single “dose” of light. The selective photo-thermolysis approach utilized by Lumenis OptiLIGHT when treating the delicate skin and dry eye-related targets of the periocular surfaces is possibly what makes it the only FDA-approved system.

As IPL can be beneficial for numerous ocular surface conditions, including dry eye, MGD, ocular rosacea, and microbial blepharitis, there are accordingly numerous patients who can potentially benefit from treatment with OptiLIGHT. Deciding which patients are good candidates for treatment begins with assessing their Fitzpatrick skin type.^35,109 The Fitzpatrick skin type assessment uses a scale from I-VI, with I corresponding to a very fair complexion and VI indicating a dark complexion.^110-112 The reason skin typing is critical to candidate selection for IPL treatment goes back to its core mechanism of action. The light energy delivered by IPL is absorbed by pigment; therefore, those with fairer complexions will have less pigmentation and absorb less energy, whereas individuals with darker skin have more pigmentation that absorbs more energy.^35,109 For this reason, OptiLIGHT treatment is only recommended for Fitzpatrick types I-IV, as types V and VI are at greater risk for adverse events, such as burns or pigmentation changes, due to greater energy absorption.^36,35,113

Accordingly, the OptiLIGHT treatment process begins with determining a patient’s Fitzpatrick skin type. Once this has been established, you simply enter this value into the OptiLIGHT interface and it will provide the recommended fluence for treatment, which corresponds to the amount of energy delivered per unit area. Determining the appropriate fluence is vital, as most adverse reactions that occur with IPL treatment are related to using fluence values that are too high.¹⁰⁹ It is also crucial to note that Fitzpatrick skin type and fluence have an inverse relationship. When a patient has a lower Fitzpatrick skin type, such as type I, they will require a higher fluence than someone with a Fitzpatrick skin type of IV. This is because lower Fitzpatrick skin types have less pigmentation and therefore will have a lesser ability to absorb light energy compared to a higher Fitzpatrick type that represents a greater amount of pigmentation that will more readily absorb light energy. Therefore, lower Fitzpatrick skin types need higher fluence values to get adequate energy absorption compared to higher Fitzpatrick types that more easily absorb energy at lower fluences. For this reason, if a patient is on the borderline between Fitzpatrick skin types, it is recommended to go with the higher Fitzpatrick skin type and reduce the fluence accordingly. Additionally, if there is ever a question as to how a patient may react to IPL, it is recommended to perform a “test shot” prior to full treatment. This involves applying one to two shots, typically to an inconspicuous location on the neck or arm, and then waiting one week to assess tolerability and verify there are no adverse reactions.

Once a patient’s Fitzpatrick skin type has been assessed and the corresponding fluence determined, they are ready to be prepped for treatment. This involves covering the eyes with adhesive eye patches with goggles or protective OPT Shields. Those performing the treatment should wear protective eyewear as well. After the shields have been applied, clear, fragrance-free ultrasound gel is applied from tragus to tragus over the nose, as this region will serve as the treatment area.^32,36,35 It is important to ensure the ultrasound gel is clear, as any dyes or pigments could potentially interfere with light reaching the target tissue, as the coupling gel improves comfort and energy delivery. Shots are then applied from tragus to tragus over the nose with an overlap of no greater than 1 mm between applications. This is repeated twice for a total of two passes. The gel and ocular protection are then removed.

Aftercare is also crucial as patients will be more sun-sensitive after treatment. Therefore, patients should be advised to wear sunscreen and avoid excessive sun exposure for two weeks following treatment, especially in the initial 48 hours after the procedure.^114-116 Additionally, abrasive facial scrubs and the use of retinol-containing products should be avoided; however, the use of a gentle moisturizer can be beneficial.^36,117,118 Treatments are typically well-tolerated, though some patients may experience redness and irritation that is usually mild and transient.³⁵

This process is repeated for four total sessions, typically spaced two weeks apart, followed by maintenance treatments that are usually performed every 6-12 months or as needed.^36,38 Follow-up evaluation is recommended four to six weeks after completion of the fourth treatment.

Other considerations include the presence of melasma, which can potentially darken with IPL treatment; however, IPL has also been used to treat melasma, so the use of IPL with this condition is controversial.^120,121 This is also true of the erythematous malar rash associated with SLE, which can potentially be exacerbated by IPL use, although it too has been utilized as a treatment for this condition.^122,123 Accordingly, if these conditions are present, they should be approached with caution and all risks, benefits, and alternatives discussed with the patient. Therefore, there is a degree of clinical judgment to be exercised when performing IPL treatment.

Additionally, the use of concurrent oral doxycycline is also somewhat controversial. One potential side effect of doxycycline use is increased photosensitivity. However, it is thought that the photosensitive reactions that are associated with doxycycline are related to exposure to UV-light, which is not part of the light spectrum emitted during IPL treatment.¹²⁴ In fact, it has been shown that patients who underwent IPL treatment while concurrently using doxycycline did not experience any adverse photosensitivity-related effects.¹²⁴

In patients with a history of cold sores or herpetic infection but without active lesions, it can be beneficial to prescribe oral antivirals prophylactically prior to treatment to avoid potential reactivation.³³

Like any procedure, education is key when discussing OptiLIGHT treatment with patients. Reviewing a patient’s individual ocular surface conditions, such as dry eye, MGD, or ocular rosacea, and then explaining how treatment with OptiLIGHT specifically benefits these areas can be an effective way to both provide education and encourage patients to embrace treatment.

Having a patient education script can facilitate discussions about OptiLIGHT treatment, and Dr. Lappin shares his.

Setting expectations is also key to successful treatment with OptiLIGHT. It’s important to always tell patients from the start that four treatment sessions are considered a standard treatment series, and therefore, they need to perform at least four treatments to serve as a foundation. Explain to patients that since the procedure is based on energy delivery, it can take time to take effect and that, from experience, many patients will not be able to feel much of a difference until the third or fourth treatment. This education is crucial, as patients may otherwise begin to worry that their treatment is ineffective if they do not immediately notice a difference, especially if they still cannot notice a change after the second treatment. So, by setting this expectation, it helps provide patients with a better understanding of their treatment timeline. In addition to this, implement objective dry eye testing such as meibography, tear meniscus height analysis, TBUT, and lipid layer interferometry, and perform these tests before and after treatment. In many cases, improvements in symptoms can lag behind improvement in signs, so it can be incredibly beneficial to show patients that they have experienced improvement in their objective testing even if they have not yet noticed improvement in their symptoms.

Additionally, explain that they will eventually need repeat treatment for maintenance after their initial series; however, let them know that it will be tailored to meet their individual needs. This helps prevent any confusion, as some patients may otherwise assume that their initial treatment series will be all that is required. This understanding also helps patients track their condition. Advise them that an increase in symptoms after completing treatment, even if nothing else in their treatment plan has changed, can be a sign that they may be in need of a maintenance session.

Radiofrequency (RF) can improve MGD by delivering heat to the meibomian glands via radio waves,^125,126 especially when used in conjunction with IPL, as demonstrated by pairing the use of OptiLIGHT IPL and OptiPLUS RF technologies.¹²⁷ A benefit of using RF is that heat can be delivered to specific tissue depths by altering the frequency of the generated radio waves.^128,129 Additionally, RF stimulates collagen synthesis, which can increase lid tone and potentially improve blinking mechanics, which in turn can enhance meibum secretion and tear spreading over the ocular surface.^127,128,130

RF functions through the production of a rapidly alternating electrical current that flows through the target tissue. Water molecules contained within the tissue are polar, as they have both positively charged and negatively charged regions. When the electrical current alternates, it causes the water molecules to rapidly change position, which results in friction that generates the heat delivered by RF treatments.^125,127,131

Monopolar RF delivers a “cloud” of vibrational energy deep into the tissue, with the energy grounding occurring at a distant “neutral plate,” typically placed on bare skin between the shoulder blades. This configuration allows for a deeper and more beneficial energy flow into the skin. In contrast, bipolar RF sends a focused “arc” of vibrational energy directly into the skin, with the tip of this arc generally defined as half the distance between the electrodes in the handpiece tip. A grounding plate is unnecessary in this case, as the energy flow occurs solely between the two surface electrodes.¹³²

Both monopolar and bipolar RF techniques are influenced by various factors affecting the depth, area, and amount of heat generated. In monopolar RF, the type of electrode that contacts the skin is crucial to consider. In bipolar RF, the distance between the two surface electrodes in contact with the skin plays a critical role.¹³² Monopolar RF is particularly advantageous because it ensures optimized contact around the eyes, enhancing patient comfort and safety.¹³³

For both monopolar and bipolar frequencies, heat is produced by the vibration of water molecules within the tissue. This process is regulated by:¹³²

Importantly, the frequency of the RF determines the depth of penetration, with lower frequencies allowing for deeper penetration than higher frequencies. Therefore, in areas where the skin is thicker or where the target is located deeper, the ability to easily adjust the frequency for the desired outcome is essential for optimal results.¹³²

Clinical studies have shown that the results of OptiLIGHT treatments are enhanced by the addition of OptiPLUS. The combination of dual-frequency RF and OPT technology significantly improves the expressibility of meibomian glands, the clarity of meibum, and the associated symptoms.¹²⁷

Some unique features and functions of OptiPLUS include its use of dual-frequency technology, user-friendly design, and its ability to cater to diverse skin types, regardless of Fitzpatrick skin type. Its monopolar nature allows for deeper penetration and treatment.

Dual-frequency RF technology allows for precise heat delivery across different skin tissue layers. It effectively targets both the meibomian glands in the deeper tarsal plate and the superficial skin to enhance collagen production.^127,128 Clinical trials indicate that this treatment is safe and effective in reducing the signs and symptoms of dry eye disease.^134,135

Applications in optometric and ophthalmic practice include maximizing the results of OptiPLUS treatments and promoting aesthetic advancement, as well as enhancing collagen synthesis for facial skin rejuvenation.

When a clinical exam has demonstrated that there is some degree of MGD responsible for a patient’s dry eye disease, which is the vast majority, OptiPLUS will commonly provide some measure of relief. Not all MGD is caused by physical gland obstructions by waxy, toothpaste-like meibum or scar tissue, as has been demonstrated using confocal imaging that shows intra- and peri-ductal fibrosis.^136-138 Some cases are primarily inflammatory in nature, as is the case in more classic rosacea-related disease, where gland expression produces thin, easily expressed oils that are sometimes turbid or mixed with foamy residues (in which one can use the analogy of meibum being like kerosene when extra virgin olive oil would be preferred). It is therefore important to keep in mind that heated expression alone is not always capable of fully correcting all cases of MGD. That said, it appears that waxy plugs are common to many cases of obstructive MGD and that effective melting and expression of these clogs is capable of restoring the function of these glands.¹³⁹ Additionally, clinical observation has shown that simply turning over the older “less healthy” oils in the course of a treatment appears to benefit the production of newer, fresher, better oils. Heat can dilate orifices, make oils flow more easily, and help achieve the goal of efficiently turning oils over more completely, regardless of the cause of the MGD (barring total gland atrophy).

The OptiPLUS protocol for dry eye involves a six-minute treatment for each eye, which is divided into two, three-minute segments. Before starting treatment, a grounding pad is placed on the bare skin of the patient’s back, typically between the shoulder blades. A conducting cream is then applied to the skin beneath the eye. The electrode is then moved in a C-shaped pattern below the lower eyelid. OptiPLUS uses dual-frequency technology, so during the first segment, a lower energy frequency (1 MHz) is utilized, which targets the meibomian glands, while the second segment uses a higher frequency (4 MHz) that is more superficially acting, which delivers heat to the skin of the eyelids and periorbital region.¹⁴⁰ The use of different frequencies allows for heat delivery to specific depths and targets, which is the key to RF’s particular efficacy, as the thermal energy produced can be delivered much more directly and efficiently. This targeted heat delivery facilitates exceptional post-treatment gland expression quality.

During treatment, no local, oral, or systemic anesthetics should be used as the patient needs to be able to provide real-time feedback on their comfort level (which can help avoid over-treatment that can result in adverse outcomes such as burns). The patient should also be insulated from metal objects, especially those with which they may be in direct contact with (such as portions of the treatment chair). Skin temperature should be kept to 38-42° C, as this temperature range promotes collagen production.^141,142 However, temperatures of 43° C and above should be avoided in the periocular region as this can result in fat lysis.¹⁴³ During treatment with OptiPLUS, skin temperature is actively monitored to allow for safe and effective treatment, and heat delivery can be modified by altering the power as well as how quickly the electrode is moved over the treatment area (faster motion can result in lowering of skin temperature as the quicker contact time allows heat to dissipate).

Potential side effects should be discussed, which can include:

It’s best to talk with patients about how OptiPlus can help reduce inflammation, clear blocked meibomian glands, and enhance tear production. Although this can be difficult, Dr. Jacooma shares the patient education script he uses.

Due to their mechanisms of action, performing OptiLIGHT and OptiPLUS together has a synergistic effect. A study by Chelnis et al. showed that when OptiLIGHT and OptiPLUS were performed together, there was a significant increase in the number of expressible meibomian glands as well as improvements in meibum quality and patient symptoms.¹²⁷

Although OptiLIGHT and OptiPLUS are focused on treating the signs and symptoms of dry eye, they also provide intrinsic cosmetic benefits. Adding such ocular aesthetics into clinical practice can provide practice differentiation, growth, and revenue opportunities. By addressing the cosmetic concerns associated with dry eye and ocular surface disease, you are effectively treating the whole patient, which optimizes the patient experience by improving self-esteem and addressing the patient’s mental state, which can be impacted by self-image.

The cosmetic impact of ocular surface disease on the eyes and periocular region is often a major source of concern for ocular surface disease patients, sometimes being even more important to the patient than irritation or discomfort. This is not surprising considering the critical role the eyes play in social interactions, including eye contact and nonverbal communication.¹⁴⁴ Additionally, the eyes are considered the most attractive facial feature by both men and women.¹⁴⁵ Therefore, ocular and periocular cosmetic concerns can have a major psychological impact on patients’ well-being and quality of life.¹⁴⁶ Although “aesthetic” treatments are often placed in a separate category from treatments for “health,” the two are often intertwined, especially when it comes to ocular health. In fact, features that are considered “traditionally attractive” are often associated with health and vitality and accordingly referred to as “healthy” looking.^147-151

We see this relationship particularly well when treating the ocular surface with OptiLIGHT and OptiPLUS. Firm lid tone is not only considered healthy and attractive, but there is a functional component to this as well. The eyelids and blinking mechanics are intrinsically tied to meibum and overall tear secretion, as well as the proper spreading of tears over the ocular surface.^{12,93,152-155} As skin naturally loses its rigidity and elasticity with age, this can lead to inadequate lid closure and poor lid apposition against the globe, which can interfere with proper blinking and tear secretion,^156,157 in addition to the “tired” or “droopy” appearance that is a common complaint amongst patients. However, OptiLIGHT and OptiPLUS can both enhance fibroblast activity and collagen synthesis to help restore rigidity and elasticity to the lid skin, which in turn not only improves the cosmetic appearance of the eyes but may also indirectly improve MGD via improved blinking mechanics and lid tone.^{37,54,57,69,127,128,130,158,159}

A major concern many eyecare providers have when implementing technologies like OptiLIGHT and OptiPLUS into their practices is how to approach the discussion of cost with patients, as these treatments are not covered by insurance. While there are many different ways to approach this subject, Dr. Lappin has personally found the simplest and most effective way is to have an upfront and honest conversation, keeping the focus on the patient’s condition, and empowering the patient to take ownership of the decision. This begins with proper education surrounding how OptiLIGHT and OptiPLUS will address and benefit a patient’s specific issues. After the patient has a firm understanding of how OptiLIGHT and OptiPLUS work, it is easier to have an informed discussion around cost-benefit analysis.

It’s important to explain that these treatments are not covered by insurance, and that this is typical for most dry eye-related in-office therapies. As doctors, it should never be our job to “sell” our patients on a treatment or to pressure them into a decision. In fact, Dr. Lappin routinely tells patients he does not want them to do a procedure unless they are 100% on board. It is simply our responsibility to educate them on their condition, the treatment options available, and answer any questions they may have to help them make the decision that is right for them. By using this straightforward approach, there is greater patient acceptance as it empowers the patient to make an informed choice about their treatment by providing all the necessary information.

It is also a good practice to educate all staff members on the basics of OptiLIGHT and OptiPLUS treatment. This allows them to answer any questions that may arise, especially when you may not be available to answer them, while also building patient confidence in the treatments by ensuring there is a consistent message within your practice.

Determining the logistics surrounding a new treatment is often just as important as the procedure itself, and this remains true for OptiLIGHT and OptiPLUS. Both procedures can be performed by a doctor or by an appropriately trained staff member. OptiLIGHT is a relatively short procedure, typically taking around 15 minutes, often with 5-10 minutes of that being hands-on treatment time, whereas OptiPLUS takes about 20 minutes between setup time and the 6-minute per eye treatment. In Dr. Lappin’s office, we perform OptiLIGHT and OptiPLUS at the same visit, back-to-back, starting with OptiLIGHT and then finishing with OptiPLUS. Although both procedures can easily be performed the same day as a dry eye evaluation, we have found a “procedure day” works best for office flow by scheduling all OptiLIGHT and OptiPLUS procedures on the same day, back-to-back as this allows for a consistent flow and maximizes the number of treatments that can be performed without disrupting the established schedule. Also, we found it is important to answer as many questions as possible before the day of treatment, as the most common source of disruption to the flow of a procedure day is extensive patient questions or concerns that would have been better addressed beforehand.

OptiLIGHT and OptiPLUS offer powerful treatment options for our dry eye patients. Pairing the unique OPT IPL of OptiLIGHT and the dual-frequency RF technology of OptiPLUS allows doctors to effectively manage the multifactorial nature of dry eye disease by addressing several of the contributing factors to DED, while also providing a side-benefit of improving cosmetic appearance. This empowers doctors to treat the “whole” patient while also building and growing their practices.