Light Therapy Frequently Asked Questions
Let’s go back to the key cause of all these ocular diseases that we talk about: Inflammation, inflammation, inflammation. Where is this inflammation? This inflammation is in all the cells that are periorbital around your eye. We have good, solid clinical data that IPL and low-level light therapy, and particularly the two done in concert, generate an improved physiological benefit to the patient.
If you are going right after the inflammation that causes these diseases, you can mitigate that problem that the patient has, for a significant period of time.
One of my favorite things to do is put the mask on a doctor at a show, and after 15 minutes, they tell me, “Wow! This feels really great!”
The core cause of these things that we’re treating is inflammation. It’s inflammation, inflammation, inflammation. I want everybody to kind of understand that IPL works. So, otherwise we wouldn’t have it in the Epi-C Plus technology. But IPL by itself is like an antagonist. It’s really only on the surface. It’s about two millimeters deep. It’s hot, but it’s only hot for a tenth of a second. And so the point is we’re treating surface inflammation.
It’s shown that IPL alone is about two times compared to traditional methods, right? LLLT is two and a half times the efficacy of these traditional methods, but when you combine IPL with LLLT, you get about four times the efficacy. So it really doubles down the therapeutic benefits.
In the early days of doing IPL, when it was first being discussed in Dr. Toyos’s office, with the smaller crystals or smaller applique, you could get into the upper lids. The problem with this is multifold. Number one, IPL crystal is an epilator. And so, IPL crystal placed too close to the hair follicles on the upper lid margin can have the eyebrows fall out.
And another way I like to explain it is when you look at this vascularity or these broken capillaries or spider veins, as we commonly refer to it, think of it as a root system in a tree, right? If you eliminate that root system or take it away, then the canopy also suffers. And a lot of time with ocular rosacea, that’s a network of capillaries that start from beneath on the cheeks. So when you eliminate that root system and the rest of the canopy will die out as well. It’s a good way I like to explain it.
The shape and safety of the Epi-C Plus and Equinox are able to address the full periorbital area.
IPL is great for people on the Fitzpatrick scale of one to four, right? So the really dark pigmented, lots of melanin skin types, you want to stay away from so it does see color. You also want to stay away from face tattoos, dark face tattoos, any sort of metal piercings in the nose or the lip. There are some counter indications where we want to stay away from IPL.
All of these do not apply for LLLT, which is applicable to a broader patient base.
The unit is a larger size, right? You can order something off Amazon and it comes with a little three-volt lithium ion battery. But the real efficacy behind our unit is within the capacitors, right? We’re plugged into a wall and we’re charging up the energy that we deliver to the epidermal area. And then we also have software driven computer chips, right? So we’re getting just the right pulse to the face.
But the point when you’re talking about low-level light therapy delivered to the inflammatory spot is there are two terms that you need to be real comfortable with and understand. One is called stroke, which would be the distance at which you have to put the energy. The second thing is called fluence, and this is the amount of energy at that spot, so it’s the size of the area and the amount of energy that’s applied at that point for how long. So you have to control the distance, you have to control the area, and you have to control the power.
We have FDA-approved medical diodes controlled by microchip to control those three things, the stroke, the fluence, the area, so that we get the correct application at the correct depth for the cells that we’re trying to work on.
You’ll often notice that those lower-cost instruments don’t advertise openly what kind of energy they’re laying down on the skin surface in the brochure. Our Epi-C Plus, it puts on 100 joules per centimeter squared, so it’s very important to ask those questions, not only the field team, but the practitioners as well.
If you look at the masks from the Epi-C Plus, so the photobiomodulation mask, whether it’s an Epi-C Plus or our Equinox, which is basically low-level light therapy, when you rotate it over and you look at the mask, the therapeutic diodes are basically squares. And the area that’s around the eye, there really aren’t any diodes there.
It’s a red light. Basically, to give the patient a complete red component, but this whole area is actually shielded. So again, everything has been thought out here. The strategic placement of the LEDs, the power of the LEDs, the stroke and the fluence of the LEDs, and also the coverage of the eye.
To put it simply, the red mask addresses inflammation. And that’s going to be the key component of the efficacy in this system. And then for patients with acne or demodex mites, we’ll use the blue mask that addresses bacteria and then for drainage and swelling, we have a yellow spectrum as well.
So you’ll find that when you look at these technologies and the masks that we have, the simple way of being able to differentiate one mask from the other is a red dot on the top for inflammation, blue dot on the top for bacteriological. Red is most commonly used, so most certainly we’re going to do it for any inflammatory process in the periorbital area. The applications are very broad and the red mask is the key one to be used in practice.
But blue particularly has a bacteriostatic effect. It helps killing bacteria. The red and blue are most certainly best in pathologies which have a bacteria-induced inflammation.
So where would we use yellow in everyday practice? Patients who have blepharoplasty, so we’re going in and we’re reducing the puffy, baggy periocular skin and what not that they have.
When they have surgery, there’s a lot of fluid drainage in there, there’s a lot of edema, and yellow makes that from a drainage perspective, most of that go away in 24 to 48 hours and so we get a lot faster healing.
The only known counter-indication that I’ve experienced or that I’ve even seen in the literature on low-level light therapy or photobiomodulation is that there is a very, very small cohort of patients that are so photophobic or photosensitive that they cannot stand to have the red light mask, the LEDs on their face.
In addition, counter-indications include pregnancy, presence of cancer in the treatment area, photosensitivity to yellow and red light or history of light-induced nervous system disorders like epilepsy or migraine, and presence of non-removable metallic piercings in the treatment area.
Radiotherapy delivers heat. It’s generated by electrical currents that are applied directly to the inner layer of the skin around the eyes. And this is supposed to relieve symptoms that we have in dry eye. But the electrical currents really, what they do is they only treat about 5mm deep into the dermis. The effect that they have on the meibomian glands is the fact that because there is heat involved, we actually can, for lack of a better term, melt the mucin, make the meibomian glands actually flow better, the lipid to flow better. What you’re doing is you’re going from a solid state to a liquid state to a solid state to a liquid state.
And so what happened is heat therapy, at best case, lasts about one year. At worst case, only lasts about three months. And so, doing something like radiotherapy or any kind of heat treatment, what you’re doing is you’re treating a symptom, not a cause. You’re getting a short-term relief, not a long-term outcome, which is what we’re trying to get when we do IPL and LLLT in combination.
You can take your exam chair, a nice tilt or recline chair, about 45 degrees back and just use what you already have. A lot of practitioners like to do kind of a boutique-style room, right? So you can go all out with that. You could get a massage chair from Costco or from Amazon, and add a little bit of heat to massage calves and back. Because that 15 minutes in front of the low-level light therapy, you really want to kind of nurture your patient’s brain, when they’re sitting there. So a lot of practitioners will suggest that you bring your iPods, right, or your earphones, and listen to a podcast or a Spotify playlist or what have you, as a way to occupy your brain, your mentality while you’re in the treatment.
I found that doctors may start out with a reclined chair, but the fact that when they’re doing these therapies, it only takes about a minute or two to do an IPL, but it takes 15 minutes to do the low-level light therapy. So, from the time at which we enter the patient into the room until the time we leave them, at best case, if you’re super-efficient, you’ve got a 30-minute block.
In some cases, that’s tough for a practitioner to eliminate the ability to use that chair and stand for that 30-minute period of time. And so, a dedicated room is going to be much more utilitarian than trying to use the chair and stand.
For the IPL, you want to set expectations with the patient before the appointment. You want to make sure they’re free of makeup. It’s very important. It will reflect the light. Also make sure that they’re void of any retinoids. So that’s retinol or retinal. And so make sure they’re not using any creams like that on their skin.
And then you do want to have their contacts taken out. So make sure that their contacts are out.
One of the things is that we have a fair number of patients that love to worship the sun. Okay? Or they’re tanners. They go to tanning beds. One of the things that you want to make sure is if you find a patient like that that is a chronic tanner, that they don’t do that for a period of about 72 hours before they come into the treatment.
Also, just for IPL and not for LLLT, we recommend avoiding sun/UV exposure for 2 weeks after the treatment and consider applying sunscreen when outdoors.
Common questions on the unit when things go wrong. Most certainly, in my career, I’ve had either a number of practices, or a number of sales reps representing the product, plug in the unit, turn it on, and nothing comes on the screen. Well, on the top of the unit, there’s a nice big red button. The red button is an emergency switch. If you push the red button down, this locks the whole unit up so that you cannot get aberrant release of that bright flash from that xenon flash lamp. And so really it’s a simple matter of grabbing the red button, pulling it up, everything comes right back on.
In reality, there have been very minimal (less than one per year on average) cases of minor skin burns. These are likely caused by misuse, rather than the technology. For example, the masks were being placed too close to the patients’ faces, with the strap being pulled too tight, and the open-air circuit (which conducts electricity, and the electronics could have increased the temperature due to usage) ended up burning the skin. This is due to mishandling of the device.
The second thing that crops up every once in a while, it’s fairly rare, but you turn on the unit, and it goes through Windows CE, and it goes through the Espansione software, and it comes up to the page where you have to put in the password. Everybody knows now the password is 12345. But you go to the keypad and you try to enter 12345. And the keypad does not work at all.
What you do is you turn the unit off. Put your finger on the screen, or thumb, doesn’t make any difference. Put your finger on the screen to hold it. Turn the unit back on. And wait for it to go completely through Windows. Wait for it to go through the Espansione software and what will show up on the screen is a touch screen calibration screen.
And you’re going to have a little black X in each corner. And all you need to do is take your stylus, the back of your pen, whatever. Touch each one of the four crosses and the screen will recalibrate. It’ll take your password. Everything works fine.
Wherever you are at this point, if you looked up or looked out, you’re going to see a light. That light could be an incandescent light, that light could be a fluorescent light, it could be a halogen light, it could be an LED light. But if you take that light and you turn it on and you turn it off and turn it on and turn it off, eventually even if it’s a diode, it’s going to fail.
Our commitment from Essilor Instruments through our dealer partners and from Espansione in Italy, which is the manufacturer, is that when you turn this instrument on, the stroke, the fluence, the area of treatment, the amount of joules that are expressed in that area, the depth at which you’re going, all of these are medically controlled. You are guaranteed to have the exact same medical response every time you do that treatment.
Let’s say you had a 500-treatment photobiomodulation mask and it failed at 498, the commitment from Espansione and Essilor to you is they will replace that with a brand-new 500-shot mask or a 500-shot IPL crystal.
If you break that down by what it costs to replace that cartridge or replace that photobiomodulation mask, you get the cost of doing an IPL and the cost to do a low-level light therapy on a patient.
When you take a look at what it costs you to replace that crystal and the number of years that it’s going to actually last, then you divided into the number of therapies that you do, you get a comparable cost per session. So does it make any difference whether you buy that in a limited number with guaranteed success or you have to replace the crystal later, I think it is immaterial. The cost is exactly the same.
As ophthalmic instrument consultants, the answer to this is that at this moment, this is a cash procedure. There is no CPT code for IPL or intense pulse light delivery or photobiomodulation.
Third-party insurance might pay for this. So if you bill this out to Aetna or United Healthcare or what not, and you give them your workup, dry eye, meibomian gland disease, rosacea, blepharitis, chalazions, they’re all diagnostic. They all have an ICD 9 code. If you can say, look, this is your patient’s diagnosis, and here’s the therapy I’m applying, you would be quite pleasantly surprised how many third-party insurance might pay for that procedure, at least initially.