Dry Eye Disease Management Via Technological Methods: A Systematic Review and Network Meta-analysis

Abstract

Introduction: In recent years, various technological therapeutic modalities have emerged aiming to target the underlying pathophysiology of dry eye disease (DED).

Methods: A systematic search was conducted in PubMed, Scopus, and Embase databases up to July 29, 2023, using predefined search terms related to DED and technological treatments, including intense pulsed light (IPL), LipiFlow, TearCare, iLux, low-level light therapy (LLLT), and acupuncture. Randomized controlled trials (RCTs) evaluating technological interventions for DED with outcome measures for tear secretion, meibomian gland quality, tear break-up time (TBUT), corneal surface health, and symptom scores at 1-2 months post-treatment were included. Data extraction followed PRISMA guidelines. Risk of bias was assessed using Cochrane guidelines. A random-effects frequentist network meta-analysis model was employed, and standardized mean differences (SMDs) were calculated for comparative analyses. P-scores were used to rank treatment efficacy.

Results: Ultimately, 45 RCTs involving 3455 patients were included. TearCare combined with meibomian gland expression (MGX) demonstrated the highest efficacy for improving meibomian gland secretion (SMD - 10.08, 95% CI - 13.35 to - 6.82). IPL-based treatments, including IPL combined with diquafosol sodium or LLLT, significantly improved TBUT and symptom scores, with IPL alone ranking highest for symptom relief (P-score 0.811). Acupuncture was the only intervention significantly superior to conservative treatment for increasing Schirmer test values (SMD - 0.69, 95% CI - 1.06 to - 0.32). LipiFlow demonstrated modest improvements but was not significantly superior to other technologies.

Conclusions: These findings underscore the potential of advanced technological interventions in the short-term management of DED and support the need for standardized, long-term comparative studies.

Keywords: Dry eye disease; Intense pulsed light; Meibomian gland dysfunction.

Fig. 1

Summary of the article selection process. Out of 3727 records identified initially, 46 were ultimately included in this study according to the PRISMA guidelines. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

Fig. 2

Summary of the judgments of each risk of bias domain presented as an overall summary. Risk of bias was assessed utilizing the Cochrane Society’s guidelines and is presented with the RevMan tool. Presented is the overall risk of bias of the included studies. Individual study risk of bias can be found in Supplementary Fig. 1

Fig. 3

Tear break-up time scores. TBUT tear break-up time, HEM heated eye mask, LLLT low-level light therapy, IPL intense pulsed light, IRPL intense regulated pulsed light, MGX meibomian gland expression, MGP meibomian gland probing. a Network diagram. Every vertex represents an intervention. The width of the connecting lines is proportional to the number of direct comparisons between each two interventions (also shown in blue numbers). b Forest plot of the mean tear break-up time compared with conservative treatment. Error bars represent 95% confidence intervals (95% CI)

Fig. 4

Corneal staining scores. TES transcutaneous electrical stimulation, HEM heated eye mask, LLLT low-level light therapy, IPL intense pulsed light, IRPL intense regulated pulsed light, MGX meibomian gland expression. a Network diagram. Every vertex represents an intervention. The width of the connecting lines is proportional to the number of direct comparisons between each two interventions (also shown in blue numbers). b Forest plot of the mean corneal staining score compared with conservative treatment. Error bars represent 95% confidence intervals (95% CI)

Fig. 5

Subjective symptoms score. TES transcutaneous electrical stimulation, HEM heated eye mask, LLLT low-level light therapy, IPL intense pulsed light, IRPL intense regulated pulsed light, MGX meibomian gland expression, MGP meibomian gland probing. a Network diagram. Every vertex represents an intervention. The width of the connecting lines is proportional to the number of direct comparisons between each two interventions (also shown in blue numbers). b Forest plot of the mean symptoms score compared with conservative treatment. Error bars represent 95% confidence intervals (95% CI)

Fig. 6

Meibomian gland quality scores. HEM heated eye mask, LLLT low-level light therapy, IPL intense pulsed light, IRPL intense regulated pulsed light, MGX meibomian gland expression. a Network diagram. Every vertex represents an intervention. The width of the connecting lines is proportional to the number of direct comparisons between each two interventions (also shown in blue numbers). b Forest plot of the mean meibomian gland quality score compared with conservative treatment. Error bars represent 95% confidence intervals (95% CI)