Dynamic Muscle Stimulation of the Periorbital Area for Improvement of Blinking in Dry Eye Patients

James G Chelnis,1,2 Alexandra Chelnis1 1Manhattan Face and Eye, New York, NY, USA; 2New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USACorrespondence: James G Chelnis, Manhattan Face and Eye, 150 W 58th St &num;1C, New York, NY, 10019, USA, Tel +1212-484-9707, Email [email protected]: To investigate whether Dynamic Muscle Stimulation technology (DMSt) in the peri-orbital area improves blinking quality in subjects with lower lid laxity and dry eye disease (DED) due to Meibomian Gland Dysfunction (MGD).Patients and Methods: Eligible subjects had lower lid laxity and DED due to MGD. Treatment consisted of DMSt administered 4 times at 1-week intervals. Outcome measures were tested before each treatment and at the follow-up (FU) 4 weeks after the final treatment. The main hypothesis was a decrease in the proportion of subjects with lower lid laxity, defined as abnormal lower lid distraction test (LLDT) or abnormal snap-back test (SBT). Outcomes related to DED comprised the modified meibomian gland score (mMGS), tear breakup time (TBUT), and symptoms of DED (OSDI). Other outcomes included the Margin to Reflex Distance 1 and 2 (MRD1 and MRD2), estimation of blink rate, blink quality, and eyelid appearance.Results: 30 subjects completed FU. LLDT decreased from 11.1 (SD 2.2) mm to 5.3 (SD 1.3) mm (P< 0.0001). The proportion of subjects with normal LLDT and SBT increased from 3% to 80% and from 30% to 93%, respectively (p< 0.0001). Lower lid laxity decreased from 100% at BL to 23% at FU (p< 0.0001). MRD2 gradually decreased from 5.5 (SD 0.9) mm at BL to 5.0 (SD 0.4) mm at FU (P< 0.001). TBUT, mMGS, and OSDI changed by +286%, − 78%, and − 53%, respectively (P< 0.0001). The proportion of subjects with normal eyelid appearance, blink quality, blink rate and eyelid closure increased from 0 to 63% (p< 0.0001), 0 to 73% (p< 0.0001), 36% to 93% (p< 0.0001) and 73% to 100% (p< 0.01), respectively. No adverse events occurred.Conclusion: In DED patients, DMSt in the peri-orbital area decreases lower lid laxity and improves blinking quality. These, in turn, may be useful for managing signs and symptoms of DED due to MGD.Plain Language Summary: Evaporative dry eye disease (DED) is one of the most common pathologies of the ocular surface. This multi-factorial disease is mostly due to poor function of meibomian glands within the eyelids (MGD). Patients with DED due to MGD suffer from discomfort, visual disturbances, and a deterioration in the quality of life. The condition is often accompanied by abnormal blinking, as a result of lid laxity and reduction of muscle mass around the eyelids. Traditionally, lid laxity can be surgically corrected, however this intervention carries some risks and recovery can be slow. A non-surgical approach would be useful for shortening the recovery time and reducing those risks. One candidate is trans-cutaneous electrical stimulation, using Dynamic Muscle Stimulation technology (DMSt) developed by Lumenis Be. This technology, adopted from aesthetics, improves skin elasticity and increases muscle tone, both of which deteriorate with age. Hence, we reasoned that in subjects with lid laxity such treatment could be helpful for restoring lid function. In turn, this would improve blinking quality and reduce signs and symptoms of ocular surface disease. In a prospective study, 30 subjects with lower lid laxity and moderate to severe DED due to MGD were treated with DMSt applied below the lower eyelids. Treatment consisted of four sessions at 1-week intervals. One month after the last treatment, the number of subjects with lower lid laxity decreased by 80%. In 8 subjects with incomplete closure of eyelids, this abnormality completely disappeared. Eyelid appearance and blinking quality improved by 60% and 70% each. The number of subjects with a normal blinking rate increased by about 60%. In addition, there were clinically significant improvements in both signs and symptoms of DED. No complications were observed. We conclude that this novel approach is safe and useful as an adjunct solution for management of evaporative DED.Keywords: dry eye disease, meibomian gland dysfunction, lower lid laxity, neuromuscular stimulation