Arita 2019.

Methods	Study design: randomised controlled trial Study grouping: parallel group, where both eyes from an individual participant were considered as independent samples for the statistical analysis (representing a unit of analysis issue). Exclusions after randomisation (if Yes, provide relevant details from the paper): 3 participants in the MGX (control) group subsequently withdrew from the study because of pain during the procedure. Percentage of participant follow‐up (include details for all intervention groups): MGX group: 20/23 participants (87% follow‐up); IPL‐MGX group: 22/22 participants (100% follow‐up) Study duration (of intervention): quote: "Each patient underwent a series of eight treatment sessions at 3‐week intervals. After the eight treatment sessions, each patient underwent three follow‐up examinations over the course of 11 weeks." Was a sample size calculation reported (Yes/No): yes
Participants	Baseline characteristics IPL + MGX group Number of participants (number of eyes): 22 (44) Sex (number of females/males): 13/9 Age (mean): 61.0 (SD 18.0) years MGX only group Number of participants (number of eyes): 20 (40) Sex (number of females/males): 12/8 Age (mean): 61.9 (SD 12.2) years Overall Number of participants (number of eyes): 42 (84) Sex (number of females/males): 25/17 Age (mean): not reported Inclusion criteria: aged ≥ 20 years; diagnosis of MGD according to Japanese MGD diagnostic criteria, including ocular symptoms, plugged gland orifices, vascularity of lid margins, irregularity of lid margins, and decreased meibum quality and quantity (Shimazaki grading); Fitzpatrick skin type of 1–4 according to sun sensitivity and appearance of the skin; absence of active lesions, skin cancer or specific skin pathology that would exclude treatment with IPL; refractory MGD as defined by the failure to respond over ≥ 2 years to ≥ 3 types of conventional therapy prescribed in Japan, including topical or systemic anti‐inflammatory therapy, topical or systemic antibiotic therapy, lubricant eyedrops or topical ointment, automated thermal pulsation, and intraductal probing. Exclusion criteria: none reported. Significant pretreatment baseline differences? No significant inter‐group differences at baseline. Severity of dry eye: reported as "refractory MGD;" dry eye severity not explicitly reported.
Interventions	IPL + MGX group Description: IPL + MGX. IPL administered using the M22 (Lumenis) device, adjusted to the appropriate setting (range 11–14 J/cm²). Participants received about 13 light pulses (with slightly overlapping areas of application) from the left preauricular area, across the cheeks and nose, to the right preauricular area, with the treated area reaching up to the inferior boundary of the eye shields. The procedure was then repeated in a second pass. For the MGX, eye drops containing 0.4% oxybuprocaine hydrochloride were administered to minimise pain. Duration: 8 treatment sessions at 3‐week intervals. After the 8 treatment sessions, each participant underwent 3 follow‐up examinations over the course of 11 weeks (32 weeks total). Co‐interventions: warming compresses once a day and diquafosol eyedrops (Diquas; Santen, Osaka, Japan) 6 times a day. MGX only group Description: MGX only. MGX performed on both upper and lower eyelids of each eye with an Arita Meibomian Gland Compressor (Katena) every 3 weeks. Eye drops containing 0.4% oxybuprocaine hydrochloride were administered to minimise pain. Duration: 8 treatment sessions at 3‐week intervals. After the 8 treatment sessions, each participant underwent 3 follow‐up examinations over 11 weeks (32 weeks total). Co‐interventions: warming compresses once a day and diquafosol eyedrops (Diquas; Santen, Osaka, Japan) 6 times a day.
Outcomes	(As reported in the paper) Primary and secondary outcomes: not explicitly stated Measurements included: safety: visual acuity, lens opacity, intraocular pressure and fundus examination at baseline and 32 weeks after the first treatment; effectiveness: LLT of the tear film as determined with a LipiView instrument (TearScience, Morrisville, North Carolina, US); NIBUT of the tear film and tear interferometric fringe pattern as determined with the DR‐1α tear interferometer (Kowa, Aichi, Japan); lid margin abnormalities as observed with a slit lamp microscope, BUT of the tear film as determined by fluorescein staining as well as the corneal and conjunctival staining (CFS) score; meibum grade, as determined by slit lamp microscopy; morphological changes of meibomian glands as assessed by non‐invasive meibography (meiboscore); and tear production as measured by the Schirmer test performed without anaesthetic; symptoms were also assessed with the SPEED validated questionnaire, at baseline and each follow‐up visit.
Identification	Funding sources: no specific grant from funding agencies in the public, commercial or not‐for‐profit sectors. Declarations of interest: RA holds patents on the non‐contact meibography technique described in this manuscript (Japanese patent registration no. 5281846; US patent publication no. 2011–0273550A1; European patent publication no. 2189108A1), is a consultant for Kowa Company (Aichi, Japan) and Lumenis Japan (Tokyo, Japan), and has received financial support from TearScience (Morrisville, North Carolina, US). The other authors declared no potential conflict of interest. Country: Japan Setting: Itoh Clinic Comments: Publication status: published study Journal of publication: Ocular Surface Language: English Trial registration number: UMIN000022747. Contacting study investigators: 1 review author (LED) contacted the corresponding author August 2019 to confirm that data presented in the paper represented the inclusion of data from both eyes, as independent samples, without adjustment for within‐person correlation. LED contacted the corresponding author in November 2019 to obtain further information about the random sequence generation and allocation concealment methods, which informed the risk of bias assessment. LED asked for relevant information relating to the within‐person correlation. However, the authors advised that they would not be able to provide this information or the data to facilitate its calculation. Date study conducted: May 2016 to August 2017 Corresponding author's name: Reiko Arita Institution: Itoh Clinic, Saitama, Japan Email: ritoh@za2.so‐net.ne.jp Address: Department of Ophthalmology, Itoh Clinic, 26‐11 Minami‐Nakano, Minumaku, Saitama, Saitama, 337‐0042, Japan
Notes	Adverse events: not explicitly reported.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "Refractory MGD patients were randomly assigned to receive either IPL with MGX (IPL‐MGX) or MGX alone as a control." Judgement comment: email correspondence with Dr Arita (5 November 2019) confirmed that the randomisation code was generated using a computer‐generated list.
Allocation concealment (selection bias)	Low risk	Quote: "Refractory MGD patients were randomly assigned to receive either IPL with MGX (IPL‐MGX) or MGX alone as a control." Judgement comment: email correspondence with Dr Arita (5 November 2019) confirmed that the allocation was concealed by means of a computer‐based system for participant randomisation.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Judgement comment: open label or no information on masking. We assume that in the absence of reporting, participants and personnel were not masked.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Judgement comment: open label or no information on masking. We assume that in the absence of reporting, outcome assessors were not masked.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Quote: "Ninety eyes of 45 patients were enrolled in the study. Three patients in the MGX (control) group subsequently withdrew from the study because of pain during the procedure, leaving a total of 20 patients in the MGX group and 22 patients in the IPL‐MGX group." Judgement comment: missing data < 20% (i.e. > 80% participant follow‐up) and relatively equal follow‐up in both groups and no obvious reason why loss to follow‐up should be related to outcome.
Selective reporting (reporting bias)	High risk	Judgement comment: mismatches between clinical trial registry entry for outcome measures, and how data were reported in the paper. For example, corneal and conjunctival fluorescein staining score and NIBUT are reported in the paper but not listed in the clinical trial registry. The primary outcome measure listed on the clinical trial registry (meibum grade quality) is reported in the paper, but not specified as the primary outcome measure.
Other bias	Low risk	Judgement comment: no other apparent sources of bias.