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Scott E. Schachter, O.D.Vision Source-Pismo Beach, CA

DEMODEX BLEPHARITIS, DIAGNOSIS ANDMANAGEMENT Dear Madam, did you never gaze,

Thro' Optic-glass, on rotten Cheese?There, Madam, did you ne'er perceiveA Crowd of dwarfish Creatures live?The vain,Lords of their plelittle Things, elate with Pride,Strut to and from, from Side to Side:In tiny Pomp, and pertly asing Orb, they reign;And, fill'd with harden'd Curds and Cream,Think the whole Dairy made for them.So Men, conceited Lords of all,Walk proudly o'er this pendent Ball,Fond of their little Spot below,Nor greater Beings care to know;But think, those Worlds, which deck the Skies,Were only form'd to please their Eyes.

ON MITES by Steven Duck (1736)

Most likely on the end of the nose or in the eyelash follicles of the reader.

-T.O. Coston, M.D., 1967

WHERE IS THE NEAREST MITE?

For thirty years, under slit-lamp magnification, I studied patients with lid symptoms, unaware that mites were literally”at the root"of the trouble.

-T.O. Coston, M.D., 1967

Coston, Tullos O. "Demodex folliculorum blepharitis." Transactions of the American Ophthalmological Society 65 (1967): 361-392

READ THIS!

Swelling or inflammation of the eyelids, usually where the eyelash hair follicles are located. The most common lid margin disease.

• Demodex Infestation• Excessive oil, MGD • Excessive bacteria• Allergies • Rosacea

Increasing severity, A-H

Common Causes of Blepharitis:

BLEPHARITIS

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An Often Overlooked Link to

Blepharitis Demodex Infestation

• shorter .2-.3mm• live in oil glands• harder to find• posterior blepharitis,

chalazia, rosacea• solitary

HUMAN DEMODEX TYPESBrevis

• longer .3-4mm• live in follicle• anterior blepharitis, rosacea• live in clusters

Folliculorum

ANATOMY AND LIFE CYCLE CYLINDRICAL DANDRUFF

30 minutes time lapsed

A rare sighting

Male folliculorumsex organs

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Laying an egg

FOLLICULORUM

Adults and Nymphs

Demodex Mites1:

1. Mechanically block hair follicles2. Secrete digestive enzymes3. Destroy the epithelial barrier and penetrate into surrounding tissue4. Trigger reactions of the immune system as a foreign body and as

their waste is exposed upon death and decay5. Transport bacteria around the ocular and skin surface

Demodex Mites Linked to Lid Margin Diseases through Various Mechanisms

1Jarmuda, Stanislaw et al. Potential Role of Demodex mites and bacteria in the induction of rosacea. Journal of Medical Microbiology. 2012; 61;1504-1510.

Results in irritation, inflammation, and unhealthy dermis and epidermis

• Blepharitis• Meibomian Gland

Dysfunction• Rosacea• Chalazia• Pterygia

Demodex Mites Linked to Many Lid Margin & Ocular Surface Diseases

1Czepita, D. et al . Investigations on the occurrence as well as the role of Demodex folliculorum and Demodex brevis in the pathogenesis of blepharitis. Klin Oczna 2005;107(1-3):80-2

High Age-Dependent Prevalence of Ocular Demodex Infestation

95% in 71 to 96 year-old

87% in 51 to 70 year-old

69% in 31 to 50 year-old

34% in 19 to 25 year-old

13% in 3 to 15 year-old

Eyelashes from 435 people with ages from 2 to 96 years were examined under a light microscope. Demodex infestation was classified on the

basis of presence of mature and larval forms or after observing chitinous exuviae (cylindrical dandruff) affixed to the subjects eyelashes1

• N = 29

• Mites found in 70% of 18 yo

• Verified by DNA scrapings

Thoemmes MS, Fergus DJ, Urban J, Trautwein M, Dunn RR (2014) Ubiquity and Diversity of Human-Associated Demodex Mites. PLoS ONE9(8): e106265. https://doi.org/10.1371/journal.pone.0106265

Ubiquity and Diversity of Human-Associated Demodex Mites

100% of people over 18 years of age appear to host at least one Demodex species

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• Because the eye is surrounded by the projecting bones of the eyebrow and nose, hygiene in this area can be limited1

• Research suggests that altered fatty acid profiles produce sebum that is favorable for mite development2

• Demodex Infestations are more prone in patients whose immune status is compromised by topical or systemic administration of steroids or other immunosuppressive agents3

1Liu, Jingbo et al. Pathogenic role of Demodex mites in blepharitis. Current Opinion in Allergy and Clinical Immunology. 2012; 10: 505-510.

2Ni Raghallaigh, S., et al. The fatty acid profile of the skin surface lipid layer in papulopustular rosacea. Br Journal of Dermatology. 2012; 166; 279-287

3Kulac, M. et al. Clinical importance of Demodex folliculorum in patients receiving phototherapy. Int J Dermatology. 2008; 47:72-77

If Demodex is so common, why isn’t everyone symptomatic?

Symptoms and conditions occur when a Demodex population overgrowth or infestation occurs (demodicosis)

What causes an infestation?

Diffuse CDDiffuse CD Sporadic CDSporadic CD CleanClean

1Coston, Tullos. Demodex Folliculorum Blepharitis. Tr. Am. Ophthalmology Soc. 1967; 65:361-392. 2Gao, Ying-Ying et al. High Prevalence of Demodex in Eyelashes with Cylindrical Dandruff. IOVS. 2005; 46:3089-3094.

Cylindrical dandruff (CD) is diagnostic for Demodex mites1,2

Greasy ScalesGreasy Scales

Diagnosing Demodex

• Lash selection is important: crusty, lots of debris and mucus • Rotate or twirl the lash to better express debris and mites• Use fluorescein on the slide for better mite visibility1

• Sample two from each lid • Examine under 100x magnification

1Kheirkhah, Ahmad et al. Fluorescein Dye Improves Microscopic Evaluation and Counting of Demodex in Blepharitis With Cylindrical Dandruff. Cornea. 2007; 26: 697-700

Celestron LCD #44345

(40x – 1600x total magnification)

Diagnosing Demodex

Lash Epilation or Rotation & Microscope Examination Tips

• Trichiasis, malalignment, madarosis

• Epilation forceps• Glass slides and cover slides • LCD Digital Microscope

Supplies

Eyelash manifestation

1Scott G Hauswirth, Scott E Schachter, and Milton M HomSymptoms Associated with the Presence of Demodex folliculorum

Invest. Ophthalmol. Vis. Sci. 55: E-Abstract 1996.

Demodex Blepharitis is Frequently Associated with Conjunctival Inflammation1

Consider Demodex as a possibility when you see blepharitis with conjunctival inflammation

1Liu, Jingbo et al. Pathogenic role of Demodex mites in blepharitis. Current Opinion in Allergy and Clinical Immunology: 2012; 10: 505-510.

Demodex mites live in and feed on the oil in the sebaceous glands. Demodex Brevis in particular is most commonly found in the meibomian glands.1

Meibomian Gland Manifestation

1Coston, 1967, English, 1971, English & Nutting, 1981, Heacock,1986, Fulk & Clifford, 1990, Fulk et al, 1996, Kamoun et al. 1999, Morfin, 2003

Skin Manifestation

Demodex has been linked to rosacea, pityriasis folliculorum,perioral dermatitis, pustular folliculitis, and basal cell carcinoma1

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Statistically Significant Correlation between Demodex Infestation and Serum Immunoreactivity to Bacillus Oleronius in Rosacea Patients1

1Li, Jianjing et al, Correlation between Ocular Demodex Infestation and Serum Immunoreactivity to Bacillus Proteins in Patients with Facial Rosacea. Ophthalmology, 2010; 117:870-877.

• A prospective, masked study of 59 age-matched patients• The Demodex count was statistically significantly higher in patients

with facial rosacea (6.6 ± 9.0 vs. 1.9 ± 2.2, P=0.014).

• A statistically significant correlation between serum immunoreactivity and facial rosacea (P=0.009), lid margin inflammation (P=0.040), and ocular Demodex infestation (P=0.048), but not inferior bulbar conjunctival inflammation (P=0.573).

• A statistically significant correlation of facial rosacea with lid margin inflammation (P=0.016), but not with inferior bulbar conjunctival inflammation (P=0.728).

1Liang et al, Am. J. Ophthalmol., in press, 2013

all P<0.001

Study Reports Demodicosis is Significantly More Prevalent in Chalazia than Control1

BREVISBrevis and Folliculorum Infestation in Chalazia and Control

all P<0.001

Brevis Folliculorum Brevis Folliculorum Brevis FolliculorumEntire Pediatric Adult

1Liang et al, Am. J. Ophthalmol., in press, 2013

FOLLICULORUM

Infestation of Particular D. Brevis Is Significantly More Prevalent In Chalazia Than Control1

Total With

DemodicosisWithout

DemodicosisP

Eyes 68 34 34

M:F 43:25 27:7 16:18 0.006

Age 51.9±14.3 53.2±14.4 50.6±14.2 0.448

Range 26-80 27-77 26-80

Follow-up (M)follow-up

(M)15.7±8.7 17.3±13.9 0.568

Range 6-72 6-40 6-72

Recurrence 16 (23.5%) 14 (41.2%) 2 (5.9%) 0.001

ATD Dry Eye 25(36.8%) 16 (47.1%) 9 (26.5%) 0.078

1Huang, Yukan et al, Ocular Demodicosis as a Risk Factor of Pterygium Recurrence. Ophthalmology, 2013; 120:1341-7.

Study Reports that Ocular Demodicosis is a Risk Factor for Pterygium Recurrence1

AFTER 1 MONTH OF AT-HOME TREATMENT, 22 YO MALE

Clinical Evidence on the Role of Eye Hygiene in Managing Lid Margin Diseases

Approach Targets

Warm compress Oil glands

Baby shampoo Lid margin, lashes

Lid scrub Lid margin, lashes

Topical antibiotics Microbes

Omega-3 fatty acids Inflammation

Oral Tetracycline/Doxycycline Microbes

THE OLDE WAY(The Janitor)

NONE of these kill mites

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1Gao, Ying-Ying et al. In vitro and in vivo killing of ocular Demodex by tea tree oil. Br J Ophthalmol, 2005;89;1468-1473.

Cannot be killed by 10% Providone iodine (surgical scrub)

Cannot be killed by 75% alcohol

Cannot be killed by Macrolides such as erythromycin (antibiotic)

Cannot be killed by Metronidazole (for Rosacea treatment)

Demodex mites killed dose-dependently by Tea Tree Oil (TTO)

Study Shows that Conventional Treatment Methods Are Not Effective in Killing DEMODEX MITES1

Tea Tree Oil is the

EXTERMINATOR

Treatment with TTO

BeforeBefore

AfterAfter

1Kheirkhah, Ahmad et al, Corneal Manifestations of Ocular Demodex Infestation. AJO, 2007; 143:743-749.

Before

Example 1: Blepharitis

After 8 weeks

Before After 6 weeks

Example 2: Conjunctival inflammation

RS, 70 yo F• OD, June 2014 and September 2014.• Did Cliradex bid, OU x 1 month. Now twice per week.

OKRA-based Zocukit

-Well-tolerated, no anesthetic required-Commercially available-Low cost of goods-Takes about 8 minutes-

INNOVATION

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Intense Pulsed Light

-Likely kills demodex-Effective against rosacea-Low/no cost of goods-Takes about 5 minutes--Treats chalazion

INNOVATION PRACTICE MANAGEMENT

How to talk to patients:“You have a very common condition, affecting about 25% of my patients. It’s caused by a small mite. Most people have SOME of these mites, you have TOO MANY, and we need to reduce the population”.

If you think compliance will be an issue, show anterior segment photos, or epilate and show them the mites.

Take baseline photographs to monitor effectiveness of treatment, and to educate patients.

If mild, treat at home, TTO bid and recheck in one month. Taper.

If moderate to severe, treat in-office 3 times, one week apart. Support with bid use of TTO at home.

Demonstrate the use of TTO so patients knows what to expect.

Fan the face after applying to cool off.

TTO is better tolerated the longer it is used.

Use it as a facial wipe, eyelashes, forehead, cheeks, base of nose, and ears.

Wash all linens on high heat.

Discard makeup.

Evaluate family members.

Use an ABN for in-office treatment.

Look for improvement, not eradication.

Sometimes, you just can’t win.

PRACTICE MANAGEMENT 1.Ocular Demodex infestation is treated the same way as eyelash infestation by Pediculus humanus capitis (head lice).

2. 100% eradication of demodex infestation is the goal.

3. Tea tree oil is safe and non toxic.

4. The clinician must epilate to detect demodex in a lash/follicle

5. Demodex is only found in the eyelid.

6. One can get demodex infestation from a dog.

7. There is a procedure code to treat demodex in the office.

8. Demodex blepharitis is an isolated condition.

9. Demodex excretion/droplets produce collarettes and greasy eyelashes.

10. Demodex is only seen in elderly patients.

DEMODEX MYTHS