common condition with limited treatment options

1. GANESH NETRALAYA
“Caring Vision - Our Mission”
Unmet needs in the management of Demodex
blepharitis
Dr Vishwanath Ankad
Consultant ophthalmologist
Cornea and Refractive services
Ganesh netralaya Sirsi – Sagar -- Bhatkal

2. GANESH NETRALAYA
“Caring Vision - Our Mission”
INTRODUCTION
• Demodex blepharitis is a common inflammatory eye condition
oftenly under diagnosed.
• It involves all eyelid structures like eyelid skin, lashes ,eyelash
follicles, meibomian glands and also adjacent ocular surface.
• Lack of standardized diagnostic technique and absence of
universally accepted treatment regimen makes this condition
inadequately treated .

3. GANESH NETRALAYA
“Caring Vision - Our Mission”
• Demodex mites are microscopic ectoparasitic
arthropods found in human skin, especially the cheeks, nose,
eyebrows and eyelids as part of the skin’s natural microflora
• Demodicosis : overpopulation of demodex mites, upsets the
natural ecology of the lids and lashes leading to the features
of blepharitis.
• Demodex follicularum : Found on the lashes and lash follicles
– Anterior blepharitis
• Demodex brevis : Found in the sebaceous glands – Posterior
blepharitis
Demodex brevis
Demodex follicularum

4. GANESH NETRALAYA
“Caring Vision - Our Mission”
Predisposing factors
Multi-factorial disease, influenced by external and/or internal factors.
• Older age and males
• Pre-existing blepharitis and MGD
• Immunodeficiency
• Contact lens wearers
• Poor nutrition
• Chronic alchoholics / Smoking
• Sunlight exposure / Sudden change in climate
Bernstein JE. Rosacea flushing. Int J Dermatol. 1982;21(1):24. doi:10.1111/j.1365-
4362.1982.tb00483.x

5. GANESH NETRALAYA
“Caring Vision - Our Mission”
DIAGNOSIS
Clinical diagnosis:
• Recurrent and recalcitrant blepharitis, Conjunctivitis or keratitis that is unresponsive to
conventional treatments
• Recurrent ocular discomfort, itching ,redness swollen eyelids, matted and crusty lashes
Signs:
• Cylindrical dandruff
• Features of ocular Rosacea like thickened and erythmatous lid margin with telangiectasia
• Eyelash disorders like trichiasis, Distichiasis, Madarosis
• Meibomian gland dysfunction / Recurrent chalazia
• Demodex blepharoconjunctivitis / Blepharokeratitis

6. GANESH NETRALAYA
“Caring Vision - Our Mission”
Lab diagnosis:
• Coston method of eye lash sampling :
Epilation of 4 random non-adjecent lashes per lid
(Lashes with cylindrical dandruff) and examining under microscope
• The detection of Demodex eggs, larvae, and adult mites in epilated
eyelashes confirms the diagnosis
• Sodium fluorescein will enhance the microscopic visualization of mites
• In vivo confocal laser scanning microscopy (CLSM)
Coston TO. Demodex folliculorum blepharitis. Trans Am Ophthalmol Soc. 1967;65:361-392.

7. GANESH NETRALAYA
“Caring Vision - Our Mission”
Treatment
Principle :
• Management of demodicosis is not aimed at complete eradication, but rather a reduction in mite
count to restore the balance of the ocular surface ecology
• Demodex will not respond to antibacterial, antiviral, or antifungal treatment and baby shampoo
• Resistant to other broad antimicrobial agents such as 75% alcohol and 10% povidone iodine
• Patient education
Cornea. 2007 Feb;26(2):136-43.

8. GANESH NETRALAYA
“Caring Vision - Our Mission”
General meaures:
• Long term lid hygiene and frequent the face wash
• Warm compression to loosen collarette and crusts
combination of lid scrubs and removal of the eyelash collarettes with the use of a blepharitis brush or a
cotton-tipped applicator and lid foam.
Lid cleansing wipes (Terpinen-4-ol)– To wipe away debris and make the eyelid environment unsuitable for
mites to mate, lay eggs, or hatch
Patients should be instructed to use the wipes on their eyelashes, forehead, eyebrows, and cheeks as the
mites live in all of those areas
• Avoid cosmetics, greasy makeup and oil based cleansers

9. GANESH NETRALAYA
“Caring Vision - Our Mission”
TEA TREE OIL (TTO)
Natural essential oil , steam distilled from the leaf of Melaleuca alternifolia
Potential for controlling Demodex infestation with well-tolerated degrees of irritation.
TTO exhibits a clear dose-dependent ability to kill Demodex
Active ingredient : Terpinen-4-ol has acaricidal activity
Mechanism of killing action (Acaricidal) : Presumebly induced by anti-cholinesterase activity
TTO force the mites out of the lash follicles and meibomian glands and makes the lid surface unsuitable for
mites to mate, lay eggs, or hatch
Acta Ophthalmol Suppl. 1970;108:7-85.

10. GANESH NETRALAYA
“Caring Vision - Our Mission”
Availiable concentration :
2% & 5% for BID application
50% for weekly application
Duration of treatment :
Regimen : Initial treatment with TTO 2-5% in BID dosage for 6 weeks
(as this corresponds to two life cycles of the mite)
Followed by OD /once every other day as a prophylaxis
Side effects : Ocular irritation, contact dermatitis and allergic response especially with higher
concentration of TTO
Curr Opin Ophthalmol. 2015;26(4):295-300.

11. GANESH NETRALAYA
“Caring Vision - Our Mission”
Intense pulse therapy (IPL)
• More effective for Demodex ad Rosacea as well
Principle :
Delivery of high intensity polychromatic light (400-1200 nm) to the target tissue
• Chitinous exoskeletons of Demodex contain chromophores that absorb the energy delivered by the pulsed light that
leads to a rapid heating of the mite, resulting in death via coagulative necrosis.
A typical IPL treatment protocol for DB would be 4 total treatments spaced 3-4 weeks apart
Advantages :
• Reduces the number of bacteria
• Decreases inflammation via photobiomodulation
• Regression of proinflammatory telangiectatic blood vessels associated with ocular rosacea.
Photobiomodul Photomed Laser Surg. 2020 Aug;38(8):472-476.

12. GANESH NETRALAYA
“Caring Vision - Our Mission”
Microblepharoexfoliation:
Eye lid cleansing with a device to remove eyelash collarettes
The high-speed rotary sponge is soaked in eyelid cleanser
Aids in removal of biofilm on eyelid and eyelash surfaces,
while removing mite eggs at the base of the eyelash follicle.
Contact Lens Anterior Eye J Br Contact Lens Assoc. 2018;41(1):77-82.
doi:10.1016/j.clae.2017.10.012

13. GANESH NETRALAYA
“Caring Vision - Our Mission”
For associated MGD and Ocular Rosacea
• Non preservative tear suppliments
• Omega 3 Fatty acids
• Topical antibiotic ointment: Azithromycin / Bacitracin / Fusidic acid
• Oral Doxycycline- 100mg twice a day for 3-4 weeks followed by once a day for several months
Sub microbial dose of 40 mg/day for several months
• Topical steroids : Severe inflammation , Marginal keratitis
• Immunomodulators : Cyclosporine drops
Cornea. 2016 Sep;35(9):1185-91.

14. GANESH NETRALAYA
“Caring Vision - Our Mission”
Treatments under investigation
• Oral ivermectin, 200 µg/kg + oral metronidazole, 250 mg
• Topical gel containing ivermectin, 0.1% + metronidazole, 1%
• Lotilaner ophthalmic solution 0.25%
• Permithrin 5% cream
J Ophthalmol. 2021;2021:3862684. doi:10.1155/2021/3862684

15. GANESH NETRALAYA
“Caring Vision - Our Mission”
Take home message
• Though demodex infestation is a common cause of blepharitis, a dearth of disease
awareness, a lack of best diagnostic practices, and an absence of FDA-approved
treatments remain as obstacles in the management of this ophthalmic condition
• High index of suspicion , multimodal approach and good patient education helps in
treating this condition.

16. GANESH NETRALAYA
“Caring Vision - Our Mission”
THANK YOU