When Dry Eye or Blepharitis Resists Treatment, it Might be Mites
By Marguerite McDonald, MD, FACS
You can’t see them, and your patients have probably never even heard of them. But demodex mites are common – they’re present in more than 75 percent of patients over age 45,1 and nearly half of all blepharitis patients.1 And they contribute to a host of ocular conditions including meibomian gland disorder, blepharitis, and floppy eyelid syndrome. Further, there is evidence that the greater the demodex infestation, the more severe the ocular discomfort.
So, in any Dry Eye Center of Excellence, it may be a good idea to be on the lookout for demodex mites in patients complaining of itching eyelids, elderly patients, or those whose dry eye or blepharitis symptoms resist treatment.
Demodex mites are microscopic creatures that feed on the oils, hormones, and other fluids around hair follicles. They are most often found around the head and are particularly fond of living in the follicles of our eyelashes and eyebrows.
They are most common in older patients; in fact, some estimates indicate they will be present in nearly 100 percent of elderly patients.2
They may be tiny, but demodex mites are destructive. They damage tissue, causing inflammation and distention of the lash follicle, may contribute to meibomian gland granulomas and meibomian gland dysfunction,3 and can act as a vector for infection.4
To confirm demodex infestation, I combine review of a patient’s clinical history with diagnostic techniques.
Generally, demodex may be more likely if a patient’s history includes:
Blepharitis, conjunctivitis or keratitis
Blepharoconjunctivitis or recurrent chalazia in young patients whose conditions resist treatment or who experience a recurrence after treatment
Madarosis or recurrent trichiasis
If I suspect demodex infestation, I include a silt-lamp examination in the clinical evaluation. If this reveals cylindrical cuffs, sleeves or dandruff around base of eyelashes, that is an indication that demodex mites are present.
Other indications of demodex mites include:
Abnormal lash integrity or growth
Corneal and conjunctival inflammation4
Treatment of Demodex Mites
When you begin treatment for demodex mites, three goals should be uppermost in the treatment plan:
Remove mites and their offspring
Help prevent re-infestation through an eyelid hygiene regimen
I have found the Demodex Kit offered by OCuSOFTTM to be one of the more effective treatments. The kit includes:
Pesticide-free topical solution containing tea tree oil, sea buckhorn oil, and other natural oils
Liposome eyelid spray
A brush for applying the solution
The treatment itself takes about 10 to 15 minutes and can be done in the office. Start by applying a topical anesthetic and cleansing the eyebrows, eyelids and eyelashes using the pads. It’s not necessary to rinse.
Next, place a small amount of demodex solution on the included brush and gently apply to the eyebrows, edge of the lower eyelid and lower eyelashes, then upper eyelid and upper eyelashes. It may be necessary to re-wet the brush with more solution. It is important to avoid direct contact with the eye, because it may cause stinging and burning.
Wait two to five minutes, then remove the demodex solution along with softened debris from the eyebrow, eyelid and eyelashes using a fresh scrub pad. I typically repeat the application.
Finally, remove any remaining demodex solution with scrub pads; the patient may also rinse face and eye areas with water if desired.
It is important to have the patient adopt a mite-destroying cleansing regimen of eyelids, eyebrows, and eyelashes at home to prevent mites from returning.
The most effective regimen includes rubbing azithromycin solution onto lids after scrubbing and applying liposome spray to closed eyelids. However, if insurance does not cover the azithromycin solution, use EES ung QHS OU instead of bland ung.
Demodex mites are a contributing factor in MGD, blepharitis, and other eyelid irritations.
Henle FGJ: 1941 Demodex folliculorum. Zuricher Naturforscher gesellschaft
Roth AM. Demodex folliculorum in hair follicles of eyelid skin. Ann Ophthalmol 1979; 11:37-40.
English FP, Nutting WB; Demodicosis of ophthalmic concern. Am J Ophthalmol 1981; 91(3): 362-372.
English FP, Ivamoto T, Darrell RW, Devoe AG. The vector potential of Demodex folliulorum. Arch Ophthal 1970; 84: 83-5.
Marguerite McDonald, MD, FACS, with OCLI on Long Island, NY, is clinical professor of Ophthalmology at NYU Langone Medical Center, NY, and clinical professor of Ophthalmology at Tulane University Health Sciences Center, New Orleans, Louisiana.