With a recent study finding that more than 50% of U.S. patients with conditions such as dry eye disease, glaucoma, and blepharitis also had Demodex blepharitis,¹ checking the lids of patients for signs of an overpopulation is increasingly important. Untreated Demodex blepharitis can result in complications, such as lid margin inflammation, meibomian gland dysfunction, eyelash growth abnormalities, and, in more severe cases, corneal damage, according to Cecelia Koetting, OD, FAAO, DipABO, Optometric Management’s Dry Eye columnist, and Katherine Mastrota, MS, OD, EMBA, FAAO, Diplomat American Board of Optometry, director of optometry for the New York Hotel Trades Council and Hotel Association of NYC Health Center, Inc., and inventor of the Mastrota Meibomian Paddle and iLidClean.

“I think that all optometrists at least assess the upper lid margin by sweeping the slit lamp beam over once or twice,” explains Dr. Koetting. “However, I don’t think that it is yet common place for any eye care professional to really take the time to have the patient look down and truly hunt for Demodex and collarettes.”

Here, Dr. Koetting and Dr. Mastrota discuss the importance of looking for Demodex blepharitis and what to do when an overpopulation is found.

PROPER EXAMINATION TECHNIQUE

Both doctors agree that the best way to check for Demodex is to examine the eyelids while the patient is looking down. The reason: This provides a better angle of view for examination of Demodex-related changes on the eyelashes and upper lid margin.

“The view we obtain when the patient is looking straight ahead can be misleading and often lead to missed diagnosis of lid margin blepharitis and Demodex,” says Dr. Koetting. “It is easier to view debris and collarettes along the upper lid margin when we flip the perspective and have the patients gaze down.”

“Examining a patient in downgaze is helpful to detect changes/debris at the base of the upper eyelashes that can be missed in primary gaze,” says Dr. Mastrota, adding that the base of the lower lashes should also be examined.

WHEN DEMODEX ARE FOUND

If it is believed that the Demodex population is precipitating patient signs and symptoms, at-home basic lid margin hygiene should be discussed, says Dr. Mastrota. There are numerous commercially available eyelash and eyelid cleansing solutions, foams and gels, from simple micellar water to hypochlorous acid that can be complimented by mechanical debris removal for daily eyelid margin maintenance once or twice a day. Silicone brushes can be useful for loosening impacted debris, and are available in a variety of sizes, price points, and complexity depending on patients’ dexterity and needs.

“If possible, in-office debulking of the collarettes will increase patient success with at home cleaning,” adds Dr. Koetting. “At this time this typically involves blepharoexfoliation with manuka honey, okra extract and/or tea tree oil-based products.”

When discussing the diagnosis with patients, both doctors emphasize that Demodex are normal to find on humans, but in this case their number has overgrown. Dr. Koetting says she tells her patients, “just like we brush our teeth and wash our face, we have to clean the eyelids to keep things in check.”

ADDITIONAL RESOURCES

The American Academy of Ophthalmology has a patient education page on Demodex blepharitis available at bit.ly/AAOdemodex . Tarsus Pharmaceuticals has also launched a website, www.eyelidcheck.com , as part of Tarsus Pharmaceutical’s “Don’t Freak Out. Get Checked Out” awareness campaign for Demodex blepharitis. OM

REFERENCE

1. Trattler W, Karpecki P, Rapoport Y, et al. The Prevalence of Demodex Blepharitis in US Eye Care Clinic Patients as Determined by Collarettes: A Pathognomonic Sign. Clin Ophthalmol. 2022;16:1153-1164. DOI:10.2147/OPTH.S354692