AJMC ® : In your opinion, why are there no formal guidelines for Demodex blepharitis?
MATOSSIAN: Ophthalmologists and other eye care providers have known about Demodex blepharitis for a very long time. [The condition] involves an infestation or an overpopulation of Demodex mites at the base of the lashes and at the edge from the lid margins. We all have Demodex mites around different body parts, but when there’s an overabundance of these little mites, they start to possess a negative impact on the cover margin, on the lashes themselves, and on the ocular surface. All of us haven’t had clear definitive treatment guidelines about this type of blepharitis because we haven’t experienced a truly good treatment. Of course, we’ve recognized about ways to minimize the infestation or overpopulation of the Demodex mites, such as good lid hygiene—washing the edge or even margin of the eyelids, removing mascara and other eye makeup before going to sleep, plus taking great care of the periocular region.
AJMC ® : In your experience, has the lack of guidelines impacted the diagnosis and management of Demodex blepharitis?
MATOSSIAN: Sometimes, when we don’t have got a very good therapy modality, all of us don’t even bring up the particular underlying pathology. Why mention a subject when we don’t have a treatment for it? For example , decades ago, we all didn’t bring up dry eye disease, because the only treatments available were artificial tear solutions and ointments. We all skipped over dry vision disease plus discussed some other diagnoses that the patient was given or that will we made for that patient as we performed their eye examination. Demodex blepharitis is falling into the same pattern. Until now, all of us didn’t have a good way to diagnose and treat it.
This disease is very prevalent, and it’s significantly underdiagnosed, because attention care practitioners haven’t gotten in the particular habit associated with looking with regard to it, and they didn’t have a tool or a therapy modality regarding addressing this particular epidemic illness. Now that a treatment is on the horizon, we can begin to look for Demodex blepharitis.
What are some ways to look intended for this condition? Obviously, ask the patient to get a history. Ask if their eyelid margins itch or even become red, inflamed, and a little swollen. Ask if they are always rubbing their eyelashes because they’re uncomfortable, and if there is burning plus stinging of their ocular surface.
If the patient answers “yes” to some of those questions, then a careful a slit-lamp examination is all an eyesight care provider needs to do to make the analysis. Providers should have the individual look down a little bit, and then start in order to focus the joystick and the slit lamp on the lid margin at the particular base associated with the lashes. Look pertaining to little collarettes that almost look like turtlenecks around the base from the eyelashes. The collarettes may have various widths, but, if there is circular debris, that calamari-looking ringlet at the foundation of the lash is very characteristic of Demodex infestation.
Another telltale sign is misdirected lashes. When the normal swoop up of the lash with that very gentle curve will be missing; if the lashes are sticking straight out, downward, or in different directions; if lashes are usually slightly broken; or in case there are missing eyelashes, Demodex pests may be present.
AJMC ® : In the absence of FDA-approved treatments, what constitutes the current standard administration strategy meant for Demodex blepharitis?
MATOSSIAN: After the diagnosis of Demodex blepharitis is made, the only option we have is to educate the particular patient without scaring them. Providers ought to let the patient know that Demodex infestation is extremely common—they just have an oversupply of the particular mites. This particular condition can be [managed], but this often recurs. We can control it yet not cure it forever, so in order to speak. With this information, the sufferer better understands what’s going on and what they need to perform to keep the infestation and inflammation under control.
Tea tree oil is available in the variety of products. I often prescribe lid wipes that contain different concentrations associated with it. We prescribe towelettes with the highest concentration of tea tree oil; they come in individual foil pouches. I tell the patient to take 1 side from the towelette, close their eyes, and wipe back plus forth, back and forth, at least 10 times on their lashes, after which move it onto their eyebrow. I instruct men with hairy ears also to clean the hairs in their ear. I tell my patients to flip the towelette to the clean side and do the same thing (again, with the clean side)—swipe back plus forth 10 times around the eyelid margins, lashes, eyebrows, and ear hairs, and after that discard the particular towelette. I actually tell all of them to repeat that every day for 60 days; you need a 2-month cycle to break the parasitic cycle of eggs being laid and hatched. Thereafter, the towelettes must be used the same method intermittently to keep the pests under manage. Importantly, application of green tea tree oil stings, especially when used in that focus. To reduce stinging plus burning, individuals must maintain their eye closed and count slowly to 25 or 30 prior to opening their own eyes.
An additional [management] option is in-office procedures, such as microblepharoexfoliation with a sponge using a prescription eyelid hygiene product—hypochlorous acid, tea tree oil, or a product that includes tea tree oil—while the particular sponge is usually rotating. This process debulks the Demodex mite load. It removes the particular biofilm in the base of the lashes, which the mites need as the food source. It also removes their regurgitated debris.
That in-office [procedure] often is definitely needed every 4 months, every 6 months, or actually once each year, depending on the severity from the situation. Again, that can be customized in order to the patient’s needs. On the other hand, an at-home version is available that involves use of a handheld electric eyelid plus eyelash brush with a viscous product that will doesn’t spray all more than the place. The product may or might not contain tea woods oil. Once again, removal associated with debris each day or every additional day minimizes the risk of mites building back up in quantity and causing deleterious adverse effects.
AJMC ® : How effective are these tea woods oil–based products as management options, and how well do patients respond to them?
MATOSSIAN: Tea shrub oil is the best option we have. There’s evidence that mechanical debridement done concomitantly along with application of tea forest oil decreases the number of mites within the eyelids. But teas tree fat can sting and burn, which may discourage patients from continuing its use. Patients may use it for a short period of time, or even they may not be very adherent. The over-the-counter items or the prescription products designed for wipes with a higher tea sapling oil concentration represent the only real good therapeutic option that we have had.
For me, [management] entails debulking having a mechanical in-office procedure, followed with a good at-home debulking procedure upon a daily or every-other-day basis, plus the tea shrub oil.
AJMC ® : Are there any treatments coming?
MATOSSIAN: There are some products along with excellent safety and comfort profiles within the preliminary studies. Lotilaner, which is now under investigation by Tarsus Pharmaceuticals here in the United States, hopefully will be available over the next 1 to 2 years. Instillation associated with 1 drop of this product into the eyes twice a day for the 6-week period may achieve no detection of collarettes at about 6 weeks. Of course, mites are on our bodies, and there is a chance of reinfestation. The treatment may have to be repeated semiannually in sufferers who need this. This would be the first doctor prescribed product to treat Demodex blepharitis.
In the particular area of dry eyes disease, ocular surface disease, and blepharitis treatment, therapies often are usually additive, plus they’re layered 1 on top of the various other. Very few are exclusive treatments, meaning it’s the only thing you use. I view Demodex blepharitis within a very similar fashion. Of course , when lotilaner is certainly approved by the particular FDA, it will become a definitive prescription pharmacologic agent to treat Demodex mite infestation. At the same time, performing a debulking procedure in the office in order to remove biofilm, which is the food resource for the mites, may help to provide comfort and ease to the particular patient faster and help the pharmacologic agent work best simply by opening the orifices associated with the meibomian glands. Thus, the drug can penetrate and kill any of mites living inside the meibomian glands and at the base of the particular lashes. Use of the at-home remedies, maybe including a low focus of herbal tea tree essential oil for maintenance therapy from home, may discourage the particular quick buildup of Demodex mites. Use of the at-home microblepharoexfoliation treatment with an oscillating head also can help keep the lash base and lid margins healthy to minimize the particular overgrowth of mites. When there’s an overgrowth associated with mites, and symptoms become apparent, we can always re-treat with a prescription product. I see it as adjunctive therapy that may minimize the need for in-office treatments plus that helps to keep the eyelids as healthful and the patient because comfortable since possible.
AJMC ® : What should managed care providers know about current and forthcoming treatments for Demodex blepharitis?
MATOSSIAN: Demodex blepharitis is very common. Eye care providers should start looking for it. They will be very surprised at how commonly they are going to see the collarettes and the misdirected lashes of the particular patients in their offices. Most of the time, adherence drops off when treatment must be used chronically plus multiple times a day. For example , patients with glaucoma need to use multiple products that must be instilled a few times a day, forever. The potential upcoming treatment with regard to Demodex blepharitis is not like that. It’s expected to be used twice a day time for 6 weeks. Once patients understand that there’s a light at the end of the tunnel, it’s very doable. Most patients may be adherent for the 6-week period.
Help is on the way, hopefully soon, along with the FDA approval of a product that appears to be very promising. We will have a means to deliver care and treatment for our patients to help them with the discomfort that Demodex blepharitis can cause. Whether it’s itchy eyelids, red eyelid margins, telangiectatic vessels, burning, or stinging, the signs and symptoms of Demodex blepharitis may be improved along with treatment.
Dr Matossian is the founder associated with Matossian Eye Associates within Pennington, New Jersey.
For other articles and videos in this AJMC ® Perspectives publication, please visit “ The Evolving Landscape of Demodex Blepharitis Management. ”