Be Your Patient s Hero: Demodex Blepharitis
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1 Be Your Patient s Hero: Demodex Blepharitis Melanie Mason, OD, FAAO melanie.mason.od@gmail.com Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.
2 Disclosure Statement: Nothing to disclose
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5 Subepithelial infiltrates Photos: Kheirkhah et. al. Corneal Manifestations of Ocular Demodex Infestation. American Journal of Ophthalmology, 5/2007. Kheirkhah A et. al. Corneal Manifestations of Ocular Demodex Infestation
6 Photo: aao.org
7 Makeup Blepharitis Cylindrical Dandruff Trichiasis Photo: contactlensupdate.com
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10 1 2 Eyewiki.aao.org contactlensupdate.com orauf8.wix.com 3 4
11 contactlensupdate.com contactlensupdate.com reviewofoptometry.com
12 Cylindrical Dandruff is highly associated with Demodex blepharitis
13 pinterest.com
14 contactlensupdate.com
15 Ocular Rosacea (Pediatric ) By Mika Moy, OD, FAAO and Michelle Chun, OD, FAAO References: 1. Chamaillard M, Mortemousque B, Boralevi F, et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol. 2008;144(2): Vieira ACC, Höfling-Lima AL, Mannis MJ. Ocular rosacea: a review. Arq Bras Oftalmol. 2012;75(5): Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol. 2004;51(3): Geria AN, Culp B, Scheinfeld NS. Rosacea: A review. Kosmet Medizin. 2008;29(6): Wilkin J, Dahl M, Detmar M, et al. Standard grading system for rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2004;50(6): Akhyani M, Ehsani AH, Ghiasi M, Jafari AK. Comparison of efficacy of azithromycin vs. doxycycline in the treatment of rosacea: A randomized open clinical trial. Int J Dermatol. 2008;47(3): Nazir SA, Murphy S, Siatkowski RM, Chodosh J, Siatkowski RL. Ocular rosacea in childhood. Am J Ophthalmol. 2004;137(1): Kroshinsky D, Glick SA. Pediatric rosacea. Dermatol Ther. 2006;19(4): Pelle MT, Crawford GH, James WD. Rosacea: II. Therapy. J Am Acad Dermatol. 2004;51(4): Valentín S, Morales A, Sánchez JL, Rivera A. Safety and efficacy of doxycycline in the treatment of rosacea. Clin Cosmet Investig Dermatol. 2009;2: Sloan B, Scheinfeld N. The use and safety of doxycycline hyclate and other second-generation tetracyclines. Expert Opin Drug Saf. 2008;7(5): Bikowski JB. Subantimicrobial dose doxycycline for acne and rosacea. Skinmed. 2003;2(4): Voils SA, Evans ME, Lane MT, Schosser RH, Rapp RP. Use of macrolides and tetracyclines for chronic inflammatory diseases. Ann Pharmacother. 2005;39(1):86-94.
16 Subtype Erythemato-telangiectatic Papulopustular Phymatous Ocular Culp B, Scheinfeld N. Rosacea: A Review. Pharmacy and Therapeutics. 2009;34(1): Characteristics Flushing >10 mins Persistent erythema Telangiectasias Erythematous papules Pustules Facial erythema and edema Phymatous changes Thickening of skin Burning, stinging, and itching of of eyes Sensitivity to light Foreign body sensations Blepharitis Conjunctivitis
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20 A happy K.M. returned 3mos later CL Fit 2mos Doxycycline Only 2wks of lid hygiene and NPATs
21 Subepithelial infiltrates Neovascularization Restart lid hygiene, RTC 1 mo to consider CL refit Photos: Kheirkhah et. al. Corneal Manifestations of Ocular Demodex Infestation. American Journal of Ophthalmology, 5/2007. Kheirkhah A et. al. Corneal Manifestations of Ocular Demodex Infestation
22 rosacea.org
23 Anywhere on Body
24 Demodex folliculorum (Identified in 1841 by Simon) Demodex brevis (Identified in 1963 by Akbulatova) blogs.discovermagazine.com
25 D. folliculorum and D. Brevis akbuatova of Man: Redescription and Reevaluation. The journal of Parasitology. Vol 58, No 1, ~14-18 days Demodex folliculorum 5. Male 6. Female 7. Ovum 8. Larva 9. Protonymph 10. Nymph Demodex brevis 11. Male 12. Female 13. Ovum 14. Larva 15. Protonymph 16. Nymph
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28 Demodex love faces High density of pilosebaceous glands Eyelids Surrounded by prominent facial features Near mucous membrane Difficult to clean
29 psdgraphics.com
30 Recent advances on ocular Demodex infestation. Current Opinion Ophthalmology, Vol 26, No
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33 pinterest.com
34 pinterest.com
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36 Bacillus oleronius Antigenic proteins
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42 Cylindrical dandruff at eyelash root Meibomian gland dysfunction Recurrent chalazia Trichiasis/Madarosis Conjunctivitis/Keratoconjunctivitis Papillae Corneal neovascularization Corneal subepithelial infiltrates Refractory to conventional blepharitis treatment Rosacea Elevated tear cytokines
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47 Photo: Optom Vis Sci 2013;90:e198Ye205
48 Photo: Milton Hom, Katherine Mastrota, and Scott Schachter. Demodex: Clinical Cases and Diagnostic Prot Optometry and Vision Science. Vol 90, No 7,
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50 Milton Hom, Katherine Mastrota, and Scott Schachter. Demodex: Clinical Cases and Diagnostic Protocol. Optometry and Vision Science. Vol 90, No 7,
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55 Instill NaFl under coverslip if difficulty viewing
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58 Glove Up?
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61 TTO/Meds 4. Maintenance
62 None Mild Mod Severe Averages mites/follicle Corneal compromise? Document symptoms and CL tolerance
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64 2. Clean the CD! TTO/Meds 4. Maintenance
65 Before CD Removal After CD Removal
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67 Gel Cleanser or mineral oil soak x 5mins Wash with foam cleanser NPAT WC x 10mins or Lipiflow Tearscience.com
68 TTO/Meds 4. Maintenance
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70 High concentrations = Ocular surface toxicity 100% TTO readily available
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72 Pre-TTO Tx Post-TTO Tx
73 Pre-TTO Tx Post-TTO Tx
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79 Also Rosacea Tx s Topical Insecticides Crotamiton cream (Rx) Lindane lotion (Rx) Permethrin cream (OTC) Topical Antibiotic Metronidazole (Rx) Topical Antihelminthic Ivermectin cream (Rx) Oral medications Ivermectin (Rx)
80 Antihelmintic used in veterinary medicine FDA approved for humans: onchocerciasis and strongyloidiasis Used off-label for lice and Demodex, 2 doses 1 wk apart
81 MOA: binds chloride ion channels -> increases invertebrate nerve/muscle cell membrane permeability -> paralysis and death Some serious rare SEs
82 Rosacea Demodex Lice Resistant to OTC
83 treatments unresponsive to conventional Artificial tears Cyclosporine Antihistamines Doxycycline Lid hygiene Baby shampoo Steroids Smothering with ointment
84 Future Treatment Options? Radiofrequency system (heat) Successful resolution in a 95yo Low dose 0.25% PVP-I in a gel with dimethylsulfoxide (skin penetration enhancer) Compounding pharmacy BID application to eyelids x 2 wks
85 HD-OCT Confocal Microscopy Pre-TTO Tx Post-TTO Tx
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87 2. Clean the CD! 3. Kill Demodex TTO/Meds Starve them 4. Maintenance
88 Moisturizer Sunscreen Mascara Eye Shadow Eye liner Makeup removers
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93 2. Clean the CD! 3. Kill Demodex TTO/Meds Starve them 4. Maintenance
94 Kheirkhah et. al.
95 Continue to keep food supply down Continue lid hygiene bid with mild TTO cleanser Prescribe stronger TTO boot camps PRN Warm compresses Proper makeup habits
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99 Pt B.B. 32yo Cau F 1 Day CLs, occasional 2 2 poor comfort Severe keratinization and CD Asked about her skin Pt skeptical about new products Started the conversation
100 Pt B.B. 2wks Later Debridement of lid margin and CD Demodex fell out of follicles (5/follicle) Pt reported immediate comfort improvement Rx ed lid hygiene, TTO wipes bid x3wks Phone call at 1 wk mark to convince continuation of TTO
101 Pt B.B. 3wks s/p Tx Visible improvement from afar Experience with TTO improved Eyes and face much better Pt very happy! No CD or Demodex observed Pt has another tool to help her control her rosacea Refer to dermatology for possible ivermectin cream
102 Red eyes, OS>OD SEIs 4:00 OS Moderate CD, severe mites In-office CD removal and OUST tx Lid hygiene and OUST wipes bid at home x 2wks No Demodex observed at FU Resolution of SEIs/hyperemia
103 Poor comfort DT1 CLs Moderate CD and mites Oily skin Shave Beard? Rx ed lid hygiene and TTO tx bid x 3wks 3 wk FU, no improvement 2 2 compliance TTO painful 6 wk FU, no mites visible Comfortable CL wear
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105 Pt R.H. 56 yo Hispanic male Wife complains of new lash whitening (-) Medical Hx Severe CD and mites Blepharitis is a known cause Poliosis not in Demodex literature TTO bid x 3 wks, then qhs x 3 wks 6wk FU, improvement in CD No change in poliosis
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110 CD MGD Recurrent chalazia Trichiasis/Madarosis Conjunctivitis/ Keratoconjunctivitis Papillae Corneal neovascularization Corneal SEIs Refractory to conventional blepharitis treatment Rosacea Elevated tear cytokines Be Your Patient s Hero!!!
111 Bhandari et al. Blepharitis: Always Remember Demodex. Middle East African Journal of Ophthalmology Oct-Dec; 21(4): Cheng et al. Recent advances on ocular Demodex infestation. Current Opinion Ophthalmology 2015, 26: Culp B, Scheinfeld N. Rosacea: A Review. Pharmacy and Therapeutics. 2009;34(1): Elston, D. Demodex mites: Facts and Controversies. Clinics in Dermatology 2010, Sept-Oct; 28(5): Gao et. al. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea Feb;26(2): Hom et. al. Demodex. Optom Vis Sci 2013 July;90 (7): Kabatas et. al. The Effect of Demodex Infestation on Blepharitis and the Ocular Symptoms. Eye and Contact Lens Jan;43(1): Kheirkhah et al. Corneal Manifestations of Ocular Demodex Infestation. American Journal of Ophthalmology May; Li et al. Correlation between Ocular Demodex Infestation and Serum Immunoreactivity to Bacillus Proteins in Patients with Facial Rosacea. American Journal of Ophthalmology May; 117(5): Liu et al. Pathogenic role of Demodex mites in blepharitis. Current Opinion Allergy Clinical Immunology Oct: 10(5): Luo et. al. Ocular Demodicosis as a Potential Cause of Ocular Surface Inflammation. Cornea Sep 7. Maier et al. High-definition optical coherence tomography for the in vivo detection of Demodex mites. Dermatology 2012; 225(3): Ng et al. Impact of Eye Cosmetics on the Eye, Adnexa, and Ocular Surface. Eye and Contact Lens 2016;42: Ngo et. al. Short-Term Comfort Responses Associated With the Use of Eyelid Cleansing Products to Manage Demodex folliculorum. Eye and Contact Lens Sep 21. Nicholls et. al. Demodex species in human ocular disease: new clinicopathological aspects. International Ophthalmology Feb;37(1): Pelletier et al. Demodex Blepharitis Treated with a Novel Dilute Povidone-Iodine and DMSO System: A Case Report. Ophthalmology and Therapy May. Rather et al. Human Demodex Mite: The Versatile Mite of Dermatological Importance. Indian Journal of Dermatology Jan-Feb; 59(1): Rynerson et. al. DEBS - a unification theory for dry eye and blepharitis. Clinical Ophthalmology Dec 9;10: Tarkowski et. al. Do Demodex mites play a role in pterygium development? Medical Hypotheses Jan;98:6-10. Tarkowski et. al. Demodex sp. as a Potential Cause of the Abandonment of Soft Contact Lenses by Their Existing Users. Biomedical Research International Jul 2015;:
112 Please remember to complete your session evaluations on the Academy.18 meeting app Tweet about this session using the official meeting hashtag #Academy18
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