COPE#37748-AS. Demodex. Scott Schachter Scott Hauswirth Katherine Mastrota Mario Gutierrez Ben Gaddie Christine Sindt Scheffer Tseng.

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Disclosures Mites that eat and live on your lids Mites that eat and live on your lids COPE#37748-AS COPE#37748-AS Last 12 months: Allergan AMO Bausch/Valeant NiCox Cooper Milton M.

com Scott Schachter Scott Hauswirth Katherine Mastrota Mario Gutierrez Ben Gaddie Christine Sindt Scheffer Tseng Mites that eat and live on your lids Prevalence Clinical sequence Treatment Tips nce

1 Disclosures Mites that eat and live on your lids Mites that eat and live on your lids COPE#37748-AS COPE#37748-AS Last 12 months: Allergan AMO Bausch/Valeant NiCox Cooper Milton M. Hom, OD, FAAO, FACAAI(Sc). Scott Schachter Scott Hauswirth Katherine Mastrota Mario Gutierrez Ben Gaddie Christine Sindt Scheffer Tseng Mites that eat and live on your lids Prevalence Clinical sequence Treatment Tips nce Prevale Ectoparasites-most common in man 100% in patients 70 years old plus Mite density rises in the sixth decade of life Level until the eighth decade of life. ex Demod mite infestation 84% 60 years old 100% 70+ years old Stephenson M. Blepharitis diagnosis: don t forget demodex. Review Ophthalmology Sept , e sequenc l a c i n i l C 1. Clinical history: blepharitis, dry eyes or ocular allergy 2. Slit-lamp examination: cylindrical dandruff 3.Microscopic confirmation: counting of eggs, lavae and adults. Hom MM, Mastrota KM, Schachter SE.. Optom Vis Sci Jul;90(7):e

istory h Clinical 1. Clinical history Symptoms: Itch, burning, foreign body sensation, crusting, redness, blurry vision Hom MM, Mastrota KM, Schachter SE.. Optom Vis Sci. 2013 Jul;90(7):e198-205.

85% also have MGD de Venecia AB. Siong RLB. sp. infestation in anterior blepharitis, meibomian gland dysfunction and mixed blepharitis. Phillipine Journal of Ophthalmology. 2011;36(1):15-22.

2 istory h Clinical 1. Clinical history Symptoms: Itch, burning, foreign body sensation, crusting, redness, blurry vision Hom MM, Mastrota KM, Schachter SE.. Optom Vis Sci Jul;90(7):e tis ri Blepha Blepharitis & demodex Meta-analysis of 11 studies Statistically significant association Lid Debris Grade 0 (Normal) 50 year-old Clear eyelid margin h Clinical istory mite infestation 85% also have MGD de Venecia AB. Siong RLB. sp. infestation in anterior blepharitis, meibomian gland dysfunction and mixed blepharitis. Phillipine Journal of Ophthalmology. 2011;36(1): Lid Debris Grade 1 (Mild) 50 year-old Occasional fragment 1-5 collarettes Zhao YE,Wu LP,Hu L,Xu JR. Association of blepharitis with : a meta-analysis. Ophthalmic Epidemiol 2012;19:95Y102. Lid Debris Grade 2 (Moderate) 50 year-old Few fragments 6-20 collarettes Lid Debris Grade 3 (Severe) 50 year-old Many fragments collarettes 1-2 clumps Lid Debris Grade 4 (Very Severe) 50 year-old 3 clumps/strands >40 collarettes

ruff al dand ic Cylindr 12.9 mites per patient with cylindrical dandruff (CD) 0.35 mites without CD 2. Slit lamp evaluation 30 times higher when cylindrical dandruff is present. 1. Gao YY.

Cylindrical d ritis Blepha andruff ndruff ical da Cylindr Cylindrical dandruff was pathognomonic for the presence of demodex infestation. 1. Gao YY. on Distenti Blepharitis with demodex 62.

3 ruff al dand ic Cylindr 12.9 mites per patient with cylindrical dandruff (CD) 0.35 mites without CD 2. Slit lamp evaluation 30 times higher when cylindrical dandruff is present. 1. Gao YY. Di Pascuale MA. Li W. et.al. High Prevalence of in Eyelashes with Cylindrical Dandruff. Invest. Ophthalmol. Vis. Sci. 2005;46(9): Cylindrical d ritis Blepha andruff ndruff ical da Cylindr Cylindrical dandruff was pathognomonic for the presence of demodex infestation. 1. Gao YY. Di Pascuale MA. Li W. et.al. High Prevalence of in Eyelashes with Cylindrical Dandruff. Invest. Ophthalmol. Vis. Sci. 2005;46(9): on Distenti Blepharitis with demodex 62.9% Sumer et. al. 88% Alejo et.al. 97% De Venecia and Siong Sumer Z, Arıcı MK,Topalkara A,Ozçelik S, Yıldırım S.[Incidence of folliculorum in chronic blepharitis patients]. Cumhuriyet Univ Tıp Fak Dergisi 2000;22:69Y72. Alejo RL, Valenton MJ, Abendanio R. folliculorum infestation of the lids in Filipinos. Philipp J Ophthalmol 1972;4:110Y3. De Venecia AB, Siong RL. Demodes sp. infestation in anterior blepharitis, meibomian gland dysfunction, and mixed blepharitis. Philipp J Ophthalmol 2011;36:15Y22. ion ion Distent Distention caused by waste products Half of mites are follicle opening are dead Distent have no anus, and stores its waste in large cells within its gut. When the mite dies, its body disintegrates and an explosion of waste can be released. 3. Epilate and microscope

4 ope ope Microsc Celestron LCD Microscope Amazon $200 approx don t forget cover slips and slides Microsc Celestron LCD Digital Microscope II (Black) Celestron 5 MP LCD Deluxe Amazon $200 approx Have not tried Tails Bacteri a Bacillus oleronius has also been detected inside the digestive tract mites. Significant correlation serum immunoreactivity to :bacillus, demodex infestation and facial rosacea. Liu J. Sheh H. Tseng SCG. Pathogenic role of mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010; 10(5):

a Rosace Microscope ology Morph Rosacea and demodex Meta-analysis of 48 studies 10 different countries

Retrospective analysis of the association between infestation and rosacea. Arch Dermatol 2010;146:896Y902.

Discomfort in RE GP wearer Other eye no comfort problems 3 lenses over the last 2 weeks Upper lid

5 CD, maybe 2 pieces, greasy lashes. LE No debris, but greasy.

5 a Rosace Microscope ology Morph Rosacea and demodex Meta-analysis of 48 studies 10 different countries 28,527 subjects Rosacea patients 7-8x chance have Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the association between infestation and rosacea. Arch Dermatol 2010;146:896Y902. Morph ology Adult head = 1/2 to 1/3 width of lash Nymph = 25% longer than adult Case Case 28 year old Discomfort in RE GP wearer Other eye no comfort problems 3 lenses over the last 2 weeks Upper lid uncomfortable sensation Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the association between infestation and rosacea. Arch Dermatol 2010;146:896Y902. Case RE Grade 0.5 CD, maybe 2 pieces, greasy lashes. LE No debris, but greasy. Other docs prescribed Maxitrol, Pred Forte ineffective Marginal relief with Lastacaft Case Microsc ope

6 Microscope Microscope Brevis ex Demod is highly photophobic and avoids light hundreds of mites appear in severely infested lids but has never seen a mite emerge completely. Coston Microscope ex Demod No one has reported seeing the demodex folliculorum on the skin surface. Coston TO. folliculorum blepharitis. Trans Am Ophthalmol Soc. 1967;65: Coston TO. folliculorum blepharitis. Trans Am Ophthalmol Soc. 1967;65:

7 ex Demod Flexion Extension ENGLISH, FRANK P., WILLIAM B. NUTTING, and DAVID COHN. "DEMODECTIC OPPOSITION IN THE EYELID." Australian and New Zealand Journal of Ophthalmology 13.1 (1985):

Molt demodex will molt its shell once and molt its skin thrice. http://www.facedoctor.

Clean lids with lid scrub (Ocusoft, etc) 2.

3. Apply TTO (Ocusoft or mix) with cotton swab along lid margins.

com Modified from Cliff Silverman, OD tments ex a d e r o t m e e c D fi In-of 4.

8 Molt demodex will molt its shell once and molt its skin thrice. e Oil Tea Tre Tea Tree oil Ocusoft Cliradex Australian generic brand (Target) e Tea Tre Oil Cliradex.com $ cartons 24 wipes/carton Ocusoft.com e tre In-offic s atment 1. Clean lids with lid scrub (Ocusoft, etc) 2. Instill proparacaine/tetravisc/nsaid as drop in eyes and along lid margins with cotton swab. 3. Apply TTO (Ocusoft or mix) with cotton swab along lid margins. Use a fresh swab for each lid margin. Ocusoft.com Modified from Cliff Silverman, OD tments ex a d e r o t m e e c D fi In-of 4. Clean lashes with the short Bleph brush (Ocusoft demodex kit) removing all collarettes and debris that remain. Optional: cotton swab 5. After 5 or more minutes, irrigate. I prefer CL solution with PHMB ( acaricide ) 6. Clean again with lid cleaning pads. 7. Repeat TTO, irrigate and scrub again

9 In-office treatments 8. Send home with Cliradex 2x day if moderate/severe, 1x day if mild/moderate 9. Return in about 2 weeks for 2nd treatment Tip sheet If you see rosacea and see no demodex, you are missing it Everyone has it, normal mites; like bacteria Q: infestation or not In-office will not get rid all of them We only try to control the numbers Add Tea tree oil shampoo Add Tea tree oil soaps Tip sheet Space 1-2 weeks apart, lifecycle of the mite Minimum 2 treatments, sometimes more is needed Use Cliradex pads 2 x day or 1x day evenings Squeeze pads before opening to spread TTO, sometimes pads are dry Use pads on eyebrows and rest of face Tip sheet Squeeze and fan Lay pads on lids without scrubbing for most sensitive patients Q: Do your own mix or not? Use at own risk TTO:Macadamian nut oil; 50:50 mix Be careful of too much TTO with Bleph brush Caraway oil can be used, but $$ Emulsion drops with oil activates the mites Tip sheet Mites in children - Poster Friday Scott Schachter Mites mistaken for allergy Look for lots of cuff dandruff to epilate. Look for distended bases. Waste products & dead mites. Go for juicy or sick lashes (short, discolored, mis-directed, etc) Tip sheet Drop cover slip first, then add emulsion drop at the side Show and tell Give patients cell phone number

Steroids Steroids Hom s banned list 82 female patients with perioral dermatitis 70 control female subjects. Mite density increased significantly with length of treatment with topical steroids (p<0.

10 Steroids Steroids Hom s banned list 82 female patients with perioral dermatitis 70 control female subjects. Mite density increased significantly with length of treatment with topical steroids (p<0.001) Dolenc-Voljc M, Pohar M, Lunder T. Density of folliculorum in perioral dermatitis. Acta Derm Venereol. 2005;85(3): Strong link to rosacea Strong link to MGD (85%) Under-diagnosis = increasing mite counts? Zhao YE. Wu LP. Peng Y. et.al. Retrospective analysis of the association between infestation and rosacea. Arch Dermatol Aug;146(8): De Venecia AB. Siong RLB. Demodes sp. infestation in anterior blepharitis, meibomian gland dysfunction, and mixed blepharitis. Phillipp J Ophthalmol 2011;36(1):15-22 Kheirkhah A, Casas V, Li W, Raju VK, Tseng SC. Corneal manifestations of ocular infestation. Am J Ophthalmol. 2007;143(5): Steroids 2. Emulsion drops 3. Restasis 4. Prostaglandins 5. Latisse 6. Antibiotics (waste of time) Thank you Milton M. Hom, OD, FAAO, FACAAI(Sc). eyemage@mminternet.com

Dry eye diagnosis and treatments: The Elevator speeches COPE # Dry eye diagnosis and treatments: The Elevator speeches COPE # 5/11/2015.

Dry eye diagnosis and treatments: The Elevator speeches COPE # Dry eye diagnosis and treatments: The Elevator speeches COPE # Milton M. Hom, OD, FAAO, FACAAI (Sc). eyemage@mminternet.com Disclosures Last