Disclosures

Mites that eat and live that eat and live Last 12 months: ! on your lids on your lids Allergan COPE#37748-AS COPE#37748-AS AMO Bausch/Valeant NiCox Cooper ! Milton M. Hom, OD, FAAO, FACAAI(Sc). [email protected]

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

Prevalence Demodex Clinical sequence

Demodex 1. Clinical history: , dry Ectoparasites-most common in eyes or ocular allergy man Demodex infestation 2. Slit-lamp examination: 100% in patients 70 years old plus 84% 60 years old cylindrical dandruff 100% 70+ years old Mite density rises in the sixth 3.Microscopic confirmation: decade of life counting of Demodex eggs, lavae

Level until the eighth decade of Stephenson M. Blepharitis diagnosis: don’t forget demodex. Review and adults. Ophthalmology Sept 6 2012, http://www.revophth.com/content/c/36411/ Hom MM, Mastrota KM, Schachter SE. Demodex. life. Optom Vis Sci. 2013 Jul;90(7):e198-205. Clinical history Clinical history

Symptoms: Demodex mite 1. Clinical history infestation Itch, burning, foreign body 85% also have MGD sensation, crusting, redness, blurry vision

de Venecia AB. Siong RLB. Demodex sp. infestation in anterior blepharitis, meibomian gland dysfunction and mixed blepharitis. Phillipine Journal of Hom MM, Mastrota KM, Schachter SE. Demodex. Ophthalmology. 2011;36(1):15-22. Optom Vis Sci. 2013 Jul;90(7):e198-205.

Lid Debris – Grade 0 (Normal) Lid Debris – Grade 1 (Mild) 50 year-old 50 year-old Blepharitis

Blepharitis & demodex Meta-analysis of 11 studies • Occasional fragment • Clear margin Statistically significant association • 1-5 collarettes !

Zhao YE,Wu LP,Hu L,Xu JR. Association of blepharitis with Demodex: a meta-analysis. Ophthalmic Epidemiol 2012;19:95Y102.

Lid Debris – Grade 2 (Moderate) Lid Debris – Grade 3 (Severe) Lid Debris – Grade 4 (Very Severe) 50 year-old 50 year-old 50 year-old

• Many fragments • Few fragments • 21-40 collarettes • ≥3 clumps/strands • 6-20 collarettes • 1-2 clumps • >40 collarettes Cylindrical dandruff Cylindrical dandruff

12.9 mites per patient with 2. Slit lamp cylindrical dandruff (CD) “Cylindrical dandruff was 0.35 mites without CD pathognomonic for the presence evaluation ! of demodex infestation.” 30 times higher when cylindrical dandruff is present.

1. Gao YY. Di Pascuale MA. Li W. et.al. High Prevalence of 1. Gao YY. Di Pascuale MA. Li W. et.al. High Prevalence of Demodex in with Cylindrical Dandruff. Invest. Demodex in Eyelashes with Cylindrical Dandruff. Invest. Ophthalmol. Vis. Sci. 2005;46(9):3089-3094. Ophthalmol. Vis. Sci. 2005;46(9):3089-3094.

Cylindrical dandruff Blepharitis Distention

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 in chronic blepharitis patients]. Cumhuriyet Univ Tıp Fak Dergisi 2000;22:69Y72. ! Alejo RL, Valenton MJ, Abendanio R. Demodex 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. !

Distention Distention

Demodex have no anus, and Distention caused by waste stores its waste in large cells 3. Epilate and products within its gut. Half of mites are follicle opening ! microscope are dead When the mite dies, its body disintegrates and an explosion of waste can be released. Microscope Microscope

Celestron 44340 Celestron 44341 LCD Digital LCD Microscope Microscope II (Black) Amazon ! $200 approx Celestron 5 MP LCD Deluxe ! ! don’t forget cover slips and slides Amazon $200 approx Have not tried

http://waynesword.palomar.edu/redmite7a.htm

Tails Bacteria

Bacillus oleronius has also been detected inside the digestive tract mites. Significant correlation serum immunoreactivity to :bacillus, demodex infestation and facial . Liu J. Sheh H. Tseng SCG. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010; 10(5): 505–510. Rosacea Microscope Morphology

Rosacea and demodex Meta-analysis of 48 studies 10 different countries 28,527 subjects Rosacea patients 7-8x chance have Demodex

Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol 2010;146:896Y902. !

Morphology Case

28 year old Adult head = 1/2 to 1/3 width of lash Discomfort in RE GP wearer Nymph = 25% longer than adult Case 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 Demodex infestation and rosacea. Arch Dermatol 2010;146:896Y902. 1115 !

Case Case Microscope

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. Microscope Microscope Microscope

Brevis Demodex Demodex

Demodex is highly photophobic and avoids light “No one has reported seeing the ! demodex folliculorum on the “hundreds of mites appear in severely surface.” infested lids but has never seen a mite

emerge completely.” Coston TO. Demodex folliculorum blepharitis. Coston Trans Am Ophthalmol Soc. 1967;65:361–392. Coston TO. Demodex folliculorum blepharitis. Trans Am Ophthalmol Soc. 1967;65:361–392.

Demodex Demodex Demodex

http://www.youtube.com/watch?v=f4d3qklad_8 Demodex Demodex Demodex

Demodex Demodex Demodex

Demodex Demodex Demodex

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): 71-73. Demodex Demodex Molt

“demodex will molt its shell once and molt its skin thrice.”

http://www.facedoctor.ca/research/research01.html

Tea Tree Oil Tea Tree Oil

Tea Tree oil ! Ocusoft Cliradex.com Cliradex $480 20 cartons Australian generic brand 24 wipes/carton (Target)

! Ocusoft.com

In-office treatments In-officeDemodex treatments

1. Clean lids with lid scrub (Ocusoft, etc) 4. Clean lashes with the short “Bleph” brush (Ocusoft demodex kit) removing all collarettes 2. Instill proparacaine/tetravisc/NSAID as and debris that remain. Optional: cotton swab drop in eyes and along lid margins with cotton swab. 5. After 5 or more minutes, irrigate. I prefer CL solution with PHMB (“acaricide”) 3. Apply TTO (Ocusoft or mix) with cotton swab along lid margins. Use a fresh swab for 6. Clean again with lid cleaning pads. each lid margin. 7. Repeat TTO, irrigate and scrub again

! Modified from Cliff Silverman, OD Ocusoft.com In-officeDemodex 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

!

Demodex Demodex Tip sheet If you see rosacea and see no demodex, you Tip sheet are missing it Space 1-2 weeks apart, lifecycle of the mite Everyone has it, normal 1000-2000 mites; like Minimum 2 treatments, sometimes more is bacteria needed Q: infestation or not Use Cliradex pads In-office will not get rid all of them 2 x day or 1x day evenings We only try to control the numbers Squeeze pads before opening to spread TTO, Add Tea tree oil shampoo sometimes pads are dry Add Tea tree oil soaps Use pads on eyebrows and rest of face ! !

Demodex Demodex Demodex

Tip sheet Tip sheet “Squeeze and fan” Mites in children - Poster Friday Scott Tip sheet Lay pads on lids without scrubbing for most Schachter Drop cover slip first, then add emulsion drop sensitive patients Mites mistaken for allergy at the side Q: Do your own mix or not? Use at own risk Look for lots of cuff dandruff to epilate. Show and tell TTO:Macadamian nut oil; 50:50 mix Look for distended bases. Waste products & Give patients cell phone number Be careful of too much TTO with Bleph brush dead mites. ! Caraway oil can be used, but $$ Go for “juicy” or “sick” lashes (short, Emulsion drops with oil activates the mites discolored, mis-directed, etc) ! ! ! Steroids Steroids Hom’s banned list

82 female patients with perioral Strong link to rosacea dermatitis Strong link to MGD (85%) 1. Steroids 70 control female subjects. ! 2. Emulsion drops ! Under-diagnosis = increasing mite 3. Restasis Mite density increased significantly counts? with length of treatment with topical 4. Prostaglandins 5. Latisse steroids (p<0.001) Zhao YE. Wu LP. Peng Y. et.al. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol. 2010 Aug;146(8):896-902. De Venecia AB. Siong RLB. Demodes sp. infestation in anterior blepharitis, 6. Antibiotics (waste of time) Dolenc-Voljc M, Pohar M, Lunder T. Density of Demodex meibomian gland dysfunction, and mixed blepharitis. Phillipp J Ophthalmol folliculorum in perioral dermatitis. Acta Derm Venereol. 2011;36(1):15-22 Kheirkhah A, Casas V, Li W, Raju VK, Tseng SC. Corneal manifestations of ocular 2005;85(3):211-5. Demodex infestation. Am J Ophthalmol. 2007;143(5):743–749.

Thank you!

Milton M. Hom, OD, FAAO, FACAAI(Sc). [email protected] ! !