Technological University Dublin ARROW@TU Dublin Doctoral Science 2020 Investigation and Management of Demodex Folliculorum Blepharitis in Clinical Practice Orla Murphy Technological University Dublin Follow this and additional works at: https://arrow.tudublin.ie/sciendoc Part of the Optometry Commons Recommended Citation Murphy, O. (2020) Investigation and Management of Demodex Folliculorum Blepharitis in Clinical Practice , Doctoral Thesis, Technological University Dublin. doi:10.21427/6yf9-6g68 This Theses, Ph.D is brought to you for free and open access by the Science at ARROW@TU Dublin. It has been accepted for inclusion in Doctoral by an authorized administrator of ARROW@TU Dublin. For more information, please contact [email protected], [email protected]. This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 License Investigation and management of Demodex folliculorum blepharitis in clinical practice Student: Orla Murphy BSc Optom PhD Thesis Technological University Dublin Supervisors: Dr Aoife Lloyd-McKernan Dr Veronica O’ Dwyer School of Physics & Clinical & Optometric Sciences November 2019 i Abstract Introduction: Blepharitis is a chronic inflammatory disorder of the eyelid margin. Blepharitis patients routinely present to and are managed by optometrists and ophthalmologists in practice. Demodex folliculorum is associated with anterior blepharitis. Presently, treatment with 50% tea tree oil is recommended by the American Academy of Ophthalmology for Demodex blepharitis. However, over-the-counter products have been developed and marketed at being effective for treating Demodex blepharitis. Purpose: To examine the efficacy of over-the-counter lid hygiene products and warm compress therapy for the treatment of Demodex blepharitis. Methods: Two hundred and forty-six participants were examined at multiple visits over four studies, for the presence and quantity of Demodex folliculorum. OCuSOFT® Lid Scrub® PLUS, dr.organic® tea tree face wash, Johnson’s® No More Tears® baby shampoo, MGDRx EyeBag® and the OPTASETM Moist Heat Mask were examined for treating Demodex blepharitis. Results and Conclusions: OCuSOFT® Lid Scrub® PLUS significantly reduced the quantity of Demodex folliculorum when used over two and four weeks. Dr.organic® tea tree face wash significantly reduced the quantity of Demodex folliculorum when used over four weeks. The OPTASETM Moist Heat Mask significantly reduced the quantity of Demodex folliculorum when used over eight weeks. The MGDRx EyeBag® did not demonstrate a significant reduction in the quantity of Demodex folliculorum over the duration of the study. Johnson’s® No More Tears® baby shampoo had no effect on the quantity of Demodex folliculorum and demonstrated a significant increase in tear film instability when used over an eight-week treatment period. ii Declaration I certify that this thesis which I now submit for the examination for the award of PhD is entirely my own work and has not been taken from the work of others, save and to the extent that such work has been cited and acknowledged within the test of my work. This thesis was prepared according to the regulations for graduate study by research of the Technological University Dublin and has not been submitted in whole or in part for another award in any other third level institution. The work reported on in this thesis conforms to the principles and requirements of the Technological University Dublin's guidelines for ethics in research. The Technological University Dublin has permission to keep, lend or copy this thesis in whole or in part, on condition that any such use of the material of the thesis be duly acknowledged. Signature __________________________________ Date: 8th November 2019 Candidate: Orla Murphy iii Acknowledgements Firstly, I would like to express my sincere appreciation to my supervisors, Dr. Aoife Lloyd-McKernan and Dr. Veronica O’ Dwyer, for their continued support and guidance throughout this research project. You are both inspirational in your teaching and leadership, and I will eternally be grateful to have had you both as advisors and mentors for my Ph.D. I would like to thank Declan, Marie, Una, Alena, Paul and all the staff of the National Optometry Centre and Optometry Department, for providing the facilities to conduct this research project and helping with participant recruitment and appointments. I would also like to extend my sincerest thanks to the students and their supervisors who helped with participant recruitment over the last number of years. Gabhaim buíochas le mo thuismitheoirí, Colm agus Claire, as an moladh agus spreagadh a thug sibh dom thar na blianta. Ní bheinn anseo gan bhur ngrá agus tacaíocht. Do Chiara and Darragh, bhí an tádh liom fás suas le clann lán de spiorad agus díograis. Táim ana bhródúil as gach atá bainte amach agaibh go dtí seo. Do mo Nana Rita, a bhí ann ón tús, agus atá fós ana lárnach i mo shaol. Is duine ar leith tú. Táim fíor bhuíoch duit as do chabhair ar fad thar na blianta. To my extended family, I am blessed to be part of such a loving, supportive and encouraging family. A very special thank you to Eugene Murray. You have been amazingly patient, understanding and supportive throughout this whole process. Thank you for being my rock, my confidant, my best friend. iv Abbreviations α Alpha AAO American Academy of Ophthalmology AIDS Acquired immunodeficiency syndrome ANOVA Analysis of variance Baby shampoo Johnsons® No More Tears® baby shampoo BPPP Blepharitis Preferred Practice Pattern CD Cylindrical dandruff DB Demodex brevis DED Dry eye disease DEQ-5 5 – item dry eye questionnaire DF Demodex folliculorum Eyebag MGDRx EyeBag® FDA Food and Drugs Administration HIV Human immunodeficiency virus κ Cohen’s kappa KW Kruskal Wallis H MGD Meibomian gland dysfunction MGOTM Methylglyoxal MWU Mann-Whitney U NITBUT Non-invasive tear break-up time OCuSOFT OCuSOFT® Lid Scrub® PLUS Optase OPTASETM Moist Heat Mask OSDI Ocular surface disease index ROC Receiver operator characteristic rs Spearman’s correlation coefficient SD Standard deviation SPSS Statistical Package for Social Sciences v SPEED Standard patient evaluation of eye dryness TBUT Tear break-up time TTFW dr.organic® tea tree face wash TTO Tea tree oil TU Dublin Technological University Dublin UK United Kingdom WSR Wilcoxon-signed ranks test X2 Chi - square vi Table of Contents Abstract ............................................................................................................................. ii Declaration ...................................................................................................................... iii Acknowledgements .......................................................................................................... iv Abbreviations .................................................................................................................... v Table of Contents ............................................................................................................... 1 List of Tables .................................................................................................................... 11 List of Figures .................................................................................................................. 16 CHAPTER ONE: DEMODEX BLEPHARITIS .............................................................. 20 1.1 Background ........................................................................................................ 20 1.2 Systematic Review ................................................................................................. 21 1.3 Introduction to Demodex.................................................................................... 31 1.4 Classification...................................................................................................... 32 1.4.1 Demodex folliculorum ..................................................................................... 32 1.4.2 Demodex brevis ............................................................................................... 33 1.5 Pathogenicity...................................................................................................... 34 1.6 Risk Factors and Associated Conditions............................................................ 36 1 1.6.1 Age .............................................................................................................. 36 1.6.2 Rosacea ....................................................................................................... 37 1.6.3 Immunodeficiency ....................................................................................... 38 1.6.4 Contact Lenses ............................................................................................ 40 1.6.5 Makeup ....................................................................................................... 41 1.7 Ocular Surface Inflammation ............................................................................. 41 1.7.1 Dry Eye ....................................................................................................... 41 1.7.2 Blepharitis .................................................................................................. 42 1.7.3 Meibomian Gland Dysfunction ................................................................... 44 1.7.4 Symptoms ...................................................................................................