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Update on Demodex Blepharitis

MHE PublicationMHE February 2024
Volume 34
Issue 2

Christopher Starr, M.D., of Weill Cornell Medical College in New York discusses of the challenges of making a diagnosis and a new treatment.

In this Managed Healthcare Executive K-Cast video series, Christopher Starr, M.D., provided an overview of the symptoms and diagnosis of Demodex blepharitis and discussed the consequences of the first FDA-approved treatment. Starr is an associate professor of ophthalmology at the Weill Cornell Medical College in New York.



You can view the video series at here.

This transcript of Starr’s remarks has been edited for clarity and length.

Demodex blepharitis has had a very substantial impact on people’s quality of life for a number of reasons. The eyes can be red, and the eyelid margin can be swollen, red, crusty and flaky. That doesn’t look great, and people get very self-conscious. People pay a lot of money for long, full eyelashes, and this condition can lead to loss of those eyelashes, which, of course, has cosmetic implications. Also, the eyelashes are important for protecting the ocular surface: They are there for a reason. When you lose your eyelashes, things can get into your eye and your eyes can be more irritated.

Both forms of Demodex blepharitis — follicular and brevis — can lead to recurrent chalazion or hordeolum. When those are present, you have big bumps on the eyelids, and in some cases, they can cause preseptal cellulitis.

We know that Demodex blepharitis goes hand in hand with dry eye disease, and dry eye disease can have a major impact on quality of life, on people’s wellness and well-being. It can also be very expensive.

Types of blepharitis

Blepharitis is Latin for inflammation of the eyelids, which is very nonspecific. Anterior blepharitis and posterior blepharitis are two ways it can be categorized, and Demodex blepharitis is probably the most common cause of anterior blepharitis. Posterior blepharitis is often called meibomian gland dysfunction, and Demodex brevis is related to that.

When there is blepharitis from Demodex — really any form of blepharitis — that can lead to ocular surface issues [such as] pterygium or pinguecula.

Risk of blindness

When there’s Demodex blepharitis, there is often bacterial overload as well. The bacteria generally tend to be the [staphylococcal] and [streptococcal] gram-positive bacteria. Those are the same bacteria that lead to one of the most horrific complications of cataract surgery, which is endophthalmitis. If you see Demodex blepharitis, anterior blepharitis or collarettes prior to surgery, you have a pretty good idea that there’s an extra load of bacteria on those lids and it behooves you, as the surgeon, to reverse that, to treat it aggressively prior to not only finalizing your ocular surgery measurements but certainly before making any incisions and doing the surgery itself. Usually, it’s not Demodex but rather the bacteria that go hand in hand with Demodex that cause the infection. In a lot of those cases, the majority of [patients in those] cases do end up legally blind. We have to do everything we can to prevent that from happening.

Common symptoms and a vicious cycle

Patients with blepharitis will probably have a lot of the same symptoms as a patient [with] dry eye, as the person with exposure keratitis, as a person with allergic conjunctivitis or infectious conjunctivitis, and so on and so forth. When these patients come in with these symptoms — dryness, itchiness, redness, my eyes are itchy, they’re gritty, they get a foreign body [in the eye] sensation, my vision fluctuates — those symptoms can be attributable to virtually any of the ocular surface diseases. Many practitioners will just say, ”You have dry eye, so go take some artificial tears and you’ll be fine” and sweep it under the rug.

We need to isolate the symptoms and try to pin each symptom to an actual diagnosis. The best way to do that is certainly with a very careful and thoughtful examination.

Pearls for patients

Itching is something that we hear a lot. [My approach is to ask] whether it is your eyes that are itchy or is it your eyelids. Show me how you [rub] your eyes when they get itchy, and when somebody does this, it’s probably allergy. But when somebody takes their finger down and goes across their eyelashes, that to me is eyelid itching. That kind of scratching with the fingernail on the lashes is, in my experience, almost assuredly related to anterior blepharitis, and in most cases, that’s going to be Demodex. I think that’s a great little pearl for all practitioners and patients.

When you’re seeing 50, 60, 70 patients a day, you have very limited time. A lot of doctors will recoil at anything that’s related to the ocular surface. They won’t take that extra five seconds and ask a couple of pointed little questions about the symptoms or the way they itch or the signs. And that’s all it takes.

Challenges to diagnosis

One of the biggest challenges with diagnosing Demodex blepharitis has been the guaranteed kind of diagnosis. The way that diagnosis was guaranteed was you would have to remove an eyelash or a few eyelashes, which never feels good for the patient, [and look at them under a microscope for Demodex]. It’s time consuming and costly. A lot of times, you might pluck a few eyelashes and not see Demodex. Then you have these false-negative diagnoses.

The second challenge has always been this uncomfortable discussion [about infestation with mites]. When you’re having that conversation with somebody, when there wasn’t an FDA-approved medication to treat it, that conversation is really uncomfortable. So uncomfortable that, and I’m guilty of this too, you just don’t discuss it at all.

We would recommend the same treatments that we would recommend for everybody with any form of blepharitis: warm compresses … a little baby shampoo on your eyelids, maybe an antibiotic here or there, a little ointment, and so on and so forth. [And] maybe [don’t] mention the fact that there are mites.

Easier to talk about

Now that we do have an FDA-approved treatment, we have an effective treatment, I’m much more likely to bring it up when I see Demodex.

We know that collarettes now are pathognomonic; you don’t have to pluck the eyelashes, you don’t need a microscope in your office, you don’t need glass slides and all that cumbersome stuff. If you see the collarettes, then the best way to diagnose is have the patient look down when you’re looking at them under the slit lamp. [If] you see the collarettes, you’ve got your diagnosis.

It’s still uncomfortable [to tell patients about the diagnosis] because anytime you talk about mites and infestation, it’s uncomfortable, plain and simple. But it’s much more comfortable now that there’s a prescription medication that can treat
this effectively.

New FDA-approved treatment

The lotilaner eyedrops differ substantially [from treatments used in the past]. Probably the most important distinction is that they are FDA approved.

They are also an eyedrop. [The other treatments I have mentioned] were scrubs and ointments, procedural things, oral medication, and so on and so forth. This is really the first eyedrop. It’s a twice-a-day eyedrop for a six-week course. It was, at least in the phase 3 clinical trial, very well tolerated, very comfortable. I think 90% of patients considered it to be a neutral or very comfortable drop. [The results] showed, compared with the placebo, a highly statistically significant improvement in the eradication of mites, reduction in collarettes, and reduction in eyelid redness or erythema.

Education needed

I think that there’s a lot of education to be had around Demodex blepharitis for practitioners, patients, healthcare systems, hospitals and insurance companies because this is an extremely common condition. It might have been underreported and underdiagnosed in prior times for all the reasons that I mentioned. Now that there’s FDA treatment approved, we’re going to be seeing more and more [Demodex blepharitis diagnoses]. [It’s] not that the prevalence of it is going up. It’s just that we’re going to be diagnosing it more because we have effective treatments for it now.

For practitioners, I think the most important educational tip here is very simply to make the diagnosis. It might require a slight change to the way we practice because a lot of doctors don’t necessarily have patients always look down. It’s also important to educate providers that there is an FDA-approved treatment. There’s a lot of new stuff happening in all aspects of eye care. A lot of people might not even know that we have an FDA-approved product now for Demodex blepharitis.

For healthcare systems [and insurers], it will save time and money in the long run if we look for [Demodex blepharitis], diagnose it and treat it on [the first] visit rather than [the 12th] visit after the patient has tried a zillion other prescription medications, wipes, surgical procedures
and so on.

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