A Q&A with Cynthia Matossian, MD, FACS
AJMC®: In your opinion, why are there no formal guidelines for Demodex blepharitis?
MATOSSIAN: Ophthalmologists and other eye care providers have known about Demodex blepharitis for a very long time. [The condition] involves an infestation or an overpopulation of Demodex mites at the base of the lashes and at the edge of the lid margins. We all have Demodex mites around different body parts, but when there's an overabundance of these little mites, they start to have a negative impact on the lid margin, on the lashes themselves, and on the ocular surface. We haven't had clear definitive treatment guidelines about this type of blepharitis because we haven’t had a truly good treatment. Of course, we've known about ways to minimize the infestation or overpopulation of the Demodex mites, such as good lid hygiene—washing the edge or margin of the eyelids, removing mascara and other eye makeup before going to sleep, and taking good care of the periocular region.
AJMC®: In your experience, has the lack of guidelines impacted the diagnosis and management of Demodex blepharitis?
MATOSSIAN: Sometimes, when we don't have a very good treatment modality, we don't even bring up the underlying pathology. Why bring up a subject when we don't have a treatment for it? For example, decades ago, we didn't bring up dry eye disease, because the only treatments available were artificial tear solutions and ointments. We skipped over dry eye disease and discussed other diagnoses that the patient was given or that we made for that patient as we performed their eye examination. Demodex blepharitis is falling into the same pattern. Until now, we didn't have a good way to diagnose and treat it.
This disease is very prevalent, and it's significantly underdiagnosed, because eye care practitioners haven't gotten in the habit of looking for it, and they didn't have a tool or a treatment modality for addressing this epidemic disease. Now that a treatment is on the horizon, we can start to look for Demodex blepharitis.
What are some ways to look for this disease? Obviously, ask the patient for a history. Ask if their eyelid margins itch or become red, inflamed, and a little swollen. Ask if they are always rubbing their lashes because they're uncomfortable, and if there is burning and stinging of their ocular surface.
If the patient answers “yes” to some of those questions, then a careful a slit-lamp examination is all an eye care provider needs to do to make the diagnosis. Providers should have the patient look down a little bit, and then start to focus the joystick and the slit lamp on the lid margin at the base of the lashes. Look for little collarettes that almost look like turtlenecks around the base of the eyelashes. The collarettes may have different widths, but, if there's circular debris, that calamari-looking ringlet at the base of the lash is very characteristic of Demodex infestation.
Another telltale sign is misdirected lashes. If the normal swoop up of the lash with that very gentle curve is missing; if the lashes are sticking straight out, downward, or in different directions; if lashes are slightly broken; or if there are missing lashes, Demodex infestation may be present.
AJMC®: In the absence of FDA-approved treatments, what constitutes the current standard management strategy for Demodex blepharitis?
MATOSSIAN: After the diagnosis of Demodex blepharitis is made, the only option we have is to educate the patient without scaring them. Providers should let the patient know that Demodex infestation is very common—they just have an oversupply of the mites. This condition can be [managed], but it often recurs. We can control it but not cure it forever, so to speak. With this information, the patient better understands what's going on and what they need to do to keep the infestation and inflammation under control.
Tea tree oil is available in a variety of products. I often prescribe lid wipes that contain different concentrations of it. I prescribe towelettes with the highest concentration of tea tree oil; they come in individual foil pouches. I tell the patient to take 1 side of the towelette, close their eyes, and wipe back and forth, back and forth, at least 10 times on their lashes, and then move it onto their eyebrow. I instruct men with hairy ears also to clean the hairs in their ears. I tell my patients to flip the towelette to the clean side and do the same thing (again, with the clean side)—swipe back and forth 10 times on the eyelid margins, lashes, eyebrows, and ear hairs, and then discard the towelette. I tell them to repeat that every day for 60 days; you need a 2-month cycle to break the parasitic cycle of eggs being laid and hatched. Thereafter, the towelettes must be used the same way intermittently to keep the infestation under control. Importantly, application of tea tree oil stings, especially when used at that concentration. To minimize stinging and burning, patients must keep their eyes closed and count slowly to 25 or 30 before opening their eyes.
Another [management] option is in-office procedures, such as microblepharoexfoliation with a sponge using a prescription eyelid hygiene product—hypochlorous acid, tea tree oil, or a product that includes tea tree oil—while the sponge is rotating. This process debulks the Demodex mite load. It removes the biofilm at the base of the lashes, which the mites need as a food source. It also removes their regurgitated debris.
That in-office [procedure] often is needed every 4 months, every 6 months, or even once each year, depending on the severity of the situation. Again, that is customized to the patient's needs. On the other hand, an at-home version is available that involves use of a handheld electric eyelid and eyelash brush with a viscous product that doesn't spray all over the place. The product may or may not contain tea tree oil. Again, removal of debris every day or every other day minimizes the risk of mites building back up in quantity and causing deleterious adverse effects.
AJMC®: How effective are these tea tree oil–based products as management options, and how well do patients respond to them?
MATOSSIAN: Tea tree oil is the best option we have. There's evidence that mechanical debridement done concomitantly with application of tea tree oil decreases the number of mites on the eyelids. But tea tree oil can sting and burn, which may discourage patients from continuing its use. Patients may use it for a short period of time, or they may not be very adherent. The over-the-counter products or the prescription products for wipes with a higher tea tree oil concentration represent the only good therapeutic option that we have had.
For me, [management] involves debulking with a mechanical in-office procedure, followed with an at-home debulking procedure on a daily or every-other-day basis, plus the tea tree oil.
AJMC®: Are there any treatments on the horizon?
MATOSSIAN: There are some products with excellent safety and comfort profiles in the preliminary studies. Lotilaner, which is now under investigation by Tarsus Pharmaceuticals here in the United States, hopefully will be available over the next 1 to 2 years. Instillation of 1 drop of this product into the eyes twice a day for a 6-week period may achieve no detection of collarettes at about 6 weeks. Of course, mites are on our bodies, and there is a chance of reinfestation. The treatment may have to be repeated semiannually in patients who need it. This would be the first prescription product to treat Demodex blepharitis.
In the area of dry eye disease, ocular surface disease, and blepharitis treatment, therapies often are additive, and they're layered 1 on top of the other. Very few are exclusive treatments, meaning it's the only thing you use. I view Demodex blepharitis in a very similar fashion. Of course, if lotilaner is approved by the FDA, it will be a definitive prescription pharmacologic agent to treat Demodex mite infestation. At the same time, performing a debulking procedure in the office to remove biofilm, which is the food source for the mites, may help to provide comfort to the patient faster and help the pharmacologic agent work best by opening the orifices of the meibomian glands. Thus, the drug can penetrate and kill any of mites living inside the meibomian glands and at the base of the lashes. Use of the at-home remedies, maybe including a low concentration of tea tree oil for maintenance therapy at home, may discourage the quick buildup of Demodex mites. Use of the at-home microblepharoexfoliation treatment with an oscillating head also can help keep the lash base and lid margins healthy to minimize the overgrowth of mites. When there's an overgrowth of mites, and symptoms become apparent, we can always re-treat with a prescription product. I see it as adjunctive therapy that may minimize the need for in-office treatments and that helps to keep the eyelids as healthy and the patient as comfortable as possible.
AJMC®: What should managed care providers know about current and forthcoming treatments for Demodex blepharitis?
MATOSSIAN: Demodex blepharitis is very common. Eye care providers should start looking for it. They will be very surprised at how commonly they are going to see the collarettes and the misdirected lashes of the patients in their offices. Most of the time, adherence drops off when treatment must be used chronically and multiple times a day. For example, patients with glaucoma need to use multiple products that must be instilled a few times a day, forever. The potential upcoming treatment for Demodex blepharitis is not like that. It's expected to be used twice a day for 6 weeks. Once patients understand that there's a light at the end of the tunnel, it's very doable. Most patients can be adherent for a 6-week period.
Help is on the way, hopefully soon, with the FDA approval of a product that appears to be very promising. We will have a means to deliver care and treatment for our patients to help them with the discomfort that Demodex blepharitis can cause. Whether it's itchy eyelids, red eyelid margins, telangiectatic vessels, burning, or stinging, the signs and symptoms of Demodex blepharitis may be improved with treatment.
Dr Matossian is founder and past medical director of Matossian Eye Associates.
For other articles and videos in this AJMC® Perspectives publication, please visit “The Evolving Landscape of Demodex Blepharitis Management.”