February 2008

 

OPINIONS AND COMMENTARY

 

EyeMail Insights

Demodex management


by J.E. “Jay” McDonald II, M.D.

   

Physician shares insights in managing eyelash-irritating mites

Individual demodex organism

demodex

Individual demodex organism on an epilated lash Source: Steven Safran, M.D.

Lid margin with organisms Lid margin with organisms

A species of Demodex

A species of Demodex on a patient’s eyelashes Source: Steven Safran, M.D.

Patients with blepharitis continue to frequent our practices and keep us scratching our heads for diagnosis and treatment. The role of Demodex “varmints” in blepharitis was revisited by one of the ASCRS EyeMail cataract listserv members, Steven G. Safran, M.D., Lawrenceville, N.J., as we reported in last month’s column. Dr. Safran shared his aggressive approach in dealing with Demodex mites and elicited some interesting responses from our members. His diagnosis and management—as well as the conventional wisdom regarding Demodex that counters Dr. Safran’s approach—are shared below.

We have been diagnosing and treating Demodex since May with great success. I would say that the incidence in chronic blepharitis is over 50%, and I have learned a tremendous amount about this since I started observing and treating patients. It is a complicated issue. Here’s a summary of what I’ve learned: The diagnosis requires a microscope to examine lashes so you’ll learn what you are looking at. Once you know what to look for, you can diagnose it at the slitlamp. The little beasties sit head down and tails up, with the tails aligned along the lash at the root. Often there is columnar dandruff or cylindrical cuffing. If you rock the lash from side to side and pull, you’ll see the tails spread out along the base of the lash like little bristles. When you pull the lash, often the mites stay in the follicle, and you have to dip the lash back down into the follicle to get some of the mites onto the lash for evaluation. Patients will wonder what you’re doing until you show them the mites moving under the microscope. When they see that, they’re ready to listen. Morning itching and irritation is very common with these mites because they don’t like light. They come out at night and mate, lay eggs on the lashes, and then crawl back into the follicle in the morning, causing itching. Some people have a lot of Demodex but no symptoms. I leave those people alone. Others have what appears to be an allergy to the mites, causing severe itching and inflammation. These are the blepharitis patients that respond to Patanol (olopatadine hydrochloride, Alcon, Fort Worth, Texas), but it doesn’t cure them. The presence of the mites explains why so many husbands and wives come in with blepharitis that flares up at the same time. (We’ve all seen this and never could understand or explain it … until now). Treatment involves tea tree oil (50% strength) applied to the lid margin and lashes in three applications per session done at least three times a week apart from each other. I do the treatments myself, completely debriding the base of the lashes of all crust and junk and getting the oil into the roots. I also sweep the lashes aggressively, taking care not to get the stuff in the eyes, as it is irritating. Do not use full-strength tea tree oil. I tried that on myself, and it was not a pleasant experience!! The patient must institute hygiene at home … tea tree shampoo scrubs and face wash and hair shampoo every day. The older ladies who go to the beauty salon once a week to get their hair washed so they have “frozen cotton candy” hair were very resistant to instituting proper hygiene and really can’t be eradicated of the problem without it. The mites also live in the nose and ear so that you must clean up the eyes and eyebrows and then keep them from finding the way back to the eye area with good hygiene and occasional touch-up treatments. We are using a tea tree ointment that we get from Dr. Scheffer Tseng (director, Ocular Surface Center, Miami) for some patients. It’s expensive, but for some folks it’s worth it. We use other ointments (bacitracin and erythromycin) at bed time after lid scrubs, as I think it reduces the mites’ mobility.

There was an Emedicine article on this topic

(www.emedicine.com/oph/topic517.htm) prior to the tea tree oil revelation. The tea tree oil is probably not the last word on killing these guys, but it’s better than anything else I have right now. Perhaps sound or heat therapy would work better. I have seen patient with pannus, cornea ulcers, non-specific keratitis, you name it, respond favorably to treatment for mites after being recalcitrant to other treatments. I frequently see rosacea patients with subepithelial infiltrates but no history of epidemic keratoconjunctivitis (EKC), and they have responded well to this treatment. There was actually a study comparing tea tree oil to pilocarpine gel, and it showed pilocarpine to be ineffective while the tea tree oil worked well. The study was published in 2005 in the British Journal of Ophthalmology (http://bjo.bmj.com/cgi/content/abstract/89/11/1468).

I don’t see any reason to bother with pilocarpine and all the side effects when we have something that works better without these side effects. I’ve been mixing the tea tree oil with macadamia nut oil. I am very aggressive about debriding the lids completely of all crust and debris at the base of the lashes. Once you learn how to recognize Demodex mites, you will be able to see them at the slitlamp, but it takes a few months of careful observation to figure out what you’re looking at. That’s where a microscope to view the lashes is important. The critters are about 0.3 mm in size.

It’s very important to be absolutely certain about what you are seeing and telling your patients because they will “freak out” and go for a second opinion from somebody who will invariably say you are “nuts and they’ve never heard of such a thing” unless you can show them the little beasties direct from their lids to the microscope slide in perfect clarity, wiggling their little legs around. At that point, they’ll do what you tell them, which involves a lot of home remedy. They have to change their personal hygiene, throw out their makeup, change their sheets, use new pillows and shampoos, etc. Often you have to treat the spouse as well. It is absolutely worth it though, because I’ve seen some pretty amazing stuff in the last six months.

Steven G. Safran M.D.

Lawrenceville, N.J.

Editors’ note: Dr. Safran was then asked what kind of scope he uses to view the Demodex mites. He provided an answer along with some additional insights:

The tea tree shampoos are available readily at health food stores, beauty supply stores, and Wegman’s. Any of them will do. I also recommend tea tree face wash and soaps as well as pads for patients to try. We don’t make specific brand recommendations.

My treatment regimen is one visit per week for three weeks (sometimes four), with three applications per treatment visit with each application about 10 minutes apart. The patient wears no makeup; first the lids are aggressively cleaned with a lid scrub if necessary to debride them. Patients usually report an improvement of symptoms within 48 hours and one week out, the eyes look much less red.

When working with these patients, I use the old microscope for examining my AK/RK blades. It works just fine. I’m not sure what the magnification is, but it’s perfect. A drop of Fluress (fluorescein sodium and benoxinate hydrochloride solution, Akorn, Buffalo Grove, Ill.) on the lash digests away some of the crust and makes it easier to see the mites. You can’t just pull the lash and get the mites—you have to really look at the root of the lash and catch the mites as you pull the lash; otherwise, you’ll miss them. One or two mites isn’t what I’m looking for. It’s the patients who have 10 or 20 per lash root or have an allergy to the mites with marked inflammation who I’m anxious to treat, as they will improve the most. I do the treatments myself at this point. I started to delegate this to my staff, but we had a run of EKC in the office back in July/August so I started to do the treatments again myself to get it under control, which we did. With EKC going around, I didn’t want my staff treating patients for fear that we could be blamed for causing a problem. The EKC has since passed but I’m still doing the treatment myself.

Steve Safran, M.D.

How can you justify this economically?

Joel Shugar, M.D., M.S.E.E.

Perry, Fla.

I charge for the treatments outside of insurance. I also give the patients a money-back guarantee that they will be improved. So far I haven’t had to refund anybody’s money. If the patients need any additional treatments in follow-up, I do not charge for that. I also don’t bill insurance for the treatment visits—the treatments are separate. I explain to patients they are paying for my expertise and time and that my time is expensive because of office overhead and other expenses. They are quite understanding. We’re not really making much, but we’re not losing money on this, and we’re helping a lot of patients.

Steve Safran, M.D.

James McCulley, M.D., University of Texas Southwestern, Dallas, has studied Demodex, and his studies have shown no relationship to symptoms of blepharitis. The Demodex theory regarding blepharitis came up years ago when I was in training but never made the cut.

I am not sure when the studies were published. I contacted Dr. McCulley, who has published heavily on blepharitis over the past 25 years. He said he studied a large number of patients, and the blepharitis does not in any way correlate with the presence or absence of Demodex in his studies. So he does not treat it but has no problem with those who so believe.

John M. Haley M.D.

Garland, Texas

I would refer you to an article in May 2007 from the American Journal of Ophthalmology, entitled “Cornea manifestations of ocular Demodex infestation.” Perhaps because there was not an effective treatment before, it was difficult to determine what role Demodex played. Without eliminating them, how can you judge what symptoms they are causing? We have seen incredible improvements in patient symptoms and inflammation of the ocular surface with treatment for this problem and eradication of the mites. Dr. Tseng, who I’ve been in contact with about this, has seen similar results, as have others around the country who have been involved with this. This is no placebo…we are seeing patients who have had red irritated eyes for years with chronic injection and cornea inflammation markedly improved a week after treatment. I can also tell you that almost every patient I see that has pannus in the cornea extending from the limbus as a solitary finding has tremendous Demodex infestation. I don’t know how somebody can rule out the role of Demodex in blepharitis without removing it from the equation. We haven’t been able to do this before.

Steve Safran, M.D.

Anecdotes are hazardous, and the May 2007 American Journal of Ophthalmology article does admit to the possibility of placebo effect (being non-randomized control) and the effects of tea oil extract other than the killing of Demodex. Nevertheless, I’m going to try it; there’s nothing to lose, and it seems plausible that spiders copulating and defecating and playing poker in your lashes would have some ill effect.

 Mitchell Gossman, M.D.

St. Cloud, Minn. 

As somebody who has been studying Demodex for the last six months, I can tell you that it’s not a simple matter of having it or not having it. There are different levels of infestation varying from an occasional one on occasional lashes to having 15 to 20 of them living at the base of each lash. There are also varying responses of the host to the Demodex depending on whether they are sensitive to the mites…we’ve seen some moderate levels of involvement with tremendous inflammation and more marked infestation with a lesser degree of inflammation. What I can tell you is that almost all primary anterior blepharitis patients do have Demodex involvement, and they get markedly better with treatment. The posterior blepharitis patients (meibomitis) do not appear to have any strong correlation with Demodex. If you see crusting, cylindrical dandruff, or scaly red lids, it’s very highly associated with Demodex. You can’t just pull lashes and examine under the microscope either because the mites will remain in the follicle. You have to pull the lash from side to side and tease the mites up and out to the surface and then you will see their tails at the slitlamp. Then as you pull the lash you can catch them with the end of the lash on the way out of the follicle. (If you just grab lashes and pull them, you won’t get any mites to come with the lash unless it’s very early in the morning…then sometimes the mites are less burrowed in and can be seen on the lash itself. Usually they are burrowed head down at the base of the lash and tails up in clusters and don’t come out with a simple epilation). It’s amazing to see the level of improvement in patients. Patients who’ve had chronically red eyes and beefy, injected palpebral conjunctiva come in one week after starting treatment and have porcelain white and quiet eyes. I’ve treated many physicians, lawyers, ER docs, nurses, you name it, and in some cases the change in appearance is almost as big as the improvement in symptoms. I think a patch test for Demodex will be helpful to determine who is allergic to the mites, but I believe I’m at the stage where I can tell that clinically.

Steve Safran, M.D. 

This may sound bizarre but I can relate this to my previous career in veterinary medicine. Just because some people have Demodex and don’t have significant signs of reaction/blepharitis does not mean it can’t happen in other people. I think Dr. Safran is correct in his assertion about the allergic response. We used to see dogs with severe allergic dermatitis as a result of fleas. They might only have two or three visible fleas. Other dogs would come in covered with fleas and not seem to have any significant problem. I am excited about this. I am searching on Ebay for a microscope right now.

Keith Kellum, M.D. Houma, La.

Editors’ note: The physicians who posted messages have no financial interests related to their comments.

Editors’ note: If you are not following these threads on the ASCRS Web discussion, you are missing the latest developments in cataract, refractive, glaucoma, and business practices. To join ASCRS EyeMail, where you can receive and exchange the most current thoughts about the hottest topics in ophthalmology, search archives, and more, log onto www.ascrs.org.

Contact Information

Gossman: mgossman@eyesurgeonsandphysicians.com

Haley: bigdeyedoc@hotmail.com

Kellum: dr2k2@kellum-eye-center.com

Safran: safran12@comcast.net

Shugar: stareyes@gtcom.net

ABOUT THE AUTHOR

J.E. “Jay” McDonald II, M.D.J.E. “Jay” McDonald II, M.D., is the EyeMail editor. He is director of McDonald Eye Associates, Fayetteville, Ark. Contact him at 479-521-2555 or mcdonaldje@mcdonaldeye.com.

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