A Novel Lid Hygiene Detergent Successfully Eliminated Demodex Mites, a Common Pathogen of Refractory Obstructive Meibomian Gland Dysfunction.

INTRODUCTION: Demodex mites are microscopic arthropods that have been shown to be responsible for chronic blepharitis. Although many reports have demonstrated positive effects of lid hygiene on demodicosis, some have produced conflicting results. We retrospectively evaluated the effect of lid margin cleansing with a novel lid hygiene detergent, Eye Shampoo, in patients with ocular demodicosis. METHODS: Outpatient clinic notes recorded over a 24-month period between June 30, 2016, and June 29, 2018, at Keio University Hospital in Japan were reviewed to identify patients diagnosed with ocular demodicosis who started cleansing their lid margins with Eye Shampoo at least once daily as a lid hygiene therapy. RESULTS: Five patients diagnosed with ocular demodicosis who started cleansing their lid margins using Eye Shampoo for lid hygiene were identified. In four cases, Demodex mites were successfully eliminated, and ocular conditions were ultimately improved with no recurrence. Active Demodex mites were still noted after 3 months of lid hygiene therapy in one case; further observation of this case was not available. There were no adverse effects of Eye Shampoo in any of these cases. CONCLUSION: Lid hygiene therapy using Eye Shampoo successfully eliminated Demodex mites, a common pathogen of refractory obstructive meibomian gland dysfunction.

Upper Eyelid Nodule - An Unusual Presentation of Ocular Demodicosis.

INTRODUCTION: Demodex mite is an external parasite which is implicated in various ocular conditions like anterior blepharitis, posterior blepharitis, meibomian gland dysfunction, chalazia and others. Although demodex has been shown to be a causative agent of chalazia, occurrence of a solitary inflammatory nodule due to demodex infestation has not been reported in literature. CASE: Our case describes the occurrence of an upper eyelid mass in a 62-year-old female which was found to have an associated demodex infestation. CONCLUSION: This is the first report of demodex infestation presenting as a nodular eyelid mass. This parasite needs to be considered in the differential diagnosis of eyelid masses as this condition requires specific management.

[Demodex and ocular surface disease]. / Demodex et pathologies de la surface oculaire.

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Blepharitis Caused by Demodex

Objective: Demodicosis is a Skin disease in humans caused by Demodex folliculorum (D. folliculorum) and Demodex brevis (D.brevis) mites. Demodex infestation is mostly located in sebaceous and meibomian glands in the hair follicles. The aim of this study was to determine the age and sex distribution of Demodex infestation in patients with blepharitis. Methods: Between 2011-2018, eyelashes from 335 patients with blepharitis, visual impairment or conjunctivitis attached to the cellophane tape were sent to the laboratory of Department of Medical Parasitology in Çukurova University Medical Faculty and were examined within 1 hour. Results: D. folliculorum was detected in 143 (42.6%) of the 335 patients. Of the patients in whom D. folliculorum was detected, 50 (35%) were female and 93 (65%) were male. The mean age of patients with D. folliculorum was 64.1 years and the mean age of patients without D. folliculorum was 52.7 years. Conclusion: In patients with blepharitis, the incidence of Demodex increases with age.

Double-Masked and Unmasked Prospective Study of Terpinen-4-ol Lid Scrubs With Microblepharoexfoliation for the Treatment of Demodex Blepharitis.

PURPOSE: To evaluate terpinen-4-ol lid scrubs (Cliradex) with Microblepharoexfoliation (MBE) (BlephEx) in the treatment of Demodex blepharitis. METHODS: An Institutional Review Board (IRB) approved the randomized prospective double-masked trial of 50 patients with Demodex positive blepharitis. All subjects were given an in-office MBE treatment and randomized to masked lid scrubs (terpinen-4-ol or sham) twice daily for 1 month. All subjects then returned for an additional MBE treatment and received open-label terpinen-4-ol scrubs twice daily for 1 month. OUTCOMES: Demodex levels, Ocular Surface Disease Index, tear osmolarity, MMP-9, Schirmer 1 and grading of the lid margin appearance, meibomian gland dropout, and meibomian gland secretions. RESULTS: Forty-six subjects (23 per group) were included for the analysis; 4 lost to follow up. Total Demodex folliculorum levels in the Cliradex group improved: 4.7 to 3.6 (first month interval P = 0.266) to 2.6 (second month interval P = 0.279), overall P < 0.05 over 2 months. Total levels in the sham group improved: 5.1 to 3.0 (first month interval P < 0.05) to 2.5 (second month interval P = 0.496), overall P < 0.05 over 2 months. No clear statistically meaningful improvements in other dry eye and blepharitis data metrics were observed. CONCLUSIONS: In-office MBE treatments combined with either Cliradex terpinen-4-ol medicated lid scrubs or sham scrubs showed a statistically significant reduction in D. folliculorum infestation levels; however, conclusions on clinical significance could not be made. In-office MBE with terpinen-4-ol lid scrubs showed no significant improvement over sham scrubs.

Intense Pulsed Light Therapy for Patients with Meibomian Gland Dysfunction and Ocular Demodex Infestation.

To observe the clinical changes of meibomian gland dysfunctipn (MGD) and ocular Demodex infestation after intense pulsed light (IPL) treatment to further examine the mechanism of IPL treating patients with MGD and ocular Demodex infestation. The medical records of 25 patients (49 eyes) with MGD treated with IPL, were retrospectively examined to determine outcomes. Associated ocular-surface parameters (ocular surface disease index, OSDI; lipid layer thickness, LLT; noninvasive first breakup time, NIF-BUT; noninvasive average breakup time, NIAvg-BUT; tear film breakup area, TBUA; Schirmer I Test, SIT; corneal fluorescein staining, CFS), eyelid margin abnormalities, meibum quality and expressibility, MG morphological parameters (macrostructure and microstructure), and the number of Demodex infestation were examined before and after treatment. The MG microstructure and the Demodex infestation were examined via in vivo confocal microscopy (IVCM). The results showed that there were statistically significant differences in associated ocular-surface parameters (all P<0.05) before and after IPL treatment, except SIT (P=0.065). Eyelid margin abnormalities, meibum quality and expressibility obviously improved in upper and lower eyelid after IPL treatment (all P<0.0001). MG macrostructure (MG dropouts) decreased in upper (P=0.002) and lower eyelid (P=0.001) after IPL treatment. The nine parameters of MG microstructure in upper and lower eyelid all distinctly improved after IPL treatment (all P<0.0001). The mean number of Demodex mites on the upper lid margin (6.59±7.16 to 3.12±3.81/9 eyelashes) and lower lid margin (2.55±2.11 to 1.29±1.53/9 eyelashes) significantly reduced after IPL treatment (all P<0.0001). The Demodex eradication rate was 20% (8/40) in upper lid margin and 34.15% (14/41) in lower lid margin. These findings indicate that IPL shows great therapeutic potential for patients of MGD and ocular Demodex infestation.

The correlation between the microstructure of meibomian glands and ocular Demodex infestation: A retrospective case-control study in a Chinese population.

Meibomian gland dysfunction (MGD) is a common disease in ophthalmic clinic. This study aimed to explore ocular Demodex infestation on the microstructure changes of the meibomian glands (MGs) in patients with MGD by in vivo confocal microscopy (IVCM).We retrospectively reviewed 103 eyes of 52 patients with MGD and 62 eyes of 31 non-MGD patients. All enrolled patients underwent IVCM examination. The following IVCM parameters were recorded: the MG acinar density (MAD), MG acinar longest diameter (MALD), MG acinar shortest diameter (MASD), MG orifice area (MOA), severity of MG fibrosis (MF), MG acinar irregularity (MAI), meibum secretion reflectivity (MSR), inhomogeneous appearance of walls of acinar units (AWI) and periglandular interstices of acinar units (API), and the number of Demodex.The positive rate of Demodex infestation in MGDs was 89.32%, and statistically higher than control group (controls; P < .001). All parameters showed statistically significant differences between MGDs and controls (P < .001), and Demodex-negative group and Demodex-positive group (P < .05) in both MGDs and controls, except MAD (P = .826) in controls. The number of Demodex was positively correlated with MALD, MASD, MF, MAI, MSR, AWI, and API in MGDs and controls (P < .05), and negatively correlated with MAD and MOA in MGDs (P < .05). MOA showed a strong significant correlation with the number of Demodex in controls (P < .001), whereas there was no significant difference between the number of Demodex and the MAD in controls (P = .448).Demodex can cause microstructural changes of MGs, which can cause or aggravate MGD, and the more the number of Demodex infestation, the more serious the structural damage.

Significant correlation between meibomian gland dysfunction and keratitis in young patients with Demodex brevis infestation.

AIMS: To report the clinical characteristics and correlation between meibomian gland dysfunction (MGD) and keratitis in young patients with ocular demodicosis. METHODS: Observational case series of 60 patients younger than 35 years with ocular demodicosis, of which the diagnosis was based on microscopic counting of Demodex folliculorum and D. brevis of epilated lashes. Severity of keratitis and MGD was graded by photography and meibography, respectively, in a masked fashion. RESULTS: MGD was detected in 54/60 (90%) patients with the loss of meibomian gland in the upper lid more than the lower lid (p<0.001). Blepharoconjunctivitis and a variety of corneal pathologies were noted in 47/60 (78.3%) and 39/60 (65%) patients, respectively. For a total of 120 eyes, normal cornea was noted in 53 (44.2%) eyes, superficial punctate keratitis or limbitis was noted in 17 (14.2%), while corneal stromal infiltration was found in 50 (41.7%) eyes. Both univariate and multivariate analyses showed that the severity of meibomian gland loss was significantly correlated with higher D. brevis count and more severe keratitis (all p<0.05). Rapid resolution of keratitis and blepharoconjunctivitis was accompanied by significant reduction of the Demodex count in 48 patients receiving lid scrub directed to kill mites. CONCLUSIONS: There is a significant correlation between MGD and keratitis in young patients with ocular demodicosis especially inflicted by D. brevis.

[Prevalence and treatment effects of Demodex species in eyelash follicles in patients with meibomian gland dysfunction].

Objective: To investigate the prevalence and treatment effects of Demodex species in eyelash follicles in patients with meibomian gland dysfunction (MGD). Methods: The MGD patients (MGD group) and normal subjects (control group) were collected from the Ophthalmology Clinic in PUMCH from July 2015 to December 2015. The symptom score of MGD patients was recorded. Eyelash sampling, Demodex counting, tear film break-up time (BUT), cornea fluorescein staining (Fl) and Schirmer test Ia (S Ⅰ aT) were measured for both groups. All the measurements were repeated after 4 weeks of meibomian function treatment for the MGD group. Symptom score, BUT, Fl and S ⅠaT were normally distributed and displayed as mean± standard deviation. Demodex counting was not normally distributed and displayed as median (interquartile range P25, P75). Results: Forty-four MGD patients (88 eyes) and 48 controls (96 eyes) were recruited. For the MGD and control groups, the number of Demodex was 3.5 (2, 7) and 0 (0, 7), respectively (Z =-4.912,P= 0.000). The percentage of Demodex infestation was 86.4% and 39.6%, respectively (χ(2)=35.957, P=0.000). The BUT was (3.57±2.09) s and (10.17±3.25) s, respectively (t=-5.154, P=0.000). The Fl was 2.73±1.23 and 0.85± 0.33, respectively (t=4.583, P=0.000). The SⅠaT was (8.75±5.61) s and (14.51±5.29) s, respectively (t=-2.278, P=0.028). The symptom score of the MGD group before and after treatment was 4.77 ± 3.01 and 2.79 ± 2.01, respectively (t=6.224, P=0.000). The BUT, Fl and number of Demodex of the MGD group after the treatment were (5.43±2.37)s, (1.91±0.66) and 2 (0, 3), respectively, and all had significant difference with the data before the treatment (BUT, t=-4.705, P=0.000. Fl, t =3.902, P =0.000. number of Demodex, Z=-4.623, P =0.000). The S Ⅰ aT of the MGD group after the treatment was 8.86 ± 6.76, with no significant difference with the data before the treatment (t=-0.277, P=0.833). Conclusions: The Demodex infestation has some effects on the pathogenesis of MGD. The treatment of MGD may help to decrease the number of Demodex and thus relieve the ocular discomfort.(Chin J Ophthalmol, 2017, 53:193-197).

[Demodex folliculorum a hidden cause of blepharitis].

UNLABELLED: Meibomian gland dysfunction (MGD) is a common cause of dry eye disease. Demodex mites can cause MGD with symptoms like itching, dryness and general ocular discomfort. It is important to consider infestation with Demodex mites in individuals who are non responsive to traditional MGD treatment but also equally important when cylindrical dandruff is seen at the base of the eye lashes.. We report two individuals who had not responded to ocular and systemic treatment for MGD and were then diagnosed with Demodex mites. Treatment with BlephEx and Tea tree oil was successful. This is the first report on Demodex folliculorum in Iceland where a genetic analysis was done. KEY WORDS: Demodex, blepharitis, debris, tea tree oil, dry eye. Correspondence: Sigurlaug Guðrún Gunnarsdóttir sigurlaug@sjonlag.is.

Demodex treatment in external ocular disease: the outcomes of a Tasmanian case series.

Demodex species (spp.) have previously been implicated in the pathogenesis of blepharitis. This study aims to correlate improvement in symptoms of external ocular disease with treatment of underlying Demodex spp. This is a prospective, observational case series of patients with chronic external ocular disease. Demodicosis was confirmed by microscopic examination of epilated eyelashes. The main outcome measure was response to the treatment (5 % tee tree oil) in regard to change in subjective symptoms utilising a symptom-based patient questionnaire assessment. Overall patients had a good response to the treatment in terms of improvement or resolution of symptoms, with 91 % of patients reporting at least some improvement in symptoms. The treatment of underlying Demodex spp. appears to result in improvement of symptoms in patients with long standing external ocular disease and underlying Demodex spp. infestation.

Recent advances on ocular Demodex infestation.

PURPOSE OF REVIEW: To summarize recent advances on ocular Demodex infestation. RECENT FINDINGS: Demodex infestation is a potential cause of ocular surface inflammation. The pathogenesis of Demodex in eliciting ocular surface inflammation has been further clarified. Cliradex is currently the treatment of choice, it comprises the most active ingredient of tea tree oil, that is terpinen-4-ol, which helps eradicate Demodex mites and reduce ocular surface inflammation. SUMMARY: Ocular demodicosis is a common but overlooked eye disease that manifests a number of morbidities. Demodex folliculorum causes chronic anterior blepharitis whereas Demodex brevis causes posterior blepharitis, meibomian gland dysfunction, recurrent chalazia, and refractory keratoconjunctivitis. The lash sampling and microscopic counting method and in-vivo confocal microscopy are key diagnostic methods. Cliradex shows promising potential to reduce Demodex counts with additional antibacterial, antifungal, and anti-inflammatory actions.

In vivo confocal microscopy as a novel and reliable tool for the diagnosis of Demodex eyelid infestation.

AIMS: Demodex mites are implicated in several ocular surface diseases such as blepharitis, ocular rosacea and dry eye syndrome. Demodex eyelid infestation is classically diagnosed by analysing depilated eyelashes under the light microscope. The use of in vivo confocal microscopy (IVCM) could be an easy way to improve its diagnosis. The ability of IVCM to identify Demodex was evaluated and compared with the classic depilation method. METHODS: Eight healthy subjects, 22 patients with dry eye syndrome without anterior blepharitis and 18 patients with anterior blepharitis were examined using lower eyelid IVCM (lash follicles and meibomian glands (MGs)). Twenty-five of the 48 subjects underwent both an IVCM examination and classic depilation to compare the two methods. Ex vivo Demodex obtained from lash depilation were also analysed using the confocal microscope. RESULTS: IVCM found 100% of the mite infestations among patients with anterior blepharitis, 60% among dry eye patients without blepharitis and 12% in healthy subjects, whereas the depilation technique found 100%, 50% and 0%, respectively. Demodex brevis and Demodex larvae inside the lash follicles were better detected by IVCM. In symptomatic patients, the Demodex infestation was often associated with MG dysfunction, which was better characterised using IVCM in symptomatic patients (60% and 40% of meibomianitis and gland fibrosis, respectively). CONCLUSIONS: IVCM is an efficient and reliable tool for the diagnosis of eyelid mite infestation and may also provide an evaluation of MGs.

Blepharitis: always remember demodex.

PURPOSE: To determine the incidence and density of Demodex species on the eyelashes of subjects with normal eyelids, anterior blepharitis (AB), meibomian-gland dysfunction (MGD), and mixed blepharitis (MB). MATERIALS AND METHODS: One hundred and fifty consecutive patients diagnosed with AB, MGD, and MB were recruited. An additional 50 individuals were recruited who were free of lid and margin disease to serve as a control group. All patients underwent a standard eye examination. Data on ocular symptomatology were gathered. Digital photography was performed of the lid margins. Lash sampling was performed by epilating the lashes and the lashes were checked for Demodex based on morphology using light microscopy. The total number of mites were tabulated for each eye. Comparison between the affected eyes and the control eyes was performed. Data were analyzed using the Chi-square test. RESULTS: A total of 200 patients were included. Twenty percenth had AB, 40% had MGD, and 40% had MB. The incidence of Demodex infestation was 90% in cases of AB, 60% in MGD cases, and 90% in MB cases. The incidence of Demodex in control subjects was 18%. CONCLUSIONS: The incidence and density of Demodex infestation was highest in patients with AB and MB. Lid irritation and presence of cylindrical dandruff were indicative of a high-density infestation. These signs should alert the clinician to treat concomitant Demodex infestation.

Demodex.

PURPOSE: Demodex folliculorum and Demodex brevis are ectoparasites with an astounding prevalence of 100% in patients aged 70 years and older. Every person in this age group is estimated to carry a colony of 1000 to 2000 mites. With such a high prevalence, little attention has been paid to the mite among eye care practitioners. We demonstrate a clinical sequence in a set of case reports to identify the mite. The clinical sequence includes a clinical history of blepharitis, dry eyes, and/or ocular allergy; slit lamp examination of cylindrical dandruff; and confirmation using light microscope evaluation of epilated lashes. CASE REPORTS: Patient 1 was a 68-year-old woman who demonstrates associations with dry eyes and diabetes. Patient 2 was a 44-year-old man with uncommonly seen D. brevis present. Patient 3 was a 40-year-old woman with dry eyes and allergy, showing mite tails protruding from base of lashes. Patient 4 was a 60-year-old woman who demonstrates the association with rosacea. Patient 5 was a 53-year-old woman intermittently taking topical steroid and antibiotic combination medications, with an actual mite photographed on the surface. CONCLUSIONS: Following a clinical sequence helps identify Demodex, the underdiagnosed, undertreated, and underappreciated ocular surface disease.

Evaluation of the presence of Leishmania spp. by real-time PCR in the lacrimal glands of dogs with leishmaniosis.

Leishmania infantum infection is highly prevalent in endemic areas. Dogs with leishmaniosis may develop keratoconjunctivitis sicca (KCS). The goals of this study were (1) to quantify Leishmania amastigotes in the Meibomian glands (MG), main lacrimal gland (MLG) and nictitating membrane gland (NMG) from dogs with leishmaniosis; (2) to compare these results to immunohistochemistry (IHC), and (3) to explore the association between the Leishmania parasite load and the presence of ocular clinical signs. Twenty-five dogs diagnosed with leishmaniosis were included. MG, MLG and NMG from both eyes were collected. Histopathology, IHC and real-time PCR were performed. All specimens yielded positive real-time PCR results. For all three glands, samples from dogs with ocular clinical signs had mean ΔCt (cycle threshold) values significantly lower (higher parasite loads) than those from dogs without signs. Cut-off values of ΔCt<0, ΔCt<4 and ΔCt<4.9 for MG, MLG and NMG, resulted in a likelihood ratio of positives of 5.9, 6.38 and 6.38, respectively. Samples with ΔCt values below the reported cut-off were significantly more likely to display clinical signs related to KCS than those with results above the cut-off, for all three glands. Similarly, ΔCt values below the cut-off were significantly associated with positive IHC. In this study real-time PCR has been standardised for use in MG, MLG and NMG. A cut-off value established for each of these tissues may aid the clinician in the discrimination between ocular signs related to Leishmania from those associated with other causes of KCS.

Characterization of lacrimal gland lesions and possible pathogenic mechanisms of keratoconjunctivitis sicca in dogs with leishmaniosis.

In a previous study, it was found that 2.8% of dogs with leishmaniosis had keratoconjunctivitis sicca (KCS). The aim of this study was to characterize the lesions present in the lacrimal glands of dogs with leishmaniosis and to determine the presence of the parasite by means of immunohistochemistry. The inflammatory infiltrate was described as granulomatous or pyogranulomatous and was located around the ductal component of the glands. Immunoperoxidase staining localized the parasites following the same pattern. Samples from eyes that had clinical signs compatible with KCS presented inflammatory infiltrate and parasite more commonly than those from eyes without clinical signs. One of the mechanisms of KCS in dogs with leishmaniosis may be the inflammatory infiltrate located around the ducts of lacrimal glands, producing retrograde accumulation and retention of secretion. Meibomian gland was the most commonly affected by the infiltrate, highlighting the possibility of a qualitative KCS in these dogs.

Prevalencia de Demodex folliculorum en pacientes con blefaritis crónica / Prevalence of Demodex Folliculorum in patients with cronic blepharitis

La etiología de las blefaritis crónicas es diversa. Demodex folliculorum es un ácaro que habita en las glándulas de Meibomio y en los folículos de las pestañas. Objetivo. Conocer la prevalencia y características clínicas de la infestación por Demodex folliculorum en pacientes con blefaritis crónica. Materiales y métodos. Realizamos un estudio prospectivo, transversal, comparativo y observacional. Se incluyeron pacientes con blefaritis crónica realizando cultivo, antibiograma y búsqueda de Demodex folliculorum en folículos de pestañas, comparándose este último parámetro con un grupo de sujetos sanos. Resultados. Evaluamos 100 pacientes por grupo. Encontramos positividad para Demodex folliculorum en 35 por ciento de los casos con blefaritis y en 7 por ciento de los controles sanos. La prevalencia más alta se encontró después de los 60 años (51 por ciento), el sexo femenino fue el mas afectado (85 por ciento). Los collaretes en la base de las pestañas, alteraciones en su dirección, madarosis y obstrucción de glándulas de Meibomio sugieren la presencia del parásito. Conclusiones. Demodex folliculorum muestra mayor prevalencia en pacientes con blefaritis crónica comparada con sujetos sanos siendo más abundante después de los 60 años y predomina en mujeres. Debe considerarse su búsqueda y tratamiento en blefaritis crónicas resistentes al tratamiento.

Demodex sp. in California ground squirrels.

An undescribed species of Demodex (Acari: Demodecidae) was observed in hair follicles and ducts of sebaceous glands in the ear canals of seven California ground squirrels (Spermophilus beecheyi) from Santa Clara County, California (USA). The animals had died of unrelated causes and were submitted for necropsy between September 1994 and February 1996. Similar mites were observed in the lumens of hair follicles and ducts of Meibomian glands in the eyelids of two of these squirrels. Microscopic changes in the epithelium and surrounding dermis, when present, were minimal. No associated clinical signs of disease or macroscopic lesions were observed. To our knowledge, this is the first report of Demodex sp. in a ground squirrel.

Demodex bisonianus sp. nov. (Acari, Demodicidae) a new parasite of the bison (Bison bonasus L.).

Demodex bisonianus sp. nov. (Acari, Demodicidae) and its stages of development has been described. It was found in the Meibomian glands of the Bison bonasus L. from the Puszcza Bialowieska (Poland).