Efficacy and Safety of Lotilaner Ophthalmic Solution (0.25%) for the Treatment of Demodex Blepharitis: A GRADE Assessed Systematic Review and Meta-Analysis of Observational & Experimental Studies.

PURPOSE: Several treatments have been in use for Demodex blepharitis, before the discovery of lotilaner, like tea tree oil and antibiotics; however, they either have irritable effects or systemic adverse effects, respectively. Lotilaner, a novel ectoparasiticide, has been proposed as a treatment for patients grappling with Demodex blepharitis. This review aims to assess the safety and efficacy of lotilaner in the treatment of Demodex blepharitis. DESIGN: Systematic review and meta-analysis. METHODS: An extensive search was conducted on PubMed, Cochrane Library, Scopus, and Google Scholar to find relevant literature till July 31, 2023 following the PRISMA guidelines. A total of 143 articles were retrieved by database searching, out of which 6 studies met the inclusion criteria and were included in the review. Four randomized controlled trials were included in the meta-analysis of mite eradication incidence. The review is registered with PROSPERO: CRD42023459997. RESULTS: Lotilaner is effective in eradicating Demodex mites in individuals suffering from Demodex blepharitis according to RR for the intervention versus the control group of 3.55 (95% confidence interval [CI]: 2.87-4.40, P < .00001, I2 = 0%). The meta-analysis of clinically meaningful collarette score revealed the summary RR for the intervention versus the control group was 3.15 (95% CI: 2.56-3.89, P < 0.00001, I2 = 27%). In conclusion, the results of the included studies were comparable and consistent. CONCLUSIONS: Our results indicated that lotilaner is an effective, well-tolerated, and promising drug in treating patients with Demodex blepharitis. Lotilaner administration and cost-effectiveness should now be contemplated for the study population as these constituents have a vital impact on its treatment success.

Corneal Effects of Tea Tree Oil.

PURPOSE: The purpose of this study is to report a case of corneal epithelial defects resulting from topical treatment of blepharitis with tea tree oil (TTO). METHODS: A 44-year-old man with a 1 year history of blepharitis non-responsive to eyelid hygiene was found to have signs of Demodex infestation. He was treated with a topical, off-label 50% TTO solution. Shortly afterward, the patient complained of bilateral ocular discomfort. RESULTS: Slit-lamp examination revealed conjunctival injection and a corneal epithelial defect in both eyes. Treatment with lubricant, antibiotic, and steroid eye drops as well as bandage contact lenses was required to facilitate corneal healing. CONCLUSIONS: Topical use of off-label, 50% concentration TTO can result in corneal epithelial defects. Eye care professionals should remain aware of this risk and only use approved, low-concentration TTO products when treating Demodex-related blepharitis.

[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.

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.

The Efficacy of Warm Compresses in the Treatment of Meibomian Gland Dysfunction and Demodex Folliculorum Blepharitis.

Purpose: To investigate and compare the effect of warm compresses on meibomian gland dysfunction and Demodex folliculorum blepharitis.Methods: Forty-two subjects (13 males, 29 females; mean age of 56.45 years) enrolled and completed the two-month warm compress treatment study. Three warm compress therapies were compared: Warm face cloth, MGDRx EyeBag® and OPTASETM Moist Heat Mask. Subjects attended for four visits: baseline, two weeks, four weeks, and eight weeks. Subjective symptoms, osmolarity, non-invasive tear break-up time, ocular surface staining, Schirmer I test, meibum expressibility and clarity, and eyelash manipulation and epilation to assess for the presence of Demodex folliculorum, were measured at each visit.Results: Meibomian gland dysfunction, based on a composite score of meibum quality and expressibility, reduced significantly with the MGDRx EyeBag® and the OPTASETM Moist Heat Mask (p < .05). There was no significant difference in efficacy for treating meibomian gland dysfunction between the two devices (p = .29). No improvement in meibomian gland dysfunction was detected with the warm face cloth. Only the OPTASETM Moist Heat Mask significantly reduced the quantity of Demodex folliculorum over eight-weeks of treatment (p = .036, only baseline to week eight significant p = .008). Symptoms and ocular surface staining improved significantly in all three groups (p < .05). There was no significant change observed in osmolarity, non-invasive tear break-up time or Schirmer I test within each group (p > .05, respectively).Conclusion: The MGDRx EyeBag® and the OPTASETM Moist Heat Mask exhibited superior efficacy in treating signs and symptoms of meibomian gland dysfunction, compared to the use of a warm face cloth, over the eight-week period. The OPTASETM Moist Heat Mask demonstrated dual therapeutic abilities, treating both meibomian gland dysfunction and Demodex folliculorum blepharitis. Repeated application of heat for the treatment of meibomian gland dysfunction may continue to present a good home-remedy option for patients.

Efficacy of treatments for Demodex blepharitis: A systematic review and meta-analysis.

PURPOSE: We conducted a systematic review and meta-analysis to evaluate the efficacy of different treatment for Demodex blepharitis. Parameters studied were mites count, improvement of symptoms and mites' eradication, stratified on type of treatments and mode of delivery of treatments (local or systemic). METHOD: The PubMed, Cochrane Library, Embase, ClinicalTrials.gov, Google scholar and Science Direct databases were searched for studies reporting an efficacy of treatments for Demodex blepharitis. RESULTS: We included 19 studies (14 observational and 5 randomized clinical trials), for a total of 934 patients, 1741 eyes, and 13 different treatments. For mites count, eradication rate, and symptoms improvement, meta-analysis included fifteen, fourteen and thirteen studies, respectively. The overall effect sizes for efficiency of all treatments, globally, were 1.68 (95CI 1.25 to 2.12), 0.45 (0.26-0.64), and 0.76 (0.59-0.90), respectively. Except usual lid hygiene for mites count, Children's Hospital of Eastern Ontario ointment (CHEO) for both eradication rate and symptoms, and CHEO, 2% metronidazole ointment, and systemic metronidazole for eradication rate, all treatments were efficient. Stratified meta-analysis did not show significant differences between local and systemic treatments (1.22, 0.83 to 1.60 vs 2.24, 1.30 to 3.18 for mites count; 0.37, 0.21 to 0.54 vs 0.56, 0.06 to 0.99 for eradication rate; and 0.77, 0.58 to 0.92 vs 0.67, 0.25 to 0.98 for symptoms improvement). CONCLUSION: We reported the efficiency of the different treatments of Demodex blepharitis. Because of less systemic side effects, local treatments seem promising molecules in the treatment of Demodex blepharitis.

Therapeutic Effect of Intense Pulsed Light on Ocular Demodicosis.

PURPOSE: To evaluate the clinical efficacy of Lumenis® M22TM intense pulsed light (IPL) in reduction of ocular Demodex infestation in eyelashes in a prospective study. METHODS: Forty patients with ocular demodicosis were recruited. Then half were randomly picked to receive the IPL treatment, while the other half got 5% tea tree oil (as the control group). Demodex counts, the ocular surface disease index (OSDI) score, lid margin abnormalities, conjunctival congestion, tear break-up time (TBUT), corneal staining with fluorescein, meibomian gland (MG) expressibility, meibum quality, modified Schirmer I test with anaesthetic (SIT), were assessed on the day before treatment and after treatment of 30 and 90 days, respectively. Changes in the parameters were compared between the IPL group and the control group on the days after treatment of 30 and 90 days. RESULTS: No differences were observed in Demodex counts, lid margin abnormalities, conjunctival congestion, corneal staining with fluorescein, MG expressibility, SIT in the two groups on the days after treatment of 30 and 90 days (p > 0.05), whereas there was a statistically significant difference in the OSDI score, TBUT, meibum quality (p < 0.05). The Demodex eradication rate was more thorough in the IPL group (100%) than in the control group (75%). CONCLUSIONS: IPL shows the preferably therapeutic potential for ocular Demodicosis.

Comparing the in vitro effects of MGO™ Manuka honey and tea tree oil on ocular Demodex viability.

PURPOSE: To compare the in vitro antiparasitic effects of MGO™ Manuka honey and tea tree oil against ocular Demodex. METHODS: Fifty-two viable Demodex mites were acquired from the epilated eyelashes of 9 participants with blepharitis and symptomatic dry eye. Viable mites were randomised to one of five treatment groups: cyclodextrin-complexed and uncomplexed Manuka Honey, 100% and 50% tea tree oil, and no treatment. Following treatment application, mite viability was assessed for 240 min, based on limb and body movement and/or the development of a crenated/translucent appearance. Kaplan-Meier survival analysis was then performed. RESULTS: The log-rank test demonstrated a significant treatment effect on the survival distribution of Demodex mites (p < 0.001). Bonferroni-corrected post-hoc pairwise analysis showed that all treatments except for uncomplexed honey effected lower survival probabilities than the untreated group (all p < 0.001). Among the four treatments, survival probabilities were lowest with 100% tea tree oil (all p < 0.001), and highest with uncomplexed honey (all p ≤ 0.001). No difference was observed between complexed honey and 50% tea tree oil (p = 0.81). CONCLUSIONS: The in vitro efficacy of cyclodextrin-complexed Manuka honey was comparable with 50% tea tree oil, an established treatment for ocular Demodex. The findings support future clinical trials investigating the therapeutic effects of complexed honey in demodectic blepharitis patients.

Evaluation of the Efficacy of Tea Tree Oil On the Density of Demodex Mites (Acari: Demodicidae) and Ocular Symptoms In Patients With Demodectic Blepharitis.

The objective of this study was to examine the efficacy of 7.5% tea tree oil (TTO) eyelash shampoo on the density of Demodex (Acari: Demodicidae) and ocular symptoms in patients with demodectic blepharitis. A total of 135 patients diagnosed with demodectic blepharitis, following clinical inspection and parasitological examinations, were included in the study. Patients were treated with eyelash shampoo, with or without TTO. Full Demodex reduction was attained in 36% of the patients who used eyelash shampoo with TTO, and the average Demodex count was reduced from 6.33/eyelash to zero ( P < 0.001). In contrast, the average Demodex count in patients who did not achieve full reduction (64%) was reduced from 12.46/eyelash to 4.15/eyelash ( P < 0.001). Full reduction was observed in 11.7% of patients who used TTO-free eyelash shampoo, and average Demodex count reduced from 2.00/eyelash to zero ( P = 0.017). The average Demodex count was reduced from 11.98/eyelash to 7.91/eyelash in patients (88.3%) who did not achieve full reduction ( P = 0.024). Additionally, ocular symptom scores (which are generated based on subjective experiences of itching, burning, the feeling of a foreign body in the eye, eye redness, and cylindrical dandruff) were reduced significantly ( P < 0.001) in patients who used the eyelash shampoo with TTO. The symptom scores remained almost the same in patients who used TTO-free eyelash shampoo ( P > 0.05). In conclusion, it was determined that eyelash shampoo with TTO is 3 times more effective at achieving full Demodex reduction, significantly reducing the Demodex count, and relieving ocular symptoms in patients where full reduction cannot be attained, without adverse side effects.

The efficacy of tea tree face wash, 1, 2-Octanediol and microblepharoexfoliation in treating Demodex folliculorum blepharitis.

PURPOSE: To compare the efficacy of Dr Organic Tea Tree Face Wash, OcuSoft Lids Scrub Plus and the BlephEx™ device at treating of Demodex folliculorum blepharitis. METHODS: Eighty-six subjects (33 males/36 females) were enrolled in a randomised controlled interventional treatment study. Subjects completed a dry eye symptom questionnaire and were assessed for presence of Demodex folliculorum. Subjects were divided into three groups according to treatment: Dr Organic Tea Tree Face Wash (A) (n=28), OcuSoft Lid Scrub Plus (B) (n=30), or in-house lid scrub with the BlephEx™ device before nightly lid scrubs with OcuSoft Lid Scrub Plus (C) (n=28). Subjects were advised to clean their eyelids nightly for four weeks. Each subject was re-assessed for symptoms and Demodex folliculorum blepharitis after two weeks and four weeks of treatment. RESULTS: The quantity of Demodex folliculorum was significantly reduced after four weeks of treatment in all three groups (p<0.05). Overall, there was no difference in efficacy between the three treatments (p>0.1). Symptoms reported by subjects were significantly improved after two and four weeks of treatment (p<0.05). Overall, there was no difference in efficacy between the three treatments to reduce symptoms after two or four weeks (p= 0.813 and p=0.646 respectively). CONCLUSION: All three methods tested have shown good ability to reduce Demodex folliculorum quantity, improve subjective symptoms and help treat Demodex folliculorum blepharitis.

[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.

[Demodex folliculorum: diagnosis and therapy today]. / Demodex folliculorum: Diagnostik und Therapie im klinischen Alltag.

Demodex folliculorum is an ectoparasite found in eye lashes. A Demodex-associated blepharoconjunctivitis is common. Demodex are diagnosed via microscopy in a drop of oil after epilation of a few eye lashes. You can often watch the mites in movement under the microscope. Treatment includes lid hygiene and metronidazole gel 1-2 %. The treatment often improves the symptoms of the patient. Demodex folliculorum is often found in patients with persistent blepharoconjunctivitis. Every ophthalmologist should have a microscope to find the mites. Then you will be able to treat the patients in an early stage.

Ocular demodicidosis as a risk factor of adult recurrent chalazion.

PURPOSE: To report Demodex infestation in adult recurrent chalazion and its clinical response to weekly lid scrub with 50% tea tree oil (TTO) and daily lid scrub with tea tree shampoo. METHODS: This is a retrospective review of 30 adult patients (48 eyes) who presented with recurrent chalazion within 6 months after conventional treatment. Demodex was detected by random lash sampling and microscopic examination. Patients with confirmed ocular Demodex infestation were treated with weekly lid scrub with 50% TTO and daily lid scrub with tea tree shampoo. The study is limited by the lack of a control group. RESULTS: The mean age of patients was 39.1 ± 10.2 years (range 18-69). The mean follow-up of patients is 10.0 ± 3.0 months (range 6-24 months). Among 48 eyes with recurrent chalazion, Demodex mites were found in 35 (72.9%). Recurrent chalazion was found to be associated with ocular demodicidosis (Fisher exact test, p = 0.017). Tea tree oil treatment was given to 31 eyes with recurrent chalazion associated with Demodex infestation. Among the treatment group, all cases except one had no recurrence after the TTO treatment. The success rate of preventing recurrence is 96.8%. Treatment of TTO was found to be associated with preventing recurrence of chalazion associated with Demodex infestation (Fisher exact test, p = 0.002). CONCLUSIONS: The possibility of demodicidosis should be considered in adults presenting with recurrent chalazia. Tea tree oil eyelid scrubs is an effective treatment in preventing recurrence.

Pharmacological treatment for infectious corneal ulcers.

INTRODUCTION: Cornea ulceration and infectious keratitis are leading causes of corneal morbidity and blindness. Infectious causes are among the most frequent and most severe. Management strategies for bacterial corneal ulcers have changed significantly over the last decades, however with a more limited progress in the treatment and management of nonbacterial, infectious ulcers. AREAS COVERED: This paper provides an overview of the current principles, strategies and treatment choices for infectious corneal ulcers in adults. EXPERT OPINION: Topical application with a broad-spectrum antimicrobial remains the preferred method for the pharmacological management of infectious corneal ulcers. Increasing reports of clinical failures and in vitro resistance to antibiotics to treat the most common infectious (bacterial) corneal ulcers are increasing concerns. New approaches for improvement in the pharmacological management of corneal ulcers should focus on strategies for a more rational and evidence-based use of current antimicrobials and development of products to modulate the host immune response and to neutralize microbial toxins and other immune modulators.

Ocular surface discomfort and Demodex: effect of tea tree oil eyelid scrub in Demodex blepharitis.

The purpose of this study was to evaluate the relation between ocular discomfort and ocular Demodex infestation, and therapeutic effects of tea tree oil (TTO) in Demodex blepharitis patients. Three hundred and thirty-five patients with ocular discomfort were evaluated for ocular Demodex infestation and subjective symptoms with ocular surface discomfort index (OSDI) score. Among them, Demodex-infested patients were randomized to receive either eyelid scrubbing with TTO (TTO group,106 patients) or without TTO (Control group, 54 patients) for 1 month. Demodex were found in 84% of patients with ocular discomfort. The number of Demodex was significantly correlated with age (P = 0.04) and OSDI score (P = 0.024). After eyelid scrub treatment, Demodex count was reduced from 4.0 ± 2.5 to 3.2 ± 2.3 in the TTO group (P = 0.004) and from 4.3 ± 2.7 to 4.2 ± 2.5 in the control group (P = 0.27). Also, OSDI score was reduced from 34.5 ± 10.7 to 24.1 ± 11.9 in the TTO group (P = 0.001) and from 35.3 ± 11.6 to 27.5 ± 12.8 in the control group (P = 0.04). In conclusion, Demodex number showed a significant positive correlation with age and subjective ocular discomfort. The tea tree oil eyelid scrub treatment is effective for eliminating ocular Demodex and improving subjective ocular symptoms.