Laura M. Periman, MD

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Research indicates that because nocturnal evaporative stress is a frequently overlooked and undermanaged component of dry eye care.

We frequently educate our patients on the role of sleep as a facilitator of overall good health. But what happens when our diligent sleepers wake up with dry eye symptoms that are decidedly worse, not better?

The strange phenomena of my patients getting more and better sleep-and still waking up with peak severity dry eye symptoms-led me to investigate the cause of, and potential remedies for, symptomatic dry eye that worsens overnight.

According to recent research published by Korb, Blackie, and Nau in 2017, poor eyelid performance while sleeping-and subsequently, the 

 that follows-is prevalent in patients suffering from refractory dry eye. Further, they identified that poor lid performance correlates relatively neatly with moderate-to-severe symptoms.

This research is significant because NES is a frequently overlooked and undermanaged component of dry eye care. By taking a more proactive approach to identifying and managing this nuanced set of aggravators, we can help soften our patients’ symptoms and boost their quality of life.

First, we should recognize that the severity of nocturnal evaporative stress is influenced by both external and internal factors as well as 

External factors, such as those studied by Korb et. al., are essentially biomechanical failures: for instance, poor lid performance, sleeping position preference or the presence of floppy eyelid syndrome (which has been shown to negatively impact the tear film’s functionality).

Internal factors may include medications, allergic responses to dust mites, or direct contact with turbulent vent and fan air, all of which can induce desiccating stress that damages the eye’s protective layers, aqueous or lipid.

Dry eye practitioners are good at investigating external factors. Most of us already advise our dry eye patients to avoid fans and allergens and review the medications list for relevant drying side effects. More careful examination for evidence of poor nocturnal lid performance is a good place to start, as diagnostic testing and remedial options are both straightforward and effective.

Intense Pulsed Light Therapy For The Treatment Of Chalazia

However, from my experience talking to patients and colleagues, we can improve our considerations and assessments for a wider range of internal factors with improved knowledge of common ocular surface drying medications.  

To test my patients’ lid performance in clinical examination, I have adopted the Korb-Blackie lid leak test, which was described as a way to evaluate dry eye symptom prevalence and severity with respect to lid closure.

The test itself is simple: in a darkened room, place a muscle light or transilluminator gently at the upper tarsus of the closed eye, and direct the light toward the interpalpebral fissure. If light escapes between the eyelids, it is a positive test. More light leakage indicates a more significant nocturnal lid seal insufficiency which is associated with more exposure/desiccating stress and greater symptom severity.

The test is so simple and informative, I made it a part of my standard dry eye diagnostic workup. It takes 15 seconds to perform. We record this in the EMR as “Lid Seal Insufficiency”-negative, mild, moderate, or severe-based on the amount of light leaking in between the closed eyelids.

I complement this test by performing an even simpler “snap test:” pulling gently on the patient’s upper and lower lids to assess elasticity, with slow return to normal position indicating a lack of elasticity, and subsequently, lid performance.

Lift the upper lids to look for excess laxity, papillary reaction of the superior palpebral conjunctiva. These two findings, in addition to temporal upper eyelash ptosis, suggests floppy eyelid syndrome and a sleep study for obstructive sleep apnea is ordered.

If light is escaping, the lids are not adequately protecting the ocular surface. A special eye mask can make a significant difference for these cases. Clinically, I’ve observed in cases of asymmetric lid seal insufficiency that the meibomian gland drop is often more pronounced on the more severe lid seal insufficiency side.

Once I identify poor nocturnal lid protection, I instruct the patient to take a series of proactive steps to protect the ocular surface from overnight desiccating stresses, even if he or she does not report disproportionate pain or discomfort in the morning. First, I instruct them to direct fans and vents well away from the head. I also tell them to avoid dust-mite allergens (dust mite pillow covers, mattress covers, and weekly hot water washings of bedding).

If the patient’s lid seal insufficiency is mild and the signs and symptoms are mild, I may suggest over-the-counter preservative free lubricating gels and ointments. However, these topicals may dry out overnight and patients may report increased morning irritation and discomfort. I am increasingly recommending my patients purchase a high-quality sleep mask.

The silicone, medical-grade products offered by Eye Eco, particularly Eye Seals, work very well in my patients. Patients readily adapt to the masks and some even report improved sleep (by keeping out ambient light and early morning light). Typically, patients also report improved morning eye comfort and satisfaction with the masks, provided they are properly cleaned and maintained.

This simple approach to identifying and managing poor nocturnal lid protection is, in my opinion, particularly helpful for patients with micro-exposures, since reduction of ongoing desiccating stress may help us manage MGD.

Research from James Jester, et. al. showed that inducing desiccating stress in mice created an altered protein-to-lipid ratio in the meibomian gland, inducing MGD in this in vivo mouse model.

 Specifically, the meibomian glands upregulated cell turnover in response to desiccating stress, inducing faster meibum production yet with an abnormal protein-to-lipid ratio.

As with any animal study, it is important to realize the limitations of early research and base clinical decisions primarily on human-based evidence. However, we understand that MGD is a complex, multifactorial condition that heavily influences the broader dry eye “vicious circles,” so to speak.

By aggressively treating nocturnal evaporative stress in our MGD patients, we have potentially much to gain with very little or nothing to lose. Controlled moist heat masks may help promote healthy meibomian gland function, as well as improve signs and symptoms of MGD as part of homecare continuance of in-office therapeutic processes like LipiFlow.

As busy practitioners, we are often forced to minimize our patient consultation time and see as many patients as possible. Accordingly, it is tempting to run new dry eye patients through a minimalist protocol or script that covers the basics: medication, lifestyle, and other surface-level factors that provide important, but not comprehensive information.

Taking a few extra seconds to examine a little deeper and identify nocturnal evaporative stress is worth the time spent. Simply asking your dry eye patients “How do your eyes feel upon awakening?” and using the lid seal test provides us a very efficient way to simply make a big difference for our dry eye and MGD patients. If we, as practitioners, are going to recommend patients focus on good sleep hygiene and habits, we should also ensure that their eyes are also getting full rest from drying exposures.

Sharpen Your Medical Mind. Be A Dry Eye Sleuth.

Dr. Periman reports she is a speaker for Allergan, Lumenis, Shire, Takeda, Novartis, and Sun Pharmaceuticals. Dr. Periman serves as a consultant for Eyedetec, Eyevance, Science Based Health, TearLab, Visant, and Umay.

1. Korb, D. Blackie, C. Nau, A. Prevalence of Compromised Lid Seal in Symptomatic Refractory Dry Eye Patients and Asymptomatic Patients. 

Investigative Ophthalmology & Visual Science.

2. Liu, D. et. al. Tear Film Dynamics in Floppy Eyelid Syndrome. 

3. Korb, D. Blackie, C. The Korb-Blackie Lid Light Test. 

Investigative Ophthalmology & Visual Science

4. Sulahim, J. et. al. Effect of Desiccating Stress on Mouse Meibomian Gland Function. 

Articles

Poor eyelid performance while sleeping a common contributing factor

Physicians should investigate nocturnal evaporative stress in dry eye patients

,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by 

. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Many medical specialties share medications and technologies, from various classes of drugs to diagnostic testing and surgical instruments. In ophthalmology, we tend to see ourselves as set apart from most specialties because of the unique needs and limitations of working with the eye. We’ve seen 

 recently, however, particularly from aesthetics. Here are just a few “adopted” technologies we’re happy to see in the hands of ophthalmologists.

 has been used in aesthetics since the 1990s to improve skin texture and treat rosacea. First-generation platforms required tremendous expertise, but newer, sixth-generation technologies (Optima IPL with the OPT technology, Lumenis), coupled with corneal shields, have the safety profile needed to address the eyelid and adnexa, particularly targeting telangiectasias associated with ocular inflammation.

We do not yet have published papers comparing the clinical efficacy of treating directly on the eyelids (with large, laser-grade, corneal-shield protected globes) compared to treating outside the orbital rim (with disposable laser-grade external ocular shield stickers). 

Dozens of peer-reviewed papers report the efficacy of IPL as an effective drug-free approach 

to treating ocular rosacea-associated and non-rosacea-associated meibomian gland dysfunction (MGD) and DED

. This effect is thought to occur via multi-level impacts on the inflammation factors that drive both the MGD and DED components of ocular surface disease.

IPL has been shown to improve noninvasive tear breakup time more than 5 seconds over baseline, and 86% of patients report improved symptoms.

 With three or four IPL treatments, spaced 2-5 weeks apart, we observe statistically significant reductions in MMP-9 levels and improved tear osmolarity.

Patients then repeat IPL 1 or 2 times per year, depending on the severity of the underlying disease comorbidities. Additionally, recent confocal microscopic evidence exists for microstructure improvements of meibomian glands as well as significant decreases in peri-glandular inflammatory cells with IPL therapy.

Patients report high satisfaction and appreciate the aesthetic benefits, such as improved eyelid redness, conjunctival redness and 

Botulinum toxin A (BTA) (Botox, Allergan; Dysport, Galderma; Xeomin, Merz Aesthetics)

Once an orphan drug, BTA demonstrated efficacy in the treatment of strabismus because of its ability to selective relax muscles and was subsequently used for various facial spasms and aesthetics, as well as pain and autonomic disorders.

Recently, neurologists and ophthalmologists have been exploring BTA’s potential for treatment of neuropathic pain syndromes.

 Strategic injection of BTA also could produce any number of benefits to the ocular surface by addressing corneal allodynia and neuralgia of the ophthalmic branch of the trigeminal nerve.

In ophthalmology, BTA injections in young aesthetic patients can mitigate lateral canthal rhytids addressing decreased Schirmer’s testing and tear breakup time.


	Conversely, in patients with blepharospasm and concurrent 

, strategic injection at the lateral canthus and pretarsal orbicularis can improve symptoms and reduce inflammatory cytokine production.

In refractory filamentary keratitis patients, a similar low-dose pre-tarsal injection technique was shown to resolve filaments in nearly 90% of patients.

 A single lower eyelid injection medial to the punctum can weaken the Horner’s muscle, reducing tear drainage by approximately 40%.

This technique also increases post-LASIK patient satisfaction by reducing lubricant dependency, with fewer complications than silicone punctal plugs.

 Injections in the lacrimal gland have helped patients with epiphora due to hyperreflexive lacrimation.

 Lastly, injected specifically to induce ptosis, BTA can offer a temporary tarsorraphy to protect the ocular surface.

In recent years, we have seen several topical medications migrate both ways between aesthetics and ophthalmology. Few other ophthalmic pharmaceuticals have successfully transitioned into the aesthetic world like the topical drug, bimatoprost. Widely used for glaucoma, the drug’s side effect of increased eyelash growth led to its rebranding for aesthetic treatment of hypotrichiasis (Latisse, Allergan).

Unfortunately, in addition to the aerodynamic impacts on evaporative dry eye from the abnormal eyelash lengthening effect associated with overuse, prostaglandins can also create lid margin redness, discoloration, dermatitis, and exacerbation of MGD.

XAF5, a topical prostaglandin ointment by Topokine Therapeutics, is undergoing phase 2b/3 trials to assess its efficacy in treating lower eyelid steatoblepharon, capitalizing on the side effect of periorbital atrophy induced by topical ophthalmic prostaglandin analogs for aesthetic use.

The potential for MGD exacerbations, dermatitis, eyelid hyperpigmentation, and other side effects associated with this modality of aesthetic treatment may pose issues if it becomes FDA approved.

 have been used in intraocular surgery for decades. The aesthetic uses of HAG products such as Juvederm (Allergan) and Restylane (Nestle Skin Health) are well known and offer a popular method of non-invasive facial rejuvenation. However, more recently, the functional use of fillers to improve eyelid malposition or mid-face revolumization has shown promise.

HAG has been found to be as efficacious as allograft dermal grafting or hard palate grafting to improve the position of the lower eyelids,

 as well as to improve and restore normal eyelid anatomy to correct lagophthamos, congenital ectropion, upper eyelid retraction, among other malpositions.

Clearly, ophthalmology, dermatology, and aesthetics benefit each other through shared medications and technologies. In the future, we anticipate seeing many more crossovers and “adopted” technologies used routinely in ophthalmology.

Dr. Periman is an ocular surface disease expert and Director of Dry Eye Services and Clinical Research in Seattle, WA. You can follow her on Twitter 

SF Gotox, a Mobile Aesthetic Care Company

1. Liu R, Rong B, Tu P, et al. Analysis of Cytokine Level in Tears and Clinical Correlations After Intense Pulsed Light Treating Meibomian Gland Dysfunction. 

2. Craig JP, Chen YH, Turnbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015 Feb 12;56(3):1965-70.

4. Yin Y, Liu N, Gong L, Song N. Changes in the Meibomian Gland After Exposure to Intense Pulsed Light in Meibomian Gland Dysfunction (MGD) Patients.

5. Scott AB, Miller JM, Shieh KR. Treating Strabismus by Injecting the Agonist Muscle with Bupivacaine and the Antagonist with Botulinum Toxin. 

6. Romanov A, Pokushalov E, Ponomarev D, et al. Long-term suppression of atrial fibrillation by botulinum toxin injection into epicardial fat pads in patients undergoing cardiac surgery: Three-year follow-up of a randomized study. 

7. Park J, Park HJ. Botulinum Toxin for the Treatment of Neuropathic Pain. 

8. Diel RJ, Kroeger ZA, Levitt RC, et al. Botulinum Toxin A for the Treatment of Photophobia and Dry Eye. 

9. Ho MC, Hsu WC, Hsieh YT. Botulinum Toxin Type A Injection for Lateral Canthal Rhytids.

10. Lu R, Huang R, Li K, et al. The influence of benign essential blepharospasm on dry eye disease and ocular inflammation. 

11. Gumus K, Lee S, Yen MT, Pflugfelder SC. Botulinum toxin injection for the management of refractory filamentary keratitis. 

12. Sahlin S, Chen E, Kaugesaar T. Effect of eyelid botulinum toxin injection on lacrimal drainage. 

13. Fouda SM, Mattout HK. Comparison Between Botulinum Toxin A Injection and Lacrimal Punctal Plugs for the Control of Post-LASIK Dry Eye Manifestations: A Prospective Study. 

14. Singh S, Ali MJ, Paulsen F. A review on use of botulinum toxin for intractable lacrimal drainage disorders. 

15. MÃ©rida S, Palacios E, Navea A, Bosch-Morell F. New Immunosuppressive Therapies in Uveitis Treatment. 

16. Goldberg RA, Lee S, Jayasundera T, et al. Treatment of lower eyelid retraction by expansion of the lower eyelid with hyaluronic Acid gel. 

17. Mancini R. Managing eyelid malpositions with hyaluronic acid gel injections. 

Many medical specialties share medications and technologies, from various classes of drugs to diagnostic testing and surgical instruments. Here are just a few “adopted” technologies we’re happy to see in the hands of ophthalmologists.

How ophthalmology can “adopt” technologies from other specialties

Laura M. Periman, MD, starts treatment with patients for ocular surface care 6 weeks prior to surgery for best results. Provide patients with detailed preoperative kits to ensure compliance.

,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Managing cataract surgery and ocular surface disease can be tricky and can vary from patient to patient. However, by properly screening patients first and following the steps below, optimal ocular surface results can be achieved preoperatively and postoperatively.

1. Give all cataract patients a SPEED questionnaire

We have good evidence of the high prevalence of

 dry eye and meibomian gland dysfunction (MGD)

 in older adults. Any cataract surgeon focused on optimizing the accuracy of his or her surgical results has to take this seriously, because dry eye has been correlated with IOL calculation errors and poor refractive outcomes.

The answer is better, more consistent screening. In my practice, every cataract patient is supposed to complete a SPEED questionnaire at check-in. A SPEED score ≥8 automatically triggers my technicians to add a layer of dry eye testing before I see the patient.

In our case, that includes osmolarity, MMP-9, and meibography. A higher SPEED score also prompts me to look carefully for comorbidities and exacerbating medications. I also pay close attention to lid anatomy, lid closure, and lid mechanics in my exam.  None of this adds much to my total time with the patient, but it does help ensure that I catch more dry eye before surgery.

 can indeed exacerbate ocular surface disease and if dry eye and MGD are not recognized and treated prior to surgery, then patients often blame the surgery, the surgeon, and sometimes the entire eyecare team.

Ocular surface problems represent a brewing storm on the horizon. As tempting as it is to focus only on the refractive or cataract surgery, ocular surgery may steer your patient straight into that storm.

2. Have a postoperative plan for the patient with MGD

For patients with significant MGD, a short, 6-week course of topical and nutritional therapy will likely not be sufficient to truly address all of the six interrelated pathophysiologic processes that are affecting their 

meibomian gland function and tear film quality

The topical medications and surgical impact on the corneal nerves may make the MGD worse postoperatively. In many cases, I tell them that rehabilitation of their ocular surface will be a two-step process. Phase 1 is getting them ready for surgery with the kit described earlier. Phase 2, after they have recovered from surgery, involves treating their MGD to get the most out of their new vision.

I like to treat these patients with a foundational therapy of omega-3 fatty acids and an immunomodulator. Then I’ll layer on as appropriate a combination of hypochlorous acid (Avenova) to control the bacterial component of MGD, intense pulsed light (IPL) for inflammation, and thermal pulsation therapy (Lipi- Flow) for the gland obstruction.

In my clinical experience, waiting until after cataract surgery and making sure I have cleared up the inflammation first helps to ensure that patients get a longer duration of effect from the thermal pulsation therapy. Practically, identifying the problems before surgery and separating out dry eye and MGD management from cataract or refractive surgery also separates out the surgical event from the longer-term maintenance of the tear film and ocular surface health.

Education, images, and objective testing help patients to understand that surgery did not cause their lid problems. MGD has to be treated as a separate problem from cataract and refractive surgery-but one that very much affects their quality of vision and satisfaction with the surgery.

Younger patients may not routinely get a dry eye screening, but we need to make sure we have easy ways to evaluate the ocular surface quickly when something during the exam suggests it may be a contributing factor. I recently worked in a family friend for an eye exam while she was home from college on break. This young computer science major was complaining of blurry, fluctuating vision.

It turns out she was wearing orthokeratology lenses at night. Both eyes had significant corneal warping and, in the left eye, subepithelial fibrosis, mild haze, and an off-center optical axis that contributed to her visual complaints and reduced BCVA.

Since we had not done a full dry eye workup on her, I performed a quick retroillumination exam of the lower lids which identified significant gland dropout.

Then, I took a quick infrared image of the meibomian glands using a topographer (ReSee-Vit Antares, Veatch Instruments). While this is not as detailed as meibography (Antares, Lumenis Corporation) that is typically performed, it was a rapid test that then demonstrated the significant gland atrophy problem to the young patient.

Once thought to be an age-related condition, MGD is showing up increasingly in children and young adults.

A recent study also demonstrates that contact lens wear causes significant morphological and functional changes in the meibomian glands.

We do not yet know whether changing wear habits or reducing digital device use can reverse damage and lead to improvements.

I recommended immediate discontinuance of orthokeratology and instructed she return to glasses and soft contacts along with anticipatory guidance that the vision will fluctuate as the corneal warpage improves.  I started her on omega-3 supplements (to help compensate for her self-reported nutrient-poor college diet) and the topical immunomodulator that her insurance would cover-in this case, lifitegrast (Xiidra, Takeda Pharmaceuticals).

She also had acne rosacea and was using harsh skin washes that can affect the meibomian glands. I like to treat inflammatory skin conditions with intense pulsed light (IPL) therapy and educate the patient on ingredients and skin care practices anywhere near the eyelids that negatively impact dry eye and MGD.    

4. Encourage collaboration to benefit your glaucoma patients

Glaucoma patients have very high rates of ocular surface problems due to the preservatives and active ingredients in IOP-lowering medications.  In fact, 58% of patients using topical glaucoma drops and 92% of those on prostaglandin monotherapy have MGD.

  Working together with our networks of referring optometrists and with glaucoma colleagues, we have a huge opportunity to help these patients. 

Optometrists should be encouraged to refer these patients earlier for laser trabeculoplasty, with or without a minimally-invasive glaucoma surgery (MIGS) procedure and cataract surgery if indicated.  These options can reduce the number of topical medications needed to control IOP.

It is highly satisfying to see the patient’s symptoms, appearance and ocular surface improve as drops are minimized.  We also need to aggressively rehabilitate the ocular surface with oral omega-3 supplements, a topical immunomodulator (cyclosporine or lifitegrast), and other treatments as needed, including BlephEx (Scope Ophthalmics) to remove scales and debris, LipiFlow, IPL, and/or TrueTear (Allergan).

Six months later, these patients often look entirely different, with a sparkle in their eye again.  “Saving” their ocular surface benefits everyone, including the referring optometrist, who may otherwise be dealing with variable refractions, glasses remakes, contact lens intolerance, contact lens dropout, patient dissatisfaction, and noncompliance with topical glaucoma therapy.

I tell patients that most people would not attempt to run a marathon without training.  Similarly, they shouldn’t have eye surgery without getting their ocular surface in better shape. The concept of getting “measure twice and cut once” is one that resonates very easily with patients, especially if we can show them objective measures such as osmolarity, MMP9, topography or a clinical photograph to illustrate how much corneal staining they have or how bad their glands look.  

I am very confident that I can get most eyes in better shape during the 6-week interval between the initial cataract or refractive surgery consultation and surgery, as long as treatment is started right away and the patient complies throughout that preop period. 

I know I’m asking them to do a lot, so I make it easier on them with written instructions, a treatment schedule and a starter kit.  My kit contains a hypochlorous acid lid cleanser (Avenova), heat mask (Bruder), preservative free artificial tears, an immune modulator (Restasis (Allergan), or Xiidra) and an Omega-3 supplement (HydroEye, ScienceBased Health).

I tell them if they follow this regimen, we can measure biometry at the next visit and typically proceed with the surgery we’ve scheduled in 6 weeks.  If a steroid is necessary, and the insurance covers it, I reach for low BAK formulations to minimize the counterproductive impacts of the preservative.

Dr. Periman is an ocular surface disease specialist in Seattle, Wash. She is a consultant for Advanced Tear Diagnostics, Allergan, Eyedetec, Eyevance, Lumenis, Science Based Health, Shire, Sun, TearLab, Visant and Umay. Contact her at dryeyemaster@gmail.com. Follow her on Twitter at 

1. Epitropoulos A, Matossian C, Berdy GJ, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. 

2. Gupta PK, Stevens MN, Kashyap N, Priestley Y. Prevalence of meibomian gland atrophy in a pediatric population. 

3. UÃ§akhan Ã, Arslanturk-Eren M. The role of soft contact lens wear on meibomian gland morphology and function. 

4. Mocan MC, Uzonosmanoglu E, Kocabeyoglu S, et al. The association of chronic topical prostaglandin analog use with meibomian gland dysfunction. 

Start ocular surface treatment 6 weeks prior to cataract surgery for best outcomes

5 ways to integrate ocular surface care into your patients’ regimen

Any time we perform ocular surgery—whether 

, oculoplastic, or any other ocular procedure—we want to set the patient up for success. 

Part of that is addressing any potential sources of infection, inflammation, and ocular surface disease that could complicate the postoperative course. It is common to see patients with meibomian gland dysfunction (MGD), dry eye disease (DED), and blepharitis.

For long-term efficacy, therapeutic choices are focused on the underlying cause or causes of the problem. 



Considering Demodex infestation and cataract surgery

 was 1 potential cause that we tended to overlook or ignore, because there was little we could do to address the specific problem of 

 mite infestation. 

Now we are beginning to understand the role of 

 in blepharitis and inflammatory DED, and the treatment outlook has markedly improved.


 is the presence of collarettes, or cylindrical dandruff, at the base of the eyelashes.

 

These waxy collarettes are the waste material of 

 mites living inside the hair follicles. When you regularly look for collarettes, you’ll likely be surprised at how common 

About 84% of people 60 years or older have 

 infestation, as do 100% of patients 70 years or older.

 overpopulation as well, particularly those with MGD and keratitis.

 

The higher incidence in older populations is not well understood. We hypothesize that the natural defenses and skin barrier function may be compromised with age, allowing 

 to gain the upper hand, but we do not know for certain.



Drop shows effectiveness for Demodex blepharitis in phase 2a stud

 can have a spectrum of manifestations, from asymptomatic infestation to significant blepharitis inflammation. 

Generally, significant 

 infestation results in significant inflammation. Patients have classic dry eye and blepharitis symptoms, including dry or gritty feeling, foreign body sensation and fluctuating vision. 

Because mites inside the lash follicles cause the condition, patients also can have follicular distention, hyperplasia, eyelash loss, and eyelid keratinization.

 blepharitis and bacterial blepharitis are also strongly correlated.


Despite its prevalence, there have been few treatments for 

 infestation, and there are no treatments approved for that specific indication. 

Although many patients with 

 infestation come to me having already been prescribed an immunomodulator such as cyclosporine (Cequa; Sun Pharma; Restasis; Allergan) or lifitegrast (Xiidra; Novartis), these medications treat the ocular surface sequelae of 

 infestation rather than the infestation itself. 



Making dry eye manageable for patients working from home


We could hypothesize that these medications might increase the ability to fight 

 by reducing inflammation and improving skin health, but we do not have evidence to support that idea.

Certain comorbidities, such as diabetes, place patients at higher risk for 

 blepharitis, so a primary care physician should help manage any systemic condition that has not been adequately controlled. 

To prepare a patient with 

 infestation for surgery, I usually use a combination of mechanical and chemical methods to remove collarettes, kill mites, and enhance skin barrier function in the patient.



For patients, home maintenance is important to help keep the 

 population under control. It is key to communicate this to patients.

In the office, we can perform microblepharoexfoliation using mechanical tools (AB Max; Myco Industries; BlephEx) or kits that combine tools and agents to treat Demodex (Cliradex; Bio-Tissue; ZEST; Zocular).



Where to start with treating OSD patients

and rosacea, intense pulsed light (IPL) therapy (Optima IPL; Lumenis) can be used to decrease the 

 burden in patients also afflicted with rosacea.

, ivermectin can be prescribed orally or topically (Soolantra; Galderma) to control the facial Demodex burden.


At home, good hygiene is essential to keep 

 under control after in-office treatment, but traditional shampoos are not very effective. 

Cleansing towelettes with 4-terpineol isolate (Cliradex; Bio-Tissue), the miticidal component of tea tree oil, have the highest antidemodectic activity of all the commercial cleansers.


Patients use the towelettes to clean the eyelids, lashes, and face. Hypochlorous acid cleanser (Avenova; NovaBay Pharmaceuticals), which I use for many dry eye patients, has minimal effect on 

but it can be used as a complementary therapy to 4-terpineol isolate.

Patients can also use a device at home that cleans the eyelid margins and stimulates the meibomian glands (NuLids; NuSight Medical), as well as gel cleaner for the eyelids and lashes (ZocuShield; Zocular).


 blepharitis are very new, and more treatments are in development. They are the consequence of our growing understanding of the disease and the pressing need to address it effectively. 

We have gone from strictly mechancal approaches to removing the mites, to chemical options, to the possibility of pharmaceutical options for the treatment of patients with this issue.



Amid pandemic, friendly bugs can help protect the eye from infection

 burden that is driving blepharitis and inflammation is growing rapidly, making it easier than ever to resolve the problem before elective surgery and keep patients on track long term. 




Periman is an ocular surface disease expert and director, dry eye services and clinical research, Periman Eye Institute, Seattle, Washington.

1. Gao YY, Di Pascuale MA, Li W, et al. High prevalence of Demodex in eyelashes with cylindrical dandruff. 

. 2005;46(9):3089-3094. doi:10.1167/iovs.05-0275

2. Liu J, Sheha H, Tseng SCG. Pathogenic role of Demodex mites in blepharitis. 

2010;10(5):505-510. doi:10.1097/ACI.0b013e32833df9f4

3. Liang L, Liu Y, Ding X, Ke H, Chen C, Tseng SCG. Significant correlation between meibomian gland dysfunction and keratitis in young patients with Demodex brevis infestation. 

. 2018;102(8):1098-1102. doi:10.1136/bjophthalmol-2017-310302

4. Fishman HA, Periman LM, Shah AA. Real-time video microscopy of In vitro Demodex death by intense pulsed light. 

2020;38(8):472-476. doi:10.1089/photob.2019.4737

5. Cheung IMY, Xue AL, Kim A, Ammundsen K, Wang MTM, Craig JP. In vitro anti–demodectic effects and terpinen-4-ol content of commercial eyelid cleansers. 

 2018;41(6):513-517. doi:10.1016/j.clae.2018.08.003

6. Kabat AG. In vitro demodicidal activity of commercial lid hygiene products. 

 2019;13:1493-1497. doi:10.2147/OPTH.S209067

New options open possibilities for treatment, resulting in better outcomes for patients.


Treating Demodex blepharitis efficiently before surgery

,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. “

” continues with this latest piece by Laura Periman, MD. The views expressed in these blogs are those of their respective contributors and do not represent the views of 

Laura M. Periman, MD

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Treating Demodex blepharitis efficiently before surgery

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Physicians should investigate nocturnal evaporative stress in dry eye patients

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