Demodex blepharitis: Diagnosis, treatment response, and recurrence

How should clinicians recognize Demodex blepharitis, and which specialists should be looking for it? These questions framed a recent Ophthalmology Times Clinical Forum in New Orleans, Louisiana: “Demodex Blepharitis in Focus: Enhancing Diagnosis and Expanding Treatment Options.”

Himani Goyal, MD, a cornea specialist and clinical associate professor of ophthalmology at New York University (NYU) Grossman School of Medicine and NYU Langone Health in New York, moderated the roundtable. Goyal also teaches residents at Bellevue Hospital in New York and sees patients at the NYU Langone faculty practice in Brooklyn.

Recognition across subspecialties

Participants discussed what Demodex blepharitis is, how to diagnose it, and the latest approaches to treating it, with an emphasis on what each was doing in practice. Goyal said the group asked whether clinicians use lotilaner ophthalmic solution (Xdemvy; Tarsus) alone or alongside techniques they relied on for many years before it became available.

The group included a couple of retina specialists, several anterior segment surgeons, and representatives from oculoplastics and glaucoma, and each had a different view of blepharitis, Goyal said. For some, it is an obstacle to clear before a retinal injection or surgical preparation. For others, it is a front-and-center complaint that brings patients in for treatment. She called the range of subspecialties a highlight of the discussion, as it brought a variety of patient populations to the table.

A physician from the Veterans Affairs system asked how to present the diagnosis to older patients who may not complain of symptoms, and what clinicians’ responsibilities are in treating Demodex blepharitis in that population. Goyal said all participants learned from one another and could change their practice or how they think about Demodex blepharitis and its treatment.

A patient with recurrent styes

Goyal presented a patient with recurrent styes for several years, who normally saw the practice’s oculoplastics surgeon to treat acute blepharitis and to drain chalazia. She landed on Goyal’s schedule during a transition period in the practice, around the time lotilaner became available, and was one of Goyal’s first patients treated with it. The patient worked as a model and could not work while she had active styes, which were occurring often.

The patient had grade 4 collarettes. Three weeks into treatment, her collarettes were much improved and had fallen off. Goyal photographs every patient so they can see the difference. “It was actually really, really life-changing for her,” Goyal said.

The patient has not returned with recurrent styes in approximately 3 years, and she received another course of treatment at about the 1- or 2-year mark. Participants also discussed long-term data that are now available, including recurrence after treatment. Meibomian gland dysfunction improves after the 6-week course, Goyal said, and newer data show meibomian gland function continues to improve over the following 6 weeks.

Advanced disease in an older patient

Goyal said she had prepared a second case that the group did not have time to discuss. The patient was older and had grade 4 collarettes. Early in Goyal’s experience with lotilaner, patients waited a couple of weeks to receive the medication. At a follow-up 3 to 4 weeks later, the patient had a large decrease in collarettes but also lost many lashes because the follicles were so full of disease.

Goyal said the case shows what clinicians can expect with advanced disease: Lash loss can occur when the follicles are heavily affected, but clinicians can reassure patients that the lashes will grow back.

Recurrence risk and wider awareness

After several years of using lotilaner, clinicians have noticed that some patients experience recurrence, and the group discussed what puts patients at higher risk, Goyal said. She described 2 points as new to the table. The first was from one attendee, who noted that a low brow may make it easier for mites to inhabit the lashes because they have much less distance to travel, a consideration in older patients with bushier or lower brows.

The second was the role of retina specialists. The group discussed retina specialists paying attention to Demodex blepharitis and considering it in patients who receive multiple injections, with the goal of decreasing bacterial load around the eyes. Goyal said anterior segment specialists and oculoplastic surgeons were already embracing treatment and combining it with other cleansing techniques.