Practical strategies: Managing Demodex blepharitis in surgical patients for ocular surface optimization

A recent recognition is that Demodex blepharitis is much more prevalent than previously thought. The Titan Study reported that 56% of patients scheduled to undergo cataract surgery have Demodex blepharitis (collarettes),¹ according to Alice Epitropoulos, MD, director of the Dry Eye Center of Excellence, The Eye Center of Columbus in Columbus, Ohio.

She moderated a recent Ophthalmology Times Case-Based Roundtable® that focused on optimizing the ocular surface of patients scheduled for surgery. The participants discussed two cases with different ocular disorders in the presence of Demodex, recognizing the pathogen, and the best possible treatment approaches.

Cases demonstrating Demodex in surgical and chronic dry eye patients

Case 1. This was a 78-year-old patient with wet age-related macular degeneration (AMD) in the right eye (VA, 20/70) treated with injections and dry AMD with geographic atrophy in the left pseudophakic eye (VA, 20/150). The patient reported a progressive decrease in vision, difficulty reading and seeing street signs, and glare at night. The patient denied experiencing itching, redness, and crusting.

The clinical examination was significant for 2+ collarettes, a visually significant 3+ nuclear sclerotic cataract in the right eye, and dermatochalasis.

Following treatment with lotilaner (Xdemvy; Tarsus Pharmaceuticals), the patient described the eyes as more comfortable and the collarettes resolved prior to cataract surgery.

Case 2. This case was a 54-year-old patient who had a 20-year history of ocular rosacea, Demodex blepharitis, and meibomian gland disease (MGD). The patient reported being very bothered by redness and dryness around the lids, burning, itching, and crusting, stating “my eyes control my life.”

Previous treatments providing minimal or temporary relief included lid hygiene, warm compresses, tea tree scrubs, hypochlorous acid, tobramycin/dexamethasone ophthalmic (TobraDex; Novartis Pharmaceuticals), thermal pulsation (Lipiflow; Johnson & Johnson Vision), loteprednol etabonate ophthalmic suspension 0.25% (Eyesuvis; Alcon), azithromycin ophthalmic solution 1% (Azasite; Thea Pharma), metronidazole drops, varenicline solution nasal spray (Tyrvaya; Oyster Point Pharma), fish oil, and moisture goggles.

The examination was significant for 4+ collarettes and biofilm, telangiectatic lid margins with MGD, reduced tear breakup time to 4 seconds, lid swelling, and moderate conjunctival injection (SPEED 20).

The patient had an immediate positive response to lotilaner with resolved collarettes, lid swelling, burning, crusting, itching, and redness. Eyesuvis was no longer needed (SPEED reduced to 4).

Takeaways from the cases

Regarding case 1, Epitropoulos believes that the attendees realized the importance of diagnosing Demodex because of the significant effect it can have on the outcomes of ocular surgeries, in this case cataract surgery. “They came to the realization of the importance of diagnosing Demodex and treating it before a surgery. The discussion kept returning to the notion that this disorder is not “standard” blepharitis. Clinicians must look for the classic lid findings, ie, the collarettes, and actively think about Demodex as a separate treatable diagnosis,” she said.

She described this as “a shift in thinking” about preoperative workups. “Many attendees seemed to leave the discussion with the idea that optimizing the ocular surface is really no longer an optional approach for surgical patients, especially those with high expectations for implantation of premium intraocular lenses,” she commented.

Regarding case 2, the primary takeaway was how often Demodex blepharitis is an underlying factor in what was previously considered chronic dry eye disease. “The patient history resonated with the attendees in that dry eye treatment extended over years with only minimal improvement. This is a scenario that is not uncommonly seen in clinic,” she said.

The rapid turnaround following treatment with lotilaner was an eye-opener for the attendees. “The improvement emphasized the importance of examining the lashes and rethinking the diagnosis especially in cases that have been refractory to standard dry eye treatment.^1,2 This case reinforced the practical mindset shift that if a patient is not responding to treatment as expected, a closer look at the lid margin and lashes for collarettes can make a meaningful difference in our patients,” Epitropoulos said.

Gupta et al.² demonstrated that 0.25% lotilaner ophthalmic solution significantly reduces Demodex infestation and improves meibomian gland function in patients with MGD. The treatment effectively clears collarettes and enhances gland secretion, offering a targeted solution for underlying mite-induced gland obstruction. Considering Gupta’s findings, discussions among attendees pointed to lotilaner as a potential treatment option for chronic meibomian gland disease, even without visible collarettes.

She also emphasized that the case-based roundtable format was particularly valuable due to its interactive and practical nature, allowing participants to engage with the nuanced details of complex cases while gaining insight into real-world clinical decision-making. Unlike more traditional formats that focus on guidelines or didactic lectures, this approach offered perspectives that are more directly applicable to everyday practice.

“This format highlighted how frequently Demodex is overlooked in surgical and dry eye patients, as well as the potential consequences of not treating this condition, and clarified when it is appropriate to consider targeted therapies such as lotilaner,” said Epitropoulos. “It brought greater awareness to the often-overlooked role of Demodex, leading to more focused and implementable treatment approaches.”

References

1. Trattler W, Karpecki P, Rapoport Y, et al. The prevalence of Demodex blepharitis in US eye care clinic patients as determined by collarettes: A pathognomonic sign. Clin Ophthalmol. 2022;16:1153-1164. doi:10.2147/OPTH.S354692

2. Gupta PK, Gaddie IB, Shultz MC, et al. Effects of lotilaner ophthalmic solution, 0.25% on Demodex blepharitis patients with meibomian gland disease. Clin Ophthalmol. 2026;20:527753. doi:10.2147/OPTH.S527753