Preparing the ocular surface for surgery in the presence of Demodex blepharitis

In this Q&A, Alice T. Epitropoulos, MD, FACS, reflects on the treatment used in two cases in which the patients’ ocular surfaces were optimized before surgery. The ocular surface in these cases was complicated by the presence of Demodex. Both cases had different ocular disorders, and she discussed the importance of recognizing the pathogen and the best possible treatment approaches. She is the director of the Dry Eye Center of Excellence, and a cofounder of The Eye Center of Columbus, Columbus, OH.

A recent recognition is that Demodex blepharitis is much more prevalent than previously thought. In fact, the Titan Study reported that 56% of patients scheduled to undergo cataract surgery have Demodex blepharitis (collarettes). Demodex is often overlooked in surgical and dry eye patients, as well as the potential consequences of not treating this condition, and she clarified when it is appropriate to consider targeted therapies.

Ophthalmology Times: When considering the case of a patient who received injections to treat wet age-related macular degeneration (AMD) in the right eye (visual acuity [VA], 20/70) and who had dry AMD with geographic atrophy in the left pseudophakic eye (VA, 20/150), what were the takeaways from the treatment of the ocular surface before a scheduled cataract surgery?

Alice T. Epitropoulos, MD, FACS: This 78-year-old patient had wet 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 progressively decreasing vision, difficulty reading and seeing street signs, and glare at night, but did not report itching, redness, or crusting.

The clinical examination revealed [more than] 2 collarettes, a visually significant [more than] 3 nuclear sclerotic cataracts in the right eye, and dermatochalasis. Treatment with lotilaner (XDEMVY, Tarsus Pharmaceuticals) resulted in increased patient comfort and resolution of the collarettes before cataract surgery.

It is important to diagnose Demodex before surgery because of the significant effect it can have on the outcomes of ocular surgeries, in this case, cataract surgery. Demodex blepharitis disorder is not “standard” blepharitis. Clinicians must look for the classic [eye]lid findings, ie, the collarettes, and actively think about Demodex as a separate treatable diagnosis.

This is a shift in thinking about preoperative workups, no longer just an option for surgical patients, especially those with high expectations for implantation of premium intraocular lenses.

OT: The second case was a patient with a 20-year history of ocular rosacea, Demodex blepharitis, and meibomian gland disease (MGD). What was the takeaway about Demodex from the treatment of this complex ocular surface?

Epitropoulos: This case was a 54-year-old patient who reported being extremely bothered by redness and dryness around the lids, burning, itching, and crusting, stating, “my eyes control my life.” The patient had undergone previous treatments that provided minimal or temporary relief that included lid hygiene, warm compresses, [and] tea tree scrubs; hypochlorous acid, TobraDex (tobramycin/dexamethasone ophthalmic, Novartis Pharmaceuticals), Lipiflow (Johnson & Johnson Vision); Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Alcon), AzaSite (azithromycin ophthalmic solution) 1%, Thea Pharma) and metronidazole drops; and Tyrvaya (varenicline solution, Viatris; Harrow will acquire the drug in the second half of 2026), fish oil, and moisture goggles.

The examination was significant for [more than] four collarettes and biofilm, telangiectatic lid margins with MGD, reduced tear breakup time to 4 seconds, lid swelling, and moderate conjunctival injection.

The patient responded immediately and positively to lotilaner, [which] resulted in resolution of the collarettes, lid swelling, burning, crusting, itching, and redness. Eysuvis was no longer needed.

The primary takeaway was how often Demodex blepharitis is an underlying factor in what was previously considered chronic dry eye disease. The patient’s history was noteworthy in that the dry eye treatment extended over years with only minimal improvement. This is a scenario that is not uncommonly seen in clinic.

OT: What message about the patient evaluation would you like to extend to ocular clinicians?

Epitropoulos: The rapid turnaround following treatment with lotilaner was an eye-opener in both cases. 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. For patients not responding to treatment as expected, a closer look at the lid margin and lashes for collarettes can make a meaningful difference.

Gupta et al¹ 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. Lotilaner is a potential treatment option for chronic meibomian gland disease, even without visible collarettes.

Reference
1. 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