Evolving information about recognizing and treating Demodex blepharitis: Greater awareness of Demodex in patients undergoing surgery and those with dry eye

A fairly recent recognition is that Demodex blepharitis is much more prevalent than previously thought. In fact, findings from the Titan study reported that 56% of patients scheduled to undergo cataract surgery have Demodex blepharitis with the characteristic collarettes,¹ according to Alice Epitropoulos, MD, FACS, director of the Dry Eye Center of Excellence at The Eye Center of Columbus in Ohio.

Demodex, which is often associated with blepharitis, does not simply present a cosmetic concern but can cause serious ocular complications. “Blepharitis frequently disrupts the ocular surface, leading to conjunctivitis, conjunctival erythema, functional tear deficiency, and keratitis. It may also exacerbate symptoms of coexisting ocular surface diseases, including allergic conjunctivitis and aqueous tear deficiency. The chronic nature of blepharitis, its uncertain etiology, and frequent coexistence of other ocular surface diseases contribute to the challenge of managing affected patients,”² Brandon Ayres, MD, and colleagues commented.

Consensus panel

It was not until 2023 that the Demodex Expert Panel on Treatment and Eyelid Health, comprised of 12 ocular surface disease experts, convened to establish consensus about Demodex blepharitis.² The study was led by first author Ayres, who is from the Wills Eye Hospital in Philadelphia, Pennsylvania.

To meet their stated goal, online surveys were administered using scaled, open-ended, true/false, and multiple-choice questions. Following 3 surveys, the experts reached agreement that Demodex blepharitis is chronic (n = 11), recurrent (n = 12), and often misdiagnosed,² they said.

The panel achieved consensus on the following factors:

• Inflammation drives symptoms (median, 7; range, 7-9).

• Collarettes are the most common sign of (n = 10) and pathognomonic for Demodex blepharitis (median, 9; range, 8-9).

• Itching is the most common symptom (n = 12).

The expert panelists also agreed that Demodex blepharitis may be diagnosed based on collarettes, mites, and/or patient symptoms (n = 10) and felt that patients unresponsive to typical therapies should be evaluated for Demodex blepharitis (n = 12). However, the panelists did not reach agreement about the most effective currently available over-the-counter treatment. When this panel convened, lotilaner ophthalmic solution 0.25% (Xdemvy; Tarsus Pharmaceuticals) had not yet been approved by the FDA.

The authors commented on the value of the study and what it added to the body of information about Demodex blepharitis. Ayres and colleagues said, “Through a systematic process of literature review, successive surveys, and peer-to-peer discussion, this expert panel came to consensus about many aspects of Demodex blepharitis. Consensus was reached about the typical patient, key signs and symptoms, effective examination strategies to best recognize Demodex blepharitis, and associated ocular and systemic conditions. While there was agreement about some aspects of treatment, further study is warranted to reach consensus on the most effective management strategies.”

Pharmacotherapy for Demodex

A recent study³ led by first author Aleksandra Czępińska-Myszura, MD, from the Clinic Department of Diagnostics and Microsurgery of Glaucoma at Medical University of Lublin in Poland, looked at the standard and innovative therapies for Demodex blepharitis.

The standard therapies include eyelid hygiene, antiparasitic agents such as metronidazole and ivermectin, and tea tree oil. A review of the literature showed that the standard methods remain the recommended approach. “However,” they commented, “in recent years, promising new treatments for Demodex blepharitis have emerged, such as lotilaner ophthalmic solution 0.25%, which has shown positive results in clinical trials. Mechanical techniques, including intense pulsed light (IPL) therapy and eyelid peeling procedures such as blepharoexfoliation, have also demonstrated promise but have not been tested sufficiently.

“Only lotilaner ophthalmic solution 0.25% can compete with standard therapies. Among the innovative options, it is the only one that has been clinically tested on a larger scale and has demonstrated high efficacy in studies, with only mild adverse effects in a few cases,” Czępińska-Myszura and colleagues stated. IPL therapy and blepharoexfoliation have not been tested on a sufficiently large number of patients and require further research.

Roundtable discussion

Epitropoulos moderated a recent Ophthalmology Times Case-Based Roundtable^® that focused on optimizing the ocular surface of patients scheduled for surgery. The participants discussed 2 cases with different ocular disorders in the presence of Demodex, recognizing the pathogen, and the best possible treatment approaches.

Case 1: AMD

This was a 78-year-old patient with wet age-related macular degeneration (AMD) in the right eye (visual acuity [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 grade 2 or higher collarettes, a visually significant nuclear sclerotic cataract of grade 3 or higher in the right eye, and dermatochalasis. Following treatment with lotilaner, the patient reported that the eyes were more comfortable and the collarettes resolved before 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 that provided minimal or temporary relief included lid hygiene, warm compresses, tea tree scrubs, hypochlorous acid, tobramycin/dexamethasone ophthalmic suspension (TobraDex; Novartis Pharmaceuticals), LipiFlow (Johnson & Johnson Vision), loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis; Alcon), azithromycin ophthalmic solution 1% (Azasite; Thea Pharma), metronidazole drops, varenicline solution (Tyrvaya; Oyster Point Pharma), fish oil, and moisture goggles.

The examination was significant for grade 4 or higher collarettes and biofilm, telangiectatic lid margins with MGD, reduced tear breakup time to 4 seconds, lid swelling, and moderate conjunctival injection. The patient had an immediate positive response to lotilaner, with resolved collarettes, lid swelling, burning, crusting, itching, and redness. Loteprednol etabonate was no longer needed.

Takeaways from the cases

Regarding case 1, Epitropoulos believed 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. 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.

She explained that Gupta et al⁴ demonstrated that lotilaner 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 MGD, even without visible collarettes, she explained.

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,” Epitropoulos said. “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. Ayres BD, Donnenfeld E, Farid M, et al. Clinical diagnosis and management of Demodex blepharitis: the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). Eye (Lond). 2023;37(15):3249-3255. doi:10.1038/s41433-023-02500-4
3. Czępińska-Myszura A, Kozioł MM, Rymgayłło-Jankowska B. Pharmacotherapy of Demodex-associated blepharitis: current trends and future perspectives. Pharmacy (Basel). 2025;13(5):148. doi:10.3390/pharmacy13050148
4. 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