Dry Eye

Insights into Demodex Blepharitis with Eric Donnenfeld, MD, and Preeya Gupta, MD

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In a recent discussion hosted by Ophthalmology 360, Dr Eric Donnenfeld and Dr Preeya Gupta delved into the complexities of Demodex blepharitis, shedding light on its prevalence, diagnosis, and groundbreaking treatments. Their insights offer valuable guidance for ophthalmologists aiming to deepen their understanding of this often underestimated condition.

Understanding Demodex Blepharitis
Demodex blepharitis, once regarded as a benign presence, has now emerged as a significant concern in ophthalmology. “For decades, I thought that Demodex was a commensal organism, that it’s a mite that lived in the lid and didn’t bother anybody, but I was dead wrong,” admitted Dr Donnenfeld.

Dr Gupta echoed this sentiment, underlining the evolving understanding of Demodex and its impact on ocular health, especially among patients with ocular surface diseases.

Prevalence and Clinical Manifestations
Dr Gupta explained that while Demodex is ubiquitous on human skin, its population tends to increase on the ocular surface, particularly among individuals with ocular surface diseases. Central to its pathology is the mite’s colonization at the base of the lash, leading to inflammation, epithelial disruption, and chemical reactions from its byproducts.

Dr Donnenfeld emphasized the underdiagnosis of Demodex, attributing it to a lack of awareness and vigilance among clinicians. He reflected on his own practice, noting a shift in perspective upon recognizing the profound impact of Demodex on ocular health.

“When you look for it, you’ll see it constantly,” he said.

Identifying key clinical signs is crucial in diagnosing Demodex. Dr Gupta said that the presence of cylindrical dandruff or collarette along the lash margin serves as a hallmark feature, removing the need for invasive diagnostic procedures like lash plucking.

“If you’re not looking for it, you’re not going to see it,” she asserts, emphasizing the accessibility of these signs during routine slit lamp examinations,” she explained.

Both speakers underscored the importance of vigilant observation and targeted questioning to identify symptoms such as itching and lid erythema, which often masquerade as other ocular conditions.

“The symptom that I’m looking for is itching,” said Dr Donnenfeld. “But when someone says, ‘My eyes itch,’ I stop the patient right then and there and I say to them, ‘Do your eyes itch or do your eyelids itch?’ And that’s a very important differential that we should be asking all of our patients who come in with itching, whether it’s lid or whether it’s the eye itself. And when it’s a lid, it’s Demodex until proven otherwise.”

‘Game-Changing’ Treatment Options
The advent of lotilaner ophthalmic solution 0.25% marks a paradigm shift in Demodex blepharitis management.

In 2 large clinical trials involving over 800 patients with Demodex blepharitis, lotilaner 0.25% was administered as 1 drop twice a day for 6 weeks. The patients enrolled in the trials exhibited severe symptoms, with an average grade of 3, indicating over a hundred collarettes per lid. The results showed a remarkable improvement, with 85% of patients transitioning from grade 3 to grade 1, characterized by fewer than 10 collarettes.

Additionally, the trials involved plucking lashes and counting the number of mites present, with both measures showing improvement post-treatment. Importantly, lotilaner demonstrated robust efficacy in not only eliminating mites but also in improving clinical signs associated with Demodex blepharitis. Moreover, the treatment was well-tolerated by patients, with a low incidence of adverse reactions noted during the trials.

Lotilaner is a neurotoxin specifically targeting Demodex mites, with no adverse effects on humans. It aims not only to eradicate existing mites but also to eliminate newly hatched eggs, ensuring a comprehensive treatment approach. Despite Demodex’s potential for recurrence, long-term efficacy studies have shown promising results, according to Dr Donnenfeld. A recent paper presented findings indicating sustained benefits even a year post-treatment, with patients experiencing reduced erythema, itching, irritation, and dry eye symptoms.

Dr Donnenfeld said lotilaner has had a transformative impact on patient outcomes, citing remarkable improvements in symptoms and quality of life. He emphasized the need for a shift from traditional therapies, like tea tree oil, to embrace lotilaner’s superior tolerability and efficacy.

Dr Gupta agreed, emphasizing the importance of early recognition and targeted intervention to mitigate the significant burden of Demodex-associated morbidity.

Dr Donnenfeld and Dr Gupta’s video discussion can be found here.