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Treatment approaches to address Demodex mites on lids


Milton Hom, OD, FAAO, discussed diagnosis and treatment of the mite Demodex at the American Academy of Optometry’s annual meeting in Seattle.

Seattle-Milton Hom, OD, FAAO, discussed diagnosis and treatment of the mite Demodex at the American Academy of Optometry’s annual meeting in Seattle.

Demodex are found in 100% of patients 70+ years of age, and mite density rises in the sixth decade of life.

The clinical sequence includes:

• Clinical history, including blepharitis, dry eye, or ocular allergy;

• Slit-lamp examination, looking specifically for cylindrical dandruff;

• Microscopic confirmation of Demodex, including counting of eggs, larvae, and adults;

Patients with an overinfestation of Demodex exhibit symptoms of itch, burning, foreign body sensation, crusting, redness, and blurry vision. Some 85% of patients with Demodex also have meibomian gland dysfunction.

Cylindrical dandruff is a hallmark of Demodex. About 12.9 mites per patients were found with signs of cylindrical dandruff, in contrast to 0.35 mites per patient without.

Rosacea patients have a 7 to 8 times higher incidence of Demodex. “If you see rosacea and no Demodex, you’re missing it,” says Dr. Hom.

In-office treatments include lid scrubs, tea tree oil, and use of a bleph brush. Patients need to return for several treatments over the course of several weeks and add a home regimen. Suggest use of tea tree oil shampoo and soap to patients with an infestation of Demodex. Remember that everyone has some Demodex; we just try to control the numbers when they get out of hand.


• Tea tree oil pads are sometimes dry on one side, so squeeze the pad so both sides are wet.

• Don’t forget children…kids can have large Demodex populations as well as adults.

• Mites are frequently mistaken for allergy.

• When epilating lashes, look for cylindrical dandruff at the base of the lash, and look for “sick” lashes (short, discolored, misdirected).

Dr. Hom’s banned list for Demodex control:

• Steroids;

• Emulsion drops;

• Restasis (cyclosporine, Allergan);

• Prostaglandins (these stimulate mite counts);

• Latisse (bimatoprost, Allergan);

• Antibiotics (useless in controlling mite population).


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