Blepharitis

What is blepharitis?

Blepharitis is a common and persistent inflammation of the eyelids. Symptoms include irritation, itching and occasionally, a red eye. In addition, blepharitis can cause the eyes to be tired and this condition can exacerbate dry eyes and allergies.

This condition frequently occurs in people who have oily skin, dandruff, or dry eyes. Blepharitis can begin in early childhood although it is more commonly a problem that develops later in life.

Bacteria reside on the surface of everyone’s skin, but in certain individuals they thrive in the skin at the base of the eyelashes or even enter the oil glands in the eyelid called meibomian glands. The resulting irritation, sometimes associated with overactivity of the nearby oil glands, causes dandruff-like scales and particles to form along the lashes and eyelid margins.

For some people the scales or bacteria associated with blepharitis produce only minor irritation and itching, but in others they may cause redness, stinging or burning. Some people may develop an allergy to the scales or to the bacteria which surround them. This can lead to a more serious complication, inflammation of the eye tissues, particularly the cornea. An important concept is the fact that blepharitis is a chronic condition, cleansing and any therapy needs to be continued for a long time (i.e. several months) to be effective.

How is blepharitis treated?

Blepharitis can be a stubborn problem. Although there is no specific cure, it can be controlled through a careful, regular program of hygiene. The problem is abnormal oily areas surrounding the lashes and plugged glands with abnormal secretions. The solution is the application of a warm washcloth for a minimum of 10″ over the lids to gently clean and liquify the abnormally thick secretions in the meibomian glands. After this a gentle scrubbing of the lids with the washcloth will squeeze the secretions from the glands.

If this regime is followed once or twice per day, over a 2-3 month period, the condition will gradually improve. The use of a clensing agent such as baby shampoo is not harmful but often causes irritation and in general is unnecessary.

Will medication help?

Many medications are available for the treatment of blepharitis, including antibiotics and steroid (cortisone) preparations in drop or ointment form. While cortisone medications often hasten relief of symptoms, long-term use can cause some harmful side effects.

Once the acute phase of the condition is overcome – a process which may take several weeks – milder medications, if any, may be helpful to control your blepharitis. However, medications alone are not sufficient; the daily cleansing routine described above is essential.

learning series let me just

introduce

our speaker for today today we have

optoma he is

an optometrist he finished his

bachelor’s at lotus college of optometry

india

and currently he is a phd candidate at

the university of alabama

his special interests are in myopia

control

optics and anterior segment and today

he’s going to share

his ideas and his views on the treatment

blepharitis so welcome ku and

thank you very much for taking out this

time

go ahead kayu

hi um greetings everyone i know

we are at different time zones um sunday

morning for me sunday evening and night

probably for y’all

but thank you so much for uh joining

today

and um i would like to thank

the ols series um especially for this

opportunity

um and uh mr barodawala for

allowing me to present this topic and

share this information with you all

um without further ado i think i will go

ahead and get started

okay so we are going to be talking about

treating demodex clepharitis

and before i start

into that a little bit of my background

it’s

especially in this topic so i’ve been

working on a systematic review

um about treating demodex blepharitis

for

almost most of the past 18 months the

review idea was

initially proposed uh almost two years

ago and then six months later

um it fell into my laps and i have been

working consistently

on getting some information on this and

creating a comprehensive guideline sort

so i think uh that way i have learned a

lot

um of this topic and i would go ahead

and start

sharing the information with you all so

what we’re going to be talking about

is first what is demodex blepharitis uh

which i guess one of the audience member

already asked

um if i could share something about

demodex blepharitis so yes that will be

there

um and this is going to be very clinical

focused so

um it’s good i’m going to speak about

the clinical features

the diagnosis like how one can go about

in a daily clinical practice diagnosing

this condition

and the management um management of this

condition

so i think the most important thing or

the

take home from this whole presentation

today would be is to remember that

demodex mites are present nearly in 30

of patients with patients with

blepharitis and

demodex infestations are generally

generally remain

undiagnosed and untreated till date

um we will go into a lot of details as

to why

this is happening and uh you know things

like how we can do better

as a clinical community of optometrists

uh to improve the diagnosis and the

treatment of this condition

and the objective is to really

understand how to diagnose this

condition

and the clinical management of how to

best treat your patients

and make sure that they get the most out

for your services um this

so my journey started as i said almost

18 months ago

where it fell into my lab um almost two

years ago

my mentor dr andrew parker was

approached by the cochrane

database and systems review to do a

systematic review on demodex blepharitis

a systematic review is basically looking

into all the credible

research and scientific data on a

particular topic out there

and then putting it together in one one

document one piece of information

so that it can be accessible for

individual clinicians researchers etc

and they don’t have to look for

all of these thousands of papers that

might be available on the same topic

um so i was approached

after a meeting by my mentor and he was

like looks like we’ve been offered to do

this

review and i was like okay what’s the

topic and he’s like

it’s demodex blepharitis and i’m like

huh sounds interesting now then as an

optometrist i knew what blepharitis was

um and but i did not know what demodex

was so

in my head i’m like wait i don’t

remember

learning ever at all about this topic

and my mentor is like so do you think

you would be interested

in like leading this out like yeah sure

i can do that

i got it and um of course i didn’t want

him to know that i did not know what the

topic was

and so immediately afterwards after the

meeting i go and google

demo text blepharitis and yeah a couple

of hits show up

and looks like it is a blepharitis

condition

and i’m like okay so this exists out

there

uh probably i just was sleeping in class

when they taught it and

taught it at lotus so i decided to go

back to the olden and faithful

kanski clinical ophthalmology and

look up the word demodex in the index

and surprisingly

um in my copy there was no mention of

demodex at all

and i was like that is weird then i

looked through the blepharitis chapter

and i could not find anything at all

i was like i haven’t even seen a single

patient

um like or diagnosed or heard of this

diagnosis throughout my

time as a clinician so i was like

why is cochrane wanting to do a review

for something that is so rare they

generally do reviews for topics which

have

significant amount of information that

people might get confused

when they try to look it up and so i

guess it was

a revelation that this this condition

exists

and um it was a journey for me

to actually witness the start of a new

disease and

excuse my um covet references

uh throughout the presentation but i

have a few of them

uh so yeah and um i looked up kanski it

wasn’t there so then i thought okay

um i looked up at the in the eighth

edition which is the most recent one

which is not

what i used when i was going through

optometry and surprisingly

um almost one third of the demodex

chronic blepharitis condition in kansuki

in the eighth edition has been revised

to add demodex i was like okay

if they’re changing one third of the

topics as common as blepharitis

this might definitely be something big

and i should look into and read up at

least for my clinical

uh knowledge and so that’s how the whole

story started and

um so that everyone is on the same page

um i will start right from the basics

as to what is blepharitis even though i

know most of us

have gone through this like a billion

times since it’s one of the first topics

we taught in um

anterior segment uh in optometry so

blepharitis is primarily the

inflammation of the eye

and there are lots of lots and lots of

symptoms

it can be irritated and itchy eyelids

and

you can look at it as someone someone

might say they have photophobia

burning sensation in the eye

etc etc like dry eyes and anything

in that realm can be a symptom

for blepharitis what we generally

see on the slit lamp is gender fly

scales

on the lids and lashes and

as you can see in the picture over here

there are these

tiny dandruff like particles at the end

of the lashes

and there can be many causes for these

and i will not go into the details of

those causes because

this is about demodex blepharitis and

not blepharitis

um and primarily there are two chronic

types one is the anterior blepharitis

and posterior blepharitis also if you

open

or so the khan skin twenties um the

seventh edition will say

if you open it up uh that there are

these two major types of blepharitis

uh the eighth edition adds demodex

blepharitis um

and most common forms of treatment

are lid hygiene basically and you could

say

um washing or cleaning your lids with

baby shampoo

uh water massaging the lids etc etc

and the list of uh treating um

blepharitis

is like super long also as a side note

all my references are on the same slides

so if someone

is trying to look for the same

information in the future

you can just try and google these

references and you would get a detailed

setup a set of information on what i was

talking about

and that can be super helpful sometimes

especially when you’re trying to read up

something later on

so the next big question is then

what is demodex blepharitis if this is

blepharitis

i think a little bit of a giveaway was

um my points to remember slide

wherein um i spoke about demodex

as a mite so demodex blepharitis is

nothing but

blepharitis that involves demodex mite

infestation

um and these are the two

types of demodex mites found in humans

now i specifically say found in humans

because uh there are other types of

demodex mice

just the fact that they don’t infest or

they are not generally found in humans

we will not be talking about

those these are the ones that are

primarily found in humans

the first one is demodex follicularum

which is approximately 0.4 mm long so

they are super super

tiny you probably need a microscope of

some sort to even

look at them and perceive them and this

one is gemma x brevis

which is about 0.2 mm long so that is

one-fifth of a millimeter that is like

tiniest section on your regular ruler

so these are the two mites uh

that are infested that infest humans and

as you can see

they have kind of like eight feet um

so they are classified as arachnids and

this is

their uh sort of face or

part where they feed and their thoracic

region

and the rest of the tail and the body

clinically

we really don’t um it doesn’t really

matter

about their anatomical structure so i am

going to skip

all of those facts and details and go

dive deep into their life cycle

and um because that will be helpful to

decide how to manage them

or what should the treatment be like so

the blepharitis demodex life cycle

of both of them are roughly they are not

that

different um and that is an adult

will take about three to four days to

lay eggs

uh the eggs will take about three to

four days to

hatch and form a larva and then about a

seven day duration

from there um those larvaes will become

uddled

again and then the cycle continues over

and over and over

again so if you add up these numbers

it comes around to 12 to 14 days worth

of cycle

which is a total of two weeks um and

one other important thing to remember

about their life

is what do they actually feed on and

they feed on the follicular and

glandular epithelial cells that are

present

in the eyelids and near the lashes

um also if they feed something they have

to excrete something

and their excreta may actually cause

mechanical blockage

of orifices and by orifices if you go

back to your eyelid anatomy it would be

my birmingham gland orifice where the

me burn comes out of or the um

follicles or the hair uh hair the hair

follicles

these are the places where they might

cause blockage

um so now that you know

a little bit about demodex blepharitis

you might be wondering

um wait if this is so common

and um they are there why haven’t

we seen them and like what what

what really is happening out there

because of this

so to go into the epidemiology um

caution

in 1967 uh was

among the first ones to identify these

mites in

uh blepharitis patients so he had some

blepharitis patients and he saw them

in these blepharitis stations we’ve

known about these mites

in almost about 100 years i think the

first

reference i could find was 1915

but they were primarily classified as a

skin condition so

you could get just like you can get

dandruff on your

hair and because of that you can get a

lot of skin conditions like acne

and rosacea on your face etc uh that’s

where demotic smites had been

primarily classified as but in 1967

and around that time a lot of people

showed that these are also present in

the eyelids and latches

and so they are ocular in nature the

prevalence

uh findings are not very concrete

uh and i i will go into the details as

to why the prevalence range

is so so huge so we have a prevalence of

somewhere around as low as 29

so out of every 10 normal individuals

you would see this

in three individuals and as up to as

a hundred percent uh depending on what

age group you’re looking at

um a lot of people are shocked to see

that or shocked to hear that

these um amazing looking tiny creatures

as i’ve fallen in love with them would

probably be creeping and crawling

on some of our eyelashes um as we speak

right now

so yeah i know that is gross for some

people but um

yeah they are that commonly prevalent uh

they

however they are rarely seen under the

age of 16

um one of the reasons being

that there are particular secretions

from our

uh sebum that do not happen and this is

what the

democrats might really like or feast on

and that is why

they have seen less under the age of 16

but after

um after we grow into a proper adult

um at the age of 17 18 that’s when we

start seeing these

the prevalence increases with age so as

i said the prevalence findings are up to

100

and some of the papers exclusively state

that about the age of 70

every individual would have um demodex

mites in their eyes

and since they are so common um there is

a lot of controversy in the field saying

that demodex might might just be

a part of the normal bioflora of the eye

they are not an infestation probably and

we we

just see them normally because that’s

something like the gut bacteria that we

have and

um there are some um

postulated like thesis of theories that

they actually

might be beneficial and not all that

harmful

and they affect males and females both

equally

so yes it’s not that one gender is

preferred over the other

in this case um the prevalence worldwide

across geographical regions

so far all the information states that

it is

almost similar but since our prevalence

range is so huge already and we haven’t

narrowed it down

that is something potential students

and future researchers can look into

to see if that differs from region to

region

but so far we believe that the

prevalence should not change

because there shouldn’t be any other

differences affecting these

demonic smite so how do you

get it like i’m pretty sure none of us

are born with might so

where does this my like how do you

contract it

and um excuse another one of my favorite

19 references but yes it spreads through

human contact

so probably your best solution is to

keep um

a six feet or two meters distance from

your closest other human being

uh but no that is not we are like that

is not something what we are

recommending here

so yes but it spreads to human contact

and

it is it is understood or

it is hypothesized that um especially

when we are growing up

and say we are about the age of 16 17

whenever someone touches our face or

something like that

especially i know my grandmother used to

love to pull my cheeks each time i would

see her

and so i guess if i have demodex mites

if i find that out

um i probably say that that’s how i got

my first smite

and then they have not left me ever

since then um

so yeah it stretched through human touch

especially if you

if someone touches their face and then

touches your face

that that’s a very common way to spread

it um

it does it it is not caused or spread

via animals so especially dogs

have a condition which is quite popular

as well

if you own a pet it’s called demodex

mandy i believe and it’s caused by

demodex canis as i said earlier there

are lots of types of demodex

and this is not spread via that so if

your dog has

that condition it’s and if you end up

having demodex

that it’s not the same um same might and

it’s not that your dog gave it to you or

you could give it to your dog

so yeah there is no worry over there

this condition

might be symptomless and is often and it

often is because i believe as

optometrists we all believe

that our lid is super hygienic and we

we have the least chance of having these

but um

i have looked at some of my optometry

colleagues over here

and a lot of us seem to have it and so

i believe that yes most of us do have it

but at the same time it is symptomless

and this is where the argument comes in

wherein it might be just a part of the

normal bioflora of the human eye

and hence we don’t face any symptoms and

it can also spread via uncleaned bed

sheets or pillowcases

if two people are sharing that then it

can spread via that

um one of the recent researches i found

was

um looking at how demodex can spread why

are using

us the same microscope a lot of us uh

especially like things like in optometry

lenso materials and

retinoscopes and ophthalmoscopes as

students we tend to share a lot of those

um and it might spread via that as well

um and it could spread through skin

infections

for some um people it infects the skin

and if it is infected the skin for the

same individual

it might spread from their skin or

cheeks to their eyes so there have been

cases where that has been seen

so these are primarily the causes and if

you look at all of the causes

um there isn’t much we can do about uh

these like yes i can understand we can

have clean

bed sheets and pillow cases etc but

other than that

um human contact has is one of

as we can we are facing social

distancing we know how important it is

so i guess there’s not much we can do

about avoiding the causes so much

so to go ahead to understand what we can

do to manage this condition

i think it’s very important to see as

optometrists what would

your patient show up as in the clinic

like what would you see when the patient

comes up with this condition

and since most of you must be thinking

wait i haven’t seen this common super

common condition

in the past um so i’m pretty sure you

haven’t come across

it but no that’s probably not true most

of us have come across

demodex blepharitis in our lives in the

patients as well

we just haven’t been able to recognize

it and so here

let me give you an example of a case

that i’m pretty sure

all of us have seen um a demo expression

shows uh sorry a blepharitis patient

shows up

and um has mild form of blepharitis

probably in their 40s or 50s

and has itching etc the classic symptoms

and we treat them with asking them to do

lid hygiene

like take baby shampoo and scrub it and

wash their eyelids

um and they’re fine after a week you do

a follow-up probably and they’re like oh

this is perfect like all is gone and i’m

fine and you look at the lids and they

are all super clean

everything’s going good and then um

you say the patient yeah you’re all fine

and good to go keep up with the lid

hygiene but other than that should not

be a problem

after probably two or three months this

patient will come back to you again

and they they seem to have the same

problem

and sometimes they’ll be like yes but i

already tried all of the lid hygiene

like i’ve not stopped it at all

and i’ve been continuously doing it so i

don’t know why i’m getting it again

and we and we are at our wits end

sometimes we might think maybe

the patient isn’t compliant and they

might have stopped for a while and they

got it

i’ve heard other excuses like oh this

patient has

really oily skin and that is why they

tend to produce a lot of medium

and that’s what causes all of this and

things would be other explanations would

be like like

if you get dandruff on your head it’s

highly likely that it spreads from there

and comes to your eyelids

or i’ve also heard explanations so it’s

just a seasonal change

it’s super hot in the summer we tend to

sweat a lot and these kind of things

tend to happen

well if you look closer at all of those

cases

if you’ve ever seen any i think you will

find that it is probably

not any of those other reasons but

demodex blepharitis that is causing the

recurrence

of that condition so going on to what

you would see in the clinical features i

think i pretty much described

what you would see but here are some

things that

will help you the next time you see such

a patient to differentiate between

a common blepharitis condition and

something which is generic specialities

so you have to understand that demodex

blepharitis can

primarily be diagnosed by signs

more than the symptoms because the

symptoms would be

very um vague and

would um be anything that could um span

the range of

all forms of blepharitis dry eyes and

conjunctivitis and all of those so

that’s why

signs are more important in this case

than um the symptoms that the patient

will tell you

one of the most pathogenomic sign of

demodex blepharitis

is the cylindrical dandruff like scaling

this image is primarily of um

cylindrical dandruff like scaling and uh

they are

also known as clarets depending on which

part of the world you are

but what is important to remember here

is that if demodex is the cause then

your cylindrical dandruff

is primarily stuck very close to the

base

of the eyelid and um it’s almost

always just there and not at the other

ends

of the eyelashes or it doesn’t really

fall

off etc unless it’s huge in amounts in

which case it will fall off

but if you’re just looking at a

different blepharitis condition

seborrheic um probably caused by some

bacteria etc

you will see um i know this is not a

very clear picture but you would see

that the blepharitis scales or

the the dandruff scales are spread

throughout the islands

and not throughout the eyelashes and not

just at the base

and just to go back quickly to the life

cycle

a life part that we study about demodex

blepharitis we know that they eat

um the follicular and glandular

uh epithelial cells and so

those are very close to the eyelids

and if they are eating there if their

food is there they probably reside there

in the follicles and if they’re residing

there they would excrete in the same

area

and that excrete would generally just

collect in these edges and not spread

far off

and that is how we can somehow say

that this is the cylindrical dandruff is

primarily being caused by

demodex blepharitis instead of any other

cause

also other than that as i already

mentioned

that you have a lot other a lot of other

symptoms

often there might be no symptoms at all

and sometimes symptoms would be like

itching dryness burning sensation

photophobia etc

all the other symptoms that you can

think of which affect

anterior segment dry eye kind of

conditions

and symptoms would also be associated

with conditions like

blepharoconjunctivitis ty formation

meibomian gland dysfunctions

you might have had patients that come

frequently to you

saying um like you know every

six months or eight months they probably

have a style or

a chileasian or internal external

cordulum as we like to call them um

and these might be just sometimes these

are just the associated condition

to the primary condition being demodex

blepharitis not always but sometimes

they are just associated conditions

and we of course treat these associated

conditions and they go away

um but again after a few months the

patient comes back with another similar

problem

and we are like oh yeah this is a

chronic patient

he’s going to have this for a long long

time probably an allergy or something

like that

but it might be wise to look at the

patient to see

if they have demodex nephritis and now

that we know

all the clinical features that we should

be looking at

i think it is time for us to um

to really understand how can the

diagnosis happen

or what is the ultimate test that you

can do in your clinic

to say okay this patient has demodex

refrigerants and i should start treating

them

accordingly um well good luck there

because there is no official test for

diagnosis though we’ve known for demodex

blepharitis

in the eye for 50 years the primary two

problems that i perceive

are one they are so tiny that for a lot

of those 50 years most of us

didn’t have um equipment or enough

technology to actually be able to

diagnose it

um and then you’d be like but well

people had slit lamp

in most parts of the world like 20 years

ago or 30 years ago it’s not the first

time

someone saw split lamp in this century

the other

part is that we don’t have any official

test or clinical diagnosis set up or any

guidelines

so most of the practitioners and

probably even our faculty

um that’s why we weren’t taught uh in

school

and and i’m so sorry if i was sleeping

in that class but i hope

i wasn’t um is that we are not aware of

this condition

existing and we’ve been treating just

the symptoms that show up

and for a lot of us it solves the

problem

because it might just be that demodex is

a part of the normal

flora and fauna one of the reasons that

comes up

is that um even though a lot of people

argue it might be a normal bioflora

the thing could be that it is

normal bioflora until it is in a certain

amount

but if it starts growing in the

population

uh super quickly that is when the

numbers rise up and

that is when it starts causing all the

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