Spontaneous acinar and ductal regrowth after meibomian gland atrophy induced by deletion of FGFR2 in a mouse model

PURPOSE

We have demonstrated that deletion of fibroblast growth factor receptor 2 gene (Fgfr2) leads to Meibomian gland (MG) atrophy in an inducible conditional knockout mouse model, referred as Fgfr2^CKO. Herein, we investigated whether MG spontaneously recovers after atrophy in this model.

METHODS

Two months old Fgfr2^CKO mice were injected peritoneally once or twice of doxycycline (Dox) at 80 μg/gm of body weight to induce MG atrophy of various severities via Fgfr2 deletion. Recovery of acinar and ductal tissues was monitored by meibography, lipid staining and immunofluorescence against keratin-6a in MG whole-mount. Biomarkers for acinar and ductal differentiation and proliferation were also examined by immunostaining.

RESULTS

Single Dox injection in Fgfr2^CKO mice caused severe acinar and moderate ductal atrophy. Severe ductal shortening or loss occurred after second Dox injection, presumably related to the reported slower cycling of the ductal epithelia. Spontaneous acinar regrowth after atrophy was observed over a period of 60 days in both injection regimens. However, less robust acinar recovery was associated with more disrupted ductal structures in twice injected Fgfr2^CKO mice.

CONCLUSIONS

Our current findings further substantiate the role of FGFR2 in MG homeostasis, and suggest that FGFR2-signaling may provide a potential strategy for regenerating acini from age-related MG dysfunction in humans. Our data demonstrated that spontaneous MG recovery depends on the extent of ductal atrophy, suggesting that ductal epithelia may provide the progenitor cells for acinar regeneration. Nonetheless, the role of ductal tissue as the source of acinar progenitors awaits further investigation.

An observational study on ocular manifestations in patients of psoriasis in a tertiary care hospital in western India

Background

The aim of the study is to observe the ocular manifestation in patients of psoriasis.

Methods

All the diagnosed cases of Psoriasis by the dermatology department of this tertiary care hospital were included in this study. Relevant details of the history pertaining to disease duration, type of psoriasis, and treatment undertaken including ocular symptoms were obtained. Disease severity was quantified using the PASI score. Complete ocular examination including intraocular pressure, Schirmer I and II tests, Tear Film Breakup Tme (TBUT); was carried out for all the patients.

Results

Of 126 patients of psoriasis, ocular manifestations were seen in 76 patients (60.3%). Dry eyes (27%) and blepharitis (15.9%) were the most common ocular manifestations. Uveitis was seen in 3.2% of the patients of which 75% patients were HA B27-positive psoriatic arthritis, which was statistically significant (p = 0.001). There was no statistical correlation between duration of the disease and ocular manifestations (p value is 0.077 using chi square test). The ocular manifestations were more common in patients with PASI score 10 when compared with the patients with PASI score 10 (p value = 0.028) which was statistically significant.

Conclusions

In our study, prevalence of ocular manifestation was 60.3% which increased with the increasing PASI score. Dry eyes and blepharitis were the most common manifestations. Hence, routine ocular examination is recommended in patients with psoriasis.

Interobserver and Intraobserver Agreements of the Detection of Demodex Infestation by in Vivo Confocal Microscopy

Objectives

The purpose of the study was to determine interobserver and intraobserver agreement, repeatability, and intrasubject variation of the detection of Demodex infestation in eyelids of blepharitis patients using in vivo confocal microscopy (IVCM).

Methods

Eighty-three eyes of 42 blepharitis patients were included in the study. All eyelids were evaluated from temporal to nasal with IVCM using section mode and 10 lashes with their follicles were imagined, and every image with suspicion of Demodex infestation was recorded. Two experienced and two inexperienced ophthalmologists were masked for the diagnosis and interpreted the IVCM images regarding the presence of Demodex infestation with a 3-week interval. Interobserver and intraobserver agreements were calculated with Cohen's kappa and its variant statistics between and within experienced observers and between inexperienced observers.

Results

While average sensitivity for the diagnosis of demodicosis in IVCM images was 83.35% for experienced and 51.35% for inexperienced observers, the average positive predictive value was 88.6% for experienced observers and 91.05% for inexperienced ones. Interobserver agreement between experienced observers was moderate (κ = 0.529) and intraobserver agreements within experienced observers were perfect (κ = 0.918 for observer-1; κ = 0.958 for observer-2). Interobserver agreement between inexperienced observers was poor (κ = 0.162) and intraobserver agreements within inexperienced observers were fair (κ = 0.427 for observer-3; κ = 0.475 for observer-4).

Conclusion

The sensitivity, interobserver and intraobserver agreements in IVCM image analysis for the detection of Demodex infestation were highly associated with the clinical experience on IVCM imaging. In the hands of an experienced clinician, IVCM could be reliable for the diagnosis of ocular demodicosis.

Short-term tolerability of commercial eyelid cleansers: A randomised crossover study

PURPOSE

To evaluate the short-term tolerability of five commercially available anti-demodectic eyelid cleansers; OCuSOFT Oust Demodex (OD), I-MED I-Lid'n Lash Plus (ILL+), Labtician BlephaDex (BD), Chrissanthe Eye Cleanse (EC), and Théa Blephademodex (BDdx).

METHODS

Thirty healthy non-contact lens wearers (18 female; mean ± SD age, 33 ± 12 years) were enrolled in a prospective randomised crossover study. On separate visits, spaced at least 48 h apart, participants were randomised to receive topical application of one of five eyelid cleansers or saline. Participants rated subjective ocular discomfort during the 10-minute post-application period. Visual acuity, non-invasive tear film stability, conjunctival hyperaemia, and ocular surface staining were assessed at baseline and 10 min.

RESULTS

No inter-group differences in ocular parameters were noted at baseline (all p > 0.05). Ocular discomfort scores significantly exceeded baseline scores for 60 s following BD application, 120 s with OD, 135 s with BDdx, 150 s with ILL+, and 195 s with EC (all p < 0.05). Deterioration in non-invasive tear film stability, limbal conjunctival hyperaemia, as well as corneal, conjunctival, and lid margin staining was detected following EC application (all p < 0.05), and increased bulbar conjunctival hyperaemia was observed following both EC and ILL+ treatment (both p < 0.05).

CONCLUSIONS

Study outcomes highlight varying tolerability profiles with different anti-demodectic lid cleanser preparations, and the potential to induce tear film instability, conjunctival hyperaemia and ocular surface staining on application. Awareness of possible adverse effects arising from topical application of commercial anti-demodectic lid cleanser formulations may help clinicians set realistic patient expectations and encourage better compliance in their use of lid hygiene therapies.

Discoid lupus erythematosus of eyelids - Diagnostic and therapeutic challenges

Discoid lupus erythematosus (DLE) is the most common form of chronic cutaneous lupus erythematosus commonly seen in photoexposed regions. Eyelid involvement in DLE is relatively rare. We present three cases of DLE with eyelid involvement. It closely mimics many clinical conditions; hence, diagnosis is often late. When left untreated, it can lead to many complications. The aim of this case series is to emphasize that ophthalmologists and dermatologists are aware of the various presentations of DLE in eyelids to prevent any misdiagnosis.

Treatment of ocular Demodex infestation with topical ivermectin cream

Purpose

To evaluate the use of ivermectin 1% cream for the treatment of sleeves associated with Demodex blepharitis.

Observations

A retrospective chart review was conducted on patients with moderate to dense sleeves secondary to Demodex folliculorum, who were treated with one or two applications of topical ivermectin 1% cream. Those who had been documented photographically pre- and post-treatment were evaluated. In this series of 5 cases, ivermectin 1% cream was highly effective in reducing or eliminating sleeves, which is the primary clinical sign of D. folliculorum infestation of the eyelids.

Conclusions and Importance

A single or double application of ivermectin 1% cream is well tolerated and highly effective in reducing or eliminating the characteristic sleeves associated with Demodex blepharitis. The use of ivermectin 1% cream merits further investigation.

Long-Term Intraocular Pressure-Lowering Effects and Adverse Events of Ripasudil in Patients with Glaucoma or Ocular Hypertension over 24 Months

Introduction

Glaucoma is a leading cause of irreversible blindness and ripasudil was the first Rho kinase inhibitor approved as antiglaucoma medication. Here we present the final analysis of the ROCK-J study, a large-scale post-marketing surveillance study to evaluate the long-term safety and effectiveness of ripasudil in Japanese patients with glaucoma or ocular hypertension in a real-word clinical setting.

Methods

ROCK-J was a 24-month, prospective, open-label, observational study that included ripasudil-naïve patients with glaucoma or ocular hypertension who were initiating treatment with ripasudil according to the Japanese approved indication between June 1, 2015 and April 30, 2017. The primary safety endpoint was the incidence of adverse drug reactions (ADRs) (including blepharitis, plus assessment of its background factors); the primary efficacy endpoint was change in intraocular pressure (IOP) from baseline to 24 months.

Results

A total of 3374 Japanese patients with glaucoma or ocular hypertension were evaluated for safety and 3178 for effectiveness of ripasudil over a mean 524.5-day observational period. Overall, 853 (25.3%) patients experienced adverse drug reactions; the most common were blepharitis (8.6%), conjunctival hyperemia (8.5%), and conjunctivitis (6.3%). Multivariate analyses demonstrated that patients were more likely to experience the ADR blepharitis with ripasudil treatment if they were female (hazard ratio [HR] 1.307; p = 0.040), had comorbid or a previous history of blepharitis (HR 2.178; p = 0.001), or had a history of allergy to pollen (HR 1.645; p = 0.003) or medication (HR 2.276; p < 0.001). IOP decreased significantly from baseline with ripasudil; the least-squares mean ± standard error change in IOP from baseline to 24 months was − 2.6 ± 0.1 mmHg (p < 0.001). Significant IOP changes were seen in four types of glaucoma, namely primary open-angle glaucoma, normal-tension glaucoma, primary angle-closure glaucoma, and secondary glaucoma, and ocular hypertension.

Conclusion

Ripasudil was safe and effective as an antiglaucoma medication with no new safety signals identified and significant reductions in IOP maintained over 24 months of treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02023-y.

Different Approach to Manage Demodex Blepharitis - Initial and Maintenance Treatment

PURPOSE/AIM OF THE STUDY

To evaluate the improvement of ocular signs and symptoms in patients suffering from Demodex blepharitis using a combined treatment approach: use of eyelid wipes impregnated with 2.5% terpinen-4-ol (T4O) and 0.2% hyaluronic acid (HA) in the initial treatment period and investigation of maintenance of the treatment effect with the use of eyelid cleansing wipes.

MATERIALS AND METHODS

Fifty patients with Demodex blepharitis were treated in the initial treatment period with sterile eyelid T4O impregnated wipes for 28 days. In the following four-week maintenance period, 82% patients received sterile eyelid maintenance wipes, while 16% continued treatment with T4O impregnated wipes. Global ocular discomfort, adapted TOSS, SANDE score, and individual blepharitis symptoms were assessed by patients at day 28 and day 56. Ocular signs were evaluated by the investigator at the study visits. Investigator's assessment of the overall treatment performance, patient's assessment of treatment satisfaction, and tolerability were evaluated with questionnaires.

RESULTS

All global ocular discomfort symptoms and disease specific symptoms assessed by patients as well as all parameters evaluated by the investigators significantly improved in the initial treatment period with the application of eyelid wipes impregnated with 2.5% terpinen-4-ol until day 28. The therapeutic effect was maintained or even improved during the maintenance period under administration of mainly eyelid maintenance wipes until day 56. Both products were well tolerated. No adverse events and no clinically relevant changes in visual acuity were observed during both periods.

CONCLUSIONS

Once daily treatment with T4O impregnated eyelid wipes in the initial treatment period significantly improved the ocular symptoms and signs and reduced the mite count in patients with Demodex blepharitis within four-weeks administration. Subsequent maintenance treatment with maintenance wipes for another 4 weeks preserved or further intensified the treatment success. The products were well tolerated and were convenient to use.

[Hordeolum and chalazion : (Differential) diagnosis and treatment]

Hordeolum and chalazion are the most frequent inflammatory eyelid tumors. They can occur in association with underlying diseases causing Meibomian gland dysfunction and/or chronic blepharitis. Due to the typical morphological features and clinical course, the diagnosis can mostly be clinically established. The majority of these lesions resolve spontaneously over time. In some instances, surgical intervention is unavoidable. In persistent, recurrent or clinically atypical cases malignant tumors must be excluded as a differential diagnosis by excisional biopsy and histopathological assessment.

Successful management of chronic Blepharo-rosacea associated demodex by lid scrub with terpinen-4-ol

Purpose

To report a successful treatment of chronic rosacea associated ocular demodicosis with lid scrub containing terpinen-4-ol (T4O).

Observations

A 72-year old woman presented with recurrent and refractory ocular erythema, irritation, dryness, and photophobia despite conventional medical treatment (artificial tears, hypochlorous acid lid hygiene, doxycycline, and erythromycin) for 5 years. Examination revealed facial erythema, telangiectasias on cheeks, nose and lids, and cylindrical dandruff (CD) on bilateral upper and lower lashes. Epilation sampling confirmed demodicosis. After treatment with lid wipe containing T4O (Cliradex, Biotissue, Miami, FL) over face and lids, ocular discomfort, CD, facial and eyelid erythema, telangiectatic vessels were significantly reduced. Complete eradication of demodex mites and resolution of symptoms and signs lasted 8 months of follow-up.

Conclusions

This case suggests that T4O is effective in treating chronic rosacea associated ocular demodex blepharitis.

Shared Makeup Cosmetics as a Route of Demodex folliculorum Infections

Purpose

The aim of the study was to examine Demodex survival in makeup cosmetics, i.e., powder cream, mascara, and lipstick, and to determine whether cosmetics shared with others can be a source of D. folliculorum infection.

Methods

Live D. folliculorum adults were placed in cosmetic samples and their motility was observed under a microscope. The mites were fully or partially immersed in the powder cream and lipstick, and only partially immersed in the mascara. Partial immersion means that only the opisthosoma was covered by the cosmetic, whereas the gnathosoma and podosoma had no contact with the cosmetic. Cessation of motility was regarded as a sign of death.

Results

In the control (mites placed on a microscope slide with no cosmetics), the survival time was 41.2 h. D. folliculorum that were immersed fully or partially in the lipstick substrate were viable for 38.5 h and 148 h, respectively. The survival time of the mites at full and partial immersion in the powder cream was 0.78 h and 2.16 h, respectively. The average survival time in the mascara was 21 h.

Conclusions

Makeup cosmetics used by different individuals at short intervals (from several hours to several days) can be a source of transmission of Demodex sp. mites.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11686-020-00332-w.

Interventions for Demodex blepharitis and their effectiveness: A systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis was performed to evaluate the effectiveness of interventions in the treatment ofDemodex blepharitis in adult patients.

METHODS

A systematic review and meta-analysis of studies reporting the efficacy of treatments forDemodex blepharitis in the main databases (PubMed / Scopus / Cochrane / EMBASE / Science Direct / WOS / Scielo / Google Scholar / metaRegister of Controlled Trials / ClinicalTrials.gov/ WHO ICTRP) until November 24, 2020 was performed according to the PRISMA statement for meta-analysis.

RESULTS

Overall, 18 studies were included for 29 different interventions in 1195 participants with 1574 eyes that were positive for Demodex Spp. Demodex counts, total eradication, clinical improvement, Ocular Surface Disease Index, Tear Break-Up Time, cylindrical dandruff, Schirmer test, osmolarity and adverse reactions were analysed, and stratified sub-analyses conducted. The overall effects for Demodex count (mean difference), total eradication (risk ratio) and adverse reactions (risk difference) were -2.07 (95 % CI -3.99 to -0.15) p = 0.03, 1.84 (95 % CI 1.27-2.66) p = 0.001 and 0.24 (95 % CI 0.08 to 0.41) p = 0.005, respectively. The most frequent interventions evaluated in the included studies were tea tree oil (TTO) and its derivatives, such as terpinen 4-ol.

CONCLUSION

Multiple therapeutic choices were evaluated in this meta-analysis. Pharmacological interventions were superior to non-pharmacological (mechanical, thermal and pulsed light) interventions. It was not possible to establish significant differences between TTO and non-TTO-derived treatments. Adverse reactions were more frequent in TTO-derived treatments, however all were mild. It is necessary to execute studies with longer follow-up times to determine whether re-infestation occurs after the administration of different treatments.

Efficacy of Intense Pulsed Light Treatment for Moderate to Severe Acute Blepharitis or Blepharoconjunctivitis: A Retrospective Case Series

Objectives:

We aimed to evaluate the efficacy of periocular intense pulsed light (IPL) therapy in the treatment of moderate to severe acute blepharitis or blepharoconjunctivitis.

Materials and Methods:

This was a retrospective study performed in one institution. Eleven patients who received bilateral periocular IPL therapy using an IPL device (E>Eye, ESwin, Paris, France) were retrospectively evaluated. The following findings obtained at baseline and 10 weeks after the treatment were recorded: slit-lamp examinations; symptom scores of the Compression of the Eyelid (COTE) grading system and Ocular Surface Disease Index (OSDI); ocular surface staining with Oxford grading scale (OXFORD) scores; lipid layer thickness (LLT); and non-invasive tear meniscus test (TMH), non-invasive break up time measurement (NIBUT), and meibography performed by using I.C.P. Ocular Surface Analyzer (SBM System, Turin, Italy).

Results:

Significant improvements in OSDI symptom scores (p<0.0001), LLT (p<0.0001), and meibography (p<0.0001) were obtained at 10 weeks after bilateral periocular IPL therapy. COTE and ocular surface staining scores decreased by 59.72% and 57.14% respectively, while NIBUT and TMH increased by 47.34% and 22.16%, respectively. In parallel to the improvement in OSDI, LLT, and meibography, findings of acute blepharitis or blepharoconjunctivitis improved in slit-lamp examination. There were no adverse effects.

Conclusion:

Serial IPL therapy improves the clinical signs and symptoms of moderate to severe acute blepharitis or blepharoconjunctivitis, meibomian gland morphology, and secretion quality.

Ophthalmic manifestations in patients with collagen vascular disorders: a hospital-based retrospective observational study

AIM

To study frequency and characteristics of ocular manifestations in Indian patients with collagen vascular disorders.

METHODS

The medical records of 73 patients (Males: Females 16:57) aged between 22 and 78 years (mean ± SD = 43.5 ± 12.9 years) with collagen vascular diseases were analyzed retrospectively for demography, subtypes of collagen vascular disease, and findings of complete ophthalmic examination.

RESULTS

Lupus erythematosus (LE) in 39(53.4%, (SLE 18, DLE 21), systemic sclerosis in 27(37%), dermatomyositis in 5(6.8%), and primary Sjögren's syndrome in 2(2.7%) patients, respectively, were observed. Only 35(47.9%) patients had ocular manifestations. In LE keratoconjunctivitis sicca (n = 6), keratitis (n = 5), severe blepharitis (n = 3), retinopathy (n = 2), and optic neuritis in one patient, respectively, were major ocular manifestations. Major abnormalities occurring in systemic sclerosis included restricted eyelid mobility of variable severity (n = 8), eyelid telangiectasia (n = 5), keratoconjunctivitis sicca (n = 6), cataract (n = 5), shallow fornices (n = 4), conjunctival surface disease (n = 4), and uveitis, keratitis, episcleritis in one patient each, respectively. One patient with dermatomyositis had heliotrope rash. Two patients with primary Sjögren's syndrome had keratoconjunctivitis sicca.

CONCLUSIONS

The study shows that LE frequently presented with keratoconjunctivitis sicca, retinopathy, and optic neuritis. Systemic sclerosis commonly develops eyelid immobility, blepharitis and telangiectasia, ocular surface disease and keratoconjunctivitis sicca, corneal abnormalities, and uveitis. A comprehensive ocular evaluation is imperative for early detection and management particularly of ocular surface disease, uveitis, and retinopathy to prevent potential sight-threatening complications. Limitations include retrospective study design and small number of patients for stratification.

Therapeutic potential of castor oil in managing blepharitis, meibomian gland dysfunction and dry eye

The multifactorial pathogenesis and interrelationship of blepharitis, meibomian gland dysfunction and dry eye disease poses challenges to any therapeutic approach. Current treatments are mostly palliative, with success limited by perceived inefficacy and poor patient compliance. Castor oil, a natural derivative of the Ricinus communis plant, is widely used as an emollient in cosmetics and personal care products, drug delivery systems and wound dressings. Castor oil is deemed safe and tolerable, with strong anti-microbial, anti-inflammatory, anti-nociceptive, analgesic, antioxidant, wound healing and vaso-constrictive properties. Its main constituent, ricinoleic acid, has a bipolar molecular structure that promotes the formation of esters, amides and polymers. These can supplement deficient physiological tear film lipids, enabling enhanced lipid spreading characteristics and reducing aqueous tear evaporation. Studies reveal that castor oil applied topically to the ocular surface has a prolonged residence time, facilitating increased tear film lipid layer thickness, stability, improved ocular surface staining and symptoms. This review summarises the properties, current uses of, and therapeutic potential of castor oil in managing ocular surface disease. The biochemical, medicinal actions of castor oil are explored from the perspective of ocular surface pathology, and include microbial and demodectic over-colonisation, inflammatory and oxidative processes, as well as clinical signs and symptoms of dryness and discomfort.

Increased incidence of chalazion associated with face mask wear during the COVID-19 pandemic

Purpose

To determine whether the incidence of chalazion increased significantly in the San Francisco Bay Area and Los Angeles County following the widespread adoption of face mask wear in response to the COVID-19 pandemic.

Methods

This is a retrospective multicenter study of two ophthalmology institutions: a private Oculoplastics practice in San Francisco and the Oculoplastics division of the Stein Eye Institute at the University of California, Los Angeles. All patients seen during the studied time periods with a diagnosis of chalazion or hordeolum were identified through review of electronic medical records and included in the study. Incidence was determined for each month between January and August 2020, and compared to data from prior years via ANOVA to evaluate for changes after the onset of the pandemic.

Results

In San Francisco, the incidence of chalazion rose significantly in June through August of 2020 when compared to the same interval in 2016, 2017, 2018, and 2019. In Los Angeles, the rise in chalazion incidence in 2020 was also statistically significant when compared to data from the years 2018 and 2019.

Conclusion

Importance: Widespread mask wear does appear to correspond to an increased incidence of chalazion. This risk may be minimized, while still maintaining the protective benefits of mask wear, by taking the proactive measures discussed to decrease mask induced eye dryness and changes in the eyelid microbiome.

[Pediatric ocular rosacea effectively treated with topical 1.5% azithromycin eye drops]

Ocular rosacea in children is a rare but often underdiagnosed condition. It is typically associated with chronic blepharoconjunctivitis, chalazia, corneal opacity and corneal neovascularization. The recommended treatment consists of topical (eyelid hygiene, steroids, cyclosporin, lubricants) and systemic (antibiotics e.g. erythromycin) measures. This case series of 8 children demonstrates the efficacy of local 1.5% azithromycin treatment together with eyelid hygiene in pediatric ocular rosacea. A further advantage of this topical treatment is that the required application of only twice daily for 3 days followed by 7 days without treatment is convenient and improves adherence to treatment.

[Demodex and ocular surface disease]

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary Care Family Physicians

Primary care presentations of dry eye disease (DED) are common and pose a diagnostic challenge due to the variety of symptoms and the absence of certainty for family practitioners. While there are many published articles on the topic, the 2017 Tear Film and Ocular Surface Society Dry Eye Workshop was a landmark report in distinguishing multifactorial differences. Redefined terms clarified the DED disorder. The ocular surface—the tear/air interface—is the primary refractive component of the eye, which is why DED is so significant and impacts vision. There is a high prevalence of DED in the community, ranging from 5% to 30% of people across multiple studies. Elderly patients have up to 75% increased risk of DED and receive more intensive treatment than younger age groups. DED is also more common in women than men, occurring in 9.8% of postmenopausal women. The causes of DED span defective lacrimal apparatus and systemic disorders. Despite its prevalence, up to one-half of patients with confirmed DED do not receive proper alleviating treatment. Risk factors on functional and environmental bases follow. Tools to elicit a diagnosis more confidently are outlined using the Ocular Surface Disease Index (OSDI) and the Symptom Assessment in Dry Eye questionnaires (SANDE). Lacritin, lutein, vitamin A, and balanced nutrition are essential contributors to maintaining healthy eyes with appropriate management and treatment. The authors hope that this paper will prompt a more accurate and expedient diagnosis of DED in primary care practice and an earlier recognition of specialist referrals.

Dry eye disease (DED) poses a diagnostic challenge to primary care physicians. The condition involves the tear/air interface, at the corneal (ocular) surface, where light enters the eye. Any change in light refraction affects regular sight. Symptoms of DED include itching, grittiness, foreign body sensation, redness, excessive tearing, and visual blurring, the lattermost being the most common presentation. Ultimately, the untreated disease leads to continued discomfort and visual deficit, but when severe, it can result in blindness. Up to 30% of the population suffers from DED, with the elderly, particularly women, more affected. Unfortunately, up to 50% of those affected have inadequate treatment. Questionnaires help in diagnosis. Simple office tests can indicate the severity of eye problems. Technology with smartphone photography can take high-resolution images, which are useful in education and teaching. A multitude of conditions cause DED, including blepharitis, an infection of the eyelids. Environmental risks also abound. Proper nutrition is essential in maintaining eye health. Intermittent eye symptoms are likely to be underrated by the public, by purchasing over-the-counter products such as artificial tears rather than seeking a proper medical check. Newer prescription medications are now available for DED relief before advancing to debility requiring specialist treatment.

Clinical characteristics and topographic findings of corneal ectasia in patients with symptomatic Demodex blepharitis

PURPOSE:

The purpose of this study is to present characteristics and topographic findings of patients with corneal ectasia and symptomatic ocular demodicosis.

MATERIALS AND METHODS:

A retrospective, noncomparative study. Twenty-one patients with symptomatic ocular demodicosis and corneal ectasia since 2017 to 2019 were enrolled. Patients with dry eye syndrome and meibomian gland dysfunction were identified and treated. Demographic data, topography, and clinical data were collected. All patients underwent lash sampling to confirm Demodex mite infestation by direct visualization under the microscope.

RESULTS:

Twenty-one ectasia patients (36 eyes) were enrolled with male preponderance (M:F =18:3). Mean age (years) was 28.6 ± 8.12. Of the 21 cases reviewed, the average number of topography taken was 6.8 within 43.8 months of follow-up. Corneal ectasia was characterized by focal thinning area beside central cornea, with corresponding mean thickness of 487.1 μm and 518 μm, respectively. All ectasia patients were combined with Demodex blepharitis and associated symptoms, proven by direct microscopic examination. After treatment with eyelid cleanser (OCuSOFT® Lid Scrub® PLUS), warm compress, and improved daily hygiene, ocular demodicosis and topographic changes were controlled and even reversed.

CONCLUSION:

Our results indicated that ocular demodicosis may be potentially associated with corneal ectasia. Demodex blepharitis still remains an overlooked differential diagnosis in clinic; however, it may be one of the risk factors triggering eye rubbing. Comorbidity of lid infestation with eye rubbing may lead to corneal ectasia, even in elder patients with thick cornea. Therefore, meticulous examination and intensive treatment were highly recommended in this group of patients.

In which rosacea patients should Demodex in the eyelashes be investigated?

Aim

The aim of this study was to investigate the relationship between the presence of Demodex on the face and within the eyelash follicles in patients with rosacea.

Subjects and Methods

This prospective cross-sectional study included 80 participants, 40 patients with rosacea and 40 individuals with no rosacea as controls. The presence of Demodex on the face was assessed by standard superficial skin biopsy. Sixteen eyelashes were epilated from each patient and control.

Results

The rate of Demodex infestation and severe infestation on the face in patients with rosacea was significantly higher than the control group. Demodex count within the eyelash follicle was significantly higher in patients with erythematotelangiectatic type rosacea than the control group. There was no increase in blepharitis in rosacea patients but when blepharitis was present, the rate of the presence of Demodex was higher in this group. There was a statistically significant relationship between the presence of Demodex within the eyelashes and itchy eyes in people without blepharitis.

Conclusion

When at least one Demodex is found on the face in rosacea patients, the eyelashes should be examined for effective treatment of the mite. Itchy eyes may be an important sign of the presence of Demodex in people without blepharitis.

Ocular Myasthenia Gravis with Severe Blepharitis and Ocular Surface Disease: A Case Report

Ocular myasthenia gravis (OMG) is an autoimmune disease of the neuromuscular junction and commonly associated with other immune diseases. We describe a 16-year-old female who presented to our clinic with 1-month complaints of diplopia and strabismus, visual acuity deterioration, and ocular irritation. Her examination showed crossed diplopia and alternating exotropia of 25 prism diopters, severe blepharitis, conjunctival hyperemia, corneal pannus, epithelial irregularities, and subepithelial opacities. Workup included pediatric neurologic examination, laboratory tests, imaging, and electrophysiological tests. Diagnoses of OMG and blepharitis with ocular surface disease were made. Topical treatment included eyelid hygiene, tea tree oil scrubbing, topical steroids, and tacrolimus ointment. Systemic treatment included corticosteroids, pyridostigmine, azathioprine, intravenous immunoglobulins, amitriptyline, and doxycycline. Both diseases were refractory to intensive immunosuppressive treatment and had simultaneous relapses and an intertwined course. Our hypothesis is that a shared immune mechanism may be the cause of both OMG and ocular surface disease in our patient.

Eyelid Disorders in Ophthalmology Practice: Results from a Large International Epidemiological Study in Eleven Countries

Purpose

Anecdotal evidence suggests that eyelid disorders are common, although estimates of prevalence vary. The current study determines the prevalence of eyelid disorders, meibomian gland dysfunction (MGD) and related diseases (specifically ocular surface disease) in a population of patients presenting for routine ophthalmologic consultations.

Methods

This cross-sectional epidemiologic survey evaluated patients presenting for routine ophthalmic visits. During the consultation an ophthalmologist completed a questionnaire, and each patient underwent an ophthalmic examination and completed a quality of life questionnaire.

Results

Three hundred forty-nine ophthalmologists, recruited from 11 countries, provided data on 6525 patients. Patients were predominantly females (61.6%). The mean age of the study population was 57.0 ± 17.6 years. Eyelid disorders were diagnosed in 5109 (78.3%) patients and were statistically associated with: atopic dermatitis, seborrheic dermatitis, dry eye, age-related macular degeneration, diabetes, cataract, allergy and MGD (P < 0.05, all associations). Eyelid abnormalities were identified in 59.6% of patients; conjunctival or corneal abnormalities were observed in 64.9% and 28.1% of patients, respectively. MGD was diagnosed in 54.3% patients and was statistically significantly associated with the presence of eyelid disorders and eyelid margin abnormalities (P < 0.001, both comparisons). Dry eye was diagnosed in 61.8% of patients. Concurrent dry eye and MGD were present in 67.6% of patients. Most patients reported some degree of impaired vision and daily/work activities related to dry eye. Impact on contact lens usage, emotions and quality of sleep was also reported. The effects on daily life were associated with the presence of MGD.

Conclusion

In conclusion, eyelid disorders were highly prevalent in this ‘real-world’ population of patients from ophthalmology clinics. Routine ophthalmologic consultations provide an opportunity to improve patient quality of life and to modify topical therapy in patients who may be predisposed to eyelid disorders.

Topical ivermectin-metronidazole gel therapy in the treatment of blepharitis caused by Demodex spp.: A randomized clinical trial

PURPOSE

To evaluate the efficacy of topical ivermectin-metronidazole combined therapy in the management of Demodex-associatedblepharitis.

METHODS

Sixty patients with a diagnosis of Demodex-associatedblepharitis were recruited in a randomized clinical trial. Thirty receiving topical ivermectin (0.1%)-metronidazole (1%) gel treatment on days 0, 15 and 30. Thirty additional patients were used as a control group receiving vehicle on days 0, 15 and 30. The primary efficacy measure was the number of Demodex spp. mitesin the eyelashes of patients. The secondary outcomes included clinical improvement of signs and adverse events.

RESULTS

Complete eradication of Demodex spp. was found in 96.6% of patients in the treatment group. Furthermore, a significant reduction of inflammation signs were found in all treated patients versus controls. None of the patients experienced any adverse effects associated with the treatment.

CONCLUSION

Demodex infection was controlled satisfactorily with the ivermectin (0.1%)-metronidazole (1%) gel, and no adverse effects were observed. Application of this gel for the treatment of different parasitic infections of the eyelids could be feasible, and this requires further exploration.