At the Lid Line: Unmasking Demodex Across the OSD Spectrum

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Dr. Devries:
This is CE on ReachMD. I'm Dr. Doug Devries, and I'm joined here today with Cecilia Koetting, and we're going to at this point summarize really our experiences with treating and integration of treating Demodex blepharitis into our practices and find some of the best practice that we have.

So Cecilia, could you talk a little bit about coming up with the initial diagnosis and how you're handling that patient in the very beginning?

Dr. Koetting:
So thankfully the ability to diagnose these patients and identify who's got a problem is as easy as look down. And that's been the best thing for me as far as not needing a special test. We all have slit lamps, right? And we're all going to do a slit lamp exam. So just having your patient look down, and at this point it is 100% part of all of my exams. So look for the collarettes.

Now, the sneaky ones are when maybe you don't see a collarette and you suspect it because they've been cleaning and they're complaining about itching. You see a little bit of redness along the lash line. You see a little telangiectasia, maybe some misdirected or short brittle lashes.

And then the next step regardless of what you see is pushing on those glands. And if you start to see some MGD, take all of that together to kind of create your clinical picture as to what's going on, and then that helps to fuel the discussion and your treatment that you're going to talk with them, right?

So having the discussion with the patients about Demodex. Yes they're part of our natural flora and fauna, we have a mite that's overgrown and it can cause problems. So we're going to treat that, right, and going into a couple of different treatments. And I say hey we're going to set the stage with- this is your cleaning you're going to be doing at-home cleaning the rest of your life. It's like brushing your teeth and flossing. We need to do it.

So adding that in, setting the stage, but then saying but first we're also going to debulk. We're going to start you on lotilaner. I'm going to prescribe this so that we can knock out the bulk of those guys and get them back to a more manageable population so that we can, from there on, manage primarily with your day-to-day cleaning.

And that's really honestly I start there. I bring them back for a 6- to 8-week follow-up just because I know getting medication and cleaning products and things like that in hand and getting started can take a couple of weeks. And then I want to encourage them, right? I want to see are they doing what they should be doing, are they having any problems. But also say hey good job, it's looking better, now keep going with it, because we know that you can't stop the lotilaner. You've got to get through that whole treatment. Otherwise, you don't get through the two life cycles of the mite that we need to ensure that we've really brought down that population.

Dr. Devries:
And it really all starts with making a commitment within your practice, because you need to integrate it into the practice. Because you can't just say well when there's so many collarettes and the patient is looking straight ahead I see the collarettes and those are the ones I'm going to treat. Those are the grade 4s. The grade 3s and 4s. You really have to make a commitment.

But education of the staff is so important to make sure that the staff can finish the sentence that you're starting, that they actually know because they're going to spend that time with the patient. But I think the commitment and the integration to the practice and realizing this is a condition where we can make people feel better. And when we make people feel better and we take care of the surface, we can improve their whole quality of life on that.

And so, I think integrating and making that commitment. And absolutely it all starts with having the patient look down. And that is part anybody that comes in and follows me in an exam room says you say it on every single patient, new or established, look down, what I'm looking for. And then pressing on those meibomian glands. And if you take a glance at the lashes and you're not seeing collarettes but you have an obstructed meibomian gland, look again.

And I think the most important part of practice integration is don't reserve lotilaner for the severe. Any other tips that you have for integration into the practice?

Dr. Koetting:
I think that you had a really good point with staff. My staff, especially when we first started this, it was getting them to understand. And they are such a good resource and tool for us to discuss these things with patients, because inevitably yes there are going to be some callbacks from patients saying, ‘Hey wait, I need more information on this because I'm pretty sure I heard you say the word mite,’ and we want to empower them to help our practice.

Dr. Devries:
Well Cecilia, it's been a pleasure bringing these points out and talking, and I thank the audience. And thank you. It’s just some great tips that we have here.

Dr. Koetting:
Thank you.

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