At the Lid Line: Unmasking Demodex Across the OSD Spectrum

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Dr. Devries:
This is CE on ReachMD, and I'm Dr. Douglas Devries, and I'm joined here today with Dr. Cecilia Koetting. Cecilia, welcome, and we're going to talk about misdiagnosis at this particular point, because I think it’s a real common finding that we have being in a referral center.

And this is a 45-year-old software engineer who complains of dry eyes. He's got mild collarettes, has mild Demodex blepharitis and other forms of anterior and posterior blepharitis and symptoms. So the first question that I have for you, Cecilia, is do you see this often within your practice? Because I see it all the time where patients are mistakenly treating somebody for a dry eye when it's Demodex. 

Dr. Koetting: 
Yes, oh absolutely. I have it almost daily where someone's referred in and it's misdiagnosis. What I think is interesting though is that you are talking about a—let's talk about a patient who has few or no collarettes, right, or let's talk about that few because I feel like this is where some of us hem and haw on whether or not to reach for prescription treatment for these patients. And what I would say is it's almost binary. It's a 1 or a 0. You have it or you don't. While it may be only 1 or 2 collarettes that I see, I'm not going to go through that whole eyelid and I'm not going to count all of them so I can probably be safe to say if I see 1 or 2 there's probably more and I might be missing it. And so, if I only see 1 or 2, I'm going ahead and I'm reaching for a prescription treatment because even if they have, we get the second part of the symptoms or no symptoms.

There's been many of these patients who come in and have no symptoms quote unquote and then I treat them and all of a sudden they come back saying, ‘I had no clue, I didn't feel good. I had normalized’ or they had essentially normalized what they thought was going on.

Dr. Devries: 
Well and you hear this all the time with other illnesses. People say, ‘I didn't realize how bad I felt until I felt better.’

Dr. Koetting:
Right.

Dr. Devries:
And I think that Demodex is really one of those. And that really brings the point up when you have that. I mean, the key and how my exam has been altered, I always press on the meibomian glands because I want to see the quality of the meibum and then I'm going to look very carefully and I'm going to ask the patient some questions. Because one of the hallmarks of Demodex can be where the lashes themselves itch. And with that patient, so I'll ask them do you ever do anything like that and sometimes patients will say ‘yeah I do lid scrubs twice a day.’  I say why. ‘Because my lids itch.’ Well, they're knocking off and that may be the reason you see few if none collarettes because taking the collarettes aren't going to do anything for the disease process. 

Dr. Koetting: 
Right. Which is why it's important to look for the other signs, looking for telangiectasia, looking for red line across the meibomian glands especially on the upper lid, looking for misdirected lashes. And I think meibomian gland dysfunction and poor expression or poor quality expression with or without collarettes is also something because you bring up a great point. If somebody is already cleaning and/or even itching, right, they may be knocking off a lot of those collarettes. So going back to the 1 or 2, I'm binary. It’s you got it or you don't. 

Dr. Devries:
Yeah absolutely. And then there's the Alpenglow sign also. If we're seeing that on the bridge of the nose and that just looks like little miniature spikes coming up and that can also lead to more questions and asking– 

And then of course it's failure on conventional dry eye therapy that the patient isn't getting better, then you've got to dig deeper. But when I look at the meibomian glands and I see that there's obstruction in there and it's turbid and not clear, I mean that’s where I am going to go back to the lids again, kick up the magnification, and look at the base of that lash because it is 100% pathognomonic. It's binary. You have it or you don't have it. And regardless of it, irritation, inflammation, and bacteria we want to take care of that on our ocular surface.

Dr. Koetting: 
There was a study that I did with Liz Yeu looking at concomitant bacterial strains along with Demodex. And when you look back at this, all the studies, you find that, yes, there's a high correlation. When you see collarettes or Demodex and have a positive Demodex finding, you are also going to find more often a number of different bacterias along with it. And so that is another reason that we want to make sure that we're decreasing the mite load, to also help with, and clean, to help with all of these bacterias, which thinking about our patients who are going to be referred over for cataract surgery and the risks that come along with that, I think it's important to address.  

Dr. Devries: 
And like you mentioned, those surgical patients, and really we as referring optometrists need to really look and prepare that surface. And if we have irritation, inflammation, and bacteria, that's part of it. And you talk to any surgeon, they'll say, ‘yeah, we don't want bacteria.’ Nope.

So, a great discussion. Great discussion on this, Cecilia. Thanks so much.

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