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This Is What Optometrists Think About Demodex Mites

Nov 4, 2015
14 min read

This is a sponsored post by Eye Eco, a supporter of CovalentCareers & new graduate optometrists! 😎 

Demodex infestation has been the subject of much attention within the ophthalmic community.

In this article, optometrists, Dr. Antonio Chirumbolo and Dr. Matthew Geller, will teach you the clinical science behind demodex, but also share their personal stories and treatment opinions! Specifically they will focus on their experience with Eye Eco lid cleansing products. Enjoy!


The Clinical Science Behind Demodex

Demodex is a species of intradermal parasitic mites, that generally inhabit the skin, face and head. These parasites have been heavily linked with various ocular conditions such as dermatitis, rosacea, and Demodex blepharitis.1-3

We must pay particular attention to two species of this parasitic mite, Demodex folliculorum and Demodex brevis. D. folliculorum causes misdirected lashes and dandruff due to epithelial hyperplasia due to its propensity to cluster around lash roots.4 D. brevis has been found to burrow deeply within the meibomian glands, causing mechanical blockage of the duct. This blockage can lead to a cascade that causes an innate immune response resulting in miebomian gland dysfunction with associated tear deficiency.4

The incidence of Demodex infestation increases with age, found in 84 percent of the population at age 60, and 100 percent of the population over the age of 70.5,6

It is therefore imperative that we look meticulously for signs of Demodex in our patients, especially those we treat for blepharitis and dry eye without any signs of improvement with the conventional therapies available to us.

Signs and Symptoms:

The classic presentation of individuals affected by Demodex blepharitis includes: 4

  • cylindrical, waxy collarettes at the base of the eyelashes
  • red and swollen lid margins
  • madarosis
  • MGD
  • blepharoconjunctivits

Patients with Demodex blepharitis usually complain of loss of lashes, itching at the lash margins, chronic redness and foreign body sensation.4,7


Demodex mites are difficult to impossible to observe with routine slit lamp examination, as these mites tend to stay buried within lash follicles. It is therefore recommended that high magnification microscopy of epilated lid lashes be utilized to confirm this diagnosis.

There has also been reported success using forceps to rotate or displace lashes in circular fashion, which aids in evacuation of Demodex organisms from the follicle.4,7

Treatment and Management:

Due to the distinct pathophysiology of Demodex blepharitis, treatment must be geared specifically towards the eradication of these organisms. Treatment with warm compress, steroids, and antibiotics may be futile, but there has been reported success with the use of tea tree oil, which works by interrupting the life cycle or directly killing these mites.8,9

There are a vast range of tea tree oil treatments available, generally found in the form of lid scrubs, ointments, and shampoos, possessing numerous concentrations of its active ingredient 4-terpineol, as high as 50 percent. Patients tend to have a difficult time tolerating formulations above 50 percent concentration that can contain toxins and be uncomfortable on the ocular surface.4

A common practice is to use one of the many options available: Cliradex wipes, Advanced i-Lid Cleanser, Ocusoft Demodex kit in conjunction with or in addition to in-office treatments like BlephEx.4,10

No matter what initial treatment options you choose, it is important to remember that Demodex blepharitis is a chronic condition that requires ongoing treatment and maintenance.

A New Way To Manage Demodex

Eye Eco has developed three products that can be perfect for ongoing maintenance. While they may not be strong enough for initial treatment, their formulation provides a perfect solution for maintenance therapy.


The three products include:

  • The original formula with 1% tea tree positioned as a ‘gentle’ cleanser for use once, even twice a day. It is recommended for patients who will be compliant washing their face daily.
  • The advanced solution with 2%  tea tree which is a bit stronger, is ideal for those who do not wash as frequently.
  • A new anti-aging formula that has 1% tea tree along with active ingredients to reduce dark circles, puffiness and fine lines. This is perfect for the anti-aging crowd, who can achieve both their anti-aging objectives, while also using a product that will keep their eyelids clean and hydrated.
EyeEco-Products-768x1024 (1).jpg

All products are formulated for use on lids and the entire face, are non-irritating to the eyes, safe to use daily, and are only available through doctor’s offices. They also save patients time and money having one product to use for cleaning lids and the entire face.

Here are the main differences and advantages of these formulas versus other lid cleansers that you should be aware of:

  • Eye Eco’s product is recommended for cleansing eyelids and the face.
  • Eye Eco’s product is formulated to be non-irritating to the eyes (no stinging or burning).
  • This formulation is great for hydrating the skin while cleansing.
  • Provides a good cost effective solution for patients.

The perfect analogy for patients is that equivalent to ‘brushing your teeth.’

  • Think of the Original Formula as ‘regular toothpaste’
  • Think of the Advanced 2% Formula as ‘tarter control’
  • Think of the the Anti-Aging Formula as ‘teeth whitening’

Here Is What Dr. Antonio Chirumbolo & Dr. Matt Geller Think About Demodex

Dr. Geller Weighs In On Demodex


Treating dry eye syndrome helped me to become a staple in the San Diego community. I was seeing about 40 patients / week, and about 15% had some variety of demodex and blepharitis that needed treatment. From young children, to senior patients, I saw it all.

Yet is was extremely gratifying to me because I was able to treat them and really impact their life. The most common symptoms I saw was red, chapped lids, skin dryness, ocular surface dryness and overall discomfort. As soon as I got them behind the microscope, BOOM, there it was – lash collarettes, waxy lid margins and telangiectatic eyelid vessels. Personally I rarely examined for demodex under the microscope because regardless, my treatment regime remained fairly similar.

Dr. Geller’s Personal Experiences With Demodex
Now let me share with you a secret… I’ve got mild blepharitis, and I’ve had a colleague or two tell me there might be some demodex in there. Every day, I wake up with very gunky eyes. It’s because my eyes tear while I am falling asleep. It’s a reflex from being tired but these tears build up on my lids and lashes, depositing debris, therefore creating a nice environment for bacteria, including demodex. Also, my cats insist on sleeping with me, and it make my eyes tear even more due to mild allergic conjunctivitis. It’s something I have dealt with for 2 years now and something I will need to manage into the future.

Dr. Geller’s Treatment Regimen for Himself and His Patients

Every patient needs to be treated uniquely, but here is the approach that works about 80% of the time for my patients. I can go deeper into my treatment algorithm, so ask me questions in the comments and I can tell you there.

  1. Grade the patient’s blepharitis / demodex – trace, mild, moderate, or severe is all I typically record.
  2. If demodex is apparent and measurable, treat first with Cliradex lid wipes. Use one wipe, everyday, after showering.
  3. Continue treatment with Cliradex, for usually about 2 months.
  4. During these 2 months, I have the patient come into the office for manual removal of collaraettes and blepharitis flakes with forceps. This is extremely helpful and really speeds along the process to healthy eyelids and ocular surface.
  5. From day one, begin using Eye Eco 2% Tea Tree product. Apply this mostly on lashes, and eyebrows, but if mild rosacea exists, be sure to apply the Eye Eco 2% Tea Tree to the entire area.
  6. Once the condition has improved, switch to Eye Eco 1% Tea Tree product on entire face, cleansing face in the morning and at night. This really reduces discomfort and that “inflammation” feeling. I feel that my patients on this regimen are less likely to relapse with their blepharitis.

This treatment regimen, while not for everyone, works extremely well. I have been using the Eye Eco 1% Tea Tree for myself and man, WHAT A DIFFERENCE! The reason is works is because it reduces build up on my lashes from all my allergies and tearing. Because I don’t get build up, I don’t get dry eye, and because I don’t get dry eye, I don’t get discomfort.

Don’t Take My Word For It – Here is a Patient Testimonial

One of my patients, with severe blepharitis and demodex, is on Cliradex right now. It’s been about 2 months with the product and he has seen a dramatic improvement in signs and symptoms. It’s been about 2 months since I’ve had him on Eye Eco Tranquileyes warm compress every night and this has greatly improved his meibomian gland function. For 2 weeks now, he has been using the Eye Eco 2% tea tree for focusing on his eye brows and eye lashes, which in his words feels as though…

““my face and lids feel less inflamed and not as hot and noticeable. Everything just feels more fresh and more clean and the 2% tea tree really seems to be helping me maintain more comfortable eye lids.””

Dr. Chirumbolo Weighs In On Demodex


Many of the patients I see on a daily basis struggle with dry eye. This includes patients of all ages. I have found that treating dry eye syndrome is very gratifying and can really make a difference in patients’ lives.

I’ve been able to get patients back into contact lenses who had previously dropped out because of severe dry eye with the various treatment options and methodologies available to us. Therefore, dry eye can be an extremely debilitating condition and demands our attention.

The one interesting thing I’ve learned from treating dry eye, is that dry eye presents itself in so many different forms, and when it comes to treatment, rarely does one approach work for all.

The reason one approach doesn’t work for all is because dry eye can have a vast range of confounding factors and different etiologies.

Dr. Chirumbolo’s Personal Experiences With Demodex
While I don’t suffer from Demodex, I do suffer from dry eye syndrome. I am a contact lens wearer, I’ve got mild blepharitis, and meibomian gland dysfunction.

While I typically treat my own eyes with artificial tears and utilize the Tranquileyes™ Original mask, one thing, that I recently started doing, was paying a little more attention to lid hygiene. This is when I started doing some maintenance therapy with Eye Eco’s Tea Tree original formula. My experience with the Tea Tree formula has been fantastic. My lashes have significantly less scurf in the morning, and my skin overall feels fresh and radiant. I have extremely sensitive skin, so it was a pleasure to discover that Eye Eco’s Tea Tree original was not over-drying or too powerful.

Like Dr. Geller, my cat also sleeps with me, but I don’t suffer from allergies, and even if I did, I wouldn’t have it any other way!

Dr. Chirumbolo’s Regemin for His Patients

As stated above, there is no cookie cutter approach to treating dry eye and blepharitis, but this is typically how I treat patients with blepharitis that I suspect may have Demodex infestation.

  1. Close examination of the lids, lid margins, and lashes. I use forceps in an attempt to visualize any demodex mites.
  2. If I suspect Demodex blepharitis, I treat first with Cliradex lid wipes, twice a day for two months. This is a perfect way to knock back the Demodex.
  3. Once I’ve gotten the Demodex under control, I spend a lot of time educating the patient on the need for ongoing maintenance therapy.
  4. The product of choice that I have found to provide this maintenance, is the Eye Eco 1% Tea Tree product. The one thing patients appreciate, is that they can use this product not only their eyelids and lashes, but their entire face. So it is an easy thing to add to their daily skin care regimen.

Once again, my treatment protocol may not work for everyone, and if it doesn’t, I’ll adjust things accordingly. I usually find that the most difficult barrier to control, is initial treatment. Once initial control is achieved, maintenance therapy is made extremely easy with either Eye Eco’s Tea Tree Oil 1% or 2%.

A patient of mine has been using Tea Tree Oil 1% for maintenance therapy for a few weeks after an initial course of Cliradex, here is what he had to say:

“The tea tree oil has been working extremely well to keep my lids clear. I use it morning and night, and haven’t had any issues waking up with flakes or debris in my lashes. I like this product because it leaves my skin soft and does not have a very strong tea tree smell.”

Eye Eco’s new anti-aging tea tree formula has been very well received by many of my patients who do not even suffer from Demodex infestation. A patient of mine has been using it as a facial cleanser, and here’s what she had to say:

“This product has been very easy to incorporate into my nightly routine. I like the fact that this product does not contain harsh chemicals found in many facial cleansers I’ve used in the past. My skin feels extremely soft, does a fantastic job of keeping my eyelids clear, and doesn’t have an overly strong scent. It also works wonders to remove makeup!”

Lid hygiene is important for people of all ages with or without accompanying ocular surface disease. These products have been working wonderfully to meet the various needs of my patients. Make sure you give them a try!


  1. Li J, O’Reilly N, Sheha H, et al: Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with facial rosacea. Ophthalmol. 2010 May;117(5):870-877.
  2. Zhao YE, Wu LP, Hu L, Xu JR. Association of blepharitis with Demodex: a meta-analysis. Ophthalmic Epidemiol. 2012;19:95-102.
  3. Czepita D, et al. Demodex folliculorum and Demodex brevis as a cause of chronic marginal blepharitis. Ann Acad Med Stetin. 2007;53(1):63-7.
  4. Andrew S. Gurwood, Alan G. Kabat, Joseph W. Sowka. Ocular Demodicosis. Handbook of Ocular Disease Management. 2015 June; (17th Edition):9A-11A.
  5. Post CF, Juhlin E. Demodex folliculorum and blepharitis. Arch Dermatol. 1963;88:298–302.
  6. Liu J, Sheha H, Tseng SCG. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allerg Clin Immunol 2010;10:505-510.
  7. Karpecki, Paul M., OD. “Getting a Grip on Blepharitis.” Review of Optometry, 05 May 2015. Web. 14 Sept. 2015.
  8. Gao YY, Di Pascuale MA, Li W, Baradaran-Rafii A, et al. In vitro and in vivo killing of ocular Demodex by tea tree oil. Br J Ophthalmol 2005; 89: 1468-73.
  9. Liu, J, Sheha H, Tseng S. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010 October; 10(5): 505–510.
  10. Kabat AG, Sowka JS. New Blepharitis Treatments. Rev Optom. 2014 October.
About Antonio Chirumbolo, OD

Antonio works in Client Marketing at CovalentCareers. His passions are everything and anything digital media.

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