Call it “The Case of the Mighty Mite.” For decades, refractory blepharitis has confounded ophthalmologists. Some patients respond to lid scrubs; some do not. Some present within days of a spouse’s presentation. Some present concurrently with pterygia. Blepharitis seems more pronounced in some than in others. The cause of blepharitis may be as simple as the Demodex mite. A recent journal article noted a variety of pathologic features together with conjunctival inflammation can be found in patients with Demodex infestation of the eyelids.1 These same kinds of pathologies are commonly found in ocular rosacea, said Scheffer C.G. Tseng, M.D., director of the Ocular Surface Center and medical director, Ocular Surface Research & Education Foundation at TissueTech, Miami. “When conventional treatments for rosacea fail, tea tree oil lid scrubs seem to eradicate the mites,” Dr. Tseng said. “In any type of ocular inflammation where the condition is refractory, doctors need to consider Demodex as a causative agent,” he said. “For instance, recurrent pterygia may be the result of an inflammatory disease, and it may be Demodex that hasn’t been well treated. That would explain the pterygia’s recurrence.”


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Demodex tails around the root of the lash
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Demodex head close-up


Identifying symptoms of Demodex

Early morning itching and irritation is common with these mites because of their aversion to light, Dr. Safran said. “They come out at night and mate, lay their eggs on the lashes, and then crawl back into the follicle in the morning, causing the patient to itch,” he said. What makes the diagnosis of Demodex difficult is that some patients will have “a lot of Demodex, but no symptoms. I leave those people alone,” Dr. Safran said. “Other people have what appears to be an allergy to the mites causing severe itching and inflammation. These are the blepharitis patients that respond to Patanol (olapatadine, Alcon, Fort Worth, Texas), but it doesn’t cure them.” In patients with facial rosacea, “the pathogenesis of skin lesions has been speculated to be caused by an increasing density of mites, which trigger inflammatory or specific immune reactions, mechanically block the hair follicle, or act as a vector to bring in bacteria,” Dr. Tseng said.

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Tea tree oil treatment

Using special lid wipes with TTO 5% (i-lid ‘n lash ®  PLUS 60 wipes (5% Tea Tree Oil)) the lids and lashes should be cleaned every night before going to bed. The I-lid ‘n lash plus is made for home use as follows.

iLid n lash plus IMED_ILNLPlus&Pro_InstructionsForUse_8.5x11-EN 1

If that did not work, we can do a professional cleanup at the office with the process of BlephClean using the i-lid ‘n lash ®  PRO (Professional use only) 50 mL pump (20% Tea Tree Oil).

IMED_ILNLPlus&Pro_InstructionsForUse_8.5x11-EN 2


Dr. Safran said Dr. Tseng’s identification of tea tree oil to treat the Demodex is novel, and he has slightly modified the formulation. While physicians can buy tea tree oil from most health food stores, Dr. Safran has also used an ointment Dr. Tseng is working on. If using the heath food store variety, he said to cut the oil to 50% in Macadamia nut oil. “I apply it with cotton tip applicators after one drop of tetracaine, so there’s no shield required,” he said. “I am very aggressive with trying to get the oil into the lash roots and along the lashes to kill any eggs. I also aggressively treat the eyebrows. I don’t like the applicator dripping wet, but it should be moist enough so I can see the oil getting onto the skin when it’s touched. I treat the brow first, then the lid to get rid of the excess oil where it won’t irritate as much. I’ll do three applications a visit, about 10 minutes apart, and then finish with a tea tree ointment at 20%, which I have mixed for me at a compounding pharmacy. I do this for three visits, each one week apart.” Dr. Safran warned other physicians not to use full strength tea tree oil. “I tried that on myself, and it was not a pleasant experience,” he said. The patient must institute hygiene at home, he said, and that includes tea tree shampoo, scrubs and face wash. Dr. Safran has patients follow this protocol:

  • use tea tree shampoo for the hair and eye lashes every day
  • use tea tree soap or face wash every day
  • women should throw out makeup and not use any new makeup for a week
  • clean sheets and/or buy new pillows
  • ensure the spouse is checked
  • have any pets that sleep on the bed checked
  • for the first few weeks, patients should use tea tree ointment at night after the shampoo scrub at home


BlephClean: In-Office Lid Hygiene BlephClean is a painless in-office procedure performed by your eyecare professional. A revolving handpiece is used to carefully spin a cotton tip along the edge of your eyelids and lashes, removing scurf and debris and exfoliating your eyelids. The soaked cotton-tip is disposable and a clean one is used for each individual eyelid The procedure lasts about 5 minutes and is well tolerated. Most patients simply report a vibration sensation. A freezing drop is usually placed in each eye prior to treatment for increased comfort. After the procedure, the patient is instructed on how to maintain their clean eyelids with regular twice daily lid hygiene. The procedure is typically repeated at 3-6 month intervals. More frquently if needed due to the collection of the debris again. Demodex usually needs this treatment every week for 3 week using tea-tree oil (TTO) to control the demodex infestation.

“If there’s a lot of inflammation, I like Tobradex (tobramycin 0.3% and dexamethasone 0.1% sterile ophthalmic suspension and ointment, Alcon) that’s replaced by bacitracin or erythromycin after one week,” Dr. Safran said. Anecdotal stories from Dr. Safran’s patients indicate that upon presentation, on a scale of 1 to 10, most patients stated, “Red eyes are associated with not feeling well, lack of sleep, those sorts of things. When their eyes burn and are red, patients are very aware of it. After they have the tea tree oil treatment, patients’ scores go from a 9 to a 2, or an 8 to a 1.” Surprising asides “A surprising finding was that once we got rid of the mites, some patients’ vision improved,” Dr. Tseng said. “Originally we thought this was a coincidence. Because mites affect the oil glands, the tear film is not doing well. If the tear film is unstable, it will cause a blur when the eye opens quickly. Once the mites are gone, the tear film stabilizes, and the vision improves.” He did note that not all patients’ vision will improve; the fact that some did was a pleasant surprise. “The tea tree oil is probably not the last word on killing [Demodex], but it’s better than anything else we have right now,” Dr. Safran said.


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