Does this look like your eye? A little red, a little irritated, red rims along the lash margin?  That's the calling card of chronic inflammation caused by ocular rosacea (a type of  chronic dry eye). via

Do you have red rimmed eyes and eyelids?  Suffer from recurrent styes? Watering? Burning? Foreign body sensation? Puffy eyelids? Light sensitivity? If you answered yes to a few of these questions, chances are you have a type of inflammatory dry eye condition we refer to as ocular rosacea.  Ocular rosacea is a very common finding; studies suggest the incidence of ocular rosacea could be as high as 72% of patients with rosacea, and many of us with rosacea are undiagnosed (Chronic facial redness and flushing?  You've probably got it and just haven't been formally diagnosed!).  For years we've been treating ocular rosacea-related dry eye with lid hygiene, artificial tears, and more recently pulsing doses of oral doxycycline used to target inflammation more-so than for any antibacterial properties.  But a new study published in the International Journal of Ophthalmology last month suggests that Restasis, an anti-inflammatory eye drop used for treating dry eye, may be even more effective than our current gold standard treatment of oral doxycycline pulsed for months at a time.

The study followed 38 patients with diagnosed rosacea and ocular rosacea signs and symptoms.  The group was split evenly with 19 patients being started on Restasis eye drops taken twice daily for 3 months, and the other 19 patients being placed on 100 mg oral doxycycline taken twice daily for one month, then once daily for the two months.  All patients were instructed to use daily eyelid hygiene and artificial tears 4 times a day throughout the study period.  Before the study began and then monthly thereafter, patients were scored on symptoms (burning? watering?) and clinical signs (eyelid redness? corneal staining?) by a group of ophthalmologists.  Standard protocol dry eye testing was also performed at these visits, including OSDI surveys, Schirmer's Test and tear break up time.

Red, inflamed meibomian glands can't secrete tear film regularly as you blink,  causing dryness, burning, watering, and foreign body sensation.  That's  why a vital part of dry eye treatment includes lid hygiene and chronic use of  anti-inflammatory medications, be they topical like Restasis or oral like doxycycline.

Forgive me for the title, but I couldn't help myself.  Nothing is trending bigger in the world of eyecare than the surprisingly high incidence of Demodex mite infestation in the lids and lash follicles of a reported 84% of patients age 60 and over.  If your eyes are persistently dry, irritated, and inflamed along your eyelid margins, there is a good chance you may have Demodex m
ites compounding the problem.

Demodex mites are less than 1 mm in size and live along your eyelids and lashes via

Demodex is a parasitic mite that lives along hair follicles or sebaceous glands of the eyelid skin. Those sebaceous glands include your meibomian glands that you will often seen discussed on this blog and other dry eye resources.  Meibomian glands are essential at secreting the oils that create your surface tear film, and if they are disturbed dry eye results!   Demodex folliculurm is the hair follicle species and Demodex brevis lives in the sebaceous glands if you want to get technical.  These are microscopic mites -- an adult is only about 0.3-0.4 mm in size, so you won't see them by looking in the mirror.  They also tend to live inside the gland of their choice, so your doctor will typically only see the signs of their presence unless they "tease" the mite out at the microscope (check the video below around the 1:20 minute mark if you are curious about the method to do so).  These mites consume skin cells and the sebaceous gland secretions along your eyelid.  For a large number of people, a low count of Demodex mite activity could be completely asymptomatic.  But for those who have larger mite activity, who have a lowered immune response, or those who have a sensitivity to the bacillus proteins secreted by the mites which has been found in those with rosacea, mite infestation can lead to chronic dry eye, irritation, and persistent styes.  

This picture may seem harmless, but the cylindrical collarette shown is a classic appearance of Demodex presence.  You won't be able to see the mites in the mirror, and your doctor won't see them either because they live inside the gland or hair follicle!  via

What Your Doctor Looks For
Because of the multitude of studies demonstrating the role of Demodex in persistent blepharitis and dry eye, your doctor is looking for Demodex infestation much more actively than in years past when it was considered more rare.  Classic Demodex eyelid appearance has cylindrical build-up along the base of the eyelashes.  Remember, your doctor won't be able to see the mite on the surface of the skin because the mites live inside the glands.  To tease them out, the doctor can gently rotate a lash in a circular motion to trick the mite into leaving the gland (see video below).  Trying to pluck the lash out is not really recommended because it may cause the mite to burrow deeper.

How Do We Treat It?
Demodex mites won't be killed by typical blepharitis treatment protocols like steroids or antibiotics.  Studies show the best way to wipe out these mites is with a tea tree oil extract and daily lid hygiene.  We don't often think of carefully cleaning our eyelids and lashes, but removing dead skin cells and dried oil secretions from the margins of the eyes daily with a hot massage or eyelid cleaning product like Ocusoft can keep a mite infestation from taking hold.  When you have an active infestation, these products alone won't do the trick.  Tea tree oil-based treatments like Cliradex wipes used over the course of several weeks are the best way to get things under control.  Your doctor can even perform in office treatments with a stronger concentration to get things started.  Stay tuned for a coming post about how to use Cliradex both at home and in the office.

Cliradex wipes can be purchased at your doctor's office to decimate a Demodex infestation via

The real take home here?  Everyone, please take thirty seconds a day and clean your eyelids and lashes.  Daily maintenance can help prevent a bigger problem.  If you have dryness, itching, burning, redness, irritation, or flaky skin along your lashes, you need to be doing daily lid cleansing.  And when normal skin care isn't enough, doctors around the country are increasingly more aware of how to find these common Demodex mite infestations, and knock them out with a more targeted approach with great products like Cliradex.