Demodex Infestation Quiz for Healthcare

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Questions and Answers

What is the primary purpose of performing a slit-lamp examination in suspected cases of Demodex infestation?

To observe eyelash follicles for abnormalities

To detect and count Demodex mites (correct)

To evaluate the presence of associated conditions

To assess the overall health of the eye

Which of the following treatments is specifically FDA approved for Demodex?

XDEMVY (lotilaner ophthalmic solution) (correct)

10% povidone-iodine

Tea Tree Oil

Erythromycin

What should be emphasized to patients as crucial in managing Demodex infestation?

Maintaining strict lid hygiene (correct)

Minimizing exposure to sunlight

Using larger doses of antibiotics

Avoiding any form of eye makeup

What is a common clinical sign that may indicate a Demodex infestation in adult patients?

Recurrent chalazia Signup and view all the answers

Which of the following antimicrobial treatments is known to be resistant to Demodex?

75% alcohol Signup and view all the answers

What is the primary consideration when assessing angular blepharitis?

Rule-out staph involvement Signup and view all the answers

Which organism is associated with epidemic outbreaks of angular blepharitis in institutional settings?

Moraxella lacunata Signup and view all the answers

What is a key symptom of Moraxella-related angular blepharitis?

Wet eyes Signup and view all the answers

What antibiotic is commonly used to treat Staphylococcus-associated angular blepharitis?

Erythromycin Signup and view all the answers

What is a common sign observed in patients infested with Demodex mites?

Collarette formation Signup and view all the answers

Which of the following treatments is effective against both Moraxella and Staphylococcus infections?

Polysporin (bacitracin & polymyxin B) Signup and view all the answers

What percentage of patients older than 70 years is observed to have Demodex infestation?

100% Signup and view all the answers

What symptom may exacerbate irritation from Demodex infestation?

Warm weather Signup and view all the answers

What is the primary mechanism of inflammation related to the bacteria in the eyelid?

Production of lipase Signup and view all the answers

What is one of the typical clinical signs of eyelid infection caused by bacteria?

Flakes starting at the base of the lash Signup and view all the answers

Which symptom is most likely to worsen upon awakening?

Foreign body sensation Signup and view all the answers

What does the presence of pus typically indicate?

Bacterial infection Signup and view all the answers

Which of the following symptoms is NOT commonly associated with eyelid inflammation?

Visual disturbances Signup and view all the answers

What outcome results from an inflammatory response caused by bacteria?

Increased blood vessel dilation Signup and view all the answers

What type of irritation might increase due to the production of free fatty acids by bacteria?

Eyelid irritation Signup and view all the answers

What is the primary cause of inflammation in anterior blepharitis?

Inflammation centered around eyelashes and follicles Signup and view all the answers

Which type of blepharitis is associated with inflammation involving Meibomian glands?

Posterior blepharitis Signup and view all the answers

Acute blepharitis can be caused by which of the following?

Bacterial infections Signup and view all the answers

What is a common symptom of chronic blepharitis?

Ulceration of lashes Signup and view all the answers

Which organism is primarily associated with staphylococcal blepharitis?

Staphylococcus epidermidis Signup and view all the answers

Which condition is NOT considered a cause of primary blepharitis?

Infectious processes Signup and view all the answers

What distinguishes angular blepharitis from other types?

It can be caused by Moraxella Signup and view all the answers

What is a characteristic sign of staphylococcal blepharitis?

Painful sensation around the eyes Signup and view all the answers

What is the primary treatment for blepharitis?

Lid scrubs Signup and view all the answers

Which condition is characterized by thickening of the eyelid tissue?

Tylosis Signup and view all the answers

What common symptom results from damage to eyelash follicles due to exotoxins?

Loss of lashes Signup and view all the answers

What is the composition of collarettes related to eyelash health?

Cylindrical tubes of material Signup and view all the answers

What is a high association with punctate epithelial erosion (PEE)?

Ocular surface dryness Signup and view all the answers

Which of the following treatments is not recommended for lid scrubs?

Diluted baby shampoo Signup and view all the answers

When applying antibiotics for lid disease, what method is preferred?

Using a cotton swab Signup and view all the answers

Which anatomical changes can result from trichiasis?

Eyelashes growing under the eyelid Signup and view all the answers

What is the main use of Doxycycline in treating Staphylococcus infections?

Inhibits lipase synthesis by the bacteria Signup and view all the answers

Which antibiotic is combined with dexamethasone in Tobradex?

Tobramycin Signup and view all the answers

What is a primary concern when prescribing steroids for eye inflammation?

Increased intraocular pressure (IOP) Signup and view all the answers

Which of the following antibiotics is NOT an aminoglycoside?

Erythromycin Signup and view all the answers

Why should oral antibiotics usually not be the first choice for treatment?

They lead to rapid resistance Signup and view all the answers

What is the primary function of BlephEx in eye care?

Removing debris and exfoliating eyelids Signup and view all the answers

What is the recommended follow-up period for patients with mild symptoms after treatment?

2-3 weeks Signup and view all the answers

Which combination of medication and corticosteroid is effective in treating bacterial infections?

Neomycin + Polymyxin B + Dexamethasone Signup and view all the answers

What is the correct term for lash loss due to eyelid conditions?

Madarosis Signup and view all the answers

Which of the following describes a potential management option for Demodex infestation?

Tea tree oil products Signup and view all the answers

What active ingredient in Cliradex is proven to be more effective against Demodex mites?

4-Terpineol Signup and view all the answers

What is the lifespan of Demodex mites, which impacts treatment duration?

2-3 weeks Signup and view all the answers

What is the recommended method for applying anti-microbial treatments in case of super-infections?

In-office procedures Signup and view all the answers

Which product is specifically designed for the removal of adult Demodex mites and their offspring?

Oust™ Demodex Swabstix™ Signup and view all the answers

What is a common characteristic of a chalazion?

Plugging of meibomian glands Signup and view all the answers

What procedure may be recommended to ensure lid hygiene in Demodex management?

Aggressive lash scrubs Signup and view all the answers

What is the primary diagnostic indicator of Demodex folliculorum infestation?

Gelatinous cylindrical sleeves at the eyelash base Signup and view all the answers

Which species of Demodex is primarily associated with sebaceous glands?

Demodex brevis Signup and view all the answers

What factor may contribute to the overpopulation of Demodex mites?

Lack of immune response Signup and view all the answers

What is a common symptom experienced by individuals infected with Demodex mites?

Swelling of lid margins Signup and view all the answers

During which stage of its lifecycle does Demodex lay eggs?

Adult stage Signup and view all the answers

What is the size range of Demodex folliculorum?

0.28 - 0.44 mm Signup and view all the answers

What behavior do Demodex mites exhibit to evade light?

Burrow head-first into follicles Signup and view all the answers

Which age group has the highest prevalence rate of Demodex infestation?

51-90 years Signup and view all the answers

What is a common initial symptom experienced during a Demodex infestation?

Crusting Signup and view all the answers

What potential consequence can result from unmanaged Demodex overpopulation?

Formation of chalazions Signup and view all the answers

Study Notes

Blepharitis

Blepharitis is inflammation of the eyelids.
Anterior blepharitis affects the eyelashes and follicles.
Staphylococcal blepharitis is caused by Staphylococcus epidermidis.
Seborrheic blepharitis is a disorder of sebaceous gland function potentially linked to dandruff.
Posterior blepharitis involves Meibomian glands.
Angular blepharitis typically affects the lateral canthi.
Possible organisms linked with angular blepharitis are: Moraxella lacunata and Staphylococcus aureus or epidermis.
Demodex mites infesting the follicles are found in 50% of blepharitis cases.
Demodex mites are observed in 100% of patients over 70-years of age.
Blepharitis can be acute or chronic.

Primary vs Secondary Blepharitis

Primary blepharitis includes rosacea, seborrhea, and hypersensitivity caused by staphylococcal toxins.
Secondary blepharitis is a result of another disease entity (ex: infections, infestations, trauma, allergies)
Infectious processes including bacterial (virus vs.) cause secondary blepharitis.

Acute vs Chronic Blepharitis

Acute: Causes include infections, infestations, trauma, toxicity, and acute allergies. Signs/symptoms: hyperemia, edema, telangiectasia, flaking, debris, discharge, foreign body sensation, and pain..
Chronic: Causes include poor hygiene, seasonal/perennial allergies, ocular rosacea, and makeup overuse. Signs/symptoms: lash involvement, ulceration, hordeolum (stye), and dry eye.

Staphylococcal Blepharitis

Etiology: Infection of lash follicles & lid margins with Staph.
Staphylococcus epidermidis is more common.
Staphylococcus aureus is less common, normally not present in the lids

Inflammatory Response

Mechanism: Bacteria produce lipase.
May alter tear lipid spectrum; cause increased free fatty acids irritants to the eyelids.
May induce inflammation and hyperkeratinization of Meibomian orifices.
Effect: blood vessels dilate (redness), increased vascular permeability (edema), and movement of neutrophils (PMNs) from blood into tissues.

Symptoms

Variable depending on severity and damage to tissue.
Variable depending on time of day.
Worse upon awakening.
Foreign body sensitivity, grittiness, stinging, burning, and irritation.
Possible pain, tender lids, and itching.
Dry eye symptoms.

Clinical Signs

Crusts (flakes) start at the base of the lash. They look similar "impaled cornflakes" indicative of staph exotoxin activity.

Grading Scales

Efron Grading Scale: Used for evaluating blepharitis (trace-4+).
Always grade findings when applicable, allowing you to see if the condition is improving/progressing.
Trace is very early signs
4+ is the most severe

Lids

Erythema: Diffuse redness along the lid margin.
Edema: Puffiness resulting from fluid accumulation; tender to palpation.

Lids (cont'd)

Lid neovascularization: Glomerular fronds of vessels at margins; deeper vessels causing pink "cast".
Tylosis: Thickening of the eyelid tissue.
Indurated: Hardened.

Collarettes

Cylindrical tubes of material that go up the eyelash base.
Sleeves start at last base
Collarettes go higher up the eyelash base

Eyelashes

Exotoxins damage follicles and cause structural changes.
Madarosis: Loss of lashes.
Poliosis: Whitening of eye lashes.
Trichiasis: Misdirected lashes

Secondary Conditions

Blepharoconjunctivitis: Secondary conjunctival infection.
Punctate Epithelial Erosion (PEE): Pooling of exotoxins in the tear lake; inferior 1/3 of the cornea.

Clinical Pearl (PEE)

PEE = epithelial cell loss in cornea, small divots in the cornea
Stains with fluorescein (enhanced viewing with cobalt (blue) filter).
Pattern indicates possible etiology.
High association with ocular surface dryness.

Treatment

Lid Hygiene

Warm Compresses: Soften and loosen crusts, improve blood flow (10-15 mins/time bid to qid).
Lid Scrubs: Primary treatment for blepharitis; scrub lid margins to remove debris (bid to qid). Can use lid wipes, foam cleansers; often manage most mild cases.
Diluted baby shampoo (not recommended anymore).

Antibiotics

Ointments preferred over drops for lid disease.
Moderate: qhs or bid; Severe: tid or qid.
Remove crusts before applying.
Avoid direct application to the eye from tube (prevent contamination & quantity issues).
Bacitracin: Cell wall inhibitor, excellent against staph, little hypersensitivity.
Polymyxin B, Neomycin, Erythromycin: vary in efficacy against bacteria
Gentamicin: Aminoglycoside, very effective against staph.
Tobramycin: Aminoglycoside, very good against staph.

Oral Ab

Usually, not the first choice of treatment.
Consider when severe; patient unable to comply with ointment and lid hygiene.
Patient has systemic illness.
Doxycycline (100 mg PO bid x 7-10 days): Inhibits lipase synthesis; inhibits cytokines and chemokines.
Helpful even if bacteria are resistant to the antibiotic

Steroids

Consider in moderate-severe immune processes.
Significant erythema, pain, and tenderness.
Lid inflammation is responsive to steroids.
Combination therapy (Ab+Steroid).
Examples include Tobradex and Maxitrol.
Steroid use requires monitoring for complications (increased IOP, PSC (posterior subcapsular cataract)).

Clinical Pearl (Steroids)

Always monitor IOP with steroid use.
Complications include increased IOP (intraocular pressure) and PSC (posterior subcapsular cataracts).
Usually takes 2-3 weeks to see IOP effects and may not observe at 1 week follow up.

BlephEx

Medical-grade disposable micro-sponge used to remove scurf/debris from eyelids & lashes.
Treatment procedures routinely include proparacaine for numb the eye area.
Eyes rinsed afterwards.
6-8 minute procedure.

Follow-up

1-3 weeks depending on severity and prescribed medications.
Consider follow-up 2-3 weeks later, or within days of cornea involvement.
Lifetime condition requiring lifetime treatment and management.
Emphasis on routine lid hygiene.
Patient return to office for flare-ups.

Associated Conditions

Marginal Corneal Infiltrate: Hypersensitivity to staph toxins; inflammatory response instead of direct infection: white blood cells infiltrate between epithelium and stroma.
Phlyctenule: Type IV hypersensitivity to staph toxins; causes elevated white lesions (conjunctiva, limbus, cornea); vasculature may be present.
Possible associations with tuberculosis

Seborrheic Blepharitis

Seborrhea is a disorder of sebaceous gland function (unknown etiology); characterized by excess oil production and retention.
Often associated with seborrheic dermatitis. (e.g., dandruff is hallmark).
Also associated with rosacea and acne juvenilis.

Signs/Symptoms (Seborrheic Blepharitis)

Greasy scales: foamy-looking, irregularly shaped, at bases of lashes or spiraling around lashes.
Scurf: "dandruff-like scales."
Symptoms often depend on other concurrent processes.
Scurf frequently asymptomatic.
Complaint of "mattering" in the morning.

Tx & Pt. Ed. (Seborrheic Blepharitis)

Tx/Pt.ed.- Lid hygiene, lubricants, treat associated conditions, and follow-up 2-4 weeks, including education on chronic nature and need for daily lid hygiene

Considerations (Blepharitis)

Primary: Rule out staph involvement; may have mixed blepharitis with staph infection.
Secondary: Rule out dermatoses; examine other areas. Consider dermatology consult.
Tertiary: Rule out meibomian gland dysfunction; may have meibomian seborrheic blepharitis

Angular Blepharitis

Localized eczematoid inflammation at the lateral canthi (corners of the eye).
Two causative organisms: Moraxella lacunata and Staphylococcus.
Commonly Staphylococcus aureus or epidermis are more common

Signs/Symptoms (Angular Blepharitis)

Moraxella: Wet.
Staph: Dry & scaly, skin repeatedly drying out/scaling/cracking open, chronic lid irritation, and possible itching.

Tx & Pt. Ed. (Angular Blepharitis)

Antibiotics (e.g., sulfacetamide, neomycin, erythromycin, polymyxin B, and bacitracin).
Polysporin is good for both moraxella and staph
Zinc sulfate (0.25%): astringent action; reduces maceration.
Vasoclear, Clear Eyes, Visine A.C. or Zincfran drops
Culture & sensitivity if ineffective
Compliance with treatment to know efficacy.

Demodex

Mite infestation in follicles, primarily the facial area.
Demodex folliculorum: infects hair and eyelash follicles.
Demodex brevis: infects sebaceous and Meibomian glands.
Observed in 100% of patients older than 70-years of age.
Mites are likely associated to 50% of blepharitis cases.
Feed on epithelial cells of eyelid.
Females lay eggs in follicles; life span 14 days

Signs/Symptoms (Demodex)

Brittle, easily broken lashes, fall out spontaneously. Pyramidal follicles from edema, mites, and eggs.
Collarette = highly diagnostic for demodex (e.g., D. brevis blocks meibomian glands & causes MGD).
Itching, burning, corneal irritation, and heavy eyelids.
Symptoms worse at night or dim lighting (mites recess into follicles with light).
Irritation worse in warm weather.

Demodex (cont'd)

Demodex can carry bacteria on its surface (e.g., Strep and Staph).
Increased symptoms in rosacea patients.
Debris & waste may elicit host inflammatory responses (delayed hypersensitivity or an innate immune response)

Diagnosis

Clinical History: High index of suspicion for blepharitis, conjunctivitis, keratitis or blepharoconjunctivitis in adult patients who have recurrent issues that are refractory to conventional treatments.
Associated findings: Madarosis, recurrent trichiasis, collarettes and pyramidal elevation of follicles.
Slit-lamp examination: Look for collarettes and pyramidal elevations.
Microscopic confirmation: Detection and counting of Demodex eggs, larvae, and adult mites in epilated eyelashes.

Treatment (Demodex)

Resistant to 75% alcohol, 10% povidone-iodine, and antimicrobials (such as erythromycin and metronidazole).
Tea Tree Oil (50%): Highly effective against infestation.
Terpinen-4-ol (T4O): More potent.
Cliradex, Ocusoft (Oust Demodex).
Daily cleaning with lid wipes or foam cleansers.
Treat associated conditions.

Xedmvy

XDEMVY (lotilaner ophthalmic solution, 0.25%) is FDA-approved for Demodex (primarily Tarsus).
Treatment is typically 6 weeks
Possible mechanism of action: Lipophilic agent, targeting mite GABA channels.
Possible resolution seen: Improved success rates with reductions observed in number of collarettes (Saturn-1, Saturn-2 trials)

Patient Education

Stress lid hygiene.
Assure patient normal flora and common.
Takes 3-4 weeks for response.
Consider follow-up 4-6 weeks.

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Test your knowledge on Demodex infestation and its management. This quiz covers the significance of slit-lamp examinations, FDA-approved treatments, and key patient management strategies. Explore common clinical signs and antimicrobial resistance related to Demodex.