Demodex blepharitis does not have agreed standardized guidelines. The aim of this study was to classify signs and symptoms and to develop appropriate management strategies for Demodex blepharitis from a consensus of expert advice. A total of 11 anterior segment experts (ophthalmologists, optometrists and a contact lens optician) working in the United Kingdom participated in a modified 2-round Delphi panel. A mixed-methods approach was adopted and a survey questionnaire for round 1 was formulated, constructed from information in the available literature. Based on panel responses from round 1, feedback was provided and a round 2 questionnaire was formulated. More than two-thirds majority (72%) was used for consensus building. Based on the clinical presentation of signs and symptoms along with associated conditions and risk factors, a diagnostic algorithm was proposed for the clinical investigation of Demodex blepharitis. A treatment algorithm was also proposed with first-line and second-line treatment recommendations for Demodex blepharitis. The recommendation from this study provides the first effort in formulating clinical diagnostic algorithm and management guidelines for Demodex blepharitis. The guidelines include appropriate magnification on the slit lamp, associated signs, symptoms, risk factors and suggested management options. These guidelines can be used in a routine eyecare setting to encourage eyecare practitioners in tailoring the investigation and management of Demodex blepharitis.

Purpose: To investigate the knowledge, attitudes, and practice towards Demodex blepharitis among optometrists in India. Methods: The study was conducted in the form of an online survey using Research Electronic Data Capture (REDCap). The survey link was distributed via direct e-mail and social media platforms, and it was comprised of 20 questions divided into two sections. The first section focused on the practitioners’ demographics and their views on the general health of the eyelid. The second section of the survey was specific and aimed at obtaining information on identifying and treating Demodex blepharitis, and was only completed by those respondents who looked for Demodex mites. Results: The survey was completed by 174 optometrists. The prevalence of blepharitis in the general population was judged by the respondents to be 40%, whereas the prevalence of Demodex mites was estimated to be 29%. Interestingly, the prevalence of Demodex mites in people with blepharitis was estimated to be 30%. This estimated prevalence was substantially lower than that reported in the literature on the subject. 66% of participants believed Demodex mites to be a significant cause of ocular discomfort, whereas only 30% of participants would intervene to diagnose and manage Demodex blepharitis in their patients. Optometrists differed in their preferred method of diagnosis and management of Demodex infestation in eyelids. Conclusion: The result of this survey suggests that Demodex blepharitis is a highly under-diagnosed condition in India, with nearly 30% of surveyed optometrists managing this condition. The study also observed a lack of awareness and consensus among surveyed optometrists with regards to diagnosis and appropriate treatment methods to control Demodex infestation in eyelids.

Aim: The primary aim of this study was to compare how eyecare professionals in disparate regions of the world diagnose and manage Demodex blepharitis. A secondary aim was to explore interprofessional differences in diagnostic and management practices. Methods: Ophthalmologists and optometrists from India and Australia/New Zealand, were invited to complete an online survey on Demodex blepharitis. Clinical practice patterns relating to patients with Demodex blepharitis, with details of how they investigate and manage Demodex blepharitis in clinical practice, were collected along with clinician demographics and general perceptions on eyelid health. Mann–Whitney U, and Fisher’s exact tests were used for statistical analysis. Results: A total of 261 eyecare professionals completed the survey, comprising 207 from India (84% optometrists) and 54 from Australia and New Zealand (91% optometrists). Almost 70% of practitioners across the 3 countries recognized Demodex blepharitis as a cause of ocular discomfort, yet only 45% reported attempting to identify Demodex in their patients. There were significant differences noted in clinical practice between those in Australasia and India. Perceived prevalence of Demodex blepharitis also differed (60% in Australasia vs 27% in India; p< 0.01), as well as, the choice of slit lamp magnification used to detect the mites (25x in Australasia vs 16x in India; p = 0.02), preferred treatment option to manage Demodex blepharitis (tea tree oil in Australasia vs Standard lid hygiene in India; p = 0.01), treatment duration (from 3– 4 weeks to over 12 weeks in Australasia vs 3– 4 weeks in India; p = 0.02) and treatment application frequency (once daily in Australasia vs twice daily in India; p = 0.01). Conclusions: This study highlights differences in clinical evaluation and treatment practices between eyecare professionals in India and Australasia. Overall, practitioners in Australia and New Zealand were more evidence-based in their investigation and management. However, in both regions, interprofessional differences in perceived optimal treatment duration and frequency were reported.

Purpose: Demodex mites act as a carrier vector for the bacterium Bacillus oleronius . Antigenic proteins from this bacterium are capable of producing an inflammatory response. This study investigated the potential effects of Demodex spp.-associated Bacillus oleronius proteins and dry eye-induced hyperosmolarity on an immortalised human conjunctival epithelial (Chang) cell line. Methods: The Wong Kilbourne derivative of the Chang (WKD) HeLa-modified conjunctiva-derived epithelial cell line was cultured in a series of NaCl-hyperosmolar conditions with various concentrations ranging from 350mOsm/L to 550mOsm/L. Chang cells were then exposed to semi-purified B.oleronius proteins at 2 µg and 6 µg either alone or in conjunction with dry eye-induced hyperosmolar (HO) stress at 2 µg + HO500 mOsm/L and 6 µg + HO500 mOsm/L. The cell viability was assessed with the RealTime-Glo MT cell viability assay. Results: Compared to controls, the cell viability appeared to decrease in a dose-dependent manner. B. oleronius concentration at 6 µg showed significantly lower cell viability than both controls (p < 0.001) and 2 µg (p < 0.001). When 500mOsm/L was added to the 2 µg and 6 µg concentrations, the lowest cell viability was observed (p < 0.001). At 24 hours, the B.oleronius 2 μg combined with HO500 resulted in 38% viable cells, compared to 81% viability in B.oleronius 2 μg alone (p < 0.001). Similarly, the B.oleronius 6 μg combined with HO500 showed only 23% metabolising cells compared to 60% viability cells in B.oleronius 6 μg alone (p < 0.001). Conclusion: The results suggest that the presence of bacterial proteins and hyperosmolarity have a dose and time-dependent effect on cellular viability. These experiments suggest that patients affected with the comorbidity of dry eye disease and Demodex blepharitis could experience more severe signs than those with Demodex- associated blepharitis alone.