Int Ophthalmol (2016) 36:691–696

DOI 10.1007/s10792-016-0188-5

ORIGINAL PAPER

Demodex treatment in external ocular disease: the outcomes

of a Tasmanian case series
Stephen G. Nicholls . Carmen L. Oakley .
Andrea Tan . Brendan J. Vote

Received: 9 November 2015 / Accepted: 21 January 2016 / Published online: 2 February 2016
 Springer Science+Business Media Dordrecht 2016

Abstract Demodex species (spp.) have previously
been implicated in the pathogenesis of blepharitis.
This study aims to correlate improvement in symp-
toms of external ocular disease with treatment of
underlying Demodex spp. This is a prospective,
observational case series of patients with chronic
external ocular disease. Demodicosis was confirmed
by microscopic examination of epilated eyelashes.
The main outcome measure was response to the
treatment (5 % tee tree oil) in regard to change in
subjective symptoms utilising a symptom-based
patient questionnaire assessment. Overall patients
had a good response to the treatment in terms of
improvement or resolution of symptoms, with 91 % of
patients reporting at least some improvement in
symptoms. The treatment of underlying Demodex
spp. appears to result in improvement of symptoms in
S. G. Nicholls
Tasmanian Eye Clinics, Glenorchy, Australia
S. G. Nicholls
Menzies Research Institute, Hobart, Australia
C. L. Oakley (&)
A. Tan
B. J. Vote
Tasmanian Eye Institute, 36 Thistle St West,
South Launceston, TAS 7249, Australia
e-mail: carmenoakley@hotmail.com
C. L. Oakley
Save Sight Institute, University of Sydney,
New South Wales, Australia
patients with long standing external ocular disease and
underlying Demodex spp. infestation.
Keywords Demodex spp
External ocular disease

Dry eye disease
Tea tree oil
Blepharitis
Introduction/Background
Demodex folliculorum and Demodex brevis are two
species of mite found on human eyelashes. Although
the presence of Demodex spp. on the eyelid has been
implicated in the pathogenesis of blepharitis. [1–4] it
is a commonly found saprophyte, and is often regarded
as a commensal. [5] However, some studies show a
relationship with age, increasing prevalence of the
mite and intensification of symptoms, leading to the
theory the mite can cause symptomatic disease when
present in higher numbers. [1, 6–9] Other studies have
shown there is no significant difference in the
incidence of Demodex spp. in patients suffering from
blepharitis compared to a control group, indicating
that Demodex spp. may not be involved in the
pathogenesis, or that other host factors also play a
role. [10].
The aim of this study is to further investigate the
correlation between the treatment of Demodex spp.
with 5 % tea tree oil and improvement in symptoms of
ocular surface disease.

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Methods
This is a prospective, observational case series of
patients with chronic external ocular disease. Demod-
icosis was confirmed by microscopic examination of
epilated eyelashes. The main outcome measure was
response to the treatment in regard to change in
subjective symptoms utilising a symptom-based
patient questionnaire assessment.
Participants
Patients were selected if they had ongoing symptoms
of chronic external ocular disease and were diagnosed
as having demodicosis by microscopic examination of
the eyelashes. A total of 336 patients had a minimum
of 8 eyelashes examined with a bench top microscope
using powers up to 9400. The presence of Demodex
spp. was confirmed by the visualisation of any of the
cycle stages of the organisms. This varied from eggs to
adults and identifiable adult carcasses.
The treatment protocol
All patents were instructed in lid margin toileting. Five
percent (5 %) Tea Tree ointment was applied to the lid
margins nocte after eyelid toileting. The solution was
compounded by a local pharmacy, and consisted of a
base of 50 % lanolin and 50 % coconut oil, with tea
tree oil added to make a concentration of 5 %. This
was continued for 3 months. The treatment protocol
was based on current literature, which indicates 5 %
tea tree oil is effective for the treatment of Demodex
spp. [11–14] Those patients who were initially in
considerable symptomatic distress, were also com-
menced with a brief course of topical fluorometholone
which was stopped after 1 month. Patients who were
non-compliant with the treatment or lost to follow-up
were excluded from the analysis.
Outcomes
The response to the treatment was assessed through a
questionnaire administered at the completion of
3 months treatment. Patients were asked to score their
current symptoms on a scale of 0–5, with 5 being
maximum amount of discomfort prior to the treatment
and 0 being complete resolution of subjective
symptoms.
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Int Ophthalmol (2016) 36:691–696
Entrant stratification
Stratification was based upon the major known causes
of ocular discomfort. In cases where more than one
cause was contributing to symptomatology, the patient
was stratified according to what appeared to be the
most prominent cause of their symptoms and signs.
The clinical signs and symptoms used to stratify
patients into groups include:
• Anterior blepharitis—most of the inflammation
located in the anterior lamellar of the eyelid and
accompanied by significant amounts of lash debris.
• Meibomian gland dysfunction (MGD)—purulent
gland secretions, plugging, maximal inflammatory
changes at the posterior lamellar of the lid margins.
• Dry eye disease (DED)—poor tear function, with
either aqueous deficiency or evaporative disease
being present.
• Primary chronic conjunctivitis—chronic irritation,
glare disability, epiphora.
All patients were assessed for dry eye including
tear film breakup time; Schirmer’s tear testing and
tear film osmolarity in equivocal cases. There was
insufficient blepharitis or meibomian gland dis-
ease to account for the either the symptoms or
conjunctival hyperaemia. Calcinosis conjunctivae
were a common finding.
• Allergic conjunctivitis—itch and papillary con-
junctival changes.
All patients gave signed permission for their de-
identified data to be used and were free to discontinue
the trial at any time. Ethics approval was obtained
from Human Research Ethics Committee, Tasmania
(H0015095).
Results
Of the 336 patients, 333 (99 %) had identifiable
Demodicosis. Of the three patients where no cycle
stages of Demodex spp. could be identified, 1 had
heavy mascara deposits that made identification
difficult. The other two had micro deposits that we
believe are a sign of demodicosis, but as these are a by-
product of the mite, they are a ‘‘soft sign’’ in
identifying Demodex as other organisms may be
responsible. Further epilation was not undertaken
due to patient discomfort and clinic considerations.
Int Ophthalmol (2016) 36:691–696 693

Of the 333 positive identifications, 4 were Demodex
brevis, the majority being Demodex folliculorum.
These were spread across the subgroups and not
limited to meibomian gland disease sufferers. 233
patients complied with the treatment and were able to
be followed up until study conclusion and their data
were included for analysis.
The average patient age was 62 (range 9–91), and
75 % of patients were female. A breakdown of
primary condition causing symptomatology is out-
lined in Table 1. Overall, 91 % of compliant patients
reported some improvement in symptoms after
3 months of treatment.
When broken down by primary cause of symptoms,
DED had the lowest rate of patients reporting
improvement in symptoms, at 84 %. A breakdown
of patient responses according to primary cause of
their symptoms is provided in Table 1.
Discussion
Demodex spp. have been implicated in external ocular
diseases including meibomian gland disease, recurrent
chalazia and keratoconjunctivitis and several studies
have shown that patients presenting with symptoms of
blepharitis or meibomian gland dysfunction are far
more likely to have Demodex spp. infestation than
controls. [15–21] In the current literature, there is
some controversy as to the rate of Demodex spp. in
blepharitis compared to controls. One study showed
that the incidence of Demodex spp. infestation in
anterior blepharitis patients was around 90 %, com-
pared to 18 % for controls. [15] However, another
study has shown that the incidence is the same
between the two groups, indicating a host response is
likely to be involved in the pathogenesis. [10].
In this study, 91 % of patients suffering from ocular
surface disease and compliant with the treatment
reported an improvement in symptoms with the
treatment of Demodex spp. infestation with lid toilet-
ing and application of 5 % tea tree ointment at night.
Although these results are subjective, and recall bias
may be present as patients were asked to rank current
symptoms compared with previous symptoms, these
data would indicate that the treatment of Demodex
spp. results in improvement in external ocular disease
symptom. There may be some selection bias due to the
large numbers lost to follow-up, and this needs to be
taken into consideration. Additionally, some patients
were treated with fluorometholone in addition to the
tea tree oil, which may be a confounding factor. There
is currently very little in the literature in regard to
resolution of symptoms following the treatment of
Demodex spp. One study has looked at patient’s
subjective symptoms of ocular itching, and the
correlation between decrease in ocular itching and
Demodex spp. infestation with the treatment with 5 %
tea tree oil. The study found there was some correla-
tion between the density of Demodex spp. infestation
and the degree of subjective symptoms, and that both
Demodex spp. numbers and symptoms were reduced
with tea tree oil treatment. [21] However, given the
difficulties in assessing density of infestation with our
current methods, more work needs to be done in this
area. Although there appears to be improvement in
symptoms with the treatment of Demodex spp., the
mechanism by which Demodex spp. is involved in the

Table 1 Breakdown of response to the treatment by causes of external ocular disease

Grade Description Anterior Meibomian Dry eye Chronic primary Allergic Overall response
blepharitis gland disease disease conjunctivitis conjunctivitis of symptoms to
N (%) N (%) N (%) N (%) N (%) the treatment

0 Complete resolution 14 (14.1) 4 (7.1) 0 (0) 0 (0) 6 (19.4) 24 (10.3)

1 Very little problem 21 (20.2) 9 (16.1) 4 (12.9) 4 (25) 3 (9.7) 40 (16.8)
2 Much better but still 25 (25.25) 21 (37.5) 7 (25.6) 5 (31.3) 9 (29) 67 (28.9)
there
3 Somewhat better 31 (31.31) 11 (19.6) 8 (25.8) 6 (37.5) 6 (19.4) 62 (26.7)
4 Just a little better 4 (4) 5 (10.7) 7 (22.6) 1 (6.3) 3 (9.7) 20 (8.6)
5 No change 5 (5) 6 (10.7) 5 (16.1) 0 (0) 4 (12.9) 20 (8.6)
Total number of cases 99 56 31 16 31 233

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pathogenesis of external ocular disease is still unclear.
The common finding of Demodex spp. as a commensal
indicates a combination of degree of infestation and
host responses are likely play a role in patients
presenting with symptomatic demodicosis.
Some patients who reported complete resolution of
symptoms still had external signs of Demodicosis on
follow-up. All patients who claimed lack of improve-
ment had persistence of external signs, suggesting that
lid margin toileting was less than optimal. The results
are of interest in that a typical antibiotic regime is not
used, although Tea Tree oil does have some antibiotic
properties. [22, 23].
When looking at the results of this study, it is
important to consider that the majority of patients
involved in this study had previously had many other
treatments for external ocular disease. Most of the
patients diagnosed with blepharitis had previously
been prescribed topical antibiotics, with no resolution
of their symptoms. Whilst topical antibiotics are often
efficacious in the treatment of anterior blepharitis, the
treatment of underlying Demodex should be consid-
ered in patients who fail to respond. Demodex is
resistant to standard topical antibiotics and so may act
as a reservoir for virulent bacterial species that can
rapidly re-infect the lids once the antibiotic is stopped.
[24–26].
Demodicosis has not previously been considered as a
major factor in MGD, however, these results would
indicate that treating diagnosed demodicosis has a
beneficial outcome in the majority of patients. [27] It is
proposed that the presence of Demodex spp. provokes an
inflammatory field that stimulates epithelialization of
the terminal meibomian gland duct, and then secondary
factors such as stasis and infection take over in
susceptible patients. Many factors may be responsible
for an individual’s susceptibility to meibomian gland
disease, such as the makeup of the patient’s meibum, the
individual’s genetically determined inflammatory
response, the lid’s broader microbiome and the presence
of other conditions such as acne rosacea. [26–28].
Demodex has previously been implicated in the
pathogenesis of chalazia [17, 18]. A number of
patients in the MGD subgroup had a history of
recurrent chalazia. Over the 8 months of the study,
there were no recurrences in those who undertook the
treatment, but a longer time of observation is required
to draw any definite conclusions regarding reduction
in recurrent chalazia with Demodex spp. treatment.
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Int Ophthalmol (2016) 36:691–696
Although showing the least response at 84 % of
patients reporting some improvement, to have any
symptomatic improvement in a patient with severe
DED is welcomed by both patient and practitioner. Of
note is that no patient had total resolution of his or her
symptoms, no doubt to the inflammatory nature of
DED. Nevertheless, the results suggest that demodi-
cosis may be adding to the inflammation present, and
hence the treatment may be beneficial, particularly
when most other options have been exhausted.
In the patients with primary chronic conjunctivitis,
eight (50 %) presented with epiphora that failed to
clear, with syringing showing patency of the naso-
lacrimal drainage system. This would usually be
regarded as having failure of the nasolacrimal pump. It
is proposed that dysfunction of the nasolacrimal pump
is due to inflammatory changes associated with
demodicosis, extending within the nasolacrimal drai-
nage system and causing loss of function while
maintaining anatomical patency. It is possible that
longstanding inflammation may later lead to anatom-
ical blockage by chronic fibrosis or calculus
formation.
The number of patients presenting with allergic
conjunctivitis showing a total resolution of symptoms
with the treatment of Demodex spp. suggests that
Demodex spp. is a cause of ocular allergy. The partial
responders may be due to inadequate eradication
Demodex spp., or presence of other allergens. Further
study is required in this area, particularly given the
morbidity of long-term topical steroid use.
Although this study has shown good rates of
improvement in subjective symptoms, 104 patients
were non-compliant with the treatment, or lost to
follow-up. This could be due to a number of reasons;
however, failure of the treatment cannot be excluded.
Due to the high dropout rate, the percentage of patients
experiencing improvement with the treatment of
Demodex spp. needs further clarification. ‘‘Lost to
follow up’’ was 47.5 % over 5 years in a dry eye clinic
survey, with inconvenience rating highly as reason.
[29].
Conclusion
Demodicosis is commonly seen in many ocular
surface diseases with chronic symptoms. Although
this observational study has not investigated the
Int Ophthalmol (2016) 36:691–696
underlying pathogenesis of these conditions, there
does seem to be improvement in symptoms with the
treatment of Demodex spp. with 91 % of patients
showing some improvement. Further research is
warranted to determine the mechanism of how
Demodex spp. causes ocular surface disease, and
how host responses may contribute to the pathogen-
esis. Although the response to the treatment has not
been quantified in terms of eradication of the mite, the
treatment regime used is safe, simple and inexpensive,
and should be considered in patients presenting with
chronic or recurrent ocular surface disease. Further
research is warranted to accurately quantify the
percentage of patients having improvement in symp-
toms with the treatment of Demodex spp.. It would be
useful to demonstrate a reduction in the mite density
coinciding with the decrease in ocular symptoms to
solidify the proposed relationship between mite den-
sity and development of symptoms.
Acknowledgments All authors certify that they have NO
affiliations with or involvement in any organisation or entity
with any financial interest (such as honoraria; educational
grants; participation in speakers’ bureaus; membership,
employment, consultancies, stock ownership, or other equity
interest; and expert testimony or patent-licensing
arrangements), or non-financial interest (such as personal or
professional relationships, affiliations, knowledge or beliefs) in
the subject matter or materials discussed in this manuscript.
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