By Dr. Cheryl Chapman, OD – Dry Eye and Ocular Surface Disease Specialist
Demodex blepharitis is one of the most underdiagnosed yet frustrating forms of blepharitis and ocular surface disease we encounter as optometrists. As a clinician specializing in dry eye treatment, I’ve found that recognizing and treating Demodex mite infestations—especially in their early stages—can be a game-changer for both patient comfort and long-term eye health.
Step One: Diagnosing Demodex Blepharitis
During every dry eye exam, I instill sodium fluorescein (NaFl) to evaluate for punctate epithelial erosions—a common sign of ocular surface damage.
Next, I ask patients to look downward during the slit lamp examination to visualize the upper lash line, where Demodex mites typically reside. The telltale sign of Demodex blepharitis is the presence of collarettes (cylindrical dandruff) around the base of the lashes—an unmistakable clue that intervention is needed.
Step Two: Lid Hygiene—The First Line of Defense Against Blepharitis
Once Demodex is confirmed, eyelid hygiene becomes a crucial component of the treatment plan. I educate patients using a "Good, Better, Best" framework:
Good
Manual cleansing with a foaming eyelid cleanser containing terpinen-4-ol (tea tree oil’s active compound). I often recommend the Peeq Pro Foaming Eyelid Cleanser—effective and easy to use with clean fingers.
Better
Adding a manual sponge applicator to lift debris and improve foam distribution.
Best
The Peeq Waiva—a patent-pending vibrating eyelid sponge—offers a thorough, spa-like clean for sensitive eyelids, especially in patients with chronic blepharitis or dry eye disease.
Alternative for Sensitive Eyes
For patients allergic to terpinen-4-ol or those with lash extensions or dexterity issues, I switch to Hypochlorous Acid formulations like Pure & Clean:
Lid Prep Drops – used like eye drops
Lid Prep Spray – easy spray-and-massage method
Lid Prep Hydrogel – thicker solution applied with a spoolie or Waiva
💡 Pro Tip: Help patients build the habit by placing lid cleansers next to their toothbrush—“habit stacking” improves compliance.
Step Three: Addressing Meibomian Gland Dysfunction (MGD)
When meibomian glands show signs of thickened or stagnant secretions, I add adjunctive therapies:
Warm compresses to melt and release clogged oils
Omega-3 fatty acid supplements to support gland health
Patients with elevated SPEED scores or significant dry eye symptoms also benefit from:
Preservative-free artificial tears throughout the day
Nighttime eye ointments for overnight hydration and comfort
Step Four: Monitoring Dry Eye & Blepharitis Treatment
Patients return in one month for a dry eye follow-up. During this visit, we re-evaluate with:
SPEED questionnaire
Tear osmolarity testing
MMP-9 testing for inflammation
NaFl staining of the cornea
Repeat eyelid examination in downgaze
We also track patient compliance using Peeq Pro’s automated workflow—patients sign up in-office via QR code to receive reminders and educational support.
Step Five: When to Start XDEMVY for Demodex Blepharitis
If collarettes persist despite excellent lid hygiene, it’s time to begin XDEMVY (lotilaner ophthalmic solution 0.25%)—the first and only FDA-approved treatment for Demodex blepharitis.
Dosage: One drop twice daily for 6 weeks
Education: Reinforce the importance of continuing lid hygiene throughout and after treatment to prevent reinfestation.
Step Six: Post-XDEMVY Follow-Up — Unlocking Long-Term Relief
Three months after initiating XDEMVY, we schedule a comprehensive follow-up to assess progress. At this visit, we:
Recheck SPEED scores, tear osmolarity, and MMP-9
Repeat NaFl staining and lid exam
Evaluate for resolution of collarettes
Here’s the key: eliminating Demodex mites with XDEMVY removes a major trigger of blepharitis and meibomian gland dysfunction. Once the infestation is controlled, we can shift focus to advanced dry eye treatments such as:
Amniotic membrane placement for healing the ocular surface
Intense Pulsed Light (IPL) therapy to reduce inflammation
Thermal gland expression for improved lipid layer stability
Clearing Demodex blepharitis is more than symptom management—it’s foundational to long-term success in dry eye disease treatment.
Final Thoughts
Demodex blepharitis doesn’t need to be a chronic burden—for us or our patients. With the right diagnostic tools, eyelid hygiene protocols, and FDA-approved solutions like XDEMVY, we can restore clarity, comfort, and confidence.
By tackling this condition head-on, we’re not just treating symptoms—we’re transforming lives.
—Dr. Cheryl Chapman, OD
Specialist in Dry Eye & Ocular Surface Disease