 the original method of epilation and viewing. He advocated random epilation of four nonadjacent lashes per lid and adding a drop of oil before mounting the coverslip. Gao et al.24 improved the method to epilate lashes with CD, instead of random lashes, and to add alcohol. The method has been further modified by Kheirkhah et al.23 to add fluorescein at the edge of the coverslip11,24 (Table 2; Fig. 2).
The focus of these case reports is detection and diagnosis of the infestation. However, current treatment for this condition includes lid hygiene and tea tree oil lid scrubs and shampoo.5,6,11,12,21,25,29 As stated before, the following cases used the clinical sequence outlined previously.
A 68-year-old woman has been diagnosed with diabetes since 2008 and has been taking oral medications for the condition. The patient complained of dryness all the time and no itchiness or redness. Meibomian gland expression appeared opaque and solid (toothpaste-like) in both eyes. Schirmer test results were OD 10 mm OS 11 mm. There was moderate to severe amount of lid debris (flakes and crusting) in both eyes. There was no debris in the tear film. Diffuse CD was present with less than 10 pieces per eye, as classified by Gao et al.24 (Fig. 3). There was moderate distention of the follicles in both eyes. Lashes were epilated and viewed under a liquid-crystal display microscope (Celestron 44340 LCD Digital LDM Biological Microscope). Demodex was present in both eyes.
Patient 1 Discussion
This case demonstrates severe dryness symptoms but no itching or redness. Based on the observations of Koo et al.,5 less than one-half of Demodex patients have itching or redness. They identified that the most common symptom for Demodex was ocular dryness (74.7%), followed by itching sensation (42.7%), ocular irritation (39.1%), visual disturbance (32.0%), conjunctival injection (9.9%), and glare (3.6%). Schirmer test results were normal. Based on lid expression and the amount of lid debris, a diagnosis of evaporative dry eye or blepharitis could be made. Because the Schirmer test results were normal for this patient, aqueous deficient dry eye could be ruled out. However, a closer examination of the lids reveals a diffuse amount of CD, pathognomonic for Demodex, along with the lid debris. As mentioned previously, literature points to the link between MGD and blepharitis with Demodex.14,20
Three studies have associated diabetes with Demodex infestation.30–32 Yamashita et al.30 studied 42 patients in each group (control and Demodex). They found no statistically significant differences between the control and diabetes groups with regard to age and sex in both groups (p > 0.05). Demodex folliculorum was significantly more prevalent in diabetic patients (27.4%) than in control patients (19.0%).30 Clifford and Fulk32 analyzed the prevalence of Demodex on 256 subjects and also concluded that mites were more abundant in patients with diabetes. Akdeniz et al.31 found a significantly higher mean mite density and bigger mite mean size on cheek biopsy of diabetic patients compared with a control group. Both Yamashita et al.30 and Clifford and Fulk32 examined lash follicles, whereas Akdeniz et al.31 did not. The relationship between diabetes and Demodex has been theorized as a result of peripheral vascular insufficiency. Persons with diabetes may have a reduced ability of their immune systems to control mites because of vascular insufficiency.31–33
In contrast, Lee et al.6 found no relationships between Demodex in lashes and systemic diseases such as diabetes and hypertension. The number of subjects with diabetes was not stated. Lee et al.6 mention the study by Forton et al.,33 where 96% of their Demodex patients were healthy. Forton et al.33 only found three patients with diabetes in his Demodex sample of 115 patients. Forton et al.33 did not study lash follicles but found Demodex by skin biopsy.6,33
A 44-year-old Hispanic man presents with moderate to severe dry eye. The patient reported the frequency of dryness and redness to be sometimes (mild). Meibomian gland expres