My most popular Youtube video

A couple of years ago, I decided to put a few videos up on Youtube. They were nothing spectacular, and were meant partly as a record of what I have been doing in the clinic, and some others were to demonstrate surgical techniques.

It became apparent within the first year that one of the videos was different. It was getting thousands of hits, while the others were languishing with perhaps a few tens of views.

This is the video: http://www.youtube.com/watch?v=16bSxfCS0wI

It did not have sound. It was about cleaning the eyelids of mucky crusts, and of looking for tiny little mites called demodex. And as of today it has 392456 hits...

I think it boils down to the frustration many patients and doctors feel about the problem of blepharitis and the lack of effectiveness of many of the traditional treatments. When I was training, and even nowadays, a commonly taught technique was to clean the eyelids with diluted baby shampoo. The idea was to use the shampoo to help remove crusts, while it was gentle enough not to irritate the eye even if any of it went in.

However, it made little to no difference for many blepharitis sufferers. The crusts would return almost as quickly as they were removed, and the eyes would often remain irritated and itchy.

About 10 years ago, Scheffer Tseng and others began reporting research done on demodex mites and blepharitis. That piqued my interest and I started looking for them in my patients. I started finding them in many, many people...

Although the mites don't always cause trouble, they certainly have the potential to do so. Back when I first started to become aware of them, I remember a lady who had very bad persistent eye irritation that was resistant to all the dry eye treatments she had been prescribed. I happened to see her and noticed her blepharitis. Remarkably, she felt much better after a single dose of oral Ivermectin that I prescribed. In more recent years, a number of patients did not seem to respond to the oral medication, and finally I asked a compounding pharmacy to produce a topical preparation which has proved very effective. What appears to be current 'mainstream' treatment, tea tree oil, proved to be very irritating for my patients as well as not being very effective at killing the mites.

It turns out that many viewers of my video (and readers of this blog as well...thanks for reading!:)) live outside of Singapore, with many in the United States and Europe. Some viewers have asked about the availability of Ivermectin cream, and unfortunately it is not commercially available at the moment. However, Galderma has recently concluded phase 3 studies for the use of topical Ivermectin in rosacea, and the hope is that this will become commercially available soon.

At least in terms of medical videos on Youtube, it doesn't appear that you always need special effects or a South Korean origin to be popular!

P/S: since that first successful video, I made a more detailed one describing the detection of demodex in the eyelashes as well as the treatment of this stubborn condition, at this address:  http://youtu.be/NskwR1XzTtE

Itchy eyelids? Crusty eyelids? The reality of Demodex

What's Demodex? They are mites, which are microscopic little critters with eight legs. They belong in the same class  of animals as spiders. While most have heard of house dust mites, few have heard or come across demodex, except maybe dog owners. This is despite Demodex infesting many of us, only we are unaware of their presence most of the time.

Demodex are readily accessible to inspection by most ophthalmologists, only many ophthalmologists are also unaware of their presence. When they infest the lash follicles, they are readily visible on high power with the slit lamp microscope. The video shows how I look for them-by pulling lightly and twirling the eyelashes. Before I do this I clean away all debris and dandruff like material with an alcohol swab. Then, pulling lightly on the lashes causes their tails to poke out, and further twirling the lash will cause the mass of demodeces to come out and lie on the skin surface. They look like tiny shiny rod shaped objects. They can then be scooped up with the tip of a forceps and I touch them lightly on the sticky side of a cellophane tape. I then stick them on a microscope slide and have a look on a compound microscope. The picture shows one that I caught recently. However, now that I've seen quite a few of them, I can readily identify them on the slit lamp alone.

So what? It seems to me that most people with blepharitis, especially anterior blepharitis and lots of debris near the eyelashes also have lots of demodex. Coincidence? Some people say demodeces are commensals. Well, I would say it's too much of a coincidence. Several papers by Scheffer Tseng have now come out about the pathological role of demodex in ocular surface disease. I still wonder about posterior blepharitis and meibomian gland disease. I often see this without demodex infestation of the lashes. It could be that there is deeper infestation within the Meibomian gland itself, by D Brevis, but we won't know for sure unless we can somehow put a scope up the gland or maybe test the Meibum by PCR for the demodex.

If you see Demodex, what do you do? Some would do nothing. I think that is reasonable if you see one or two of them in the odd follicle, and the patient is not symptomatic. But if there are lots, and the patient is itching like crazy or the lids are inflamed, then steps should be taken. Tea tree oil has been touted as being a great mite killer-but that would only work for the ones on the lashes. If there are any in the Meibomian glands one might have to resort to something  systemic like ivermectin. I don't see how the tea tree oil would get into the Meibomian glands. So there you have it-in a nutshell. My thoughts on Demodex and blepharitis. I do welcome your comments.