The Demodex Expert Panel on Treatment and Eyelid Health (DEPTH) Consensus Regarding the Preferred Treatment for Demodex Blepharitis

Eric Donnenfeld,1 Kelly K Nichols,2 Brandon D Ayres,3 Marjan Farid,4 Preeya K Gupta,5,6 Richard Lyndon Lindstrom,7 Stephen Pflugfelder,8 Christopher E Starr,9 Nandini Venkateswaran,10 Ian Benjamin Gaddie,11 Paul M Karpecki,12 Cecelia Koetting,13 Selina McGee,14 Laura M Periman,15 Elizabeth Yeu16 1Ophthalmic Consultants of Long Island, Long Island, NY, USA; 2School of Optometry, University of Alabama at Birmingham, Birmingham, AL, USA; 3Wills Eye Hospital, Philadelphia, PA, USA; 4Gavin Herbert Eye Institute, UC-Irvine, Irvine, CA, USA; 5Triangle Eye Consultants, Raleigh, NC, USA; 6Department of Ophthalmology, Tulane University, New Orleans, LA, USA; 7Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA; 8Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA; 9Department of Ophthalmology, Weill Cornell Medicine, New York, NY, USA; 10Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; 11Gaddie Eye Centers, Louisville, KY, USA; 12Kentucky Eye Institute, Lexington, KY, USA; 13Department of Ophthalmology, University of Colorado Medical School, Aurora, CO, USA; 14BeSpoke Vision, Edmond, OK, USA; 15Periman Eye Institute, Seattle, WA, USA; 16Virginia Eye Consultants, Norfolk, VA, USACorrespondence: Elizabeth Yeu, Cornea, Cataract, External Disease and Refractive Surgery, Virginia Eye Consultants/EyeCare Partners, 241 Corporate Blvd, Norfolk, VA, 23502, USA, Tel +1 757 622 2200, Fax +1 757 622 4866, Email [email protected]: To reach consensus on Demodex blepharitis (DB) treatment approaches using a modified Delphi process involving 15 ocular surface disease experts.Methods: The Demodex Expert Panel on Treatment and Eyelid Health (DEPTH) consisted of 15 well-published ocular surface disease experts. Panelists completed two online surveys, a live consensus meeting, and a follow-up survey. The surveys consisted of scaled and multiple-choice questions related to the clinical and patient-reported outcomes of DB and its treatment. For the scaled questions using a 1 to 9 Likert scale, consensus was defined as weighted mean scores of 1– 3 and 7– 9, whereas for multiple-choice questions, consensus was achieved when a minimum of 10 of 15 panelists agreed.Results: The DEPTH panel reached consensus that lotilaner ophthalmic solution, 0.25% should be the first-line treatment for DB. Experts agreed no additional clinical findings are needed to prompt treatment with lotilaner ophthalmic solution, 0.25% for patients with > 10 collarettes (12/15), while one additional clinical finding is needed for patients with 0– 2 (11/15) or 3– 10 collarettes (10/15). In the absence of allergies, panelists would consider first-line treatment for DB in a patient with eyelid itching but without collarettes (weighted mean: 7.47; range: 2– 9). Panelists agreed that blepharoexfoliation (weighted mean: 8.27; range: 3– 9) or intense pulsed light (IPL) therapy (weighted mean: 8.4; range: 6– 9) could supplement first-line treatment with lotilaner ophthalmic solution, 0.25%. The DEPTH panelists agreed that topical (10/15) and systemic ivermectin (14/15) are not their preferred treatment for DB. Experts did not reach consensus about the use of tea tree oil to treat DB.Conclusion: Experts achieved consensus on the use of lotilaner ophthalmic solution, 0.25% as the first-line treatment for patients with DB. Panelists also agreed that blepharoexfoliation or IPL therapy could serve supplementally to lotilaner ophthalmic solution, 0.25%, if needed.Keywords: blepharitis, Demodex, treatment, Delphi