In vitro anti-demodectic effects and terpinen-4-ol content of commercial eyelid cleansers

Refining the Diagnostic Technique to Determine Prevalence of Demodex Mites in Eyelash Hair Follicles Within Standard Ophthalmic Practice: A Single-Center Outpatient Clinical Study

Purpose

A high density of Demodex infestation in human eyelids and eyelash follicles has been implicated in a variety of ocular surface conditions. However, Demodex infestation often goes undiagnosed and untreated, due to an overlap in signs and symptoms with other sources of ocular surface inflammation. We sought to refine the diagnostic technique for outpatient assessment for Demodex infestation and determine prevalence of Demodex mites in the hair follicles of eyelashes from patients in a standard ophthalmic practice.

Patients and Methods

Patients recruited from a single outpatient ophthalmology clinic were examined for the presence of Demodex mites following standard ophthalmic consultation. During anterior segment biomicroscopic examination, investigators searched for cylindrical dandruff and collarettes around the base of patient eyelashes. These were removed, and individual eyelashes manipulated with tweezers to reveal Demodex mites. Presence of Demodex, cylindrical dandruff and collarettes, time taken to identify the first Demodex mite, mean number of Demodex mites per hair shaft, and patient-reported symptoms of blepharitis were recorded and analyzed to determine potential correlations.

Results

A total of 173 patients were recruited, of whom 106 were included in Demodex prevalence analyses. Demodex infestation was identified in 100/106 (94%) patients, with a mean time of 2 minutes and 20 seconds taken to find the first Demodex mite and a mean number of 3 mites identified per hair shaft. Presence of Demodex significantly correlated with the presence of cylindrical dandruff (98/106 [92%] patients; p < 0.001), but not with the presence of collarettes (62/106 [58%] patients; p = 0.230) or symptoms of blepharitis (15/106 [14%] patients; p = 0.591).

Conclusion

These results highlight the pervasiveness of Demodex infestation, predicted by the presence of cylindrical dandruff, in the eyelashes of patients in a standard ophthalmic practice. They support the use of a non-invasive diagnostic technique to allow fast, simple identification of Demodex by ophthalmologists and optometrists in outpatient clinical practice.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

Comparison of the effect of tea tree oil eye gel with standard treatment in patients with anterior blepharitis: An open-label clinical trial

Purpose

Daily cleansing of eyelids is very important to carry out a successful blepharitis treatment. However, there are no therapeutic guidelines for blepharitis. The aim was to compare the symptomatic relief of anterior blepharitis using Blephamed eye gel, a cosmetic product, versus standard treatment.

Methods

The study was a prospective, interventional open label clinical trial at a university-based hospital. The test population was subjects aged 18-65 years who presented with mild to moderate anterior blepharitis. Eyelid hygiene was applied twice a day. At each visit, a detailed assessment of symptomatology was carried out. A two-way repeated measure mixed model ANOVA was used to compare two groups by time.

Results

In total, 61 patients with mean age of 60.08 ± 16.69 years were enrolled in the study including 30 patients in standard group and 31 patients in Blephamed group. Two groups did not differ in terms of age (P = 0.31) and eye laterality (P = 0.50). The baseline scores of erythema, edema, debris, and symptoms as well as total score were similar between two groups (all P values >0.50). Two groups became different for all these parameters at day 45 (all P values <0.001). Significant interaction was detected between time and intervention groups for all severity parameters of blepharitis as well as total score (all P values <0.001).

Conclusion

Eyelid hygiene with Blephamed more significantly decreased symptoms of anterior blepharitis compared to standard treatment.

Recent Evidence of Tea Tree Oil Effectiveness in Blepharitis Treatment

The purpose of our study is to see how beneficial is tea tree oil (TTO) for treating chronic blepharitis topically, with a focus on the Demodex mite. To discover all possibly relevant published papers, an accurate Pubmed database search analysis of the current literature was undertaken from 2012 to December 2021. Fourteen papers dealing with the use of TTO to treat chronic blepharitis have been found. The effectiveness of TTO treatment was tested in vitro by 4 authors and in vivo by 10 authors. All studied confirmed efficacy of TTO treatment, even cyclic, on Demodex mite blepharitis. TTO can be used for lid scrubs, facial cleanser, eyelid patch, eyelid gel, eyelash shampoo or, more commonly, as TTO impregnated eyelid wipes. The scientific evidence of TTO for chronic blepharitis treatment gives a lot of confidence for the progress that this treatment may have in the future clinical practice.

Antiparasitic Activity of Tea Tree Oil (TTO) and Its Components against Medically Important Ectoparasites: A Systematic Review

Ectoparasites are pathogens that can infect the skin and cause immense pain, discomfort, and disease. They are typically managed with insecticides. However, the fast-emerging antimicrobial resistance and the slow rate of development of new bio-actives combined with environmental and health concerns over the continued use of neurotoxic insecticides warrant newer and alternative methods of control. Tea tree oil (TTO), as an alternative agent, has shown remarkable promise against ectoparasites in recent studies. To our knowledge, this is the first systematic review to assess preclinical and clinical studies exploring the antiparasitic activity of TTO and its components against clinically significant ectoparasites, such as Demodex mites, scabies mites, house dust mites, lice, fleas, chiggers, and bed bugs. We systematically searched databases, including PubMed, MEDLINE (EBSCOhost), Embase (Scopus), CENTRAL, Cochrane Library, CINAHL, ScienceDirect, Web of Science, SciELO, and LILACS in any language from inception to 4 April 2022. Studies exploring the therapeutic activity of TTO and its components against the ectoparasites were eligible. We used the ToxRTool (Toxicological data reliability assessment) tool, the Joanna Briggs Institute (JBI) critical appraisal tools, and the Jadad scale to assess the methodological qualities of preclinical (in vitro and in vivo) studies, non-randomised controlled trials (including cohort, case series, and case studies), and randomised controlled trials, respectively. Of 497 identified records, 71 studies were included in this systematic review, and most (66%) had high methodological quality. The findings of this review revealed the promising efficacy of TTO and its components against ectoparasites of medical importance. Most importantly, the compelling in vitro activity of TTO against ectoparasites noted in this review seems to have translated well into the clinical environment. The promising outcomes observed in clinical studies provide enough evidence to justify the use of TTO in the pharmacotherapy of ectoparasitic infections.

Short-term tolerability of commercial eyelid cleansers: A randomised crossover study

PURPOSE

To evaluate the short-term tolerability of five commercially available anti-demodectic eyelid cleansers; OCuSOFT Oust Demodex (OD), I-MED I-Lid'n Lash Plus (ILL+), Labtician BlephaDex (BD), Chrissanthe Eye Cleanse (EC), and Théa Blephademodex (BDdx).

METHODS

Thirty healthy non-contact lens wearers (18 female; mean ± SD age, 33 ± 12 years) were enrolled in a prospective randomised crossover study. On separate visits, spaced at least 48 h apart, participants were randomised to receive topical application of one of five eyelid cleansers or saline. Participants rated subjective ocular discomfort during the 10-minute post-application period. Visual acuity, non-invasive tear film stability, conjunctival hyperaemia, and ocular surface staining were assessed at baseline and 10 min.

RESULTS

No inter-group differences in ocular parameters were noted at baseline (all p > 0.05). Ocular discomfort scores significantly exceeded baseline scores for 60 s following BD application, 120 s with OD, 135 s with BDdx, 150 s with ILL+, and 195 s with EC (all p < 0.05). Deterioration in non-invasive tear film stability, limbal conjunctival hyperaemia, as well as corneal, conjunctival, and lid margin staining was detected following EC application (all p < 0.05), and increased bulbar conjunctival hyperaemia was observed following both EC and ILL+ treatment (both p < 0.05).

CONCLUSIONS

Study outcomes highlight varying tolerability profiles with different anti-demodectic lid cleanser preparations, and the potential to induce tear film instability, conjunctival hyperaemia and ocular surface staining on application. Awareness of possible adverse effects arising from topical application of commercial anti-demodectic lid cleanser formulations may help clinicians set realistic patient expectations and encourage better compliance in their use of lid hygiene therapies.

Update on the Management and Treatment of Demodex Blepharitis

ABSTRACT

Demodex blepharitis is a common ophthalmologic disease that is often overlooked in the workup of blepharitis. Demodex infestation occurs in both symptomatic and asymptomatic individuals at similar rates; consequently, its role in the development of blepharitis has not been well elucidated. Two species have been confirmed to inhabit the human eyelid-Demodex folliculorum and Demodex brevis. These species differ in their preferred location of infestation, with D. folliculorum occupying the base of the eyelash and D. brevis inhabiting the meibomian glands, contributing to anterior and posterior Demodex blepharitis, respectively. A clinical index of suspicion must be developed from the history when blepharitis, conjunctivitis, or keratitis in adults and blepharoconjunctivitis or chalazia in children are resistant to treatment. The diagnosis can be strongly suspected by the presence of cylindrical dandruff at the base of the eyelash and confirmed by light microscopy of an epilated lash or by in vivo confocal microscopy. No cure is currently available. Management most frequently includes topical tea tree oil and its active ingredient terpinen-4-ol, both of which have produced good clinical outcomes. Topical tea tree oil is typically applied by a professional due to risk of toxicity. Several second-line treatment options have been studied, including ivermectin, metronidazole, selenium sulfide, microblepharoexfoliation, and lid hygiene. Novel, targeted therapies such as TP-03 (Tarsus Pharmaceuticals) are also currently being investigated in phase 2b/3 clinical trials. The purpose of this review purpose is to characterize Demodex blepharitis in detail, including its historical perspective and various classifications, and describe the latest diagnostic and management strategies.

Effects of Terpinen-4-ol on Meibomian Gland Epithelial Cells In Vitro

PURPOSE

Infestation with demodex mites has been linked to the development of chalazion, meibomian gland dysfunction, and blepharitis. An effective treatment is the eyelid application of terpinen-4-ol (T4O), a tea tree oil component. However, T4O is also known to be toxic to nonocular epithelial cells. We hypothesize that T4O toxicity also extends to human meibomian gland epithelial cells (HMGECs).

METHODS

Immortalized (I) HMGECs were cultured with varying concentrations (1.0%-0.001%) of T4O under proliferating or differentiating conditions up to 5 days. Experimental procedures included analyses of cell appearance, survival, P-Akt signaling, lysosome accumulation, and neutral lipid content.

RESULTS

Our findings show that T4O causes a dose- and time-dependent decrease in the cell survival of IHMGECs. After 15 minutes of exposure to 1% T4O, IHMGECs exhibited rounding, atrophy, and poor adherence. Within 90 minutes of such treatment, almost all cells died. Reducing the T4O concentration to 0.1% also led to a marked decrease in P-Akt signaling and cell survival of IHMGECs. Decreasing the T4O amount to 0.01% caused a slight, but significant, reduction in the IHMGEC number after 5 days of culture and did not influence the ability of these cells to differentiate.

CONCLUSIONS

T4O, even at levels 10-fold to 100-fold lower than demodicidal concentrations, is toxic to HMGECs in vitro.

Efficacy of Topical Ivermectin 1% in the Treatment of Demodex Blepharitis

The purpose of this study was to evaluate the efficacy of topical ivermectin 1% cream application on the eyelashes in combination with eyelid hygiene in the treatment of Demodex blepharitis.

Interventions for Demodex blepharitis and their effectiveness: A systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis was performed to evaluate the effectiveness of interventions in the treatment ofDemodex blepharitis in adult patients.

METHODS

A systematic review and meta-analysis of studies reporting the efficacy of treatments forDemodex blepharitis in the main databases (PubMed / Scopus / Cochrane / EMBASE / Science Direct / WOS / Scielo / Google Scholar / metaRegister of Controlled Trials / ClinicalTrials.gov/ WHO ICTRP) until November 24, 2020 was performed according to the PRISMA statement for meta-analysis.

RESULTS

Overall, 18 studies were included for 29 different interventions in 1195 participants with 1574 eyes that were positive for Demodex Spp. Demodex counts, total eradication, clinical improvement, Ocular Surface Disease Index, Tear Break-Up Time, cylindrical dandruff, Schirmer test, osmolarity and adverse reactions were analysed, and stratified sub-analyses conducted. The overall effects for Demodex count (mean difference), total eradication (risk ratio) and adverse reactions (risk difference) were -2.07 (95 % CI -3.99 to -0.15) p = 0.03, 1.84 (95 % CI 1.27-2.66) p = 0.001 and 0.24 (95 % CI 0.08 to 0.41) p = 0.005, respectively. The most frequent interventions evaluated in the included studies were tea tree oil (TTO) and its derivatives, such as terpinen 4-ol.

CONCLUSION

Multiple therapeutic choices were evaluated in this meta-analysis. Pharmacological interventions were superior to non-pharmacological (mechanical, thermal and pulsed light) interventions. It was not possible to establish significant differences between TTO and non-TTO-derived treatments. Adverse reactions were more frequent in TTO-derived treatments, however all were mild. It is necessary to execute studies with longer follow-up times to determine whether re-infestation occurs after the administration of different treatments.

Anti-Demodex Effect of Commercial Eyelid Hygiene Products

PURPOSE

To investigate in vitro effects of active ingredients in eye cleansing wipes and solutions on the life span of Demodex.

METHODS

Demodex mites were extracted by eyelash epilation method from volunteers who were found to have chronic demodex blepharitis during an ophthalmological examination. Preparations with three or more motile, live adult Demodex parasites were included in the study. Two drops of the test solution were dropped on the samples: saline, 2% tea tree oil (TTO; Osto®, AKD Medical products, Turkey), 7.5% TTO (Blefaritto®, Jeomed, Turkey), and 0.5% terpinen-4-ol (T4O; Blefastop plus®, NTC, Italy). Under light microscopy at 100× and 400× magnification, samples were examined and followed. The average killing time of Demodex was noted for each preparation.

RESULTS

The study was analyzed on 120 patient samples. In the control group with saline, the average killing time of Demodex had an average of 323.5 ± 21.1 min. In other groups, an average mean of 95.9 ± 25.2 min in the 2% TTO group, 67.1 ± 21.8 min in the 7.5% TTO group, and 27.3 ± 6.0 min in the 0.5% T4O group was observed. It was found that the 0.5% T4O group was significantly more effective than the other groups.

CONCLUSION

Chronic Demodex blepharitis treatment is quite difficult in ophthalmology practice. It appears that, even at very low concentrations, T4O has an effective anti-Demodex effect.

Demodex and eye disease: a review

Demodex is the most common parasite living on humans and yet little is understood about its pathogenicity with respect to the ocular surface. An increasing interest in Demodex over the past 20-years has increased our understanding of this mite and its pathogenetic role. This article begins with a review of the anatomy, life cycle, mode of transmission and advances in genetics that can distinguish between Demodex folliculorum and Demodex brevis, the only two Demodex species in humans. Additionally, a review of diagnostic procedures and existing and emerging ocular and systemic management options are presented. Despite the increasing interest in Demodex in the literature, there remains numerous obstacles for future studies, hence a section of this review is dedicated to the identification and proposal for future considerations. The lack of uniformity with respect to terminology, diagnostic technique and management approach for Demodex remain as obstacles for future study comparisons. This review summarised the current knowledge on Demodex and hopes to offer some recommendations for future directions in the study of Demodex in humans.

Topical ivermectin-metronidazole gel therapy in the treatment of blepharitis caused by Demodex spp.: A randomized clinical trial

PURPOSE

To evaluate the efficacy of topical ivermectin-metronidazole combined therapy in the management of Demodex-associatedblepharitis.

METHODS

Sixty patients with a diagnosis of Demodex-associatedblepharitis were recruited in a randomized clinical trial. Thirty receiving topical ivermectin (0.1%)-metronidazole (1%) gel treatment on days 0, 15 and 30. Thirty additional patients were used as a control group receiving vehicle on days 0, 15 and 30. The primary efficacy measure was the number of Demodex spp. mitesin the eyelashes of patients. The secondary outcomes included clinical improvement of signs and adverse events.

RESULTS

Complete eradication of Demodex spp. was found in 96.6% of patients in the treatment group. Furthermore, a significant reduction of inflammation signs were found in all treated patients versus controls. None of the patients experienced any adverse effects associated with the treatment.

CONCLUSION

Demodex infection was controlled satisfactorily with the ivermectin (0.1%)-metronidazole (1%) gel, and no adverse effects were observed. Application of this gel for the treatment of different parasitic infections of the eyelids could be feasible, and this requires further exploration.

Efficacy of cyclic therapy with terpinen-4-ol in Demodex blepharitis : Is treatment possible by considering Demodex's life cycle?

PURPOSE

To describe the effectiveness of cyclic treatment with terpinen-4-ol, a tea tree oil component, on Demodex blepharitis.

METHODS

The presence of Demodex was determined by eyelash rotation as proposed by Mastrota. Schirmer test, tear breakup time, ocular surface disease index, lid margin score, meibomian gland expressibility score, and Oxford grade were performed. Patients were advised to apply heat followed by terpinen-4-ol soaked wipes to eyelids twice a day for 2 weeks. At the end of 2 weeks, treatment was interrupted for 7-10 days. The same treatment was repeated once again. The patients were examined after the first and second cycle of treatment and after 1 year.

RESULTS

There was a statistically significant improvement in Schirmer test (10.37 ± 4.73 and 13.13 ± 3.44 mm/5 min), tear breakup time (6.47 ± 3.31 and 7.6 ± 2.89 s), ocular surface disease index (47.94 ± 19.77 and 34.28 ± 13.40), lid margin score (3.2 ± 0.7 and 2.63 ± 0.71), meibomian gland expressibility scores (1.93 ± 0.64 and 1.4 ± 0.67), and Oxford grade (0.9 ± 0.8 and 0.5 ± 0.63) after the first cycle of treatment (p < 0.05). The improvement in symptoms and tear function tests of the patients after the second cycle was significantly better than in pre-treatment levels. At 12-month follow-up, symptoms of two patients (93%) relapsed.

CONCLUSION

The administration of terpinen-4-ol to the eyelid margins in a cyclic manner in Demodex blepharitis is effective against adult and hatching Demodex and breaks the vicious cycle.

Improved Demodex diagnosis in the clinical setting using a novel in situ technique

PURPOSE

To compare existing and novel diagnostic techniques for confirming ocular Demodex infestation and to recommend the most reliable method for routine use by eye care practitioners, based on yield and clinical applicability.

METHODS

Fifteen participants with a prior Demodex blepharitis diagnosis or featuring typical cylindrical dandruff (CD) collarettes, and seven healthy controls were enrolled. Demodex presence was assessed using five techniques, applied consecutively, on a minimum of two different eyelashes on each eyelid of every participant, for each test, in situ: 1. using fine-point forceps and 25-40x biomicroscopy magnification, by eyelash rotation as proposed by Mastrota (ROT); 2. by removing cylindrical dandruff and exposing the eyelash insertion point at the lid margin (CDR); and 3. by laterally tensioning the eyelash (LET) following CDR. The typical appearance of cigar-shaped mite tails protruding from each assessed eyelash follicle was observed, and mite tails counted and averaged per participant for each assessment technique. 4. Lash epilation, and mite presence evaluated using bright-field microscopy at 10-40x magnification (EPI). 5. Finally, eyelash follicles were imaged using in vivo confocal microscopy (IVCM) and the images visually inspected for mite presence.

RESULTS

In the Demodex group, the highest numbers of mites/eyelash were identified by LET (3.8 ± 1.4), versus CDR (2.4 ± 1.6) and ROT (1.1 ± 1.2), alone (all p < 0.002). An average of 1.0 ± 0.8 mites/lash was identified by EPI. IVCM failed to offer unequivocal evidence of Demodex presence even in confimed cases.

CONCLUSIONS

A novel technique for the clinical diagnosis and grading of Demodex in situ is described. By removing cylindrical dandruff and applying static, lateral tension to the eyelash without epilation, large numbers of mites are visible at the exposed eyelash follicle. The proposed method is convenient and clinically applicable, requiring only forceps and 25-40x biomicroscope magnification, and allowing rapid, efficient evaluation of large numbers of eyelashes.

The effect of lid hygiene on the tear film and ocular surface, and the prevalence of Demodex blepharitis in university students

AIM

To evaluate the effect blepharitis lid cleansers have on the tear film and ocular surface, and to examine the prevalence of Demodex folliculorum in a young population.

METHODS

Forty-eight university students completed a randomised, controlled, investigator-masked, eight-week clinical trial. Three eyelid hygiene products were investigated: blepharitis eyelid cleanser (OCuSOFT® Lid Scrub® PLUS foam), diluted baby shampoo (10% Johnson's® No More Tears ®) and a tea-tree based face wash (dr.organic®). Cooled boiled water was used as a control. Subjects attended for four visits: baseline, two weeks, four weeks and eight weeks. At each visit, subjective symptoms, non-invasive tear break up time, ocular surface staining and Demodex folliculorum investigation were assessed to evaluate any positive or negative effect on the tear film and ocular surface. Osmolarity was also measured at baseline and week eight only.

RESULTS

The overall prevalence of Demodex folliculorum found at baseline was 15%. Subjective symptoms improved in all groups, including control. There was no significant difference in mean osmolarity between the groups or within each group after eight weeks. There was a significant increase in osmolarity inter-eye variability in the baby shampoo group (5.5 ± 5.4 vs 15.2 ± 9.5; p = 0.03). There was no significant change in non-invasive tear break up time or ocular surface staining demonstrated after eight weeks of eyelid hygiene.

CONCLUSION

A low prevalence of Demodex folliculorum can be found in a young population. All blepharitis lid cleansers used demonstrated subjective improvement in symptoms, with no negative effects on tear break-up time or ocular surface staining. The blepharitis eyelid cleanser and tea-tree based face wash revealed no adverse effect on mean osmolarity or inter-eye variability. Similarly, baby shampoo did not cause a significant increase in mean osmolarity, however, a significant increase in inter-eye variability was found; suggesting a possible increase in ocular surface inflammation.

Improvement in ocular symptoms and signs in patients with Demodex anterior blepharitis using a novel terpinen-4-ol (2.5%) and hyaluronic acid (0.2%) cleansing wipe

Purpose: To evaluate the clinical improvement in ocular symptoms and signs in patients suffering from Demodex anterior blepharitis after using a novel cleansing wipe impregnated with 2.5% terpinen-4-ol and 0.2% hyaluronic acid.

Study design: This was an exploratory, multicenter, open, randomized, two-parallel group comparative study.

Methods: Forty-eight patients with Demodex anterior blepharitis were randomly assigned to apply the sterile wipe T1172 (Blephademodex^®), either once daily (n=24, Group 1) or twice daily (n=24, Group 2) for 29 days. Overall ocular discomfort and other individual symptoms were measured using a 0–10 numeric rating scale at Day 8 and Day 29. Ocular signs, including eyelid margin hyperemia and number of cylindrical dandruff, were examined at slit lamp. Overall treatment performance by investigator, patient satisfaction and tolerance were evaluated with questionnaires.

Results: Overall ocular discomfort was significantly reduced from baseline (p<0.0001) in both groups at Day 8 (−3.6±0.3 in Group 1 and −4.0±0.4 in Group 2) and Day 29 (−5.7±0.4 and −6.8±0.7, respectively), with no difference between groups (D8: p=0.718; D29: p=0.505). Each ocular symptom associated with Demodex blepharitis was improved in both groups. Eyelid margin hyperemia was significantly reduced at Day 8 (−0.7±0.7; p<0.001) and Day 29 (−1.1±0.7; p<0.0001) in Group 1. Similar results were observed in Group 2 (Day 8: p<0.001; Day 29: p<0.0001). Total disappearance of cylindrical dandruff was reported in 30.4% of patients in Group 1 and 43.5% in Group 2. Improvements in other ocular signs were observed in both groups. The product was well tolerated. All patients were satisfied or very satisfied and would continue using it.

Conclusion: Daily eyelid hygiene using this cleansing wipe impregnated with 2.5% terpinen-4-ol and 0.2% hyaluronic acid during a 4-week period led to a rapid and marked reduction in ocular symptoms and signs associated with Demodex anterior blepharitis and was well tolerated.