Eyeworld

64 | EYEWORLD | FALL 2026 C ORNEA over-the-counter methods. "This is where subtyping anterior blepharitis is helpful. There are different opinions on the names we give the objective findings in anterior blepharitis—col- larettes, sleeves, scurf—but in general, we agree there can be staphylococcal overgrowth. This commonly looks like large, lacy, flaky debris. Here, a targeted antibiotic lid scrub may be re- quired if over-the-counter measures are ineffec- tive," she said. When there are circumferential, tube-like lash debris present, which Dr. Seitzman said are called a "sleeve" in textbooks but marketed as a "collarette" by Tarsus Pharmaceuticals, Demodex are present. This is where "XDEMVY [lotilaner, Tarsus Pharmaceuticals] works great," she said, adding that some use off-label topical ivermec- tin or tea tree oil. The latter "is not a bad idea" but can be a better idea for maintenance after a medicated round has more markedly decreased the Demodex. Dr. Pflugfelder said he'll also treat Demodex with tea tree oil, lotilaner, and alternatively, with ivermectin cream. If the cause of blepharitis is seborrheic debris, which Dr. Seitzman said "can be quite inflammatory," then a prescription steroid as a scrub can be helpful. Iatrogenic worsening of blepharitis is pos- sible as well, if patients aren't improving with attempted treatments. "Maxitrol [neomycin/ polymyxin B/dexamethasone] is cheap, but neo- mycin can be irritating. The same can be true for tobramycin or other topical aminoglycosides. Especially for atopic patients, preserved drops can worsen eyelid inflammation, and preserva- tive-free medications should be considered," Dr. Seitzman said. When it comes to mechanical procedures like intense pulsed light therapy or LipiFlow (Johnson & Johnson Vision), Dr. Seitzman said that her academic tertiary care practice doesn't offer these (often because their patients have already tried and failed to improve on them), but "we fully appreciate these technologies may be standard of care in many practices, including private practices." Dr. Donaldson said if collarettes are present, indicating Demodex, she'll treat the patient with lotilaner twice daily for 6 weeks. "Many of these patients are already using an eyelid hygiene regimen that may include tea tree oil," she said. "I generally encourage them to continue the eyelid hygiene because I think developing that healthy habit may reduce recurrence over the long term." Dr. Donaldson cautioned against higher dosages of tea tree oil, which can cause irri- tation. "I also think that use of eyelid wipes is not essential for success with lotilaner but is strictly for long-term maintenance. The key to this treatment is to treat the underlying cause (the mites), as opposed to simply treating the resultant inflammation," she said. Dr. Donaldson said lotilaner dramatically changed her treatment regimen. "Before XDEM- VY, we treated with various forms of tea tree oil and witnessed variable efficacy, poor tolerance, and poor patient compliance," she said. "We also spent significant clinic time pulling lashes and examining them under the microscope in an attempt to make a diagnosis. Now, we have a clear first-line therapy for Demodex with more consistent eradication and better patient adher- ence and comfort. This is one of the rare cases where we've moved from management to a true targeted treatment." If the cause of blepharitis is staphylococcal, the focus should be reducing bacterial load and inflammation, Dr. Donaldson said. "Treatment for anterior blepharitis includes lid hygiene (hypochlorous acid, wipes), topical antibiotics (short-course azithromycin or bacitracin), and occasional mild steroid/antibiotic combination products in short courses for flares," Dr. Donald- son said. Dr. Pflugfelder said he'll treat Staph-re- lated blepharitis with antibacterial lid wipes, hypochlorous acid spray, and antibiotics; he'll culture if there's no response to these. Posterior blepharitis caused by meibomian gland dysfunction can benefit from heat, lid hygiene, lipid-based tears, oral omega supple- ments, topical azithromycin, short courses of topical steroids, and procedural treatments, Dr. Donaldson said. "In-office procedures are very helpful for the management of MGD-driven disease," she said. "These procedures include thermal pulsa- tion (LipiFlow), which helps to improve gland outflow; intense pulsed light, which targets telangiectasia, inflammation, and Demodex (sec- ondarily) and is helpful for rosacea-associated disease; manual expression, which can be used to alleviate gland obstruction; and microbleph- aroexfoliation, which reduces the biofilm and allows glands to function more optimally. These continued from page 63

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