Efficacy of Ivermectin for the treatment of chronic blepharitis in patients with positive microbiological exam for Demodex ( spp ) Pedro Antonio Nogueira.

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Efficacy of Ivermectin for the treatment of chronic blepharitis in patients with positive microbiological exam for Demodex ( spp ) Pedro Antonio Nogueira Filho, MD, Rossen Mihaylov Hazarbassanov, MD, Ana Beatriz Diniz Grisolia, MD, Henrique Baltar Pazos, MD, Igor Kaiserman MD, José Álvaro Pereira Gomes, MD Autors have no financial interest Instituto de Suel Abujamra, Sao Paulo, SP Departamento de Oftalmologia, UNIFESP, São Paulo, SP

Purpose To evaluate the efficacy of oral Ivermectin for the treatment of chronic blepharitis with a positive microbiological exam for Demodex spp.

Introduction Chronic blepharitis is one of the most common disorders seen in clinical practice, but sometimes it is a challenging diagnose. (1) The most prevalent microbiologic agents are: bacteria Sthaphylococcus aureus, S. epidermidis, Corynebacterium sp; fungus Candida albicans, Pitysporum ovale; parasites Demodex folliculorum, Demodex brevis.

Introduction For a long time, parasites role has been discussed, raising questions regarding their pathogenic or commensal influence. (2,3) Li et al., reported correlation between Demodex mites and their symbiotic B oleronius in facial rosacea and blephatitis. (4) Other studies described a strong correlation between number of Demodex counting and severity of ocular discomfort (5,6)

Methods and Patients Prospective, longitudinal study. Carried out at the Cornea Service,“Instituto Suel Abujamra”, Sao Paulo, SP, Brazil. 20 patients previously diagnosed with chronic blepharitis with prolonged treatment, resistant to tetracyclines, were included: –Complete ophthalmologic exam (OSDI, Break-up time). –Microbiological exam of the eyelashes for Demodex spp mites; three lashes from each eyelid were collected. –Liver function screened by Alanine aminotransferase (ALT), Aspartate aminotransferase (AST) and total, direct and indirect bilirubin.

Methods and Patients The microbiological investigation of the eyelashes was performed under optical microscope (Nikon Instruments Inc, Japan ) (7) with magnification of 40x. The slides were counterstained with fluorescein. For patients with positive exam of their lashes, oral Ivermectin 6mg (Revectina®– Solvay Farma Ltda., Ivermec®- UCI-Farma) was prescribed bid for one day and the treatment was repeated after 15 days.

Photos 3. A- Demodex spp.; B- (a) The image shown the Demodex spp. in the base of the eyelashes; 1. Before the treatment; 2. After the treatment ; 5. A group of Demodex spp. In the base of the eyelashes; 6. Demodex spp.; 4. The aspect of the eyelashes with Demodex spp.;

Results 19 patients were evaluated –Mean age: 65.75±16.96 –Gender: 6 males (31.58%) and 14 females (69,02%) –4 (21.05%) patients were with blepharitis, additionally 12 (63.16%) patients were with blepharitis and Staphylococcus; and 3 (15.79%) patients were with blepharitis and Rosacea. Treated patients improved their symptoms (itching and eye redness) between 60 to 90 days post treatment –Itching was still reported in only 3 patients (15.79%) –None of them showed redness of the eyes.

Results Reduction on the number of mites within 60 days after initial treatment was statistically significant ( ϰ 2 test, p<0.0001). There was not significant difference for OSDI (one way ANOVA, p=0.132) and BUT ( ϰ 2 test, p=0.7452) in all periods compared to pre-treatment. -Liver function screened by ALT, AST and Total, direct and indirect bilirubin were normal before and after the treatment.

Pre % (n=19) 30d pos Tx % (n=17) 60d pos Tx % (n=14) 90 D Pos Tx % (n=14) ϰ 2 - test P= 0 mites0% (0/19)35.29%(6/17)92.86% (13/14) 100%(14/14)< mites68.21% (13/19) 58.82% (10/17) 7.14% (1/14)0%(0/14)< mites21.05 % (4/19) 5.88% (1/17)0% (0/14) >5 mites10.53 % (2/19) 0% (0/17)0% (1/14)0%(0/14) Results

Conclusions Treatment with oral Ivermectin decreases the number of mites in patients who present Demodex spp in the eyelashes. It might improve the symptoms and signs of chronic blepharitis and it can be considered as an alternative/adjunct treatment in these cases.

References 1. SMITH, R.E.; FLOWERS Jr, C.W.; Cronic blepharitis: a review. CLAO J. jul, 1995; 21(3): ENGLISH, F.P.; ZHANG, G.W.; McMANUS, D.P.; CAMPBELL,P.; Electron microscopic evidence os acarine infestation of the eyelid margin; Am J Oph, 109 (2), Feb 1990; CORREDOR-OSORIO R., NAVA CASATAÑEDA A., CANALLES J.L.T., POMAR J.L.T., SALAS S.M. Blefaritis por Demodex folliculorum. Revista de la faculdad de medicina vol 43, n4 jul-ago Li J,O'Reilly N,Sheha H,Katz R,Raju VK,Kavanagh K,Tseng SC. Correlation between Ocular Demodex Infestation and Serum Immunoreactivity to Bacillus Proteins in Patients with Facial Rosacea. Ophthalmology (Ophthalmology). 5. Lee SH,Chun YS,Kim JH,Kim ES,Kim JC. The Relationship Between Demodex and Ocular Discomfort. Invest Ophthalmol Vis Sci (Investigative ophthalmology & visual science). 6. MASCARÓS E.M. Parasitación por Demodex folliculorum. Em FRAUNFELDER,FT ; ROY FH. Current ocular therapy. Philadelphia:WB. Saunders company,2000.