CLINICAL RESEARCH
e-ISSN 1643-3750
© Med Sci Monit, 2017; 23: 5862-5869
DOI: 10.12659/MSM.907824
Received: 2017.10.30
Accepted: 2017.11.20 A Clinical Scoring System for Diagnosis of Ocular 
Published: 2017.12.10 Demodicosis
Author s’ Contribution: ABEF 1 Oktay Alver 1 Department of Medical Microbiology, Uludag University School of Medicine, 
 Study Design A ABCDEF 2 Sertaç Argun Kıvanç Bursa, Turkey
 Data Collection B 2 Department of Ophthalmology, Uludag University School of Medicine, Bursa, 
 Statis tical Analysis C ABDEF 2 Berna Akova Budak Turkey
Data In terpretation D BE 1 Nazmiye Ülkü Tüzemen
 Manuscrip t Preparation E EF 1 Beyza Ener
 Literature Search F
Fun ds Collection G EF 2 Ahmet Tuncer Özmen
  A part of this study was presented as a Poster at the ARVO 2017 Meeting in Baltimore, USA
 Corresponding Author: Berna Akova-Budak, e-mail: bernaakova@hotmail.com
 Source of support: Departmental sources
 Background: Demodex may cause chronic and refractory blepharitis with associated ocular surface problems, and its diag-
nosis and treatment can be quite challenging. In this study, our aim was to assess the efficacy of tea tree oil 
in Demodex treatment on caucasian patients in an industrialized region of Turkey, and to develop a systemat-
ic scoring system for extremely accurate diagnosis in the absence of advanced facilities.
 Material/Methods: Charts of 412 patients with blepharitis were reviewed. A group of 39 out of 412 cases were identified as chron-
ic and treatment-refractory, and therefore were enrolled in this study. Eyelashes from each of the lower and 
upper eyelids of both eyes were evaluated at ×40 and ×100 magnification using light microscopy. Treatment 
was started with 4% tea tree oil eyelid gel and 10% eyelash shampoo. Symptoms and findings were scored ac-
cording to the most common complaints.
 Results: The mean age of the patients was 54.1±15.4 years. Seventeen (43.5%) patients were male and 22 (56.5%) pa-
tients were female. In 30 out of the 39 patients (76.9%) D. folliculorum was detected. Symptoms disappeared 
in 25 patients. The mean score of patients who were Demodex-negative was 2.7±1.0, and the mean score of 
patients who were Demodex-positive was 3.8±1.6 (p=0.047). Ninety-four percent of those with a score of 4 
and over were found to be Demodex-positive (p=0.025).
 Conclusions: Treatment with tea tree oil can be successful. If there is no facility to identify Demodex under light microsco-
py, we recommend starting treatment for patients who have scores of 4 and over using the scoring chart de-
veloped in this study.
 MeSH Keywords: Dry Eye Syndromes • Keratitis • Mite Infestations • Ocular Surface • Score • Tea Tree Oil
 Full-text PDF: https://www.medscimonit.com/abstract/index/idArt/907824
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Alver O. et al.: 
A clinical scoring system for diagnosis of ocular demodicosis CLINICAL RESEARCH
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Background developed a systematic scoring method for accurate diagno-
sis of Demodex infestation.
Demodex spp. are mites in the subclass of Acariformes of 
the Arachnida class, which constitute an important group of 
Arthropoda. Demodex folliculorum is an obligate parasite in Material and Methods
human hair follicles, and Demodex brevis is localized in the pi-
losebaceous unit [1,2]. These mites are transmitted through The files of patients who attended our clinic between January 
close person-to-person contact, but the pathogenic mecha- 2016 and August 2017 and who were diagnosed with bleph-
nism is not fully understood [3]. D. folliculorum and D. brevis aritis were reviewed. We included 39 of 412 patients diag-
are more often found in the eyelashes and ears, and may also nosed with chronic and treatment-resistant blepharitis and 
be found in other sites, especially in the forehead and nose re- who were older than 18 years of age. Age, sex, complaints on 
gion [2,4–7]. Although many recent studies suggest that these admission, examination findings, additional systemic diseas-
parasites play a role in the etiopathogenesis of disorders such es, and Demodex examination findings from the patient re-
as skin diseases and facial blepharitis, others regard the pres- cords were recorded.
ence of mites in the pilosebaceous follicles as harmless [8].
Microscopic Demodex examination
D. folliculorum mites cause tension and plugs as mites multi-
ply in the follicles, and the penetration of parasite antigen into The diagnosis of ocular demodicosis was made at the 
the dermal structure can cause allergic reactions and facilitate Microbiology Department of Uludag University. Three eye-
the development of infection by carrying microorganisms [5]. lashes from each of the lower and upper eyelids of both eyes 
Ophthalmic complaints such as blepharitis and blurred vision were epilated (6 eyelashes from each side), made into a prep-
associated with Demodex infestation can cause dry eye, er- aration with glycerin-type separation, and evaluated at ×40 
ythematous eye lid, eye itching, burning, and irritation [6]. and ×100 magnification under light microscopy [2,9] (Figure 1). 
Chronic and treatment-refractory blepharitis is a common dis- Type separation was carried out by the same expert as soon 
order, and the diagnosis of the Demodex infestation is diffi- as all samples were taken [10,11]. Measurements were made 
cult, usually requiring an experienced parasitologist or use of oculometrically (CHWK, Olympus, Japan).
an expensive device such as an in vivo confocal microscope.
Treatments of ocular demodicosis
In the present study, we assessed the ocular surface prob-
lems associated with chronic and treatment-refractory bleph- In the patients diagnosed with Demodex infestation, treatment 
aritis, the frequency of Demodex, and the effectiveness of tea was started with 4% TTO eyelid gel (Blefatitto Gel, Jeomed, 
tree oil (TTO) in Demodex treatment in white patients living in Turkey) and 10% TTO eyelash shampoo (Blefaritto Shampoo, 
an industrialized region of Turkey. Based on our findings, we Jeomed, Turkey), as these were the commercially available 
Figure 1. A view of Demodex folliculorum under light microscope.
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CLINICAL RESEARCH A clinical scoring system for diagnosis of ocular demodicosis
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Table 1. Uludag ocular demodicosis clinic scoring.
Yes No Total
Symptom
At least one of the symptoms
that mentioned below is positive
burning, sting, itching, pain   …….
Finding
Anterior blefaritis   …….
Posterior blefaritis   …….
Additional points
Lashes
Cylindrical dandruff (If yes add 2 points)   ...…..
Ocular surface
Chronic user of an eye drop that contains preservative (If yes add 1 point)   …….
Systemic or local any cause of dry eye diseases except blepharitis (If yes 
  …….
add 2 points)
Cornea
Epithelial defect (If yes add 1 point)   …….
Keratitis (If yes add 2 points)   ……..
Total Score ……………………………………………………...................…………..
products at the time of the study. Apart from that, if kerati- present. Apart from that, cases that may have compromised 
tis was present when the patient was first examined, kerati- ocular surface were also included in the scoring. If the long-
tis treatment was started. Artificial tear treatment was started term use of drops containing a preservative (e.g., glaucoma 
if there were other factors that could cause dry-eye disease. medications) was in question, it was given 1 point; if there was 
Patients were re-examined 1 month after the initial treatment. a systemic or local disease other than blepharitis that would 
Patients whose symptoms and signs did not resolve were re- cause dry eye, it was given 2 points. If there was an epitheli-
examined for Demodex spp. al defect, 1 point was given, and if the patient was admitted 
with keratitis, 2 points were given. The presence of cylindrical 
Assessment of patients and scoring dandruff (CD) was given 2 points (Figure 2). With this scoring 
system, the rate of Demodex-positivity was assessed (Table 1).
Symptoms and findings were scored from 1 and 10 according 
to the most common complaints and findings of the patients, Statistical analysis
in comparison with the most common complaints and find-
ings in international publications by Dr. Kivanc and Dr. Akova- For the statistical analysis, SPSS 23 statistical analysis software 
Budak. This scoring system is referred to as “Uludag Ocular was used. Descriptive statistical methods were used for age, 
Demodicosis Clinical Scoring (UODS)”. The chart based on this sex, symptoms, and findings. Relations between Demodex in-
scoring is illustrated in Table 1. If there was at least 1 complaint festation and symptoms, findings, and scores were assessed 
of stinging sensation and/or burning, itching, and pain, 1 point with the Pearson chi-square test. The Wilcoxon signed rank test 
was given; otherwise, a score of 0 points was given. Based on was used for evaluating the change in OSDI score and tear film 
to the emerging findings, 1 point each was given for anterior break-up time. The Mann-Whitney test was used to compare 
or posterior blepharitis, and 2 points were given if both were the mean UODS of Demodex-positive and -negative patients.
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A clinical scoring system for diagnosis of ocular demodicosis CLINICAL RESEARCH
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Figure 2.  A Demodex-positive patient with cylindrical dandruff before and 2 weeks after TTO treatment.
Figure 3.  A Demodex-positive patient with keratitis and blepharitis before and 1 week after TTO treatment.
Results was present in 4 patients (Figure 3) and epithelial defect was 
present in 3 patients (Figure 4). In cultures taken from the pa-
We reviewed the charts of 412 patients who were seen at the tients with keratitis, Enterobacter aerogenes grew in the cul-
Ophthalmology Department of Uludag University between ture of 1 patient and Staphylococcus epidermidis grew in the 
January 2016 and August 2017 and who were diagnosed with other. There was no culture growth in 2 patients.
blepharitis. Blepharitis was chronic and treatment-refractory in 
39 (9.5%) of the adult patients. The mean age of the patients Six patients were reported to have been receiving topical glau-
was 54.1±15.4 years. Seventeen (43.5%) patients were male coma medication; and 7 patients had systemic or ocular con-
and 22 (56.5%) were female. Twenty-two patients (56.4%) had dition other than blepharitis, causing dry-eye disease. Two 
stinging and/or burning as an initial complaint, 6 patients had patients had Sjögren’s syndrome, 1 had ectropion, 1 had un-
(15.4%) itching, and 5 patients had pain (12.8%). While eye- controlled diabetes, 1 had acne rosacea, 1 had keratoplasty, 
lid edema, loss of eyelash, irritation, and frequent chalazion and 1 had ocular surface lesion secondary to trauma.
were present in each patient, 2 patients had only complained 
of dandruff on their eyelids. Biomicroscopic examination re- In 30 of the 39 patients (76.9%) D. folliculorum was detected. 
vealed anterior blepharitis in 19 patients (48.7%), posterior In 1 patient, D. brevis was detected together with D. folliculo-
blepharitis in 7 patients (17.9%), and both anterior and pos- rum. No Demodex spp. was detected in 9 patients (Table 2).
terior blepharitis in 13 patients (33.3%). Fourteen (35.9%) pa-
tients had foamy secretions. In addition to blepharitis, keratitis 
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CLINICAL RESEARCH A clinical scoring system for diagnosis of ocular demodicosis
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Figure 4. A Demodex-positive patient with epithelial defect.
Table 2. Demographics, symptoms and findings of the patients.
Anterior Posterior Burning, staining, 
N Age Gender (F/M) blepharitis blepharitis itching, pain*** 
(Yes/No) (Yes/No) (%)
Demodex positive 30 54.1±14.6 16/14 24/6 15/15 83
Demodex negative 9 56.3±18.7 6/3 8/1 5/4 89
0.741* 0.704** 0.480** 0.535** 0.575**
* Mann-Whitney test; ** Fisher’s exact test (1-sided); ***One of those findings was positive. F – Female; M – Male.
Table 3. Ocular surface findings at initial and 1 month examination in demodex positive patients.
N Initial examination 1 month examination P value
OSDI score# 12  39.6±10.1  33.0±2.7 0.002*
TBUT## 10  8.3±4.0  10.1±3.3 0.042*
Keratitis 4 4 0 –
Epithelial defect 2 2 0 –
Blepharitis 30 30 5 –
# Ocular surface disease index; ## Tear film break up time; * Wilcoxon signed rank test.
The ocular surface disease index (OSDI) scores of the patients had seasonal allergy symptoms. At the end of the first month, 
at presentation and in the first month, as well as the tear film we found that D. folliculorum was positive in 5 of the patients 
break-up time (BUT) values, are illustrated in Table 3. Only 12 who continued to have blepharitis. Antibiotic and steroid 
patients had OSDI score for both visits and 10 patients had fixed-combination medicine was added to the TTO treatment. 
BUT values. The patients who were detected to have D. fol- At the end of the third month, 3 of 5 patients had blephari-
liculorum were started on eyelash cleaning twice a day with tis. Demodex positivity was detected again in the re-exami-
TTO shampoo and TTO eyelid gel twice a day. Additionally, ar- nation of these 3 patients. The distribution of symptoms and 
tificial tear treatment was initiated. Patients came in for re- indications in the patients who did not improve with treat-
examination after applying this treatment for 1 month; 28 of ment was similar to the symptoms and indications in the pa-
30 patients were re-examined 1 month later. Complaints dis- tients who improved with treatment. The mean age of the pa-
appeared in 25 patients (89.2%) and blepharitis findings dis- tients who did not recover with the treatment was 60.4±12.2 
appeared in 23 (82.1%) patients. The blepharitis symptoms years, while the mean age of the patients who benefited from 
disappeared in 3 patients whose complaints did not resolve. the treatment was 51.9±15.1 years. There was no statistical-
While 2 of these patients had Sjögren’s syndrome, 1 patient ly significant relationship between the positivity for Demodex 
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mites and indications and symptoms of the patients. However, the oral ivermectin alone, and oral ivermectin and metroni-
Demodex was found to be positive in all patients who had CD dazole treatment, and concluded that at the end of 4 weeks, 
on eye lashes and systemic and ocular predisposing factors combined treatment in blepharitis patients was more benefi-
that could cause dry eyes, except for blepharitis. cial than ivermectin treatment alone. However, patients prefer 
topical medication to oral medication. The most popular and 
The mean UODS of patients who were Demodex-negative was successful topical treatment is the application of tea tree oil 
2.7±1.0, while the mean UODS in those who were Demodex- eyelid gel after the cleaning of eyelashes. In a study conduct-
positive was 3.8±1.6 (p=0.047). Ninety-four percent (94%) of ed in Tasmania, it was reported that symptoms decreased in 
those with a score of 4 and over were found to be Demodex- 91% of patients with 5% TTO use. In the same study, it was 
positive (p=0.025). However, scores of only 54% of the revealed that the patients who recovered the least were those 
Demodex-positive patients were 4 or higher. Eighty-three who had underlying dry-eye disease [12]. Gao et al. [18] found 
percent of those with scores of 3 and above were Demodex- that weekly eye lid cleaning with 50% TTO and daily eye lid 
positive, but it was found that 72% of all Demodex-positive cleaning with 5% TTO were effective. However, it was also re-
patients had a score of 3 or more (p=0.140). The score of all of vealed that daily eye lid cleaning with 50% TTO and massage 
the patients who did not recover from blepharitis with 1-month with 5% gel were effective [19,20]. A Korean study compared 
treatment was 3 and above and 80% of the patients had a patients who did weekly 50% TTO, 10% daily TTO, and only sa-
score of 4 and above. In this group, 28.6% of the patients did line cleaning, reporting that while the average number of mites 
not recover with the TTO treatment. While none of the pa- in patients who cleaned with TTO decreased from 4.0 to 3.2, 
tients complained of the TTO use, 1 patient with nasolacrimal cleaning with saline did not lead to any decrease in number 
duct obstruction had acute dacryocystitis 1 month after TTO of mites [21]. In the present study, patients were told to wash 
was started, and was then treated with oral antibiotic therapy. with 10% TTO eye shampoo and to massage with 4% gel. With 
this particular treatment, complaints were reduced in 89% of 
patients and findings disappeared in 82%. Despite the fact 
Discussion that the findings of 3 patients disappeared, their complaints 
continued. Two of these patients had Sjögren’s syndrome, 
Demodicosis etiopathogenesis in patients with blepharitis has and the other had seasonal allergy symptoms. Similarly, other 
been the subject of intensive research in the years 2000 to studies [22,23] also pointed out that the changes in objective 
2010, showing it was present at high rates in chronic bleph- ocular symptoms did not always lead to recovery. However, 
aritis patients. The present study was carried out in a tertia- since this was a retrospective study and the patients did not 
ry hospital in the most industrialized region of Turkey. We report any complaints, the parasitologic examination, which 
found that Demodex ratio was approximately 77% in chron- is a relatively invasive procedure, was not repeated. However, 
ic and treatment-refractory patients. In Tasmania, which is we found that the OSDI scores of the patients who had TTO 
more of an agricultural and forestry region, Demodex positiv- treatment and their BUT values were improved with the de-
ity was found in 99% of patients with chronic ocular surface crease of patients’ subjective complaints. In a previous study, 
disease [12]. A study conducted in Seoul, one of the most de- it was revealed that the patients with high OSDI but low BUT 
veloped cities in Korea, found that the Demodex ratio in the score had high numbers of Demodex mites, but the effect of 
routine examination of eye disease in outpatient clinics was treatment on these scores was not evaluated [13]. It was re-
70% [13]. However, we believe that the comparison of these ported that the number of Demodex mites was correlated with 
studies will be scientifically problematic since the groups of pa- the OSDI score. In their study in Korea, Koo et al. found that 
tients included in the majority of studies were quite different. 85% of patients with ocular disease had Demodex [21]. They 
found that while the OSDI score of the patients who cleaned 
Treatment is another challenging issue. In the literature, dif- with TTO decreased from 35 to 24, there was a statistically 
ferent treatments were tried for Demodex. Fulk et al. [14] significant improvement in OSDI scores of those who washed 
showed, in a study conducted in 1996, that pilocarpine re- with saline. In their study utilizing in vivo confocal microscopy, 
duced the number of Demodex, but this treatment was not Randon et al. [24] reported that Demodex was found in 60% 
very popular. Hirsch-Hoffmann et al. [15] found that while the of the dry-eye patients who did not have anterior blepharitis.
average number of Demodex was 13 after 2 months of 5% TTO 
treatment, this number was 13 with ivermectin, 22 with oral Meibomitis secondary keratitis or keratoconjunctivitis develop-
metronidazole, 12 with 0.02% TTO, and 9 with metronidazole ment has been reported in many studies [25,26], but they do 
ointment. Holzchuh et al. [16] found that the 28-day oral iver- not mention if any search for the presence of Demodex were 
mectin treatment managed to reduce the number of mites carried out on patients. Demodex has been shown to cause 
with D. folliculorum treatment, reducing them from 5 mites to many different corneal findings [27]. Demodex-related corneal 
0.5 on average. Salem et al. [17] reported that they compared findings can be encountered and may lead to visual loss. In our 
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study, 18% of patients had keratitis or corneal epithelial de- of patients with a UODS of 4 or above. We recommend initia-
fect, and 86% of these patients were Demodex-positive. While tion of TTO treatment for the patients in this group. We found 
D. brevis was positive in the majority of patients with corneal that this rate was 85% in the patients with a score of 3 or 
manifestation [15], in our study D. folliculorum was detected in above. We have started to use this scoring successfully in our 
all patients except in 1 patient who had D. brevis and D. follicu- own current practice.
lorum together. Previous studies reported that Bacillus oleroni-
us proteins were found in the Demodex mite, and emphasized In our study, the most common complaints from patients with 
that these Bacillus proteins delay healing of wounds, which may Demodex were stinging, burning, and itching, in line with the 
hence cause inflammation, non-healing keratitis, and scar for- results reported by Gao et al. [20]. It was also proved that there 
mation in the demodulated patients [28,29]. In their study of was a relationship between stinging, burning, and itching, and 
corneal abnormalities in Demodex patients, Kheirkah et al. [27] Demodex [20]. However, since none of them is a single pathog-
found that while D. folliculorum was detected in all of the 6 nomonic finding and there is no chance for all physicians to 
patients who were found to have anterior blepharitis and CD, demonstrate Demodex positivity, we have introduced a new 
D. brevis was detected only in 3 patients. In the same study, 5 scoring system. In the years since the relationship between 
of 6 patients had meibomian gland disfunction and 4 patients blepharitis and Demodex was first described in 1960s [31,32], 
had rosacea. It was reported that there was marginal corne- approximately 60 original studies on Demodex blepharitis or 
al inflammation in 2 eyes and a phlyctenule-like lesion in 1 ocular demodicosis were found in PubMed in the English lit-
patient, superficial corneal opacity in 1 patient, and nodular erature. When we look at the number of studies, while it is 
corneal scar in 2 patients. In our study, we found that 20% of expected that there should have been more studies conduct-
the Demodex-positives had corneal findings and Demodex was ed on a common disease related to blepharitis, we think that 
positive in 86% of the patients with chronic and treatment-re- the relatively small number of studies may be attributed to 
fractory blepharitis and corneal findings. Among the 39, 7 pa- the difficulty in diagnosis. In order to make a diagnosis, an 
tients had corneal findings, of which 5 were diagnosed with experienced microbiologist in the field of parasitology or an 
D. folliculorum and 1 was diagnosed with D. folliculorum and expensive instrument such as an in vivo confocal microscope 
D. brevis. In 4 of these 6 patients, keratitis was diagnosed and are needed. Therefore, the number of studies on easily per-
the patients were treated with TTO. Three patients of the 4 re- formed diagnostic tests have been increasing in recent years. 
covered from keratitis, but persistent epithelial defect devel- We also set up a scoring algorithm in our study and used a 
oped in the other, and healed with in a month. In the other 2 scoring that would allow us to start treatment without delay 
patients, epithelial defects were present. based on symptoms and clinical findings, particularly where 
there was no experienced parasitologist or no confocal mi-
In many studies, the presence of CD in ocular demodicosis was croscope. It is also important to note that this scoring system 
regarded as pathognomonic. In the present study, we found should be verified by prospective studies before it is imple-
that Demodex sp. was positive in all the patients with CD. In mented in large populations of patients.
another study, CD was found to be positive in 31% of the pa-
tients who were Demodex-positive [19].
Conclusions
In vivo confocal microscopy has been used along with microbi-
ological methods. It is not possible to perform Demodex diag- Demodex infestation is a common disorder in adult patients 
nosis when there is no confocal microscope and when micro- with chronic and refractory blepharitis in an industrialized 
biological examinations are not available, or when the patient region of Turkey. TTO treatment was found to be effective. 
refuses to have eyelashes pulled out. However, different meth- Patients with Demodex infestation had many ocular surface 
ods were also proposed in the literature to diagnose Demodex and corneal findings. Therefore, this scoring system should be 
sp. from eyelashes [24,27,30]. Even though it is claimed that useful in making accurate diagnosis when advanced investi-
CD is diagnostic, it is not possible to detect in every patient. gation techniques are not available.
In this paper, we introduce a clinical scoring system based on 
the most common complaints and symptoms encountered in Conflict of interest
our work as well as in studies by other groups. With this scor-
ing method, which we developed for correct diagnosis ade- None.
quate treatment of patients, Demodex was detected in 94% 
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A clinical scoring system for diagnosis of ocular demodicosis CLINICAL RESEARCH
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