etcetera journal

Volume 2 Issue no. 1 | June 2016

The quarterly journal about everything CET

www.cetpoints.com

GOC standards of practice What do the new rules mean?

Page 5

When is CET interactive? Clearing up the confusion surrounding interactivity

0

Know your enemyInvestigating effective treatment of DemodexPage 12

2 etCETera | June 2016

Welcome to the second edition of etCETera. We hope you love our new journal design as much as we do – and in particular, our rather fascinating looking cover star.

Demodex is a hot topic, and this edition’s CET article doesn’t pull any punches. Independent optometrist and clinical contributor David Crystal offers some expert advice on how to tackle the mites head on. Find the article on p.9 and complete multiple choice questions at cetpoints.com to get your CET point.

Interested in what the new GOC standards of practice mean to you? Get the lowdown on all the changes, from our Clinical Editor Katie Stewart on p.5.

On p.8 our Managing Director Peter Charlesworth sheds some light on the matter of interactivity, a subject that’s had many scratching their heads when it comes to meeting their CET requirements.

We also take a look back at the success of the Eyecare Conference & Exhibition 2016 on p.6 & 7 – an event which shaped up to be one of our biggest and most positively received. It certainly bodes well for next year’s 20th anniversary conference…

Louise Boyd, Editor

We are pleased to have a number of experts from the world of optics on board to offer opinions and guidance on our CET and journal content.

Editor’s note Contents

Meet our advisory board

5 Standards of Practice: What do the new rules mean?

6 Jump on your bike and help Vision Aid Overseas

8 Looking back at Eyecare 2016

10 What makes CET interactive?

12 Know your enemy: Rich snippet on Demodex

18 Top five CET videos of 2016

Optometrist Kevin Wallace is an independent practitioner based in Edinburgh. He is Clinical Advisor to the AOP, Optometric Advisor to NHS Lothian and NHS Borders and has been an AOP councillor for 9 years.

Optometrist and PhD student at Cardiff University Stephanie Campbell is researching the development of the cornea in people who have Down’s syndrome. She has extensive experience in teaching at the university, and is also a faculty member for The Vision Care Institute of Johnson & Johnson.

Optometrist Claire Mallon has extensive experience in local paediatric initiatives and regional diabetic retinopathy screening services. She practices as a Clinical Optometrist in Edinburgh and is studying for her Independent Prescribing qualification.

Optometrist Francesca Marchetti graduated from Glasgow Caledonian University and is the West Midland councillor for both the College of Optometrists & the AOP. She has been the chair of National Eye Health Week and is a visiting lecturer at Aston University, with a particular interest in dry eye and refractive surgery.

Optometrist Fatima Nawaz facilitates peer discussions, leads peer reviews and mentors and supervises pre-reg optometrists. She has been appointed by the Council for the Association of Optometrists to represent early-career optometrists.

Optometry student Jaspreet Hothi is originally from Canada, and currently studies at Aston University. She has previously volunteered for two years at the Mazankowski Heart Institute at the University of Alberta Hospital and hopes to gain a Masters in Optometry in the future.

Optometrist Katie Stewart is an accredited peer discussion facilitator and a faculty member at The Vision Care Institute of Johnson & Johnson. She has recently qualified as an Independent Prescriber and specialises in refractive surgery.

Contact Lens Optician Suzanne Czerwinski was awarded the AOP Contact Lens Practitioner of the Year Award in 2014 and the Optician Magazine Contact Lens Practitioner of the Year award in 2016. She manages a large Specsavers and has a passion for multifocal contact lenses.

Dispensing Optician Richard Rawlinson has over 30 years’ experience in the optical sector and is a registered dispensing optician and qualified diabetic retinal grader. He is a Commsioning Lead for the Local Optical Committee Support Unit and represents the Association of Dispensing Opticains on the UK Domiciliary Eyecare Committee.

Optometrist Sarah Farrant runs an independent practice and works in a specialist practice within a GP surgery. She is chair of the Somerset Local Optical Committee, sits on the College of Optometrists Council and has a particular interest in dry eye and therapeutics.

Optometrist Sarah Smith completed her PhD at Aston University and has worked as Professional Relations Consultant with Bausch & Lomb. She runs an independent practice in Harrogate and is a member of North Yorkshire LOC.

Optometrist Karen Sparrow organises CET programmes for Vision Express and the AOP and has 25 years’ experience supporting other optometrists in their careers. She is currently studying for a Masters in Public Health for Eye Care at the London School of Hygiene and Tropical Medicine.

Contact - Eyecare, Thornhill House, 39 Thistle Street Lane South West, Edinburgh EH2 1EWT: (+44)131 526 3800 E: [email protected] EyecareLearning @eyecarelearning

June 2016 | etCETera 5

By Katie Stewart BSc (Hons) MCOptom

On 1st April this year, the GOC changed the Code of Conduct for Individual Registrants to the new Standards of Practice for optometrists and dispensing opticians.

What does this mean?The Standards of Practice set out what the regulator (the GOC) expects from the members of its profession. As GOC registrants, we are all obliged to gain CET points in order to remain on the register and be able to practice. The new ‘Standards of Practice’ competency has replaced the old ‘Code of Conduct’, so we need to complete CET covering the new standards too.

Who will it affect?The Standards of Practice apply equally to all optometrists and dispensing opticians. There is a slightly different set of standards for student optometrists and student dispensing opticians, and one for businesses registered with the GOC. The standards mostly relate to things we do at work – such as keeping case records, working with colleagues and safeguarding patients. But some go wider

and affect what we do in our personal lives; being honest and trustworthy and not damaging the reputation of your profession through your conduct are good examples.

What’s really changed?There are still 19 standards, the same number as in the old Code of Conduct. Most standards are similar to those in the previous Code but some, such as “a duty to be candid when things have gone wrong”, are new. The GOC has also added more detail to each standard to ensure that the responsibilities expected of you as a registrant are clearer. The GOC says these are based on fitness to practice case law and reflect the evolving healthcare environment. Other regulators (the GMC, GDC and HCPC) have produced similar standards.

What should we do?The Standards are not a rule book – they are guidance, giving room for you to use your professional judgement in deciding how to apply the Standards in any given situation. The GOC has recommended that you read the standards and ensure you are confident in being able to apply them in your work. The first time you log into your GOC CET account you will be asked to confirm you have read the standards document.

The AOP has produced a helpful guide with their advice on interpreting the Standards to further protect you as a GOC registrant. For example, regarding the Standard “to be candid when things have gone wrong”, they advise their members to contact the AOP before accepting responsibility or offering an apology for any clinical matter (although this does not extend to offering an apology for say an order that has been delayed or ordered incorrectly).

You can read the full Standards of Practice on the GOC website www.optical.org

The AOP’s guidance is available in the members’ section of its websitewww.aop.org.uk

About the authorKatie has over ten years’ experience in optometry and now works in the refractive surgery sector. She is an accredited peer discussion facilitator and a faculty member at The Vision Care Institute of Johnson & Johnson. In recent years, she has collaborated on CET approved distance learning for a number of providers and has recently qualified as an Independent Prescriber.

What do the new rules mean?Standards of Practice:

6 etCETera | June 2016 June 2016 | etCETera 7

We’ve teamed up with eye care charity Vision Aid Overseas to organise the 3rd annual Cycling for Sight charity bike ride – this year, around the glorious Lake District. And we’re looking for cyclists – teams or individuals – to join us.

The charity cycle takes place on Sunday 28th August and promises to be a fun event for all involved. The money raised from this event will help Vision Aid Overseas and the Optometry Giving Sight initiative to continue to transform lives in Africa by making eye care services and spectacles accessible and affordable to people suffering from visual impairment. We’re pleased to welcome Rodenstock, Zeiss, Topcon and Essilor as sponsors of this year’s event.

You can choose from three routes – two on the road, and one mountain biking challenge. Both road routes start from the charming market town of Keswick. The longer route covers 87 miles (140km), with the shorter option covering a distance of 45 miles (72km), each taking in stunning stretches of the famous Lake District countryside.

The mountain biking route offers a different kind of challenge and covers ancient woodland, steep mountain crags and lakeside bays along its 17 miles (28km). There’s plenty of single track and a technical descent to keep the adrenaline pumping.

Last year’s event in Yorkshire raised an incredible £6,948, which is now being used to support and train optometry professionals in Ethiopia, Ghana and Zambia, so that more people can access eye care and spectacles.

We’re hoping this year’s event will be even better, so if you love a good bike ride – please do sign up! Registration costs £40 and covers a cycling top, goody bag, guides for the mountain biking route, vehicle support and a well-deserved evening meal. Optical professionals taking part can also earn a CET point, by taking part in the poster quiz at the end of the ride.

To find out more, visit http://cycling-for-sight.eventbrite.co.uk

Jump on your bike... ...and help Vision Aid Overseas


This year’s Eyecare conference and exhibition was a roaring success thanks to high attendance levels and a positively received agenda. Held at the Hilton Hotel in Glasgow on 17th and 18th January, the event saw strong attendance from more than 300 visitors and nearly 200 exhibitors on 62 different stands.

The Eyecare conference and exhibition boasted a packed schedule of clinical lectures and workshops, as well as the largest gathering of suppliers to the optical industry outside London and Birmingham. With 27 interactive CET points available, across 58 lectures and workshops, it was certainly a busy couple of days for delegates who came from across the UK.

Based on feedback we tried out a new format this year - with more workshops and an extended 2-hour lunch, which proved a huge success. The feedback from delegates on Eyecare 2016 was overwhelmingly positive with 98% of delegates rating the event overall as excellent or good.

Forward thinking lectures from industry-leading expertsOur lectures covered a broad range of topics, including:• understanding the needs of

dementia patients • current thinking on myopia control• refracting the un-refractable• acanthamoeba keratitis• genomic medicine • an optometrist’s guide to

ocular toxicology• amblyopia

And our skills workshops, discussion workshops and seminars covered an equally diverse range of subjects, including glaucoma assessment and managing blepharitis.

You can now watch some of the filmed Eyecare 2016 lectures at cetpoints.com and answer the multiple choice questions to get CET points.

Networking and exhibitorsThe exhibition space proved a great place for comparing products and making new contacts for delegates. The latest tools and equipment were on show, and it was an excellent opportunity for attendees to find out about new products coming to market. Amongst other exhibitors, we were joined by Johnson & Johnson, Xeyex, Topcon, Birmingham Optical and Scope Opthalmics.

In the evening, delegates had the chance to let their hair down and mingle in the Riverside Suite of the Hilton, whilst enjoying music and an optical themed quiz.

Looking back at EYECARE 2016

“ An excellent chance to come and get CET points and network with others we don’t see throughout the year” Delegate, 2016

Great results at Eyecare 2016

Visitors

Indicating they will attend again in 2017

313

98%

99%

194

58

Visitors

Visitor Exhibitor Exhibitorex 2

Lectures and workshops

Rating Rating

Visitors



Rating RatingVisitors












Rating Rating

Exhibitors on 62 stands

Visitors



Rating Rating


Visitors rating the their experience as excellent or good

Visitors



Rating Rating

CONFERENCE AND EXHIBITION

Kill 27 birds with one stone.Get up to 27 interactive CET points in two days, from 60 industry-leading workshops, lectures and seminars.

Sunday 22nd & Monday 23rd January 2017

For more information visit: www.eyecareglasgow.com

Telephone: 0131 526 3800 or email: [email protected]

Save the date - Eyecare 2017Next year marks a special occasion for the Eyecare conference and exhibition – our 20th anniversary. We’re planning on celebrating in style, with even more lectures, workshops, experts and exhibitors throughout Sunday 22nd & Monday 23rd January.

We’re expecting even higher numbers of visitors and exhibitors, as Eyecare continues to be one of the must-attend events in the UK optical market. The exhibition itself is free to attend, and offers the perfect opportunity to connect with new suppliers and browse the latest products to hit the market. You can also access the keynote lecture for free.

Follow us on Facebook and Twitter to keep up to date with the latest speakers and exhibitors as they’re added to the agenda. To book your ticket to Eyecare 2017 visit www.eyecareglasgow.comSee you there!


We’re all familiar with the requirement to gain interactive CET points. In fact, the interactive requirement is half our total requirement for the CET cycle. But what actually counts as interactive CET? The GOC recently issued new advice to providers to help explain it. It’s all about interacting with your peers.

Usually interactiveThings you physically attend are usually interactive. This includes lectures, workshops, lab tours and peer review sessions. They are interactive by virtue of the fact you attend and interact with your peers. The provider has to record a summary of the Q&A or discussion, but there’s nothing extra for you to do to earn interactive points.

The only exception is visual recognition tests, often called poster trails. These involve answering questions on case histories with pictures. They are only interactive if the provider requires you to discuss each case with a colleague and record a summary of that discussion on your answer sheet. Otherwise you’ll earn non-interactive (also called general) points.

Sometimes interactiveDistance learning is not usually interactive. So articles you read in journals, videos you watch online and modules you complete in an app normally earn non-interactive CET points. But there are exceptions. If the distance learning requires you to interact with your peers then interactive

points can be awarded. Live webinars with a Q&A, online modules followed by a live discussion, distance learning that forms part of a supervised course of study leading to a qualification and distance learning which requires you to interact with a colleague can all carry interactive points.

How can I tell? Look out for the interactive symbol when you complete CET. CET providers are required by the GOC to use this symbol to tell you the CET you’re completing is worth interactive points, in the same way they use the target audience logos to show who CET is approved for.

What about CET on cetpoints.com?The GOC’s recent guidance means that distance learning on the Eyecare website is not currently interactive. But we’re working to reintroduce interactive distance learning this summer.

You can read the CET guide for registrants and the principles and requirements of the enhanced CET scheme on the GOC website (www.optical.org).

interactive?What makes CET


Know your enemy:

Unless recently qualified, it is unlikely that information regarding Demodex was included in your optometric training. And, until recently, the subject has even remained absent from post-graduate diploma courses in Ocular Therapeutics.

I t has been estimated that Demodex mites are the most common, but often overlooked, cause of ocular

surface inflammation from blepharitis and meibomian gland dysfunction, which account for 37% and 47% respectively1 of the patients seen in clinical practices by ophthalmologists and optometrists. A higher incidence is witnessed in elderly patients: Demodex are present in 84% of the population at age 60, rising to 100% of those older than 70 years2.

It is perhaps surprising the first case of Demodex mites was reported in 1842, yet it is only in the last three years that an evidenced-based method for eradicating them has begun to form3. Blepharitis is still widely understood to be a chronic, incurable staphylococcal based condition, the symptoms of which can only be managed. Consequently, an entire product industry has arisen and practitioners have had to choose from a multitude of lid hygiene and dry eye products that are not miticidal.

Recent press and media attention has increased public awareness by suggesting that Demodex are simply endemic4. For the majority of people the presence of Demodex will be

low-grade and asymptomatic5, but herein lies the professional conundrum – there is compelling evidence that links the presence of Demodex to the chronic lid margin disease blepharitis6, meibomian gland dysfunction and ocular surface inflammation from blepharo-keratitis7, which can be sight threatening8. Collectively this group of conditions, when associated with Demodex, is known as ‘Ocular Demodecosis’.

Ocular Demodecosis causes itching, soreness, redness and crusting of the lid margins, and blurred vision. It is the major cause of evaporative dry eye which is the most common condition presenting to optometrists. There is also an association with facial rosacea9 and pterygia10.

Transmission occurs by direct contact with an individual who has a Demodex infestation, or from pillows and towels. Since Demodex multiply with time the risk to vision also increases with age, especially for individuals with a depressed immune system such as steroid users.

Demodex

by David Crystal

Understanding DemodexDemodex mites are microscopic

parasites that live inside eyelids. One of the two human species, Demodex folliculorum, buries itself face down, next to the shaft of the eyelash and feasts on the cells and sebum that line the follicle. The other species, Demodex Brevis, burrows deeper towards the base of the eyelash to depths of up to 2.3mm, where the follicle’s sebaceous gland is located. Brevis also burrows deep into the meibomian gland orifices (Fig. 1).

The mites have eight claws at the front, which they use for locomotion. Every night male Demodex folliculorum leave the hair follicles to mate by reversing out along the eyelash shaft, which is not smooth but has a layered, slated, texture. In doing so the mite’s claws push out a mixture of keratinized skin cells and sebum11, in the same way a mole pushes up earth when surfacing. This quickly accumulates around the base of the lashes as cylindrical dandruff (CD). CD is the new term for lash collarets and its observation is pathognomic for Demodex (Fig. 2).

Moving slowly at 6-8mm/ hour, the folliculorum mites leave a trail of Staphylococci bacteria in their effort to find a female and copulate. Eggs are laid just inside the eyelash follicle. Nymphs hatch 3-4 days later and they take about a week to develop into adults. The total lifespan of a Demodex is no more than 18 days. At the end of their life, a Demodex’s entire internal contents are expulsed in a single event as waste products. Outside of the body, a Demodex can survive up to 56 hours in a drop of oil.

Figure 1 - Original artwork commissioned by David Crystal

Figure 2 – Cylindrical dandruff is attached to base of lashes – loose “flakes” are not CD

The activity and life cycle of Demodex Brevis within the meibomian glands is believed to cause obstruction resulting in meibomian gland disease (MGD), with associated lipid tear deficiency. Clinical and histopathologic studies have revealed that terminal duct occlusion due to hyperkeratinization of the ductal epithelium within the glands is the most significant factor in the pathogenesis of MGD12. Micro-abrasions caused by the mite’s claws can induce epithelial hyperplasia and reactive hyperkeratinization13, so Demodex Brevis is a prime candidate for causing MGD.

It is thought that bacteria from Demodex can either convert neutral meibomian gland oils into irritating fatty acids or cause release of exotoxins into the tear film. Either way, if the tear lipid layer is not perfectly formed, further disruption may lead to evaporative dry eye symptoms.

Treatment is based on waiting for eggs to hatch, killing the mites, and preventing them from reproducing. Demodex folliculorum are the easiest to destroy as they reside in the hair follicles and regularly surface to mate. In contrast, Demodex brevis live deeper and, being solitary in nature, do not surface as often; they are much more difficult to reach, and hence are much harder to eliminate.

In trying to deliver miticidal agents to the deepest Brevis at a 2.3mm depth from the lid margin, follicular penetration researchers have found, using Optical Coherence Tomography, the presence of CD acts as a physical plug barrier to follicular penetration. The follicle needs to be “opened” by removal of the dried sebum by mild peeling or dissolving to render the lash follicle receptive for penetration.

The phrase “like dissolves like” predicts that a solute will dissolve best in a solvent that has a similar chemical structure to it. The follicular canal is a lipoidal environment and sebum is primarily composed of triglycerides (~41%), wax esters (~26%), squalene (~12%), and free fatty acids (~16%). Jojoba oil (which is actually a liquid wax) is assessed to most closely resemble human sebum.

In tests, the deepest follicular penetration occurred by applying formulations containing nano-particles of around 600nm in size, which, in conjunction with digital massage, recorded a maximum penetration depth of only 1.2mm. Formulations with both smaller or larger particle sizes penetrated less, proving that size matters. As such, the deepest Brevis are out of reach.

Continued overleaf »Figure 3 - With kind permission from Biotissue

Rich snippet on


Cliradex Complete (Fig. 5) – For professional use only – contains the strongest concentration of T4O formulated as a white coloured paste for in-office application as a replacement for 50% TTO mixtures.

Cliradex Wipes - These are pre-formulated towelettes containing 4% T40, equivalent to about 25% TTO, for use by patients to support in-office treatments. Despite marketing efforts to portray this as a gentle, natural product, make no mistake the wipes are highly astringent, but have been the product of choice in our practice for one year.

Cliradex Light – A foam preparation containing 2% T4O for treated patients who commonly request a maintenance product. This is the newest product, and a welcome addition to the range.

Figure 4In the above picture (Fig. 4) the tea tree oil quality is high having > 38% Terpinen 4-ol but the TTO content is actually around 2%. These are excellent cleaning wipes but they are unlikely to have sufficient miticidal effect to kill significant numbers of Demodex.

T40: the facts

Occlusive creams or ointments containing 5% TTO have been successful in treating Demodex however when this was tried15, allergic reactions were observed16. TTO suffers from aerial oxidation causing a dramatic rise in irritating substances such as p-cymene and epoxides (which also greatly reduces the active terpinen-4-ol). Furthermore, ointments, creams and gels commonly contain one or more of the known mucosal eye irritants: Benzyl Alcohol, Phenoxyethanol, Benzoic acid, Isopropyl myristate and Ethylhexyl Stearate. This is the problem with all of the 5% TTO products: Helios Tea Tree Cream, E-Derma cream, Thursday Plantation Tea Tree Cream, Australian Tea Tree Cream.

When evaluating new products check for these irritating ingredients. For example Ivermectin 1% cream (Soolantra, Galderma Labs) has recently been approved for the treatment of Demodex but contains Phenoxyethanol and 10% of patients experience a burning feeling.

Best practice with evidence-based products

In July 2016, the Cliradex range of products (Biotissue, Florida USA) will be available to UK optometrists. Cliradex products are the only commercially available products that isolate T4O and are a direct result of Tighe’s evidence-based research. There are three preservative-free products.

In-office procedure

1. Without anesthesia, dry debride large CDs using a “Golf Spud” tool

Clinical tip - if the CDs become wettheybecomedifficulttosee

2. Apply topical anesthetic to upper and lower lid margins

3. Insert daily disposable contact lens as protective bandage.

4. Use BlephEx procedure to “open” the follicles by spinning the sponge tip along the edge of the eyelids and lashes to remove scurf and debris. This action has a similar effect to eyelash rotation. (A lid scrub solution is fine for this purpose).

5. Using a fine “paint” brush target lash bases with 50% TTO / 50% Jojoba Oil* mixture. (see video)

Clinical tip - *in preference to Macadamia nut oil.

6. Leave for 15 minutes and remove with dry cotton buds.

7. Demonstrate application of Cliradex wipes (first visit only).

8. Remove contact lens, discharge patient and review one week.

Home procedure

1. Replace pillowcases / towels on night of every in-office treatment session.

2. Abandon eyeliners, mascara, eye shadow and skin moisturisers during the treatment period.

3. Use Cliradex wipes nightly before sleep, do not wash off.

4. TTO shampoo eyelids in a morning shower to remove previous night’s CD.

> T4O has a greater miticidal effect than TTO alone with less irritation.

> 10% T4O kills mites on a microscope slide in 15 minutes compared to 145 minutes for 10% TTO.

> Concentrations of T4O as low as 1% have been observed to be effective at killing the Demodex mites.

> Although 100% pure TTO should contain around 38% T4O, batches and products vary and the T4O content can be as low as 30% (this is the minimum Australian Industry Standard). This means that a product that contains a lower-quality 5% TTO component has just enough T4O to be miticidal (30% of 5% = 1.5% T4O).


Diagnosis and treatment protocol

In our Edinburgh optometry practice we find around 15% of all patients show the signs of cylindrical dandruff (CD), which can only be observed by slit-lamp biomicroscopy. Recording the number of upper lid lashes affected per eye (in most cases this is not symmetrical):

Up to 5 lashes with CD

borderline-mild NB: patient not advised unless young and symptomatic

Up to 5 - 10 CDmild – moderate (easier to treat)

More than 10 CD

moderate – severe (harder to eradicate)

How to guideProfessional conundrum - Would you inform and prophylactically treat an asymptomatic young person aged 20 presenting with 10 lashes with CD?

Given the increasing risk of demodicosis with age, we would recommend that you inform the patient, warn them of the possible symptoms and risks and proceed with treatment if consensual. As a profession, we should be routinely educating our young patients in the importance of prophylactic lid hygiene.

In order to demonstrate with certainty the diagnosis of ocular demodecosis, we epilate up to two eyelashes from each lid, place them on a microscope slide with a drop of sodium fluorescein17 and examine them at 540x magnification, using a digital video microscope.

Clinical tip – pull the lash round in a full circle four times before epilation otherwise no demodex may be seen. Because the shaft of the lash has a slate-like texture, moving the hair acts like a geared pump that forces Demodex upwards and out.

Presenting the evidence of active Demodex to the patient confirms the nature of their problem.

Evidence based treatmentsResearch has shown that 50% Tea Tree Oil (TTO), 100% Caraway Oil and 100% Dill Weed Oil exerted effective in vitro killing of mites within 15 minutes. Unfortunately these latter two agents are not amenable for clinical use because of their intrinsic toxicity and irritation to the eye. Whilst 50% TTO is also capable of delivering a chemical burn to the cornea, its careful application to the lid margins represents the current paradigm in treatment for Demodex.

Tighe et al. 201314 found that the most active ingredient in TTO to kill Demodex mites is Terpinen 4-ol (T4O) (Figure 3)

Continued »

Continued overleaf »

Visit cetpoints.com to watch videos of Demodex folliculorum feeding from cuticle sebum, and Demodex brevis with two Demodex folliculorum on each side.

Treatment is based on delivering miticidal agents over two life cycles. This is done by a combination of in-practice “clean and kill” sessions lasting 45 minutes and a supportive home treatment aimed at disrupting their reproductive cycle. Currently there is no effective way for a patient to self-treat their Demodex. Up to 6 weekly return visits are needed and eradication of Demodex is achieved for 7 out of 9 patients.

In every patient treated, a resurgence of CD production is seen at the one-week follow up (which suggests step four of the home procedure is ineffective).

Figure 5 - Cliradex Complete


Despite the patient exiting the first treatment session with perfectly clean-to-the-base lashes, the CD’s return to the extent that they appear similar to the pre-treatment visit. As the treatment weeks advance, there is progressively less returning CD to deal with. Because TTO or T4O usage promotes outward migration of Demodex, the quick reformation of CD after opening the follicles is expected, as Demodex are being purged. With a decreasing active population of Demodex, the amount of CD being formed also reduces and this is conformational the treatment is working. We have noticed a proportional relationship between the amount of resurgent CD and the initial pre-treatment CD count.

Innovative treatmentTea tree oil contains chemically sensitive substances. Several oil constituents oxidize on contact with air at room temperature, especially when there’s light, too. In this way, air greatly reduces the terpinen-4-ol content. What’s worse is that the gradual loss of active constituents is accompanied by a dramatic rise in the concentration of substances, such as p cymol, ascaridol and 1,2,4-trihydroxymenthane, which irritate the skin and can cause allergic reactions.

One way out of this predicament is the molecular inclusion of T4O in a suitable cyclodextrin – a method that has proved effective for fragrances, vitamins, and other lipophilic substances. Cyclodextrins are ring-shaped sugar molecules comprising several interlinked glucose units. Each cyclodextrin molecule can house a lipophilic guest molecule in its cavity, and will release it again under suitable conditions. It is best to imagine a cyclodextrin molecule as a tiny safe in which an individual molecule is kept and protected against the influence of oxygen, light and heat. When necessary, the safe is opened

and the molecule emerges completely unchanged – as fresh as when it was put inside. The key to opening these molecular safes is moisture.

For as long as the T4O remains enclosed in the cyclodextrin, it enjoys perfect protection – it can neither evaporate nor be altered chemically. The skin’s natural moisture and temperature are sufficient to release the T4O. The T4O thus reaches the skin in juvenile form. There are no skin irritating and sensitising oxidation and degradation products.

Accelerated treatmentTo improve patient outcomes for severe cases, we have tried a slow release version of T40 entrapped in Cyclodextrin on four patients, to deliver 10% T4O active over 12 hours. The product particles are around 5000nm in size, which is far too large for deep follicular penetration and resemble talcum powder. Applied onto the eyelids and lashes before sleep it is absent upon wakening. Patients report no irritation whatsoever. We have observed a greater production of resurgent CD, which may imply a quicker evacuation of Demodex.

Another agent, related to limonene and a by-product of the orange juice industry is also miticidal but has not yet been commercialised. There is scope for further product development.

Currently, Demodex treatment is an arduous process for both practitioner and patient. The time burden, commitment required and commercial revenue lost in the disruption of the provision of spectacles and contact lenses makes this work unattractive for most practices. However the professional reward in curing a condition where others have failed is priceless and the patients are extremely grateful.

About the authorDavid Crystal transferred from an undergraduate degree course in Physics with Computing at Bradford University to study Optometry at Caledonian University Glasgow in 1980. He established Scotland’s first specialised dry and watery eye clinic, with routine punctal occlusion and tear duct syringing procedures. David gained his Post Graduate Diploma in Ocular Therapeutics in 2002, becoming the first of his kind in Scotland. He now occasionally facilitates workshops for Glasgow Caledonian University Ocular Therapeutics course. David is currently pursuing treatments that eradicate Demodex; the most common indirect cause of evaporative dry eye. Outside of optometry, his interests are snowboarding and website SEO. He also created EyeDispense, Just Reading Test Types and Maddox Rod iPad apps.

David Crystal can be contacted at www.crystaloptometry.co.uk

References1 English FP, Nutting WB (1981),

‘Demodicosis of ophthalmic concern’ Am J Ophthalmol, 91:362–372.

2 Lee SH, Chun YS, Kim JH, et al. (2010), ‘The relationship between demodex and ocular discomfort’, Invest Ophthalmol Vis Sci. 51:2906–2911

3 Spickett SG (1961), ‘Studies on Demodex folliculorum’, Parasitology, May, 51:181-192.

4 www.bbc.co.uk/earth/story/20150508-these-mites-live-on-your-face

5 Turk M, Ozturk I, Sener AG, et al. (2007), ‘Comparison of incidence of Demodex folliculorum on the eyelash follicule in normal people and blepharitis patients’, Turkiye Parazitol Derg. 31:296–297.

6 Liu J, Sheha H, Tseng SC (2010), ‘Pathogenic role of Demodex mites in blepharitis’, Curr Opin Allergy Clin Immunol, 10:505-10

7 Kheirkhah A, Casas V, Li W, et al. ‘Corneal manifestations of ocular Demodex infestation’.

8 English FP, Nutting WB (1981), ‘Demodicosis of ophthalmic concern’, Am J Ophthalmol, 91:362–372.

9 Bonnar E, Eustace P, Powell FC (1993), ‘The Demodex mite population in rosacea’, J Am Acad Dermatol. 28:443–448.

10 Huang Y, He H, Sheha H, Tseng SCG (2013), ‘Ocular demodicosis as a risk factor of pterygium recurrence’. Ophthalmology, 120:1341–1347.

11 Gao Y-Y, Di Pascuale MA, Li W, et al. (2005), ‘High prevalence of ocular Demodex in lashes with cylindrical dandruffs’. Invest Ophthalmol Vis Sci. 46:3089–3094. [PubMed]

12 Nichols KK, Foulks GN, Bron AJ, et al. (2011), ‘The international workshop on meibomian gland dysfunction: executive summary’ Invest Ophthalmol Vis Sci. 52(4):1922-9.

13 Gao Y-Y, Di Pascuale MA, Li W, et al. (2005), ‘High prevalence of ocular Demodex in lashes with cylindrical dandruffs’. Invest Ophthalmol Vis Sci. 46:3089–3094. [PubMed]

14 Tighe et al. (2013), ‘Terpinen-4-ol is the Most Active Ingredient of Tea Tree Oil to Kill Demodex Mites’ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860352/

15 Gao YY, Xu DL, Huang lJ, Wang R, Tseng SC. (2012), ‘Treatment of ocular itching associated with ocular demodicosis by 5% tea tree oil ointment’, Cornea. Jan. 31(1):14-7. [Medline].

16 Simpson et al. (2004) ‘Prevalence of botanical extract allergy in patients with contact dermatitis’, Dermatitis 15:67-72.

17 Kheirkhah A, Blanco G, Casas V, Tseng SC (2007), ‘Fluorescein dye improves microscopic evaluation and counting of demodex in blepharitis with cylindrical dandruff’, Cornea. Jul. 26(6):697-700. [Medline].

Further sources:

English FP, Cohn D, Groeneveld ER. (1985), ‘Demodectic mites and chalazion. Am J Ophthalmol’, 100:482–483. [PubMed]Kheirkhah A, Casas V, Li W, et al. (2007), ‘Corneal manifestations of ocular Demodex infestation’, Am J Ophthalmol. 143:743–749.Kim J, Chun Y, Kim J. (2011), ‘Clinical and immunological responses in ocular demodecosis’, J Korean Med. 26:1231–1237.Knop E, Knop N, Millar T, et al. (2011), ‘The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysi- ology of the meibomian gland’, Invest Ophthalmol Vis Sci. 52(4):1938-78. Koksal M, Kargi S, Taysi BN, Ugurbas SH. (2003), ‘A rare agent of chalazion: demodectic mites’, Can J Ophthalmol. 38:605–606. [PubMed]Liang L, Safran S, Gao Y, et al. (2010), ‘Ocular demodicosis as a potential cause of pediatric blepharoconjunctivitis’, Cornea. 29:1386–1391.Obata H. (2002), ‘Anatomy and histopathology of human meibomian gland’, Cornea. 21(7 Suppl):S70-4 24. Wertz PW (2009), ‘Human synthetic sebum formulation and stability under conditions of use and storage’, Int J Cosmet Sci. Feb, 31(1):21-25


CET videos of 2016

It’s BV Jim, but not as we know it – tips and tricks to improve your everyday binocular vision

Many consider binocular vision to be a subject that’s difficult to understand. However this video lecture simplifies core binocular vision tests and helps you pick up some useful top tips, such as the best ways to test young children.

Introducing our five most popular CET videos of 2016 so far, all available at cetpoints.com…

Education, education, education: when to refer

As an eye care practitioner, it’s likely you frequently encounter problems that need to be referred to a colleague or an ophthalmologist. This video looks at some of the most common issues that require referral and how and when action should be taken.

Let’s face it: impairments of face perception for eye care professionals

Faces are among the most important objects that our visual system recognises. This video looks at how the brain recognises faces, and the problems that can arise with impaired face perception due to ocular disease. There is also a section on prosopagnosia – otherwise known as face-blindness.

Referral urgency of common eye conditions

Sometimes timing is crucial. Making a timely and appropriate referral to the hospital eye service can improve patient care and enhance your relationship with your peers. This lecture looks at common eye conditions such as eyelid lumps and bumps, cataract, glaucoma, red eye, vascular conditions and pigmented retinal lesions and discusses how urgently they should be referred.

Driving vision and road safety

This video offers some useful advice when it comes to advising patients whether they meet the DVLA requirements to drive. It also contains some helpful information on the best way to communicate with related professionals, such as driving instructors, GPs and road safety officers.

5TOP

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Watch these videos and more at cetpoints.com

Fast facts about 2013-15 CET cycle

More than 1 million CET points were awarded to more than 21,000 registrantsMore than 16,000 CET applications were made by more than 400 providersThe average number of CET points accepted by Optometrists and DOs was 38CET in the last cycle scored an average feedback rating of 89%

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