BlephEx for Demodex & Blepharitis

BlephEx is a ten-minute in-clinic procedure that deep-cleans the eyelid margins and the base of the lashes. It is available at Rose Optometry in Frankton, Hamilton, and we use it as the opening step of a structured six-week programme for blepharitis and Demodex, not as a treatment on its own.

Book a Dry Eye Evaluation online: open our online booking, then scroll down the appointment list to "Dry Eye Evaluation" and choose a time. This is a paid, in-depth assessment (TearCheck, meibography and ScoutPro osmolarity) and the fee is confirmed when you book. Prefer to talk? Call (07) 847 3195.

What is blepharitis, and what are Demodex?

Blepharitis is chronic inflammation of the eyelid margins. Bacteria and skin debris build up along the lash line and form a sticky biofilm, which irritates the lids, blocks the meibomian gland openings and feeds the cycle of dry eye. Common signs are red, itchy or burning lid edges, crusting on waking, recurring styes and lashes that fall out or grow in odd directions.

Demodex are microscopic mites that live in hair follicles. Everybody carries some, and their numbers rise with age. When they overpopulate the lash follicles they cause an itchy, inflamed lid margin and, characteristically, cylindrical waxy sleeves at the base of the lashes called collarettes. Collarettes are considered pathognomonic: if we see them at the slit lamp, Demodex is the diagnosis. In one large US clinic survey more than half of all patients had collarettes, and most of them had never been diagnosed. Itching, crusting and lid redness are the other common signs.

What BlephEx does

BlephEx is a hand-held device with a fine, single-use medical-grade micro-sponge that spins along the edge of the eyelids and around the base of each lash. It removes the biofilm, scurf, bacterial debris and collarettes that lid wipes and warm flannels cannot shift. This is called microblepharoexfoliation. Anaesthetic drops are used, both lids of both eyes are cleaned, and the whole thing takes around ten minutes. It feels like a light tickling or brushing along the lashes. You can drive afterwards.

Why a six-week programme

The Demodex life cycle is roughly two to three weeks from egg to adult. Any treatment that only kills adult mites leaves the next generation to hatch, so a programme needs to run for at least six weeks, covering two to three cycles. BlephEx clears the environment and gives the mites nowhere to hide; the daily lid regime then keeps them down. Our standard programme is:

• Week 0: BlephEx in clinic to remove biofilm and collarettes.
• Weeks 0 to 6: Twice-daily lid cleansing with a tea-tree derived product containing terpinen-4-ol, the component of tea tree oil that is most active against Demodex in laboratory studies (a 2020 Cochrane review found the clinical trial evidence for tea tree oil still limited), from our online store. Warm compresses and gland massage where MGD is present.
• Review: Slit-lamp check for collarettes and lid inflammation, and repeat BlephEx if needed.

Our article on lid and lash hygiene explains the home routine.

The evidence, honestly

We want to be straight about this. A 2024 double-masked, sham-controlled randomised trial in 42 patients with treatment-resistant blepharitis found no significant difference between BlephEx and a sham procedure in symptoms or signs at four weeks, and its authors concluded it could not be recommended as a standalone treatment. That is a useful finding, and it matches our own view: a single mechanical clean of the lids does not cure a chronic condition. What it does is remove the biofilm and mite debris that stop home treatments working properly, and it gives us a clean baseline to see whether the programme is doing its job. So we position BlephEx as the opening move of a six-week Demodex and blepharitis programme with terpinen-4-ol lid hygiene, and where appropriate a heat treatment such as Blephasteam, LipiFlow or IPL for the glands. The whole programme, not the device, is what changes symptoms.

Prescription options: Soolantra (ivermectin) and in-office treatment

For established Demodex blepharitis, lid hygiene alone is sometimes not enough, and there are two further steps we use.

Soolantra (ivermectin 1% cream)

Ivermectin is an anti-parasitic that kills Demodex mites. Soolantra is a 1% ivermectin cream approved in New Zealand for the skin condition rosacea, and it is used off-label for Demodex blepharitis: a very small amount is applied to the base of the lashes and lid margin at night, typically for six to twelve weeks so that it covers the mite life cycle. Small clinical studies, including a randomised trial of a topical ivermectin-metronidazole gel and a study of ivermectin 1% cream applied to the lids, report reduced mite counts and improved lid signs and symptoms. Because it is a prescription medicine used outside its licence, it is prescribed after examination by one of our therapeutically qualified optometrists, with clear instructions on how to keep it out of the eye, and it sits inside the six-week programme rather than replacing it. Prescription lotilaner eye drops (Xdemvy), which have strong trial evidence overseas, are not yet routinely available in New Zealand.

In-office treatment

The in-clinic side of the programme is BlephEx microblepharoexfoliation to strip the biofilm and collarettes, followed where the meibomian glands are involved by gland expression and a heat treatment such as Blephasteam, LipiFlow or IPL, and where indicated an intense in-office lid-margin clean with a tea tree preparation. We then review at about six weeks at the slit lamp: if collarettes have gone and the lid margins are quiet, you move to maintenance; if not, we repeat BlephEx and adjust the home regime or add Soolantra. Everything is measured, not assumed.

The assessment decides the treatment

Whether you have Demodex, bacterial blepharitis, MGD or a mix is decided at the slit lamp and with the imaging we do at every assessment at our Dry Eye Clinic in Hamilton. Waikato patients have been driving to Auckland for structured lid and dry-eye care; it is available in Frankton for Hamilton, Cambridge, Te Awamutu, Morrinsville, Huntly and Raglan, and assessment is also offered at our affiliated practice, Visique Rototuna Optometrists. Rose Optometry is a member of the Dry Eye Specialist Group.

Frequently asked questions

Does BlephEx hurt?

No. With anaesthetic drops it feels like a light brushing along the lashes and takes about ten minutes for both eyes.

How often is it needed?

Once at the start of a programme, then at review if collarettes or biofilm have returned. Some people with recurring blepharitis have it every six to twelve months as maintenance.

My lashes itch in the morning. Is that Demodex?

Very possibly. Morning itch, crusting and collarettes are the classic signs. Book an assessment and we will look properly.

I keep getting styes. Will BlephEx help?

Recurrent styes usually mean blocked glands and a bacterial load on the lid margin. Clearing that biofilm and treating the glands is a sensible approach, though we do not have trial data showing BlephEx itself prevents recurrence, and it is the whole programme that does the work.

Can I just buy the tea-tree cleanser?

You can, from the store, and it will help. But if collarettes and biofilm are established, the cleanser works better once the lids have been properly cleaned first. Call (07) 847 3195 or email info@roseoptom.co.nz to book or book a Dry Eye Evaluation online (scroll to it in the list).

What kills Demodex mites on eyelashes?

Terpinen-4-ol, the active component of tea tree oil, is the best-studied over-the-counter agent, used as a lid cleanser twice daily for at least six weeks so that it covers the mite life cycle. In-clinic BlephEx clears the debris the mites live in. Prescription lotilaner drops (Xdemvy) have strong trial evidence overseas but are not yet routinely available in New Zealand; ask us about current options.

How do I know if I have Demodex?

Only an examination can confirm it: we look for collarettes, the cylindrical waxy sleeves at the base of the lashes, at the slit lamp. Morning itch, crusting, red lid margins and recurring styes raise the suspicion.

References

• Siegel H, Merz A, Gross N, et al. BlephEx-treatment for blepharitis: a prospective randomized placebo-controlled trial. BMC Ophthalmol. 2024;24(1):503. PMID 39558272. doi:10.1186/s12886-024-03765-3
• Trattler W, Karpecki P, Rapoport Y, et al. The Prevalence of Demodex Blepharitis in US Eye Care Clinic Patients as Determined by Collarettes: A Pathognomonic Sign. Clin Ophthalmol. 2022;16:1153-1164. PMID 35449733. doi:10.2147/OPTH.S354692
• Savla K, Le JT, Pucker AD. Tea tree oil for Demodex blepharitis. Cochrane Database Syst Rev. 2020;6(6):CD013333. PMID 32589270. doi:10.1002/14651858.CD013333.pub2
• Tighe S, Gao YY, Tseng SC. Terpinen-4-ol is the Most Active Ingredient of Tea Tree Oil to Kill Demodex Mites. Transl Vis Sci Technol. 2013;2(7):2. PMID 24349880. doi:10.1167/tvst.2.7.2
• Liu J, Sheha H, Tseng SC. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol. 2010;10(5):505-510. PMID 20689407. doi:10.1097/ACI.0b013e32833df9f4
• Fromstein SR, Harthan JS, Patel J, Opitz DL. Demodex blepharitis: clinical perspectives. Clin Optom (Auckl). 2018;10:57-63. PMID 30214343. doi:10.2147/OPTO.S142708
• Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: Management and Therapy. Am J Ophthalmol. 2025;279:289-386. PMID 40467022. doi:10.1016/j.ajo.2025.05.039
• Ávila MY, Martínez-Pulgarín DF, Rizo Madrid C. Topical ivermectin-metronidazole gel therapy in the treatment of blepharitis caused by Demodex spp.: A randomized clinical trial. Cont Lens Anterior Eye. 2021;44(3):101326. PMID 32461053. doi:10.1016/j.clae.2020.04.011
• Choi Y, Eom Y, Yoon EG, Song JS, Kim IH, Kim HM. Efficacy of Topical Ivermectin 1% in the Treatment of Demodex Blepharitis. Cornea. 2022;41(4):427-434. PMID 34173370. doi:10.1097/ICO.0000000000002802