What to expect when recovering after DMEK or DSAEK surgery for Fuchs’ dystrophy
The following article is taken from the National Rosacea Society website - https://www.rosacea.org/patients/demodex
The Ecology of Your Face: Demodex, Rosacea and You
As a disorder of unknown origin, rosacea’s signs and symptoms may be attributable to a variety of possible causes, such as a dysfunctional immune system, genetics, a propensity toward flushing and various external factors that may trigger these unhealthy responses.
Even before the emergence of new scientific evidence, Demodex, a microscopic mite that is a normal inhabitant of human facial skin, was long considered a potential culprit in rosacea flare-ups by virtue of its often-greater numbers on the faces of individuals with this disorder.1, 2 Now a growing body of medical research on Demodex has uncovered a broad range of knowledge that may yield a clearer picture of its characteristics and prevalence, as well as its possible role in triggering or enhancing the signs and symptoms of rosacea.
Demodex may be best understood in the context of the human microbiome – the ecological community of microorganisms that live within and on the human body, and has been the subject of a recent five-year study at the National Institutes of Health that is leading to a paradigm shift in the understanding of the human body.3
Microbes are our friends
Contrary to popular perception, humans are not biologically self-sufficient organisms whose immune systems must fight off invasion by microbes in order to avoid disease. In fact, it’s just the opposite: the human body can’t survive without them. For example, according to the Human Microbiome Project, bacteria in the gastrointestinal tract are essential to allow people to digest foods and absorb certain nutrients. In addition, these fundamental microbes produce beneficial compounds like certain vitamins and protective anti-inflammatories that humans cannot produce by themselves.
Moreover, of the trillions of cells in a typical human body – at least 10 times as many cells in a single individual as there are stars in the Milky Way – only about one in 10 is human, and the remaining 90 percent are microbes.4 Because they are so small, however, they account for only about 1 to 2 percent of our body mass – about three to five pounds in weight, or enough to fill a big soup can.3
The process of acquiring microbes is a lifelong activity and begins the moment we are born. Though babies develop in a sterile environment – the uterus is without microorganisms – a newborn emerges as a bacterial sponge, and begins picking up microbes that contribute to its health and ability to survive beginning with its passage through the birth canal. Microbes include bacteria, fungi, protozoa and others, and may be found in greatest concentrations in the ears, nose, mouth, vagina, digestive tract, anus and the skin.5
Like other microbes, Demodex mites are a natural part of this human microbiome, and they may serve a useful function by feeding off of dead skin cells to help rid the face of waste. In fact, dead human skin cells are the largest component of household dust and, just like dust mites, Demodex folliculorum may be part of a natural cleaning system.6
The Demodex mite
While Demodex may have only recently gained more attention in the rosacea research community, the mite has a much longer historyin the realm of medical science. According to Dr. Rusiecka-Ziółkowska and colleagues in the Department of Microbiology at Wroclaw Medical University in Poland, reports of Demodex mites were recorded as early as 1841, more than 150 years ago. A year later, a German dermatologist found Demodex-type mites in hair follicles, almost 100 years before human Demodex was first observed in the development of rosacea.7
Great numbers of Demodex appear to be very common in virtually all humans. Using advanced technology, researcher Dr. Megan Thoemmes and colleagues recently found that Demodex mites exist in every adult over 18 years old.8 Moreover, researchers have discovered that two separate species of Demodex inhabit the skin of humans – D. folliculorum, which live in hair follicles primarily on the face as well as in the meibomian glands of the eyelids, and D. brevis, which live in the sebaceous glands of the skin.8,9
Demodex have often been found in 15 to 18 times greater numbers in rosacea patients than in healthy subjects,1,2 and medical scientists have advanced a variety of theories about why this unusually high incidence may trigger inflammation in individuals with rosacea. A recent meta-analysis of 48 studies on Demodex found a significant association between the relative density of Demodex and the development of rosacea, suggesting that the mites may be involved in the disease process, according to Dr. Erin Lesesky, assistant professor of dermatology at Duke University.10 Moreover, while it has long been debated whether the higher incidence of Demodex is a cause or a result of rosacea, new evidence has increasingly suggested it may be the former.
In a recent key medical journal article, Dr. Fabienne Forton, a dermatologist in Brussels, Belgium, characterized the mites as a potential missing link in understanding the onset of subtype 2(papulopustular) rosacea.2 She hypothesized that skin infections and disruption of the skin barrier may set off a chain of inflammatory reactions in individuals with rosacea, noting that when the number of mites is reduced to normal through treatment the typical rosacea complaint of sensitive skin often disappears. Dr. Stanislaw Jarmuda and colleagues also found that while mite density is greater on the skin of individuals with rosacea, mites are even more dense in individuals with the bumps and pimples of papulopustular rosacea.9
Other researchers believe D. folliculorum's true connection to rosacea may be via Bacillus oleronius, a bacterium on the Demodex mite that was found to stimulate an immune response in some individuals with rosacea, according to Dr. Kevin Kavanagh and colleagues at the National University of Ireland-Maynooth.11 In addition, the B. oleroniusassociation may hold true for those with ocular rosacea as well. Dr. Jianjing Li and colleagues at the Ocular Surface Center in Miami found a significant correlation between facial rosacea, infestation of the eyes with Demodex mites and reaction to B. oleronius.12
While rosacea may have many causes, individuals who suspect they have this disorder are urged to see a dermatologist for diagnosis and appropriate treatment. “Patients who don’t respond to traditional treatment for papulopustular rosacea may have an increased density of Demodex mites or an increased immune response to these mites,” Dr. Lesesky said, noting that treatments with antiparasitic properties targeting Demodex might be useful for successful patient management.13
1. Jarmuda S, O’Reilly N, Zaba R, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Med Microbiol 2012;61:1504-1510.
2. Forton FMN. Papulopustular rosacea, skin immunity and Demodex: pityriasis folliculorum as a missing link. J Eur Acad Dermatol Venereol2012;26:19–28.
3. NIH Human Microbiome Project defines normal bacterial makeup of the body. National Institutes of Health June 13, 2012.
4. Marantz Henig R. Fat factors. New York Times Aug. 123, 2006.
5. Ackerman J. How bacterial affect our bodies protect our health. Scientific American May 15, 2012, pp.
6. House dust mite. Wikipedia Accessed 11/25/14.
7. Rusiecka-Ziółkowska J, Nokiel M, Fleischer M. Demodex – an old pathogen or a new one? Adv Clin Exp Med 2014;23:295–298.
8. Thoemmes MS, Fergus DJ, Urban J, Trautwein M, Dunn RR (2014) Ubiquity and diversity of human-associated Demodex mites. Public Library of Science One 9(8):e106265. Doi:10.1371/journal.pone.0106265.
9. Jarmuda S, O’Reilly N, Zaba R, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Medical Microbiol2012;61:1504-1510.
10. Zhao YE, Wu LP, Peng Y, et al. Retrospective analysis of association between Demodex infestation and rosacea. Arch Dermatol2010;146(8):896-902.
11. Erbagci Z, Ozgoztaosi O. The significance of Demodex folliculorumdensity in rosacea. Int J Dermatol 1998;37:421-425.
12. Li J, O’Reilly N, Sheha H, et al. Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with facial rosacea. Ophthalmology 2010;117:870-877.
13. Demodex surfaces again at summer AAD meeting. National Rosacea Society Weblog Accessed 11/25/14.
Acknowledgment: This section was reviewed and edited by Dr. Julie Harper, clinical associate professor of Dermatology at the University of Alabama-Birmingham.
What determines your outcome after cataract surgery? Most people view cataract surgery as a simple procedure with a guaranteed outcome of clear distance vision without glasses. Cataract surgery is a complex micro-surgery that takes 7-10 years of surgical training to perform well and with a low risk of complications. Assuming that you are having surgery by a consultant ophthalmologist who is an experienced surgeon, how predictable is your post-operative result and vision.
On of the critical tests before cataract surgery is called biometry. Biometry measures various anatomical features of your eye including corneal curvature, eye ball length and natural lens position. This information is fed into a formula that predicts the outcome from a specific lens implanted into the eye. Unlike a pair of glasses where your optician can ask you whether your vision is clearer with one lens or another, your eye surgeon needs to predict the lens strength that will give a certain result. In other words for each patient the formula will predict that X powered lens results in virtually no prescription and clear distance vision.
A typical biometry read out with lens predictions
If everything was that simple everyone would always have perfect results. However, modern lens prediction formulae are at best accurate to within +/-0.5 dioptres (the unit of a glasses prescription) in 70% of people and within +/- 1 dioptre in 90% of patients. 10% of patients can be outside these limits. Astigmatism may also affect clarity of post op vision. Some of these patients will require glasses for their best possible vision.
Whilst modern cataract surgery is highly successful and life enhancing, outcomes are determined by predictability of lens formulae. For the majority of people this is perfectly fine, but if you are paying to have a multifocal lens then you obviously want to have perfect vision. For the average cataract surgeon faced with a unpredicted outcome and hence a patient with blurred vision after multifocal lenses the option is to either perform a lens exchange operation or encourage the patient to simply wear glasses. The other less invasive and more precise option is the ability to perform laser eye surgery to refine the outcome of surgery to achieve perfect vision. This can eliminate residual prescription and astigmatism.
Choosing a surgeon that is able to perform laser eye surgery as well as cataract surgery is beneficial for the simple reason that lens prediction isn't exact and because this allows your surgeon to achieve your best potential vision with all types of lens implants.
What does your eye doctor mean when they talk about neuro-adaptation after cataract surgery with multifocal lens implants
Neural adaptation after multifocal lens implants
Patients are always surprised when shown a photograph of their own cataract, but then understand why it is that they don't see well. The natural lens is like a large Smarty or M&M - essentially a lens made of protein. When young this is completely clear, but with age the protein becomes hazy, yellow or brown. This change is called a cataract. As the person with a cataract looks through this murky material their vision is also blurred as a result.
A yellow-brown cataract can be seen in the centre of the pupil in this recent patient
Cataract surgery removes the cloudy lens and replaces it with a crystal clear artificial lens implant. This lens can correct long-sight, short-sight and even astigmatism. Sophisticated lenses such as the trifocal lens implant can allow patients to read without glasses.
The trifocal lens implant gives patients independence from glasses
Contact us if you'd like to find out more about achieving your best potential vision if you're having cataract surgery.
LASIK or LASEK - a patient's perspective
Mr Angunawela is part of the winning team from Moorfields Eye Hospital that won a National Patient Safety Award on the 4th of July. The prestigious prize was awarded in the category for governance, risk management and patient safety and highlights the hospital's dedication to ensuring the best standards of care for its patients and its position as the leading eye hospital in the UK. The prize is competitively awarded nationally and across all medical specialities.
Mr Angunawela was the first to recognise a rare complication of drops prescribed after routine cataract surgery leading to loss of vision in some patients. This led to a focused team effort by doctors, pharmacists and risk management experts to address this issue resulting in a national alert trigger when the same combination of drops are prescribed anywhere in the country and no further complications reported over the last year since the problem was first recognised.