High prevalence of <span class="elsevierStyleItalic">Demodex spp.</span> infestation among patients with posterior blepharitis: Correlation with age and cylindrical dandruff | Archivos de la Sociedad Española de Oftalmología (English Edition)

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in glandular acini&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> The morphology of demodex is similar in all species&#46; No cases of zoonosis has been described&#44; so infestation appears to be preferably species-specific&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Most of the biological cycle of mites takes place in the hair follicle&#44; although part of its early development and maturation from egg to larva occurs in the sebaceous glands&#44; which could account for their inflammation and obstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;3</span></a> Even though since the past century demodex has been described as a frequent finding in sebaceous glands and hair follicles of skin and eyelids of humans&#44; its relationship with blepharitis has been studied only in the past decade&#46; To date&#44; several studies had linked the presence of <span class="elsevierStyleItalic">Demodex spp&#46;</span> with various diseases&#44; including blepharitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#8211;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Blepharitis&#44; or palpebral edge inflammation&#44; is a very frequent disease in ophthalmological practices&#46; It compromises the anterior or posterior laminae&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> usually expressing as a chronic inflammatory condition with frequent peaks&#44; presence of scale&#44; loss of eyelashes and symptoms of itching or pruritus&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> Its etiology is multifactorial and is associated to ocular diseases &#40;dry eye&#44; Meibomium gland dysfunction&#44; styes and chalazion among others&#41; as well as to skin diseases &#40;rosaceae and seborrheic dermatitis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a> Due to the ecologic diversity and coexistence of diseases in patients with blepharitis&#44; in many cases treatments are inefficient&#44; leading to chronicity and palpebral edge deterioration&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#44;13&#44;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The infectious etiology of blepharitis is mainly attributed to staphylococci-type bacteria&#44; whereas the viral&#44; fungal and parasitic origin has been scarcely described&#46; The latter include infestation by <span class="elsevierStyleItalic">D&#46; folliculorum</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;5&#44;6&#44;9</span></a> Although the presence of the mite has been described in patients with blepharitis&#44; Meibomium gland dysfunction and chalazion&#44; its pathogenic role remains unclear because the parasite has also been found in populations without ocular diseases<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">4&#44;15&#8211;17</span></a> and with greater frequency in people over 70&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">16</span></a> The latter points at age as a predisposing factor of demodex infestation&#46; Accordingly&#44; some authors define demodex as an opportunistic micro-organism&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10&#44;18&#44;19</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The presence of large amounts of adult <span class="elsevierStyleItalic">D&#46; folliculorum</span> specimens and nymphs in the same follicle produces enlargement as well as hyper-keratinization thereof&#44; with typical formation of cylindrical scale and loss of eyelashes&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">11&#44;20</span></a> Both effects are frequently observed in patients with blepharitis&#46; Demodex has also been described as a vector for bacteria from the skin toward the depths of the sebaceous glands and palpebral edges&#46; In this regard&#44; microbiological studies reveal a higher density and variety of bacteria species in patients with demodex than in those who do not have the parasite&#46; This could be a potential factor promoting infection&#44; inflammation and ocular surface damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;21&#8211;25</span></a> In the population of Chile&#44; a recent study with 32 patients reported high frequency of Demodex in patients with various ocular surface diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a> The objective of the present study is to assess the prevalence and infestation index &#40;II&#41; of <span class="elsevierStyleItalic">Demodex spp</span>&#46; In patients of different age groups with blepharitis &#40;and posterior laminae compromise&#41; and to assess the association thereof with the presence of cylindrical dandruff &#40;CD&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0030" class="elsevierStylePara elsevierViewall">To determine the prevalence and II of <span class="elsevierStyleItalic">Demodex spp</span>&#46; in patients of different age groups with blepharitis &#40;and posterior laminae compromise&#41; and assessing association with the presence of CD&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A prospective study including 178 patients of the <span class="elsevierStyleItalic">Fundaci&#243;n Oftalmol&#243;gica Los Andes</span> &#40;Santiago&#44; Chile&#41;&#44; with clinic diagnostic of blepharitis with posterior laminae compromise&#44; recruited during the 2013&#8211;2015 period&#44; without previous topical or systemic acaricide treatment&#46; The study was carried out in accordance with the principles of the 1975 Helsinki Declaration and following the recommendations of the local Ethics Committee&#46; The patients were referred to the Ocular Surface Laboratory for identification of mites in the eyelashes&#44; which were extracted with the hair follicle applying traction in accordance with Coston&#39;s method for detecting and calculating II by <span class="elsevierStyleItalic">Demodex spp&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">7&#44;26</span></a> To this end&#44; four eyelashes were extracted from each eyelid of each eye&#44; i&#46;e&#46;&#44; one eyelash of the temporal portion&#44; one of the nasal portion and 2 of the middle portion &#40;8 eyelashes per eye&#41;&#46; The number of extracted eyelashes was registered for each patient as well as the presence and amount of CD&#46; The latter was assessed according to the following scale relative to density in the palpebral edge &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58; grade 0&#44; absence of CD&#59; grade 1&#44; small amount or presence in only one sector of the eyelids&#59; grade 2&#44; moderate amount in both eyelids or abundant in a single eyelid&#44; and grade 3&#44; presence of abundant CD in both eyelids&#46; The extracted eyelashes were selected randomly regardless of the clinic presence of CD in order to obtain a representative sample of all palpebral edge portions&#46; Subsequently&#44; they were placed on a slide and covered with a drop of immersion oil &#40;Merck&#44; Darmstadt&#44; Germany&#41;&#46; The presence of mite was established by inspection under a light microscope AxioLab&#46;A1 &#40;Carl Zeiss&#44; Gottingen&#44; Germany&#41; with overall magnification of 100&#215;&#46; Each sample was photographed with a Cannon EOS Rebel T3 digital camera &#40;Cannon&#44; Miami&#44; United States&#41; and the EOS Utility software version 2&#46;10&#46;0&#46;0 &#40;Cannon&#44; Miami&#44; United States&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; For each eyelid&#44; the amount of adult specimen&#44; larvae&#44; nymphs and eggs of <span class="elsevierStyleItalic">Demodex spp</span>&#46; were recorded&#46; The II was calculated as the quotient between the overall number of observed specimens regardless of their development or species and the total number of extracted eyelashes&#46; II values of 0&#46;5 mite&#47;eyelid or more were considered as positive&#47;pathological&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The observed values were analyzed with the GraphPad Prism software version 5&#46;01 &#40;GraphPad Prism&#44; San Diego&#44; California&#44; United States&#41; for application of the T for student and Pearson&#39;s correlation statistical tests&#46; Values of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 were taken as statistically significant&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">General epidemiology and infestation index</span><p id="par0045" class="elsevierStylePara elsevierViewall">Overall&#44; the study included 178 patients with blepharitis compromising the posterior laminae&#46; Of these&#44; 87 &#40;48&#46;9&#37;&#41; were female and 91 &#40;51&#46;1&#37;&#41; were male&#46; The mean age of the studied population was 58&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;66 years &#40;range 10&#8211;101 years&#41;&#46; Of these&#44; 149 &#40;83&#46;7&#37;&#41; were infested&#44; with a mean II of 0&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;84<span class="elsevierStyleHsp" style=""></span>mites&#47;eyelid&#46; Infestation prevalence by age groups varied between 71 and 96&#37; in all groups&#44; with the exception of patients aged 20 or less&#44; in which group only 1 infested patient was found &#40;9&#46;1&#37;&#41;&#44; who exhibited a low II of 0&#46;31 mites&#47;eyelid &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The age of the patients and the II had a Pearson&#39;s linear correlation coefficient &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span>&#41; of 0&#46;12 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Taken together&#44; patients aged 50 or less had an infestation prevalence of 60&#46;07&#37; in contrast with an infestation prevalence of 94&#46;2&#37; shown by patients over 50&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">On the other hand&#44; the arbitrary consideration of patients of different age groups that exhibited an II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>mites&#47;eyelid showed the prevalence of 39&#46;8&#37; in patients aged 50 or less versus 75&#37; in patients over 50&#46; In these&#44; the mean II was 0&#46;54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;66<span class="elsevierStyleHsp" style=""></span>mites&#47;eyelid in the 50 years or less group and 1&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;86<span class="elsevierStyleHsp" style=""></span>mites&#47;eyelid in the group of patients over 50&#46; These differences were statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cylindrical dandruff</span><p id="par0060" class="elsevierStylePara elsevierViewall">The presence of CD was assessed in the 178 patients of the study &#40;infested or not by demodex&#41;&#46; The presence of CD was observed in 127 subjects &#40;71&#46;4&#37; of patients&#41;&#46; Practically all &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>125&#41; were in patients of all age groups infested with a II<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;5 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; According to the semi-quantitative estimation described in the Materials and Methods section&#44; the average amounts of CD of observed in all age groups were low or moderate&#44; although these values were significantly higher in patients over 50 years of age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Similarly&#44; a positive correlation was observed between the amount of CD and II &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;33&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Only a small number of patients with blepharitis who were infested did not exhibit CD &#40;13&#46;5&#37;&#41;&#44; the majority belonging to the age group under 50 years of age&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">In accordance with the results obtained in the present study&#44; in patients with posterior blepharitis the presence of said mites is nonexistent or very small in children and teenagers&#44; infrequent in young patients and highly frequent in adults and older adults&#46; The most significant change occurs after 50&#44; when prevalence rates close to 95&#37; were observed&#46; Similar studies have reported prevalence rates of this magnitude in subjects over 70 with or without diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">16&#44;27</span></a> The results of the present study indicate that subjects with blepharitis could have a predisposition to earlier infestation by <span class="elsevierStyleItalic">Demodex spp&#46;</span> In comparison with literature reports for subjects without diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">7&#44;13&#44;16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In the population with blepharitis&#44; the II was high&#44; exhibiting a positive correlation with age&#44; particularly in the group of patients over 50 vis-&#224;-vis the group under 50&#46; This observation matches the majority of published prevalence studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;15&#8211;17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The presence of CD was a frequent finding in the studied group&#44; with a strong association with the presence of the ectoparasite &#40;between 90 and 100&#37; of patients with CD&#41;&#44; which indicates that CD could represent a highly indicative sign of infestation&#46; Tseng et al&#46; found similar evidences when comparing a group of patients with CD in the palpebral edge and a group without evidences of CD as a control group&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> In the group exhibiting CD&#44; all patients were infested by the mite in contrast with the control group where only 22&#37; of patients were infested&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> On the other hand&#44; only 13&#46;5&#37; of patients with blepharitis and infestation did not exhibit this sign in the palpebral edge&#46; Thus&#44; infestation by demodex on the basis of the presence of CD would have a highly predictive value&#46; However&#44; associated factors could detract from this conclusion&#44; such as the presence of seborrheic dandruff and scale or crusts on the palpebral edge as well as the presence of residues of eyedrops and makeup&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A semiquantitative estimation of CD enabled the observation of a positive correlation between CD and II&#44; either due to a higher amount of mites or more specifically to a higher amount of mites in the same eyelid&#44; which would promote alteration in the hair follicle and the ensuing palpebral damage&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The presence of scale in the palpebral edge&#44; as well as its detachment and entry into the eye&#44; could be associated to foreign body and pruritus symptoms frequently described by the studied patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">14&#44;27</span></a> The loss of eyelids would be a belated event caused by the loss of tension and hyper-keratinization produced by the presence of several mites in the same follicle&#46; It is not known whether the infestation is self-limited when all eyelashes have been lost&#44; but the migration of mites from one sector of the palpebral edge to another or even to the eyebrows has been described&#44; which would explain the unequal and in some cases sectorial distribution of the mites&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;3</span></a> Random exploration and extraction of eyelashes would enable the estimation of an II representative of the palpebral edge&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The detection of <span class="elsevierStyleItalic">Demodex spp&#46;</span> by means of extracting eyelashes in patients with blepharitis was a simple and efficient method with minimum discomfort for patients&#46; In the majority of studied patients&#44; the II was the result of the count of <span class="elsevierStyleItalic">D&#46; folliculorum</span>&#44; with the observation of <span class="elsevierStyleItalic">D&#46; brevis</span> being exceptional &#40;4 adult specimens in 4 patients of the study group&#41;&#46; However&#44; the hair removal utilized for diagnosing the presence of <span class="elsevierStyleItalic">D&#46; folliculorum</span> does not mean that infestation by <span class="elsevierStyleItalic">D&#46; brevis</span> can be discarded due to its location in sebaceous glands that are difficult to access&#46; The original Coston method includes the extraction of 5 eyelashes per eyelid&#46; In the experience of the authors&#44; 4 eyelashes from different portions of the palpebral surface suffice to objectively estimate the II&#46; With diagnostic purposes&#44; other authors have applied the hair removal method of extracting less eyelashes and searching for the mites in selected eyelashes with slit lamp&#44; either due to exhibiting CD or showing the distal portion of the mite&#44; which is in some cases observable with higher magnification&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">15</span></a> Even though this procedure is simple and efficient for detecting mites&#44; it does not allow for an objective estimation of the II because infestation is frequently focalized and asymmetric with eyelid areas free of mites&#46; However&#44; focused hair removal as well as the visualization of mites with confocal scanning microscope could be useful in patients with madarosis and could become noninvasive alternatives vis-&#224;-vis eyelash removal and exfoliation techniques utilized for detecting mites on the skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Estimating II by demodex is important for managing patients with blepharitis&#44; particularly those over 50 years of age in whom the probability of presenting the mite is high regardless of the presence or absence of symptoms suggesting ocular surface disease&#46; High II would facilitate association studies considering that patients having more than one ocular surface disease could have an opportunistic infestation in which the predominant condition could facilitate infestation in younger patients or the increase of pre-existing mite population in the palpebral edge of patients over 50&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion&#44; infestation by <span class="elsevierStyleItalic">D&#46; folliculorum</span> is highly prevalent in patients with blepharitis and posterior laminae compromise&#46; Likewise&#44; II exhibits a positive correlation with patient age and the amount of CD in the palpebral edge&#46; The presence of CD appears to be a good indicator of infestation by demodex&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">Partially funded by <span class="elsevierStyleGrantSponsor" id="gs1">Fondecyt-Chile</span>&#44; Grant <span class="elsevierStyleGrantNumber" refid="gs1">R-1151005</span>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">No commercial interests were declared by the authors&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine prevalence of <span class="elsevierStyleItalic">Demodex spp&#46;</span> and infestation index &#40;II&#41; by the parasite among patients of different ages with blepharitis and to assess association with occurrence of cylindrical dandruff &#40;CC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Prospective study including patients diagnosed with posterior blepharitis between 2013 and 2015&#44; without previous acaricide treatment&#44; was conducted by Fundaci&#243;n Oftalmol&#243;gica Los Andes &#40;Chile&#41;&#46; Four eyelashes were randomly extracted from each eyelid for parasite detection&#46; The II was calculated as the ratio between the total number of demodex specimens found in the total number of eyelashes removed&#46; A semi-quantitative determination of the CC was performed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 178 patients &#40;91 men&#44; 87 women&#41;&#44; with a mean age of 58&#46;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;66 years&#44; were included&#46; It was found that 83&#46;7&#37; of patients were infested with <span class="elsevierStyleItalic">Demodex folliculorum</span> with a mean II of 0&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;84 mites&#47;eyelash&#46; The II was significantly higher in patients over 50 years &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; Patient age and II showed a Pearson correlation coefficient &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span>&#41; of 0&#46;12 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; CC was observed in 71&#46;4&#37; of patients&#44; with those over 50 years-old showing significantly higher values&#46; A positive correlation was also observed between the amount of CC and the II &#40;<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;33&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The prevalence of infestation by <span class="elsevierStyleItalic">D&#46; folliculorum</span> is high in patients with posterior blepharitis&#46; The II by the parasite is positively correlated with age and with the occurrence of CC on the eyelid border&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia e &#237;ndice de infestaci&#243;n &#40;II&#41; por <span class="elsevierStyleItalic">Demodex spp</span>&#46; en pacientes con blefaritis en distintos grupos etarios y evaluar su asociaci&#243;n con la presencia de caspa cil&#237;ndrica &#40;CC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo que incluye a pacientes de la Fundaci&#243;n Oftalmol&#243;gica Los Andes &#40;Chile&#41;&#44; con diagn&#243;stico cl&#237;nico de blefaritis con compromiso de la l&#225;mina posterior entre 2013 y 2015&#44; sin tratamiento acaricida previo&#46; Cuatro pesta&#241;as de cada p&#225;rpado fueron extra&#237;das al azar para la detecci&#243;n del ectopar&#225;sito y determinaci&#243;n del II&#44; calculado como el cociente entre el n&#250;mero observado de espec&#237;menes de demodex y la totalidad de las pesta&#241;as extra&#237;das&#46; Adem&#225;s&#44; se realiz&#243; una determinaci&#243;n semicuantitativa de la presencia de CC&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; a 178 pacientes&#44; de los cuales el 51&#44;3&#37; eran hombres&#46; La edad promedio fue de 58&#44;49<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#44;66 a&#241;os&#46; El 83&#44;7&#37; de los pacientes resultaron infestados por demodex&#44; con un II promedio de 0&#44;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;84 &#225;caros&#47;pesta&#241;a&#46; El II fue significativamente mayor en pacientes sobre los 50 a&#241;os &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; La edad de los pacientes y el II presentaron un coeficiente de correlaci&#243;n lineal de Pearson &#40;R<span class="elsevierStyleSup">2</span>&#41; de 0&#44;12 &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; El 71&#44;4&#37; de los pacientes presentaron CC&#44; con valores significativamente m&#225;s altos en pacientes mayores de 50 a&#241;os&#46; Se observ&#243; una correlaci&#243;n positiva entre la cantidad de CC y el II &#40;R<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;33&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Existe una elevada prevalencia de infestaci&#243;n por demodex en pacientes con blefaritis posterior&#46; El II por <span class="elsevierStyleItalic">D&#46; folliculorum</span> se correlaciona positivamente con la edad de los pacientes y con la presencia de CC en el borde palpebral&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez-Ponce D&#44; Zuazo F&#44; Cartes C&#44; Salinas-Toro D&#44; P&#233;rez-Valenzuela C&#44; Valenzuela F&#44; et al&#46; Alta prevalencia de infestaci&#243;n por <span class="elsevierStyleItalic">Demodex spp</span>&#46; en pacientes con blefaritis posterior&#58; correlaci&#243;n con edad y caspa cil&#237;ndrica&#46; Arch Soc Esp Oftalmol&#46; 2017&#59;92&#58;412&#8211;418&#46;</p>"
      ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Semiquantitative estimation of cylindrical dandruff in the palpebral edge&#58; &#40;A&#41; grade 0&#44; &#40;B&#41; grade 1&#44; &#40;C&#41; grade 2&#44; &#40;D&#41; grade 3&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Microphotograph with 100&#215; magnification&#44; showing eyelid &#40;P&#41; with hair follicle &#40;FP&#41;&#44; adult specimens of <span class="elsevierStyleItalic">Demodex folliculorum</span> &#40;black arrows&#41; and nympth &#40;N&#41;&#46; Reference bar&#58; 250<span class="elsevierStyleHsp" style=""></span>&#956;m&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age Range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#35; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#35; of infested patients n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Average II<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patients with II<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;5 n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8804;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;9&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">21&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">31&#8211;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;77&#46;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;61&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">41&#8211;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;71&#46;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;62<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;42&#46;86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">51&#8211;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">61&#8211;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;92&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;23<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;72&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">&#8805;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52 &#40;94&#46;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;76&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">149 &#40;83&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">113 &#40;63&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age range&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#8804;50 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#62;50 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Infested patients n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">113 &#40;94&#46;17&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
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                      "doi" => "10.1136/bjophthalmol-2014-305671"
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