Anterior blepharitis is a significant concern for a number of our patients. If not addressed appropriately it can lead to a number of symptoms including itchy eyelid margins, discomfort, blurred vision, hyperemia along the eyelid margins and bulbar hyperemia. Clinically, one of the challenges seems to be differentiating bacterial blepharitis versus demodex blepharitis. Suspicion is increased for demodex over population once cylindrical dandruff is present at the base of the lashes. The definitive way to diagnose demodex blepharitis is to epilate several lashes from each of the eyelid margins and then place them on a slide and view them with the traditional light microscope, looking for the presence of demodex mites. The reality is that most practitioners don’t have access to a light microscope, and even if available, it can actually be a time consuming procedure. Now, relatively recently, brought to light in particular by Dr. Katherine Mastrota, a number of practitioners have been performing eyelash rotation to determine the presence of demodex over population at the eyelid margin. The eyelash is simply grasped with a set of jeweler’s forceps and rotated in the follicle, in a similar way that a spatula is rotated around a frying pan. What this does, if demodex is over populating the follicle, is it will aggravate the mites and encourage their emergence from the follicle. This will be visible at the slit lamp under high magnification. Treatment of Demodex requires tea tree oil which is derived from Melaleuca plant. Terpinen-4-ol is the active ingredient that is toxic to demodex mites. There is not a clear consensus on how often to apply tea tree oil to the lid margins but there are now commercially available lid cleansers with tea tree oil that allows the patient to easily apply this to their eyelid margin. The patient gently presses the wipe along the eyelid margin for about 5 to 10 seconds to allow the tea tree oil to seep into the eyelash follicle. We have had great success by having patients perform this once a day. Usually within 4 to 8 weeks of applying tea tree oil regularly to the eyelid margins, the over population of demodex is significantly reduced and patient’s symptoms will also have significantly improved. After the demodex population is controlled, patients will usually try a brief period of discontinuing the treatment to determine if the population stays controlled. If demodex over populates lash follicles again, patients will need to be on some type of maintenance therapy with tea tree oil to keep the demodex mites at low levels and thus keeping the patient symptom-free. Now, remember when examining patients with blepharitis to differentiate between bacterial and demodex blepharitis. Do this by utilizing either a light microscope with epilation or eyelash rotation. Incorporate tea tree oil on the eyelash margins to reduce demodex populations and always follow up with patients to make sure overpopulation does not return. Keeping these things in mind will help improve patient outcomes which is ultimately why we do what we do. We hope that this has been clinically insightful.