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Dry Eye Disease - rr 1. Dry eye disease (also known as dry eye syndrome) refers to a group of disorders of the tear film that are due to reduced tear production or tear film instability, associated with ocular discomfort and/or visual symptoms and inflammatory disease of the ocular surface. 2. Classification: - Mild: mild dry eye disease may have symptoms of irritation, itching, soreness, ocular discomfort, burning, or intermittent blurred vision - Moderate: have increased discomfort and frequency of symptoms, and the negative effect on visual function may become more consistent - Severe: have an increasing frequency of visual symptoms that may become constant as well as potentially disabling 3. Many risk factors for dry eye have been proposed: -

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Older age and female gender have been identified as major risk factors. Increased prevalence of dry eye disease among Japanese office workers using visual display terminals. Concurrent use of glaucoma medication containing benzalkonium chloride (BAK) was also shown to be a risk factor in patients. Rheumatoid arthritis was associated with dry eye in two studies. Smoking and multivitamin use were associated with an increased risk of dry eye, whereas caffeine use was associated with a decreased risk risk factors for dry eye included the use of antihistamines, antidepressant and antianxiety medications, and oral corticosteroids. Angiotensin-converting enzyme inhibitors were associated with a lower risk. Postmenopausal women in the Women’s Health Study, hormone replacement therapy, and, in particular, estrogen use alone, was associated with an increased risk of clinically diagnosed dry eye disease or severe symptoms. dry eye among patients with diabetes particularly those with poor metabolic control

4. When there is an associated systemic disease such as Sjögren syndrome, an inflammatory cellular infiltration of the exocrine glands (including lacrimal gland) leads to saliva- and tear-production deficiency (see Appendix 3). About 10% of patients with clinically significant aqueous deficient dry eye have an underlying primary Sjӧgren syndrome 5. Aqueous tear deficiency may develop in other systemic conditions such as lymphoma, sarcoidosis,61,62 hemochromatosis, and amyloidosis63 that results in infiltration of the lacrimal gland and replacement of the secretory acini. Dry eye may develop in patients with systemic viral infections; it has been reported in patients infected by the retroviruses, Epstein-Barr virus,64 human T-cell lymphotropic virus type 1, and human immunodeficiency virus (HIV)

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Meibom Gland Disorder : 1. The International Workshop on MGD defined the disease as “a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/

quantitative changes in the glandular secretion. It may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease 2. Risk factors of MGD include aging, deficiency of sex hormones notably androgens, Sjogren’s syndrome (SS), Stevens-Johnson Syndrome (SJS), psoriasis, atopy, polycystic ovary syndrome (PCOS) and hypertension. In addition, ophthalmic factors namely aniridia, chronic blepharitis, contact lens wear, eyelid tattooing, trachoma, Demodex folliculorum infection have been shown to impact Meibomian gland function. Use of antibiotics, Isotretinoin for Acne, antihistamines, antidepressants, and hormone replacement therapy are found to be associated with MGD. 3. Classification:

4. 2011 International Workshop on Meibomian Gland Dysfunction

5. Eye drops a. Cyclosporine A The first one of the new generation immunomodulatory drugs, which has a immunosuppressive effects following systemic application. It acts as a selective inhibitor of interleukin-2 (IL-2) release during the activation of T-cells and causes cell-mediated immune response suppression. CsA's mechanism of action is based on its effects on subconjunctival and lacrimal gland inflammation, resulting in an increase in tear production and conjunctival goblet cell density in a significant number of moderate-to-severe DES patients who received treatment b. Topical steroids target the inflammatory component of DES in a nonspecific manner. This therapy can be considered as a short-term pulse for the inflammation because of the high risk of complications with chronic use [45]. When blepharitis is the underlying cause or a contributory element of dry eye, topical tetracyclines have become the treatment of choice [. c. Topical (NSAIDs) There are two randomized trials with topical diclofenac and topical ketorolac that provide evidence of NSAID efficacy. Oral pilocarpine has been demonstrated to increase tear production and flow, thus it improves the symptoms of DES in Sjögren's syndrome patients [51]. d. Vitamin A eye drops are also effective for the treatment of dry eye disorder [52]. An o/w emulsion of 0.01% all-trans-retinoic acid (tretinoin, vitamin A) was prepared and clinically evaluated in DES patients by Selek et al. It was reported that tear film breakup time was significantly improved by retinoic acid treatment. e. Insto  Tetryzoline is an alpha agonist for alpha-2 receptor and imidazoline receptor I-1 agonist.

Mainly due to its alpha-2 agonism it can constrict conjuctival blood vessels of the eye when taken in the form of eye drops.[4] This relieves the redness of the eye caused by minor ocular irritants. To treat allergic conjunctivitis, tetryzoline can be combined in a solution with antazoline.[5] In an overdose, slow heart rate and low blood pressure are mainly due to imidazoline-1 receptor agonism. Dry mouth and sedatingeffects are due to alpha-2 agonism. 6. Treatment for vertigo and nausea