TFOS DEWS III: Summary of Guidelines for Dry Eye Disease

The TFOS DEWS III (Tear Film & Ocular Surface Society Dry Eye Workshop III) provides an updated, evidence-based framework for understanding, diagnosing and managing dry eye disease (DED). It emphasizes that dry eye is a multifactorial disease of the ocular surface involving tear-film instability, hyperosmolarity, inflammation, neurosensory abnormalities and damage to the ocular surface.

1. Definition and pathophysiology

Dry eye is not simply a deficiency of tears. It results from disruption of the normal interaction between the tear film, ocular surface, eyelids, lacrimal glands and sensory nerves. Tear-film instability can increase evaporation and tear osmolarity, triggering inflammation and epithelial damage. A vicious cycle develops in which inflammation further destabilizes the tear film.

DEWS III places particular importance on evaporative dry eye and meibomian gland dysfunction (MGD), which are extremely common and may coexist with aqueous-deficient disease.

2. Symptoms and diagnosis

Diagnosis should begin with a detailed assessment of symptoms. Common symptoms include dryness, burning, grittiness, fluctuating vision, photophobia, irritation and ocular fatigue.

Patients with suggestive symptoms should undergo objective testing. Important clinical parameters include:

• Tear-film breakup time or non-invasive breakup time
• Tear-film instability
• Ocular surface staining
• Tear osmolarity
• Tear production, including Schirmer testing when appropriate
• Assessment of the eyelids and meibomian glands
• Evaluation of blink pattern and incomplete blinking
• Corneal and conjunctival examination
• Assessment for associated ocular or systemic disease

The diagnosis should distinguish aqueous-deficient dry eye, evaporative dry eye/MGD and mixed disease, while recognizing that patients may have overlapping mechanisms.

3. MGD and evaporative dry eye

DEWS III recognizes MGD as a major contributor to dry eye. Evaluation should include meibomian gland structure, expressibility and secretion quality, together with examination for lid-margin abnormalities.

Management may include warm compresses, lid hygiene, treatment of blepharitis, meibomian gland expression and thermal therapies when indicated. In selected patients, procedures such as thermal pulsation may be considered as part of a comprehensive treatment plan.

4. Stepwise management

Treatment should be individualized according to severity, mechanism and patient needs.

Initial measures include patient education, environmental modification, regular blinking, appropriate screen habits, reduction of airflow exposure and lubricating eye drops. Preservative-free preparations are preferred when frequent application is required.

For persistent disease, treatment may include management of MGD and blepharitis, anti-inflammatory therapy, short courses of topical corticosteroids in selected cases, and longer-term immunomodulatory treatment such as cyclosporine or lifitegrast, depending on availability and clinical circumstances.

More advanced disease may require autologous serum tears, scleral lenses, punctal occlusion, therapeutic contact lenses or other specialist interventions.

5. Individualized and long-term care

A major principle of DEWS III is that dry eye is usually chronic and requires continuing management rather than a one-time treatment. Treatment should be reassessed according to symptoms, signs, treatment response and adverse effects.

Overall, TFOS DEWS III promotes a mechanism-based, patient-centred approach: identify the predominant cause, assess both symptoms and objective signs, address modifiable risk factors, treat inflammation and MGD where present, and escalate therapy according to disease severity.