TFOS DEWS III Report Published with Updated Guidelines for Diagnosis and Management of DED

The Tear Film and Ocular Surface Society (TFOS) has released the TFOS DEWS III report, its third set of reports exploring the diagnosis and management of dry eye disease.

The findings of the TFOS DEWS III report were published in the American Journal of Ophthalmology and follow prior versions published in 2007 and 2017. According to TFOS, the report included input from 80 experts from 18 countries.

TFOS DEWS III comprises seven topics including Sex, Gender, and Hormones; Epidemiology; Pathophysiology; Tear Film; Pain and Sensation, Iatrogenic; and Clinical Trial Design and explores how each of these inform diagnostic methodology, disease subtype and management of dry eye disease. The report defines dry eye as a “multifactorial, symptomatic disease” linked to loss of tear film and/or ocular surface homeostasis. It also emphasizes the need for clearly reported patient-reported symptoms. Subclassification of dry eye was expanded beyond aqueous-deficient vs. evaporative; and now includes specific etiological drivers, such lipid layer issues, blinking, lid health, and ocular surface abnormalities.

With the goal of making routine screening faster, more consistent, and efficient, the report introduced a streamlined three-step algorithm that includes a short OSDI-6 questionanarie; objective testing; and surface staining.

1. OSDI‑6 questionnaire (shortened 6-item version; score ≥4 indicates dry eye)
2. Objective testing: noninvasive tear breakup (<10 s) or osmolarity (≥308 mOsm)
3. Surface staining: corneal (>5 spots), conjunctival (>9 spots), or lid margin changes (>2 mm × 25%)

TFOS DEWS III makes management toolkit recommendations for a variety of dry eye symptoms and treatment options, including: 

• Tear replenishment & conservation (supplements, lipid/OCT-based drops, scleral lenses)
• Meibomian gland dysfunction care: warm lid therapy, IPL, plasma, low-level light, novel drugs (e.g., topical selenium sulfide)
• Neuromodulation (e.g., pharmacologic agents like Tryptyr, devices stimulating tear secretion)
• Eyelid disease & Demodex, with treatments like lotilaner, okra-based cleansers, manuka honey
• Surface regeneration: blood-derived therapies, lubricin, amniotic membranes
• Nutritional/alternative methods: omega-3 PUFAs (modestly beneficial—but dosage/formulation still under study), acupuncture, lifestyle changes .
• Surgical interventions for advanced cases (e.g., salivary gland grafts, reinnervation, pterygium removal)

The American Journal of Ophthalmology published the report in an open access. To see the full report, including the Digest Report, Diagnostic Methodology, Management and Therapy Report, and an accompanying editorial, click here.