One of the most useful shifts in TFOS DEWS III starts with a simple premise: dry eye is not one disease, and a diagnosis is just the beginning. Developed by 80 experts from 18 countries, DEWS III offers an evidence-based framework for finding the etiologic drivers behind disease and matching care to each patient.¹
During a recent Dry Eye Fireside Chat, Damon Dierker, OD, FAAO and Jessilin Quint, OD, MBA, FAAO discussed whether that framework can really work in everyday eye care. Their answer was yes, and it starts with knowing what to look for.
“We really have to understand what the etiologic drivers are for individual patients, and it's not just, ‘I have dry eye, step 1, 2, 3, 4.’”
Dry eye fast facts
- DEWS III defines dry eye as a multifactorial, symptomatic disease involving loss of tear film and/or ocular surface homeostasis.1
- The Ocular Surface Disease Index-6 (OSDI-6) is the recommended screening questionnaire, with a score of 4 or greater prompting further evaluation.1
- Diagnosis requires symptoms plus at least one clinical sign of disrupted ocular surface homeostasis.1
- After diagnosis, DEWS III emphasizes identifying individual etiologic drivers rather than moving every patient through the same treatment sequence.1,2
- Tear film deficiencies, eyelid abnormalities, and ocular surface or neurosensory dysfunction can all drive disease.1
- Lifestyle, environment, medications, procedures, sleep, stress, diet, and other modifiable or iatrogenic factors can influence disease and long-term management.2,3
Screening can find what patients do not know to report
Dry eye does not always present with an obvious dry eye complaint. Sometimes patients come in because of blurred vision, tired eyes, or because they think they need a spectacle prescription. Others have lived with and adapted to their symptoms for so long that they do not describe them clearly. That is where the clinician has to ask the right questions.
DEWS III can change primary eyecare in a very practical way. Dr. Quint previously used the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire mainly during dedicated dry eye visits and follow-ups.
She now incorporates the OSDI-6 into comprehensive examinations, giving her a way to uncover symptoms earlier. A score of 4 or greater prompts further evaluation, although symptoms alone do not establish the diagnosis. DEWS III requires symptoms plus evidence that ocular surface homeostasis has been disrupted.1
That does not mean turning every comprehensive exam into a full dry eye workup. In Dr. Quint’s practice, symptoms paired with even one clinical sign, such as abnormal staining or tear breakup time, may be enough to dictate the next course of care and bring the patient back for a deeper evaluation.
The ocular surface is also a vision issue. The best glasses or contact lens prescription may still disappoint if it is measured over an unstable surface. Finding and treating the problem can improve comfort, but it can also improve the quality and consistency of the vision clinicians are trying to correct.
The diagnosis does not tell you what to treat
Once dry eye is identified, the more useful question is: How did this patient get here?
DEWS III shifts the focus toward systematically identifying the etiologic drivers and tackling them deliberately.1,2 Tear deficiency may dominate one case. Another may involve meibomian gland dysfunction, Demodex, incomplete lid closure, inflammation, neurosensory dysfunction, or several of these at once. The diagnosis may be the same, but the path to it may be very different.
That distinction matters because clinicians have an impressive range of diagnostics, treatment options, and modifications available today. More choices only help when they are aimed at the right problem.
“It’s not a one-size-fits-all.”
DEWS III provides a framework that can be applied in primary eyecare, a dedicated dry eye clinic, or somewhere in between. The technology available may change, but the process remains useful: look for symptoms, look for loss of homeostasis, dig further, identify the drivers, and begin tackling them one at a time.
When the pieces do not fit, keep looking
Sometimes the symptoms and clinical findings simply do not line up. A patient may report significant discomfort with few visible findings, while another has substantial ocular surface disease and surprisingly little discomfort. That mismatch is not a reason to stop looking. It may be the reason to look harder.
DEWS III gives neurosensory dysfunction a more prominent place in that assessment.1,3 The wider picture matters, too. Eyelid position, incomplete blinking, Demodex, meibomian gland function, medications, hormonal influences, environmental exposure, and iatrogenic dry eye related to medications, contact lenses, surgery, or other interventions may all contribute.1,3
Long-standing dry eye that remains underdiagnosed or undertreated can carry consequences of its own. Chronic inflammation and years of ocular surface damage may alter corneal sensation, and some patients may eventually present with blurred vision rather than the discomfort clinicians expect. The absence of a classic complaint does not necessarily mean the surface is healthy.
Build the foundation, too
Finding the etiologic drivers does not mean overlooking the basics. Dr. Quint emphasizes building a solid foundation and making that conversation part of every patient encounter.
Sleep, stress, diet, nutraceuticals when appropriate, blinking behavior, and environmental exposure all deserve attention. Sometimes the modification is as simple as asking a patient not to sleep with a fan blowing directly across the face.
However, these changes do not replace pharmacologic or procedural treatment when it is needed. They help create a better foundation for it. DEWS III incorporates environmental and lifestyle considerations into management alongside targeted therapies, recognizing that what happens outside the exam room can continue to influence the ocular surface every day.2
Conclusion
DEWS III has not made dry eye simpler. It has made the clinical reasoning more precise.
Its real-world value is in giving clinicians a framework they can actually use: ask the right questions, look for symptoms and loss of homeostasis, dig deeper when something does not fit, identify the etiologic drivers, and tackle them one at a time while building a foundation that supports long-term ocular surface health.
Dry eye is not one disease, and DEWS III gives clinicians a practical way to stop treating it as though it were.
This article was written by Dianne Barnard, RN based on the recorded conversation between Drs. Dierker and Quint.
