The Tear Film & Ocular Surface Society (TFOS) has begun the staggered release of its newest Dry Eye Workshop (DEWS III) report with the publication of the Diagnostic Methodology report at the end of May.
While the full report will be extensive in length, we’ll give you a Glance-ified overview.
Let’s start with the basics on TFOS.
Launched in 2000, TFOS is a Boston, Massachusetts-headquartered nonprofit organization specializing in eye health education.Its focus:
- Advancing research, literacy, and education of the tear film and ocular surface
- Organizing and coordinating international conferences, workshops, seminars, and events
- Promoting interactions among TFOS members and recruiting new members with diverse expertise (industry; scientists; academic clinicians)
And since its founding, the organization has contributed to:
- Promoting increased international awareness of external ocular diseases
- Enhancing governmental funding for tear film and ocular surface research
- Supporting the development of therapeutic drugs and diagnostic devices
- Impacting the design and conduct of clinical trials for novel OSD treatments
Now to DEWS.
Before we get to this latest installment, a brief rundown on the original DEWS (and DEWS II) is in order.
About DEWS: Published in the Ocular Surface Journal in 2007, this initial report was a global consensus on dry eye disease (DED) resulting from a +3-year, global collaborative effort of 150 clinical and research experts.
- The purpose: To review current knowledge of DED as well as the methods used for diagnosing, evaluating, and treating the ocular surface disease (OSD).
- Specifically: The report delivered evidence-based, unbiased reference material that was an update from the 1995 National Eye Institute/Industry Workshop.
And DEWS II?
As an update to the 2007 DEWS, DEWS II was a nearly 400-page report published in 2017 following almost 2.5 years of collaboration involving 150 experts from 23 countries.
Its purpose: The report redefined dry eye as a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film.
- Included in this: Proposed recommendations for clinical trial designs to assess new pharmaceuticals for dry eye treatment as well as a revised definition of DED.
- And importantly: A need for sub-classification post-DED diagnosis was emphasized.
- Check it out here.
Now to this latest installment.
TFOS began teasing the expected launch of DEWS III earlier this year, announcing plans to update DEWS II by focusing on “new and significant advances in the diagnosis, management, and classification” of DED.
Per the organization, a DEW III initiative of 80 experts from 18 countries utilized an “evidence-based approach” with “open communication, dialogue, and transparency” to develop a digest highlighting new advances in the dry eye field, including:
- Sex
- Gender
- Hormones
- Epidemiology
- Pathophysiology tear film
- Pain and sensation
- Iatrogenic dry eye
- Clinical trial design
Talk about the release of this Diagnostic Methodology report.
We’ll begin with its purpose, which involves several components.
- Revisiting the current definition of DED and ensuring its alignment with clinicians’ current understanding of the disease
- Utilizing risk/associated factors for DED (as outlined in the DEWS II report) and masquerading diseases to guide appropriate history and symptom-taking
- Identifying any necessary updates to the 2017 DED diagnosis, with an emphasis on the need for change and notable challenges to available evidence
- Proposing a new etiological driver-based approach to DED subclassification
- Discussing potential future directions to better inform further DED diagnosis and subclassification advances
Circling back this DED definition. Were any changes made?
Yes, actually. The DEWS III authors made a few minor (but still significant) adjustments to the definition.
For reference, the DEWS II definition read as follows:
- “Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”
And the updated DEWS III definition:
- Dry eye was reintroduced as a "multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability …”
The change: DED is referred to as a "symptomatic" disease and the loss of homeostasis is linked to either the tear film or ocular surface instead of more generalized “ocular symptoms.”
Any other updates to note?
Indeed. Specifically in regards to that “symptomatic” component.
The details: The DEWS III authors stressed the need to begin the dry eye identification process with patient input via a validated questionnaire.
- For example: The 12-question Ocular Surface Disease Index (OSDI) has long been used to evaluate symptoms of ocular association with DED and the impact on visual function
The change: While DEWS II recommended two potential questionnaires (including the OSDI and the 5-item Dry Eye Questionnaire [DEQ-5]) be used for this process, the DEWS III authors noted that these have since been found to risk “variability in diagnosis” depending on the chosen instrument.
- As such, a single questionnaire was developed: OSDI-6.
How is this different from the OSDI?
To start: This shorter, six-question questionnaire is a simplified version of the standard 12-question option.
- Specifically: It’s described as “ideal for screening and is recommended to be conducted as the first component within eye care examinations to identify those patients who would benefit from a fuller diagnostic evaluation to determine the likely drivers of disease.”
Gotcha. Can we get a look at these six questions?
You bet. See below.
- Do you feel eye pain rather than discomfort?
- Do you have any facial flushing/redness, mouth dryness, or enlarged salivary glands?
- When did your symptoms start and can you recall any triggering event?
- Is your vision affected and, if so, does it improve on blinking?
- Are the symptoms or any redness much worse in one eye than the other?
- Do the eyes itch, are swollen, crusty or have given off any discharge?
To note: A “detailed examination of the ocular surface is recommended” where a patient’s responses may suggest the potential presence of eye conditions that might be disguised as DED.
And what does the full DEWS III diagnostic algorithm entail now?
The three-step process involves:
- Administering of the OSD-6 questionnaire
- Measuring either noninvasive tear breakup time or osmolarity
- Cutoff: < 10 seconds or ≥308 mOsm, respectively
- Assessing ocular surface staining
- Cornea >5 punctate spots and/or
- Conjunctiva >9 punctate spots and/or
- Lid margin ≥2mm length and ≥25% width
So should this be the only questionnaire for DED, or can others be used?
The DEWS III authors acknowledged that others may be utilized—such as the OSDI or DEQ-5—to “gain further understanding of the environmental risk factors” for the disease.
- However: This “standardized diagnostic questionnaire” is considered necessary for achieving “diagnostic consistency for all patients,” they noted.
As such: The shorter questionnaire “further simplifies the procedure for application in clinical practice.”
Alrighty, what other updates to be aware of?
While we’ll emphasize that the full DEWS III report is not yet released, this Diagnostics Methodology report did note the following key changes from the DEWS II report:
- Updates made to known DED risk/associated factors based on scientific evidence (released since DEWS II was published) as well as factors known to be associated with or cause DED
- See here for these; a more detailed look at this will be available in the DEWS III Digest Epidemiology section.
- New evidence supports a more detailed subclassification of DED based on etiological drivers, enabling identification for an individual patient’s more appropriate management and therapy
Good to know … so when can we expect more of this report to be released?
A few other sections (plus an editorial) have been released since the Diagnostic Methodology report’s publication, including:
- TFOS DEWS III Editorial (published May 28, 2025)
- TFOS DEWS III Management and Therapy Report (published June 2, 2025)
- TFOS DEWS III Digest Report (published June 3, 2025)
Stay tuned for more!