TFOS DEWS III: What Changed in Dry Eye Diagnosis and Treatment
Last updated: October 2026
The Tear Film & Ocular Surface Society's third Dry Eye Workshop (TFOS DEWS III) was published in 2025 in the American Journal of Ophthalmology, eight years after DEWS II. It tightens the definition, standardises the diagnostic sequence, and replaces the aqueous-versus-evaporative split with driver-based subtyping. Several new drugs have also arrived since DEWS II.
The revised definition
DEWS III describes dry eye as a multifactorial, symptomatic disease characterised by a loss of homeostasis of the tear film and/or ocular surface. Tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities remain the etiological factors. The two changes to notice: symptoms are now part of the definition itself, and the ocular surface is named alongside the tear film.
Diagnosis: DEWS II vs DEWS III
| Step | DEWS II (2017) | DEWS III (2025) |
|---|---|---|
| Symptoms | OSDI ≥13 or DEQ-5 ≥6 | A single questionnaire: OSDI-6, positive at ≥4 |
| Tear film test | Any one of the signs below was enough with symptoms | Either non-invasive tear break-up time (NIBUT) <10 s or tear osmolarity ≥308 mOsm/L. The two perform similarly. |
| Ocular surface staining | One of the optional signs | Performed in every case: >5 corneal spots, >9 conjunctival spots, or lid margin staining ≥2 mm long and ≥25% of its width |
| Optional extras | — | Schirmer test, meibography and other tests when time and resources allow |
Use fluorescein for the cornea and lissamine green for the conjunctiva and lid margin. Check the full DEWS III diagnostic methodology report for the exact decision rule before using it in a thesis.
Subtyping by drivers, not by two boxes
- Almost all dry eye has an evaporative component, so the old aqueous-deficient vs evaporative dichotomy is no longer the organising principle.
- Instead, look for the drivers in each patient across three areas: the tear film layers (lipid, aqueous, mucin), the eyelids (meibomian glands, blinking, lid closure, Demodex) and the ocular surface.
- Each driver is matched to evidence-graded treatments in the DEWS III management report. One therapy may address two drivers, and a lid treatment a third.
- Corneal nerve and sensation assessment is recognised as important, but there is not yet a standard method.
New drugs since DEWS II
| Drug | Mechanism and target | Evidence and notes |
|---|---|---|
| Lotilaner 0.25% (Xdemvy, FDA July 2023) | Antiparasitic (GABA-Cl channel inhibitor) for Demodex blepharitis | Twice daily for 6 weeks. Collarette cure at day 43: 44% and 55% vs 7% and 12% with vehicle (Saturn-1 and Saturn-2). Stinging in about 10%. |
| Perfluorohexyloctane (Miebo, FDA 2023) | Water-free semifluorinated alkane that forms an anti-evaporative layer | For evaporative dry eye and meibomian gland dysfunction. Preservative-free. |
| Cyclosporine 0.1% in a semifluorinated alkane (Vevye, FDA 2023) | Immunomodulator in a water-free vehicle | Another option alongside cyclosporine emulsions and lifitegrast. |
| Acoltremon 0.003% (Tryptyr, FDA May 2025) | First-in-class TRPM8 (cold receptor) agonist that triggers reflex basal tearing | Schirmer gain of ≥10 mm at day 14: 42.6% and 53.2% vs 8.2% and 14.4% with vehicle (COMET-2 and COMET-3). Instillation burning in about half of patients. |
| Varenicline nasal spray (Tyrvaya, FDA 2021) | Nicotinic agonist acting on the trigeminal parasympathetic pathway | Increases natural tear production. Sneezing is common. |
Most of these are US approvals. In India, the core of management remains lid hygiene and warm compresses, preservative-free lubricants, cyclosporine, short courses of mild steroids, tea tree oil for Demodex, and procedures such as thermal pulsation or IPL where available.
Viva pearls
- Cylindrical dandruff (collarettes) at the lash base is pathognomonic of Demodex. D. folliculorum lives in lash follicles and D. brevis in meibomian glands.
- Osmolarity ≥308 mOsm/L is the tear-film cut-off.
- OSDI-6 replaces the full OSDI and DEQ-5 as the DEWS III screening questionnaire.
- DEWS reports: 2007, 2017, 2025.
Related: cornea notes, ocular pharmacology and presbyopia eye drops.
Key sources
- Review of Optometry: DEWS III diagnostic protocols and subtyping
- AOP: TFOS DEWS III updates definitions and diagnosis
- TFOS DEWS III: Diagnostic Methodology (PubMed)
- FDA Drug Trials Snapshot: Xdemvy
- EyeWiki: Acoltremon (Tryptyr)
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