Dry eye: where are we today?

Symptoms of dry eye represent a significant impairment. Hundreds of millions of people worldwide suffer from dry eye disease. It is one of the  main reasons for visits to eye care providers specialists; in moderate to severe cases, it isassociated with considerable pain, restricted movement, low vitality and poor general health.¹

The Tearfilm & Ocular Surface Society (TFOS) was founded in 2000 and set a milestone with the first TFOS Dry Eye Workshop (DEWS) Report ² in 2007. TFOS is a non-profit organisation founded to promote research, education and training in the field of the tear film and ocular surface. TFOS has launched numerous global initiatives. The best known are probably the TFOS workshops. These give rise to regular white papers. Recognised experts conduct intensive literature research and summarise their findings in a report. 
Following the first TFOS DEWS Report, the TFOS DEWS Report II (2017) ³ represented another milestone. For the first time, based on the existing litera-ture and the consensus of the experts at this workshop, a defined workflow was described that reflects the definition of dry eye on the one hand and allows for a clear diagnosis of dry eye on the other.⁴

The aim was to ensure that the diagnosis of dry eye is made correctly, re-gardless of where the patient is examined. Without such a defined workflow, dry eye might be diagnosed in one practice but not in another.

A disease is described as precisely as possible in a definition. The diagnostic method is based on this definition. The diagnosis is followed by further exami-nations, which ultimately allow specific treatment. In addition to the diagnostic flowchart, the TFOS DEWS II Report published a step-by-step algorithm for the management and treatment of dry eye.⁵ 

It was left to the eye care providers to assign the treatment options to the underlying causes of dry eye in each individual case after a comprehensive examination.

Eight years have now passed and the TFOS DEWS III Report has recently been published.1,6-8 As the TFOS DEWS II Report was very comprehensive with 10 individual reports,^4,5,9-16 it was decided before the TFOS DEWS III Report was compiled to write a so-called digest report ⁷ summarising 7 reports in order to focus on the report for diagnostic methods ⁶ and the report for management and treatment⁸.

Furthermore, the definition of dry eye has been clarified. Two key points to highlight are, firstly, that dry eye is understood as a combination of objective abnormalities and symptoms. Secondly, in addition to the homeostasis of the tear film, the homeostasis of the ocular surface, including the eyelids, is included in the definition.^6,7

Possible differential diagnoses and modifiable and non-modifiable risk factors are now summarised in very clear graphics, facilitating the workflow in practice. The specified diagnostic workflow remains almost unchanged from that of Report Two. Only the screening questionnaires, the Ocular Surface Disease Index (OSDI) and Dry Eye Questionnaires 5 (DEQ-5), have been replaced by the OSDI-6 questionnaire ¹⁷. 
 

For an objective diagnosis of dry eye, it remains necessary to examine tear film stability non-invasively and/or measure tear film osmolarity, as well as to classify the stainability of the ocular surface and eyelids with fluorescein and lissamine green (conjunctival and corneal spots; lid wiper epitheliopathy). Both tests – assessment of the tear film and staining of the ocular surface – must be performed. If one of these so-called homeostasis markers is positive and the OSDI-6 questionnaire is positive, dry eye is considered to be diagnosed.⁶
 

This is followed by various observations, including tear film volume, lipid layer, eyelid margins, meibomian glands, meibomian gland secretion, and eyelid blinking, in order to determine the cause of dry eye in individual patients and then to address specific treatment options.

There are three categories (tear film deficiencies; eyelid ab-normalities; ocular surface abnormalities) which have been excellently presented in a chart and for which the treatment options have been classified according to evidence. This is a huge help for practitioners in choosing the best possible treatment for dry eye.

It has been shown that, in addition to the simple options of recommending different types of eye drops specific to the subclassification of dry eye, there are successful options for more severe cases of dry eye, such as special aids, dietary supplements, as well as numerous in-office options, such as professional therapeutic expression of the meibomian glands, professional eyelid margin care, intense pulse light (IPL) ther-apy and Low-Level Light Therapy (LLLT). Depending on the type and cause of dry eye and the severity of the condition, these numerous options are very promising in many cases.⁸ This brings us full circle: in order to be able to address the best possible treatment options, the diagnosis must be correct and differential diagnoses must have been clarified. On the other hand, the subclassification according to cause must have been correctly determined. A corresponding workflow has been defined in TFOS DEWS II and TFSO DEWS III. This should be followed.

Since the TFOS DEWS II Report, it has become clear, that a minimum level of instrumental equipment and skill is required to run a dry eye practice with a clear conscience and on an evidence-based basis. With regard to diagnosis, noninvasive observation of the tear film is crucial,^4,6 for which at least a so-called cold light illumination should be used, up to the option of using multifunctional instruments such as video topographers with additional functions for dry eye. It is not necessary to purchase a supposedly more expensive multifunctional instrument immediately, but cold light illumination such as the Polaris (Construtione Strumenti Ophthtalmology, Florence, Italy; bon Optic Vertriebsges. mbH) or Easytears (Easytear S.R.L., Rovereto, Italy) represent the minimum equipment required for the diagnosis of dry eye (assessment of homeostasis markers).

This standardised workflow for the diagnosis of dry eye from TFOS DEWS II was confirmed in the TFOS DEWS III report and its strict application was classified as fundamental. However, diagnosis alone is not sufficient to establish an optimal treatment plan. Dry eye usually has multifactorial causes, which must also be examined in a defined manner according to any deficiencies in the tear film, abnormalities of the eyelids and abnormalities of the ocular surface, taking into account differential diagnoses. 

Here, too, a minimum level of technology should be used.⁶ This include for example, measurement of the tear meniscus using at least a measuring ocular (or digital options such as multifunctional instruments, or using software from a video slit lamp microscope, etc.), assessment of the interference of the lipid phase using cold light illumination, expression of the meibomian glands with repeatable pressure relevant to eyelid closure (e.g. TearScience™ Meibomian Gland Evaluator, Johnson & Johnson, Jacksonville, USA) and assessment of the morphology of the meibomian glands using meibography and the resulting option of estimating the success of treatment in cases of meibomian gland dysfunction, for example.^6,18 

The TFOS DEWS III Diagnostic Methodology Report clearly describes the possible standard and advanced test options and provides an example of a test sequence for diagnosing and identifying the causes (subtypes) of dry eye. These appear to be sensible guidelines that can be implemented in practice.

Looking at the various examinations and tests for dry eye worldwide, it is clear that in practice, the TFOS DEWS II Report is not being implemented to the extent hoped for.¹⁹ As in all areas of ophthalmology and optometry, knowledge and the necessary skills are increasing considerably, as are the technical possibilities. Whether it is the diagnosis and management of glaucoma or other retinal diseases, special refraction techniques or dry eye, specialisation with the right equipment for proper, evidence-based care of our patients should be standard. The gap between what happens in practice and what is needed is a problem for reliable dry eye care. At the same time, it seems that not all eye care providers are aware of the extensive treatment options available. As a result, there are numerous cases in which patients are not referred to a specialist practice for the treatment of dry eye, even though this would be promising in terms of obtaining the optimal treatment option.²⁰

Scientifically, we have made great progress in the last two decades, and many eye care providers are applying these findings for the benefit of those affected, but there is still considerable room for improvement among many eye care providers. This may be due to an underestimation of the issue. However, as dry eye is an important topic at practically every specialist conference, the literature is extensive and the TFOS reports are freely accessible to everyone, this gap should now be closed quickly.

Literaturverzeichnis:

[1] TFOS DEWS III Leadership group. (2025). TFOS DEWS III Editorial. Am. J. Ophthalmol., S0002-9394, 00273-00279.

[2] No authors listed. (2007). The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee   of the International Dry Eye WorkShop Ocul. Surf., 5, 65-204.

[3] Craig, J. P., Nelson, J. D., Azar, D. T., Belmonte, C., Bron, A. J., Chauhan, S. K., de Paiva, C. S., Gomes, J. A. P., Hammitt, K. M., Jones, L., Nichols, J. J., Nichols, K. K., Novack, G. D., Stapleton, F. J., Willcox, M. D. P., Wolffsohn, J. S., Sullivan, D. A. (2017). TFOS DEWS II Report       Executive Summary. Ocul. Surf., 15, 802-812.

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[9] Novack, G. D., Asbell., P., Barabino, S., Bergamini, M. V. W., Ciolino, J. B., Foulks, G. N., Goldstein, M., Lemp, M. A., Schrader, S., Woods, C., Stapleton, F. (2017). TFOS DEWS II Clinical Trial Design Report. Ocul. Surf., 15, 629-649.

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[11] Bron, A. J., de Paiva, C. S., Chauhan, S. K., Bonini, S., Gabison, E. E., Jain, S., Knop, E., Markoulli, M., Ogawa, Y., Perez, V., Uchino, Y., Yokoi, N., Zoukhri, D., Sullivan, D. A. (2017). TFOS DEWS II pathophysiology report. Ocul. Surf., 15, 438-510.

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[20] Craig, J. P., Wolffsohn, J. S., Stapleton F. Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) III. (2025). In: BCLA Clinical Conference and Exhibition; 2025 5-7 June 2025; Birmingham; 2025