Symptoms of dry eye disease (DED) are a leading cause of visits to eyecare providers and affect hundreds of millions of people globally. Treating and managing patients with DED pose a significant challenge for eyecare providers because it is a complex multifactorial disease that comprises many different etiological factors. Many dry eye patients have seen multiple doctors over several years without any relief from their symptoms and their symptoms often continue to worsen. Dry eye is a symptomatic disease that significantly impairs quality of life—it restricts daily activities such as computer work, reading, watching TV, outdoor activities, sleeping, and driving. Its impact on daily life is comparable to more severe chronic illnesses like moderate-severe angina or mild psoriasis.1 Over the last decade, DED has matured into a true specialty within eye care, but many practices still struggle with the same practical question: How do you translate consensus guidance into a workflow that is both clinically sound and operationally realistic? This is where TFOS DEWS III can become especially useful in clinic.
TFOS DEWS Background
The mission of the Tear Film and Ocular Surface Society DEWS reports is to continuously update and refine the definition, classification, diagnosis, and treatment strategies for DED based on current evidence-based knowledge. The field of ocular surface disease is relatively young when compared to other areas of eye care: Dry eye was first recognized as a disease in 1995 following the National Eye Institute/Industry Workshop on Clinical Trials in Dry Eye and the first DEWS report was published in 2007 to update the 1995 report. Since the initial DEWS I report, there have been significant advancements in the field of ocular surface disease and our clinical understanding of DED has deepened. Subsequent DEWS reports have updated and guided clinicians, researchers, and regulatory agencies in identifying, treating, and studying DED more effectively.
The most current report, DEWS III, was published in 2025.2-4 It characterizes dry eye as a multifactorial, symptomatic disease that is marked by loss of tear film, ocular surface homeostasis, or both. Tear film instability, hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities all serve as etiologic factors. The deliberate inclusion of “symptomatic” matters because it reinforces that dry eye is fundamentally a patient-experienced disease, even if signs and symptoms do not always correlate perfectly, which they often do not. DEWS III updated prior recommendations on the definition of dry eye, diagnostic methodology, and management while moving DED subclassification away from the old broad “aqueous-deficient vs evaporative” model and toward an etiological driver-based framework.
After confirming that a patient truly has dry eye by a validated symptom questionnaire (ie, the OSDI-6) plus objective sign showing loss of homeostasis (see the next section), DEWS III recommends identifying the specific drivers that are responsible for that individual’s disease so treatment can be better matched to mechanism, rather than forcing patients into overly simplistic severity categories. For the busy clinician, the goal is to identify the drivers of disease early, subtype appropriately, and then layer treatment in a rational way that matches the patient’s clinical findings, symptoms, lifestyle risk factors, systemic drivers, and likelihood of adherence to the treatment plan.
In practice, the most successful dry eye clinics build around 3 principles:
- Diagnose with consistency.
- Treat to subtype and mechanism of the underlying cause.
- Educate patients and staff so the treatment plan feels logical rather than overwhelming.
When clinics adopt these principles into clinical practice, the “step ladder” becomes less of a rigid staircase and more of a strategic framework. For practices trying to apply DEWS III, this is a helpful mindset shift. Dry eye should be framed as a chronic, multifactorial, symptomatic ocular surface disease that deserves the same systematic approach we would apply to glaucoma, macular degeneration, or diabetic eye disease. We should not be treating DED as a mild inconvenience to our patients; it is a chronic disease that affects quality of life and can lead to permanent ocular surface damage and vision loss if improperly treated.
A Practical DEWS III Diagnostic Workflow
DEWS III moves the field toward a more streamlined diagnostic pathway that can start before the doctor enters the room. The report recommends a single validated questionnaire, the Ocular Surface Disease Index-6 (OSDI-6), as a symptom screening tool. The purpose of a single questionnaire is to standardize diagnosis of DED, have a repeatable tool for documenting symptoms, and offer a comparable way to monitor patient symptoms over time. Once symptoms are established, diagnosis requires at least 1 objective sign of homeostatic loss, such as noninvasive breakup time under 10 seconds, tear hyperosmolarity at or above 308 mOsm/L in either eye or an intereye difference greater than 8 mOsm/L, or characteristic ocular surface staining thresholds involving the cornea, conjunctiva, and/or lid margin.
In practice, the workflow can be simplified into 4 steps:
- Screen symptoms consistently with a validated questionnaire.
- Confirm loss of homeostasis with objective testing.
- Identify the dominant etiological drivers and subtype the disease.
- Match therapy to the drivers.
Step 3 is where many practices underperform. They diagnose “dry eye” and then prescribe a generic treatment bundle that may not address the underlying cause of the patient’s condition. Following the DEWS III protocol pushes us beyond that. Is the problem primarily lipid deficiency, aqueous deficiency, mucin/glycocalyx compromise, blink abnormalities/dysfunction, lid margin disease, exposure, ocular surface inflammation, neurosensory abnormalities, or a combination of several factors? A patient with short break-up time, poor meibum quality, lid margin telangiectasia, and minimal staining does not need the same first-line emphasis as a patient with aqueous tear deficiency, significant conjunctival staining, and ocular surface damage. Likewise, a patient with Demodex blepharitis, incomplete blinking, rosacea, or exposure-related disease may need treatment directed to the lids or adnexa before the ocular surface improves meaningfully.
If we follow DEWS III guidelines, technicians and doctors need to see every test not as a data point to collect, but as a clue to what is driving the disease. Once dominant drivers have been identified, DEWS III emphasizes evidence-based management options based on 3 etiological subtypes of dry eye disease: tear film deficiencies, eyelid abnormalities, and ocular surface abnormalities.
Broad subgrouping is often inadequate because multiple pathogenic drivers commonly exist at the same time, can change over time, and often need multiple concurrent treatments. A postmenopausal patient, for example, may have evaporative dry eye from meibomian gland dysfunction, incomplete blinking from screen habits, surface inflammation, early conjunctivochalasis, and fluctuating symptoms that are worsened by environment or systemic medications. If we treat only 1 driver, we underperform clinically and frustrate the patient.
Keeping this in mind is essential for providing optimal patient outcomes, preventing worsening of the disease, and improving quality of life. Algorithms are provided in the DEWS III management and therapy report for each etiological subtype to aid clinicians in selecting appropriate evidence-based treatment options.
The goal is to develop a comprehensive treatment plan that addresses all the factors contributing to the patient’s symptoms. Sometimes this can be tricky because we don’t want to overwhelm patients with a treatment plan that is too complex and burdensome for them to follow. In these instances, we want to start a treatment plan that addresses what appears to be the main driver of their symptoms, then layer on additional treatments after the patient has become comfortable with the current treatment plan. We want to help our patients stack habits over time that will ultimately address underlying causes and bring them significant relief from their symptoms.
The modern dry eye “step ladder” should be viewed less as a strict sequence and more as a layered treatment model:
- Subtype-directed therapy for lids, tears, and ocular surface
- Foundational support for tear film homeostasis
- Escalation based on response, severity, and chronicity
- Ongoing maintenance to preserve gains
That is how DEWS III translates best into real practice: It moves us away from trying step 1 treatments and, when those do not work, moving onto step 2 treatments and so on. It allows us to treat the underlying cause from multiple angles at the same time.
Layer 1: Build the Foundation
The first rung of the ladder is still foundational care, but DEWS III helps clarify its purpose. Stabilization of the tear film and tear supplementation continue to be a mainstay in the treatment of dry eye disease because these treatments can often address multiple etiological factors at the same time. First-line management focuses on replenishing, conserving, and stimulating the tear film, and it continues to regard ocular lubricants and related tear-support strategies as core tools. Lifestyle modification, including blink optimization, environmental adjustments, and dietary support where appropriate, also plays a significant role.
In the clinic, this means the foundation often includes preservative-free lubricants or other appropriate tear supplementation, tear conservation devices (eg, contact lenses, moisture retaining glasses, and punctal plugs), nutritional education, environmental counseling (ie, humidity, airflow, and screen behavior blink education, especially for digital device users), medication and risk factor review, contact lens wear, and cosmetic and hygiene counseling.
Patient Education at This Layer
The mistake many practices make is presenting some of these steps as “simple” or “conservative,” which patients often interpret as “optional.” Doctors and staff should instead present them as foundational treatments that are essential for improving their symptoms. How we educate our patients matters and is an essential step for patient success. Patients should hear, “This is the foundational base of your treatment plan because we are trying to treat the root cause of the disease, stabilize the ocular surface, and improve the quality of your tears.” In chronic diseases, foundational therapy is the base that supports all other interventions.
Patient adherence to the treatment plan is often one of the most difficult factors in treating dry eye patients. The way we frame treatment plans to our patients can improve adherence, which is key for their success. It is important not only to tell the patient what the treatment plan is but also to explain how to properly utilize the treatments, and why this treatment is going to help improve their symptoms. Patients are far more likely to follow a treatment plan correctly and make behavioral changes when they understand the why behind what they are doing and when it sounds logical, specific, and connects to their symptoms. They do not need a lecture on tear film biochemistry, but they do need to know why each treatment exists. Therefore, foundation therapy should not sound like a brush-off before the “real” treatment begins. It should be framed as necessary treatment that supports every other intervention.
Prioritizing treatments can also be helpful for patient compliance. A new dry eye patient is likely to leave with several different recommended treatments, but not all recommendations should carry the same weight. I suggest separating the plan into must-do now, helpful support, and next steps to reduce overwhelm and make follow-up visits more productive.
Layer 2: Treat the Lids Early and Aggressively
One of the biggest practical messages in DEWS III is the importance of lid disease, especially meibomian gland dysfunction, as a major driver of dry eye. The management report specifically discusses lid hygiene strategies and warm compresses, topical corticosteroids and/or antibiotics, and a broad range of in-office lid-directed options, including heat-based and light-based devices such as intense pulsed light (IPL), low-level light therapy (LLLT), and blepharoexfoliation.
For many clinicians, this guidance validates what they already see every day: If the lids are not improved, the tears and ocular surface often stay unstable, and symptoms do not improve. This is where the step ladder becomes more strategic. In a predominantly evaporative patient, escalating earlier to lid-directed therapy will be more effective than spending months cycling through additional artificial tears. A patient with capped glands, poor meibum expression, telangiectatic lid margins, rosacea, or recurrent chalazion often needs more than home care and should be offered more advanced treatment options such as IPL, LLLT, blepharoexfoliation, or a combination. Likewise, a patient with Demodex blepharitis will not improve predictably if the parasitic load remains untreated.
A practical DEWS III takeaway is that clinicians should offer patients procedure-based therapy early in the step ladder when the exam supports it. The goal is not to “wait until they fail enough.” It is to intervene at the level of pathology and provide treatment options that address the underlying cause of the disease.
Patient Education at This Layer
For staff, this is one of the most important educational opportunities in the entire dry eye service line. Team members need to be able to explain, in plain language, that healthy tears depend on healthy oil glands and healthy lids. When a technician can say, “Your tears are evaporating too quickly because the oil layer is not functioning well and this is a root cause of your symptoms,” patients understand why tears alone have not solved the problem and are more likely to accept advanced treatment options. This is also where imaging can change the conversation and help patients better understand their condition by connecting anatomical changes to symptoms and treatments. When patients see their own gland structure, lid margin disease, ocular surface staining, and/or inflammatory changes, the condition becomes more tangible.
Layer 3: Address Inflammation and Ocular Surface Damage
As dry eye progresses, or in patients who present with significant ocular surface findings from the beginning, the ocular surface itself becomes a more prominent treatment target. DEWS III includes anti-inflammatory medications and advanced therapies among its evidence-based options, and it notes that more advanced interventions, such as epithelial promoters (ie, blood-derived products and amniotic membranes), in-office procedures (eg, IPL and LLLT), and complex surgical methods, may be appropriate for severe or refractory disease.
This is the point in the ladder where clinicians must balance short-term symptom relief with long-term control of the disease process. The exact treatment mix will vary, but the principle remains the same: Once inflammation, epithelial compromise, or chronic surface injury become prominent, the plan must move beyond lubrication and lid hygiene. In practice, this may include prescription anti-inflammatory therapy, biologic support in selected patients, protective or regenerative approaches in more advanced disease, and management of contributory ocular surface pathology.
The key is not merely adding more treatments; again, it is the principle of matching the intervention to the dominant barrier of homeostasis through diagnostic testing and clinical examination. Is inflammation the dominant barrier? Is it exposure causing chronic epithelial damage? Is lid disease adequately managed? Are signs and symptoms out of alignment with each other, suggesting a neurological component? DEWS III is especially helpful here because it moves the conversation away from arbitrary stage labels. A patient may have severe symptoms with relatively little staining, or obvious surface damage with a surprisingly muted symptom profile. That is why treatment should be driven by disease drivers and clinical context, not just by a blanket severity bucket.
Patient Education at This Layer
Follow-up visits are an essential component for patient success. Dry eye should not be treated as 1 visit with yearly follow-up. The initial dry eye exam should serve to establish a baseline, determine main drivers, and choose appropriate evidence-based therapy. Follow-up visits serve to measure response to treatment, adjust treatments accordingly, and reiterate the chronic nature of the disease.
Layer 4: Use Combination Therapy When the Exam Supports It
A useful real-world application of DEWS III is stressing that dry eye is a multifactorial disease and often combination therapy is necessary for optimal results. As discussed, many patients do not belong on just 1 rung of the ladder; they belong on several at once, and treating only 1 factor will often produce only partial improvement; patients may conclude that the treatment “doesn’t work” and stop it prematurely.
Patient Education at This Layer
Sometimes when there are many different factors that need to be addressed, patients are likely to be overwhelmed. Explain the roadmap to them: “Today we are staring with foundational treatments and addressing the inflammation. At your follow-up, we will discuss more options to improve meibomian gland dysfunction.” This gives the patient a manageable starting point with the knowledge that additional treatments will be explored later because it is a logical response to a multifactorial problem and they understand we are addressing the underlying cause of their symptoms. The team can help with this. The best educational framework is simple: “You have more than 1 factor contributing to your symptoms, so we are treating this from more than 1 angle.”
It is also helpful to remind patients that symptom improvement will take time and will require maintenance therapy to maintain stability. This way, patients will be more likely to accept and stick with the treatment plan and not give up after 2 weeks when they feel the treatment is not working.
Build a Practice Workflow Around the DEWS III Algorithm
A common concern is that DEWS III sounds complex and hard to adopt in a busy clinic. In reality, it can make workflows cleaner if implemented intentionally, especially if you use the algorithms and tables presented in the report to aid in appropriate diagnostic testing. They can help identify the etiological drivers and select treatments that are supported by the literature. The most successful dry eye clinics are not necessarily the ones with the longest menu of services. They are the ones that make diagnostics, evaluation, education, treatment selection, and follow-up exams consistent.
The key is to standardize diagnosis, treatment, and education for DED. Every dry eye evaluation should include a symptom screen, core objective testing, and a structured doctor assessment that answers a few essential questions:
- Does this patient meet DEWS III diagnostic criteria?
- What are the dominant drivers?
- Is the disease mainly tear film, lid, ocular surface, or mixed?
- What should be treated now?
- What therapies should be considered at follow up?
The technician’s role is critical for patient success. Staff should understand why each test is performed and how it helps the doctor choose what therapies to utilize. When staff know the logic behind each test, they become advocates for our patients in their dry eye journey. This is where scripting also helps. The technician who says, “I’m measuring your tear stability because that tells us whether your tears are evaporating too quickly,” is doing more than collecting data. That technician is increasing patient trust through education, priming the patient for the doctor’s explanation, and reinforcing the value of the exam.
Training Staff: Where Most Dry Eye Programs Succeed or Fail
The most sophisticated dry eye treatment ladder will underperform if the staff cannot explain it to patients in a way that they understand. Patients obtain valuable information from the team before they see the doctor. In many practices, the doctor understands the disease deeply, but the team describes it vaguely: “We’re just checking for dry eye,” or “The doctor may recommend some drops or a treatment.”
If dry eye is going to become a true clinical service line, staff need to be educated in a structured way. The first goal is conceptual understanding of the disease state and its chronic, symptomatic, and multifactorial nature. Team members do not need fellowship-level knowledge, but they should understand the multifactorial nature of the disease and the major buckets (ie, tear film deficiencies, eyelid abnormalities, and ocular surface abnormalities). They should also understand that blurred or fluctuating vision can be a dry eye symptom, meibomian gland dysfunction is often central to the problem, and treatment usually works best when multiple contributing factors are addressed together.
The second goal is diagnostic test literacy. Every staff member involved in workup should know what each diagnostic element is looking for and how it influences management. If they do not know why a test matters and how the findings affect the treatment plan, they cannot explain it to patients. Staff should be able to explain, in simple language, why the practice uses questionnaires, tear stability testing, osmolarity, staining, meibography, and other diagnostic tools. It is also helpful if the staff knows what the doctor may recommend when specific findings are abnormal. This means that they truly understand the reasoning behind the testing, findings, and treatments.
The third goal is communication consistency. The practice should decide how it talks about dry eye and then train everyone to use similar language. Patients should hear the same core message from the front desk, the technician, the doctor, and the treatment coordinator: Dry eye is chronic, multifactorial, diagnosable, and treatable but treatment works best when matched to the cause and followed consistently.
Scripts are useful for this and improve patient acceptance. Their purpose is not to make the staff sound like AI robots or rehearsed, but rather to make communication consistent to aid with patient understanding.
Create standard scripts for common moments:
- Explain why dry eye testing is being done
- Introduce imaging or tear analysis
- Describe meibomian gland dysfunction
- Explain why home care alone may not be enough
- Prepare patients for procedural recommendations
- Reinforce that improvement takes time and consistency
Keep the scripts simple and conversational to ensure that patients consistently hear accurate explanations from check in to check out.
Practical Staff Training Tips
One of the most effective strategies is to teach DED to staff in layers, just as we treat it in layers clinically. Start with the big picture. Teach them that dry eye is a multifactorial disease that causes loss of balance in the tear film and ocular surface system which leads to patient symptoms. Then move into the 3 major treatment zones that DEWS III emphasizes. Educate the staff on how multiple treatments are often necessary to best manage the disease. Finally, teach the common therapies your practice uses, what problem each one is meant to solve, and the why behind how the treatment is going to address the underlying cause of patient symptoms.
Repetition and case-based learning can be an effective tool for training staff members. Review 1 or 2 dry eye cases each week in a short team huddle. Show the symptoms, images, findings, subtype, and treatment logic. This is how staff start better understanding the reason behind diagnostic testing and the proposed treatment plan.
Another highly effective tactic is to train staff to use analogies. Saying, “treating dry eye is much like building muscle or losing weight. It is not going to happen overnight or in a couple of weeks. It is going to take time and consistency to improve symptoms.” Similarly, “We are not just treating with artificial tears; we are treating the reason why the patient’s tears are unstable, which is the cause of their symptoms” is a powerful line because it reframes the entire encounter and helps patients see that we are addressing an underlying cause of the disease, not just providing a band-aid.
Finally, education should be woven into every patient touchpoint. The front desk sets expectations about the multifactorial nature of the disease and the need for a comprehensive treatment plan. The technician builds understanding through testing and education and discusses how we are treating the underlying cause of their symptoms. The doctor confirms the diagnosis and develops a treatment plan that is aimed at addressing the underlying etiological drivers. The check-out process reinforces the why behind the treatment plan and possible next steps. When that chain is aligned, adherence improves dramatically.
Make the Treatment Plan Feel Logical
One important lesson DEWS III reinforces for clinicians and staff alike is that dry eye treatment works better when patients understand the logic behind the plan. Even the best matched treatment plan will underperform without patient education and adherence. Patients often resist dry eye therapy for predictable reasons: The disease is chronic, symptoms fluctuate, treatment can involve several modalities, improvement may be gradual, and out-of-pocket costs may be involved. All of that becomes easier when the practice can clearly connect findings to symptoms to recommendations. In other words, education should answer 3 questions: What is causing my symptoms? Why are you recommending this treatment? What outcome are we trying to achieve? When the team answers those well, patients start understanding why they have symptoms and how the proposed treatments are addressing the underlying causes of their symptoms.
Final Thoughts
TFOS DEWS III does not eliminate the value of the dry eye step ladder. It refines it. It reminds us that dry eye is a multifactorial, symptomatic disease that should be diagnosed with consistency, subtyped thoughtfully, and treated according to mechanism rather than habit. It supports a practical workflow that is built around symptom screening, confirmation of homeostatic loss, and targeted management across the tear film, lids, and ocular surface.
For clinicians, the opportunity is to stop thinking in generic sequences and start thinking in etiological drivers. For staff, the opportunity is to become educators, not just assistants in a workup. And for patients, the result is better understanding, better adherence, and better odds of meaningful improvement.
The practices that will lead in dry eye over the next decade will be the ones that identify the dominant etiological drivers through appropriate diagnostic testing, match evidence-based therapy to those drivers, combine treatments when needed, educate patients accordingly, and refine the plan over time.OM
References
- Cutrupi F, De Luca A, Di Zazzo A, Micera A, Coassin M, Bonini S. Real life impact of dry eye disease. Semin Ophthalmol. 2023;38(8):690-702. doi:10.1080/08820538.2023.2204931
- Perez VL, Chen W, Craig JP, et al. TFOS DEWS III: executive summary. Am J Ophthalmol. 2026;282:135-145. doi:10.1016/j.ajo.2025.09.035
- Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: management and therapy. Am J Ophthalmol. 2025;279:289-386. doi:10.1016/j.ajo.2025.05.039
- Wolffsohn JS, Benítez-Del-Castillo JM, Loya-Garcia D, et al. TFOS DEWS III: diagnostic methodology. Am J Ophthalmol. 2025;279:387-450. doi: 10.1016/j.ajo.2025.05.033
