TFOS DEWS III Refines Key Diagnostic Protocols, Emphasizes Importance of Subtyping

Easy as 1-2-3: TFOS DEWS III says clinicians can get the most bang for the buck in terms of chair time by first administering a simplified OSDI questionnaire, then measuring noninvasive tear breakup time (osmolarity testing is an appropriate alternative) and finally assessing ocular surface staining. Adding more tests and considerations will naturally increase diagnostic accuracy.  Photo: James Wolffsohn, PhD, Suzanne Sherman, OD, Scott Hauswirth, OD. Click image to enlarge. As dry eye affects up to 30 million people in America alone, and 10 times as many worldwide, standardizing the approach doctors take helps to ensure good outcomes for as many patients as possible; it also creates a common framework for discussion among researchers and educators. The Tear Film and Ocular Surface Society (TFOS) has been leading the charge toward this for years by distilling the collective wisdom of experts into a series of reports and other resources. TFOS’s 2017 Dry Eye Workshop (DEWS) II report was a watershed moment that redefined dry eye—literally—and countless aspects of its management. Its successor, TFOS DEWS III, has just begun rolling out to the medical community, starting with the Diagnostic Methodology report, which appeared on Friday as an article in press from American Journal of Ophthalmology. The final published report may yet include additional revisions of note, but there’s much to glean from the current document.“The subtyping of dry eye disease is the biggest change,” notes James S. Wolffsohn, PhD, lead author of the Diagnostic Methodology report. “Previously, we just recommended stratifying aqueous deficiency from evaporative-driven disease, but virtually all dry eye disease has an evaporative component. This limits the differentiation of treatment strategies for an individual patient.” As such, there’s a new emphasis on the importance of greater precision in identifying dry eye subtypes and tailoring treatment as such. “Drivers from the tear film layers, eyelid and ocular surface can be each identified and then mapped to the evidence presented in the TFOS DEWS III management and therapies report as to identified effective approaches,” Dr. Wolffsohn explains.  The TFOS team also made small but significant changes to the formal definition of dry eye. Recall that the TFOS DEWS II definition was 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.”DEWS III adds symptomatic where noted in red and ties loss of homeostasis to either the ocular surface itself or the tear film rather than just the latter:“Dry eye is a multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities are etiological factors.”In line with the importance of symptomatic effects, DEWS III notes that identifying dry eye cases should begin with input from the patient, ideally in the form of a waiting room questionnaire such as the Ocular Surface Disease Index (OSDI) instrument, which has a long history of use in research settings. As some clinicians may find the full 12-question OSDI cumbersome for everyday use, a simplified version with just six questions, called OSDI-6, was developed. The TFOS DEWS III report advocates routine use of OSDI-6; DEWS II had recommended either the full OSDI or the 5-item Dry Eye Questionnaire. The change in recommendation to just OSDI-6 removes variability and adds simplicity, Dr. Wolffsohn points out. The TFOS DEWS III Diagnostic AlgorithmFirst, administer the OSDI-6 questionnaire (≥4 is significant for dry eye)Next, measure either noninvasive tear breakup time (cutoff: <10 sec) or osmolarity (cutoff: ≥308mOsm/L)Finally, assess ocular surface staining (cornea >5 punctate spots and/or conjunctiva >9 punctate spots and/or lid margin ≥2mm length and ≥25% width) “The OSDI-6 is a short questionnaire, ideal for screening and is recommended to be conducted as the first component within routine eye examinations to identify those patients who would benefit from a fuller diagnostic evaluation to determine the likely drivers of disease,” the draft of the Diagnostic Methodology report states. It asks patients about sensitivity to light, blurred vision, trouble driving at night, screen use and discomfort from windy conditions or low humidity.After administering the OSDI-6, doctors should proceed to the clinical evaluation. Here, TFOS’s DEWS III report aims to advise clinicians on the merits of all available approaches, from old standbys like Schirmer testing to more high-tech methods like meibography, while recognizing that time and resource constraints often necessitate a streamlined approach. The new diagnostic algorithm also offers a sequence that the authors believe will deliver the most clinically useful information in a concise amount of time.Practices without access to tear meniscus osmolarity testing, for instance, can rely on noninvasive tear break-up time, as the two seem equally useful, the report notes. “Further research has shown that using noninvasive breakup time or osmolarity has a similar impact on the number of people diagnosed with dry eye disease,” Dr. Wolffsohn explains, “whereas assessing ocular surface staining (including corneal fluorescein staining and lissamine green staining of the bulbar conjunctiva and lid margin) must be included.” The full TFOS DEWS III Diagnostic Methodology report explains numerous grading scales for ocular surface staining that have been validated for clinical use, and also articulates the role of many other methods that practitioners and/or researchers may have access to when circumstances allow. Still, “the use of the shorter OSDI-6 and the need to only test two signs as part of the diagnosis should save chair time,” Dr. Wolffsohn notes.Owing to the emphasis on disease subtyping, the report also aims to link specific dry eye forms, clinical presentations, appropriate diagnostic tests and optimal management approaches into a continuum. This is likely where the biggest clinical benefit—and the biggest educational effort—is to be had. “Subtyping largely uses existing multimodal device measurements, but practitioners may not have a standardized way of assessing the corneal nerves and sensation, for example,” says Dr. Wolffsohn. “However, TFOS reports are known to drive technological innovation, so this may give more and lower cost options in the future.”Looking ahead to the rollout of the TFOS DEWS III, he notes that “presentations and summaries of the reports will teach practitioners about the refinement of the definition, the updated risk factors (a useful figure to address patient’s questions about lifestyle, medication and other effects on their eye dryness), differential diagnosis questions, revised diagnosis and subtypes.” Dr. Wolffsohn and several coauthors will be present a first overview of TFOS DEWS III to the profession this Friday at the BCLA annual conference in Birmingham, UK. Look for coverage of that briefing in our news feed soon thereafter.What’s in the offing for those who adopt the newest TFOS DEWS III recommendations? Simply put, better patient care. “The changes will allow more robust diagnosis and better, evidence-based, individualized treatment of patients,” Dr. Wolffsohn offers.Click here for the journal source. Wolffsohn, James S.Arita, Reiko et al. TFOS DEWS III diagnostic methodology. Am J Ophthalmol. May 30, 2025.