TFOS DEWS III Treatment Report Details Full Panoply of Interventions

The abundance of options to manage dry eye gives clinicians great flexibility to tailor treatments to each patient but also adds a level of complexity that can prompt some doctors to just rely on a handful of familiar standbys—and as a result, potentially miss opportunities to improve their care. Seeking to help busy doctors navigate the countless treatments available, the Tear Film and Ocular Surface Society (TFOS) undertook the most comprehensive literature review to date when working on its newly released Dry Eye Workshop (DEWS) III Management and Therapy report, which cites over one thousand research papers (1,056, to be exact). The report appeared in   in early June. Click here to download a PDF of the TFOS DEWS III Management and Therapy algorithms.  “The TFOS DEWS III Management and Therapy report is evidence-based and scoured the literature for publications that provided clinicians with peer-reviewed evidence concerning the use of these devices and products,” says lead author Lyndon Jones, PhD, FCOptom, director of the Centre for Ocular Research & Education at the University of Waterloo School of Optometry.No Stone Unturned“The report divides up the available therapies into 10 sections,” Dr. Jones explains, often organized around specific treatment goals (e.g., tear stabilization, eyelid hygiene). Although TFOS’s work on DEWS III has been underway for several years, the report discusses many recent new entrants into the market, up to and including Alcon’s Tryptyr, approved just a few weeks ago. Tryptyr is addressed in a new section on neuromodulation that discusses pharmacological and device-driven ways to stimulate the production of various tear components.Other new products described in DEWS III include “a wide variety of tear supplements and stabilizers, including an update on lipid-containing supplements, perfluorohexyloctane ophthalmic solution, ectoine and antioxidant-containing supplements,” Dr. Jones explains. The report also discusses tear conservation using moisture-retaining spectacles and scleral lenses.A large section describes at-home and office-based treatments for meibomian gland dysfunction, including up-to-date information on novel drugs such as topical selenium sulfide. “The devices covered under this section include low-level light therapy, IPL, internal and external eyelid heating devices and newer methods such as plasma treatment, QMR electrotherapy and thermo-mechanical skin treatment,” Dr. Jones says. One innovation of the DEWS III management and therapy report is the creation of the above three algorithms, which connect evidence-based treatment options (right column) to each category of clinical impact that can arise (left column) within the realm of dry eye and ocular surface disease. Click image to enlarge. Treatments for eyelid anomalies include sections on methods to manage incomplete lid closure, along with several treatments that reduce microbial load. “These include the latest information on therapies to manage Demodex blepharitis (including lotilaner ophthalmic solution and okra-based therapies), lid hygiene products, low-level light therapy and manuka honey,” says Dr. Jones.A section on ocular surface regeneration “provides an in-depth discussion of the many and varied blood-based treatments now available,” he points out, “along with updates on lubricin and amniotic membrane options. An update on nutritional modifications and alternative therapies offers readers the latest findings for various macro- and micronutrients, says Dr. Jones, along with information on therapies such as acupuncture and several nutritional supplements. The final section provides a wide range of surgical options to manage dry eye disease, describing the management of anatomical surface abnormalities such as pterygium and pinguecula, as well as more complex surgical procedures such as salivary gland transplantation and reinnervation of the lacrimal gland. DEWS III also emphasizes the prominent role of day-to-day patient lifestyle factors in how dry eye arises—and how it can be quelled. The TFOS Lifestyle Report, published in 2023, “very eloquently covers the impact of the lifestyle choices that patients make,” notes Dr. Jones. That report covers a broad variety of topics, including the impact of the environment, medications, recreational drugs, contact lenses, digital devices, cosmetics and nutrition on dry eye signs and symptoms. “It is clear from those reports that lifestyle modifications have the potential to reduce and/or modify the degree to which patients suffer from dry eye disease,” he says.Often, these modifications are relatively simple to achieve and should be recommended by the eyecare practitioner as additional factors for consideration and discussion with patients reporting dry eye symptoms, Dr. Jones encourages. “Such modifications, in tandem with application of devices or products, as described in the new TFOS DEWS III Management and Therapy report, can help provide patients with relief from the signs and symptoms of dry eye disease.” Connecting the DotsOnce the report has laid out a systematic overview of all possible interventions, it then concludes by proposing three treatment algorithms for clinicians to follow (see figure above), each rooted in the careful approach to disease subtype recognition articulated in the TFOS DEWS III Diagnostic Methodology Report.“The previous TFOS DEWS II report provided a relatively simplistic treatment algorithm that suggested a staged approach to the management of dry eye, based upon clinical acumen rather than using an evidence-based approach,” Dr. Jones points out. DREAM StateIn 2018, during the period between the publication of DEWS II and DEWS III, the somewhat controversial DREAM study took a popular dry eye therapy to task, claiming that omega fatty acid supplementation was no better than placebo. How does DEWS III consider this treatment option?The TFOS DEWS III report provides a figure that diagrammatically describes the key metabolic pathways for omega-6 and omega-3 fatty acids, Dr. Jones mentions. “Broadly speaking, the omega-6 pathway results in the production of inflammatory mediators and in the omega-3 pathway, alpha-linolenic acid is converted to long-chain fatty acids that include eicosapentaenoic (EPA) and docosahexaenoic acid (DHA), subsequently leading to the generation of various anti-inflammatory mediators.” Diets with a high-omega-6 to omega-3 ratio are considered proinflammatory, he says, increasing the likelihood of signs and symptoms of dry eye disease, due to a bias towards the production of proinflammatory mediators. The relevant section of TFOS DEWS III “reviews the available literature on the potential role of PUFAs on dry eye, including the DREAM study, and concludes that the overall evidence would suggest a beneficial effect of the use of oral supplements of omega-3 PUFA; however, the optimal source, dosage and/or ratio of omega-3 to omega-6 requires further investigation,” Dr. Jones explains. The paper in AJO states that systems that attempt to group patients into discrete categories (e.g., mild, moderate, severe; stages 1, 2, 3, 4; aqueous deficient vs. evaporative dry eye) provide “a suboptimal architecture for DED and can result in decision making that omits effective therapeutic interventions because of categorization that fails to describe the complexity and the changing nature of the multiple pathogenic drivers that result in signs and symptoms of DED.”According to Dr. Jones, “TFOS DEWS III goes beyond this by providing three algorithms that list evidence-based management options. These three algorithms cover the three areas of the ocular surface and adnexa that are impacted by dry eye disease, namely the tear film, lids and ocular surface.”The DEWS III concept is to first identify the “clinically relevant drivers” of the patient’s condition (shown on the left side of each algorithm) and then consider the therapeutic options available to modulate them (right side of each algorithm). “This method of mapping the type of dry eye with the proven management options should assist practitioners with choosing appropriate management options,” Dr. Jones explains. “For each of the algorithms provided, tables outline treatment options for the subtypes of dry eye diagnosed, for which there is current evidence available,” he says.Dr. Jones offers an example that pulls from each of the three algorithms. “If the eyecare practitioner diagnoses that their patient has a poor lipid quality [algorithm #1], Demodex blepharitis [algorithm #2] and a pterygium that is causing tear film breakup over the ocular surface [algorithm #3], they can refer to the algorithms and select appropriate options to help manage these three conditions.” More to Come“Multiple treatments used together are the likely and most appropriate management strategy, considering that DED has multiple pathogenic drivers,” states the Management and Therapy report. The challenge is to sharpen one’s skills in both identifying and then addressing them. This, broadly speaking, is the goal of TFOS DEWS III.Clearly, a resource of this size and scope will require guidance from thought leaders to practicing clinicians interested in implementing the approach. The principal authors have begun presenting the DEWS III concepts to the profession and will continue to routinely throughout the year. Review of Optometry will continue to develop articles that can assist as well. Those behind the undertaking assert that it’s worth the effort. “The TFOS DEWS III approach of identifying the etiological drivers of an individual patient’s DED and matching this with the evidence-identified mechanism of action of treatment and therapies should enhance patient outcomes and quality of life,” states the report.Click here for the journal source. Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III management and therapy report. Amer J Ophthalmol. In press June 2, 2025.