DEWS III Decoded: What Clinicians Need to Know

Hosts Kaleb Abbott and Andrew Pucker welcome renowned ophthalmologist Penny Asbell to discuss the key updates from the recently published TFOS DEWS III report, the latest international consensus document on dry eye disease. The report spans over 300 pages and cites more than 1,000 references, making it extremely comprehensive but not very user-friendly for busy doctors who want to absorb the key points. Dr. Asbell—one of the authors—is here to help. The conversation begins with the updated definition of dry eye disease. While DEWS III’s version is similar to the DEWS II definition, the key change is an expanded concept of homeostasis, which now encompasses not just the tear film but also the ocular surface more broadly. The etiological factors listed include tear film instability, hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities. Next, the three doctors unpack the OSDI-6 patient questionnaire, a streamlined six-question version of the original 12-question form. Covering symptoms, activity limitations and environmental triggers, it is scored from 0-24, with scores of four or above indicating significant dry eye. The hosts and Dr. Asbell agree it is an easy, efficient screening tool suitable for routine clinical use. The group then discusses the role of inflammation in dry eye, with Dr. Asbell noting that while DEWS III emphasizes inflammation as a key factor, her own experience, including data from the somewhat controversial NIH-funded DREAM trial, suggests it is not universal across all dry eye patients. She expresses hope that improved ocular biomarkers will eventually help clinicians better identify which patients have meaningful inflammation and would benefit most from anti-inflammatory therapies. The conversation also addresses the report’s expanded focus on eyelid abnormalities, including blink mechanics and incomplete lid closure, topics that Dr. Asbell notes were championed by dry eye guru Donald Korb decades ago. The trio share practical clinical tips for identifying nocturnal lagophthalmos, including the Korb-Blackie light test, and discuss often-overlooked causes such as blepharoplasty and Botox use. Regarding disease classification, DEWS III moves beyond the traditional aqueous-deficient vs. evaporative binary, instead organizing dry eye into three categories: tear film deficiencies, eyelid abnormalities and ocular surface abnormalities. This framework forms the basis of the DEWS III approach to treatment, providing a structure that can allow for a streamlined approach. The episode ends with thoughts on dry eye treatment, with notable discussions including semi-fluorinated alkanes (Miebo), hyaluronic acid lubricants, corticosteroids, tacrolimus ointment and regenerative therapies such as autologous serum. Dr. Asbell also raises important questions about the quality of evidence supporting certain devices and procedures, noting the difficulty of running well-controlled clinical trials in dry eye, given the highly subjective experience of patients. Relevant Articles: TFOS DEWS III Treatment Report Details Full Panoply of Interventions Simplifying the Diagnosis of Dry Eye Disease TFOS DEWS III Refines Key Diagnostic Protocols, Emphasizes Importance of Subtyping