TFOS DEWS II Report Clinical Applications

Distilling the lessons in the nearly 400 pages of the new report.

By Leslie O’Dell, OD

The original Tear Film & Ocular Surface Society Dry Eye WorkShop (TFOS DEWS) report, released in 2007, was a consensus document authored by 58 clinicians and researchers from 12 countries. Six subcommittees produced 140 pages that laid out a new definition and organization for dry eye disease (DED).

A decade later, the TFOS DEWS II report was compiled by 150 clinicians and researchers from 23 countries, and its 12 subcommittees released a document that is 397 pages long. The goals of the TFOS DEWS II report authors were to update the definition, classification, and diagnosis of DED; to assess the etiology, mechanism, distribution, and impact of DED; and to review the management and therapy of DED.


The TFOS DEWS II report is a paradigm shift for the identification and treatment of dry eye disease. Knowing how to apply the information in the report’s findings to your practice is integral to successful patient care.

Due to the overwhelming volume of literature to review (grown from 10,000 sources for the first DEWS report to 20,000 today), the new report took 2 years to write and publish. The work began in April 2015 and the document was finally printed in the July 2017 issue of The Ocular Surface.1-11 The report is dedicated to the late Juha M. Holopainen, MD, PhD, of Finland, who served on both the steering committee and tear film subcommittee for the report.

In this article, I outline some of the features of the new report and suggest how the document can be applied in an eye care practice. In the text below, suggestions for how to apply the lessons of the TFOS DEWS II report are marked.


The TFOS DEWS II report adjusted the definition for DED. The report states:

“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.”2

Loss of homeostasis is a great descriptor of all of the changes we see clinically during a DED examination.
• The new definition above also reinforces that signs and symptoms can both have a negative impact on the ocular surface.
• DED is a disease of the ocular surface which can lead to tissue damage. Like most other ocular diseases, progression or failure to treat can lead to decreased acuity and as the primary providers of vision health we need to treat dry eye disease with the same level of concern and diligence we do other vision threatening diseases.
• Inflammation and hyperosmolarity are still recognized as the underlying causes of damage to the ocular surface. When we diagnose DED, we should think of hyperosmolarity and inflammation and develop a plan to treat it. Clinicians must stop ignoring these markers, by failure to use the point-of-care diagnostic testing available. This new definition reinforced the need for a Clinical Laboratory Improvement Amendments waiver and to start utilizing point-of-care testing.


In an effort to improve patient care and outcomes, the TFOS DEWS II report provides clinicians with a detailed classification system for DED. Refer to the Definition and Classification chapter of the TFOS DEWS II report to view the figure.2

• DED is not one or the other—that is, DED is not just aqueous deficient or just evaporative. Aqueous deficient and evaporative DED are not mutually exclusive subtypes of DED. Indeed, much of what presents at the clinic is mixed DED. Determining where the clinical findings are more heavily weighted (predominantly evaporative or predominantly aqueous deficient) will help to improve management and treatment of the patient.
• Simplify. The four categories laid out in TFROS DEWS II help to make a complex disease state easier to digest are: normal, asymptomatic with clinical findings, symptomatic with clinical findings, and symptoms without clinical findings. Not all ocular surface disease is DED. This is a powerful statement and could be the reason why therapies fail. If the diagnosis is incorrect, the treatment may not be effective.
• Note that the goal of treatment is to restore homeostasis. Although DED is a chronic and progressive disease, by restoring homeostasis we can work to prevent ocular surface damage. This is analogous to efforts to lower intraocular pressure in a glaucoma patient in an attempt to minimize nerve fiber layer loss and delay vision loss over time.


Several new subcommittees were convened in the process of compiling the TFOS DEWS II report. Each contributed an article (or chapter, if the whole of the report is considered as a book) to the report.

Sex, Gender, and Hormones

This chapter discusses the impact of sex hormones and sex steroids on the ocular surface (cornea, conjunctiva, and tears) and ocular adnexa (lacrimal gland, meibomian glands, etc). It also explains the differences between sex and gender.3

• Understanding that sex hormones and sex steroids differ between male and female patients allows the clinician to focus efforts on female patients, who have a higher prevalence for DED. This TFOS DEWS II report chapter also looks at other disease trends and medications often used by female patients that may contribute to DED.
• Learning the gender differences between men and women may raise the question of whether men need better screening for DED. They often do not receive the same level of maintenance care, and they tend to self-report symptoms less often than women.

Pain and Sensation

Dryness and discomfort are forms of pain. TFOS DEWS II defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” Pain can be classified as nociceptive, chronic, or neuropathic. Nociceptive pain is pain arising from damage to tissues and is due to the activation of nociceptors. Neuropathic pain is pain caused by “a lesion or disease of the somatosensory system,” the peripheral or central nervous system.6

• Understanding that dryness is a form of pain rather than simply a complaint allows the clinician to better explain the disease process. Many people living with DED feel alone and often depressed because their symptoms do not receive the attention they deserve. This chapter of the report also emphasizes that, in some patients, there is a disconnect between signs and symptoms. A better understanding of when to refer DED patients for pain management can greatly improve outcomes.

Iatrogenic DED

Iatrogenic DED is DED induced unintentionally by medical treatment. This can include drug-induced DED, whether due to systemic medications or to topical medications containing harsh preservatives; surgically-induced DED after LASIK, cataract surgery, lid surgery, and even cosmetic procedures; and contact lens–induced DED.8

• Take time to review the medication list of the patient with DED. If offending systemic agents are noted, it may be that changes can be made to the class of medication. If topical drugs are affecting the ocular surface, a change to the class of eye medication or the preservative load may be helpful.
• Treating DED before the patient undergoes any surgical procedure can improve outcomes. We should also consider counseling high-risk patients about when to avoid elective surgery, cosmetic procedures, and even the use of contact lenses. Remember the Hippocratic oath: First, do no harm. Educate patients to help them make the best decisions.


David Sullivan, PhD, an associate professor in the department of ophthalmology at Harvard Medical School and a senior scientist and the Margaret S. Sinon Scholar in Ocular Surface Research at Schepens Eye Research Institute at Harvard, is the founder of TFOS. David’s wife, Rose Sullivan, RN, is the operations manager for TFOS. Amy Gallant Sullivan, BS, the couple’s daughter and a co-founder of TFOS, serves at the executive director of TFOS. Ben Sullivan, the couple’s son, is a founder of TearLab Corporation.

Together, they are the perfect team to ignite the passion of clinicians, researchers, industry, and patients to deepen our understanding of DED. The eye care industry owes them a debt of graditute for their tireless efforts.

Diagnosis and Management

Medicine is an art, and treatment plans may vary from patient encounter to patient encounter. The diagnosis chapter once again helps clinicians to simplify the diagnosis process and allows them to feel confident that they have the correctly identified pathology.9

It is important for eye care providers to be sure they are treating actual DED. The triaging questions that are our first point of contact with the patient allow quick evaluation of other possible ocular surface conditions (ie, epithelial basement membrane dystrophy, recurrent corneal erosion, etc.).

• Symptoms: Use a questionnaire. The TFOS DEWS II report recommends using either the Dry Eye Questionnaire 5 or the Ocular Surface Disease Index. Do it! It is a fast, easy, and reliable method to identify symptoms.
• Signs: Look for DED using one of the following: noninvasive tear breakup time with fluorescein, osmolarity testing, or ocular surface staining of the cornea and conjunctiva using fluorescein and lissamine green vital dyes. The other tests we have matter, but keep it simple for initial diagnosis.
• Subtype classification: Use all of the amazing technology available in DED management to help determine the classification of the disease (predominantly evaporative or predominantly aqueous deficient). The more data points you collect, the better your understanding of the complex tear film. Get a Clinical Laboratory Improvement Amendments waiver and invest in point-of-care testing immediately.
• Proper diagnosis: After starting therapy at any level, schedule a return visit to evaluate the signs and symptoms, and change treatment if the clinical findings are not improving. Schedule the return at a 1-to-3-month interval after any new treatments are initiated.


The TFOS DEWS II report is a lot to swallow in one sitting. Breaking up the report into smaller pieces and implementing the its recommendations into your practice in increments will reduce clinical disruption and maximize your likelihood of success. Future issues of Advanced Ocular Care will tackle the individual chapters of the report. Stay tuned.

1. Nelson JD, Craig JP, Akpek EK, et al. TFOS DEWS II Introduction. Ocul Surf. 2017;15(3):269-275.

2. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283.

3. Sullivan DA, Rocha EM, Aragona P, et al. TFOS DEWS II Sex, Gender, and Hormones Report. Ocul Surf. 2017;15(3):284-333.

4. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017;15(3):334-365.

5. Willcox MDP, Argüeso P, Georgiev GA, et al. TFOS DEWS II Tear Film Report. Ocul Surf. 2017;15(3):366-403.

6. Belmonte C, Nichols JJ, Cox SM, et al. TFOS DEWS II pain and sensation report. Ocul Surf. 2017;15(3):404-437.

7. Bron AJ, de Paiva CS, Chauhan SK, et al. TFOS DEWS II pathophysiology report. Ocul Surf. 2017;15(3):438-510.

8. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511-538.

9. Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology report. Ocul Surf. 2017;15(3):539-574.

10. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.

11. Novack GD, Asbell P, Barabino S, et al. TFOS DEWS II Clinical Trial Design Report. Ocul Surf. 2017;15(3):629-649.

Leslie E. O’Dell, OD
• director, Dry Eye Center of PA, Wheatlyn Eye Care, Manchester, Pa.
• financial disclosure: speaker, Allergan, RPS, Shire; consultant, Bruder, Paragon BioTeck
• @HelpMyDryEyes; 717-266-5661; 717-521-7161;;