Clinical ophthalmology (Auckland, N.Z.) · 2026
The Evolving Landscape of Dry Eye Disease Risk Factors: A Comparative Analysis of the TFOS DEWS II (2017) and DEWS III (2025) Reports.
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Badian Reza A
Аннотация
OBJECTIVE: To systematically compare the classification of risk factors for dry eye disease (DED) between the Tear Film and Ocular Surface Society (TFOS) International Dry Eye Workshop (DEWS) II (2017) and DEWS III (2025) reports, highlighting changes in the level of evidence certainty, modifiability status, and clinical implications.
METHODS: The TFOS DEWS II Epidemiology Report and the TFOS DEWS III reports were analyzed. Risk-factor classifications were extracted and compared along two axes: evidence certainty (consistent, probable, inconclusive) and modifiability (non-modifiable, modifiable). Key changes were identified, grouped into categories that included upgrades, downgrades, and reclassifications, and then reorganized and transformed into a practical table format based on the level of evidence certainty.
RESULTS: The DEWS II framework classified risk factors into a 2×3 matrix, whereas DEWS III introduced a more detailed 4-quadrant risk-factor matrix. This study effectively reorganized and transformed the aforementioned risk-factor matrix into a practical table format designed to maximize its clinical utility. The most notable change was the reclassification of meibomian gland dysfunction (MGD) from a non-modifiable to a modifiable risk factor, reflecting a shift toward early intervention and advances in treatment options. Other key updates included elevating thyroid disease, sarcoidosis, and anticholinergics from probable to consistent evidence, and downgrading hormone replacement therapy and air pollution from consistent to probable evidence. Several conditions, such as rosacea, pterygium, and psychiatric disorders, were reclassified from non-modifiable to modifiable. DEWS III also introduced revised diagnostic thresholds and a refined subtype classification system.
CONCLUSIONS: The shift from DEWS II to DEWS III marks a significant development reflecting an evolution in the understanding of DED risk factors. The reclassification of MGD as a modifiable risk factor has profound implications for clinical practice, emphasizing the importance of early detection and proactive management. By incorporating the updated criteria and providing this newly reorganized and transformed practical table, this framework can serve as a practical tool that facilitates the application of the consensus framework for researchers and clinicians, with the goal of improving clinical diagnostic precision and enhancing personalized patient care. These changes underscore the need for revised and updated clinical guidelines and support the identification of future research priorities.
METHODS: The TFOS DEWS II Epidemiology Report and the TFOS DEWS III reports were analyzed. Risk-factor classifications were extracted and compared along two axes: evidence certainty (consistent, probable, inconclusive) and modifiability (non-modifiable, modifiable). Key changes were identified, grouped into categories that included upgrades, downgrades, and reclassifications, and then reorganized and transformed into a practical table format based on the level of evidence certainty.
RESULTS: The DEWS II framework classified risk factors into a 2×3 matrix, whereas DEWS III introduced a more detailed 4-quadrant risk-factor matrix. This study effectively reorganized and transformed the aforementioned risk-factor matrix into a practical table format designed to maximize its clinical utility. The most notable change was the reclassification of meibomian gland dysfunction (MGD) from a non-modifiable to a modifiable risk factor, reflecting a shift toward early intervention and advances in treatment options. Other key updates included elevating thyroid disease, sarcoidosis, and anticholinergics from probable to consistent evidence, and downgrading hormone replacement therapy and air pollution from consistent to probable evidence. Several conditions, such as rosacea, pterygium, and psychiatric disorders, were reclassified from non-modifiable to modifiable. DEWS III also introduced revised diagnostic thresholds and a refined subtype classification system.
CONCLUSIONS: The shift from DEWS II to DEWS III marks a significant development reflecting an evolution in the understanding of DED risk factors. The reclassification of MGD as a modifiable risk factor has profound implications for clinical practice, emphasizing the importance of early detection and proactive management. By incorporating the updated criteria and providing this newly reorganized and transformed practical table, this framework can serve as a practical tool that facilitates the application of the consensus framework for researchers and clinicians, with the goal of improving clinical diagnostic precision and enhancing personalized patient care. These changes underscore the need for revised and updated clinical guidelines and support the identification of future research priorities.