Dry Eye Treatment: An Evidence-Based Perspective
Five dry eye treatment myths that still show up in clinic, and what the TFOS DEWS III evidence actually supports instead.
The short answer
Evidence-based dry eye treatment means finding the drivers before prescribing. TFOS DEWS III recommends assessing the tear film, eyelids and ocular surface, then combining treatments matched to each driver, with tear supplements and lid hygiene as the foundation.
Evidence-based dry eye treatment has changed a lot since I first wrote about these myths in 2024. The TFOS DEWS III reports, published in 2025, gave us an updated definition of the disease, a new diagnostic sequence and a management approach built around disease drivers instead of severity steps. Yet many of the same assumptions still shape how dry eye gets diagnosed and treated.
Here are five of the most common ones, updated with what DEWS III now supports.
What evidence-based dry eye treatment means now
The TFOS DEWS III Management and Therapy report reviewed more than 1,000 papers. Its biggest shift is how we choose treatment. DEWS II used a staged plan based on severity. DEWS III replaces it with three algorithms, one each for the tear film, the eyelids and the ocular surface. You identify which drivers are active, then match a treatment to each one, and combination therapy is expected.
Artificial tears are the primary solution for every patient
Fact: Tears are the foundation, not the whole plan. Effective treatment targets the mechanisms driving each patient’s disease.
Dry eye involves tear film instability, inflammation, hyperosmolarity, and problems with tear production or evaporation. Lubricating drops alone can miss the drivers that keep the cycle going.
A patient with meibomian gland dysfunction needs the glands addressed with daily lid care using an eyelid cleanser, heat, or in-office treatment. A patient with active inflammation may need a prescription anti-inflammatory. Many need both at once.
An individualized plan may include:
- Artificial tears selected for the patient’s tear film deficiency
- Daily eyelid hygiene and warm compresses for gland function
- Environmental and lifestyle changes
- Prescription therapy when clinically indicated
- In-office procedures for appropriate patients
What DEWS III says: Tear supplements remain the cornerstone of first-line management, but the report expects combination therapy because dry eye has multiple drivers.
All artificial tears work the same way
Fact: Formulations differ in viscosity, lipid content, osmoprotectants and preservatives, and those differences matter for specific drivers.
Before you name a tear, ask four questions:
- Which driver? Evaporation, low aqueous production, or both?
- Which formulation? Lipid-containing, hyaluronic acid, or higher viscosity?
- Preservatives? Patients dosing more than four times a day, or using several drops, should go preservative-free.
- Tolerance? Will blur or stinging stop the patient from using it?
For evaporative disease and MGD, a lipid-containing tear like Systane Complete PF or OPTASE MGD Advanced supports the lipid layer. For aqueous deficiency, a hyaluronic acid drop like OPTASE Intense or a higher-viscosity option like Refresh Celluvisc supports hydration. For overnight exposure, a bedtime ointment like OPTASE HYLO Night lasts longest.
Preservative-free drops to name, by job
Systane Complete PFLipid support for evaporative dry eye and MGDView drop
OPTASE IntenseHyaluronic acid hydration for aqueous deficiencyView drop
Refresh CelluviscHigher viscosity when tears don’t lastView drop
OPTASE HYLO NightBedtime protection for overnight exposureView drop
See the full lineup in our eye drops collection.
Dry eye is a minor condition that rarely needs intervention
Fact: DEWS III defines dry eye as a chronic, multifactorial disease that can cause visual impairment, not just discomfort.
Patients describe burning, foreign body sensation and fluctuating vision that interferes with reading, screens, driving and contact lens wear. Persistent inflammation and epithelial damage can lead to complications, including corneal injury.
Signs and symptoms often don’t line up. Some patients report severe discomfort with mild findings, which can point to a neurosensory component. Others show significant staining with few complaints. That’s why a structured evaluation matters.
A comprehensive dry eye evaluation may include:
- A validated symptom questionnaire, such as the OSDI-6
- Tear breakup time, ideally non-invasive
- Ocular surface staining
- Eyelid margin and meibomian gland evaluation
- Tear osmolarity, meibography or tear production testing when available and indicated
What DEWS III says: The updated definition adds ocular surface epitheliopathy, inflammation and neurosensory abnormalities to the core features of the disease, and the diagnostic algorithm starts with a short symptom screen before confirming with clinical markers.
Over-the-counter treatments are enough for most patients
Fact: OTC care is essential, but it rarely resolves persistent inflammation, gland obstruction, Demodex or reduced tear production on its own.
Most patients start with drops, compresses or a store-bought lid wipe. If symptoms persist, that’s the signal for a full evaluation and a driver-specific plan. Depending on findings, DEWS III-supported options include:
- Anti-inflammatory therapy: a short course of a steroid such as loteprednol 0.25%, then cyclosporine or lifitegrast for long-term control
- Evaporation control: perfluorohexyloctane (Miebo)
- Demodex blepharitis: lotilaner 0.25% (Xdemvy) alongside daily lid hygiene
- Tear stimulation: varenicline nasal spray (Tyrvaya) or acoltremon drops (Tryptyr)
- Tear conservation: punctal occlusion in well-selected patients
- In-office gland treatments: thermal pulsation, IPL and expression
Set realistic expectations. Dry eye is usually chronic, and improvement often comes gradually. Regular follow-up lets you reassess which drivers are still active and adjust the plan.
Moving patients from OTC to medical care? Dr. Chris Wolfe covers OSDEs, E/M coding and documentation in Billing and coding dry eye like a pro.
Dry eye is simply an unavoidable part of aging
Fact: Prevalence rises with age, but dry eye affects patients of every age and is never something to dismiss as normal.
Age-related changes in tear production, gland function and hormones play a role. So do many factors that have nothing to do with age:
- Digital devices: reduced and incomplete blinking increase evaporation
- Environment: low humidity, airflow and air conditioning
- Medications: some antihistamines, antidepressants and isotretinoin
- Hormonal changes: including menopause
- Contact lens wear: lens-related tear film disruption
- Systemic conditions: autoimmune disease, diabetes and others
- Cosmetics and lash extensions: product buildup along the lid margin
A thorough history finds these contributors. Instead of assuming dry eye is inevitable, evaluate the risk factors and treat what you find.
What the evidence says: The TFOS Lifestyle Workshop reports describe how digital environments, cosmetics, nutrition and other daily habits affect the ocular surface, which is why lifestyle changes remain part of the DEWS III foundation.
Building an evidence-based dry eye plan
Evidence-based care isn’t one product or one protocol. It’s a repeatable sequence:
- Screen. Ask about symptoms with a validated questionnaire at every comprehensive exam.
- Find the drivers. Work through the tear film, eyelids and ocular surface, and list what’s active.
- Treat in combination. Match a treatment to each driver, and keep lid hygiene, the right tear and lifestyle changes running underneath.
- Reassess. Treatment and adherence change which drivers are active. Adjust at every visit.
The piece that most often breaks down is the last one: what patients actually do at home. Consistent lid hygiene, the right drop in the right place, and easy access to the products you recommend make the difference between a good plan and a followed one.
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What is evidence-based dry eye treatment?
It means choosing treatment based on the drivers you find on exam and the current research, rather than habit. Under TFOS DEWS III, that means assessing the tear film, eyelids and ocular surface, then combining treatments matched to each active driver.
What does TFOS DEWS III recommend for dry eye treatment?
DEWS III replaces the stepwise, severity-based plan with three algorithms for the tear film, eyelids and ocular surface. It keeps tear supplements as the first-line cornerstone and expects combination therapy for most patients.
Are artificial tears enough to treat dry eye?
For mild, occasional symptoms they may be. Persistent dry eye usually involves inflammation, gland dysfunction or other drivers that tears alone don’t address, so it needs a full evaluation and a targeted plan.
Which artificial tears are best for evaporative dry eye?
Lipid-containing, preservative-free tears such as Systane Complete PF or OPTASE MGD Advanced support the tear film’s oil layer. If the glands are blocked, add heat, lid hygiene or in-office treatment, since drops can’t open them.
When should a dry eye patient move to prescription treatment?
When signs of inflammation, Demodex or reduced tear production are present, or when symptoms persist despite consistent foundational care. Some patients need prescription therapy from the first visit.
Is dry eye a chronic disease?
Yes. TFOS DEWS III defines dry eye as a chronic, multifactorial disease. Most patients need ongoing management, and improvement usually comes gradually rather than all at once.
Do omega-3 supplements help dry eye?
The DEWS III management report found an overall benefit for omega-3 supplementation, though the best source and dose still need more study. They fit as part of the foundation when clinically appropriate.
Can young people get dry eye?
Yes. Screen use, contact lenses, medications such as isotretinoin, cosmetics and environment can all cause dry eye in younger patients. Age is a risk factor, not a requirement.
Cheryl Chapman, OD, FAAO, IACMM, FIAOMC, Diplomate ABO
Dr. Chapman is an optometrist, dry eye expert, specialty contact lens clinician and co-founder of Peeq Pro. Her work spans advanced ocular surface care, specialty lenses, myopia management, and the systems that help independent practices turn recommendations into consistent patient care.
Originally published March 2024; updated November 2026 to reflect TFOS DEWS III. Clinical education only. Treatment should be individualized by the treating eye care professional and follow current product labeling. Product names are trademarks of their respective owners; mentions are examples, not endorsements. Sources: Jones L, et al. TFOS DEWS III: Management and Therapy. Am J Ophthalmol. 2025; TFOS DEWS III Executive Summary. Am J Ophthalmol. 2025; TFOS Lifestyle Workshop reports. Ocul Surf. 2023.