Making DEWS III Work Without Billing Pitfalls

DEWS III swapped the treatment ladder for a map. Here’s the management report in five minutes, how to pick a drop for each driver, and how to keep the workflow billable.

Cheryl Chapman, OD, FAAODry eye specialist and Peeq Pro co-founder

If you want a TFOS DEWS III summary you can actually use in clinic, it comes down to one question: what’s driving this patient’s dry eye today? DEWS III moves us away from a rigid stepwise ladder and toward a diagnosis-driven map. Below, I break down the management report, how to choose drops by driver, and what the shift looks like in an independent practice, from foundational care and inflammation to documentation, ocular surface disease evaluations and billing.

Let’s start with the obvious: everyone with eyelids should be cleaning them every single day. At Peeq Pro, we call it “peeqing” your lids, and it’s the foundation of every healthy ocular surface. When the lid margins stay clean and the meibum flows, you’re addressing one of the most basic pieces of ocular surface care.

TFOS DEWS III summary: management at a glance

The TFOS DEWS III Management and Therapy report, published in the American Journal of Ophthalmology in 2025, reviewed more than 1,000 papers. Its biggest change isn’t a new drug. It’s how we decide what to use.

DEWS II gave us a staged, severity-based plan. DEWS III drops it, because patients don’t stay in one category. A patient with lid disease and low tear production can fix the lids with good hygiene, then slide back a month later when the warm compresses stop. Severity labels can’t keep up with that.

Instead, DEWS III gives three algorithms, one for each area you already examine:

1. Tear filmIs there a deficiency in the aqueous, lipid or mucin layer?
2. EyelidsBlepharitis (including Demodex), MGD, lid wiper epitheliopathy, and blink or lid closure problems.
3. Ocular surfaceCorneal and conjunctival staining, plus pterygium, pinguecula or conjunctivochalasis that disrupt the tear film.

Work through all three, list the active drivers, then match a treatment to each one. A single patient might need a lipid-supporting tear, Demodex therapy and a surface procedure at the same time.

The basics still matter

DEWS III does not mean abandoning conservative care. The foundation still matters, and it can continue alongside more targeted treatment.

• Lid hygiene. Consistent cleansing with a gentle eyelid cleanser remains a core part of supporting the ocular surface and managing the lid margin.
• Warm compresses. At-home heat stays in the conversation, especially when meibomian gland function is part of the picture.
• Omega-3s. Supplementation can remain part of the foundational plan when clinically appropriate for the individual patient.

From a ladder to a map

DEWS II gave us that comforting staircase: start simple, escalate later. Step 1, artificial tears and hygiene. Step 2, maybe a short steroid pulse. Step 3, advanced drops or devices. But the reality? Patients don’t live in steps.

Some patients walk in with obvious inflammation from day one, with red conjunctiva, punctate staining and angry lid margins, and still get sent home with another bottle of tears. Instead of asking, “What step am I on?” DEWS III has us ask, “What’s driving this disease right now?” Then we treat that driver directly, in context with the rest of the patient’s ocular surface care.

Treat the driver, not the step number.

Drop selection under DEWS III: match the drop to the driver

“Use artificial tears” isn’t a plan anymore. DEWS III links each treatment to the driver it acts on, and that includes the bottle we send patients home with. Over-the-counter tears deserve the same care as a prescription: pick a specific formulation for a specific reason, and write it down.

Preservative-free drops to name, by job

OPTASE IntenseHyaluronic acid hydration for aqueous deficiencyView drop Refresh CelluviscHigher viscosity when tears don’t lastView drop Systane Complete PFLipid support for evaporative dry eye and MGDView drop OPTASE HYLO NightBedtime protection for unstable tear filmView drop

See the full lineup in our eye drops collection.

Inflammation: act early, then think long-term

Inflammation is a common thread across many dry eye presentations, whether the patient is aqueous-deficient, evaporative, mixed, or dealing with a more complex pain component. DEWS III supports addressing it earlier, instead of waiting for a patient to “fail” a series of conservative steps first.

1. Identify active inflammation. Recognize inflammatory signs and symptoms as part of the patient’s current disease picture.
2. Calm the cycle. Use short-term anti-inflammatory management when clinically appropriate to quiet the active process.
3. Maintain control. Transition toward a longer-term plan based on the patient’s ongoing drivers and needs.

Keep the foundation running alongside it: lid hygiene, warm compresses, omega-3s, hydration and environment.

“It’s not ‘Step 1 or Step 2.’ It’s ‘What’s active today, and how can I quiet it down?’”

The clinical plan is only half the equation

Here’s where the clinical meets the bureaucratic. A comprehensive exam, often billed under a vision plan, is not the same as a medical management visit. If you identify dry eye, educate the patient, and move immediately into full medical management under the comprehensive exam, you can create billing and documentation problems.

So how do we practice an integrated DEWS III model without tripping over billing rules? Split the process, not the care.

Separate the visits without disconnecting the care

The goal is not to delay appropriate care. It’s to create a clinical and documentation sequence that makes sense for both the patient and the chart.

After a period of consistent self-care, reassess. If inflammation or other signs remain active, you now have a clearer clinical picture and a documented rationale for moving further into medical management. Sometimes that window will be shorter because the patient needs more immediate intervention. The point isn’t to force every patient into the same timeline. It’s to keep a clear, defensible care sequence.

Follow the map, not the ladder

DEWS III doesn’t erase the fundamentals. It validates the reality that dry eye is multifactorial, dynamic and highly individual. Patients don’t want a “step plan.” They want a plan that reflects what is happening with their eyes today.

Clinically, that means treating the patient in front of you. Operationally, it means giving the practice a repeatable path: a defined identification visit, a follow-up point, a documentation standard and a care pathway the whole team understands. Split your billing process when needed, but don’t split your clinical logic.

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.

Connect with Dr. Chapman on LinkedIn

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 of one brand over another. Source: Jones L, Craig JP, Markoulli M, et al. TFOS DEWS III: Management and Therapy. Am J Ophthalmol. 2025;279:289–386.