Tiered management strategies.

Based on the TEFOS DEWS2 Report.

TFOS DEWS – Staged Management & Therapy of Dry Eye Disease

Dry Eye Disease (DED) management follows a stepwise (staged) approach, beginning with lifestyle and environmental measures, progressing to prescription and procedural therapies when needed.


This ensures treatments are targeted, evidence-based, and appropriate to disease severity.

🔹 Stage 1 — Foundational Management

(For mild, early, or intermittent symptoms)

  • Patient education – explain the chronic nature of DED and treatment goals.

  • Environmental modification – optimise humidity, avoid drafts, reduce screen time, manage airflow.

  • Dietary advice – increase omega-3 intake or supplementation.

  • Medication review – identify and adjust systemic or topical drugs contributing to dryness.

  • Lid hygiene – daily cleaning of lid margins to control blepharitis.

  • Warm compresses – promote meibomian gland oil flow and improve tear stability.

  • Lubricants/artificial tears – preservative-free formulations for symptomatic relief.

🔹 Stage 2 — Targeted Medical Therapy

(For persistent or moderate disease)

  • Continue Stage 1 measures.

  • Tear conservation: punctal plugs or moisture chamber glasses.

  • Anti-inflammatory therapy:

    • Topical corticosteroids (short course)

    • Cyclosporine (Restasis/Ikervis)

    • Lifitegrast (where available)

  • Secretagogues / Tear stimulants: diquafosol or oral pilocarpine (selected cases).

  • In-office gland therapies:

    • Meibomian gland expression (manual or device-assisted)

    • Thermal pulsation systems (e.g. LipiFlow)

    • Intense Pulsed Light (IPL) for MGD-related inflammation

🔹 Stage 3 — Advanced / Refractory Disease Management

(For chronic, moderate–severe DED unresponsive to earlier measures)

  • Continue Stage 1–2 strategies.

  • Systemic medications: tetracyclines or macrolides for MGD; immunomodulators for autoimmune causes.

  • Autologous serum or platelet-rich tear substitutes.

  • Scleral or PROSE lenses to protect and hydrate the ocular surface.

  • Advanced meibomian gland treatment (combined IPL + expression series).

  • Low-dose topical corticosteroids under close monitoring.

🔹 Stage 4 — Severe / Resistant or Structural Disease

(For severe, sight-threatening, or non-responsive DED)

  • Continue supportive care from previous stages.

  • Amniotic membrane grafts for epithelial healing and inflammation control.

  • Punctal cautery for permanent tear retention.

  • Tarsorrhaphy (partial lid closure) to reduce exposure.

  • Systemic immunosuppressants for severe inflammatory or autoimmune cases (in collaboration with rheumatology).

  • Surgical lid correction if anatomical abnormalities contribute to exposure or incomplete closure.

Key Principle

At every stage:

  • We re-evaluate underlying causes and contributing factors.

  • Adjust treatment intensity gradually.

  • Combine ocular surface protection, anti-inflammatory control, and tear film restoration for optimal outcomes.