TFOS DEWS II DISTILLED: A Five-Minute Briefing

Laura Periman, MD

#YouCan’tRideaThreeLeggedHorse – Part II

Originally Published on Ophthalmology Management

More Cowboy Wisdom I learned on the Montana ranch: To lead your CDED sufferers to greener pastures, you’ll need a four-legged horse.

Leg one-ask questions. #What’sHappeningInThePasture?

Assess this by using patient questionnaires. There are many free ones to choose from online. #PickAHorse (questionnaire) that is validated and used in clinical research such as the OSDI or SPEED score and #StickToIt. The questionnaires are a powerful way to show a patient they are making progress.

Leg two-assess risk factors. #How’dYouGetHere?

Hormone status, age, medications, lifestyle, nutrition, systemic disease, past ocular history, and autoimmune disease, to name a few. Autoimmune disease is like wolves near the herd and needs high vigilance. Add up the risk factors for each patient. Some are modifiable, others aren’t. However, by the time you have 4-5 arrows pointing in the same direction, the likelihood of CDED is high.

Leg three-diagnostics. #GetACloserLook. #SimpleThenFancy

Simple: stack a sterile fluorescein strip and Lissamine green strip, wet with saline, and instill a tiny amount (too much volume floods and masks the findings) to examine the staining pattern, tear break up time, tear distribution, tear volume. #EasyDoesIt. Instead of forcibly expressing glands with your finger, use a Korb Meibomian Gland Evaluator. It is a gentler, more physiologic assessment method. Fancy: osmolarity, MMP-9 testing or imaging (NIKBUT, meibomography). Point spread function analysis can give you trails to track.

Leg four-classify and treat. #TheBarnDon’tCleanItself

Inflammation is present and the barn is dirtier than it looks. (i.e. the inflammatory burden can still be present if MMP9 is negative). You know the tools you need to clean it up, so what are you waiting for?

Figure 1. To view the original DEWS II Diagnosis and Categorization Algorithm, click here.

My grandfather – Montana rancher and horse whisperer.

The entire TFOS DEWS II report is available to all for free at

Laura M. Periman, MD is Director of Dry Eye Services and Clinical Research at Evergreen Eye Center in Seattle, WA. Relevant to this series, she discloses relationships with Allergan, Bio-Tissue, Eyedetec, Lumenis, Science Based Health, Sun Pharmaceuticals, TearLab, Topcon and Visant.