DRY EYE DISEASE: CURRENT GUIDELINES AND EMERGING THERAPEUTIC STRATEGIES
Abstract
Background: Dry eye disease (DED) is a chronic, multifactorial disorder of the ocular surface characterized by loss of tear film homeostasis, resulting in ocular symptoms and heterogeneous clinical signs. It affects both elderly and working-age populations, with increasing prevalence related to environmental exposure, digital device use, and lifestyle changes. Advances summarized in the TFOS DEWS II reports have substantially improved understanding of DED pathophysiology, highlighting the roles of tear film instability, hyperosmolarity, chronic inflammation, meibomian gland dysfunction, and neurosensory abnormalities.
Methods: This narrative review analyzes current international guidelines and peer-reviewed literature published between 2015 and 2025. PubMed/MEDLINE and Google Scholar were searched using keywords related to dry eye disease, ocular surface disease, TFOS DEWS II, meibomian gland dysfunction, diagnostics, and treatment. Consensus reports, randomized controlled trials, meta-analyses, and systematic reviews were included.
Results: Evidence indicates that DED is a heterogeneous condition requiring an individualized, phenotype-based diagnostic and therapeutic approach. Contemporary guidelines recommend combining symptom assessment with objective diagnostic testing to guide management. Stepwise treatment strategies emphasize patient education, environmental modification, tear supplementation, and targeted anti-inflammatory therapy. Recent advances include immunomodulatory agents, therapies for meibomian gland dysfunction, evaporation-reducing agents, neurostimulatory approaches, and biological treatments for severe or refractory disease.
Conclusion: Dry eye disease remains a complex clinical challenge. Implementation of updated diagnostic criteria and stepwise, phenotype-oriented treatment strategies enables improved disease control and quality of life. Continued research into inflammatory and neurosensory mechanisms, along with development of novel therapies, is essential for further optimization of personalized DED management.
References
Amescua, G., Akpek, E. K., Farid, M., Garcia-Ferrer, F. J., Lin, A., Rhee, M. K., … Musch, D. C. (2024). Dry eye syndrome preferred practice pattern®. Ophthalmology, 131(4), P1–P49. https://doi.org/10.1016/j.ophtha.2023.10.021
Asbell, P. A., Maguire, M. G., Pistilli, M., Ying, G. S., Szczotka-Flynn, L. B., Hardten, D. R., … DREAM Study Research Group. (2018). n−3 fatty acid supplementation for the treatment of dry eye disease. New England Journal of Medicine, 378(18), 1681–1690. https://doi.org/10.1056/NEJMoa1709691
Barabino, S. (2024). Dry eye disease: Pathogenesis and clinical signs. European Review for Medical and Pharmacological Sciences, 28, 1881–1890.
Bron, A. J., de Paiva, C. S., Chauhan, S. K., Bonini, S., Gabison, E. E., Jain, S., … Sullivan, D. A. (2017). TFOS DEWS II pathophysiology report. The Ocular Surface, 15(3), 438–510. https://doi.org/10.1016/j.jtos.2017.05.011
Craig, J. P., Nichols, K. K., Akpek, E. K., Caffery, B., Dua, H. S., Joo, C. K., … Stapleton, F. (2017). TFOS DEWS II definition and classification report. The Ocular Surface, 15(3), 276–283. https://doi.org/10.1016/j.jtos.2017.05.008
Craig, J. P., Nelson, J. D., Azar, D. T., Belmonte, C., Bron, A. J., Chauhan, S. K., … Sullivan, D. A. (2017). TFOS DEWS II report executive summary. The Ocular Surface, 15(4), 802–812. https://doi.org/10.1016/j.jtos.2017.08.003
Dua, H. S., Said, D. G., Messmer, E. M., Rolando, M., Benítez-del-Castillo, J. M., Hossain, P. N., … Geerling, G. (2020). Neurotrophic keratopathy. Progress in Retinal and Eye Research, 66, 107–131.
Geerling, G., Tauber, J., Baudouin, C., Goto, E., Matsumoto, Y., O’Brien, T., … Tsubota, K. (2017). The international workshop on meibomian gland dysfunction. The Ocular Surface, 15(3), 423–437.
He, C. Z., Tong, Q., Zheng, K., Ying, G. S., & Zhou, X. (2024). Autologous serum eye drops for dry eye disease: A systematic review and meta-analysis of randomized controlled trials. Frontiers in Medicine, 11, 1298743. https://doi.org/10.3389/fmed.2024.1298743
Jones, L., Downie, L. E., Korb, D., Benitez-Del-Castillo, J. M., Dana, R., Deng, S. X., … Craig, J. P. (2017). TFOS DEWS II management and therapy report. The Ocular Surface, 15(3), 575–628. https://doi.org/10.1016/j.jtos.2017.05.006
Lemp, M. A., Baudouin, C., Baum, J., Dogru, M., Foulks, G. N., Kinoshita, S., … Sullivan, D. A. (2017). The definition and classification of dry eye disease. Cornea, 36(3), 275–284.
Leng, X., Wang, Y., Wang, J., & Zhou, M. (2021). Intense pulsed light therapy for meibomian gland dysfunction: A meta-analysis. The Ocular Surface, 19, 1–10. https://doi.org/10.1016/j.jtos.2020.10.006
Liu, Y., Kam, W. R., Ding, J., & Sullivan, D. A. (2020). Meibomian gland dysfunction: A review. Survey of Ophthalmology, 65(2), 205–231. https://doi.org/10.1016/j.survophthal.2019.08.004
Messmer, E. M., Ahmad, S., Benítez-del-Castillo, J. M., Dart, J. K. G., Figueiredo, F. C., Geerling, G., … Rolando, M. (2023). Management of inflammation in dry eye disease: Recommendations from a European panel of experts. European Journal of Ophthalmology, 33(4), 1294–1307. https://doi.org/10.1177/11206721221120789
Nichols, K. K., Foulks, G. N., Bron, A. J., Glasgow, B. J., Dogru, M., Tsubota, K., … Sullivan, D. A. (2017). TFOS DEWS II tear film report. The Ocular Surface, 15(3), 366–403.
Polskie Towarzystwo Okulistyczne. (2018). Wytyczne PTO dotyczące diagnostyki i leczenia zespołu suchego oka. Warszawa: PTO.
Polskie Towarzystwo Okulistyczne, Polskie Towarzystwo Reumatologiczne, & Polskie Towarzystwo Hematologów i Transfuzjologów. (2020). Zapobieganie i leczenie ciężkiego zapalenia rogówki w przebiegu zespołu suchego oka – wytyczne kliniczne. Warszawa.
Stapleton, F., Alves, M., Bunya, V. Y., Jalbert, I., Lekhanont, K., Malet, F., … Jones, L. (2017). TFOS DEWS II epidemiology report. The Ocular Surface, 15(3), 334–365.
Sullivan, D. A., Rocha, E. M., Aragona, P., Clayton, J. A., Ding, J., Golebiowski, B., … Jones, L. (2017). TFOS DEWS II sex, gender, and hormones report. The Ocular Surface, 15(3), 284–333.
Wolffsohn, J. S., Arita, R., Chalmers, R., Djalilian, A., Dogru, M., Dumbleton, K., … Jones, L. (2017). TFOS DEWS II diagnostic methodology report. The Ocular Surface, 15(3), 539–574.
Wolffsohn, J. S., Craig, J. P., Dua, H. S., Akpek, E. K., Gomes, J. A. P., … Stapleton, F. (2017). TFOS DEWS II management and therapy report. The Ocular Surface, 15(3), 575–628.
Wolffsohn, J. S., & Nichols, K. K. (2024). Contemporary management of dry eye disease. BMJ, 384, e072563.
FDA. (2020). Loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis) – prescribing information.
FDA. (2021). Varenicline solution nasal spray (Tyrvaya) – prescribing information.
FDA. (2023). Perfluorohexyloctane ophthalmic solution (MIEBO) – prescribing information.
Novaliq GmbH. (2023). Perfluorohexyloctane for evaporative dry eye disease. Drugs, 83(10), 903–912.
Tauber, J., Karpecki, P., Latkany, R., Luchs, J., Martel, J., Sall, K., … OPUS Investigators. (2015). Lifitegrast ophthalmic solution 5.0% for treatment of dry eye disease. Ophthalmology, 122(12), 2423–2431.
Nichols, J. J., & Willcox, M. D. P. (2019). Contact lenses and dry eye disease. Investigative Ophthalmology & Visual Science, 60(3), DES1–DES7.
Pflugfelder, S. C., & de Paiva, C. S. (2017). The pathophysiology of dry eye disease. Ophthalmology, 124(11), S4–S13.
Pflugfelder, S. C., Stern, M. E. (2020). Biological functions of tear film. Experimental Eye Research, 197, 108079.
Bron, A. J., Tiffany, J. M., Gouveia, S. M., Yokoi, N., & Voon, L. W. (2017). Functional aspects of the tear film lipid layer. Experimental Eye Research, 163, 113–123.
Sullivan, B. D., Whitmer, D., Nichols, K. K., Tomlinson, A., Foulks, G. N., Geerling, G., … Lemp, M. A. (2017). An objective approach to dry eye disease severity. The Ocular Surface, 15(3), 488–498.
Galor, A., Moein, H. R., Lee, C., Rodriguez, A., Felix, E. R., Sarantopoulos, C. D., & Levitt, R. C. (2018). Neuropathic pain and dry eye. Ophthalmology, 125(7), 1139–1148.
Galor, A., Levitt, R. C., Felix, E. R., Martin, E. R., & Sarantopoulos, C. D. (2015). Neuropathic ocular pain. British Journal of Ophthalmology, 99(5), 665–670.
Baudouin, C., Irkec, M., Messmer, E. M., Benítez-del-Castillo, J. M., Bonini, S., Figueiredo, F. C., … Aragona, P. (2016). Clinical impact of inflammation in dry eye disease. Ocular Surface, 14(2), 163–174.
Goto, E., Yagi, Y., Matsumoto, Y., & Tsubota, K. (2019). Impaired functional visual acuity of dry eye patients. American Journal of Ophthalmology, 200, 15–23.
Schaumberg, D. A., Dana, R., Buring, J. E., & Sullivan, D. A. (2018). Prevalence of dry eye disease among adults. American Journal of Ophthalmology, 185, 1–8.
Craig, J. P., & Tomlinson, A. (2016). Importance of the lipid layer in tear film stability. Contact Lens and Anterior Eye, 39(4), 242–246.
Downie, L. E., & Keller, P. R. (2015). Nutrition and dry eye disease. Current Opinion in Ophthalmology, 26(4), 293–299.
Wolffsohn, J. S., & Craig, J. P. (2019). Management of dry eye disease in clinical practice. BMJ, 364, l132.
Copyright (c) 2025 Karolina Nowacka
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
