Published in Ocular Surface

2026 Dry Eye Report

The TFOS DEWS III Report defines dry eye as “a multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities are etiological factors.”1

Dry eye disease (DED) is a common condition affecting hundreds of millions worldwide and, in severe cases, can cause significant discomfort, vision issues, and a decreased quality of life. Management of DED involves multiple treatment strategies to be effective, and clinicians need the tools necessary to not only screen and diagnose but also to manage DED effectively.1

The 2026 Dry Eye Report, our sixth installment, continues to explore emerging challenges in dry eye care, including insights from a wide range of eyecare professionals—from optometrists just starting to experienced clinicians with decades of practice.

The 2026 Dry Eye Report covers:

  • The primary challenges in dry eye screening and diagnosis
  • The barriers to expanding OSD lines of service in optometry practices
  • The most popular go-to treatments for dry eye disease
  • Confidence in treatment and ongoing management—including current and emerging therapies
  • And more!

Key Takeaways from the 2026 Dry Eye Report

83% of practice owners are interested in implementing in-office OSD treatments, but ~51% see the cost of equipment and technology as the main obstacle.

In 2026, more doctors (~8.8% increase) screen patients for dry eye disease than in 2025.

38% of optometrists would consider implementing new treatments for dry eye; however, common reasons for avoiding certain options include familiarity with alternatives, lack of knowledge, and the perception that the treatments are too invasive.

We trust that the 2026 Dry Eye Report will enable you to manage DED effectively. As the population ages and the number of patients increases, ECPs need to stay up to date on the latest best practices in eye health.

Diagnostic algorithm and clinical evaluation of DED

Symptom-sign correlation in DED is notoriously poor, which is precisely why DEWS III moves away from severity grading toward a three-step diagnostic algorithm:

  1. Symptom screening: Administer the validated six-item Ocular Surface Disease Index (OSDI-6). A score of four or higher is required to proceed. Symptoms are the gatekeeper.
  2. **Homeostasis markers:**Confirm loss of homeostasis with at least one objective test:
    1. Non-invasive tear breakup time (NIBUT) less than 10 seconds
    2. Fluorescein tear breakup time (FTBUT) less than 5 seconds
    3. Tear osmolarity of 308 mOsm/L or higher in either eye; an inter-eye osmolarity difference of 8 mOsm/L or greater is also positive, as asymmetry can reflect early or laterally dominant disease even when absolute values appear normal
  3. Ocular surface staining:An alternative confirmatory route when Step 2 markers are negative or unavailable. Positive criteria include:
    1. More than 5 corneal fluorescein punctate spots, and/or more than 9 conjunctival lissamine green punctate spots, and/or lid margin lissamine green staining of 2 mm or more in length and 25% or more in width.
    2. Meeting any one of these thresholds alongside a positive OSDI-6 confirms the diagnosis of DED.

Once DED diagnosis is confirmed, post-diagnostic testing maps the specific etiological drivers present, and that map drives therapy selection.

DED management: Driver-based combination therapy

DED is multifactorial. Isolating one pathway while deferring others allows progression and delays recovery. DEWS III is explicit: concurrent, driver-targeted combination therapy is the standard, not the escalation.

This approach is philosophically analogous to the broader goal of glaucoma management: preventing structural damage and disease progression from the point of first diagnosis, rather than waiting for irreversible loss before escalating intervention.

The interventional dry eye philosophy

The DEWS III framework provides robust evidence-based support for an interventional approach to dry eye care. Rather than a passive, observation-first model, DEWS III directs clinicians to identify and address etiological drivers at the point when homeostasis is first compromised, before overt ocular surface damage occurs.

Conclusion

DEWS III represents a meaningful evolution in the evidence-based management of dry eye disease and ocular surface disease more broadly. Its most significant contribution is not a redefinition of the disease, but a restructuring of how it is diagnosed and managed: from severity-based escalation to driver-based, simultaneous, targeted intervention.