TFOS DEWS III and Rohto Dry Aid’s Role

When the Tear Film and Ocular Surface Society released its third Dry Eye Workshop report (TFOS DEWS III) in late 2025,1 it recommended a major shift in how clinicians approach diagnosis, classification, and management of dry eye disease (DED). In this article, Dr Margaret Lam explains how TFOS III reframes DED management and demonstrates how (and why) Rohto Dry Aid fits into the treatment paradigm.

WRITER Dr Margaret Lam

Dry eye disease has become one of the most prevalent and disruptive conditions seen in contemporary optometric practice. As digital habits intensify, device use increases, and demographic ageing continues, clinicians are encountering increasing numbers of symptomatic patients who experience fluctuating comfort and unstable vision throughout the day. Yet, despite its ubiquity, dry eye remains complex: signs often do not correlate with symptoms, disease mechanisms overlap, and patients present with a broad range of functional impacts.

Unlike previous frameworks, DEWS III places strong emphasis on restoring tear-film homeostasis, understanding neurosensory drivers of symptoms, and adopting a more personalised diagnostic approach to dry eye management based on etiological factors rather than rigid subtypes.1

DEWS II TO DEWS III: THE EVOLUTION

TFOS DEWS II (2017) gave clinicians the foundational definition of DED and introduced a staged management model that is still widely used.2 However, in practice, clinicians often encountered patients whose symptoms were disproportionate to signs, or in whom multiple mechanisms coexisted.

DEWS III addresses these gaps by:

• Emphasising loss of tear film homeostasis as the core feature of DED,3

• Strengthening the role of neurosensory abnormalities, acknowledging why symptoms often appear before measurable signs,

• Updating diagnostic thresholds, including ocular surface disease index-6 (OSDI-6) ≥4 and non-invasive tear break-up time (NIBUT) <10 seconds, better reflecting clinical reality,4,5 and

• Shifting from rigid classification to etiological drivers, encouraging targeted therapy (e.g., tear film instability, meibomian gland dysfunction, inflammation, and blink issues).

This updated structure supports more personalised care and reinforces the need for therapeutic approaches that stabilise all layers of the tear film while addressing patient comfort and neurosensory triggers.

WHERE ROHTO DRY AID FITS IN

A 28day prospective randomised controlled study from Santos et al.,6 evaluated Rohto Dry Aid in 26 participants (52 eyes) with mild to moderate DED. Findings demonstrated that Rohto Dry Aid fits into the updated model for management of dry eye disease, improving tear-film stability, ocular surface integrity, and patient symptoms – outcomes that align closely with the objectives of DEWS III and the needs of modern digital-age patients.

The microemulsion lubricant contains povidone, propylene glycol, sesame oil, castor oil, and polyoxyl-40 stearate. Together, these components create a multi-layer therapeutic effect:

Mucoaqueous enhancement. Povidone integrates with the mucous layer, improves hydration, and reduces friction.

Lipid-layer supplementation. Sesame and castor oils replenish both polar and non-polar lipids, improving evaporation resistance – critical given that 86% of patients have an evaporative component.

Improved tear-film spreadability. Surfactants such as polyoxyl-40 stearate help stabilise the lipid–aqueous interface.

Neurosensory modulation. Low-dose menthol stimulates TRPM8 pathways, promoting basal tearing and providing a soothing effect.

These mechanisms directly support the DEWS III goal of restoring tear film homeostasis, making Rohto Dry Aid a strong early-stage and maintenance therapy for patients with evaporative, mixed-mechanism, or symptomatic DED.

CLINICAL FINDINGS

The outcomes from the Santos et al. study provide strong, clinically relevant evidence:

Tear break-up time. Improved significantly from 6.3 seconds to 10.0 seconds (p<0.001), with the proportion of eyes achieving TBUT ≥10 seconds increasing from 25% to 63.5%.

Corneal epithelial integrity. Eyes with a corneal staining score of 0 increased from 23.1% to 69.2%.

Meibomian gland function. Normal gland scores rose from 3.8% to 30.8%, demonstrating structural and functional benefits.

Visual acuity. Improved from 79.87 to 84.06 letters (p<0.001), correlating with improved tear film smoothness.

Symptoms and quality of life. OSDI scores dramatically reduced, with 50% of participants achieving OSDI ≤12 by day 14, sustained at day 28.

Qualityoflife indices. Improved significantly, measured by EurQol 5-Dimensions, 5-Levels questionnaire, a standardised, internationally validated questionnaire to measure health-related quality of life outcomes. Patients reported less pain or discomfort with symptoms interfering less with daily activities; they felt less distress associated with eye discomfort; and their overall perceived health score increased.

These findings are clinically meaningful because TBUT, staining, and symptom burden are among the most useful metrics in everyday practice, and the study validated results based on significant improvement in quality-of-life outcomes. The study’s outcomes strongly align with DEWS III’s central focus on restoring tear film stability and improving functional visual performance.

PRACTICAL APPLICATION IN OPTOMETRIC CARE

Rohto Dry Aid is well suited as a foundational therapy within DEWS III-guided management as it:

• Addresses evaporative and mixed mechanisms via lipid enhancement,

• Reduces neurosensory disruption through menthol/TRPM8 signaling,

• Provides measurable improvements within two to four weeks,

• Pairs effectively with inpractice treatments such as warm compresses, gland expression, and lid hygiene, and

• Enhances outcomes for digital device users who experience fluctuating vision and evaporative stress.

REFRAMING DRY EYE MANAGEMENT

TFOS DEWS III reframes DED management around restoring homeostasis, tailoring therapy to both tear film and neurosensory mechanisms, and integrating patient-centred diagnostic thresholds. Rohto Dry Aid fits seamlessly within this updated paradigm: its multi-layer stabilising action, neurosensory benefits, and strong clinical evidence, highlighted by randomised controlled trials, make it an excellent drop for early and ongoing management.

Importantly, these findings are reinforced by the broader body of evidence supporting microemulsion-based povidone and propylene glycol formulations. In the Santos et al. study,6 patients experienced not only significant improvements in TBUT and corneal staining, but also a meaningful reduction in OSDI scores within 28 days, with half of all participants shifting into the mild or asymptomatic category. The proportion of eyes achieving a completely clear corneal surface (staining score 0) increased nearly threefold, and meibomian gland function improved across all categories, demonstrating that multi-component lubricants can positively influence both tear film stability and lid function. These improvements were achieved with excellent tolerability, with minimal transient stinging, and no serious adverse events reported – an important consideration when selecting drops for sensitive or high-frequency users.

Together, these findings strengthen the rationale for selecting a microemulsion lubricant like Rohto Dry Aid as a foundational therapy for patients across the spectrum of DED severity. Available in a multidose and a preservative-free single-dose format, Rohto Dry Aid can support clinicians in delivering modern, evidence-based dry eye care that aligns with the principles of DEWS III and responds to the practical needs of today’s patients.

Contact: Ophthalmopro (AUS) 1300 578 288 or visit ophthalmopro.com.au.

This article was sponsored by Rohto.

References available at mivision.com.au.