Your oil glands aren't a lost cause: what the new international dry eye report changed

If you've been told your oil glands are "blocked" or "not working well", it can be easy to assume that's simply how your eyes are. A new analysis of the latest international dry eye reports suggests a more hopeful framing: meibomian gland dysfunction (MGD) is now classed as a modifiable risk factor for dry eye disease. Here's what changed, what it means, and what it doesn't.

What are the DEWS reports?

The TFOS Dry Eye Workshop (DEWS) reports are large international consensus documents, written by expert panels who review the research and agree on definitions, diagnostic tests and treatment approaches. DEWS II was published in 2017, and DEWS III in 2025. Among other things, each report sorts dry eye risk factors by how strong the evidence is and whether the risk factor can be changed.

About this paper

In 2026, Badian published a comparison of the risk-factor classifications in the two reports in Clinical Ophthalmology. It is a single-author secondary analysis: no new patients were studied, and no systematic literature review was done. Instead, the author extracted the risk factors from each report and compared how they were classified.

DEWS II used a grid with three levels of evidence (consistent, probable or inconclusive) and two levels of modifiability (modifiable or non-modifiable). DEWS III uses a simpler four-quadrant grid with two evidence levels (consistent or probable) and the same two modifiability levels. The author grouped changes into four predefined types: upgraded (stronger evidence), downgraded (weaker evidence), reclassified (modifiability changed) and newly identified.

The headline change: MGD is now modifiable

In DEWS II, MGD was listed as a non-modifiable risk factor with consistent evidence. In DEWS III, it is listed as modifiable, still with consistent evidence. The author calls this a "paradigm shift".

That matters because the DEWS III Executive Summary is cited as saying most dry eye is evaporative or hyperevaporative, with MGD as the main driver. If the most common driver of dry eye is something that can be changed, then assessing and managing the oil glands becomes central, rather than just soothing symptoms with drops. The author suggests checking meibomian gland function routinely, even in people without symptoms, and especially in older people.

It's worth being clear about what "modifiable" means. It's a consensus judgement that MGD can be influenced, not new trial evidence that any particular treatment works, and it doesn't mean every case can be reversed.

Other changes worth knowing

• Upgraded (stronger evidence): thyroid disease and anticholinergic medicines moved from probable to consistent. Acne and oral contraceptives moved from inconclusive to probable.
• Downgraded (weaker evidence): hormone replacement therapy and air pollution moved from consistent to probable.
• Reclassified as modifiable: rosacea, pterygium and psychiatric conditions were all previously listed as non-modifiable. Psychiatric conditions remain at the probable evidence level.
• Newly identified in DEWS III: dupilumab, antiandrogen therapies, chemotherapeutic agents, altered gut microbiome, and deficiencies of vitamin B12 and vitamin D. The paper also says DEWS III broadened autoimmune, pain and surgical or procedural risk factors.

The paper also reports that sarcoidosis was upgraded, but its abstract and results describe the earlier DEWS II rating differently, so we've left the details aside.

Medicines and skincare featured in DEWS II too: antihistamines, antidepressants, anxiolytics and isotretinoin were listed as modifiable risk factors with consistent evidence. If you use vitamin A-based products, our post on retinol, tretinoin and dry eye looks at that evidence. Never stop a prescribed medicine without talking to your prescriber.

Diagnosis is getting more specific too

The paper summarises DEWS III diagnostic thresholds, including an OSDI-6 symptom score of 4 or more for screening, tear osmolarity of 308 mOsm/L or more (or a difference between eyes of more than 8 mOsm/L), and a non-invasive tear break-up time under 10 seconds. DEWS III also moves away from the simple "aqueous-deficient versus evaporative" split, towards three broad categories: tear-film component deficiencies, eyelid anomalies and ocular-surface abnormalities.

A note on the numbers

Because this paper compares classifications rather than running a trial, it doesn't report effect sizes, confidence intervals or p-values. "Consistent" and "probable" are expert judgements about how strong the evidence is, not measures of how much a risk factor raises your chance of dry eye. One figure the paper does carry over from DEWS II is that dry eye prevalence rises with age by 2.0–10.5% per decade, depending on the diagnostic criteria used.

What the studies can't tell us

• One author's reading. Every "change" depends on a single author's interpretation, with no second reviewer and no published extraction protocol.
• Different frameworks. DEWS II had an "inconclusive" category that DEWS III doesn't. Some apparent upgrades may partly reflect that change in structure rather than new evidence.
• Incomplete details. For several factors, only one part of the change is described, and the tables in the paper weren't available in the version we reviewed. The status of factors such as contact lens wear, screen use and diabetes in DEWS III isn't stated in the text.
• Consensus, not trials. Classifications reflect expert agreement and may not capture all the nuances of the underlying research. The original DEWS III documents remain the authoritative source.
• Funding unclear. Funding and disclosure statements weren't included in the text we reviewed.

Treat the cause, not just the symptom

The practical message is encouraging: your oil glands aren't necessarily a lost cause. That doesn't guarantee any outcome, but it does mean a proper look at your glands is worthwhile. A Dry Eye Evaluation can include assessment of how your meibomian glands are working, alongside your tear film, eyelids and any medicines or health conditions that may contribute. From there, a plan can be tailored to what's actually driving your symptoms; our treatments page outlines the options.

At Rose Optometry in Hamilton, our optometrists, including Jagrut Lallu and Jacqueline Rowe, offer Dry Eye Evaluations. To find a clinic near you, visit our member practices page to book. For more research-focused reading, see the New Zealand Eye Research Centre.

References

• Badian RA. The Evolving Landscape of Dry Eye Disease Risk Factors: A Comparative Analysis of the TFOS DEWS II (2017) and DEWS III (2025) Reports. Clinical Ophthalmology. 2026;20:614576. PMID 42892870. DOI: 10.2147/OPTH.S614576