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Understanding dry eye starts with understanding exactly what is causing it. For years, the global gold standard for dry eye research has been the Tear Film & Ocular Surface Society’s Dry Eye Workshop (TFOS DEWS). With the recent release of the highly anticipated DEWS III report, the scientific community has completely mapped out the risk factors that trigger and exacerbate dry eye disease.
The DEWS III committee organized these triggers into a brilliant, patient-friendly ‘risk matrix’. It categorizes risk factors by Certainty (Is the scientific evidence Consistent or just Probable?) and Modifiability (Is it something we cannot change, or something we can actively fix?).
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The Unchangeable: Non-Modifiable Risk Factors
These are the cards you are dealt. While you cannot change them, identifying them is the first critical step in acknowledging why your eyes are struggling and tailoring a specific treatment plan.
Consistent & Non-Modifiable Triggers:
Demographics: Ageing inevitably changes tear production. Additionally, female sex/gender (heavily linked to hormonal shifts) and Asian/non-white racial backgrounds are consistently proven to carry a higher baseline risk for developing dry eye.
Systemic Autoimmune & Hormonal Disorders: Conditions like Sjögren’s syndrome, Rheumatoid Arthritis, Lupus, Thyroid disease, and Diabetes fundamentally alter the body's inflammatory response and glandular function.
Pain & Atopic Syndromes: Interestingly, the updated data strongly links systemic pain disorders (like fibromyalgia, IBS, and chronic migraines) as well as asthma to a higher incidence of dry eye.
Past Surgeries: Any procedure that cuts the delicate corneal nerves, such as LASIK, PRK, cataract surgery, or even cosmetic eyelid surgery (blepharoplasty), can disrupt the brain-to-eye signaling required for healthy tear production.
The Action Zone: Modifiable Risk Factors
This is where the DEWS III report becomes incredibly empowering for patients. The bottom half of the matrix focuses entirely on modifiable factors - elements of your health, environment, and daily life that you and your doctor can actively change, treat, or optimize.
1. Environment, Climate & Lifestyle
DEWS III places a massive, updated emphasis on how our modern world is drying out our eyes.
The Screen Time Epidemic: As discussed with the 20-20-20 rule, prolonged digital screen use reduces your blink rate, leading to stagnant meibomian glands and rapid tear evaporation.
Climate & Air Quality: Consistent evidence points to low humidity environments as major triggers. Furthermore, new probable evidence highlights the damaging effects of extreme high/low temperatures, indoor air conditioning, and urban air pollution.
Cosmetics & Skincare: The chemicals, preservatives, and retinols used in daily skincare routines and makeup are now recognized as consistent, modifiable triggers that actively degrade the eyelid margin and meibomian glands.
2. The Mind-Body Connection
One of the most profound updates in DEWS III is the formal recognition of mental health's role in ocular surface disease.
Psychiatric & Sleep Disorders: Depression, anxiety, and chronic stress are now listed as consistent modifiable risk factors. Burnout is also recognized as a probable trigger. The nervous system governs tear production, when the nervous system is highly stressed or deprived of restorative sleep (due to insomnia or sleep apnea), tear homeostasis collapses.
3. Medications
Many patients take daily medications that unknowingly dry out their eyes.
Systemic Drugs: Anti-cholinergics (often found in over-the-counter allergy/cold meds and antidepressants), proton pump inhibitors (for acid reflux), and hormone replacement therapies are known culprits.
Topical Glaucoma/Eye Drops: The DEWS III report explicitly flags preserved topical medications. The chronic use of preservatives like benzalkonium chloride (BAK) in eye drops creates toxic surface damage over time.
4. Managing Underlying Ocular & Dermatological Conditions
You cannot fix the tear film if the foundation is broken.
Lid and Skin Health: Active Meibomian Gland Dysfunction (MGD), anterior blepharitis, and ocular rosacea must be treated (often with IPL, LLLT, or targeted expression) to stabilize the tear film. Systemic dermatological issues like eczema, general rosacea, and severe acne are also heavily linked to ocular surface inflammation.
5. Nutrition and The Gut Microbiome
DEWS III highlights that dry eye is an inflammatory disease heavily influenced by what we eat.
Deficiencies: Deficiencies in Vitamin A, C, D, B12, and Omega-3 fatty acids are direct, modifiable risk factors.
In a fascinating update, the report lists an ‘altered gut microbiome’ as a probable modifiable risk. Healing the gut through proper diet and probiotics already can play a role in managing systemic inflammation that reaches the eyes.
What This Means For You
Looking at the DEWS III matrix can feel overwhelming, but it is actually a roadmap. You do not need to (and likely can’t) fix everything at once.
Your Action Plan:
Adjust Your Lifestyle: Look at the "Modifiable" sections. Can you adjust your workstation to avoid direct air conditioning vents? Can you switch to preservative-free artificial tears? Can you swap your skincare routine and products for eye-safe ingredients?
Acknowledge the Non-Modifiable: If you have an autoimmune condition or a history of LASIK, you understand why your eyes need more support. It removes the mystery and allows you to focus on aggressive, proactive maintenance rather than a quick fix.
Holistic Discussion: Bring this perspective to your next eye exam. Discuss your sleep patterns, stress levels, and daily medications with your practitioner. Treating dry eye is no longer just about looking at the cornea and ocular surface, it is about looking at the whole patient.