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Ocul Surf. 2017 Jul;15(3):276-283. doi: 10.1016/j.jtos.2017.05.008. Epub 2017 Jul 20.

TFOS DEWS II Definition and Classification Report.

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Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand. Electronic address:
School of Optometry, University of Alabama, Birmingham, AL, USA.
Johns Hopkins University, School of Medicine, Baltimore, MA, USA.
Toronto Eye Care, Toronto, ON, Canada.
Academic Ophthalmology and Visual Sciences, Division of Clinical Neuroscience, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK.
Department of Ophthalmology, College of Medicine, Catholic University of Korea, Seoul, South Korea.
Department of Ophthalmology, Eye Institute of Xiamen University, Xiamen, China.
Specialty Care for HealthPartners Medical Group and Clinics, St Paul, MN, USA; University of Minnesota, Minneapolis, USA.
Department of Ophthalmology, School of Medicine, Keio University, Tokyo Dental College and Ichikawa Hospital, Tokyo, Japan.
School of Optometry and Vision Science, University of New South Wales, Sydney, Australia.


The goals of the TFOS DEWS II Definition and Classification Subcommittee were to create an evidence-based definition and a contemporary classification system for dry eye disease (DED). The new definition recognizes the multifactorial nature of dry eye as a disease where loss of homeostasis of the tear film is the central pathophysiological concept. Ocular symptoms, as a broader term that encompasses reports of discomfort or visual disturbance, feature in the definition and the key etiologies of tear film instability, hyperosmolarity, and ocular surface inflammation and damage were determined to be important for inclusion in the definition. In the light of new data, neurosensory abnormalities were also included in the definition for the first time. In the classification of DED, recent evidence supports a scheme based on the pathophysiology where aqueous deficient and evaporative dry eye exist as a continuum, such that elements of each are considered in diagnosis and management. Central to the scheme is a positive diagnosis of DED with signs and symptoms, and this is directed towards management to restore homeostasis. The scheme also allows consideration of various related manifestations, such as non-obvious disease involving ocular surface signs without related symptoms, including neurotrophic conditions where dysfunctional sensation exists, and cases where symptoms exist without demonstrable ocular surface signs, including neuropathic pain. This approach is not intended to override clinical assessment and judgment but should prove helpful in guiding clinical management and research.


Aqueous deficient; Classification; Definition; Dry eye disease; Evaporative; Mechanism

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