Dry Eye Disease: A Functional Medicine Approach Aligned with the Tear Film and Ocular Surface Society (TFOS)

Neda Gioia, OD, CNS, FMCP, FOWNS

Neda Gioia, OD, CNS, FMCP, FOWNS, Integrative Vision Corp., Shrewsbury, New Jersey, USA.

Corresponding author: Neda Gioia, OD, CNS, FMCP, FOWNS

E-mail: drdibaee@gmail.com

Keywords: Dry eye disease, Lifestyle, Nutrition, Ocular health, Modifiable risk factors.

Introduction

In the United States, the prevalence of Dry Eye Disease (DED) is estimated at 8.1% based on meta-analysis, with global prevalence ranging from 5% to 50%, depending on population characteristics and diagnostic criteria.^1,2 DED is not solely a localized tear deficiency, but is influenced by behavioral, environmental, metabolic, and systemic factors. The Tear Film and Ocular Surface Society (TFOS) produces evidence-based consensus reports, such as the Dry Eye Workshop DEWS (2007) and DEWS II (2017), and subsequent specialty workshops addressing ocular surface influences and therapies in DED.^3,4 More recently, the TFOS DEWS III report (2025) has further emphasized that lifestyle modifications play a crucial role in long-term DED management.^3,4 The functional medicine model of care is uniquely positioned to prioritize personalized lifestyle factors in a care plan that considers the systemic root causes of DED.

This manuscript interprets the TFOS DEWS III framework through a functional medicine lens, emphasizing the integration of lifestyle-based modifications as a foundational component in the management of DED patients. Towards this end, the Dry Eye Lifestyle Expansion Questionnaire proposed in this manuscript provides a framework for clinicians to integrate these lifestyle factors into patient assessment and care.

Narrative

According to TFOS, “Dry Eye Disease is 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.”³ The two primary types of DED, namely Aqueous Deficient Dry Eye and Evaporative Dry Eye (EDE), have distinct pathophysiology, with EDE characterized by meibomian gland dysfunction and phenotypic changes in corneal epithelial cells.³ More often, they coexist and have distinct but overlapping pathophysiology.³

Ocular pain perception is now recognized as linked to the structural integrity of corneal nerves, functional capacities of neurons, and activity of both the central and peripheral nervous systems. Neurosensory abnormalities are therefore considered etiological contributors rather than merely consequences of disease.⁵

Furthermore, TFOS DEWS III emphasized the expanding role of metabolic, hormonal, physical, neural, and cellular stresses, including hyperosmolarity, mitochondrial stress, and neurogenic inflammation as key pathogenic mechanisms.⁵

An approach to DED that considers antecedents, triggers, and mediators (ATMs) aligns with the evidence presented by TFOS, enabling clinicians to stratify patients according to dominant physiologic drivers rather than treating all phenotypes uniformly. Antecedents include hormonal transitions,⁵ long-standing dietary patterns,^6,7 sedentary behavior, and chronic sleep disruption.⁸ Triggers such as acute digital strain,⁷ environmental dryness,⁷ allergen exposure,⁷ and psychosocial stress⁸ shape symptom patterns and can aid in clinical phenotyping. Mediators, encompassing chronic systemic inflammation,⁶ altered lipid composition,⁶ oxidative stress,⁶ and autonomic imbalance,⁸ influence disease chronicity and prognosis. By identifying ATMs in individual patients, targeted interventions spanning nutrition and lifestyle modifications can be provided based on their specific underlying physiological drivers.

When reviewing the core fundamentals of modifiable lifestyle, we often reflect on changes including nutrition, sleep, movement, stress management, and social nodes. They represent areas where a patient can try to reduce or mitigate various systemic conditions. Elements highlighted within the TFOS reports support this approach to DED. Current evidence reinforces that lifestyle modification, including sleep hygiene and stress reduction, should be considered across all DED subtypes.⁶

Behavioral factors such as persistent digital device use negatively affect tear dynamics by functionally reducing blink rates and incomplete blinking during screen use. This leads to increased tear evaporation, destabilizing the lipid layer, promoting hyperosmolarity and inflammation. Thus, incorporating interventions, such as blink retraining, scheduled visual breaks, and ergonomic adjustments, into management plans can be helpful.⁷

Dietary modification and oral supplementation can be strategies in DED management, with particular focus on their anti-inflammatory and immunomodulatory effects on the ocular surface.⁶ Although clinical trial data remain inconclusive, without established optimal dosing strategies, polyunsaturated fatty acids, especially omega-3 derivatives such as resolvins and protectins, demonstrate biologically plausible mechanisms for reducing ocular surface inflammation and improving tear parameters.⁶ Micronutrients, including vitamins A, B12, and D, as well as trace elements such as selenium, may play essential roles in epithelial integrity, neural function, immune regulation, and oxidative balance.⁶ Associations between altered micronutrient status and DED are noted with targeted supplementation showing variable but promising therapeutic benefits.⁶

Obesity and metabolic dysfunction are associated with meibomian gland abnormalities, altered lipid secretion, and impaired tear film stability, contributing to evaporative DED phenotypes through systemic inflammation. These findings, along with evidence that sedentary behavior increases DED-susceptibility, justify incorporating metabolic assessment and weight optimization into clinical care.⁸

Environmental exposures such as outdoor and indoor pollution, including particulate matter, have been associated with increased DED prevalence. Other conditions, such as low humidity, high temperatures, wind exposure, and even excess ultraviolet light exposure, can further contribute to tear film instability and trigger DED symptoms.⁷

Translating Consensus into Clinical Workflow

The author proposes the Dry Eye Lifestyle Expansion Questionnaire (Figure 1) as an implementation framework designed to expand the integration of these lifestyle factors. This conceptual tool provides structured guidance for evaluating ATMs of dysfunction in DED in routine patient assessment. It is organized into seven lifestyle domains: digital behavior, nutrition, hydration, movement patterns, sleep quality, stress load, and hormonal stage. The questionnaire is not intended to function as a diagnostic or disease severity instrument. Rather, it facilitates the development of a dedicated clinical encounter focused on foundational lifestyle review. Such an approach may identify lifestyle domains with the greatest opportunity for intervention, and support counseling, staff delegation, and interdisciplinary nutritional collaboration in managing DED patients.

Conclusion

DED management exemplifies the convergence of conventional and functional medicine approaches. Representing the highest level of evidence-based consensus in this field, the TFOS reports now explicitly recognize lifestyle modifications as foundational therapy. TFOS has systematically evaluated the evidence and developed a framework that aligns with functional medicine principles; yet meaningful integration into routine clinical workflows remains largely unrealized.

Incorporating modifiable lifestyle risk factors into structured clinical follow-up protocols for patients with DED, alongside pharmaceutical, surgical, and procedural interventions, can address existing gaps in comprehensive disease management. This integrated approach supports a paradigm shift in which lifestyle-based interventions are prioritized as a foundational component of care, fostering meaningful patient engagement and facilitating interdisciplinary collaboration among eye care providers, clinical staff, and allied healthcare professionals.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

References

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