VISA- Inflammation,Strabismus,Vision and Appearance Classification - for Grave's Orbitopathy
Vision
The primary goal of this section is to rule out optic neuropathy. Subjectively, this is described early on as episodes of graying out with and without color desaturation. On examination, abnormalities in visual acuity, color vision assessment, relative afferent papillary defect, or peripheral visual field assessment may be detected.
Inflammation
The CAS, described and validated by Mourits and the Amsterdam Orbitopathy group, was modified and used to grade the severity of activity. The CAS includes pain, redness, swelling, and impaired visual function, which may signal acute inflammation. The CAS consists of two conjunctival signs, two eyelid signs, and two orbital signs. Each of these signs is assigned points depending on the severity at presentation [Table 1]. The maximum score is thus 8. The worst scores from any of the four eyelids are recorded. A score of 3 or less is considered as inactive and 4 or more is active eye disease and thus is supposedly more likely to respond to immunosuppression. The disadvantage of CAS is it is still very subjective in nature with a large inter-observer variation. The advantage of CAS is it is inexpensive and can be done instantly in a clinic.
Strabismus
The symptoms for strabismus include a progression from no diplopia, diplopia in horizontal or vertical gaze, intermittent diplopia in primary gaze, and constant diplopia in primary gaze. Ocular ductions can be graded from 0° to >45° in four directions, using the Hirschberg principle. Strabismus can be measured objectively by prism cover testing in different gaze directions.
Appearance/exposure
Objective measures of appearance change include eyelid retraction, proptosis, and documentation of redundant skin and fat prolapse. Measures of exposure include corneal staining or ulceration. Photographs can document the appearance changes.
Inflammation
The CAS, described and validated by Mourits and the Amsterdam Orbitopathy group, was modified and used to grade the severity of activity. The CAS includes pain, redness, swelling, and impaired visual function, which may signal acute inflammation. The CAS consists of two conjunctival signs, two eyelid signs, and two orbital signs. Each of these signs is assigned points depending on the severity at presentation [Table 1]. The maximum score is thus 8. The worst scores from any of the four eyelids are recorded. A score of 3 or less is considered as inactive and 4 or more is active eye disease and thus is supposedly more likely to respond to immunosuppression. The disadvantage of CAS is it is still very subjective in nature with a large inter-observer variation. The advantage of CAS is it is inexpensive and can be done instantly in a clinic.
Strabismus
The symptoms for strabismus include a progression from no diplopia, diplopia in horizontal or vertical gaze, intermittent diplopia in primary gaze, and constant diplopia in primary gaze. Ocular ductions can be graded from 0° to >45° in four directions, using the Hirschberg principle. Strabismus can be measured objectively by prism cover testing in different gaze directions.
Appearance/exposure
Objective measures of appearance change include eyelid retraction, proptosis, and documentation of redundant skin and fat prolapse. Measures of exposure include corneal staining or ulceration. Photographs can document the appearance changes.
Source: IJO, researchgate
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