This document discusses various classification and staging systems used in ophthalmology. It covers classifications for corneal and external eye diseases, glaucoma, uveitis, vitreo-retinal diseases, and others. For each condition, it provides details on the classifications used to describe risk factors, pathogenesis, clinical features, severity, investigations, and management approaches. The classifications discussed include international standardized systems as well as other commonly used staging methods.

1. Classifications-Grading-Staging
@ Ophthalmology
Dummy Survival Guide
Dr Yong Meng Hsien 2021

2. Discussion Approach (Anatomy):
• Cornea & external eye diseases
• Glaucoma, angle and IOP
• Uveitis
• Lens and cataract
• Vitreo-retina
• Neuro-ophthalmology
• Orbit & Oculoplastic
• Trauma

3. General Classifications
• Risk factors
• E.g. modifiable/not, ocular/systemic
• Pathogenesis
• E.g. Ischemic/occlusive/haemorrhagic, necrotic/fibrotic
• Aetiology/causes
• Clinical features/Severity/Progression/Complications
• Investigation/tests
• E.g. ocular/systemic, invasive/not
• Management
• E.g. conservative/medical/laser/surgical
• E.g. factors to be considered
• Primary vs Secondary
• Systemic vs Ocular
• Congenital vs Acquired
• Anatomical approach
• Etiological approach (VITAMINS, VEINS, VINDICATE)
• Most common, important. life/sight threatening

4. Corneal & External Eye Diseases

5. Corneal & External Eye Diseases
• Keratoconus
• Corneal dystrophies
• Dry eye
• VKC
• HSV keratitis
• Prognosis for corneal transplant
• Trachoma
• GPC

6. Global Consensus on Keratoconus and
Ectatic Diseases 2015
• Currently there is no clinically adequate
classification system for keratoconus
• Currently, there is no consistent or clear definition
of ectasia progression

7. Ref + Astig + Topo + Km + CCT
Amsler-Krumeich KC Classification

8. Belin ABCD KC Staging
• Ant & Back radius of
curvature (3mm),
• Corneal thickness
(minimal)
• Distance VA (DCVA)

9. Pentacam for KC
• K Max & ABCD & Thinnest pachy  progression
• Indices  colour code, KISA (60-100), IS (1.4-1.9)
• BAD D (enhanced ectasia)  screening & colour code
(change/different: ant 5-7 & post 12-16 )
• Covis biomechanical: CBI & TBI
• Asphericity/Q value: normal -0.01 to -0.8
• Q-val <0/-ve/oblate = normal or KC or post hyperop LVC
• Q-val >0/+ve/prolate = post myopic LVC
• Q-val=0/sphere

10. IC3D 2015 (International Classification of Corneal
Dystrophies)
- Genetic (chromosomal/gene)
- Clinical (pattern/anatomical layer)
- Pathology (histo/biochem/confocal)

11. DEWS 2017 (International Dry Eye Workshop)
Classification: Aqueous deficiency VS evaporative
• Aq deficiency
– Sjogren VS Non Sjogren
• Evaporative
– Intrinsic VS Extrinsic
Dry Eye Severity Grading Scheme
• Symptoms + Signs (conj/cornea/tear/lid & gland) + Tests (TBUT/Schimer)

12. VKC- classification
• Limbal/bulbar vs palbebral vs mixed
• Chronic vs intermittent
• VKC Grade 0-4 (various)
• Mild/mod/severe (just noticeable/most of the
day/interrupt daily routine) & vision threatening
• Papillae Grading 0-4 (size: 0.3-1-3mm, location:
tarsal-limbus)
• Shield ulcer Grading 1-3 (content: clear-debris-
plaque, treatment response/re-epithelised)

13. HSV Keratitis

14. Brightbill’s Classification:
Corneal Graft Prognosis
• Grade I to V (excellent to poor)
• Underlying pathology + secondary complication

15. Trachoma: WHO classification & SAFE strategy
SAFE strategy: Surgery for in-turned eyelashes, Antibiotics for active disease, Face washing (or
promotion of facial cleanliness), and Environmental improvement to reduce transmission.

16. Uveitis

17. Uveitis
• Classification
• AC cells & flare
• Vitreous cells and haze
• Course & progression
• Sarcoidosis
• level of diagnostic certainty
• Staging of pulmonary sarcoidosis
• Phases of FFA
• Immunomodulators
• Hypersensitivity reactions

18. SUN Anatomical Classification

19. Uveitis SUN / NIH / MUST

21. International Workshop on Ocular Sarcoidosis (IWOS)
• 7signs:
– (1) mutton-fat keratic precipitates (KPs)/small granulomatous KPs and/or iris nodules
(Koeppe/Busacca),
– (2) trabecular meshwork (TM) nodules and/or tent-shaped peripheral anterior synechiae (PAS),
– (3) vitreous opacities displaying snowballs/strings of pearls,
– (4) multiple chorioretinal peripheral lesions (active and/or atrophic),
– (5) nodular and/or segmental peri-phlebitis (± candlewax drippings) and/or retinal macroaneurism in
an inflamed eye,
– 6) optic disc nodule(s)/granuloma(s) and/or solitary choroidal nodule, and
– (7) bilaterality
• 5labs/imaging Ix:
– (1) negative tuberculin skin test in a BCG-vaccinated patient or in a patient having had a positive
tuberculin skin test previously,
– (2) elevated serum angiotensin converting enzyme (ACE) levels and/or elevated serum lysozyme,
– (3) chest x-ray revealing bilateral hilar lymphadenopathy (BHL),
– (4) abnormal liver enzyme tests, and
– (5) chest CT scan in patients with a negative chest x-ray result.
• Four levels of certainty for the diagnosis of ocular sarcoidosis (diagnostic criteria) were
recommended in patients in whom other possible causes of uveitis had been excluded:
– (1) biopsy-supported diagnosis with a compatible uveitis was labeled as definite ocular sarcoidosis;
– (2) if biopsy was not done but chest x-ray was positive showing BHL associated with a compatible
uveitis, the condition was labeled as presumed ocular sarcoidosis;
– (3) if biopsy was not done and the chest x-ray did not show BHL but there were 3 of the above
intraocular signs and 2 positive laboratory tests, the condition was labeled as probable ocular
sarcoidosis; and
– (4) if lung biopsy was done and the result was negative but at least 4 of the above signs and 2
positive laboratory investigations were present, the condition was labeled as possible ocular
sarcoidosis

22. Pulmonary Sarcoidosis
• Stage 1: Bilateral hilar lymphadenopathy
• Stage 2: Bilateral hilar lymphadenopathy and
reticulo-nodular parenchymal infiltrates
• Stage 3: Reticulo-nodular parenchymal infiltrates
alone
• Stage 4: Progressive pulmonary fibrosis

23. Phases of FFA

24. Type V (Stimulating Ab)- grave’s, MG

25. ImmunoModulator (IMT)
• Stimulant (IF/IL)
• Immunosuppressant
– Corticosteroid
– Antimetabolite (AZT/MTX/MPM)
– T cell/calcineurin inhibitor (CSA/Tacro-Siro-limus)
– Alkylating agents (cyclophosphamide/chlorambucil)
– Biologic (TNF-a AG, IL-1/IL-6 AG, IFN-a, IVIg)

26. Glaucoma & Angle

27. Glaucoma & Angle
• Angle classification
• Stages of primary angle closure
• Stages of glaucoma (severity)
• Glaucoma progression
• Classification of topical antiglaucoma
• Grading of shallow AC

28. Angle
Shaffer Spaeth
Scheie

29. • Narrow slit beam
• Perpendicular to the most peripheral part of the cornea
• Slit beam angle of about 60°
• Compare the thickness of the cornea & visible aqueous

30. Becker Goniogram
Means of drawing gonioscopic findings
Allow description of the variable anatomy of an angle within a quadrant
Record synechiae, tumors, foreign bodies, and so on

31. Stages of primary angle closure

32. Glaucoma- Stage
Hodapp Parrish Anderson
– mild/mod/advanced/severe
– By MD: 6-12-20
– By points of depression: 25%-50%-75%

33. Glaucoma Progression
Normal
• HVF MD -0.3dB/yr
• HVF VFI -1%/yr
• OCT RNFL - 0.2-0.5um/yr
• Progression
• Enlarging CDR
• New OD sign: hrge, OD pits
• HVF: + 3 spots >5dB reduction or 1 spot >10dB reduction
• Fast progression
• HVF MD -1dB/yr
• HVF VFI -3%/yr
• OCT RNFL -2um/yr
• Others
• PSD decline after MD >12
• GC reduce 20% than only HVF detected
• Blind= VFI <25%/VF less than 10degree

34. Topical Antiglaucoma Classification

35. Vitreo-retinal

36. Vitreo-retinal
• DR
• DME
• AMD
• Geographical atrophy
• RD & PVR
• Macular hole
• Retinoblastoma
• Sickle cell retinopathy
• Hypertensive retinopathy
• Best disease
• Choroidal melanoma

37. DR & DME- classification
• International classification of DR (ICDR) disease severity scale
• mild-mod-severe NDPR, PDR
• DRS & ETDRS
• NPDR severe/very severe, PDR early/high risk
• NVD >/= 1/3 DD
• NVD <1/3 DD with VH/PRH
• NVE >/= ½ DD with VH/PRH
• DME
– center involvement: CMT (center 1mm) >250um
– vision impairment: VA =/< 6/9
– focal: micro-aneurysm with circinate ring
– diffuse: cystoid ME
– +- VMT
• International classification of DME (ICDME) disease severity scale
• DME absent vs present (mild-mod-severe)
• CSME (ETDRS)
– retinal edema within 500um center of fovea
– HE with retinal thickening within 500um center of fovea
– retinal thickening >1DD located within 1DD center of fovea

41. ARMD- Type & Classification
• Dry vs wet- 90 vs 10% (blindness opposite)
• Normal/normal aging/early/intermediate/late AMD
– drusen size + pigmentary changes → CNV/GA
• Dry- drusen/GA
• Drusen- size (drupelets/63/125=vein diameter at OD margin), morphology
(hard/soft/confluent), +- dystrophic calcification +- pigmentary changes
• PED- x 4 (drusenoid/serous/hrge/FVC)
• Wet- CNV/PED/RAP/PCV
• CNV (FFA/MPS study)
– classic (20%, well defined and early, predominant/minimal), (location:
extra/juxta/subfovea, 200um vs foveola)
– occult (80%, FV PED/LLUS)
• CNV (ICG)
– Hot spot <1DD (less common, for laser)
– Plaque >1DD (more common, poor natural history)
– Combination (rare)
• Wet (CNV)- type 1/2 (subRPE/subretina) or type 3 (RCA with RAP)
• CNV (active/not)- +fluid/hrge/leak on FFA/enlarging CNV membrane/deteriorating
vision
• Variant- RAP x 3 stages (1-3: IRN/SRN/RCA), IPCV

42. AMD Classification & AREDS Staging

43. GA New OCT Classification
• New classification (OCT)
• Outer retinal atrophy (ORA) only or with RPE (RORA)
• Complete vs incomplete
• cRORA = GA
• iRORA = early GA
• cORA
• iORA

44. PVR
Others PVR classification: RSC (1-4, a-c for 3-4), silicone study (1-6, 1-3 post, 4-6 ant)

45. RRD Lincoff’s Rules
1/ Sup RD → break @higher border supnas/suptem (98%)
2/ Sup RD near total/cross vertical → break @12 oc (93%)
3/ Inf RD → break @higher border (if asym), @6oc/very slow
(if sym) (95%)
4/ Inf RD (bullous) → break @sup with peripheral track

46. Macular Hole- Classification
• Gass VS IVTS
– Stage 0/VMA
• oblique VMA at parafovea with normal fovea
– Stage 1a/VMT
• Yellow spot
• Flattened foveal depression + cyst-like schisis (inner changes)
– Stage 1b/VMT
• Yellow ring
• 1a with centrifugal displacement of photoreceptor (outer changes)
– Stage 2/small-medium FTMH with VMT
• <250/<400um hole/red spot
– Stage 3/large FTMH without VMT (no complete PVD yet)
• >400um hole/red spot base with yellow dots +- operculum
– Stage 4/FTMH (any size) without VMT (complete PVD)
• Weiss ring with red spot +- ERM

47. ICRB Classification
- size/location/SRF/SR-vitreous seed/ant-post extension -

49. ROP- Classification
• 2005 International Classification of ROP (ICROP)
– zone I-III
– stage 1-2-3-4a/b-5a/b (open/close funnel)
– plus
– extent 1-12 clock hours
– rush/aggressive posterior (APROP)
– zone 1/post zone2 + plus + diffuse border/not clear stage/progress fast to RD within days + tongue
temporal to fovea (easily missed-- TRD)
– 2 phases (active vs cicatricial)
• CryoROP
• threshold (1,2,3,5,8,+)  50% risk of blindness
• cryoT for ant area (50% reduction of poor outcome) but >Cx (eyelid/conj injury/VH +
systemic bradycardia/respi)
• Early treatment of ROP (ETROP)
– pre-threshold high risk/type 1- need Rx
– pre-threshold low risk/type 2
• STOP ROP (oxygen support doesn’t worsen prethreshold ROP)
• LIGHT ROP (light doesn’t worsen ROP)
• BEAT ROP (Avastin)

51. Goldberg staging:
Proliferative Sickle Cell Retinopathy

52. HPT retinopathy:
Keith-Wagener-Barker classification

53. Mitchell-Wong simplification of the Keith-Wagener-Barret system​
• Grade 1 (mild retinopathy) - Arteriolar narrowing (generalized and focal), AV
nicking, and/or arteriolar wall opacity
• Grade 2 (moderate retinopathy) - Hemorrhage, microaneurysm, cotton wool spot,
and/or hard exudate
• Grade 3 (malignant retinopathy) - Moderate retinopathy plus optic disc swelling
Modified Scheie classification
• Grade 0 - No changes
• Grade 1 - Barely detectable arterial narrowing
• Grade 2 - Obvious arterial narrowing with focal irregularities
• Grade 3 - Grade 2 plus retinal hemorrhages and/or exudates
• Grade 4 - Grade 3 plus disc swelling
The Scheie classification also grades the light reflex changes from arteriolosclerotic
changes
• Grade 0 - Normal
• Grade 1 - Broadening of light reflex with minimal arteriolovenous compression
• Grade 2 - Light reflex changes and crossing changes more prominent
• Grade 3 - Copper-wire appearance; more prominent arteriolovenous compression
• Grade 4 - Silver-wire appearance; severe arteriolovenous crossing changes

54. Staging of Best disease

55. Collaborative Ocular melanoma Study (COMS)
• Small (1-3mm thick, <5mm long) @1989
–natural history/observe: 30% +growth in 5yr
–mortality: 6% 5yr, 15% 8yr → photoCoag
• Medium (3-8mm thick, <16mm long) @1998
–enucleation VS brachyT (iodine 125 gold
plaque/85Gy)
–survival: same (82% @5yr) → brachyT
• Large (8mm thick, >16mm long) @1994
–enucleation alone VS pre-radiation (ext
beam/20Gy)
–survival: same (60% @5yr) → enucleation

56. Staging of Lyme Disease

57. High myopia
META-PM (meta-analysis for pathologic myopia) international classification
• for myopic maculopathy
• OCT and colour fundus photography
• retinal changes + choroid, Bruch’s membrane and the RPE
• “no myopic retinal degenerative lesion” (Category 0), “tessellated fundus”
(Category 1), “diffuse chorioretinal atrophy” (Category 2), “patchy chorioretinal
atrophy” (Category 3), and “macular atrophy” (Category 4).
• “plus” lesions: lacquer cracks, myopic choroidal neovascularisation, and Fuchs
spot.
• Posterior staphyloma was considered as a further important sign
ATN classification
• three factors: atrophy, traction and neovascularisation.

58. Lens & Cataract

59. Cataract LOCS
• Lens Opacities Classification System
• NS-CC-PSCC

60. Neuro-Ophthalmology

61. Neuro-Ophthalmology
• RAPD
• Papilloedema
• MG
• CCF
• Duane syndrome
• Facial nerve palsy (severity)

62. RAPD
Grading (Bell et al 1993)
• Grade I: Weak constriction then greater dilatation
• Grade II: No initial constriction, stall, then dilatation
• Grade III: Immediate dilatation
• Grade IV: Immediate dilatation following prolonged illumination
of the good eye for six seconds
• Grade V: Immediate dilatation with no secondary constriction

63. Staging for papilloedema (Frisen Scale )
Grade 0-5:
Principle:
- nasal  temporal
- border blur  grayish opaque 
elevation  BV obscured 
protrusion/expansion/paton’s
line
• Early: hyperemic, blurred + elevated margin, subtle peripapillary NFL edema, dilated disc
capillaries, distended retinal veins, absent spontaneous venous pulsation (SVP).
• Acute: as listed above + peripapillary hemorrhages, CWS, increased NFL edema (may
obscure retinal vessels).
• Chronic: hyperemia, CWS or hemorrhages, variable swelling, usually still elevated; ± drusen-
like deposits and optociliary shunt vessels at the disc (=vintage papilledema).
• Atrophic/late: pale atrophic disc, dswelling, attenuated arterioles.

64. MG
Osserman Grading
• I: Ocular
• II: Generalized
• III: Fulminant and crisis
• IV: Late progressive
• V : Muscle atrophy
MGFA Clinical Classification
• Class I: ocular muscle
weakness only
• Class II to IV= I +
mild/mod/severe
weakness of other
muscles
• Further a or b:
• a: > limb, axial muscles
• b: > oropharyngeal,
respiratory muscles
• Class V: Intubation

65. CCF: Barrow’s Classification
(ABCD)

66. Duane Syndrome

67. Facial Nerve Palsy Severity

68. Oculoplastic & Orbit

69. Oculoplastic & Orbit
• TED
• Orbital cellulitis

70. TED- Severity & Activity
• Mourits clinical activity score (CAS)
• PRSI: pain/red/swelling/impaired function-2/2/4/2 (=/>3/7 
4/10)
• Last 3 score for follow up (1-3mth): proptosis >2mm, VA
1line/more, diplopia >8 degree
• Mourits inflammatory index
• Conj edema3/conj red 1/lid edema 3/lid red1/pain rest1/move1
• NOSPECS (severity only)
• Modifield: SPECS further grade 0/a/b/c (Werner’s modified)
• VISA (vision/inflam/strabismus/appear: 1/10/6/3)
• Severe: Global severity grade (20pt)
• Active: I (=/>4 ), S (=/>12degree or fluctuate)
• EUGOGO
• Activity (CAS PRSI), severity (RSI + eyelid + cornea)
• mild (soft tissue/corneal SPK/no EOM)
• mod-severe (lid retraction 2mm, proptosis 3mm, EOM),
• sight threatening (ON/corneal bdown/frozen eye/choroidal fold)

74. Orbital Cellulitis: Chandler’s Classification

75. Ophthalmic Trauma

76. Ophthalmic Trauma
• Ocular trauma scoring
• Mid-facial fracture
• Chemical injury
• Hyphaema

77. Ocular Trauma Terminology
• Ocular Trauma Classification Group 1997 & Ocular
Trauma Score (OTS) 2002
• Birmingham Eye Trauma Terminology System
(BETTS)

78. OTS
• scores range from 1 (most severe injury and worst prognosis at 6 months follow-up) to 5 (least
severe injury and least poor prognosis at 6 months). Each score is associated with a range of
predicted post-injury visual acuities. It has a predictive accuracy of approximately 80%, which
means that the OTS will be accurate 4 out of 5 times

79. BETTS
Closed-globe injuries
• contusion (blunt trauma without break in eyewall)
• lamellar laceration (partial-thickness wound of the eyewall)
• superficial foreign bodies
Open-globe injuries
• rupture (blunt trauma with break in eyewall)
• laceration (full-thickness wound of the eyewall, caused by a sharp
object)
• intraocular foreign bodies, penetrating or perforating
• penetrating injury (entrance break; no exit break in eyewall)
• perforating injury (both entrance and exit breaks in eyewall)

80. Midface fracture
• Midface/Le Fort # (extended maxillary #)
I: low transverse maxillary (above teeth)
II: pyramidal maxillary-nasal/lacrimal/medial orbital
floor/rim
III: facial skeleton-base of skull detachM (orbital
floor/med/lat walls)

81. Chemical injury

83. End.
Thank you