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Classification Staging Grading in Ophthalmology

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.

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Classifications-Grading-Staging @ Ophthalmology Dummy Survival Guide Dr Yong Meng Hsien 2021
Discussion Approach (Anatomy): • Cornea & external eye diseases • Glaucoma, angle and IOP • Uveitis • Lens and cataract • Vitreo-retina • Neuro-ophthalmology • Orbit & Oculoplastic • Trauma
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
Corneal & External Eye Diseases
Corneal & External Eye Diseases • Keratoconus • Corneal dystrophies • Dry eye • VKC • HSV keratitis • Prognosis for corneal transplant • Trachoma • GPC
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
Ref + Astig + Topo + Km + CCT Amsler-Krumeich KC Classification
Belin ABCD KC Staging • Ant & Back radius of curvature (3mm), • Corneal thickness (minimal) • Distance VA (DCVA)
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
IC3D 2015 (International Classification of Corneal Dystrophies) - Genetic (chromosomal/gene) - Clinical (pattern/anatomical layer) - Pathology (histo/biochem/confocal)
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)
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)
HSV Keratitis
Brightbill’s Classification: Corneal Graft Prognosis • Grade I to V (excellent to poor) • Underlying pathology + secondary complication
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.
Uveitis
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
SUN Anatomical Classification
Uveitis SUN / NIH / MUST
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
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
Phases of FFA
Type V (Stimulating Ab)- grave’s, MG
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)
Glaucoma & Angle
Glaucoma & Angle • Angle classification • Stages of primary angle closure • Stages of glaucoma (severity) • Glaucoma progression • Classification of topical antiglaucoma • Grading of shallow AC
Angle Shaffer Spaeth Scheie
• 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
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
Stages of primary angle closure
Glaucoma- Stage Hodapp Parrish Anderson – mild/mod/advanced/severe – By MD: 6-12-20 – By points of depression: 25%-50%-75%
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
Topical Antiglaucoma Classification
Vitreo-retinal
Vitreo-retinal • DR • DME • AMD • Geographical atrophy • RD & PVR • Macular hole • Retinoblastoma • Sickle cell retinopathy • Hypertensive retinopathy • Best disease • Choroidal melanoma
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
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
AMD Classification & AREDS Staging
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
PVR Others PVR classification: RSC (1-4, a-c for 3-4), silicone study (1-6, 1-3 post, 4-6 ant)
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
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
ICRB Classification - size/location/SRF/SR-vitreous seed/ant-post extension -
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)
Goldberg staging: Proliferative Sickle Cell Retinopathy
HPT retinopathy: Keith-Wagener-Barker classification
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
Staging of Best disease
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
Staging of Lyme Disease
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.
Lens & Cataract
Cataract LOCS • Lens Opacities Classification System • NS-CC-PSCC
Neuro-Ophthalmology
Neuro-Ophthalmology • RAPD • Papilloedema • MG • CCF • Duane syndrome • Facial nerve palsy (severity)
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
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.
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
CCF: Barrow’s Classification (ABCD)
Duane Syndrome
Facial Nerve Palsy Severity
Oculoplastic & Orbit
Oculoplastic & Orbit • TED • Orbital cellulitis
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)
Orbital Cellulitis: Chandler’s Classification
Ophthalmic Trauma
Ophthalmic Trauma • Ocular trauma scoring • Mid-facial fracture • Chemical injury • Hyphaema
Ocular Trauma Terminology • Ocular Trauma Classification Group 1997 & Ocular Trauma Score (OTS) 2002 • Birmingham Eye Trauma Terminology System (BETTS)
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
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)
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)
Chemical injury
End. Thank you

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Classification Staging Grading in Ophthalmology

  • 1.
  • 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 • Riskfactors • 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 & ExternalEye Diseases
  • 5.
    Corneal & ExternalEye Diseases • Keratoconus • Corneal dystrophies • Dry eye • VKC • HSV keratitis • Prognosis for corneal transplant • Trachoma • GPC
  • 6.
    Global Consensus onKeratoconus 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 KCStaging • 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 (InternationalClassification of Corneal Dystrophies) - Genetic (chromosomal/gene) - Clinical (pattern/anatomical layer) - Pathology (histo/biochem/confocal)
  • 11.
    DEWS 2017 (InternationalDry 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/bulbarvs 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.
  • 14.
    Brightbill’s Classification: Corneal GraftPrognosis • 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.
  • 17.
    Uveitis • Classification • ACcells & flare • Vitreous cells and haze • Course & progression • Sarcoidosis • level of diagnostic certainty • Staging of pulmonary sarcoidosis • Phases of FFA • Immunomodulators • Hypersensitivity reactions
  • 18.
  • 19.
    Uveitis SUN /NIH / MUST
  • 21.
    International Workshop onOcular 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 • Stage1: 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.
  • 24.
    Type V (StimulatingAb)- 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.
  • 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.
  • 29.
    • Narrow slitbeam • 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 ofdrawing 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 primaryangle closure
  • 32.
    Glaucoma- Stage Hodapp ParrishAnderson – mild/mod/advanced/severe – By MD: 6-12-20 – By points of depression: 25%-50%-75%
  • 33.
    Glaucoma Progression Normal • HVFMD -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.
  • 35.
  • 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 OCTClassification • 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.
  • 49.
    ROP- Classification • 2005International 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.
  • 52.
  • 53.
    Mitchell-Wong simplification ofthe 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.
  • 55.
    Collaborative Ocular melanomaStudy (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.
  • 57.
    High myopia META-PM (meta-analysisfor 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.
  • 59.
    Cataract LOCS • LensOpacities Classification System • NS-CC-PSCC
  • 60.
  • 61.
    Neuro-Ophthalmology • RAPD • Papilloedema •MG • CCF • Duane syndrome • Facial nerve palsy (severity)
  • 62.
    RAPD Grading (Bell etal 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.
  • 66.
  • 67.
  • 68.
  • 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.
  • 75.
  • 76.
    Ophthalmic Trauma • Oculartrauma 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 rangefrom 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/LeFort # (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.
  • 83.