Grade Everything in Ophthalmology

How to Grade Everything in Ophthalmology

Grading in ophthalmology is an ever evolving concept. Some grading systems are more popular than others. For example, diabetic retinopathy and cell / flare are almost universally accepted, while you will rarely run across formal APD measurements or dry eye grading. Nonetheless, we wanted to catalog as many systems as possible to help you communicate your findings to others. Use the navigation menu on the left side to quickly find what you need.
Note: these are all referenced to the original primary literature so that you can learn more about the derivation of each grading system. The references are all at the end of the article to preserve readability of the tables.

Cataracts

Nuclear Sclerosing	Cortical Spoking	Posterior Subcapsular
NS tr or 1+: Nucleus clearer than anterior / posterior sections NS 2+: Nucleus equal to the anterior posterior sections (same opacity level throughout) NS 3+/4+: Nucleus denser than anterior / posterior sections. Dense white/brunescent: Cataract completely opaque / brown	CS 1+: ⅛ to ¼ of total CS 2+: ¼ to ½ of total CS 3+: ½ or more	PSC 1+: 1-2mm PSC 2 +: 2-3mm PSC 3+: >3mm

Glaucoma

Nuclear Sclerosing	Cortical Spoking
Mild / Early	Optic nerve abnormalities consistent with glaucoma but NO visual field abnormalities on any visual field test.
Moderate	Optic nerve abnormalities consistent with glaucoma AND visual field abnormalities in ONE hemifield and NOT within 5 degrees of fixation.
Advanced , Late, Severe Stage	Optic nerve abnormalities consistent with glaucoma AND glaucomatous visual field abnormalities in BOTH hemifields AND/OR loss within 5 degrees of fixation in at least one hemifield.

Nonproliferative diabetic retinopathy (NPDR)

Stage	Findings	Plan
No DR	No findings of DR	Follow -up 12 mo
Mild	Microaneurysms only	Follow- up 6-12 mo
Moderate	Microaneurysms and dot-blot hemorrhages in 1-3 quadrants Venous beading ≤ 1 quadrant No IRMA	Follow- up 6 mo
Severe	4-2-1 Rule: – Microaneurysms and dot-blot hemorrhage in 4 quadrants – Venous beading in 2 quadrants – IRMA in 1 quadrant	Follow - up 3-4 mo

Proliferative diabetic retinopathy (PDR)

Stage	Findings	Plan
Mild PDR	New NVD or NVE insufficient to meet high-risk criteria	Consider PRP vs anti- VEGF vs. close follow-up
High- risk PDR	– NVD > ⅓ disc area – Any NVD with vitreous hemorrhage – NVE > ½ disc area with vitreous hemorrhage	Recommend PRP vs. anti-VEGF

Age-related macular degeneration (AMD)

Stage	Findings
No AMD	No drusen or <5 small drusen (<63 um)
Early	Many small drusen (<63 um) or few medium-sized drusen (63-125 um)
Intermediate	Many medium -sized drusen (63-125 um) or at least 1 large drusen (>125 um)
Advanced	Wet AMD or center involving geographic atrophy
Estimating drusen size: remember that 125 um is approximately equal to the diameter of the superior and inferior vascular arcades.

Dry Eye/MGD

Dry Eye/Meibomian Gland Dysfunction

Grade	1	2	3	4
Discomfort severity	Mild episodic	Moderate	Severe frequent	Severe disabling
Visual symptoms	None	None to mild	Annoying chronic or chronic activity limiting	Constant or disabling
Conjunctival injection	None to mild	Variable	+/-	+/++
Conjunctival staining	None to mild	Variable	Moderate to marked	Marked
Corneal staining	None to mild	Mild debris , decreased meniscus	Marked central	Severe punctate erosions
Corneal/tear signs	None to mild	MGD variably	Filamentary keratitis, mucus clumping, increased tear debris	Filamentary keratitis, mucus clumping , increased tear debris, ulceration
Lid/ MG	MGD variably present	present	Frequent	Trichiasis, keratinization, symblepharon
TBUT	Variable	<= 10	<= 5	Immediate
Schirmer score	Variable	<= 10	<= 5	<=2

ROP

Retinopathy of Prematurity

Zone 1	Circle centered on nerve with radius twice the distance from nerve to fovea
Zone 2	Circle extending to ora serrata nasally
Zone 3	Temporal crescent extending to ora serrata temporally

Stage

Stage 0	Immature vascularization , no ROP
Stage 1	Demarcation line
Stage 2	Ridge
Stage 3	Extraretinal fibrovascular proliferation
Stage 4	Partial retinal detachment Stage 4A – extrafoveal Stage 4B – foveal
Stage 5	Total retinal detachment Funnel: Anterior or posterior, open or closed

Plus Disease

Plus disease	– At least 2 quadrants of venous dilation and tortuosity – Vitreous haze – Failure of pupil to dilate – Preretinal or vitreous hemorrhage
Pre- plus disease	Abnormal dilation and tortuosity not sufficient to meet plus criteria
Threshold disease	5 contiguous or 8 non-contiguous clock hours of extraretinal neovascularization in zone 1 or zone 2 with plus disease
Aggressive posterior ROP (rush disease)	Posterior location , prominence of plus disease, ill-defined nature of retinopathy

ETROP Classification

Type 1 ROP	Zone I, any stage with plus disease Zone I, stage 3 without plus disease Zone II, stage 2 or 3 with plus disease
Type 2 ROP	Zone I, stage 1 or 2 without plus disease Zone II, stage 3 without plus disease

Proliferative Sickle Cell Retinopathy

Stage 1	Peripheral arteriolar occlusions
Stage 2	Peripheral AV anastomoses
Stage 3	Preretinal sea -fan neovascularization
Stage 4	Vitreous hemorrhage
Stage 5	Tractional retinal detachment

Hypertensive retinopathy

Grade	Retinal Signs	Systemic Associations
None	No detectable signs	None
Mild	Generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, opacity (“copper wiring”) of arteriolar wall	Modest association with risk of clinical stroke, subclinical stroke, coronary heart disease , and death
Moderate	Hemorrhage (blot, dot, or flame-shaped), microaneurysm , cotton-wool spot, hard exudate	Strong association with risk of clinical stroke, subclinical stroke, cognitive decline, and death from cardiovascular causes
Malignant	Signs of moderate retinopathy plus swelling of the optic disc	Strong association with death

Macular Holes

Stage 0	Vitreomacular adhesion
Stage 1	Impending macular hole, vitreomacular traction syndrome Stage 1A – foveal pseudocyst, schisis in inner fovea Stage 1B – break in outer fovea
Stage 2	Early full-thickness macular hole Less than 400um diameter
Stage 3	Large full-thickness macular hole Greater than 400um diameter
Stage 4	Full-thickness macular hole with complete PVD

Retinoblastoma (RB)

Reese-Ellsworth Classification

Group I	Solitary tumor, <4 DD size, behind the equator OR Multiple tumors, none >4 DD size, all behind the equator
Group II	Solitary tumor, 4-10 DD size, behind the equator Multiple tumors, 4 - 10 DD size, behind the equator
Group III	Any lesion anterior to equator Solitary tumors > 10 DD behind the equator
Group IV	Multiple tumors, some >10 DD Any lesion extending anterior to ora serrata
Group V	Massive seeding involving more than half the retina Vitreous seeding

International Classification

Group A	Small tumors <3 mm confined to retina, >3 mm from fovea, >1.5 mm from optic disc
Group B	Tumors >3 mm confined to retina at any location, with SRF <6 mm from tumor margin
Group C	Localized vitreous or subretinal seeding <6 mm from tumor margin or total from multiple sites <6 mm
Group D	Diffuse vitreous or subretinal seeding >6 mm from tumor margin or total from multiple sites >6 mm . SRF >6 mm from tumor margin
Group E	No visual potential or presence of: – Tumor in anterior segment – Tumor in ciliary body – Neovascular glaucoma – Vitreous hemorrhage or hyphema – Phthisical or prephthisical eye – Orbital cellulitis-like presentation

Exam Findings

Gonioscopy

Scheie

Wide open	All structures visible
Grade I	Iris root not visible
Grade II	Ciliary body not visible
Grade III	Posterior trabecular meshwork not visible
Grade IV	None of angle structures visible

Schaffer

Grade 4	Ciliary body visible
Grade 3	Scleral spur visible
Grade 2	Only trabecular meshwork visible Only
Grade 1	Only Schwalbe’s line visible
Grade 0	Angle is closed

Spaeth

Iris Insertion	A – anterior to Schwalbe’s line B – between Schwalbe’s line and scleral spur C – scleral spur visible D – ciliary body visible E – >1 mm of ciliary body visible
Angle	0° to 50°
Peripheral Iris	r – regular s – steepq – queer b – bowed anteriorly p – plateau
Pigmentation	0 none1+ just visible 2+ mild 3+ moderately dense 4+ dense

Anterior Chamber Cell/Flare

Standardization of Uveitis (SUN) Nomenclature

	Cell	Flare
0.5 +	1-5 cells per 1×1 mm slit beam	NA
1 +	6- 15 cells	Faint
2 +	16- 25 cells	Moderate Iris and lens details clear
3 +	26- 50 cells	Marked Iris and lens details hazy Intense
4 +	> 50 cells	Fibrin or plasmoid aqueous

Vitreous Cell

NIH Grading System

	Vitreous cell
0.5+	1- 10
1 +	11- 20
2 +	20-30
3+	30- 100
4 +	> 100

Vitreous Haze

1 +	Hazy nerve fiber layer
2 +	Disc and vessels hazy
3+	Only disc visible
4 +	Disc not visible

Papilledema

Grade I	Nasal disc margin blurring with temporal sparing
Grade II	Disc margin blurring of entire disc
Grade III	Obscuration of major vessels at disc margin
Grade IV	Obscuration of major vessels on the disc
Grade V	Partial or total obscuration of all vessels

Lincoff’s Rules

Superior temporal or nasal detachments
In 98% the primary break lies within 1.5 clock hours of the highest border

Total or superior detachments that cross the 12 o’clock meridian
In 93% the primary break is between 11 and 1 o’clock

Inferior detachments
In 95%, the break is within 1.5 clock hours of the highest border

Inferior bullous detachments
The primary break is usually located above the horizontal meridian – the break is connected with the detachment by a shallow peripheral sinus

APD (afferent pupillary defect)

1 +	Weak initial constriction followed by greater redilation
2 +	Initial pupillary stall followed by greater redilation
3+	Immediate pupillary dilation
4 +	No reaction to light

Hyphema

Grade 0	No visible layering but RBCs in the AC
Grade I	Layered blood in < ⅓ of AC
Grade II	Blood filling ⅓ to ½ of AC
Grade III	Blood filling ½ to less than total of AC
Grade IV	Total hyphema

Extraocular muscles

Hirschberg

Have the patient look at a light shining from directly in front. In a non-strabismic patient, the corneal light reflex should be close to the center of the pupil. If the light reflex is deviated, you can estimate the degrees of deviation using the table below

Light reflex at pupillary margin	15 degrees (30 PD) of deviation
Light reflex at mid-iris	30 degrees (60 PD) of deviation
Light reflex at limbus	45 degrees (90 PD) of deviation

Krimsky

Hold prisms in front of the eye to center the corneal reflection, note the amount of prism necessary to center the corneal reflex.

Bruckner

Direct ophthalmoscope used to obtain both red reflexes simultaneously. If strabismus present, deviated eye will have a lighter / brighter reflex than the fixating eye.

Blog Reference Link: https://eyeguru.org/blog/grading/