BACKGROUND

These three concepts were amalgamated in 1992 into a set of guidelines by a Working group of delegates from various international thyroid associations (5). The group recommended retaining NO SPECS as a mnemonic; using objective measurements for proptosis, extraocular movements, cornea, and optic nerve; using the clinical activity scale or a recorded change in objective measures to document the disease activity, and lastly, documenting the patient’s perception of their disease status.

Since then, no one has organized these ideas into a clinical form that can be used in the office setting to record changes and to guide and assess therapy. We have developed such a classification based on the Working Group’s suggestions.

VISA CLASSIFICATION

Our system is based on four disease endpoints: vision, inflammation, strabismus, and appearance=exposure and can be remembered by the acronym, ‘‘VISA.’’ Each section records subjective and measurable objective inputs as well as plans ancillary testing.

Figure 1 shows the follow-up examination sheet with the four separate VISA sections, with historical symptoms recorded on the left, signs documented on the right, and a summary grade for each of the four categories. The first visit history differs in that it includes the date and rate of onset of both the orbital and systemic symptoms (since this may help predict the ultimate severity of the inflammatory phase). The layout is designed to simplify data recording and possible later research data collation.

INDIVIDUAL SECTION MEASUREMENTS

Vision

The primary goal of this section is to rule out TO optic neuropathy. The history includes visual blurring or color desaturation and the progress and duration of symptoms. Objective measures include best-corrected visual acuity, color vision, pupil responses, and optic nerve appearance. Ancillary

Figure 1 Examination sheet with VISA sections.

testing includes computed tomographic (CT) scans to confirm crowding of the orbital apex, standardized visual fields, and possibly VEP (visual evoked potentials) or optic nerve head photos. As a summary grade, we either list optic neuropathy as present or absent.

Our usual management for Graves’ optic neuropathy is high dose oral or intravenous steroids, adjunctive radiotherapy, followed by orbital decompression if neuropathy persists or recurs. Success of therapy from both a clinical or research standpoint would be based on specific improved measurements for central vision, color vision, and visual fields.

Inflammation

Symptoms of soft-tissue inflammation include orbital aching at rest or with movement, and eyelid or conjunctival swelling and redness.

The clinical activity score described and validated by Mourits and the Amsterdam Orbitopathy group assigns one point for each of the following: orbital pain at rest, orbital pain with movement, chemosis, caruncular edema, eyelid edema, conjunctival injection, and eyelid injection (4).

We use a slightly modified scale that eliminates caruncular edema as a separate sign (since we feel it is part of chemosis) but which grades chemosis and lid edema with a 0–2 scale (Table 1). Chemosis is graded as 1 if the conjunctiva lies behind the grey line of the lid and as 2 if it extends beyond the grey line. Lid edema is graded as 1 if it is present but not causing overhang of the tissues, and as 2 if it causes a roll in the lid skin (festoons in the lower lid). We have found this classification to be reproducible both interand intra-observer and to allow for documentation of more subtle changes in inflammatory features beyond simple absence or presence of chemosis or lid edema.

Table 1 UBC Clinic Thyroid Orbitopathy Inflammatory Score