Review Article

Graves’ Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management

Table 4

Protocol to assess the severity of Graves’ ophthalmopathy (EUGOGO). Some of the signs may be assessed by comparison with the image atlas provided by the EUGOGO (http://www.eugogo.eu/).

Soft tissuesEyelid swelling
(i) Absent 
(ii) Mild: none of the features defining moderate or severe swelling are present 
(iii) Moderate: definite swelling but no lower eyelid festoons and in the upper eyelid the skin fold becomes angled on a 45° downgaze 
(iv) Severe: lower eyelid festoons OR upper lid fold remains rounded on a 45° downgaze
Eyelid erythema
(i) Absent 
(ii) Present
Conjunctival redness
(i) Absent 
(ii) Mild: equivocal or minimal redness 
(iii) Moderate: <50% of definite conjunctival redness 
(iv) Severe: >50% of definite conjunctival redness
Conjunctival edema
(i) Absent 
(ii) Present: separation of conjunctiva from sclera present in >1/3 of the total height of the palpebral aperture or conjunctiva prolapsing anterior to grey line of eyelid
Inflammation of caruncle or plica semilunaris
(i) Absent 
(ii) Present: plica is prolapsed through closed eyelids or caruncle and/or plica are inflamed

Eyelid measurementsPalpebral aperture (mm)
Upper/lower lid retraction (mm)
Levator function (mm)
Lagophthalmos
(i) Absent 
(ii) Present 
Bell’s phenomenon
(i) Absent 
(ii) Present

ProptosisMeasurement with Hertel’s exophthalmometer. Recording of intercanthal distance.

Ocular motilityPrism cover test
Monocular ductions
Head posture
Torsion
Field of binocular single vision

CorneaCorneal integrity
(i) Normal 
(ii) Punctate keratopathy 
(iii) Ulcer 
(iv) Perforation

Optic neuropathy(i) Visual acuity (Logmar or Snellen) 
(ii) Afferent pupil defect (present/absent) 
(iii) Colour vision 
(iv) Optic disc assessment: normal/atrophy/edema