To assess the activity and grade the disease accurately, an initial examination needs to be followed by a clinical review two to three months later. At the initial visit each new patient requires a full medical assessment by the endocrinologist. The ophthalmologist performs an ocular examination, which includes an orthoptic assessment (field of binocular single vision, field of uniocular fixation, Hess chart and visual field study), Snellen visual acuity and Ishihara colour vision assessment. Exophthalmometry is performed. Orbital tension, lid lag and lid retraction, corneal exposure, conjunctival venous flow, intraocular pressure in primary gaze and elevation, pupils and optic discs are then assessed.

Activity & Staging

It is important firstly to assess disease activity and stage the disease process. An indication of activity is provided by the Mourits score1. This gives a value to each of the following signs and symptoms; orbital pain or pain during ocular movement, redness (eyelid or conjunctiva), swelling (proptosis, lid oedema, chemosis or caruncle oedema), limitation of ocular movements, and visual dysfunction (acuity, field and colour). Of a total of 10 scores, patients with a score of 3 and higher and/or an increasing score on follow-up are judged to be active.

We also routinely use Rundle staging to record the severity of the ocular involvement2. Grade 1 (mild) ophthalmopathy can present with ocular discomfort, transient oedema and mild proptosis (Rundle a). The duration is typically two to four months and it normally resolves with no sequelae. Grade 2 (moderate) ophthalmopathy includes eyelid retraction, conjunctival oedema, ocular ache and moderate proptosis (Rundle b). Grade 3 (marked) ophthalmopathy presents with ocular motility disturbance with diplopia, chemosis and marked proptosis (Rundle c). This develops over six to twelve months and often leads to persistent diplopia and proptosis. Grade 4 (severe) ophthalmopathy presents with optic nerve dysfunction with reduction of colour vision and visual acuity loss (Rundle d). After 12 to 24 months patients may be left with optic nerve damage, double vision, lid retraction and proptosis. (see table below). This is a serious eye condition with a considerable threat to vision.

Table: Rundle Staging: a- Stage 1, b- Stage 2, c- Stage 3, d- Stage 4

1 Mourits MP, Prummel MF, Wiersinga WM, Koornneef L. Clinical Activity Score as a Guide in the Management of Patients with Grave’s Ophthalmopathy. Clin. Endocrinol (Oxf). 1997; 47(1): 9-14.

2 Rundle FF. Eye Signs of Grave’s Disease. Pitt-Rivers R, Trotter WR, Et al. In: The Thyroid Gland. London, Butterworths 1964, Vol.2: 171.


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