Various Classifications and Grading Systems in Oculoplasty

Dr Joyeeta Das MBBS,DNB,
Published Online: April 1st, 2021 | Read Time: 23 minutes, 36 seconds


Grading & Classification of diseases is an ever-evolving concept. This article is a collection of various clinical grading and Classification systems in the practice of various Oculoplasty and Orbital diseases. These grading systems are useful for Trainee doctors, PG students, PG residents, and optometrists which will help them in preparations of various examinations and the initial phase of their clinical practice for systematic management of various oculoplasty cases.

Commonly used classifications in oculoplasty are:

  1. Classification of Entropion
  2. Classification Ectropion
  3. Classification Ptosis
  4. Classification of Contracted Socket
  5. Classification of Eyelid Tumor
  6. Classification of Facial Nerve Palsy
  7. Classification of TRO
  8. Classification of Orbital Cellulitis

Entropion :

Entropion is a common eyelid malposition in which the margin turns inward against the globe. Two other conditions that are close to it is trichiasis and distichiasis which must be well differentiated from trichiasis (misdirection of eyelashes) and distichiasis (anomalous eyelashes row). If untreated, this condition can cause symptoms like ocular discomfort, corneal abrasion, microbial keratitis, corneal vascularization, and visual loss

Entropion may affect both upper and lower lid but lower lid entropion is much common than upper lid entropion which is mostly due to cicatrix.

A. Classification of upper lid entropion

Etiological classification:

A. Congenital UL entropion

B. Acquired UL entropion

Rare condition

d/t vertical kink develops in the tarsal plate in utero resulting in direct opposition of lid margin to the globe

Relative vertical shortage of posterior lamellar tissue [ tarsus and or palpebral conjunctiva or UL retractor

Causes :

  1. Infection [65% of total]
      1. trachoma
      2. chronic blepharoconjunctivitis
      3. HZO
  2. Trauma [19%]
      1. Chemical injury
      2. iatrogenic
      3. mechanical
      4. anophthalmic socket
  3. Immunologic
      1. Erythema multiforme
      2. ocular cicatricial pemphigoid
      3. ocular vernal cicatricial conjunctivitis
      4. Dysthyriod

Treatment: urgent surgical excision of tarsal kink and lid eversion

Treatment: Surgical according to grade and pathology

Kemp and Collin Classification and management scheme of Upper Lid Entropion

Degree of UL entropion

Clinical signs

Surgical management


  1. Apparent migration of meibomian gland orifice
  2. conjunctivalization of the lid margin
  3. lash globe contact onUPGAZE
  1. Anterior lamellar reposition +/- lid split at grey line


Features of Minimum plus

  1. Lash globe contact on PRIMARY GAZE
  2. thickening of the tarsal plate
  3. Lid retraction
  • Anterior lamellar reposition + lid split at grey line + tarsal wedge resection
  • Lamellar division


  1. Lid retraction causing incomplete closure
  2. Gross lid distortion
  3. metaplastic lashes
  4. presence of keratin plaques
  • Lamellar advance
  • Rotation of terminal tarsus [TENZEL]
  • Rotation of terminal conjunctiva and posterior lamellar graft [ BMM graft or post auricular cartilage or hard palate graft

B. Lower lid entropion

Congenital L/L entropion

Acquired L/L entropion

Types of congenital inversion of eyelids

  1. Epiblepharon
  2. Entropion
  • Involutional
  • Cicatricial
  • Spastic

Congenital entropion

Congenital epiblepharon

  • Lid margin inversion present
  • Cilia directed towards the globe
  • No lid margin inversion
  • Only cilia vertically oriented
  • Worsen with time
  • Improves spontaneously
  • Treatment - Surgery -Hotz procedure
  • conservative
  • rarely- Hotz procedure

Acquired Entropion:



Management outline


  1. Horizontal lid laxity [HLL]
  2. LL retractor disinsertion
  3. overriding of preseptal orbicularis oculi on pretarsal orbi oculi.
  • Temporary - Transfixation suture [Quickert-Rothburn suture]
  • Permanent treatment
  • If no horizontal laxity - Weis procedure [full thickness transverse lid split +everting suture
  • If Lid laxity present
    • Quickert procedure [ Transverse lid split+everting sut+horizontal lild shortening]
    • Jones Procedure :
    • Plication of L/L retractor + horiz lid shortening
    • Wheelers orbicularis transposition [less common procedure]


  • Contracture of scar tissue in posterior lamella
  • Vertical shortening post lamella
  1. If trichiasis present : Grey line split + tretractor repositioning
  2. If no trichiasis, only LL retraction below inferior limbus
    1. <1.5 mm - tarsal fracture+everting suture
    2. >1.5 mm- posterior lamellar graft by post.auricular cartilage, hard palate or BMM


Irritation of ocular surface -

-Reflex contraction of Orbicularis oculi-

In turning of of L/L


Botulinum toxin

Ectropion :

Upper lid Ectropion:

Congenital UL ectropion

Acquired UL ectropion

  • Rare
  • total B/L eversion of U/L in newborn
  • Causes :
    • Venous obstruction
    • Chlamydia
  1. Cicatricial : due to anterior lamellar shortening by trauma, burn,acid injury etc

  1. Floppy eyelid syndrome :
    1. obese men
    2. sleep apnoea
    3. spontaneous eversion of UL during sleep - loss of lid globe contact

Lower Lid Ectropion :

Congenital Lower lid ectropion

Acquired Lower lid ectropion

  1. Blepharophimosis syndrome
  1. Involutional
  1. Down syndrome
  1. Paralysis
  1. Secondary to
    1. Anophthalmos
    2. microphthalmos
    3. buphthalmos
    4. Euryblepharon
    5. icthyosis
    6. cyst
  1. Cicatricial

  1. Mechanical

Ptosis :

Ptosis or blepharoptosis is defined as a drooping or abnormally low position of the upper eyelid with respect to the globe. It can be classified as :


Acquired ptosis

Primary - levator maldevelopement


  • Senile ptosis
  • post-surgery
  • post-trauma


  • Neurogenic
    • 3rd Nv palsy
    • Horner's syndrome
    • Marcus-Gunn JAw winking syndrome
    • Mysthenia gravis
  • myogenic
    • Blepharophimosis
    • congenital fibrosis
    • CPEO
  • Aponeurotic- post birth trauma
  • mechanical - lid mass


  • 3rd Nv palsy
  • Horner's syndrome
  • Marcuss-Gunn JAw winking syndrome
  • Mysthenia gravis


  • Chronic progressive external ophthalmoplegia [CPEO]
  • Muscular dystrophy


  • Lid mass
  • scarring

Contracted socket :

  1. Baylis et al.1 classification of contracted sockets into two groups
  1. Moist conjunctival surfaces and
  2. Dry surfaces
  1. Molgat2 and Guyuron3 classification of contracted socket:
  1. Primary volume deficits
  2. Primary mucosal deficits
  3. Both volume and mucosal deficits
  1. Bonavolonta2,3 classified contracted sockets into 6 categories:
  1. contraction of the conjunctival fornix
  2. contraction of conjunctival fornix and lid
  3. contraction of conjunctival fornix and orbital fat
  4. absence of conjunctival fornix
  5. severe contraction of orbital fat
  6. any of the above plus developmental bone abnormalities
  1. Gopal krishna classification

The soft tissue sockets were divided into five grades for the sake of convenience in management of contracted sockets.

  1. Grade-0: Socket is lined with the healthy conjunctiva and has deep and well-formed fornices.
  2. Grade-I: Socket is characterized by the shallow lower fornix or shelving of the lower fornix. Here the lower fornix is converted into a downwards sloping shelf which pushes the lower lid down and out, preventing re­tention of a artificial eye
  3. Grade-II: Socket is characterized by the loss of the upper and lower fornices,
  4. Grade- III: Socket is characterized by the loss of the upper, lower, medial and lateral fornices
  5. Grade-IV: Socket is characterized by the loss of all the fornices, and reduction of palpebral aperture in horizontal and vertical dimensions
  6. Grade-V: In some cases, there is recur­rence of contraction of the socket after re­peated trial of reconstruction

1) Baylis HI, Schorr N, Tanenbaum M, McCord CD. The anophthalmic socket: evaluation and management of surgical problems. In: McCord CD, Tanenbaum M, editors. Oculoplastic Surgery. New York: Raven Press; 1987. pp. 609–37

2) Molgat YM, Hurwitz JJ, Web MC. Buccal mucous membrane-fat graft in the management of the contracted socket. Ophthal Plast Reconstr Surg. 1993;9:267–72

3) Bonavolontà G. Temporalis muscle transfer in the treatment of the severely contracted socket. Adv Ophthalmic Plast Reconstr Surg 1992;9:121-9

4) Krishna G. Contracted sockets -I (Aetiology and types). Indian J Ophthalmol 1980;28:117-20

Classification of Eyelid Tumor :

Clinical classification:

  1. Pigmented eyelid mass :
    1. Basal cell CA
    2. Nevus
    3. Malignant melanoma
    4. Nevus of Ota
  2. Non-pigmented eyelid mass :

A. Epithelial

  1. Papilloma- sessile, pedunculated
  2. Keratoacanthoma- central crater with a keratin plug
  3. Actinic keratosis- dry rough scales
  4. Seborrhic keratosis-greasy, brown, friable
  5. Basal cell CA - shiny
  6. Squamous cell CA- crusting, erosion, fissure

B. Subepithelial

  1. Solid:
    1. Sebaceous cell CA
    2. Meibomian cyst
  2. Cystic
    1. Cyst of Moll
    2. Cyst of Zeiss
    3. Sebaceous cyst

Benign eyelid tumor

Malignant eyelid tumor

Pigmented Mass

  • Nevus
  • Nevus of Ota


  • Basal Cell CA
  • Squamous cell CA
  • sebaceous cell CA
  • Malignant melanoma
  • Kaposi sarcoma

Non-pigmented benign mass

  1. Epithelial
  • Papilloma
  • keratoacanthoma-
  • actinic keratosis
  • seborrhic keratosis
  1. Subepithelial
  • meibomian cyst
  • cyst of Mall
  • cyst of Zeiss
  • sebaceous cyst


  • Lymphoma
  • Maxillary CA
  • others

Classification and grading of Facial nerve palsy :

House-Brackmann facial paralysis scale






Normal facial function


Mild dysfunction

Gross: slight weakness noticed in close observation

At rest : normal symmetry and tone

Motion :

Forehead - Moderate to good function

Eye - complete closure with minimum effort

Mouth - slight asymmetry


Moderate dysfunction

Gross: obvious asymmetry but not disfiguring, no synkinesis

At rest : normal symmetry and tone

Motion :

Forehead - slight to moderate function

Eye - complete closure with effort

Mouth - slight weak with maximum effort


Moderate to severe dysfunction

Gross: obvious asymmetry and /or disfiguring

At rest : normal symmetry and tone

Motion :

Forehead - none

Eye - incomplete closure

Mouth - asymmetry with maximum effort


Severe dysfunction

Gross: only barely perceptible motion

At rest: Asymmetry

Motion :

Forehead - none

Eye - incomplete closure

Mouth - slight movement


Total paralysis

No movements

The CADS grading scale :

The CADS grading scale is specifically designed for periorbital involvement with a combination of objective and subjective parameters. There are 4 main aspects of the scale: Cornea, static Asymmetry, Dynamic function, and Synkinesis. Cornea takes into account the amount of corneal staining, presence of corneal sensation, Schirmer’s test, and patient’s Bell’s phenomenon



Static Asymmetry


Dynamic asymmetry




No staining


No brow ptosis

No ectropion

No upper or lower eyelid retraction


No blink lagophthalmos




PEE < 5


Mild brow ptosis

Medial ectropion

Upper eyelid at limbus

Mild lower eyelid retraction; ≤2 mm inferior scleral show

LMBD >5 mm shorter than contralateral side


  • Lagophthalmos on blink <5 mm
  • Brow elevation reduced but present


Mild eye closure when smiling/ speaking eating

Gustatory epiphora:

not bothersome


PEE≤ 1/2 cornea


Severe brow ptosis

Significant ectropion

Superior scleral show

>2 mm inferior scleral show

LMBD ≤ 20 mm


  • Lagophthalmos on blink ≥5 mm
  • Lagophthalmos on gentle closure ≤5 mm
  • Brow elevation: none or twitch


  • Signifcant eye closure when smiling/speaking/ eating

Gustatory epiphora: bothersome


PEE ≥1/2 cornea or epithelial defect



  • Lagophthalmos on gentle closure >5 mm
  • Lagophthalmos on forced closure >2 mm



If any of the below present add

  1. Absent corneal sensation
  2. Absent/reduced Bell’s
  3. phenomenon
  4. Schirmer’s ≤ 5 mm*
  5. The affected eye is the only eye



*Schirmer’s test with anesthetic and if the lower eyelid is apposed to the globe.


PEE, punctate epithelial erosions

LMBD, lid–margin brow distance

Reference: Tan P, Siah WF, Wong J, Malhotra R. Validation of CADS Grading Scale: An Ophthalmic Specific Grading Instrument for Facial Nerve Palsy. Ophthalmic Plast Reconstr Surg. 2017 Nov/Dec;33(6):419-425. PMID: 27811632.

Thyroid Orbitopathy [TRO] classifications and grading systems :

Thyroid eye disease or thyroid-related orbitopathy (TRO) or Graves orbitopathy is the most common cause of bilateral proptosis. It is a poorly understood ailment of autoimmune pathology.

The ocular presentation can vary from mild disease to severe irreversible sight-threatening complications and the varied presentations posses challenge to treating ophthalmologist according to various stages of the disease.

The ocular disease has an active and inactive phase. Since 1960 various classification and scoring systems have been proposed for better evaluation of the clinical course of the disease and its management.

The clinical examination, activity, and severity aid the ophthalmologist to decide the stage of the disease and come up with the treatment strategy for each patient

Several classification systems have been proposed to assess the clinical manifestations of TED. The evolution of various classification systems has been summarized in the table below

Classification systems

Proposed by


NO SPECS classification



Modified NO SPECS




Maurits et al


Modified CAS

Maurits et al


EUGOGO classification



VISA classification

Rootman and Dolman


CAS: clinical activity scale

EUGOGO: the European Group of Graves’ Orbitopathy

VISA: Vision, Inflammation, Strabismus, Appearance

Werner in 1969 devised a mnemonic NO SPECS to document disease severity which was modified in 1977 and is broadly used since then.This classification, however, grades clinical severity but does not distinguish the active inflammatory phase from the inactive phase, and indication for treatment was decided only according to the severity of the disease.

Modified NO SPECS classification



Signs and symptoms



No symptoms or signs



Only signs (upper lid retraction, without lid lag or proptosis)



Soft tissue involvement with symptoms (excess lacrimation, sandy sensation, retrobulbar discomfort, and photophobia, but not diplopia); objective signs as follows:




minimal (edema of conjunctivae and lids, conjunctival injection, and fullness of lids, often with orbital fat extrusion, palpable lacrimal glands, or swollen extraocular muscles beneath lower lids)


Moderate (above plus chemosis, lagophthalmos lid fullness)





Proptosis associated with classes 2 to 6 only (specify if inequality of 3 mm or more between eyes, or if the progression of 3 mm or more under observation)


absent (20 mm or less)


minimal (21-23 mm)


moderate (24-27 mm


marked (28 mm or more)



Extraocular muscle involvement (usually with diplopia)




minimal (limitation of motion, evident at extremes of gaze in one or more directions)


moderate (evident restriction of motion without fixation of position)


marked (fixation of the position of a globe or globes)



Corneal involvement (primarily due to lagophthalmos)




minimal (stippling of the cornea)


moderate (ulceration)


marked (clouding, necrosis, perforation)



Sight loss (due to optic nerve involvement)




minimal (disc pallor or choking, or visual field defect, vision 20/20 to 20/60)


moderate (disc pallor or choking, or visual field defect, vision 20/70 to 20/200)


marked (blindness, i.e., failure to perceive light; vision less than 20/200)

In 1989, Mourits et al. described the Clinical Activity Score (CAS). This score discriminates between the active and quiescent stage of the disease as it is based on the classical signs of inflammation (pain, redness, swelling, and impaired function). This was further modified in 1997. Modified CAS is used to evaluate disease activity, and a score out of 10 is given. A score of 3 or less is considered as inactive and 4 or more is considered as active eye disease at first examination. A score of 4 or more on follow-up examination indicates active disease. This scoring criterion has the disadvantage of being subjective in nature with a large interobserver variation. The advantage lies in its easy applicability in everyday clinical practice.

Clinical Activity Score amended by European group on Graves’ Orbitopathy

For initial CAS score items 1-7


Spontaneous orbital pain


Gaze evoked orbital pain


Eyelid swelling that is considered to be due to active GO


Eyelid erythema


Conjunctival redness considered due to active GO




Inflammation of caruncle or plica

Followup after 1-3 months score items including 8-10


Increase of >2 mm proptosis


A decrease in a uniocular ocular excursion in any one direction of >8 degrees


Decrease of acuity equivalent to 1 Snellen line

One point is given for the presence of each of the parameters assessed.

The sum of all points define clinical activity:

Active ophthalmopathy [TR] if at first examination score is >3/7 or in successive examination >4/10

The other grading systems used are VISA classification and the European Group on Graves' Orbitopathy (EUGOGO) classification.

Both VISA and EUGOGO systems are assessed with practical implications for guiding the management of patients, which was missing in earlier classifications by Werner. These two classification systems are not interchangeable. VISA is widely used in the United States and Canada and EUGOGO in Europe.

EUGOGO Classification :



Mild thyroid eye disease

Minor impact on activities of daily living

Insufficient justification for immunosuppression or

surgical treatment

One or more of the following

  • Minor lid retraction (<2 mm)
  • Mild soft-tissue involvement
  • Proptosis<3 mm above normal for race and gender
  • No or transient diplopia
  • Corneal exposure responsive to lubricants

Moderate‑to-severe thyroid eye disease

Impact on activities of daily living

Justifies treatment (immunosuppression and/or

surgical treatment)

Two or more of the following

  • Lid retraction 2 mm or more
  • Moderate to severe soft-tissue involvement
  • Proptosis≥3 mm above normal for race and gender
  • Diplopia (inconstant or constant)

Sight threatening thyroid eye disease

Compressive optic neuropathy

Corneal ulceration

The VISA system was developed by Dolman and Rootman in 2006 and was adopted with modifications by the International TED Society (ITEDS). Each section records subjective inputs and measurable objective inputs. This helps direct appropriate management for patients with TED in a logical sequence depending on the aspect of the disease affecting them.

VISA grading of Thyroid Orbitopathy:


Subjective input

Objective examination


Visual blurring

Color desaturation

Visual acuity, refraction

Color vision

Pupil reaction

Fundus and optic nerve examination

Standard perimetry


Visual evoked potential


Retrobulbar ache

Eyelid or conjunctival swelling

Eyelid or conjunctival redness

Inflammatory index (worst eye/eyelid)

Retrobulbar ache

  • At rest (0-1)
  • With gaze (0-1)
  • Chemosis (0-2)*

Eyelid edema (0-2)**

Conjunctival injection (0-1)

Eyelid injection (0-1)

Inflammatory index total: 10



No diplopia (0)

With gaze (1)

Intermittent (2)

Constant (3)

Extraocular movements

Restriction of Ductions

  • >45 deg (0)
  • 30-45 deg (1)
  • 15-30 deg (2)
  • <15 deg (3)

Head posture

Prism cover test

Field of binocular vision


Eyelid retraction



Foreign body


Eyelid retraction

Scleral show

Lid lag and von Graefe’s sign


Presence of redundant skin and fat



Slit-lamp examination ‑.cornea

VISA – Vision, Inflammation, Strabismus, and Appearance

Disease grading: Global severity grade (maximum of 20 points):

  • Vision (optic neuropathy) y/n (1 point),
  • Inflammation (0‑10),
  • Strabismus ‑.diplopia (0‑3); restriction (0-3),
  • Appearance/exposure: mild/moderate/ severe (0-3).


  • .0: Absent;
  • 1: Conjunctiva behind the grey line;
  • 2: Conjunctiva anterior to the grey line),

**Eyelid edema

  • 0: Absent;
  • 1: Present without redundant tissue;
  • 2: Present and causing bulging in palpebral skin including lower lid festoon.

VISA inflammatory index (activity score):

<4/10‑.treat conservatively,

>5/10 or evidence of disease progression - treat aggressively,

Grading and stages of Orbital cellulitis :

Chandler class


Clinical features


Inflammatory edema/ preseptal cellulitis

  • Eyelid edema and erythema
  • Normal extraocular movements
  • Normal visual acuity


Orbital cellulitis

Diffuse edema of orbital contents without abscess formation


Subperiosteal abscess

  • Collection of purulent exudate beneath the periosteum
  • displacement of globe


Orbital abscess

  • purulent pus collection in orbit [ CT scan ]
  • proptosis
  • chemosis
  • ophthalmoplegia
  • diminished vision


Cavernous sinus thrombosis

Bilateral eye findings



Dr Joyeeta Das MBBS,DNB,
Disha Eye Hospital , Kolkata
Dr. Joyeeta Das is a specialist Orbit and Oculoplastic surgeon having extensive clinical and surgical expertise in the field. Dr. Das joined Disha Eye hospital in 2016 as a consultant Orbit and oculoplastic surgeon. She has attended NRS Medical College, University of Calcutta as an undergraduate and received her MBBS degree. Subsequently, she did her postgraduate ophthalmology degree training in Rotary Narayana Nethralaya, Kolkata and awarded Diplomate of National Board degree in ophthalmology. Following extensive training and Long Term Fellowship in Orbit And oculoplasty from Disha Eye hospital, Kolkata she has joined Sadguru Netra Chikitsalaya, Chitrakoot, MP as consultant and Head of the department, Orbit, and Oculoplasty in 2012 and Sankara Eye hospitals since 2014 to 2016. She was actively involved in teaching postgraduate and fellowship students. To her credit, she has presented numerous papers, lectures in various national and international conferences. She has received Best lecture Award in Confluence-an International conference on-orbit and oculoplasty in 2013 held in Hyderabad and Award Proff. Dr. Ranabir Mukherjee award for best paper in Kolkata academy of Opthalmology Annual Meet 2019. She has published multiple article in various international journal of ophthalmology including BMJ case reports, Orbit and Ophthalmic plastics and reconstructive surgery and Indian journal of ophthalmology(IJO) etc. She is a reviewer of BMJ case reports journal . Her area of interest are complex eyelid reconstructive surgery , facial nerve palsy , facial dystonia and orbital disease.
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