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
(click here to learn more about cataract grading)
| 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
| Stage | Findings |
| 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 |
| 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 | Annoying or episodic activity limiting | Annoying chronic or chronic activity limiting | Constant or disabling |
| Conjunctival injection | None to mild | None to mild | +/- | +/++ |
| Conjunctival staining | None to mild | Variable | Moderate to marked | Marked |
| Corneal staining | None to mild | Variable | Marked central | Severe punctate erosions |
| Corneal/tear signs | None to mild | Mild debris, decreased meniscus | Filamentary keratitis, mucus clumping, increased tear debris | Filamentary keratitis, mucus clumping, increased tear debris, ulceration |
| Lid/MG | MGD variably present | MGD variably present | Frequent | Trichiasis, keratinization, symblepharon |
| TBUT | Variable | <=10 | <=5 | Immediate |
| Schirmer score | Variable | <=10 | <=5 | <=2 |
Meibomian Gland Dysfunction (MGD) Staging
| Stage | MGD Grade | Symptoms | Corneal Staining |
| 1 | + (minimally altered expressibility and | None | None |
| 2 | ++ (mildly altered expressibility and secretion quality) | Minimal to mild | None to limited |
| 3 | +++ (moderately altered expressibility and secretion quality) | Moderate | Mild to moderate; mainly peripheral |
| 4 | ++++ (severely altered expressibility and secretion quality) | Marked | Marked; central in addition |
| “Plus” disease – co-existing or accompanying disorders of the ocular surface and/or eyelids | |||
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 |
| 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 – steep q – queer b – bowed anteriorly p – plateau |
| Pigmentation | 0 none 1+ 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 |
| 4+ | >50 cells | Intense 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.
References
Disease Severity Staging
Cataract Grading:
Thylefors B, Chylack LT, Konyama K et al. A simplified cataract grading system. Ophthalmic Epidemiology 2002.
http://www.ncbi.nlm.nih.gov/pubmed/11821974
Glaucoma Grading:
American Academy of Ophthalmology and American Glaucoma Society. Glaucoma Quick Reference Guide. AAO 2015.
http://www.aao.org/Assets/706a6588-8001-4155-a24b-3eddad58c0f7/635672098930070000/glaucoma-icd-10-quick-reference-guide-pdf
Non Proliferative Diabetic Retinopathy:
Wilkinson CP1, Ferris FL 3rd, Klein RE et al. Proposed international clinical diabetic retinopathy and diabetic macular edema disease severity scales. Ophthalmology 2003.
http://www.ncbi.nlm.nih.gov/pubmed/13129861
Proliferative Diabetic Retinopathy:
The Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group. Ophthalmology 1981.
http://www.ncbi.nlm.nih.gov/pubmed/7196564
Age-related Macular Degeneration:
Frederick FL, Wilkinson CP, Bird A. Clinical Classification of Age-related Macular Degeneration. Ophthalmology. 2013.
http://www.ncbi.nlm.nih.gov/pubmed/23332590
Dry Eye:
The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocular Surface 2007.
http://www.ncbi.nlm.nih.gov/pubmed/17508116
Meibomian Gland Dysfunction:
Nichols KK, Foulks GN, Bron AJ. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. IOVS 2011.
http://www.ncbi.nlm.nih.gov/pubmed/21450913
Retinopathy of Prematurity:
The International Classification of Retinopathy of Prematurity Revisited. Arch Ophthalmology
http://www.ncbi.nlm.nih.gov/pubmed/16009843
Sickle Cell Retinopathy:
Goldberg MF. Classification and pathogenesis of proliferative sickle retinopathy. Am J Ophthamology 1971.
http://www.ncbi.nlm.nih.gov/pubmed/5546311
Hypertensive Retinopathy:
Wong TY, Mitchell P. Hypertensive Retinopathy. New England Journal of Medicine 2004.
http://www.ncbi.nlm.nih.gov/pubmed/15564546
Macular Hole:
Gass JD. Reappraisal of biomicroscopic classification of stages of development of a macular hole. Am J Ophthalmology 1995.
http://www.ncbi.nlm.nih.gov/pubmed/7785690
Retinoblastoma:
Resse AB, Ellsworth RM. The evaluation and current concept of retinoblastoma therapy.
Trans Am Acad Ophthalmol Otolaryngol 1963.
http://www.ncbi.nlm.nih.gov/pubmed/13973597
Shields CL, Mashayekhi A, Au AK. The International Classification of Retinoblastoma Predicts Chemoreduction Success. Ophthalmology 2006.
http://www.ncbi.nlm.nih.gov/pubmed/16996605
Exam Findings
Scheie Gonioscopy:
Scheie HG. Width and pigmentation of the angle of the anterior chamber; a system of grading by gonioscopy. AMA Arch Ophthalmology 1957.
http://www.ncbi.nlm.nih.gov/pubmed/13457548
Schaffer Gonioscopy:
Van Herick W, Shaffer RN, Schwartz A. Estimation of width of angle of anterior chamber: incidence and significant of the narrow angle. AJO 1969.
http://www.ncbi.nlm.nih.gov/pubmed/5344324
Spaeth Gonioscopy:
Congdon NG, Spaeth GL, Augsburger J. A proposed simple method for measurement in the anterior chamber angle: biometric gonioscopy. Ophthalmology 1999.
http://www.ncbi.nlm.nih.gov/pubmed/10571353
Cell / Flare Grading:
Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of Uveitis Nomenclature for Reporting Clinical Data. Results of the First International Workshop. Am J Ophthamlology 2005.
http://www.ncbi.nlm.nih.gov/pubmed/16196117
Papilledema Grading:
Scott CJ, Kardon RH, Lee AG. Diagnosis and Grading of Papilledema in Patients With Raised Intracranial Pressure Using Optical Coherence Tomography vs Clinical Expert Assessment Using a Clinical Staging Scale. Arch Ophthalmology 2010.
http://www.ncbi.nlm.nih.gov/pubmed/20547947
Lincoff’s Rules:
Lincoff H, Gieser R. Finding the Retinal Hole. JAMA Ophthalmology 1971.
http://www.ncbi.nlm.nih.gov/pubmed/5056386
Extraocular Muscles:
Choi RY, Kushner BJ. The accuracy of experienced strabismologists using the Hirschberg and Krimsky tests. Ophthalmology 1998.
http://www.ncbi.nlm.nih.gov/pubmed/9663237
