Graves’ Disease: Classification

Staging of endocrine orbitopathy (EO).

Stage Description
I
  • Foreign body sensation
  • Photophobia (light shyness)
  • Retrobulbar pressure sensation (retrobulbar, i.e., behind the eyeball).
II
  • Eyelid retractions (retraction: shrinkage, shortening) and connective tissue involvement with:
    • Chemosis (= edema of the conjunctiva):
      • In the case of more severe conjunctivitis (conjunctivitis) or
      • In inflammatory processes of the neighborhood due to lymphatic drainage disorder or congestion,
      • In case of allergic reactions,

      There is an edematous, whitish-glassy or bright red bulge-like swelling of the conjunctiva bulbi (conjunctiva/conjunctiva), which may bulge out of the palpebral fissure and partially cover the cornea

    • Eye tears
III
  • Protrusio bulbi = exophthalmos (eyeball (bulb) protrudes from the orbit).
IV
  • Ocular muscle blockages (paresis) with occurrence of double vision and motility restrictions (limitations of the ability to move)
V
  • Corneal afflictions with ulcers (ulcers) due to lagophthalmos (incomplete closure of the eyelids)
VI
  • Visual loss due to involvement of the optic nerve

For the classification of disease progression and stage of endocrine orbitopathy, there are various schemes.Since 1969, the so-called NOSPECS scheme (synonym: Werner classification) is used, a classification of the American Thyroid Association (ATA).As an extension of the NOSPECS scheme, the so-called LEMO classification has been established. It assigns integer values between 0 and 3 or 4 to the four groups of findings “eyelid changes”, “exophthalmos“, “muscle changes” and “optic nerve involvement”, depending on the degree of severity. This facet classification was first proposed by Boergen and Pickardt in 1991.

NOSPECS scheme

Class Clinical features English name
0 No signs or symptoms No signs or symptoms
1 Characters (e.g.B. Eyelid retraction), no symptoms. Only signs, no symptoms
2 Soft tissue involvement Soft tissue involvement
3 Exophthalmos Proptosis
4 Muscle changes Extraocular muscle involvement
5 Corneal complications Corneal involvement
6 Visual acuity and visual field impairment Sight loss

LEMO classification

Symptoms Class Findings
Changes in the eyelids (L) 0 missing
1 Eyelid edema only
2 True retraction (impaired eyelid closure)
3 Retraction plus upper eyelid edema
4 Retraction plus upper and lower eyelid edema.
Exophthalmos (E) 0 missing
1 Without eyelid closure insufficiency (weakness of eyelid closure)
2 Conjunctival irritation in the morning
3 Conjunctival irritation constantly
4 Corneal complications
Changes in muscles (M) 0 missing
1 Detectable only by imaging techniques
2 Pseudoparesis (“pseudoplegia”)
3 Pseudoparalysis
Involvement of the optic nerve (O) 0 missing
1 only in color vision and VEP (visual evoked potentials)
2 peripheral visual field defects
3 central visual field defects