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Graves' Orbitopathy


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categories of severity are recognized: mild, moderate-to-severe, or sight-threatening as follows:

      1.Mild: characteristics of GO have minimal impact on the patient’s life. They usually present one or more of the following signs:

      (a)minor lid retraction (<2 mm);

      (b)mild soft-tissue involvement;

      (c)exophthalmos <3 mm (above the normal range for the race and gender);

      (d)transient or no diplopia;

      (e)corneal exposure responsive to lubricants

      2.Moderate to severe: patients without sight-threatening GO whose eye disease has sufficient impact on daily life to justify the risks of immunosuppression (if active) or surgical intervention (if inactive); patients usually present one or more of the following signs:

      (a)lid retraction (>2 mm);

      (b)moderate or severe soft-tissue involvement;

      (c)exophthalmos ≥3 mm (above the normal range for the race and gender);

      (d)inconstant or constant diplopia

      3.Sight-threatening GO: patients with DON or corneal breakdown due to severe exposure; other infrequent cases are ocular globe subluxation, severe forms of frozen eye, choroidal folds, and postural visual darkening; this category warrants immediate intervention

      There is no single test that will conclusively establish or refute the diagnosis of DON. Therefore the clinician has to be alert to the possibility of DON in all patients with active disease and look for it in particular when there are certain constellations of other GO features.

      So, how then can the diagnosis of DON be made with confidence? Recent evidence suggests that the signs with the greatest specificity for DON are impairment of colour perception and optic disc swelling [13]. These signs are least likely to be influenced by confounding pathology, provided the patient is not colour blind. A practical approach would be to diagnose DON on disc swelling alone, provided other causes for this have been excluded. In patients without disc swelling, DON should only be diagnosed when there are at least two other features of optic neuropathy: impaired acuity or colour vision, an afferent pupil defect or abnormal perimetry [4]. Patients without significant visual loss who have inconclusive evidence of DON, may not require treatment; however, they should be monitored very carefully.