Grading Scales

Koch grading scales

These grading scales were published in 1984 as an appendix entitled ‘Atlas of Illustrations’ in an A5-sized soft-cover textbook published by Koch et al. The grading scales were prepared by Perrin Sparks Smith, a medical artist, and are in the form of line sketches. Most of the sketches are white on black or black on white, with some use of red, green or grey block colour. Many of the illustrations are supplemented by a written description.

Annunziato grading scales

Around 1992, Annunziato et al. published an atlas comprising 130 A4-sized loose-leaf pages secured in a three-ringed binder. This work was sponsored by Alcon Ltd. and was conducted under the auspices of the Southwest Independent Institutional Review Board (an ophthalmic clinical trials research group, Fort Worth, Texas, USA). The grading scales were in the form of full-colour traditional watercolour paintings by Monte Lay, an ophthalmic artist. Most of the paintings are accompanied by a brief description of the condition, and salient features are highlighted with the aid of black-and-white line diagrams.

Vistakon grading scales

An A5-sized spiral-bound handbook of contact lens management was published by Johnson and Johnson Vision Care in 1996, under the authorship of Andersen et al. All of the illustrations are slit lamp photographs. Although this book was primarily intended to be a guide to the management of contact lens complications, most of the conditions are presented in the form of a series of numbered photographs showing varying degrees of severity and, as such, essentially constitutes a series of grading scales. The photographs are accompanied by explanatory text.

Brien Holden Vision Institute Grading Scales

The Brien Holden Vision Institute (BHVI) Grading Scales were first formally published in 1997, although they were released before this and distributed initially as an A2-sized poster, and subsequently in the form of an A4-sized plasticised card. These scales were originally published under the title ‘Cornea and Contact Lens Research Unit (CCLRU) Grading Scales’. The term was changed to ‘Institute for Eye Research Grading Scales’ in 1998 and then to the current one in 2010. All of the conditions are depicted in the form of slit lamp photographs without accompanying text. Guidance is also given for grading certain conditions, but a series of graded photographs is not provided.

Efron Grading Scales

The first edition of the Efron Grading Scales was published in the first edition of this book in 1999, although they were released before this and distributed simultaneously in the form of an A1-sized poster and an A4-sized plasticised card in a protective slip case that contained instructions for use. These grading scales were painted by Terry Tarrant, an ophthalmic artist, and the development of the scales was sponsored by Hydron UK, Ltd. (now CooperVision Ltd.). The first edition of the grading scales depicted eight complications of contact lens wear, whereas the second edition, as presented in Appendix A of this book, depicts 16 complications.

The second edition was officially released as the ‘Millennium Edition’ in 2000 and has been available in card and poster forms since January 1, 2000. A handy plastic-coated A4-sized version of these grading scales, which comes in a handsome protective slipcase with comprehensive instructions for use, is available free of charge from CooperVision.

The original painted images of the Efron Grading Scales are housed in the Museum of the College of Optometrists in London; they are not on permanent display but may be viewed by appointment with the museum curator.

The Vision Care Institute Clinical Grading Scales

The Vision Care Institute (TVCI) Clinical Grading Scales, which were adapted from the Efron Grading Scales, were first published around 2011 by Johnson and Johnson Vision Care. Unlike the Efron scales, which were painted using traditional water colours with a paint brush, the TVCI Grading Scales were generated by an artist using digital computer graphics software. As such, they can be considered as a stylised version of the Efron Grading Scales. Guidance is also given for grading certain conditions, but a series of graded photographs is not provided.

Jenvis Grading Scales

The Jenvis Grading Scales were developed by Jenvis Research, under the authorship of Wolfgang Sickenberger et al. They were published by Alcon in 2013 under the auspices of Alcon’s Academy for Eyecare Excellence. These grading scales comprise a series of slit lamp photographs of various conditions arranged in order of increasing severity. Guidance is also given for grading certain conditions, but a series of graded photographs is not provided.

Grades depicted

The Koch and BHVI scales only depict grades 1 to 4 (not grade 0). Grade 0 is depicted for some of the complications depicted in the Vistakon system. The Annunziato, Efron, TVCI and Jenvis systems display grades 0 to 5 for all complications. Depiction of grade 0 is often useful as a baseline reference when grading complications of low severity.

Severity descriptors

The descriptions attached to the five grades of severity differ somewhat between grading systems; these are cited in Table 2.1 . Severity descriptors are not assigned to the grades in the Koch or Jenvis systems. In the other four systems, grades 0 to 2 have slightly different meanings, whereas grades 3 and 4 are described as ‘moderate’ and ‘severe’, respectively. Thus, allowing for subtle differences in nomenclature, all seven systems have the same illustrative five-point grading system, and the five systems that offer severity descriptors (Annunziato, BHVI, Vistakon, Efron and TVCI) have adopted remarkably similar descriptors for these grades.

Sub-Classifications

In the Koch and Efron systems, a single grading scale comprising five images is used to depict different levels of severity of each complication. However, in the Annunziato, BHVI, Vistakon, TVCI and Jenvis systems, a single complication can be sub-classified and depicted in the form of a number of grading scales so that different manifestations of that complication can be graded. For example, in the BHVI system, three grading scales are employed to facilitate an independent assessment of the severity of corneal staining in terms of type, depth and extent.

Conditions depicted

Putting aside sub-classifications, the number of primary conditions depicted varies markedly between grading systems – from five sets of primary grading scales in the TVCI system to 16 in the Efron system. The primary conditions depicted in each of the seven grading systems are presented in Table 2.2 .

A number of interesting observations can be made from Table 2.2 :

• A total of 21 complications have been depicted in all of the grading systems combined.

• A grand total of 64 grading scales have been developed in all of the grading systems combined.

• Only three conditions are depicted in all seven grading systems – conjunctival redness, corneal staining and papillary conjunctivitis.

• One condition is unique to the Koch system (epithelial edema), one to the Annunziato system (iritis), three to the Vistakon system (limbal staining, pinguecula and pterygium) and three to the Efron system (corneal ulcer, endothelial blebs and superior limbic keratoconjunctivitis).

Photographic versus painted scales