GRADING SCALES

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1. VERY SLIGHT 2. SLIGHT 3. MODERATE 4. SEVERE

BULBAR
REDNESS

LIMBAL
REDNESS

LID REDNESS
(area 2)

LID ROUGHNESS:
WHITE LIGHT
REFLEX
(areas 1, 2)

LID ROUGHNESS:
FLUORESCEIN
(area 2)

CORNEAL
STAINING:
TYPE

CORNEAL
STAINING:
DEPTH

CORNEAL
STAINING:
EXTENT
(area 5)

CONJUNCTIVAL
STAINING

© Copyright Brien Holden Vision Institute 2011

 GRADING SCALES
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APPLICATION OF GRADING SCALES CORNEAL STAINING GRADES

• Patient management is based on how much the normal ocular • Staining assessed immediately after single instillation of fluorescein
appearance has changed. using cobalt blue light and wratten 12 (yellow) filter over the slit lamp
• In general, a rating of slight (grade 2) or less is considered within objective.
normal limits (except staining). • The cornea is divided into five areas. The type, extent and depth of
• A change of one grade or more at follow up visits is considered staining are graded in each area.
clinically significant.
Type
1 Micropunctate
PALPEBRAL CONJUNCTIVAL GRADES 2 Macropunctate
3 Coalescent macropunctate
• The palpebral conjunctiva is divided into
4 Patch
five areas to grade redness and roughness.
• Areas 1, 2 and 3 are most relevant in
contact lens wear.
Extent Description Depth Description*
1 ≤5% 1 Superficial epithelium
2 6-15% 2 Deep epithelium, delayed stromal glow
3 16-30% 3 Immediate localized stromal glow
ADVERSE EFFECTS WITH CONTACT LENSES 4 >30% 4 Immediate diffuse stromal glow
CLPC CONTACT LENS PAPILLARY CONJUNCTIVITIS * Based on penetration of fluorescein and slit lamp optic section
Inflammation of the upper palpebral conjunctiva
EROSION
Signs
Full thickness epithelial loss over a discrete area
• Redness
• Enlarged papillae Signs
• Excess mucus • No stromal inflammation
Symptoms • Immediate spread of fluorescein into stroma
• Itchiness Symptoms
• Mucus strands • Can be painful
• Lens mislocation • Photophobia
• Intolerance to lenses • Lacrimation
INFILTRATES
CLPU CONTACT LENS PERIPHERAL ULCER
Accumulation of inflammatory cells in corneal sub-epithelial stroma.
Inset: high magnification view Round, full thickness epithelial loss with inflamed base, typically in the
corneal periphery which results in a scar. Insets: with fluorescein, scar
Signs
• Whitish opacity (focal) or grey haze Signs
(diffuse) • Unilateral, “white spot”
• Usually confined to 2-3mm from limbus • Localized redness
• Localized redness • Infiltrates
Symptoms • Post healing scar
• Asymptomatic or scratchy, foreign body Symptoms
sensation • Varies from foreign body sensation to pain
• Redness, tearing and photophobia • Lacrimation and photophobia may occur
possible
INFECTED ULCER
CLARE CONTACT LENS ACUTE RED EYE Full thickness epithelial loss with stromal necrosis and inflammation, typi-
An acute corneal inflammatory episode associated with sleeping in soft cally central or paracentral
contact lenses Signs
Signs • Intense redness
• Unilateral • “White patch” (raised edges)
• Intense redness • Infiltrates
• Infiltrates • Epithelial and stromal loss
• No epithelial break • Anterior chamber flare
Symptoms • Conjunctival and lid edema
• Wakes with irritation or pain Symptoms
• Photophobia • Pain, photophobia
• Lacrimation • Redness, mucoid discharge
•  VA (if over pupil)
POLYMEGETHISM
1. VERY SLIGHT 2. SLIGHT 3. MODERATE 4. SEVERE

VASCULARIZATION STROMAL STRIAE and FOLDS MICROCYSTS and VACUOLES

Vessel One striae = 5% edema Located in epithelium.
extension One fold = 8% edema Identified by side
beyond trans- (each additional striae showing brightness.
lucent limbal or fold indicates 1% reversed
zone more edema) Microcysts
is recorded
(mm) Vacuoles
unreversed
Record number observed Record number observed

© Copyright Brien Holden Vision Institute 2011