The VISA Classification clusters the four functions disrupted by TED in a logical sequence for recording and management. Subjective input and reproducible objective measurements are recorded for each section and a global severity grade can be assigned for each function. The subjective and objective progress and tempo of disease can be documented to reflect disease activity.
The classification system has been validated by showing that two clinicians could use the forms to assess patients independently with different manifestations of TED and to choose similar management plans. [22] It is currently being assessed by ITEDS and further refinements and validation will be conducted. A common method of documenting and classifying the disease parameters is critical for conducting multi-center clinical trials and to assess response to different therapies.
General Management Guidelines:
Patients with TED are often misdiagnosed initially, because the majority present with mild, non-specific complaints such as tearing, irritation and light sensitivity as a result of exposure from mild lid retraction. Occasionally mild inflammatory features such as eyelid or conjunctival swelling may be interpreted as allergies or viral infections. Many of these patients are frustrated with their medical care by the time the correct diagnosis has been reached. More serious manifestations of the disease such as myopathy, proptosis and visual impairment generally develop rapidly and are more readily recognized.
Understanding what bothers the patient most about their condition helps to build rapport and to plan future management. Patients appreciate reassurance and education about the natural course of TED. Clarify that their endocrinologist and family practitioner will work to control any thyroid dysfunction, and that while their orbitopathy may be linked to thyroid immune disorders, a euthyroid state does not necessarily lead to resolution of the orbitopathy. Emphasize that they can take positive steps to help their condition by quitting smoking and relieving stressors in their lives.
It is helpful to take the time to explain what is predictable about the disease, mentioning that the disease is self-limited, and that those with a mild presentation and younger age are unlikely to progress to more serious complications. For those with more serious complications, the house-fire analogy is useful to clarify the two stages of orbitopathy, and the role of anti-inflammatory or immunomodulatory therapy in the active phase and surgical reconstruction if necessary in the post-inflammatory stage. This website provides links to a number of support groups and clinicians can also identify patients who are willing to talk to newly diagnosed patients to allow sharing of their experiences.
Specific Therapies:
Specific medical, radiation and surgical therapies are detailed under the previous sections on the VISA Classification based on clinical findings.