Why the NOSPECS Classification of Graves' Eye Disease Should Be Abandoned,with Suggestions for the Characterization of This Disease

The NOSPECS classification of Graves' eye disease is inadequate for a number of reasons: (a) poor characterization of the condition with no indication of disease activity, marked underrepresentation of eyelid position, and overrepresentation of corneal problems, (b) it represents neither a continuous nor stepladder progression of disease as the numbered classification would suggest, (c) parts of it are subjective, and (d) the gradings of classes 3,5, and 6 are poor. Graves' eye disease should be characterized rather than classified, using objective clinical assessments of optic nerve function, proptosis, ocular motility, and eyelid position. It is recommended that a multicenter clinical trial be done to determine the significance of different values and changes in values for each assessment. Disease activity is to be defined by the clinical trial in terms of changes of the four assessments as a function of time. This should produce a simple characterization that would create an image of the patient's eye problems for a knowledgeable physician and be sufficient to guide decisions on whether currently accepted surgical therapies are advisable. Data from the clinical trial would enable the characterization to predict the likelihood of success of various immunosuppressive therapies.