Grading scales for vitreous haze
Medical hypothesis, discovery & innovation in optometry,
Vol. 5 No. 3 (2024),
25 January 2025
,
Page 127-135
https://doi.org/10.51329/mehdioptometry207
Abstract
Background: Grading scales for vitreous haze are crucial for the diagnosis, monitoring, and management of uveitis. The presence of inflammatory cells within the vitreous cavity is widely recognized as a key indicator of disease activity and severity, offering valuable insights into the underlying inflammatory processes. This mini-review aims to explore the evolution of vitreous haze grading scales systematically, emphasizing conventional grading methods, advances in imaging technologies, and the integration of artificial intelligence (AI) into the grading process.Methods: The PubMed/MEDLINE database was comprehensively searched for studies published between 1959 and 2024, using keywords such as “AI-based grading systems,” “artificial intelligence,” “automated grading,” “grading scales for vitreous cells,” “inflammation,” “uveitis,” and “vitreous haze.” Relevant studies were identified, and additional articles were selected by reviewing the reference lists of the included publications. The selection of articles for inclusion in the mini-review was limited to those written in English.
Results: In the current literature, two grading methods are used: the National Institutes of Health (NIH) scale and the Miami scale. Despite their widespread utilization, both scales entail subjective assessments of vitreous haze, which renders them susceptible to observer bias and interobserver variability. The NIH scale uses six levels, while the Miami scale employs nine levels, both of which require subjective assessments of vitreous haze. Recent advances in objective imaging technologies, namely ultrawide-field fundus photography and advanced optical coherence tomography-based analysis, have given rise to increasingly consistent and standardized grading systems, which may enhance the reliability of these assessments. Innovative techniques have been developed to enhance accuracy and sensitivity, thereby facilitating the early detection and precise monitoring of vitreous inflammation. Despite these advances, challenges remain, including the difficulty of distinguishing subtle variations in vitreous haze and the variability of inflammatory presentations. The incorporation of AI-driven tools and state-of-the-art imaging technologies into the vitreous cell grading signifies a substantial advance in the evaluation and management of uveitis.
Conclusions: The development of more objective, reproducible, and quantitative grading scales is imperative for optimizing uveitis evaluation and grading vitreous haze in clinical settings and clinical trials. These innovations will also provide robust endpoints for clinical studies, ultimately improving patient care. Moreover, objective grading criteria will enhance diagnostic precision, facilitate better management of ocular inflammatory diseases, and promote further advances in uveitis research and treatment.
Keywords:
- vitreous humor
- posterior uveitis
- inflammations
- uveitides
- machine intelligence
- intelligence
- artificial
- automated grading
- optical coherence tomography
- AI-based grading systems

References
1. Liu X, Hui BT, Way C, Beese S, Adriano A, Keane PA, Moore DJ, Denniston AK. Noninvasive Instrument-based Tests for Detecting and Measuring Vitreous Inflammation in Uveitis: A Systematic Review. Ocul Immunol Inflamm. 2022 Jan 2;30(1):137-148. doi: 10.1080/09273948.2020.1799038. Epub 2020 Oct 6. PMID: 33021418; PMCID: PMC8935946.
2. Liu X, Kale AU, Ometto G, Montesano G, Sitch AJ, Capewell N, Radovanovic C, Bucknall N, Beare NAV, Moore DJ, Keane PA, Crabb DP, Denniston AK. OCT Assisted Quantification of Vitreous Inflammation in Uveitis. Transl Vis Sci Technol. 2022 Jan 3;11(1):3. doi: 10.1167/tvst.11.1.3. PMID: 34982094; PMCID: PMC8742534.
3. Passaglia CL, Arvaneh T, Greenberg E, Richards D, Madow B. Automated Method of Grading Vitreous Haze in Patients With Uveitis for Clinical Trials. Transl Vis Sci Technol. 2018 Mar 23;7(2):10. doi: 10.1167/tvst.7.2.10. PMID: 29600118; PMCID: PMC5868860.
4. Madow B, Galor A, Feuer WJ, Altaweel MM, Davis JL. Validation of a photographic vitreous haze grading technique for clinical trials in uveitis. Am J Ophthalmol. 2011 Aug;152(2):170-176.e1. doi: 10.1016/j.ajo.2011.01.058. Epub 2011 Jun 8. PMID: 21652026; PMCID: PMC4556733.
5. Hornbeak DM, Payal A, Pistilli M, Biswas J, Ganesh SK, Gupta V, Rathinam SR, Davis JL, Kempen JH. Interobserver agreement in clinical grading of vitreous haze using alternative grading scales. Ophthalmology. 2014 Aug;121(8):1643-8. doi: 10.1016/j.ophtha.2014.02.018. Epub 2014 Mar 31. PMID: 24697913; PMCID: PMC4122589.
6. KIMURA SJ, THYGESON P, HOGAN MJ. Signs and symptoms of uveitis. II. Classification of the posterior manifestations of uveitis. Am J Ophthalmol. 1959 May;47(5 Pt 2):171-6. doi: 10.1016/s0002-9394(14)78240-6. PMID: 13649856.
7. Nussenblatt RB, Palestine AG, Chan CC, Roberge F. Standardization of vitreal inflammatory activity in intermediate and posterior uveitis. Ophthalmology. 1985 Apr;92(4):467-71. doi: 10.1016/s0161-6420(85)34001-0. PMID: 4000641.
8. Davis JL, Madow B, Cornett J, Stratton R, Hess D, Porciatti V, Feuer WJ. Scale for photographic grading of vitreous haze in uveitis. Am J Ophthalmol. 2010 Nov;150(5):637-641.e1. doi: 10.1016/j.ajo.2010.05.036. Epub 2010 Aug 16. PMID: 20719302; PMCID: PMC3220938.
9. Kempen JH, Ganesh SK, Sangwan VS, Rathinam SR. Interobserver agreement in grading activity and site of inflammation in eyes of patients with uveitis. Am J Ophthalmol. 2008 Dec;146(6):813-8.e1. doi: 10.1016/j.ajo.2008.06.004. Epub 2008 Aug 8. PMID: 18687418.
10. Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005 Sep;140(3):509-16. doi: 10.1016/j.ajo.2005.03.057. PMID: 16196117; PMCID: PMC8935739.
11. Pichi F, Carreño E. The Vitreous in Uveitis: Characterizing the Invisible with Optical Coherence Tomography. Ocul Immunol Inflamm. 2022 Apr 3;30(3):690-696. doi: 10.1080/09273948.2022.2075399. PMID: 35901539.
12. Köksald? S, Kayaba?? M, Mammadov T, Saatci AO. Are intravitreal hyperreflective particles alike in eyes with acute toxoplasma chorioretinitis and non-infectious uveitis? Photodiagnosis Photodyn Ther. 2024 Feb;45:103929. doi: 10.1016/j.pdpdt.2023.103929. Epub 2023 Dec 14. PMID: 38101501.
13. Invernizzi A, Zaffalon C, Manni P, Zicarelli F, Chisari D, Adani C, Mastrofilippo V, Bolletta E, Gozzi F, De Simone L, Staurenghi G, Cimino L. Anterior Vitreous Objective Assessment in Uveitis: An Anterior Segment Swept Source Optical Coherence Tomography Study. Ocul Immunol Inflamm. 2024 Apr 22:1-9. doi: 10.1080/09273948.2024.2339435. Epub ahead of print. PMID: 38648627.
14. Durmaz Engin C, Kayabasi M, Koksaldi S, Ipek SC, Saatci AO. Does Subretinal Fluid Optical Density Ratio Differ Among the Eyes with Acute Central Serous Chorioretinopathy,Vogt Koyanagi Harada Disease and Choroidal Hemangioma: A Cross-sectional Study. Photodiagnosis Photodyn Ther. 2023 Jun;42:103634. doi: 10.1016/j.pdpdt.2023.103634. Epub 2023 May 25. PMID: 37244453.
15. Keane PA, Karampelas M, Sim DA, Sadda SR, Tufail A, Sen HN, Nussenblatt RB, Dick AD, Lee RW, Murray PI, Pavesio CE, Denniston AK. Objective measurement of vitreous inflammation using optical coherence tomography. Ophthalmology. 2014 Sep;121(9):1706-14. doi: 10.1016/j.ophtha.2014.03.006. Epub 2014 May 15. PMID: 24835759; PMCID: PMC4507470.
16. Zarranz-Ventura J, Keane PA, Sim DA, Llorens V, Tufail A, Sadda SR, Dick AD, Lee RW, Pavesio C, Denniston AK, Adan A; EQUATOR Study Group. Evaluation of Objective Vitritis Grading Method Using Optical Coherence Tomography: Influence of Phakic Status and Previous Vitrectomy. Am J Ophthalmol. 2016 Jan;161:172-80.e1-4. doi: 10.1016/j.ajo.2015.10.009. Epub 2015 Oct 23. PMID: 26476212.
17. Zicarelli F, Ometto G, Montesano G, Motta S, De Simone L, Cimino L, Staurenghi G, Agarwal A, Pichi F, Invernizzi A. Objective Quantification of Posterior Segment Inflammation: Measuring Vitreous Cells and Haze Using Optical Coherence Tomography. Am J Ophthalmol. 2023 Jan;245:134-144. doi: 10.1016/j.ajo.2022.08.025. Epub 2022 Sep 7. PMID: 36084686.
18. Murugan SRB, Sanjay S, Somanath A, Mahendradas P, Patil A, Kaur K, Gurnani B. Artificial Intelligence in Uveitis: Innovations in Diagnosis and Therapeutic Strategies. Clin Ophthalmol. 2024 Dec 14;18:3753-3766. doi: 10.2147/OPTH.S495307. PMID: 39703602; PMCID: PMC11656483.
19. Mhibik B, Kouadio D, Jung C, Bchir C, Toutée A, Maestri F, Gulic K, Miere A, Falcione A, Touati M, Monnet D, Bodaghi B, Touhami S. AUTOMATED DETECTION OF VITRITIS USING ULTRAWIDE-FIELD FUNDUS PHOTOGRAPHS AND DEEP LEARNING. Retina. 2024 Jun 1;44(6):1034-1044. doi: 10.1097/IAE.0000000000004049. PMID: 38261816.
20. Keane PA, Balaskas K, Sim DA, Aman K, Denniston AK, Aslam T, And For The Equator Study Group. Automated Analysis of Vitreous Inflammation Using Spectral-Domain Optical Coherence Tomography. Transl Vis Sci Technol. 2015 Sep 16;4(5):4. doi: 10.1167/tvst.4.5.4. PMID: 26396930; PMCID: PMC4572940.
21. Haggag S, Khalifa F, Abdeltawab H, Elnakib A, Ghazal M, Mohamed MA, Sandhu HS, Alghamdi NS, El-Baz A. An Automated CAD System for Accurate Grading of Uveitis Using Optical Coherence Tomography Images. Sensors (Basel). 2021 Aug 13;21(16):5457. doi: 10.3390/s21165457. PMID: 34450898; PMCID: PMC8401645.
22. Passaglia CL, Arvaneh T, Greenberg E, Richards D, Madow B. Automated Method of Grading Vitreous Haze in Patients With Uveitis for Clinical Trials. Transl Vis Sci Technol. 2018 Mar 23;7(2):10. doi: 10.1167/tvst.7.2.10. PMID: 29600118; PMCID: PMC5868860.
2. Liu X, Kale AU, Ometto G, Montesano G, Sitch AJ, Capewell N, Radovanovic C, Bucknall N, Beare NAV, Moore DJ, Keane PA, Crabb DP, Denniston AK. OCT Assisted Quantification of Vitreous Inflammation in Uveitis. Transl Vis Sci Technol. 2022 Jan 3;11(1):3. doi: 10.1167/tvst.11.1.3. PMID: 34982094; PMCID: PMC8742534.
3. Passaglia CL, Arvaneh T, Greenberg E, Richards D, Madow B. Automated Method of Grading Vitreous Haze in Patients With Uveitis for Clinical Trials. Transl Vis Sci Technol. 2018 Mar 23;7(2):10. doi: 10.1167/tvst.7.2.10. PMID: 29600118; PMCID: PMC5868860.
4. Madow B, Galor A, Feuer WJ, Altaweel MM, Davis JL. Validation of a photographic vitreous haze grading technique for clinical trials in uveitis. Am J Ophthalmol. 2011 Aug;152(2):170-176.e1. doi: 10.1016/j.ajo.2011.01.058. Epub 2011 Jun 8. PMID: 21652026; PMCID: PMC4556733.
5. Hornbeak DM, Payal A, Pistilli M, Biswas J, Ganesh SK, Gupta V, Rathinam SR, Davis JL, Kempen JH. Interobserver agreement in clinical grading of vitreous haze using alternative grading scales. Ophthalmology. 2014 Aug;121(8):1643-8. doi: 10.1016/j.ophtha.2014.02.018. Epub 2014 Mar 31. PMID: 24697913; PMCID: PMC4122589.
6. KIMURA SJ, THYGESON P, HOGAN MJ. Signs and symptoms of uveitis. II. Classification of the posterior manifestations of uveitis. Am J Ophthalmol. 1959 May;47(5 Pt 2):171-6. doi: 10.1016/s0002-9394(14)78240-6. PMID: 13649856.
7. Nussenblatt RB, Palestine AG, Chan CC, Roberge F. Standardization of vitreal inflammatory activity in intermediate and posterior uveitis. Ophthalmology. 1985 Apr;92(4):467-71. doi: 10.1016/s0161-6420(85)34001-0. PMID: 4000641.
8. Davis JL, Madow B, Cornett J, Stratton R, Hess D, Porciatti V, Feuer WJ. Scale for photographic grading of vitreous haze in uveitis. Am J Ophthalmol. 2010 Nov;150(5):637-641.e1. doi: 10.1016/j.ajo.2010.05.036. Epub 2010 Aug 16. PMID: 20719302; PMCID: PMC3220938.
9. Kempen JH, Ganesh SK, Sangwan VS, Rathinam SR. Interobserver agreement in grading activity and site of inflammation in eyes of patients with uveitis. Am J Ophthalmol. 2008 Dec;146(6):813-8.e1. doi: 10.1016/j.ajo.2008.06.004. Epub 2008 Aug 8. PMID: 18687418.
10. Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005 Sep;140(3):509-16. doi: 10.1016/j.ajo.2005.03.057. PMID: 16196117; PMCID: PMC8935739.
11. Pichi F, Carreño E. The Vitreous in Uveitis: Characterizing the Invisible with Optical Coherence Tomography. Ocul Immunol Inflamm. 2022 Apr 3;30(3):690-696. doi: 10.1080/09273948.2022.2075399. PMID: 35901539.
12. Köksald? S, Kayaba?? M, Mammadov T, Saatci AO. Are intravitreal hyperreflective particles alike in eyes with acute toxoplasma chorioretinitis and non-infectious uveitis? Photodiagnosis Photodyn Ther. 2024 Feb;45:103929. doi: 10.1016/j.pdpdt.2023.103929. Epub 2023 Dec 14. PMID: 38101501.
13. Invernizzi A, Zaffalon C, Manni P, Zicarelli F, Chisari D, Adani C, Mastrofilippo V, Bolletta E, Gozzi F, De Simone L, Staurenghi G, Cimino L. Anterior Vitreous Objective Assessment in Uveitis: An Anterior Segment Swept Source Optical Coherence Tomography Study. Ocul Immunol Inflamm. 2024 Apr 22:1-9. doi: 10.1080/09273948.2024.2339435. Epub ahead of print. PMID: 38648627.
14. Durmaz Engin C, Kayabasi M, Koksaldi S, Ipek SC, Saatci AO. Does Subretinal Fluid Optical Density Ratio Differ Among the Eyes with Acute Central Serous Chorioretinopathy,Vogt Koyanagi Harada Disease and Choroidal Hemangioma: A Cross-sectional Study. Photodiagnosis Photodyn Ther. 2023 Jun;42:103634. doi: 10.1016/j.pdpdt.2023.103634. Epub 2023 May 25. PMID: 37244453.
15. Keane PA, Karampelas M, Sim DA, Sadda SR, Tufail A, Sen HN, Nussenblatt RB, Dick AD, Lee RW, Murray PI, Pavesio CE, Denniston AK. Objective measurement of vitreous inflammation using optical coherence tomography. Ophthalmology. 2014 Sep;121(9):1706-14. doi: 10.1016/j.ophtha.2014.03.006. Epub 2014 May 15. PMID: 24835759; PMCID: PMC4507470.
16. Zarranz-Ventura J, Keane PA, Sim DA, Llorens V, Tufail A, Sadda SR, Dick AD, Lee RW, Pavesio C, Denniston AK, Adan A; EQUATOR Study Group. Evaluation of Objective Vitritis Grading Method Using Optical Coherence Tomography: Influence of Phakic Status and Previous Vitrectomy. Am J Ophthalmol. 2016 Jan;161:172-80.e1-4. doi: 10.1016/j.ajo.2015.10.009. Epub 2015 Oct 23. PMID: 26476212.
17. Zicarelli F, Ometto G, Montesano G, Motta S, De Simone L, Cimino L, Staurenghi G, Agarwal A, Pichi F, Invernizzi A. Objective Quantification of Posterior Segment Inflammation: Measuring Vitreous Cells and Haze Using Optical Coherence Tomography. Am J Ophthalmol. 2023 Jan;245:134-144. doi: 10.1016/j.ajo.2022.08.025. Epub 2022 Sep 7. PMID: 36084686.
18. Murugan SRB, Sanjay S, Somanath A, Mahendradas P, Patil A, Kaur K, Gurnani B. Artificial Intelligence in Uveitis: Innovations in Diagnosis and Therapeutic Strategies. Clin Ophthalmol. 2024 Dec 14;18:3753-3766. doi: 10.2147/OPTH.S495307. PMID: 39703602; PMCID: PMC11656483.
19. Mhibik B, Kouadio D, Jung C, Bchir C, Toutée A, Maestri F, Gulic K, Miere A, Falcione A, Touati M, Monnet D, Bodaghi B, Touhami S. AUTOMATED DETECTION OF VITRITIS USING ULTRAWIDE-FIELD FUNDUS PHOTOGRAPHS AND DEEP LEARNING. Retina. 2024 Jun 1;44(6):1034-1044. doi: 10.1097/IAE.0000000000004049. PMID: 38261816.
20. Keane PA, Balaskas K, Sim DA, Aman K, Denniston AK, Aslam T, And For The Equator Study Group. Automated Analysis of Vitreous Inflammation Using Spectral-Domain Optical Coherence Tomography. Transl Vis Sci Technol. 2015 Sep 16;4(5):4. doi: 10.1167/tvst.4.5.4. PMID: 26396930; PMCID: PMC4572940.
21. Haggag S, Khalifa F, Abdeltawab H, Elnakib A, Ghazal M, Mohamed MA, Sandhu HS, Alghamdi NS, El-Baz A. An Automated CAD System for Accurate Grading of Uveitis Using Optical Coherence Tomography Images. Sensors (Basel). 2021 Aug 13;21(16):5457. doi: 10.3390/s21165457. PMID: 34450898; PMCID: PMC8401645.
22. Passaglia CL, Arvaneh T, Greenberg E, Richards D, Madow B. Automated Method of Grading Vitreous Haze in Patients With Uveitis for Clinical Trials. Transl Vis Sci Technol. 2018 Mar 23;7(2):10. doi: 10.1167/tvst.7.2.10. PMID: 29600118; PMCID: PMC5868860.
- Abstract Viewed: 0 times
- Full Text PDF Downloaded: 0 times