A Consensus-Based Clinical Activity Score Atlas for Thyroid Eye Disease in East Asian Patients: The Korean Society of Ophthalmic Plastic and Reconstructive Surgery Initiative

To develop a consensus-based photographic atlas tailored to East Asian patients to improve the consistency and clinical applicability of the clinical activity score (CAS) in thyroid eye disease (TED), while maintaining compatibility with the established CAS framework.

Under the auspices of the Korean Society of Ophthalmic Plastic and Reconstructive Surgery (KSOPRS), an expert Atlas Committee comprising eight TED specialists curated representative clinical photographs corresponding to the five sign-based CAS items: eyelid swelling, eyelid erythema, conjunctival redness, conjunctival swelling, and inflammation of the caruncle or plica. Images were categorized as CAS-positive or CAS-negative following multiple rounds of expert review and discussion. The finalized atlas was circulated to all KSOPRS members for consensus approval.

The atlas provides standardized photographic panels and concise operational guidance for each sign-based CAS item. East Asian-specific considerations, including thicker eyelid skin, fuller preseptal and septal fat, and epicanthal folds, are incorporated to refine interpretation of inflammatory signs that may appear attenuated compared with photographic references derived from White populations of European ancestry. The atlas emphasizes pattern recognition, distribution of findings, and side-to-side comparison rather than absolute intensity of erythema or swelling, aiming to reduce false-negative judgments and improve interobserver consistency.

This ethno-specific standard photographic atlas enables endocrinologists and ophthalmologists to perform rapid and reproducible assessments in outpatient settings, facilitating the early identification of patients requiring referral or urgent treatment.