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During the course of GO, the disease passes through several phases. From the onset, the first phase involves worsening symptoms and signs, often with visible evidence of inflammation, followed by a plateau phase during which no further deterioration occurs. A phase of gradual improvement follows until eventually no further change occurs, although permanent abnormalities in both function and appearance may remain. Such a pattern in the course of the disease is referred to as “Rundle’s curve” [31].

The “severity” of GO describes the degree of functional or cosmetic deficit at any stage [4, 32]. What is now apparent is that the first 3 phases represent a time during which there is thought to be inflammation, and these are known as the “active” phases of GO [4, 11, 33]. Hence “activity” refers to the presence of inflammation. In contrast, the final stage is not accompanied by further spontaneous change as any inflammation has probably resolved, and this is therefore referred to as the inactive phase of GO. Figure 4 illustrates the presumed relationship between severity and activity although it is not known whether the onset of activity significantly precedes any demonstrable clinical signs, i.e., severity.