Thyroid eye disease (TED) is the most common extra-thyroidal manifestation of Graves’ disease. TED can present with a myriad of ocular signs, including photophobia, proptosis, or conjunctival injection. Other signs suggestive of TED include lid lag, globe lag, lid retraction, and even, in some severe cases, evidence of optic neuropathy.
Clinical findings in Thyroid Eye Disease
| Eye sign | Clinical findings |
| Dalrymple’s sign | Lid retraction involving the upper eyelid |
| Von Grafe’s sign | Lagging of the upper eyelid upon downward gaze |
| Collier’s sign | Lid retraction involving the lower eyelid |
| Stellwag’s sign | Infrequent blinking of the eyelids |
| Rosenbach’s sign | Tremors of the eyelids upon closure |
| Gifford sign | A difficulty with eversion of the upper eyelids |
| Jellinek sign | Hyperpigmentation of the upper eyelids |
| Sainton sign | Nystagmus on the voluntary horizontal movement of the eyes |
| Ballet sign | Paresis of extraocular muscles |
| Enroth sign | Periorbital edema |
| Griffith’s sign | Lid lag involving the lower eyelid on upward gaze |
Clinical Pearl
Why do patients with Graves’ disease have upper eyelid retraction?
- Muller’s muscle (superior tarsal muscle) under the sympathetic stimulation of excess circulating thyroid hormones contracts and contributes to lid retraction.
- Due to extensive orbital inflammation, the levator palpebrae superioris is infiltrated by inflammatory cells, which leads to fibrosis and contraction of the muscle. Although lid retraction occurs in Graves disease, it is not pathognomonic for this condition and can occur in other forms of hyperthyroidism.
References
- McAlinden C (2014) An overview of thyroid eye disease. Eye and Vision 1:9
- Mallika P, Tan A, Aziz S, Alwi SS, Chong M, Vanitha R, Intan G (2009) Thyroid Associated Ophthalmopathy – A Review. Malays Fam Physician 4:8–14
- Urrets-Zavalía JA, Espósito E, Garay I, Monti R, Ruiz-Lascano A, Correa L, Serra HM, Grzybowski A (2016) The eye and the skin in endocrine metabolic diseases. Clinics in Dermatology 34:151–165
- Bartley GB (1995) The differential diagnosis and classification of eyelid retraction. Trans Am Ophthalmol Soc 93:371–389
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