Eye Signs of Thyroid Disease

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 signClinical findings
Dalrymple’s signLid retraction involving the upper eyelid
Von Grafe’s signLagging of the upper eyelid upon downward gaze
Collier’s signLid retraction involving the lower eyelid
Stellwag’s signInfrequent blinking of the eyelids
Rosenbach’s signTremors of the eyelids upon closure
Gifford signA difficulty with eversion of the upper eyelids
Jellinek signHyperpigmentation of the upper eyelids
Sainton signNystagmus on the voluntary horizontal movement of the eyes
Ballet signParesis of extraocular muscles
Enroth signPeriorbital edema
Griffith’s signLid 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.


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  2. 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
  3. 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
  4. Bartley GB (1995) The differential diagnosis and classification of eyelid retraction. Trans Am Ophthalmol Soc 93:371–389

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