Eyelid retraction

Figure 1. Lid retraction in thyrotoxicosis

Eyelid retraction is present when the upper lid margin is above the limbus with eyes in primary position and the eyes are at rest.(Figure 1) The most common cause of eyelid retraction in primary gaze, either unilateral or bilateral, is thyroid eye disease (Dalrymple's sign). Increased retraction causing lid lag may occur with downgaze (von Graefe's sign). In thyroid eye disease (Graves’ orbitopathy, Graves’s ophthalmopathy), the increased catecholamine levels cause hypercontraction of the sympathetically innervated accessory levator (Mueller’s) muscle, pulling the eyelid open. Eyelid retraction may also occur with disease of the rostral brainstem in the region of the posterior commissure (Collier’s sign). Lid retraction with posterior commissure lesions is bilateral, but sometimes asymmetric.

Unilateral eyelid retraction in this patient with proximal muscle weakness and weight loss was a clue to the presence of hyperthyroidism.

References

1. Cruz AA, Ribeiro SF, Garcia DM, Akaishi PM, Pinto CT. Graves upper eyelid retraction. Surv Ophthalmol. 2013 Jan-Feb;58(1):63-76. 2. Gaddipati RV, Meyer DR. Eyelid retraction, lid lag, lagophthalmos, and von Graefe's sign quantifying the eyelid features of Graves' ophthalmopathy. Ophthalmology. 2008 Jun;115(6):1083-8.