Eyelid Retraction

The husband of a 30-year-old woman noticed his wife's drooping right upper eyelid (A) and encouraged her to seek medical evaluation.

Although the right upper eyelid appeared to be ptotic, it was in fact the left upper eyelid that was retracted. Consider possible lid retraction when the patient's upper lid margin is level with or above the superior limbus; normally, the upper eyelid covers the superior limbus by about 2 mm.

Suspect Graves disease when eyelid retraction is accompanied by proptosis and restrictive orbitopathy. Retraction of both the upper and lower eyelids occurs in about 50% of patients with this thyroid disease.¹ Transient eyelid retraction is seen in almost every case of active hyperthyroidism. Isolated eyelid retraction is particularly common among young women with Graves disease and may spontaneously improve with time and normalization of thyroid status.²

This patient demonstrated the following key ocular signs of Graves disease:

• Dalrymple sign, or lid retraction in primary gaze (A).
• Von Graefe sign, which is lid lag, or the failure of the eyelid to follow the globe when looking downward (B).

The patient was referred to her primary care physician; a complete workup confirmed the diagnosis of hyperthyroidism. The patient was instructed to use artificial tears in her left eye to relieve the corneal dryness from increased exposure caused by the enlarged palpebral fissure that resulted from the retracted eyelid.

Surgical repair (levator recession or muellerectomy to weaken and lower the lid) may be indicated for patients with severe eyelid retraction or for those in whom the condition has persisted longer than 1 year.²

REFERENCES:1. Kanski JJ. Clinical Ophthalmology: A Systemic Approach. 4th ed. Boston: Butterworth-Heinemann; 1999:560-561.
2. Kennerdell JS, Cockerham KP, Maroon JD, Rothfus WE. Practical Diagnosis and Management of Orbital Disease. Boston: Butterworth-Heinemann; 2001:55-60.