Lid lag [Graefe's sign]

A cardinal sign of thyrotoxicosis, lid lag is the inability of the upper eyelid to follow the eye’s downward movements. Testing for lid lag involves holding a finger, penlight, or other target above the patient’s eye level and then moving it downward and observing eyelid movement as his eyes follow the target. This sign is demonstrated when a rim of sclera appears between the upper lid margin and the iris when the patient lowers his eyes, when one lid closes more slowly than the other, or when both lids close slowly and incompletely with jerky movements. (See Differentiating lid lag from bilateral ptosis, page 486.)

History and physical examination

Because the patient isn’t generally able to recognize a lid lag himself, ask a friend or family member if he has noticed it. If so, ask when he first noticed lid lag or its possible manifestation, incomplete closure of the eyelid. Explore other signs and symptoms, and ask about a history of thyroid disease. Next, perform a physical examination, focusing on the effects of thyrotoxicosis, such as an enlarged thyroid, diaphoresis, tremors, and exophthalmos.

Medical causes

Thyrotoxicosis

This disorder may produce bilateral lid lag and other ocular effects, including exophthalmos, infrequent blinking, eye dryness and discomfort, conjunctival injection, and a characteristic stare. (Thyrotoxicosis is the most common cause of unilateral and bilateral exophthalmos in adults and children.) Restricted eye movement may produce diplopia. Other effects include an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremors, palpitations, widened pulse pressure, and silken-smooth skin texture.

Because thyrotoxicosis affects virtually every body system, it can produce many other findings. For example, central nervous system effects include clumsiness, shaky handwriting, and emotional lability. Integumentary effects include smooth, warm, flushed, and thickened skin with itchy patches; fine, soft hair with premature graying and increased loss; friable nails; and onycholysis.

Cardiopulmonary involvement causes constant dyspnea; tachycardia; full, bounding pulse; widened pulse pressure; visible point of maximal impulse; and, occasionally, systolic murmur.

Besides nausea and vomiting, GI findings include anorexia, diarrhea, and hepatomegaly. Musculoskeletal findings include weakness, fatigue, and atrophy, along with paralysis and, occasionally, acropachy. Women may report oligomenorrhea or amenorrhea; men may develop gynecomastia; both sexes may experience decreased libido.

Special considerations

If lid lag is accompanied by exophthalmos, provide privacy to ease the patient’s self-consciousness. Don’t cover the affected eye with a gauze pad or other object because removal could destroy the corneal epithelium. Help the patient keep his eyes lubricated with saline drops.

Pediatric pointers

Children may have lid lag associated with aberrant regeneration of cranial nerve III or, rarely, thyrotoxicosis.

Patient counseling

Stress the importance of complying with drug therapy (such as antithyroid drugs or therapeutic radioactive iodine). Subtotal thyroidectomy may be required in rare cases.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Droopy eye-lid

Read excerpts from these other book chapters related to Droopy eye-lid:

Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Droopy eye-lid

• Back to symptom: Droopy eye-lid: Introduction (review 419 causes)
• Next Book Extract About Droopy eye-lid: Ptosis (Field Guide to Bedside Diagnosis)
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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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