Eyelid retraction, lid lag, lagophthalmos, and von Graefe's sign - Quantifying the eyelid features of Graves' ophthalmopathy

Purpose: To report the frequency and relationship of eyelid retraction, lid lag, lagophthalmos, and von Graefe's sign in a group of patients with Graves' ophthalmopathy and compare these findings to those in a group of normal individuals. Design: Retrospective comparative cohort study. Participants: Fifty consecutive Graves' ophthalmopathy patients were compared to a control group of 50 normal individuals. Methods: Measurements were made of eyelid position in primary gaze and downgaze to assess eyelid retraction and lid lag, and the presence of lagophthalmos and von Graefe's sign was noted when present. Main Outcome Measures: Eyelid position in primary gaze and downgaze and presence of lagophthalmos and von Graefe's sign. Results: In the Graves' group, eyelid retraction (38%), von Graefe's sign (36%) and lagophthalmos (16%) were observed at a significantly greater frequency (P<0.01) than in normals, whereas true eyelid lag was observed in only 8% (P = 0.67). Conclusions: The terms lid lag and von Graefe's sign have been used interchangeably in the past; however, they are distinct signs of downgaze-related upper eyelid static position and dynamic movement, respectively. Although von Graefe's sign was commonly exibited in Graves' patients, the relatively low frequency of lid lag suggests that factors other than restriction/fibrosis are likely responsible for the etiology of eyelid retraction in many cases.