Abadie’s sign is defined as spasm of the levator muscle of the upper eyelid. This spasm may be slight or pronounced and can affect one or both eyes. A positive Abadie’s sign is considered indicative of exophthalmic goiter, commonly associated with Graves’ disease.

Pathophysiology

In Graves’ disease, autoimmune stimulation of the thyroid leads to excess thyroid hormone production (thyrotoxicosis) and immune-mediated changes in orbital tissues. The levator palpebrae superioris muscle, responsible for lifting the upper eyelid, may exhibit involuntary spasm due to sympathetic overactivity and increased neuromuscular excitability. This contributes to the classic eyelid retraction and lid lag observed in exophthalmic goiter, manifesting as Abadie’s sign.

Examination technique

• Patient positioning: Seated, relaxed, with eyes open and looking straight ahead.

• Observation: Inspect for eyelid retraction or abnormal lid position at rest.

• Palpation / Induction: Ask the patient to gently close their eyes. Observe for involuntary contraction or spasm of the upper eyelid upon attempted closure or with light palpation of the levator muscle.

• Assessment: Note whether the spasm is unilateral or bilateral, and whether it is slight or pronounced.

• Interpretation: A spasm of the levator palpebrae superioris consistent with Abadie’s sign is supportive of exophthalmic goiter in Graves’ disease.

Clinical Utility

• Supportive, not definitive: Abadie’s sign is an adjunctive finding and should be interpreted alongside other features of Graves’ disease, such as exophthalmos, thyroid enlargement, tremor, and tachycardia.

• Adjunct in early diagnosis: Helpful in patients presenting with subtle hyperthyroid symptoms or minimal eye findings.

• Correlation with other ocular signs: Often assessed in conjunction with Von Graefe’s sign, Stellwag’s sign, and Dalrymple’s sign.

Differential diagnosis

Pediatric considerations

• Rare in children; if present, consider congenital thyroid disease or autoimmune hyperthyroidism.

• Examine gently to avoid inducing anxiety or ocular trauma.

Geriatric considerations

• Older adults may present with less pronounced spasm despite significant thyroid disease.

• Coexisting ocular or neurologic conditions may confound the assessment.

Limitations

• Not pathognomonic; a positive Abadie’s sign alone does not confirm Graves’ disease.

• False negatives may occur in early or mild hyperthyroidism.

• Coexisting eyelid or ocular pathology may mimic the spasm.

Patient Counseling

• Explain the purpose of eyelid observation and gentle examination.

• Reassure that the spasm is part of the disease process and is not dangerous by itself.

• Discuss further evaluation with thyroid function tests, imaging, and referral to endocrinology or ophthalmology as appropriate.

Conclusion

Abadie’s sign is a classic ocular finding in exophthalmic goiter associated with Graves’ disease. While not definitive on its own, it serves as a useful supportive clinical indicator when interpreted alongside systemic and ocular manifestations of hyperthyroidism. Proper technique, awareness of limitations, and correlation with laboratory and imaging studies enhance its diagnostic value.

References

1. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis (MO): Mosby Elsevier; 2008. p. 444–447.

2. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights (MO): Mosby Elsevier; 2010.

3. Bahn RS, et al. Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593–646.

4. Wiersinga WM. Graves’ Ophthalmopathy: Pathogenesis and Management. Endocrinol Metab Clin North Am. 2012;41(2):271–288.

5. Laurberg P, et al. Clinical manifestations of Graves’ disease. Best Pract Res Clin Endocrinol Metab. 2001;15(3):299–321.