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ULY CLINIC
ULY CLINIC
22 Septemba 2025, 23:40:55
Dalrymple’s sign
Dalrymple’s sign is characterized by abnormally wide palpebral fissures due to retraction of the upper eyelids.
Most commonly associated with thyrotoxicosis (hyperthyroidism), particularly Graves’ disease.
May present with infrequent blinking, restricted lid movement, and incomplete eyelid closure (lagophthalmos).
Often accompanied by other ocular signs of thyroid eye disease such as proptosis or periorbital edema.
Pathophysiology
Sympathetic overstimulation of the levator palpebrae superioris leads to excessive upper eyelid retraction.
Fibrosis or inflammation of eyelid tissues may contribute in chronic thyroid eye disease.
Reduced blinking and incomplete eyelid closure can result from overactive sympathetic innervation or mechanical limitation from proptosis.
Leads to exposure keratopathy and increased risk of corneal irritation in severe cases.
Examination Technique
Patient Observation
Have the patient focus on a fixed point at eye level.
Observe the width of the palpebral fissures and eyelid position.
Note blinking frequency and completeness of eyelid closure.
Additional Assessment
Ask the patient to close the eyes gently to evaluate lagophthalmos.
Assess for associated signs: proptosis, lid lag (von Graefe sign), conjunctival injection, or periorbital edema.
Clinical Utility
Indicator of thyrotoxicosis: Often one of the earliest ocular signs.
Part of thyroid eye disease evaluation: Helps assess severity of lid retraction.
Predictor of ocular complications: Identifies patients at risk for corneal exposure and keratitis.
Differential Diagnosis
Condition | Key Features | Notes |
Graves’ disease / thyrotoxicosis | Lid retraction, proptosis, tremor, weight loss | Dalrymple’s sign is classic ocular sign |
Lid retraction from scarring or trauma | Asymmetrical or localized eyelid elevation | Usually unilateral, history of trauma or surgery |
Sympathetic overactivity | Mild lid retraction, wide-eyed appearance | Consider anxiety or pheochromocytoma in rare cases |
Congenital eyelid malformations | Abnormal fissure width from birth | Often bilateral, non-progressive |
Pediatric Considerations
Rarely observed; if present, investigate for congenital thyroid disorders or systemic causes of sympathetic overactivity.
Geriatric considerations
May coexist with age-related eyelid laxity.
Careful evaluation needed to distinguish from senile lid changes versus thyrotoxic retraction.
Limitations
Mild cases may be subtle and overlooked without careful inspection.
Palpebral fissure width varies with individual anatomy; comparison with historical photographs or contralateral eye may help.
Should always be correlated with systemic thyroid function tests.
Patient Counseling
Explain that eyelid retraction is a sign of thyroid overactivity.
Emphasize importance of thyroid evaluation and management.
Advise on eye protection, artificial tears, or eyelid taping if closure is incomplete.
Discuss potential for ocular complications if left untreated.
Conclusion
Dalrymple’s sign is a key ocular manifestation of thyrotoxicosis, reflecting upper eyelid retraction and sympathetic overactivity. Early detection aids in the diagnosis of thyroid disease and helps prevent ocular complications such as corneal exposure or keratitis.
References
Dalrymple DG. The eyes in Graves’ disease. Trans Am Ophthalmol Soc. 1891;14:151–157.
Bahn RS. Graves’ ophthalmopathy. N Engl J Med. 2010;362:726–738.
Bartalena L, Tanda ML. Graves’ ophthalmopathy. N Engl J Med. 2009;360:994–1001.
American Thyroid Association. Guidelines for the Management of Thyroid Eye Disease. Thyroid. 2016;26:1343–1421.
Wiersinga WM. Thyroid eye disease: Pathogenesis and management. Best Pract Res Clin Endocrinol Metab. 2012;26:353–366.