Griffith’s sign refers to lagging motion of the lower eyelids during upward rotation of the eyes. This sign is observed in patients with thyrotoxicosis, particularly in those with Graves’ ophthalmopathy, and reflects abnormal eyelid retraction and impaired coordination between eyelid and globe movement.

Pathophysiology

• In thyrotoxicosis, increased sympathetic stimulation affects the levator palpebrae superioris and Müller’s muscles, resulting in upper eyelid retraction.

• Lagging of the lower eyelid occurs due to impaired coordination between eyelid muscles and extraocular muscles.

• This can lead to exposure of the sclera above the cornea and contributes to ocular discomfort, dryness, and proptosis.

Examination Technique

1. Patient positioning: Have the patient seated or standing comfortably at eye level.

2. Instruction: Ask the patient to focus on a steadily rising point, such as your moving finger or pen.

3. Observation: Watch the movement of the lower eyelids as the patient looks upward.

4. Assessment:

   • Positive Griffith’s sign is noted when the lower eyelids fail to follow the upward movement of the eyes smoothly, producing a “lag” behind the globe.

5. Documentation: Record side(s) affected, degree of lag, and associated ocular signs (lid retraction, proptosis).

Clinical Features

Differential Diagnosis

Pediatric considerations

• Rarely observed in children, as thyrotoxicosis is uncommon.

• If present, consider congenital hyperthyroidism or neonatal thyrotoxicosis.

Geriatric considerations

• Older adults with Graves’ disease may show more pronounced lid lag due to pre-existing orbital connective tissue changes.

• Careful ocular assessment is important to prevent corneal exposure and keratitis.

Limitations

• Mild lag may be difficult to detect visually without proper lighting and steady gaze stimulus.

• Can be confused with other eyelid disorders (ptosis, cranial nerve palsy).

• Requires cooperation and fixation by the patient.

Patient counseling

• Explain that lid lag is a sign of thyroid-related eye changes, not an isolated eye disease.

• Emphasize monitoring for ocular discomfort, dryness, or visual changes.

• Advise regular ophthalmology follow-up, especially if proptosis or diplopia develops.

• Discuss management of underlying thyrotoxicosis, which may reduce progression of lid lag.

Conclusion

Griffith’s sign is a clinical indicator of lower eyelid lag during upward gaze, commonly associated with thyrotoxicosis and Graves’ ophthalmopathy. Careful ocular and systemic assessment allows early detection, monitoring, and intervention to prevent complications such as corneal exposure or visual impairment.

References

1. Bahn RS. Graves’ ophthalmopathy. N Engl J Med. 2010;362:726–738.

2. Wiersinga WM, Bartalena L. Clinical practice: Graves’ orbitopathy. N Engl J Med. 2002;347:975–981.

3. Smith TJ, Hegedüs L. Graves’ Disease. N Engl J Med. 2016;375:1552–1565.

4. Eckstein AK, et al. Clinical features of thyroid eye disease. Ophthalmology. 2009;116:156–162.