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ULY CLINIC
ULY CLINIC
25 Septemba 2025, 01:39:15
Joffroy’s sign
Joffroy’s sign refers to immobility of the forehead or facial muscles during upward rotation of the eyes, typically observed in patients with exophthalmos due to Graves’ disease. The sign indicates limited forehead movement when the eyes look upward.
Note: Joffroy’s sign can also refer to difficulty performing simple arithmetic, which may suggest early organic brain disorder. Here, we focus on the ophthalmic manifestation associated with Graves’ disease.
Pathophysiology
Graves’ disease is an autoimmune hyperthyroidism caused by thyroid-stimulating immunoglobulins.
Autoimmune-mediated orbital inflammation and fibrosis affects the extraocular muscles and eyelid elevators.
Fibrosis and edema limit normal forehead and eyelid mobility during upward gaze.
This contributes to exophthalmos and impaired ocular function.
Examination Technique
Patient positioning: Have the patient seated comfortably at eye level.
Observation: Ask the patient to look upward while keeping the head still.
Assessment: Observe the forehead and upper eyelids for immobility or lack of wrinkling.
Documentation: Note bilateral involvement, degree of immobility, and any associated lid lag.
Clinical Features
Feature | Manifestation |
Forehead mobility | Reduced or absent wrinkling with upward gaze |
Eyelid function | Lid lag may accompany immobility |
Eye position | Exophthalmos (proptosis) typical of Graves’ ophthalmopathy |
Associated symptoms | Dryness, photophobia, diplopia, ocular discomfort |
Differential Diagnosis
Condition | Key Feature | Notes |
Graves’ disease | Forehead immobility + exophthalmos | Classic autoimmune hyperthyroidism |
Orbital tumor or mass | Proptosis with restricted movement | May cause unilateral signs; imaging required |
Facial nerve palsy | Asymmetrical forehead movement | Usually involves other facial muscles; not gaze-dependent |
Myasthenia gravis | Fatigable ptosis and ocular weakness | Improvement with rest, fluctuating course |
Pediatric considerations
Rare, as Graves’ disease is uncommon in children.
Forehead immobility may be subtle; careful observation required.
Geriatric considerations
Age-related skin changes may mask subtle immobility.
Coexisting ocular or neurological disorders should be ruled out.
Limitations
Mild cases may be difficult to detect visually.
Must differentiate from volitional lack of forehead movement or neurological facial weakness.
Not specific; should be correlated with systemic signs of hyperthyroidism.
Patient counseling
Explain that the sign reflects thyroid-related eye changes, not a primary facial muscle disorder.
Discuss Graves’ disease management and potential need for endocrinology and ophthalmology referral.
Advise on eye care to prevent dryness, irritation, or corneal exposure.
Conclusion
Joffroy’s sign is a clinical marker of forehead immobility during upward gaze, associated with exophthalmos in Graves’ disease. Recognition of this sign aids in assessing ocular involvement, guiding further evaluation, and monitoring disease progression.
References
Bahn RS. Clinical Review: Graves’ Ophthalmopathy. N Engl J Med. 2010;362:726–738.
Wiersinga WM. Graves’ Ophthalmopathy: Pathophysiology, Natural History, and Treatment. Thyroid. 2012;22(6):615–625.
Ross DS, et al. Diagnosis and Management of Hyperthyroidism in Adults: A Clinical Review. JAMA. 2016;316(10):1047–1058.
Bahn RS, et al. Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines. Thyroid. 2011;21(6):593–646.