Lid Retraction
- Upper lid elevation so that the sclera becomes visible above the cornea (“upper scleral show”)
- Caused by shortening of upper lid tissues or increased sympathetic tone
- Common causes: Graves disease, abnormally alert state, anxiety, parkinsonism
- Uncommon causes: dorsal midbrain syndrome (“Collier sign”), orbital trauma (“cicatricial retraction”)
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Core clinical features
- Patient appears to be “staring”
- Lower border of the upper lid creases the sclera rather than a portion of the cornea
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Possible accompanying clinical features
- Patient reports that the eye feels exposed, dry, or irritated
- Upper lid lags behind the eye as the eye moves downward (“lid lag”), as in Graves disease
- Ocular and orbital soft tissue is swollen and hyperemic, as in Graves disease
- Upper lid fails to lower completely (“lagophthalmos”), as in upper lid scarring, proptosis
- Lid retraction disappears when the patient becomes calm, as in anxiety and hyperalert states
- Facial expression and blink rate are reduced, as in parkinsonism
- Impaired vertical gaze, vertical ocular misalignment, tectal light-near dissociation, or convergence retraction, as in dorsal midbrain syndrome
- Verify whether the lid retraction is unilateral or bilateral
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Look for these accompanying features to uncover the cause of lid retraction and rule out imitators
- Lid lag, as in Graves disease
- Irregular lid border contour or scar, as in lid trauma or mass
- Upgaze deficit, tectal light-near dissociation, convergence retraction, as in dorsal midbrain syndrome
- Bradykinesia, rigidity, tremor, as in parkinsonism
- Hyperalert or anxiety state
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Tip: the lid retraction of a hyperalert, anxiety, or parkinsonian state is often mistaken for the lid retraction of Graves disease
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Trap: the most common causes of pseudo lid retraction are contralateral ptosis and proptosis