Double motion of upper eyelids in Graves’ orbitopathy: an additional sign for detection of thyroid dysfunction or positive thyroid autoantibodies

Hirohiko Kakizaki¹, Yasuhiro Takahashi¹, Masayoshi Iwaki¹, Akihiro Ichinose², Dinesh Selva³, Igal Leibovitch^4
1Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi, Japan; ²Department of Plastic Surgery, Kobe University, Chuo, Kobe, Hyogo, Japan; ³South Australian Institute of Ophthalmology and Discipline of Ophthalmology and Visual Sciences, University of Adelaide, South Australia, Australia; ⁴Division of Oculoplastic and Orbital Surgery, Department of Ophthalmology, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel

Purpose: To assess the effectiveness of the upper eyelid double motion sign in Graves’ orbitopathy (GO) in detecting thyroid dysfunction or a positive level of thyroid-related autoantibodies.
Methods: GO was defined when more than two GO-related eyelid symptoms, including the double motion sign, existed with at least one positive thyroid-related blood test. Blood tests were performed in patients with more than two GO-related eyelid symptoms. The double motion was defined when the upper eyelid stopped at least once during downward eye movement. Fifty patients without GO or other eyelid diseases were used as controls.
Results: There were 353 patients who showed more than two GO-related eyelid symptoms including the upper eyelid double motion sign. Of these, 300 patients were diagnosed with GO (300/353, 85.0%). The double motion sign was demonstrated in 267 patients (75.6%). A pause in double motion was typically seen around the anterosuperior direction of gaze. Double motion was not seen in any of the control eyelids. Although only 7.0% were hyperthyroid and 8.6% were hypothyroid, thyroid related autoantibodies were shown in 73.9% of patients. When the double motion sign was removed from the diagnostic criteria of GO, 263 patients had more than two thyroid-related eyelid symptoms, including 223 patients diagnosed as GO (25.7% reduction), although the rate of a correct diagnosis was almost the same (84.8%).
Conclusions: The double motion sign of the upper eyelids is frequently demonstrated in GO patients. This previously unreported sign can help in detecting thyroid dysfunction states with positive levels of autoantibodies.

Keywords: GO, self-antibody