How to elicit the eye signs of thyroid disease an OSCE guide

Following are the important eye sign in thyroid disease.

1.Exophthalmos: Unilateral or bilateral.

Comment on the widened palpebral fissure, visibility of the sclera above and below the limbus.

2. Von Graefe's sign:

3. Stellwag's sign Observe for retraction of upper eyelid and Infrequent blinking.

4.Joffroy's sign

5.Moebles sign: Look for Inability to converge the eyes.

How to elicit Joffroy's sign an OSCE guide

In Joffroy's sign there is a lack of wrinkling of the forehead when a patient looks up with the head bent forwards

Joffroys sign is a sign of hyperthyroidism.It is elicited as follows

• Patient's face is inclined downwards.
• Patient attempts to look up.
• Look  for absence of wrinkles on the forehead.

How to elicit Von Graefe's sign:an OSCE guide

Von Graefes sign is an important eye sign in hyperthyroidism.It is elicited as follows

• The patient looks straight ahead.
• Ask the patient to look down.
• Look for a lag of the upper eyelid.

It is the lagging of the upper eyelid on downward rotation of the eye and indicate  underlying  Graves' Disease

The terms lid lag and von Graefe's sign have been used interchangeably in the past; but, they are distinct signs of downgaze-related upper eyelid static position and dynamic movement, respectively.

What are the clinical manifestations of thyrotoxicosis?

The clinical presentation of thyrotoxicosis  depends on the  

• Severity of thyrotoxicosis 
• The duration of disease
• Individual susceptibility to excess levels of  thyroid hormone 
• Age of patient

Common symptoms of thyrotoxicosis are the following

Weightloss inspite of increased appetite.

Heat intolerance and sweating

Hyperactivity, irritability, dysphoria 

Palpitations

Fatigue and weakness

Diarrhea

Polyuria 

Insomnia and impaired concentration

Oligomenorrhea, loss of libido

Signs of thyrotoxicosis

Tachycardia; atrial fibrillation is commonly seen in the elderly

The high cardiac output produces a  
Bounding pulse

Widened pulse pressure 

Aortic systolic murmur 

Warm, moist skin 

Fine tremor of hands

Goiter- diffusely enlarged thyroid,firm,bruit may be heard over the thyroid

Muscle weakness, proximal myopathy 

Hyperreflexia 

Gynecomastia 

Lid retraction or lidlag due to sympathetic overactivity 

Ophthalmopathy and dermopathy are specific for Graves' disease

Thyroid dermopathy

Seen in <5% of patients with Graves' disease, usually associated with moderate or severe ophthalmopathy.

It is most frequent over the anterior and lateral aspects of the lower leg so called as pretibial myxedema), but the  skin changes can occur at other sites,  particularly after trauma. 

The typical lesion of thyroid dermopathy is a noninflammed, indurated plaque which is deep pink or purple in  color and an orange skin appearance. 

Nodular involvement of skin can occur, and the condition may rarely extend over the whole lower leg and foot, thus  mimicking elephantiasis

Thyroid acropachy 

This is a form of clubbing found in <1% of Graves' disease. It is strongly associated with thyroid dermopathy.

Thyroid ophthalmopathy