Dalrymple sign

Dalrymple sign: Widened palpebral tissue (lid retraction) or lid spasm seen in thyrotoxicosis (Graves-Basedow disease), causing abnormal wideness of the palpebral fissure.

As a result of the retraction of the upper eyelid, the white of the sclera is visible at the upper margin of the cornea in direct outward stare. A sign of thyroid-related orbitopathy (TRO) particularly in hyperthyroidism and exophthalmic goitre.

Normally the margin of the upper eyelid rests just below the edge of the corneal limbus and covers about 1 mm of the iris

History

1849 – WW Cooper published ‘On protrusion of the eyes in connexion with anemia, palpitation, and goitre‘ [1849;1(7):658-677] mentioning Dalrymple’s extensive experience and pathophysiologic explanation for this ophthalmologic sign. Cooper does not specifically use the eponym, suggesting it manifested later, probably posthumously. Cooper provides Dalrymple’s explanation:

An absence of the proper tonicity of the muscles by which the eyes are retained in their natural positions in the orbit; and some amount of venous congestion of the tissues forming the cushion behind the globes. Dalrymple relates a case of a gentleman whose eyes were so protruded that they were nearly denuded of the protection of the upper lid by a constant and powerful spasm of the levator palpebrae *superioris, which drew the lids, so far upwards and backwards, that much of the sclera above the cornea was visible.

1852 – The eponym ‘Dalrymple sign‘ is likely to have originated after the publication of his book, ‘The Pathology of the Human Eye‘ in 1852. No separate accounts or case reports were published by Dalrymple on this topic.

1884 – Fleming explains: ‘…naturally Dalrymple explains the retraction of the upper lid as due to spasm of the levator palpebrae, as Muller’s muscle had not at that time been discovered .”

Associated Persons

• Robert James Graves (1796–1853) [Graves-Basedow disease]
• John Dalrymple (1803–1852)
• Karl Stellwag von Carion (1823–1904) [Stellwag sign]
• Albrecht von Graefe (1828-1870) [Graefe sign]
• Paul Julius Möbius (1853-1907) [Möbius sign]
• Alix Joffroy (1844-1908) – [Joffroy sign]

Alternative names

• Lid retraction sign

Controversies

• Dalrymple sign is often confused with Stellwag sign

References

• Cooper WW. On protrusion of the eyes in connexion with anemia, palpitation, and goitre. London Journal of Medicine. 1849;1(7):658-677
• Cooper WW. On protrusion of the eyes in connexion with anemia, palpitation, and goitre. Lancet. 1849;53(1343):551-554
• Dalrymple J. The pathology of the human eye. London: John Churchill. 1852
• Gladstone GJ. Ophthalmologic aspects of thyroid-related orbitopathy. Endocrinol Metab Clin North Am. 1998 Mar;27(1):91-100. [PMID 9534030]
• McGee S. Evidence-Based Physical Diagnosis. Elsevier. 2017
• Cadogan M. Eponymythology: Diffuse Toxic Goitre.
• Cadogan M. Eponymythology: Graves Orbitopathy.