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Lid Lag and Stare

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Title: Lid Lag and Stare

Author (s): Zachary Mortensen, MS4, MBA

Photographer: James Gilman

Date: August 24, 2018

Keywords/Main Subjects: lid lag, stare, Von Graefe’s, graves’ ophthalmopathy, thyroid eye disease, graves’ orbitopathy, lagophthalmos

Diagnosis: Thyroid eye disease (hyperthyroidism, Graves’ orbitopathy, graves’ ophthalmopathy)


Lid lag, Von Graefe’s sign, stare, and lagophthalmos can be useful eyelid findings when evaluating a patient with thyroid eye disease. While they characteristically occur in patients with Graves’ disease, it is important to note that these signs are not pathognomonic for thyroid eye disease.1 Lid lag can be less commonly caused by congenital blepharoptosis from a fibrotic levator muscle, and lagophthalmos can occur from a lesion to the facial nerve or iatrogenically from an overaggressive upper blepharoplasty.2,3

Graves’ orbitopathy or thyroid eye disease is an autoimmune disorder that occurs in about 1/4th of patients with a hyperactive thyroid in Graves’ disease.4 However, thyroid eye disease can sometimes occur in patients with hypothyroidism (e.g., Hashimoto’s).5 In Graves’ disease, the thyroid-stimulating hormone receptor antibodies activate fibroblasts in the tissues behind and around the eye or globe. This results in inflammation, swelling, and volume expansion of the retroorbital tissues. This tissue presses on the back of the eye causing it to be pushed out. This bulging of the eye anteriorly is known as “proptosis” or “exophthalmos”. Lid lag and stare, however, are believed to be caused by excess thyroid hormone and not necessarily from the proptosis.6 The elevated thyroid hormone levels are believed to increase the contraction of the eyelid muscles, which is likely why treatment of the hormone levels can relieve the symptoms of lid lag and stare.6

The active phase is marked by eye redness, pain, and swelling. These symptoms can increase and decreases in intensity during this phase. Smoking cessation is important in management as the phase typically lasts 1 year for non-smokers and 2-3 years for smokers.5

Lid Lag

Lid lag is a static condition in which the upper eyelid is higher than normal while the eye is in downgaze.7 Lid lag can be measured by comparing the upper eyelid position in downgaze to its position in primary gaze relative to a fixed point like the pupil.1 Lid lag happens when there is increased contraction of the levator palpebrae muscles of the eyelids.6 Lid lag subsides when the hyperthyroidism is treated.6

A term often confused with lid lag is von Graefe’s sign. Von Graefe’s sign is dynamic rather than static.7 It is observed when the eye actively moves inferiorly from primary gaze and the upper eyelid follows at a slower-than-normal rate. The superior part of the iris (superior limbus) is often exposed during this slowed movement.1 Once the downgaze is fixed, and if the eyelid remains elevated, it may then be called “lid lag”.

Figure 1: A 57-year-old man with Graves’ thyroid eye disease. He has scleral injection and asymmetry in proptosis and lid positions. His lid lag is most apparent on downgaze as the lids do not entirely cover the superior limbus, iris, or pupil. Note the hyper-retracted upper eyelids.


Stare is the term used to describe the appearance of a patient with excessive eyelid retraction.6 The increased tightness of the levator palpebrae that causes lid lag can also give the patient this “staring” appearance. It is important not to confuse this with proptosis (bulging of the eye out of the socket) as they are two distinct conditions and can occur one without the other.6 Stare, like lid lag, subsides when the hyperthyroidism is treated.6

Figure 2: A 57-year-old man with Graves’ thyroid eye disease in relaxed primary gaze demonstrating stare. While the left eye appears more proptotic (bulging), both eyes have increased lid tightness. Normal eyelids would appear more relaxed.

Figure 3: A 68-year-old woman with bilateral Graves’ orbitopathy, status post thyroidectomy, taking levothyroxine, with residual mild diplopia and mild proptosis. Note that her upper eyelids are so tightly retracted that they are hardly visible, giving her the classic stare.


Lagophthalmos is the inability to completely close the eyelids.1 Excessive upper lid retraction in thyroid eye disease can result in lagophthalmos and corneal exposure even while the patient attempts to close their eyes.

Figure 4: A 57-year-old man with Graves’ thyroid eye disease has upper lid retraction with mild lagophthalmos of the left side and some corneal exposure


  1. Gaddipati, R. V., & Meyer, D. R. (2008). Eyelid Retraction, Lid Lag, Lagophthalmos, and von Graefe’s Sign: Quantifying the Eyelid Features of Graves’ Ophthalmopathy. Ophthalmology115(6), 1083-1088.
  2. Salman, M. S., & Clark, I. H. (2017). Eyelid Retraction in Isolated Unilateral Congenital Blepharoptosis. Frontiers in neurology8, 190.
  3. Shorr, N., Goldberg, R. A., McCann, J. D., Hoenig, J. A., & Li, T. G. (2003). Upper eyelid skin grafting: an effective treatment for lagophthalmos following blepharoplasty. Plastic and reconstructive surgery112(5), 1444-1448.
  4. Tanda, M. L., Piantanida, E., Liparulo, L., Veronesi, G., Lai, A., Sassi, L., … & Bartalena, L. (2013). Prevalence and natural history of Graves’ orbitopathy in a large series of patients with newly diagnosed Graves’ hyperthyroidism seen at a single center. The Journal of Clinical Endocrinology & Metabolism98(4), 1443-1449.
  5. Liaboe CA, Clark TJ, Shriver EM, Carter KD. Thyroid Eye Disease: An Introductory Tutorial and Overview of Disease. org. posted November 18, 2016; Retrieved August 23, 2018, from:
  6. Davies, T.F., Burch, H. B., Ross, D. S. (2018). Clinical features and diagnosis of Graves’ orbitopathy (ophthalmopathy). In J Mudler (Ed.), UpToDate. Retrieved August 23, 2018, from
  7. Harvey, J. T., & Anderson, R. L. (1981). Lid lag and lagophthalmos: a clarification of terminology. Ophthalmic Surgery, Lasers and Imaging Retina12(5), 338-340.

Copyright Zachary Mortensen, ©2016. For further information regarding the rights to this collection, please visit: URL to copyright information page on Moran CORE

Disclosure (Financial or other): none

Identifier: Moran_CORE_25597