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Most patients initially notice a change in appearance. This includes redness in the eyes or lids, and swelling or feeling of fullness in one or both upper eyelids, and/or bags under the eyes [1]. The single most common presenting sign is eyelid swelling, followed by eyelid lagging behind eyeball movement on downgaze (von Graefe sign) [2].

During early Graves’ orbitopathy (GO), 40% of patients also develop symptoms that relate to ocular surface irritation comprising a gritty sensation, light sensitivity (photophobia), and excess tearing [3–5].