Riesman's sign or Snellen-Riesman's sign is a clinical sign characterized by bruit heard over the closed eye with a stethoscope in Graves' ophthalmopathy (thyroid eye disease or Graves' orbitopathy or thyroid-associated orbitopathy) in thyrotoxicosis. The bruit is audible during systole.
The name comes from Dr. Herman Snellen and Dr. David Riesman. Dr. Herman Snellen (1834 - 1908) was a famous ophthalmologist from the Netherlands known for Snellen's chart for estimating the visual acuity. Dr. Ravid Riesman (1867-1940) was born in Germany. He completed his MD from the University of Pennsylvania, USA. He was a professor of clinical medicine and then a professor of history of medicine.
Method of Auscultation
The examination is preferably performed in a quiet room. Both the patient and the examiner should be comfortable and relaxed. The patient is in the sitting position. Ideally, the cone-shaped long and narrow bell of Ford-Bowles stethoscope should be used to listen to the faint sound of ocular bruit. However, the bell of the modern stethoscope is also usable. The patient should fix the gaze of their open eye of the patient on a distant object or one of the examiner's fingers. The bell of the stethoscope should be kept over the closed eye gently and firmly. The patient should not move the eyeball or eyelids during auscultation. The patient is requested to hold breath during auscultation. The contralateral carotid pulse is used to know the timing of the bruit. Valsalva maneuver may be used to accentuate the bruit.
Graves disease characteristically presents with a triad of exophthalmos or eye disease, pretibial myxedema, and hyperthyroidism. Cardiovascular features of hyperthyroidism include tachycardia, tachyarrhythmias including atrial fibrillation, increased cardiac contractility, increased preload, decreased systemic vascular resistance, peripheral edema, cardiac failure, myocardial ischemia, thyrotoxic cardiomyopathy, and a widened gap between the systolic and diastolic blood pressure.
The Snellen-Riesman's sign is due to the hyperdynamic circulation and increased cardiac output in thyroid eye disease and hyperthyroidism.
A bruit is defined as 'an audible vascular sound associated with turbulent blood flow. Although usually heard with the stethoscope, such sounds may occasionally also be palpated as a thrill'. The orbit provides a good 'window' for transmission of intracranial sounds, and there is very minimal bony dissipation. The orbital bruits result from turbulence in the intracranial or extracranial vessels. The orbit is the preferred location for auscultation of faint cranial bruit. Basic causes of orbital bruits can include:
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