Marcus Gunn Jaw-winking Syndrome



In 1883, Marcus Gunn described a 15-year-old girl with a peculiar type of congenital ptosis that included an associated winking motion of the affected eyelid on the movement of the jaw.[1] This synkinetic jaw-winking phenomenon now bears his name. See the image below.

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Congenital left upper eyelid ptosis.

Patients with Marcus Gunn jaw-winking syndrome have variable degrees of blepharoptosis in the resting, primary position. Although Marcus Gunn jaw-winking syndrome is usually unilateral, it can present bilaterally in rare cases.[2, 3]

The wink reflex consists of a momentary upper eyelid retraction or elevation to an equal or higher level than the normal fellow eyelid upon stimulation of the ipsilateral pterygoid muscle. This response is followed by a rapid return to a lower position. The amplitude of the wink tends to be worse in downgaze. This rapid, abnormal motion of the eyelid can be the most disturbing aspect of the jaw-winking syndrome.

The wink phenomenon may be elicited by opening the mouth, thrusting the jaw to the contralateral side, jaw protrusion, chewing, smiling, or sucking.[4, 5, 6, 7] This wink phenomenon is often discovered early, as the infant is bottle-feeding or breastfeeding. See the image below.

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Marcus Gunn jaw-winking with left upper eyelid retraction on opening of the mouth.

Jaw-winking ptosis is almost always sporadic, but familial cases with an irregular autosomal dominant inheritance pattern have been reported.[8]


Marcus Gunn jaw-winking is thought to be a form of synkinetic ptosis. An aberrant connection appears to exist between the motor branches of the trigeminal nerve (CN V3) innervating the external pterygoid muscle and the fibers of the superior division of the oculomotor nerve (CN III) that innervate the levator superioris muscle of the upper eyelid.[9, 10, 11, 12]

Electromyographic studies demonstrate this synkinetic innervation by showing simultaneous contraction of the external pterygoid and levator muscle. In rare cases, synkinesis may be present between the internal pterygoid and levator muscles. In these cases, the eyelid elevates on closing the mouth and clenching the teeth.[13]

A few authors have speculated that the jaw-winking is not due to a new aberrant pathway, but rather the disinhibition of preexisting phylogenetically more primitive mechanisms.[14] This is thought to explain why individuals who are not affected will often open their mouths while attempting to widely open their eyes to place eye drops or to apply makeup.

Since jaw-winking ptosis is believed by most to be due to abnormal innervation of the levator muscle and not secondary to myopathic changes, it is not surprising that most histopathologic studies have revealed normal striated muscle.

One study found variable degrees of fibrosis within the affected levator muscle and to a lesser degree in the muscle of the normal, nonptotic eyelid.[15, 16]



United States

Approximately 50% of blepharoptosis cases are congenital. Incidence of Marcus Gunn jaw-winking syndrome among this population is approximately 5%.[4]


Marcus Gunn jaw-winking syndrome is associated with strabismus in 50-60% of cases.[4] Superior rectus palsy is found in 25% of cases, and double elevator palsy is found in another 25% of cases.[4] In double elevator palsy, a deficiency in elevation of the globe occurs in all positions of gaze, secondary to an apparent weakness of the superior rectus and inferior oblique muscles. On rare occasions, horizontal strabismus in the absence of a vertical motility disturbance may occur.

Incidence of anisometropia among patients with Marcus Gunn jaw-winking syndrome is reported to be 5-25%.[4] Anisometropia exists when a refractive difference between the 2 eyes of 1.25 diopters of sphere or 1 diopter of cylinder is present.

Amblyopia occurs in 30-60% of patients with Marcus Gunn jaw-winking syndrome and is almost always secondary to strabismus or anisometropia, and, only rarely, is due to occlusion by a ptotic eyelid.[4] Amblyopia usually is defined as a decrease in vision of 2 or more lines on the Snellen chart.


No known racial predilection exists.


Early reports showed jaw-winking ptosis to be more prevalent in females than in males; however, larger case series have shown an equal prevalence among males and females.[4, 17]


Marcus Gunn jaw-winking syndrome is usually evident at birth. The winking phenomenon is often first noted by the parents when the infant is feeding.

It has been suggested, and older patients often claim, that the jaw-winking improves over time; however, it has not proven to be true on objective evaluation. More likely, patients stop seeking care as they get older, or they learn to compensate for and mask the wink response.[4, 9, 17, 18]

Likewise, the degree of ptosis may be underestimated with the patient able to adjust the height with varying jaw positions. This is referred to by some as "habitual" ptosis.[19]


Signs and symptoms of Marcus Gunn jaw-winking syndrome may include the following:

Past ocular history may include the following:

Past medical history may include the following:


See the list below:


See Pathophysiology.

Laboratory Studies

Creatine phosphokinase level: If a past medical or family history of any reactions to anesthesia exists, rule out the possibility of malignant hyperthermia prior to any surgery.

Other Tests

Basic tear secretion test: Normal measurement is more than 5-10 mm of Schirmer filter paper wetting after 5 minutes following application of topical anesthetic, such as proparacaine.

Histologic Findings

Light microscopy of surgical specimens usually reveals normal striated muscle. Fibrosis within the muscle has been reported.[15]

Medical Care

If amblyopia is encountered, treat aggressively with occlusion therapy and/or correction of anisometropia prior to any consideration of ptosis surgery.

Surgical Care

As with any patient who requires eyelid surgery, first address associated strabismus.

Superior rectus palsy

Superior rectus palsy can be corrected by resecting the superior rectus muscle but only in the absence of inferior rectus restriction.

Since the superior rectus is loosely bound to the overlying levator, the upper eyelid will be pulled inferiorly during resection, exacerbating any ptosis already present. This can be addressed during the subsequent ptosis repair.[21]

Double elevator palsy

Double elevator palsy manifests as a deficit in the elevation of the globe in all fields of gaze.

It may be the result of superior rectus and inferior oblique palsy and/or inferior rectus restriction.

Inferior rectus restriction may be suggested by the following:

Inferior rectus restriction is treated by recession of the inferior rectus muscle.

A combined superior rectus and inferior oblique (double elevator) palsy requires a transposition procedure to displace the medial and lateral recti muscles superiorly (Knapp procedure).

Other considerations

Consider eyelid surgery only when the parents (or the patient) and the surgeon agree about whether the most cosmetically objectionable condition is the ptosis or the jaw-winking or whether it is a combination of both.

Many techniques are described for the correction of jaw-winking ptosis, reflecting the ongoing controversy regarding the surgical management of this condition.

If the jaw-winking is cosmetically insignificant, it can be ignored in the treatment of the ptosis, as follows:

Although the amount of ptosis and synkinetic eyelid movement is variable, those patients with more severe ptosis tend to have the worse aberrant upper eyelid movement.

The jaw-wink is considered cosmetically significant if it is 2 mm or more.

Any attempt to repair the ptosis without addressing the jaw-winking would result in an exaggeration of the aberrant eyelid movement to a level well above the superior corneal limbus, which would be unacceptable to the patient.

If the jaw-wink is significant, ablation of the levator and resuspension of the eyelid to the brow are necessary. Several techniques have been suggested to obliterate levator function, which effectively dampens the aberrant eyelid movement, as follows:

Beard and others have advocated bilateral excision of the levator muscle and bilateral frontalis suspension.[9] While this approach almost completely eliminates the wink and arguably results in better symmetry, it is often difficult to persuade the parents and the patient to perform surgery on and effectively damage the normal contralateral levator muscle.

Satisfactory and predictable results also can be obtained after only unilateral levator excision on the affected side, combined with bilateral frontalis suspension. This leaves the normal functioning levator muscle to elevate the nonptotic eyelid in primary position but produces a lag in downgaze for improved symmetry.

Kersten et al advocate unilateral levator muscle excision and frontalis sling only on the affected side.[27] If the postoperative result is judged to be unsatisfactory, the parents or the patient can opt for further surgery to the contralateral side. Any amblyopia and strabismus should first be addressed, as there may be insufficient drive to lift the disinserted eyelid.

Islam et al described a technique of dissecting a frontalis flap hinged superiorly through a suprabrow incision that is then brought down into an eyelid crease incision.[28] The frontalis flap is used to suspend the ptotic eyelid after extirpation of the levator muscle.

Lemagne and Neuhaus described techniques that involve transection of the involved levator followed by transposition of the distal segment to the brow, which effectively suspends the eyelid to the frontalis muscle.[29, 30] Their techniques maintain normal eyelid contour, as the levator aponeurotic attachments are left undisturbed.


Consult an oculoplastic surgeon or a strabismologist if the referring physician is uncomfortable with these procedures.

Forewarn the anesthesiologist that patients with Marcus Gunn jaw-winking ptosis are at a greater risk of developing arrhythmias during eyelid surgery.

Further Outpatient Care

While the patient is awake, apply cold compresses to the eyelids for 20 minutes every 1-2 hours for 2-3 days to decrease swelling and bruising.

See the patient postoperatively in 5-7 days for suture removal.

Schedule regular follow-up appointments with a general or pediatric ophthalmologist for any child with preexisting amblyopia.

Further Inpatient Care

Marcus Gunn jaw-winking ptosis usually is treated on an outpatient basis.

Inpatient & Outpatient Medications

Antibiotic ophthalmic ointment, such as erythromycin, is prescribed postoperatively, and it should be applied 2-4 times a day along sutures and in the eye for 1 week.


Complications of surgery to repair jaw-winking ptosis include the following:


Satisfactory results are usually achieved by a medical and surgical approach to managing Marcus Gunn jaw-winking ptosis.

Patient Education

Discuss the following with the patient or the parents:


Barbara L Roque, MD, DPBO, FPAO, Senior Partner, Roque Eye Clinic; Chief of Service, Pediatric Ophthalmology and Strabismus Section, Department of Ophthalmology, Asian Hospital and Medical Center; Active Consultant Staff, International Eye Institute, St Luke's Medical Center Global City

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Michael J Bartiss, OD, MD, Medical Director, Ophthalmology, Family Eye Care of the Carolinas and Surgery Center of Pinehurst

Disclosure: Nothing to disclose.

Sean M Blaydon, MD, FACS, Fellowship Program Director, Texas Oculoplastic Consultants

Disclosure: Nothing to disclose.


  1. Gunn RM. Congenital ptosis with peculiar associated movements of the affected lid. Trans Ophthal Soc UK. 1883. 3:283-7.
  2. Sobel RK, Allen RC. Incidence of bilateral Marcus Gunn jaw-wink. Ophthal Plast Reconstr Surg. 2014 May-Jun. 30 (3):e54-5. [View Abstract]
  3. Kannaditharayil D, Geyer H, Hasson H, Herskovitz S. Bilateral Marcus Gunn jaw-winking syndrome. Neurology. 2015 Mar 10. 84 (10):1061. [View Abstract]
  4. Pratt SG, Beyer CK, Johnson CC. The Marcus Gunn phenomenon. A review of 71 cases. Ophthalmology. 1984 Jan. 91(1):27-30. [View Abstract]
  5. Bradley WG, Toone KB. Synkinetic movements of the eyelid: a case with some unusual mechanisms of paradoxical lid retraction. J Neurol Neurosurg Psychiatry. 1967 Dec. 30(6):578-9. [View Abstract]
  6. Kirkham TH. Paradoxical elevation of eyelid on smiling. Am J Ophthalmol. 1971 Jul 30. 72(1):207-8. [View Abstract]
  7. Parry R. An unusual case of the Marcus Gunn syndrome. Trans Opthal Soc U K. 1957. 77:181-5. [View Abstract]
  8. Kirkham TH. Familial Marcus Gunn phenomenon. Br J Ophthalmol. 1969 Apr. 53(4):282-3. [View Abstract]
  9. Beard C. Ptosis. 3rd ed. St. Louis: CV Mosby; 1981. 46-9.
  10. Duke Elder S. Normal and abnormal development; congenital deformities. System of Ophthalmology. St. Louis: CV Mosby; 1963. Vol 3, pt 2: 900-5.
  11. Pandey M, Baduni N, Jain A, Sanwal MK, Vajifdar H. Abnormal oculocardiac reflex in two patients with Marcus Gunn syndrome. J Anaesthesiol Clin Pharmacol. 2011 Jul. 27(3):398-9. [View Abstract]
  12. Conte A, Brancati F, Garaci F, Toschi N, Bologna M, Fabbrini G, et al. Kinematic and diffusion tensor imaging definition of familial Marcus Gunn jaw-winking synkinesis. PLoS One. 2012. 7(12):e51749. [View Abstract]
  13. Hepler RS, Hoyt WF, Loeffler JD. Paradoxical synkinetic levator inhibition and excitation. An electromyographic study of unilateral oculopalpebral and bilateral mandibulopalpebral (Marcus Gunn) synkineses in a 74-year-old man. Arch Neurol. 1968 Apr. 18(4):416-24. [View Abstract]
  14. Wartenberg R. Winking-jaw phenomenon. Arch Neurol Psychiatry. 1948 Jun. 59(6):734-53. [View Abstract]
  15. Lyness RW, Collin JR, Alexander RA, et al. Histological appearances of the levator palpebrae superioris muscle in the Marcus Gunn phenomenon. Br J Ophthalmol. 1988 Feb. 72(2):104-9. [View Abstract]
  16. Kaçar Bayram A, Per H, Quon J, Canpolat M, Ülgen E, Doğan H, et al. A rare case of congenital fibrosis of extraocular muscle type 1A due to KIF21A mutation with Marcus Gunn jaw-winking phenomenon. Eur J Paediatr Neurol. 2015 Nov. 19 (6):743-6. [View Abstract]
  17. Khwarg SI, Tarbet KJ, Dortzbach RK, et al. Management of moderate-to-severe Marcus-Gunn jaw-winking ptosis. Ophthalmology. 1999 Jun. 106(6):1191-6. [View Abstract]
  18. Doucet TW, Crawford JS. The quantification, natural course, and surgical results in 57 eyes with Marcus Gunn (jaw-winking) syndrome. Am J Ophthalmol. 1981 Nov. 92(5):702-7. [View Abstract]
  19. Bowyer JD, Sullivan TJ. Management of Marcus Gunn jaw winking synkinesis. Ophthal Plast Reconstr Surg. 2004 Mar. 20(2):92-8. [View Abstract]
  20. Wong JF, Theriault JF, Bouzouaya C, et al. Marcus Gunn jaw-winking phenomenon: a new supplemental test in the preoperative evaluation. Ophthal Plast Reconstr Surg. 2001 Nov. 17(6):412-8. [View Abstract]
  21. Bajaj MS, Angmo D, Pushker N, Hada M. Modified technique of levator plication for the correction of Marcus Gunn jaw-winking ptosis: a case series. Int Ophthalmol. 2015 Aug. 35 (4):587-91. [View Abstract]
  22. Putterman AM. Jaw-winking blepharoptosis treated by the Fasanella-Servat procedure. Am J Ophthalmol. 1973 Jun. 75(6):1016-22. [View Abstract]
  23. Bullock JD. Marcus-Gunn jaw-winking ptosis: classification and surgical management. J Pediatr Ophthalmol Strabismus. Nov-Dec 1980. 17(6):375-9. [View Abstract]
  24. Epstein GA, Putterman AM. Super-maximum levator resection for severe unilateral congenital blepharoptosis. Ophthalmic Surg. 1984 Dec. 15(12):971-9. [View Abstract]
  25. Dillman DB, Anderson RL. Levator myectomy in synkinetic ptosis. Arch Ophthalmol. 1984 Mar. 102(3):422-3. [View Abstract]
  26. Dryden RM, Fleming JC, Quickert MH. Levator transposition and frontalis sling procedure in severe unilateral ptosis and the paradoxically innervated levator. Arch Ophthalmol. 1982 Mar. 100(3):462-4. [View Abstract]
  27. Kersten RC, Bernardini FP, Khouri L, et al. Unilateral frontalis sling for the surgical correction of unilateral poor-function ptosis. Ophthal Plast Reconstr Surg. 2005 Nov. 21(6):412-6; discussion 416-7. [View Abstract]
  28. Islam ZU, Rehman HU, Khan MD. Frontalis muscle flap advancement for jaw-winking ptosis. Ophthal Plast Reconstr Surg. 2002 Sep. 18(5):365-9. [View Abstract]
  29. Lemagne JM. Transposition of the levator muscle and its reinnervation. Eye. 1988. 2 (Pt 2):189-92. [View Abstract]
  30. Neuhaus RW. Eyelid suspension with a transposed levator palpebrae superioris muscle. Am J Ophthalmol. 1985 Aug 15. 100(2):308-11. [View Abstract]
  31. Tian N, Zheng YX, Zhou SY, Liu JL, Huang DP, Zhao HY. Clinical characteristics of moderate and severe Marcus-Gunn jaw-winking synkinesis and its surgical treatment. Zhonghua Yan Ke Za Zhi. 2007 Dec. 43(12):1069-72. [View Abstract]
  32. Gupta M, Gupta OP, Vohra V. Bilateral familial vertical Duane Syndrome with synergistic convergence, aberrant trigeminal innervation, and facial hypoplasia. Oman J Ophthalmol. 2014 Sep. 7 (3):135-7. [View Abstract]
  33. Sundareswaran S, Nipun CA, Kumar V. Jaw - winking phenomenon: Report of a case with review of literature. Indian J Dent Res. 2015 May-Jun. 26 (3):320-3. [View Abstract]

Congenital left upper eyelid ptosis.

Marcus Gunn jaw-winking with left upper eyelid retraction on opening of the mouth.

Congenital left upper eyelid ptosis.

Marcus Gunn jaw-winking with left upper eyelid retraction on opening of the mouth.