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Marcus Gunn Jaw-winking Syndrome Clinical Presentation

  • Author: Barbara L Roque, MD, DPBO, FPAO; Chief Editor: Hampton Roy, Sr, MD  more...
Updated: Apr 06, 2016


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

  • Mild-to-moderate blepharoptosis, usually unilateral
  • Synkinetic upper eyelid movement with jaw-winking after one of the following:
    • Mouth opening
    • Jaw movement toward the contralateral side
    • Chewing
    • Sucking
    • Jaw protrusion
    • Clenching teeth together
    • Swallowing
  • Usually, parents first notice the phenomenon while the baby is bottle-feeding or breastfeeding.
  • Jaw-winking worse in downgaze
  • Decreased vision secondary to amblyopia
  • Strabismus (see the following)
    • Vertical deviation, usually a hypotropia on the involved side
    • Horizontal deviation (rare cases)

Past ocular history may include the following:

  • Occlusion or patching therapy for amblyopia
  • Strabismus surgery
  • Periorbital trauma (suggests an aberrant third nerve regeneration if accompanied by bizarre extraocular movements and diplopia)
  • Previous eyelid surgery
  • Dry eyes (important if contemplating ptosis repair)

Past medical history may include the following:

  • Details of birth history
  • Previous reactions to anesthesia
  • Previous diagnosis of a bleeding diathesis
  • Medication history to include anticoagulants or any nonsteroidal anti-inflammatory drugs (NSAIDs)


See the list below:

  • Complete ophthalmic examination
    • Pupillary examination
    • Visual acuity (rule out amblyopia in infants and children)
    • Cycloplegic refraction (rule out anisometropia)
  • External examination
    • Extraocular motility
    • Cover test (rule out a superior rectus or double elevator palsy)
    • Bell phenomenon (can be decreased with a superior rectus or double elevator palsy)
    • Head position
      • A child may elevate the chin to see.
      • If a child does not elevate the chin in the presence of moderate-to-severe ptosis, then consider amblyopia.
    • Ptosis evaluation
      • The degree of ptosis should be assessed with the jaw immobilized in a central position and after fusion is disrupted with brief ocular occlusion.[20]
      • Vertical palpebral fissure - Widest distance between the upper and lower eyelid
      • Marginal reflex distance (MRD) - Distance from the upper eyelid margin to corneal light reflex in primary position
      • Ptosis can be quantified - Mild (less than or equal to 2 mm), moderate (3 mm), or severe (greater than or equal to 4 mm)
      • Upper eyelid crease position - Distance from the crease to the eyelid margin
      • Levator function - Good (greater than or equal to 8 mm), fair (5-7 mm), or poor (less than or equal to 4 mm)
      • Measurement of eyelid position in downgaze
      • Presence of lid lag
    • Attempt to elicit synkinesis of eyelid movement.
      • Have the infant bottle-feed.
      • An older child can chew gum.
      • Have the patient open the mouth, move the jaw from side to side, or protrude the jaw forward.
      • Jaw-wink can be quantified - Mild (less than or equal to 2 mm), moderate (3-6 mm), or severe (greater than or equal to 7 mm)


See Pathophysiology.

Contributor Information and Disclosures

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

Barbara L Roque, MD, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Cataract and Refractive Surgery, Philippine Society of Cataract and Refractive Surgery, Philippine Academy of Ophthalmology, Philippine Society of Pediatric Ophthalmolo

Disclosure: Nothing to disclose.

Specialty Editor Board

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

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

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

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

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

Michael J Bartiss, OD, MD is a member of the following medical societies: American Academy of Ophthalmology, North Carolina Medical Society, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus

Disclosure: Nothing to disclose.

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

Sean M Blaydon, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, International College of Surgeons US Section, Pan-Pacific Surgical Association, Texas Medical Association

Disclosure: Nothing to disclose.

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