History

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)

Physical

The physical examination should include the following:

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.^[21]
  - 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)

Causes

See Pathophysiology.

Differential Diagnoses

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