Marcus Gunn jaw winking phenomenon is a congenital synkinetic movement due to synkinesis between the upper eyelid and the pterygoids and it accounts for 8% of patients with congenital ptosis. In rare instances, ptosis may be absent. We present a case of Marcus Gunn Jaw Winking phenomenon without ptosis at presentatio

Bhat, KG

Karanth, A

English

Kamalakshi G. Bhat

Anupama Karanth

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Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye

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Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 8, Issue 1; Jan-Mar 2009
Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye 
Authors
Kamalakshi G. Bhat,
Associate Professor, Department of Pediatrics
Anupama Karanth,
Associate Professor, Department of Ophthalmology
Kasturba Medical College, Mangalore.
Address For Correspondence
Dr. Kamalakshi G. Bhat,
Associate Professor of Paediatrics,
Kasturba Medical College Hospital,
Attavar, Mangalore – 575 001
INDIA.
E-mail: bhat_kamalakshi@yahoo.co.in
Citation
Bhat KG, Karanth A. Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye. 
Online J Health Allied Scs. 2009;8(1):10
URL
http://www.ojhas.org/issue29/2009-1-10.htm
http://ojhas.org 1
OJHAS Vol 8 Issue  1(10)   Bhat KG, Karanth A. Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye
 Case Report 
Abstract:
Marcus Gunn jaw winking phenomenon is a congenital synkinetic movement due to synkinesis between 
the upper eyelid and the pterygoids and it accounts for 8% of patients with congenital ptosis. In rare 
instances, ptosis may be absent. We present a case of Marcus Gunn Jaw Winking phenomenon without 
ptosis at presentation
Key Words: Congenital ptosis, Jaw winking phenomenon
Submitted: Mar 6, 2009; Accepted Apr 25, 2009; Published: May 5, 2009
Introduction:
Synkinesis is a simultaneous movement or a co-
ordinated  sequence  of  movement  of  muscles 
supplied  by  different  nerves  or  by  peripheral 
branches of the same nerve. Marcus Gunn jaw 
winking phenomenon is a congenital synkinetic 
movement  first  reported  by  Marcus  Gunn  in 
18831. Although this synkinesis between the up-
per eyelid and the pterygoids is well  known, it 
accounts for only 8% of patients with congenital 
ptosis  in  the  paediatric  practice2.  In  rare  in-
stances, ptosis itself may be absent complicating 
the diagnosis.
Case Report:
A 6 month old male infant was brought by his 
mother with complaints of widening of one eye 
at different times of the day. There were no oth-
er ocular or systemic complaints. The child was 
born full-term by vaginal delivery. The neonatal 
period was uneventful. His growth and develop-
ment were appropriate for age. Systemic exam-
ination was normal. The ophthalmologist conduc-
ted a detailed examination of the eyes. Fixation, 
gaze  and  following  movements  were  normal. 
Palpebral fissures appeared equal in both eyes. 
There was no evidence of proptosis. However, on 
the  mother's  insistence,  patient  was  re-ex-
amined a week later and at this time widening of 
left palpebral fissure was noted. An ophthalmolo-
gic  evaluation revealed  elevation  of  left  eyelid 
associated with movements of the mouth, espe-
cially chewing and sucking (Fig. 1). There was no 
evidence of ptosis at this stage. Visual develop-
ment was appropriate for age.  Rest of the ocu-
lar  examination was considered normal.  A dia-
gnosis of Marcus Gunn jaw winking phenomenon 
was made in view of the synkinetic nature of the 
abnormality, in spite of the absence of ptosis.
Figure 1: Upshoot of left upper eyelid on lateral movement of mouth. Note the absence of 
ptosis
Figure 2: Mild ptosis apparent in the left eye at one year
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OJHAS Vol 8 Issue  1(10)   Bhat KG, Karanth A. Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye
Patient was again examined at one year of age. 
He was noted to have ptosis of mild degree at 
this time (Fig. 2). Gaze, extra ocular movements 
and  fixation  were  normal.  Retinoscopy  was 
found  to  be  within  the  normal  range  in  both 
eyes. The mother felt  that the elevation of the 
eyelid  was much less  and present only during 
yawning. Various movements of the mouth were 
unable  to  induce  eyelid  elevation  at  this 
examination.
Discussion
Marcus Gunn jaw winking phenomenon is a well 
recognised synkinesis in congenital ptosis. When 
the mouth is opened or jaw is moved laterally, 
the  ptotic  eyelid  elevates.  This  results  from a 
congenital aberrant connection between the tri-
geminal nerve controlling mastication and oculo-
motor nerve supplying the levator palpebrae su-
perioris. These movements are not volitional and 
are termed as  associated reflexes  of  misdirec-
tion. The exact mechanism of these movements 
is not understood. It is thought that an abnormal 
connection exists in the central nervous system 
between the nerve supply of the two muscles1. 
In the fully developed form of Marcus Gunn phe-
nomenon, the upper eyelid covers varying por-
tions of upper cornea at rest, but when the jaw is 
opened, or moved laterally, the apparently ptotic 
eyelid shoots upwards to a level higher than the 
normal eye. The upshoot of eyelid occurs only on 
opening the mouth but is not maintained if the 
mouth is kept open.
In our patient,  we were unable to see any up-
shoot  of  the  eyelid  at  the  initial  examination. 
This was because the reflex is momentary and 
only follows movements of the mouth including 
chewing,  sucking  or  bottle-feeding.  While  the 
synkinetic nature was apparent, initial examina-
tion showed no ptosis. Six months later,  ptosis 
was obvious. The degree of ptosis can vary from 
none to mild (lid covering the cornea 2 mm more 
than the normal    2 mm coverage) to moderate 
(3 mm) to severe (4 mm or more).  It can some-
times  be  absent3.  The  management  generally 
depends upon the amount of ptosis and the de-
gree of jaw winking. In mild ptosis, as in our pa-
tient,  there may be no need for surgical  inter-
vention  at  all.  In  case  of  moderate  to  severe 
ptosis, levator resection combined with bilateral 
frontalis suspension maybe necessary4.
Detailed ophthalmologic evaluation is necessary 
to  detect  associated abnormalities.  Ptosis  does 
not affect vision directly unless it is severe, but it 
can decrease vision by the  association  of  ani-
sometropia and astigmatism. Uncorrected, these 
can lead to amblyopia. If amblyopia is detected, 
aggressive  treatment  with  occlusion  therapy 
and/or  correction  of  anisometropia  should  be 
done prior to any surgical correction for ptosis. 
Other associations include superior rectus palsy 
and double elevator palsy which may need to be 
corrected before handling the ptosis. Our patient 
exhibited no other  associations. In view of the 
later presentation of ptosis, patient still needs to 
be followed up for development of amblyopia at 
a later stage.
Patients generally feel that the upshoot of eyelid 
comes down with time, as was felt by the moth-
er of our patient.  There has been no objective 
evidence  that  synkinesis  weakens  with  time.   
However, we were unable to observe jaw wink-
ing at the last follow up.
This case is presented to increase awareness of 
a  rare condition and to  highlight  that  the dia-
gnosis  need not depend upon the presence of 
ptosis. The synkinesis may not be apparent eas-
ily  but  needs to be brought on by getting the 
child to do various movements of the mouth. De-
tailed ophthalmologic evaluation is  essential  to 
rule out possible associations of anisometropia, 
astigmatism in order to prevent amblyopia.
References:
1. Duke-Elder  S.  Congenital  anomalies  of 
the ocular adnexa. In: Duke-Elder S, Ed-
itor. System of ophthalmology. London: 
Henry Kimpton; 1964, Vol. 3, p900-905
2. Lee  V,  Konrad  H,  Bunce  C,  Nelson  C, 
Collin  JR.  Aetiology and surgical  treat-
ment of childhood blepharoptosis.  Br J 
Ophthalmol 2002;86:1282-1286
3. Kostick  DA,  Bartley  GB.  Upper  eyelid 
malpositions:  Congenital  Ptosis.  In:  Al-
bert DM, Jakobiec FA, editors. Principles 
and Practice of Ophthalmology: Clinical 
Practice.  Philadelphia:  W.B.  Saunders 
company; 1994. Vol. 4, p 3466
4. Khwarg SI, Tarbet KJ, Dortzbach RK, Lu-
carelli MJ. Management of moderate to 
severe Marcus Gunn jaw winking ptosis. 
Ophthalmology 1999;106:1191-1196
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OJHAS Vol 8 Issue  1(10)   Bhat KG, Karanth A. Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye


Congenital anomalies of the ocular adnexa. In: Duke-Elder S, Ed-itor. System of ophthalmology. London: Henry Kimpton;

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Marcus Gunn Jaw Winking Phenomenon - A case of the widening eye

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