How is Marcus Gunn jaw-winding syndrome managed?

Management of Marcus Gunn Jaw-Winking Syndrome

For patients with moderate-to-severe Marcus Gunn jaw-winking syndrome (eyelid excursion ≥2 mm with jaw movement), surgical intervention with bilateral levator excision and bilateral frontalis suspension provides the most effective resolution of synkinesis and ptosis correction, achieving good outcomes in approximately 68-88% of patients. 1, 2

Clinical Assessment and Grading

The severity of Marcus Gunn jaw-winking syndrome should be graded based on upper eyelid excursion with jaw movement 1:

• Mild: <2 mm excursion (16% of patients)
• Moderate: 2-4 mm excursion (76% of patients)
• Severe: ≥5 mm excursion (8% of patients)

During examination, have the patient open their mouth, move the jaw side-to-side, protrude the jaw forward, or perform chewing motions to elicit the synkinetic movement 1, 3. In infants, observe during bottle-feeding 3.

Treatment Algorithm

Mild Cases (Excursion <2 mm)

Observation is appropriate as the synkinesis is typically not functionally or cosmetically problematic 1. Address any associated amblyopia with eyeglasses or patching if present 3.

Moderate-to-Severe Cases (Excursion ≥2 mm)

Surgical intervention is indicated when synkinesis causes functional or cosmetic concerns 4, 1.

Preferred Surgical Approach: Bilateral Levator Excision + Bilateral Frontalis Suspension

This technique achieves 1, 2:

• Resolution of jaw-winking: 97% complete resolution or improvement to ≤2 mm
• Eyelid symmetry in primary position: Within 1 mm in 88% of patients
• Eyelid symmetry in downgaze: Within 1 mm in 88% of patients

The bilateral approach provides superior outcomes compared to unilateral procedures 2. When bilateral levator excision was performed, good results were achieved in 68.4% of patients, compared to only 40% good results with unilateral levator excision 2.

Alternative Approach: Unilateral Levator Excision + Unilateral Frontalis Suspension

This may be considered in selected non-amblyopic patients 1, though outcomes are less predictable:

• Eyelid symmetry in primary position: 75% of patients
• Eyelid symmetry in downgaze: Only 25% of patients
• Poor results occurred in 60% when combined with bilateral frontalis suspension 2

Expected Outcomes and Follow-Up

After bilateral levator excision 1, 2:

• Complete resolution of jaw-winking: 37% of eyelids
• Mild residual winking (≤1 mm, functionally insignificant): 48.2% of eyelids
• Good ptosis correction: 87% of patients at mean 62-month follow-up 1

Long-term follow-up averaging 36.9 to 62 months demonstrates sustained improvement 1, 2.

Common Complications

The most frequent postoperative complications include 1:

• Eyelash ptosis: 10% of patients
• Loss of eyelid crease: 10% of patients
• Entropion: 3% of patients

These complications are generally manageable and do not significantly compromise the overall functional outcome 1.

Critical Management Pitfalls

Do not perform unilateral frontalis suspension alone in patients with moderate-to-severe synkinesis, as this approach yields poor symmetry in downgaze (only 25% achieve symmetry within 1 mm) 1.

Do not rush to surgery without addressing amblyopia first if present—correct refractive errors and implement patching protocols before considering surgical intervention 3.

Do not underestimate the severity by failing to perform the jaw test during examination—have patients actively chew, open their mouth wide, or move the jaw laterally to fully assess the degree of synkinesis 3.