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Getting rid of the wink

An eyelid droop that causes the eye to look small is called ‘ptosis’. This condition may occur by birth (congenital), after an injury to the eye, or with old age when the muscle that opened the eyelid becomes weak.

Marcus Gunn jaw winking ptosis is a rare form of congenital ptosis where the eyelid moves up and down with movement of the jaw, while speaking or while chewing. This creates a very cosmetically unpleasant situation, and is often leads to severe psychological distress in the patient. This occurs as a result of abnormal connections between the nerves that control the muscles that help in chewing and the muscle that lifts the upper eyelid called the levator palpebrae superioris (LPS). This causes the “jaw wink”.

A 24 year old female patient presented in the ophthalmology department with the history of left upper eyelid drooping since birth. The bigger problem she faced was that the lid moved while she ate or moved her jaw. She was at a marriageable age, and this cosmetic impediment was a big hurdle in her marriage prospects.

When she was examined, we found that the lid droop was actually very minimal, but the eyelid movement with jaw movement was very marked, one of the most severe jaw winking ptosis that I had ever seen.

In a case of simple ptosis, the treatment is a surgical tightening of the weak LPS muscle. But, in her case, such a procedure would correct the ptosis, but would make the jaw wink even more prominent. Since the nerve that lifts the lid up also supplies various other structures, destruction of the nerve is not an option. The only thing left to do is to completely remove the LPS muscle, and replace that with an implant. The removal of the muscle results in a total lid droop, a total ptosis, and then a frontalis sling is placed within the lid. This is a silicone sling implant that then connects the eyelid to the frontalis muscle of the forehead above the eyebrow, and this muscle then lifts the eyelid up. That way, both the wink and the ptosis are corrected.

We did a similar procedure whereby her left upper lid LPS was removed. Leaving behind even a few fibers of the muscle can result in a residual jaw wink. So, the muscle is carefully excised out and a silicone sling is placed to then lift the lid. Post-operatively, there was no jaw wink and the lid position was ideal.

No eyelid drooping, no jaw winking- happy doctor and a very happy paient!