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Unilateral Levator Aponeurosis Excision for Marcus Gunn Syndrome and Risk Factors of Residual Jaw Winking

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Unilateral Levator Aponeurosis Excision for Marcus Gunn Syndrome and Risk Factors of Residual Jaw Winking Hindawi Journal of Ophthalmology Volume 2019, Article ID 2058047, 9 pages https://doi.org/10.1155/2019/2058047 Research Article Unilateral Levator Aponeurosis Excision for Marcus Gunn Syndrome and Risk Factors of Residual Jaw Winking Qingyao Ning , Jing Cao, Jiajun Xie, Qi Gao, Changjun Wang, and Juan Ye Department of Ophthalmology, e Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, Zhejiang, China Correspondence should be addressed to Juan Ye; [email protected] Received 12 May 2019; Accepted 17 October 2019; Published 4 November 2019 Academic Editor: Hong Liang Copyright © 2019 Qingyao Ning et al. -is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose. To investigate the association of ptosis, levator, and jaw winking in Marcus Gunn jaw-winking synkinesis (MGJWS), and the risk factor of preservation and outcomes of the unilateral levator excision and frontalis suspension. Methods. Clinical features of MGJWS case series from 2011 to 2018 were retrospectively reviewed. Association between jaw winking and ptosis/levator function was statistically analyzed. -e patients underwent unilateral levator excision and frontalis suspension using silicone rod or autogenous fascia lata. Clinical outcomes were evaluated in operated patients and the independent risk factors of residual jaw winking were investigated after a long follow-up. Results. -ere were 42 MGJWS patients in 2011 to 2018, accounting for 2.87% of all congenital blepharoptosis. 80% of mild jaw winking was accompanied with mild ptosis and fair levator function, and moderate- to-severe jaw winking was often accompanied with moderate-to-severe ptosis and poor levator function (P < 0:05). Ptosis showed a strong association with excursion of jaw winking (R � 0.785, P < 0:01). Jaw winking was resolved in all 34 operated patients with good correction of ptosis. Severity of jaw winking is an independent risk factor for the residual synkinesis after surgery. Severe preoperative jaw winking had an 18.05 times increased risk of postoperative residual synkinesis compared with moderate jaw winking (P < 0:05). Conclusions. In MGJWS eyelid excursion of jaw winking has a direct correlation with ptosis and dysfunction of levator muscle. Unilateral levator aponeurosis excision and frontalis suspension is an efficient approach for MGJWS. Severe jaw winking is a risk factor of residual eyelid synkinesis after surgery. 1. Introduction same side; and even with other variety of movements such as chewing, sucking, smiling, and so on [12, 15]. -e un- Marcus Gunn syndrome, also known as Marcus Gunn jaw- derlying etiopathogenesis of the phenomenon has not been winking synkinesis (MGJWS), was first described by Gunn completely identified up to now. Most scientists believe that in 1883 as a congenital unilateral ptosis with contraction of it involves the abnormal connection between the fifth cranial the levator palpebrae superioris in association with the nerve and the third cranial nerve supplying the levator external pterygoid muscle [1]. In previous studies, MGJWS muscle at a central or peripheral level [16–20]. was reported to occur in 2%–13% of patients with congenital It is generally recommended by ophthalmologists that ptosis [2–6]. Most cases are unilateral, although some bi- mild jaw winking (less than 2 mm) with mild ptosis could be lateral cases and familial cases have been reported [7–12]. clinically observed without surgical treatment if the patient Infrequent cases with absence of ptosis in MGJWS were also did not consider it to be a cosmetic problem. For moderate- reported in previous studies, which occurred in 1.2%–6.0% to-severe jaw winking, surgical management is considered to of MGJWS patients [13, 14]. -e affected eyelid would el- be the main therapeutic method. -e aim of the operation is evate upward with external pterygoid movement such as to eliminate synkinetic eyelid movement and correct ptosis. opening of the mouth, jaw opening to the opposite side; with A variety of surgical techniques were reported, such as the internal pterygoid movement such as jaw movement to the Fasanella–Servat procedure [21], levator sling [22–24], 2 Journal of Ophthalmology modified levator resection or plication [25], and levator improvement was defined as a decrement of 2 mm or more, muscle excision followed by frontalis suspension but with more than 1 mm remaining excursion of affected [10, 12, 18, 26]. Of the above procedures, levator excision upper eyelid with synkinesis; if the excursion decreased less with bilateral frontalis suspension was a widely used tech- than 2 mm and with more than 1 mm remaining excursion, nique for good results in both synkinesis elimination and it was considered as no improvement [12]. Patients were bilateral symmetry [12, 27]. However, some patients were examined at 2 week and 1, 3, 6, and 12 months, and then unwilling to get normal eyelids operated. In recent years, every year after operation. -e patients of moderate-to- some ophthalmologists reported single eye surgery tech- severe jaw winking who underwent surgical procedure and niques, which got satisfied surgical outcomes as well. had more than 6 months follow-up would be further ana- -e standard surgical procedure for MGJWS still re- lyzed for evaluation of surgical management. mains controversial at present. -e synkinesis is difficult to be completely eliminated with present surgical techniques. 2.2. Surgical Methods. Surgery was performed under general -e association between clinical feature, surgical techniques, anesthesia in patients younger than 18 years old. Adult and prediction of surgery intervention was not well reported patients underwent surgeries under local anesthesia. All the in previous studies. -is work retrospectively collected patients underwent unilateral levator muscle excision fol- congenital blepharoptosis patients over an 8-year period and lowed by frontalis suspension of the involved eye. In the studied all MGJWS cases with their clinical manifestations patients who were older than 4 years old, autogenous fascia and outcomes of unilateral surgery, especially analyzed the lata was used as the suspension material. In patients younger association between eyelid synkinesis and blepharoptosis, than 4 years old for whom the autogenous fascia lata was and the risk factors of the residual jaw winking after surgery. hard to harvest, and in patients who were deficient of ocular protection, silicone rod was used as the suspension material 2. Materials and Methods instead of autogenous fascia lata [28]. All surgical pro- cedures were performed by one senior oculoplastic surgeon 2.1. Patients and Investigations. We retrospectively reviewed (JY). patients with MGJWS within all congenital ptosis patients at Eyelid skin crease incision was used. Muller’s¨ muscle and the Eye Center of -e Second Affiliated Hospital of Zhejiang levator aponeurosis were exposed through standard pro- University from January 2011 to December 2018. -e study cedure. Levator aponeurosis was transected horizontally was approved by the institutional review board of the from tarsal plate and Muller’s¨ muscle. -e medial and lateral hospital and conducted in accordance with the Declaration edges of the levator aponeurosis were carefully incised as of Helsinki. All patients who underwent surgical in- completely as possible. And then, the levator aponeurosis tervention had given their written informed consent before was dissected up to 1-2 mm under the Whitnall’s ligament, surgery. For the minors, the written informed consent forms and excised after being held with a hemostat. Bipolar cautery were signed by their guardians. Signed consent for clinical was applied to cauterize the stump of the muscle and the photographs that permit identification of the patient was vertical lateral edges. Autogenous fascia lata was harvested achieved. with Crawford’s technique [29]. Frontalis suspension was Age, gender, affected eye, family history, previous sur- performed with the method described by Yoon and Lee [30]. gical history, and other associated eye disorders (including Eyelid height was set at the estimated position according to strabismus, amblyopia, and eyelid entropion) were recorded. both MRD1 and the height of contralateral normal eyelid -e following investigations were carefully assessed before (Figures 1(a)–1(d)). For the young patients who underwent surgical intervention: margin reflex distance (MRD) 1 of silicone rod suspension, the middle part of the silicone rod both eyes, levator function, jaw winking excursion of eyelid, was fixed on the tarsal plate with 5–0 nonabsorbable suture. and ocular protective mechanisms (Bell’s phenomenon, -e two ends of silicone rod were passed through the lateral orbicularis muscle function, corneal sensation, tear film and medial orbital septum tunnels, respectively, and then break-up time, and Schirmer’s test). Ptosis was recorded as formed a triangular frontalis suspension and drawn out of mild (2 mm or less), moderate (2–4 mm), or severe (more the forehead incision (Figures 1(e) and 1(f)). -e redundant than 4 mm). Levator function was recorded as good (more fascia lata and silicone rod were cut off, and the skin in- than 10 mm), fair (5–10 mm), or poor (<5 mm) [17]. Jaw cisions were sutured with 6–0 sutures. Artificial tears and wink was recorded as mild (less than 2 mm), moderate ointment were applied to the eyes for
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