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Features include: Premature ovarian insufficiency, Hypoplasia of the uterus, and Secondary amenorrhea.
Organ System | Phenotype Count | Example Features |
|---|---|---|
Hormones | 1 | Secondary amenorrhea |
FOXL2 encodes forkhead box L2 (376 aa). Transcriptional regulator. Critical factor essential for ovary differentiation and maintenance, and repression of the genetic program for somatic testis determination. Highest expression in Ovary (102.0 TPM) and Cervix Endocervix (31.4 TPM).
Premature ovarian failure 3 is associated with mutations in the FOXL2 gene on chromosome 3.
The FOXL2 protein participates in UBE2I (UBC9), PIAS1 SUMOylate FOXL2 with SUMO1, DMRT1:FOXL2 gene, and Transcriptional regulation of testis differentiation pathways.
FOXL2 is classified as a druggable target (Clinically Actionable and Transcription Factor categories) with score 2.1.
No consensus clinical diagnostic criteria for blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES) have been published.
BPES should be suspected in individuals with the following clinical findings and family history. Major clinical findings, all present at birth:
Blepharophimosis. Narrowing of the horizontal aperture of the eyelids
No approved treatments are currently available for premature ovarian failure 3. The disease remains an area of unmet medical need.
No clinical practice guidelines for blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES) have been published. Evaluations Following Initial Diagnosis To establish the extent of disease and needs in an individual diagnosed with BPES, the evaluations summarized (if not performed as part of the evaluation that led to the diagnosis) are recommended. Table 2. Recommended Evaluations Following Initial Diagnosis in Individuals with BPES
Table 4.
Recommended Surveillance for Individuals with BPES
System/Concern | Evaluation | Frequency
Eyelid
malformation | Ophthalmic follow up | Based on person's age, past procedures, results of visual acuity testing
POI | • Endocrinologic gynecologic follow up to monitor ovarian status
No clinical trials have been registered for premature ovarian failure 3.
207 publications have been identified in PubMed for premature ovarian failure 3. Kisho has analyzed 55 by research type. Research spans Review / Meta-Analysis (44%), Basic Science / Preclinical (35%), and Epidemiology / Natural History (13%).
Research Type | Count | % of Total |
|---|---|---|
Research summaries | 24 | 44% |
Data assembled from 6 of 12 sources · Last updated Sep 19, 2026, 2:58 PM UTC
Online Mendelian Inheritance in Man
Blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES) is defined by complex eyelid malformation characterized by four major features, all present at birth: blepharophimosis, ptosis, epicanthus inversus, and telecanthus. Two types of BPES have been described :
BPES type I includes the four major features and female infertility caused by primary ovarian insufficiency.
BPES type II includes only the four major features.
Complex eyelid malformation
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
Pathogenic variants predicted to result in proteins truncated before the polyalanine tract preferentially lead to POI (BPES type I). Note: The need for careful interpretation of genotype-phenotype correlations is illustrated by the co-occurrence of BPES type I and isolated POI in a three-generation family and the occurrence of both BPES type I and BPES type II within a single family . Polyalanine expansions preferentially lead to BPES type II.
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
All individuals heterozygous for a FOXL2 pathogenic variant have a BPES phenotype; thus, penetrance is complete for the eyelid phenotype. The exception is a consanguineous Indian family in which heterozygotes for a short polyalanine expansion of 19 alanines are unaffected, but homozygotes have typical BPES (with documented POI in 1 female) .
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
Epicanthus inversus. A skin fold arising from the lower eyelid and running inward and upward
Telecanthus. Lateral displacement of the inner canthi and the inferior punctum with normal interpupillary distance
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
Because of its characteristic phenotype and the absence of extraocular manifestations other than primary ovarian insufficiency, BPES can be distinguished relatively easily from other conditions in which ptosis or blepharophimosis is a major feature (e.g., NR2F2-associated 46,XX sex reversal 5 [OMIM 618901] and Say-Barber-Biesecker variant of Ohdo syndrome [see KAT6B Disorders]).
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
Genetic testing for FOXL2 is available. Testing is considered confirmatory for diagnosis.
System/Concern | Evaluation | Comment |
|---|---|---|
malformation | Exam byophthalmologist oculoplasticsurgeon | Assess for size of palpebral apertures, lacrimal duct abnormality, eyelid elevation. Vision |
POI | Eval by pediatricianor endocrinologist/gynecologist | For females w/BPES during late childhood or early puberty to assess gonadal function assess/discuss onset course of POI; See also . Genetic |
counseling | By geneticsprofessionals1 | To inform affected persons their families re nature, MOI, implications of BPES to facilitate medical personal decision making; In females w/BPES, family history can indicate type of BPES (type I inferred by assoc w/subfertility or infertility). |
Treatment of Manifestations in Individuals with BPES Manifestation/Concern | Treatment | Considerations/Other |
Eyelid malformation | Surgery | Traditionally performed in 2 stages:; Age 3-5 yrs: medial canthoplasty for correction of blepharophimosis, epicanthus inversus, telecanthus; ~1 yr later: ptosis correction, usually requiring brow suspension procedure |
POI | Standard mgmt for POI (not specific to BPES)1 | Typically consisting of:; Hormone replacement therapy; Monitoring optimizing bone health; Eval of options for parenthood (adoption, foster parenthood, embryo donation, egg donation, ovary cryopreservation) Psychological support is important. POI = primary ovarian insufficiency 1. |
Recommended Surveillance for Individuals with BPES System/Concern | Evaluation | Frequency Eyelid |
malformation | Ophthalmic follow up | Based on person's age, past procedures, results of visual acuity testing POI |
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
View trials for premature ovarian failure 3
Assess effects of hormone replacement therapy for adjustments as needed.
Psychological follow up
| Individualized, but at least annually
POI = primary ovarian insufficiency
Source: GeneReviews — "Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome"
Laboratory research
19 |
35% |
Disease patterns and progression | 7 | 13% |
New treatment approaches | 3 | 5% |
Other research | 1 | 2% |
Clinical study results | 1 | 2% |
Zhu F (2026). [PMID: 41818942](https://pubmed.ncbi.nlm.nih.gov/41818942/). *Phytomedicine*. [Basic Science / Preclinical]
Pravatta-Rezende G (2025). [PMID: 40840112](https://pubmed.ncbi.nlm.nih.gov/40840112/). *Clinics (Sao Paulo)*. [Review / Meta-Analysis]
Nie P (2025). [PMID: 40331195](https://pubmed.ncbi.nlm.nih.gov/40331195/). *Front Pharmacol*. [Review / Meta-Analysis]
Yimamuyushan S (2025). [PMID: 40814064](https://pubmed.ncbi.nlm.nih.gov/40814064/). *J Ovarian Res*. [Epidemiology / Natural History]
Pouladvand N (2025). [PMID: 40907172](https://pubmed.ncbi.nlm.nih.gov/40907172/). *Biomed Pharmacother*. [Basic Science / Preclinical]
El-Gendy ZA (2025). [PMID: 41366436](https://pubmed.ncbi.nlm.nih.gov/41366436/). *J Ovarian Res*. [Basic Science / Preclinical]
Dey P (2025). [PMID: 40489658](https://pubmed.ncbi.nlm.nih.gov/40489658/). *Mol Hum Reprod*. [Basic Science / Preclinical]
Yordanov A (2025). [PMID: 40142340](https://pubmed.ncbi.nlm.nih.gov/40142340/). *Medicina (Kaunas)*. [Review / Meta-Analysis]
Yi Y (2025). [PMID: 39922292](https://pubmed.ncbi.nlm.nih.gov/39922292/). *Complement Ther Med*. [Review / Meta-Analysis]
Erel CT (2025). [PMID: 40907339](https://pubmed.ncbi.nlm.nih.gov/40907339/). *Maturitas*. [Review / Meta-Analysis]