Brown’s Syndrome Dr Sunayana Bhat Consultant Paediatric ophthalmology , Strabismus and Neuro ophthalmology Vasan eye care , Mangalore Ph : 9611102754chanyn9@gmail.com

Historical Background • 1950 : Harold W. Brown Published on an unusual motility disorder, characterized

limited elevation in adduction

• 1970s : Short anterior sheath of the superior oblique tendon

• mid 1970s : A tight or short superior oblique tendon

PathophysiologyBrown syndrome can be divided into • Congenital • Acquired.

• To understand Brown’s syndrome

understand relationships.

• Particularly the relationship between the superior and inferior oblique.

Normal superior and inferior oblique relationship in adduction

Dr. G.Vicente

Brown syndrome OS

Dr. G.Vicente

Divergence in upgazeDown shoot in attempted elevation in adduction?

Brown Syndrome OS (from above)

Dr. G.Vicente

Congenital Helveston theory

Wright hypothesis

• Elongation - telescoping mechanism

• Central tendon fibres

( anomalous ?????)

• Computer model computer simulation of

Brown syndrome, using two specific models

(1)a short superior oblique tendon

(2)a stiff superior oblique tendon (stretched sensitivity).

Stiff muscle tendon complex

( type of CFEOM ?????)

Aquired Brown ‘s Syndrome Peritrochlear scarring and adhesions – Chronic sinusitis, trauma , blepharoplasty and fat removal, and lichen sclerosus et atrophicus and morphea

Tendon-trochlear inflammation and edema - Idiopathic inflammatory (pain and click), trochleitis with superior oblique myositis, acute sinusitis, adult rheumatoid arthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, possibly distant trauma (cardiopulmonary resuscitation [CPR] and long bone fractures), and possibly postpartum hormonal changes

Superior nasal orbital mass - Glaucoma implant and neoplasm

Tight or inelastic superior oblique muscle - Thyroid disease (inelastic muscle), peribulbar anesthesia (inelastic tendon), Hurler-Scheie syndrome (inelastic tendon), and superior oblique tuck (short tendon)

Acquired brown’s

Some statistics …• 1 in 450 strabismic pts ..• 35% have a squinting relative • Laterality , sex predilection in conclusive

History• Diplopia

▫Rare : suppression.• Pain• Acquired Brown syndrome present with inflammatory signs. - supranasal orbital pain - tenderness - intermittent limitation of elevation in adduction

Hallmark Features• Elevation limitation in adduction • Divergence in upgaze • FDT +VE

Other …• Downshoot in adduction • Widening of palpebral fissure on adduction • Ortho or hypo in primary position • Head posture ( chin up )• Audible Click

Pseudo Brown Congenital Acquired

• Anomalous inferior orbital adhesions

• Posterior orbital bands

• Floor fracture• Retinal band around inferior

oblique muscle• Inferior temporal adhesions

Differential Diagnosis • Inferior oblique paralysis

• DEP• Fracture orbital floor • CFEOM • Grave’s disease

•Hypo in primary >15 PD •SO Overaction •Ductions> versions

Brown Syndrome Treatment

Treat the underlying condition.

•Surgery indications ▫Hypotropia in primary▫Anomalous head posture: severe chin up.

Brown Syndrome Tx: SO tenotomy(for the less shy)

SR

MR LR

IR

SR

LR

RM

IRIOIO

Dr. G.Vicente

For those surgeons who are a little too chicken to completely cut the SO tendon and cause a SO palsy…

Chicken suture technique

Brown Syndrome Tx: Chicken suture

Dr. G.Vicente

Or else…….

Try the synthetic … chicken trick“ silicone expander ”

Silicone expander

Dr. G.Vicente