How to diagnose and recognize vertical deviations

How to diagnose and recognize vertical deviations Part III Brown Syndrome G. Vike Vicente, MD Eye Doctors of Washington

Brown Syndrome • Aka oblique tendon sheath syndrome • Named by Brown 1950. • Deficiency of elevation in adduction • Divergence in upgaze • Down shoot in attempted elev. in adduct. (different than IO palsy) • Click felt on trochlea in some acquired cases • Often seen with chin up position • 2/3 are mild and do not require treatment if ortho in primary

Brown syndrome OS Divergence in upgaze Down shoot in attempted elevation in adduction? Dr. G.Vicente

In honor of Valentine’s day • To understand Brown’s syndrome • You have to understand relationships. • Particularly the relationship between the superior and inferior oblique.

Normal superior and inferior oblique relationship from primary Dr. G.Vicente

Normal superior and inferior oblique relationship in adduction Dr. G.Vicente

Brown Syndrome OS (from above) Dr. G.Vicente

Brown Syndrome Treatment • If associated with other disease • ie rheumatoid arthritis or sinusitis • Treat the underlying condition. • Surgery if: • Hypotropia in primary • Anomalous head posture: severe chin up. • Consider • SO tendon tenotomy, • SO tendon silicone expander • SO tendon chicken suture (mercilene, nonabsorbable)

Brown Syndrome Tx: SO tenotomy(for the less shy) SR SR LR RM MR LR IR IR IO IO 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

For those surgeons with a sense of humor…Try the rubber chicken trickaka silicone expander

Brown Syndrome Tx: Silicone expander Dr. G.Vicente

Brown syndrome OS Divergence in upgaze Down shoot in attempted elevation in adduction? Down shoot in attempted elev. in adduct. (different than IO palsy) Dr. G.Vicente

How to diagnose and recognize vertical deviations