Brown’s Syndrome

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

2. 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

3. Pathophysiology Brown syndrome can be divided into • Congenital • Acquired.

4. To understand Brown’s syndrome understand relationships. • Particularly the relationship between the superior and inferior oblique.

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

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

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

8. Congenital Helveston theory Wright hypothesis • Elongation - telescoping mechanism • Central tendon fibres ( anomalous ?????) • Computer model computer simulation of Brown syndrome, using two specific models • a short superior oblique tendon • a stiff superior oblique tendon (stretched sensitivity). Stiff muscle tendon complex ( type of CFEOM ?????)

10. Acquired brown’s

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

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

13. 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

14. Pseudo Brown Congenital Acquired • Anomalous inferior orbital adhesions • Posterior orbital bands • Floor fracture • Retinal band around inferior oblique muscle • Inferior temporal adhesions

15. Differential Diagnosis • Inferior oblique paralysis • DEP • Fracture orbital floor • CFEOM • Grave’s disease • Hypo in primary >15 PD • SO Overaction • Ductions> versions

16. Brown Syndrome Treatment Treat the underlying condition. • Surgery indications • Hypotropia in primary • Anomalous head posture: severe chin up.

17. Brown Syndrome Tx: SO tenotomy(for the less shy) SR SR LR RM MR LR IR IR IO IO Dr. G.Vicente

18. For those surgeons who are a little too chicken to completely cut the SO tendon and cause a SO palsy…Chicken suture technique

19. Brown Syndrome Tx: Chicken suture Dr. G.Vicente

20. Or else……. Try the synthetic … chicken trick“ silicone expander ”

21. Silicone expander Dr. G.Vicente

23. Thank you !