How to diagnose and How to diagnose and recognize vertical deviationsrecognize vertical deviations

Part III Part III Brown SyndromeBrown Syndrome

G. Vike Vicente, MDG. Vike Vicente, MDEye Doctors of WashingtonEye Doctors of Washington

Brown SyndromeBrown Syndrome

Aka oblique tendon sheath syndromeAka oblique tendon sheath syndromeNamed by Brown 1950.Named by Brown 1950.Deficiency of elevation in adduction Deficiency of elevation in adduction Divergence in upgazeDivergence in upgazeDown shoot in attempted elev. in adduct. Down shoot in attempted elev. in adduct. (different than IO palsy)(different than IO palsy)Click felt on trochlea in some acquired casesClick felt on trochlea in some acquired casesOften seen with chin up positionOften seen with chin up position2/3 are mild and do not require treatment if ortho 2/3 are mild and do not require treatment if ortho in primaryin primary

Brown syndrome OS

Dr. G.Vicente

Divergence in upgazeDown shoot in attempted elevation in adduction?

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 TreatmentBrown Syndrome Treatment

If associated with other diseaseIf associated with other disease– ie rheumatoid arthritis or sinusitisie rheumatoid arthritis or sinusitis– Treat the underlying condition.Treat the underlying condition.

Surgery if:Surgery if:– Hypotropia in primaryHypotropia in primary– Anomalous head posture: severe chin up.Anomalous head posture: severe chin up.– Consider Consider

SO tendon tenotomy,SO tendon tenotomy,

SO tendon silicone expanderSO tendon silicone expander

SO tendon chicken suture (mercilene, nonabsorbable)SO tendon chicken suture (mercilene, nonabsorbable)

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

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

Dr. G.Vicente

Divergence in upgazeDown shoot in attempted elevation in adduction?

Down shoot in attempted elev. in adduct. (different than IO palsy)Down shoot in attempted elev. in adduct. (different than IO palsy)