brown’s syndrome
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Brown’s Syndrome . Dr Sunayana Bhat Consultant Paediatric ophthalmology , Strabismus and Neuro ophthalmology Vasan eye care , Mangalore Ph : 9611102754 [email protected]. Historical Background . 1950 : Harold W. Brown - PowerPoint PPT PresentationTRANSCRIPT
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Brown’s Syndrome Dr Sunayana Bhat Consultant Paediatric ophthalmology , Strabismus and Neuro ophthalmology Vasan eye care , Mangalore Ph : [email protected]
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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
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PathophysiologyBrown syndrome can be divided into • Congenital • Acquired.
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• To understand Brown’s syndrome
understand relationships.
• Particularly the relationship between the superior and inferior oblique.
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Normal superior and inferior oblique relationship in adduction
Dr. G.Vicente
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Brown syndrome OS
Dr. G.Vicente
Divergence in upgazeDown shoot in attempted elevation in adduction?
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Brown Syndrome OS (from above)
Dr. G.Vicente
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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 ?????)
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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)
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Acquired brown’s
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Some statistics …• 1 in 450 strabismic pts ..• 35% have a squinting relative • Laterality , sex predilection in conclusive
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History• Diplopia
▫Rare : suppression.• Pain• Acquired Brown syndrome present with inflammatory signs. - supranasal orbital pain - tenderness - intermittent limitation of elevation in adduction
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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
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Pseudo Brown Congenital Acquired
• Anomalous inferior orbital adhesions
• Posterior orbital bands
• Floor fracture• Retinal band around inferior
oblique muscle• Inferior temporal adhesions
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Differential Diagnosis • Inferior oblique paralysis
• DEP• Fracture orbital floor • CFEOM • Grave’s disease
•Hypo in primary >15 PD •SO Overaction •Ductions> versions
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Brown Syndrome Treatment
Treat the underlying condition.
•Surgery indications ▫Hypotropia in primary▫Anomalous head posture: severe chin up.
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Brown Syndrome Tx: SO tenotomy(for the less shy)
SR
MR LR
IR
SR
LR
RM
IRIOIO
Dr. G.Vicente
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For those surgeons who are a little too chicken to completely cut the SO tendon and cause a SO palsy…
Chicken suture technique
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Brown Syndrome Tx: Chicken suture
Dr. G.Vicente
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Or else…….
Try the synthetic … chicken trick“ silicone expander ”
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Silicone expander
Dr. G.Vicente
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