1. Brown’s Syndrome Dr Sunayana Bhat 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 Dr. G.Vicente Divergence in upgaze Down shoot in attempted elevation in adduction?

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 (1)a short superior oblique tendon (2)a stiff superior oblique tendon (stretched sensitivity). Stiff muscle tendon complex ( type of CFEOM ?????)

9. 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)

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 CongenitalAcquired 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 MR LR IR SR LR RM IR 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