This document discusses a case presentation of Brown syndrome. Brown syndrome is characterized by an inability to elevate the eye in adduction due to a tight or shortened superior oblique tendon. It presents with minimal hypotropia in primary position and minimal superior oblique overaction. The differential diagnosis includes inferior oblique paresis, monocular elevation deficiency, orbital fibrosis syndrome, and simulated Brown syndrome. Management of Brown syndrome varies and can include observation, surgery such as a superior oblique tendon expander procedure, or treatment with anti-inflammatory medications in cases of inflammatory Brown's syndrome.

1. CASE PRESENTATION
Alireza gholizade

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4. differential diagnosis

i. inferior oblique paresis
ii. monocular elevation deficiency
iii. orbital fibrosis syndrome “big mimicker”
iv. Brown syndrome
v. “simulated Brown syndrome” (e.g., orbital floor fracture,
traumatic tenosynovitis, idiopathic orbital inflammation,
metastasis to superior oblique muscle, orbital metastasis,
frontal sinus osteoma, s/p blepharoplasty, or blunt orbital
trauma)
vi. Superior oblique overaction

7. Brown Syndrome
 Brown syndrome is characterized by an inability to elevate the eye in adduction as a result
of either a tight or shortened superior oblique tendon, or a process at the trochlea that limits
the movement of the superior oblique tendon in the trochlear opening
 minimal to no hypotropia in primary position, minimal to no superior
oblique overaction,
 1928, German ophthalmologist P. A. Jaensch is presented with a child who could not elevate the
affected eye in adduction.
The case was presented in a medical journal the
following year, initially under the disease name
“Superior oblique tendon sheath syndrome”
 Harold W. Brown first described this syndrome in 1950
He labeled the disease “Brown's superior oblique
tendon sheath syndrome” or simply “Brown's Syndrome

8. The vertical saccade is normal but the eye gets to a
sudden stop
Brown syndrome is usually associated with an exotropia in
upgaze (Y-pattern
widening of the palpebral fissure in aDduction
The inability to passively elevate the eye in aDduction

10. INCIDENCE
 Incidence is low –
6 in 2583 (Croswell & Haldi )
 Familial occurrence is rare
2%(Birgit Lorenz, Michael C. Brodsky)
 Usually unilateral but 10% is bilateral

11. This child adopts a head tilt away from the affected eye to
compensate for a hypotropia of the right eye

12. This child has adopted a chin-up head posture to
compensate for a hypotropia of the left eye.

13. 
Idiopathic acquired Brown's syndrome is often intermittent and sometimes
associated with a "dick" that is felt by the patient in the superior nasal quadrant
when the patient looks up and in.
The cause of the dick and
limited elevation is not known, but it may represent
inflammation or an abnormality of fascial tissue
araund the superior oblique tendon.

14. orbital fibrosis syndrome
 It can involve one or both eyes,
sometimes in a very asymmetric fashion, and most frequently
involves the inferior, medial, superior, and then lateral rectus
muscles. It is therefore essential to always properly perform
a forced duction test (F.D.T.) on all extraocular muscles
( E.O.M.) , of both eyes, while the patient is under
anesthesia.

15. “Monocular elevation deficiency”, this deficit occurs primarily in adduction and abduction,
and can mimic Browns in the fact that there is a pronounced limitation of elevation in the
paretic eye, as is the case in this child. A difference of this is that in primary gaze, patients
often have a ptosis of the eye, and may adopt a chin-up head posture to compensate for the
ptosis.

16. Inferior oblique paresis
 Patients with a “True” inferior oblique paresis generally present with the following
symptoms, which differentiate it from Browns:
● A limitation of elevation in adduction, with a large vertical deviation in primary
position, usually more than 10 PD.
● A marked superior oblique overaction
● An evident A-Pattern convergence, noticeable in direct upgaze
● Negative forced ductions test
● positive Bielschowsky head tilt test, This imbalance is rectified upon tilting her head
to the opposite side

17. Io paresis
Brown sync.

19. Grading of Severity
● Mild – Restricted elevation in adduction only with
no hypotropia or downshoot in primary or
adduction
● Moderate – restricted elevation and downshoot in
adduction and direct elevation with minimal
hypotropia in primary position and adduction
● Severe – restriction of elevation and marked
downshoot in adduction and direct elevation.
Evident hypotropia in primary position with, but
not in all cases, adoption of abnormal head
posture.

20. Management
 Management of Brown syndrome varies widely. Imaging
of the orbit (If the cause of an acquired Brown's syndrome is in question) with
special attention to the region of the trochlea
adds significantly to the workup of the patient with acquired
Brown syndrome.
 In many cases, acquired Brown's syndrome will spontaneously resolve
over several months to even several years. Surgery
should only be considered after the patient has been
observed for at least 6 months to 1 year

21.  A significant proportion of children with Brown
syndrome will have improvement of eye motility as
they get older. Dawson, Barry, and Lee retrospectively reviewed 32 patients with
Brown syndrome
who were followed between 6 months and 9.5 years,
and reported that 75 % of patients had some improvement in their ocular
movements without any intervention. Of 6 patients with a “click,” 5 improved
 Also, as the child becomes older and taller, he/she
will look at the parents and other adults at eye level
and will not need to as frequently look up, inducing
the anomalous eye movements.
 Most adult patients
with persistent Brown syndrome, will generally position themselves and/or arrange
their desk/office in
such a way to avoid looking in the affected position of
gaze, where the deviation is manifest (e.g., a patient
with right Brown syndrome, will sit in a position in
which he/she would look at others straight ahead or in
right gaze).

22. SURGICAL INDICATIONS FOR CONGENITAL
 if there is a hypodeviation in primary position that causes a significant chin elevation
 surgery should be reserved for children older
than 4 years of age; older children are less likely to
develop postoperative Suppression and amblyopia
 operate on a child under
4 years of age if the hypodeviation is large enough to
disrupt fusion
 Management of congenital Brown's syndrome is based
on lengthening the superioroblique tendon.
 Procedures such as tenotomy and tenectomy release the restriction but are not
controlled
 so muscle is not overacting and, therefore, procedures such as tenotomy or tenectomy
often result in a secondary superior oblique paresis

23. superior oblique tendon expander
The expander allows for controlled and reversible
elongation of the
tendon while maintaining the functional integrity of
the superior oblique muscle-tendon complex
complications of the procedure are
rare, but these include extrusion of silicone and scarring of
the silicone to the sclera, causing postoperative Iimitation
of depression

24.  The treatment of inflammatory Brown's syndrome
includes a trial of systemic nonsteroidal antiinflammatory agents (e.g.,
indomethacin 25-50 mg TID) or
a local steroid injection in the area of the trochlea.