The identification of the pattern and its underlying mechanism is essential to plan a proper surgical management in strabismus. This may require recurrent treatments for symptomatic relief. Kim JH, Hwang JM. Brown H. Isolated Inferior Oblique Paralysis: An Analysis of 97 Cases. Federal government websites often end in .gov or .mil. This symptom is rare, when compared to diplopia and the same rules apply for age of patients affected. Lueder GT, Scott WE, Kutschke PJ, Keech RV. The trochlear nerve gains entry to the orbit via the superior orbital fissure, passes outside the tendinous ring of Zinn and innervates the SOM. 2010. doi:10.1016/j.ncl.2010.04.001, Tamhankar MA, Biousse V, Ying GS, et al. Pusateri TJ, Sedwick LA, Margo CE. Diagnostic Criteria for Graves' Ophthalmopathy. Inferior oblique muscle overaction (IOOA) manifests by overelevation of the eye in adduction and is frequently associated with horizontal deviations. Bilateral CN IV palsy might show bilateral excyclotorsion. Poor movement of the superior oblique tendon through the trochlea leads to limited elevation of the eye in adduction, frequently with an associated exotropia in upgaze. Brown syndrome refers to the apparent weakness of the inferior oblique muscle (i.e., limited upgaze, particularly in adduction) secondary to pathology of the superior oblique tendon sheath, usually at the trochlea. a #240 retinal silicone band), a non-absorbable "Chicken suture", or a superior oblique split tendon lengthening procedure, Iatrogenic Brown syndrome secondary to muscle plication may require reversal of the plication, In case the primary cause is a tendon cyst, removal of the cyst may be indicated. (Courtesy of Vinay Gupta, BSc Optometry), Figure 8. [2] Some advocate labelling vertical misalignments based on if the deviated eye manifests as a hypertropia or hypotropia. 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This similarity raises the question of whether some cases of Brown syndrome could arise from a similar synkinesis between the inferior and superior oblique muscles in the setting of congenital superior oblique palsy. If the degree of deviation in all fields of gaze, it is classified as comitant; it if behaves differently in different fields of gaze, it is classified as incomitant. Microvascular disease Later in life, these patients may experience decompensation of their previously well controlled CN IV palsy from the gradual loss of fusional amplitudes that occurs with aging or after illness or other stress event. Loss of fusion and the development of A or V patterns. Kushner BJ. Dr John Davis Akkara (MBBS, MS, FAEH, FMRF), https://eyewiki.org/w/index.php?title=Brown_Syndrome&oldid=87808, A click may be heard or felt by the patient with movement of the eye when attempting to elevate the eye in AD-duction, Congenital fibrosis of extraocular muscle, Significant orbital pain or pain with eye movements, A tenotomy or tenectomy to weaken the superior oblique (but beware post-operative iatrogenic superior oblique palsy), A superior oblique expansion surgery has been found to have high success rates and can be performed through a variety of techniques, including a silicon expander (e.g. [Brown's atavistic superior oblique syndrome: etiology of different types of motility disorders in congenital Brown's syndrome]. Incidence and Etiology of Presumed Fourth Cranial Nerve Palsy: A Population-based Study. This page has been accessed 163,866 times. Brown syndrome is a rare form of strabismus characterized by limited elevation of the affected eye. The procedure of choice is the recession of affected muscles. Acta Ophthalmol. a. Fourth cranial nerve palsies can affect patients of any age or gender. Am J Ophthalmol. Other features: Intorsion and abduction in downgaze. [7] Fourth nerve palsy secondary to microvascular disease will frequently resolve within 4-6 months spontaneously. Vertical recti transplantation in the A and V syndromes. -. Pseudo inferior oblique overaction associated with Y and V patterns. This is a preview of subscription content, access via your institution. The patient shows accommodative convergence in primary and downgaze as opposed to upgaze simulating a V-pattern. While Brown's syndrome is present the antagonist inferior oblique muscle undergoes isometric contracture. They can present with vertical diplopia, torsional diplopia, head tilt, and ipsilateral hypertropia. Arch Ophthalmol. Ophthalmic Surg Lasers. Simultaneous superior oblique tenotomy and inferior oblique recession in Brown's syndrome. Brown HW. The pattern needs to be corrected only if it is significant (as described above) or if the patient is symptomatic in the direction of largest deviation. [2][39][40], A dissociated vertical deviation is an upward drift of one eye when binocular fusion is interrupted (such as with alternate cover testing) that is not associated with a compensatory downward shift of the fellow eye when attention if focused on the drifting eye. These signs include supranasal orbital pain, tenderness, intermittent limitation of elevation in adduction, and pain that is associated with this ocular movement. Print. -, Kaeser PF, Kress B, Rohde S, Kolling G. Absence of the fourth cranial nerve in congenital Brown syndrome. In this head position, the ipsilateral superior rectus will compensate for the weak intorsion of the ipsilateral superior oblique, but will elevate the eye and further worsen the hypertropia. Pseudo patterns must be ruled out by measuring the deviations after prescribing appropriate refractive correction or observing the deviation under cover to prevent fusion. Vertical deviation, that increases on adduction of the affected eye. A and V patterns seen in exodeviation and esodeviation. An inverse Knapp procedure may be necessary. Strabismus secondary to implantation of glaucoma drainage device. There are several clinically significant features of the trochlear nerve anatomy. Note convergence in straight upgaze, an important point of differentiation from Brown syndrome. The SOM has action that varies depending on the angle between the muscle plane and the visual axis. Conclusions: Based on . Congenital and traumatic causes are the most frequent, Iatrogenic (ex. Curr Opin Ophthalmol. There are specific symptoms of this syndrome, such as limited elevation in . In their absence, upshifts or downshifts of the horizontal recti insertion can be planned. In order to evaluate this, the physician needs to check for a vertical deviation of the occluded eye, while the patient looks either side. Limited elevation in straight-up gaze and abduction can also be present, but are more subtle. 1996 Jan;208(1):37-47. doi: 10.1055/s-2008-1035166. [1][2] The clinical features were similar to those of an inferior oblique palsy, although there was minimal superior oblique muscle overaction. 2020;101383. Inferior oblique muscle palsy Superior oblique over-action Double elevator palsy Congenital fibrosis of extraocular muscle Thyroid eye disease Orbital fracture with entrapment Myasthenia gravis Management Management of Brown syndrome depends on symptomatology, etiology, and the course of the disease. Iatrogenic (Ex. Surgical: Strabismus surgery has to be postponed until after orbital decompression procedures have been performed and orbital inflammation is controlled. Pattern strabismus associated with craniofacial anomalies is complex and often difficult to manage. It can be acquired or congenital and is caused by damage to the trochlea of the superior oblique muscle tendon, an abnormality of the superior oblique tendon itself, abnormalities of the tissue around the rectus extraocular muscles (the rectus pulleys), or a congenital abnormality of the superior oblique muscle itself. -, Yang HK, Kim JH, Kim JS, Hwang JM. Hypertropia, that increases on head tilt to the contralateral side. In this particular case, horizontal muscle surgery or an expander may be more indicated, as suggested by Wright et al.[4]. VS often limited to adduction, Depression deficit and VS worst in abduction, Decreased force generation and saccadic velocity, Elevation deficit and VS worst in abduction, Decreased force generation and saccadic velocity, Elevation deficit and VS worst in abduction, Depression deficit and VS worst in abduction, Alternate cover testing shows an upward drift when the eye is covered, without a compensatory upward refixation of the fellow up. If congenital: There is an indication for surgery if there is a vertical deviation in primary position with an important face turn. Manley, DR and Rizwan, AA. Rosenberg JB, Tepper OM, Medow NB. Semin Ophthalmol. This page has been accessed 120,859 times. If a large hypertropia is present on primary gaze position: Ipsilateral IR resection + contralateral SR or IR recessions. 2012 Jun;90(4):e310-3. Leads to an elevation deficit/ vertical misalignment that is worst when the affected eye is abducted and with ipsilateral head tilt. The incidence of Brown's Syndrome was unrelated to tuck size. Arch Ophthalmol. Acquired Superior Oblique Palsy: Diagnosis and Management. [2] Ductional testing may be normal however or only show mild depression deficit in adduction with trochlear nerve palsies. 2010;30(1):59-63. doi:10.1097/WNO.0b013e3181ce1b1d, Prasad S, Volpe NJ. Clinical photograph of the patient showing V-pattern exotropia. CrossRef The clinical features were similar to those of an inferior oblique palsy, although there was minimal superior oblique muscle overaction. syndrome is a vertical strabismus syndrome characterized by limited elevation of the eye in an adducted position, most often secondary to mechanical restriction of the superior oblique tendon/trochlea complex. It can present in different ways causing somatic extraocular muscle dysfunction (superior, inferior, and medial recti; inferior oblique; and levator palpebrae superioris) and autonomic (pupillary sphincter and ciliary) muscles. Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips, Not logged in For this review, true Brown syndrome is due to congenital cause, with a constant limitation of elevation and a positive traction test secondary to a tight, superior oblique tendon. To make everything a bit more confusing, a Y pattern can also be present when there is an aberrant innervation of the lateral recti, in upgaze,[42] or in the case of a bilateral inferior oblique overaction (see above). Elliott RL, Nankin SJ. J AAPOS. Palsies of the Trochlear Nerve: Diagnosis and LocalizationRecent Concepts. Patients with Brown syndrome may have a variety of symptoms which may be constant, intermittent, or recurring, including: Brown 1999;97:1023-109. This may be seen in bilateral superior oblique palsy. Figure 2. In the presence of a significant Y pattern in upgaze, even if there is no significant deviation in primary position or sidegaze: Bilateral IO weakening procedures. Please enable it to take advantage of the complete set of features! Note convergence in straight upgaze, an important point of differentiation from Brown syndrome. Patients with BS can have a widening of the palpebral fissure in. 2015 Jul;26(5):357-61. J AAPOS. Strabismus. https://doi.org/10.1007/978-3-319-63019-9_15. Kushner, Burton J. government site. Direction of vertical displacement of horizontal recti in pattern strabismus- Medial rectus is shifted towards the apex and lateral rectus is shifted towards the base of A or V pattern. 1998. doi:10.1001/archopht.116.11.1544, Miller NR. Idiopathic Alexandros Damanakis, Stabismoi 2nd edition, Litsas medical editions, Athens-Greece. Bilateral involvement is rare in non-traumatic cases but is relatively more frequent after trauma (crossed, dorsal exit). JAAPOS 1999 Dec;3(6):328-32. 2023 Springer Nature Switzerland AG. 1987;94:10438. SO weakening procedures: SO expander, tenotomy, tenectomy or recession. Myectomy and extirpation/denervation have been described but are not preferred procedures by the authors, as the results may be unpredictable, and anteriorization cannot be achieved by these procedures. https://doi.org/10.1007/978-3-319-63019-9_15, DOI: https://doi.org/10.1007/978-3-319-63019-9_15. This suggests a central CN IV palsy. MRI may show an infarction in the tegmentum of the midbrain, affecting the fascicle of the fourth nerve. FOIA The SOM has different (primary, secondary, and tertiary) actions dependent on mechanical position of the eye. If masked bilateral involvement or asymmetric involvement is suspected: Bilateral IO graded anteriorization + contralateral IR recession or bilateral graded IO anteriorization + Harada-Ito procedure on the more affected side. [4], Trauma In: StatPearls [Internet]. It is paramount to rule out a vertical pattern in every case of comitant strabismus, as our management would be defined by the same. A longitudinal long-term study of spontaneous course. Jack J. Kanski- Brad Bowling, Clinical Ophthalmology- A systematic approach, Seventh Edition, Elsevier, 2011.

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