Brown Syndrome Differential Diagnoses

  • Author: Kenneth W Wright, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Apr 25, 2012
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Kenneth W Wright, MD  Director, Wright Foundation for Pediatric Ophthalmology and Strabismus Ophthalmology, Cedars-Sinai Medical Center; Clinical Professor of Ophthalmology, Keck School of Medicine of the University of Southern California

Kenneth W Wright, MD is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, and American Ophthalmological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Maria Gabriela Salvador, MD  Consulting Staff, Department of Ophthalmology, Division of Pediatric Ophthalmology and Strabismus, Colonia Polanco Chapultepec Morales

Disclosure: Nothing to disclose.

Specialty Editor Board

Anastasios J Kanellopoulos, MD  Assistant Program Director, Clinical Associate Professor, Department of Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, New York University

Anastasios J Kanellopoulos, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Eye Bank Association of America, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J James Rowsey, MD  Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Brown HW. True and simulated superior oblique tendon sheath syndromes. Doc Ophthalmol. Feb 21 1973;34(1):123-36. [Medline].

  2. Parks MM, Brown M. Superior oblique tendon sheath syndrome of Brown. Am J Ophthalmol. Jan 1975;79(1):82-6. [Medline].

  3. Helveston EM, Merriam WW, Ellis FD, Shellhamer RH, Gosling CG. The trochlea. A study of the anatomy and physiology. Ophthalmology. Feb 1982;89(2):124-33. [Medline].

  4. Wright KW. Brown's syndrome: diagnosis and management. Trans Am Ophthalmol Soc. 1999;97:1023-109. [Medline].

  5. Bhola R, Rosenbaum AL, Ortube MC, Demer JL. High-resolution magnetic resonance imaging demonstrates varied anatomic abnormalities in Brown syndrome. J AAPOS. Oct 2005;9(5):438-48. [Medline].

  6. Parks MM. Bilateral superior oblique tenotomy for A-pattern strabismus in patients with fusion (commentary). Binoc Vis. 1988;3:39.

  7. Buckley EG, Flynn JT. Superior oblique recession versus tenotomy: a comparison of surgical results. J Pediatr Ophthalmol Strabismus. May-Jun 1983;20(3):112-7. [Medline].

  8. Clarke MP, Bray LC, Manners T. Superior oblique tendon expansion in the management of superior oblique dysfunction. Br J Ophthalmol. Jul 1995;79(7):661-3. [Medline].

  9. Clarke WN, Noel LP. Brown's syndrome with contralateral inferior oblique overaction: a possible mechanism. Can J Ophthalmol. Aug 1993;28(5):213-6. [Medline].

  10. George JL, Maalouf T, Cordonnier MO, Angioi-Duprez K. [Abnormal eyelid positions in Brown syndrome]. J Fr Ophtalmol. Jun 2004;27(6 Pt 1):579-87. [Medline].

  11. Helveston EM, Birchler C. Superior oblique palsy: subclassification and treatment suggestions. Am Orthopt J. 1982;32:104-110.

  12. Prieto-Diaz J. Posterior tenectomy of the superior oblique. J Pediatr Ophthalmol Strabismus. Sep-Oct 1979;16(5):321-3. [Medline].

  13. Scott AB, Knapp P. Surgical treatment of the superior oblique tendon sheath syndrome. Arch Ophthalmol. Sep 1972;88(3):282-6. [Medline].

  14. Scott WE, Jampolsky AJ, Redmond MR. Superior oblique tenotomy: indications and complications. Int Ophthalmol Clin. 1976;16(3):151-9. [Medline].

  15. Von Noorden GK. Binocular Vision and Ocular Motility. St. Louis: CV Mosby; 1996:437-442.

  16. Wright KW. Color Atlas of Ophthalmic Surgery-Strabismus. Philadelphia, Pa: Lippincott; 1991:201-219.

  17. Wright KW. Superior oblique silicone expander for Brown syndrome and superior oblique overaction. J Pediatr Ophthalmol Strabismus. Mar-Apr 1991;28(2):101-7. [Medline].

  18. Wright KW. Surgical procedure for lengthening the superior oblique tendon. Invest Ophthamol Vis Sci. 1989;30(sup):377.

  19. Wright KW, Min BM, Park C. Comparison of superior oblique tendon expander to superior oblique tenotomy for the management of superior oblique overaction and Brown syndrome. J Pediatr Ophthalmol Strabismus. Mar-Apr 1992;29(2):92-7; discussion 98-9. [Medline].

  20. Wright KW, Silverstein D, Marrone AC, Smith RE. Acquired inflammatory superior oblique tendon sheath syndrome. A clinicopathologic study. Arch Ophthalmol. Nov 1982;100(11):1752-4. [Medline].

 
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A 3-year-old patient with acquired right Brown syndrome. Marked limitation of elevation in adduction is present in the right eye. Pseudo-overaction of the left inferior oblique is present. Courtesy of Kenneth Wright, MD.
The same patient as in the image above, 6 years later. The patient shows normal eye movements, and no signs of Brown syndrome. A spontaneous resolution occurred over a 2-year period. Courtesy of Kenneth Wright, MD.
This patient has the longest follow-up in the silicone tendon expander group at 11 years. A. Preoperative composite photograph of eye movements, showing right Brown syndrome. The patient underwent silicone tendon expander, 6 mm right eye. B. Postoperative photograph 3 years after surgery, showing full ocular motility. C. Postoperative photograph 11 years after surgery, showing continued normal ocular motility. Courtesy of Kenneth Wright, MD.
Composite photographs, showing left Brown syndrome with marked limitation of elevation in adduction. Courtesy of Kenneth Wright, MD.
Fundus torsion (direct view). The bottom set of fundus photographs represents downgaze; the center photographs, primary position; and the top photographs, upgaze. Note that in the top set of photographs, the left fundus is intorted as the foveal fixation is slightly above the top of the optic disc. Courtesy of Kenneth Wright, MD.
Table. Differential Diagnoses: Clinical Features of Brown Syndrome, Inferior Oblique Paresis, and Superior Oblique Overaction
Brown syndrome (inelastic superior oblique muscle-tendon complex) Primary superior oblique overaction Inferior oblique paresis
Limitation of elevation in adductionUsually severe (-3 to -4)Usually mildUsually severe (-3 to -4)
Limitation of elevation in adductionCommon (mild to moderate)NoNo
Bilateral involvementRare (5-10%)CommonUnusual
Vertical deviationNone or small (< 10 PD)Bilateral small (< 10 PD)Unilateral large (>10 PD)
Superior oblique overactionNone or minimalYes, markedYes, marked
PatternNone or V-pattern Y-subtype with divergence in upgazeA-pattern Lambda-subtype with divergence in downward gazeA-pattern, often convergence in upgaze
Fundus torsionNone in primary or downgaze, intorsion in upgazeIntorsion in primary, increasing in downgazeIntorsion in primary, increasing in upgaze
Head title testNegativeNegativePositive
Forced ductionsPositiveNegativeNegative
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