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Case of the week 20 ( December 2011 )
Right Brown Syndrome


The mother of this 7years old girl noted that her daughter is unable to elevate her right eye.
The condition was discovered shortly after birth , pregnancy and delivery were normal , no past history of head or ocular trauma and no history of  systemic illness precedes the condition . 
The girl doesn't acquire abnormal head posture and no diplopia complaint
Apart from this oculomotor disorder , both eyes examination shows no significant data




See the video of this patient


     

The ophthalmologist should be aware of the causes of monocular limitation of elevation


Strabismus Course : 17 Decision making

      In a case like this , it is essential to differentiate between paralytic and restricted limitation of movement . In this girl, forced duction test done under GA  showed restriction of elevation of the adducted eye , So I assume this is a case of restricted elevation of the right eye , almost a Brown Syndrome. Unlike in Brown syndrome,  other conditions  cause restriction of elevation from any gaze position and are not limited to restriction of elevation in adduction . Exceptions to this rule do occur and should be kept in mind; both an orbital floor fracture and endocrine orbitopathy may occasionally simulate Brown syndrome


The ophthalmologist should be also aware of the Clinical picture of Brown Syndrome :

Consistent Features :

Variable Features :

Limited elevation in  adduction

Limited elevation in 1ry  position

No limitation of elevation in abduction

Downshoot in adduction

+ve Forced duction up and in

Widening of lid fissure

 

Hypotropia in primary position

 

Compensatory head posture

The diagnosis of Brown syndrome was confirmed by demonstrating restricted forced ductions to elevation in adduction of the right eye  . The choice of surgical procedure depends on the experience and the preference of the surgeon. I prefer  medial approach to the superior oblique tendon and place a silicone spacer to lengthen the tendon.

 

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