1. How to diagnose and recognize vertical deviations Part III Brown Syndrome G. Vike Vicente, MD Eye Doctors of Washington

2. Brown Syndrome Aka oblique tendon sheath syndrome Named by Brown 1950. Deficiency of elevation in adduction Divergence in upgaze Down shoot in attempted elev. in adduct. (different than IO palsy) Click felt on trochlea in some acquired cases Often seen with chin up position 2/3 are mild and do not require treatment if ortho in primary

3. Brown syndrome OS Dr. G.Vicente Divergence in upgaze Down shoot in attempted elevation in adduction?

4. In honor of Valentine’s day To understand Brown’s syndrome You have to understand relationships. Particularly the relationship between the superior and inferior oblique.

5. Normal superior and inferior oblique relationship from primary Dr. G.Vicente

6. Normal superior and inferior oblique relationship in adduction Dr. G.Vicente

7. Brown Syndrome OS (from above) Dr. G.Vicente

8. Brown Syndrome Treatment If associated with other disease –ie rheumatoid arthritis or sinusitis –Treat the underlying condition. Surgery if: –Hypotropia in primary –Anomalous head posture: severe chin up. –Consider SO tendon tenotomy, SO tendon silicone expander SO tendon chicken suture (mercilene, nonabsorbable)

9. Brown Syndrome Tx: SO tenotomy (for the less shy) SR MR LR IR SR LR RM IR IO Dr. G.Vicente

10. For those surgeons who are a little too chicken to completely cut the SO tendon and cause a SO palsy… Chicken suture technique

11. Brown Syndrome Tx: Chicken suture Dr. G.Vicente

12. For those surgeons with a sense of humor… Try the rubber chicken trick aka silicone expander

13. Brown Syndrome Tx: Silicone expander Dr. G.Vicente

14. Brown syndrome OS Dr. G.Vicente Divergence in upgaze Down shoot in attempted elevation in adduction? Down shoot in attempted elev. in adduct. (different than IO palsy)