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Answers: 2004 series -  November 2, 2004 Lecture 9 of 50  NEXT»

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This 3-year-old boy was noted by his mother to have a "funny" or unusual appearance to his eyes when looking up.  Visual acuity is 20/20 in each eye.  Cycloplegic refraction is +.50 in each eye.  He is able to fuse the stereo fly and 3 of 3 animals on the Titmus test.  Versions show limitation of elevation of the left eye in adduction and an exodeviation in upgaze.  The remainder of the eye examination is normal.  A slight left head tilt with chin elevation is present in casual seeing.

1.  The most likely diagnosis in this case is:   

b -- Brown syndrome is defined as a mechanical restriction of elevation in adduction.  This case has all of  the clinical characteristics of Brown, but the diagnosis must be confirmed by demonstrating restriction to forced elevation in adduction in the left, involved eye.  With a young child like this, the forced duction test is ordinarily done with general anesthesia.

2.  The following is important in planning treatment for this patient   

d -- Brown syndrome does not need to be treated just because it is there.  A young child will grow up and become taller making the need to look up and therefore making the Brown less significant.  Also, the fact that the patient has good fusion, the eyes are aligned in the primary position, and the head posture is nearly normal militate against surgery.  This patient would be best managed by observation.  He does not need surgery at this time.  Surgical treatment could be considered if one or more of the following occurred: primary position strabismus, loss of fusion, worsening of the abnormal head posture.

3.  If treatment were undertaken for this strabismus, the most likely choice
would be  
  c -- The treatment for Brown syndrome is weakening of the left superior oblique.  This weakening can be accomplished in a variety of ways including: tenotomy, tenectomy, and with a spacer.  Results of surgical treatment of Brown can be varied and are not infrequently disappointing.  In addition to freeing the elevation in adduction without creating new problems, some not uncommon surgical results include persistent Brown and superior oblique palsy requiring later antagonist inferior oblique weakening.


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