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 -  Brown Syndrome Lecture of 0  NEXT»

Brown syndrome was originally described by Harold W. Brown,M.D. 50 years ago as "superior oblique tendon sheath syndrome". The definition of the syndrome has since been expanded to limited elevation in adduction from mechanical causes around the superior oblique. For more than 100 years (since Difffenbach 1839), the mechanical cause of Brown syndrome, which had also been called pseudo paresis of the inferior oblique, evaded clinical strabismologists.




Left Brown - Limited Elevation in Adduction 


Favored head posture with left Brown: head up and to right where eyes do not go! Eyes positioned down and left to look straight ahead.

Clinical Characteristics of Brown Syndrome

1. Vision and stereo acuity usually normal

2. Chin up face points to opposite side

3. Deficient elevation in adduction

4. Usually some elevation limitation in straight upgaze and in abduction

5. Widened palpebral fissure on adduction

6. May or may not have downshoot of involved eye in adduction

7. May be acquired

8. May be intermittent with or without pain

Some Causes of Brown Syndrome



"Short" Superior Oblique Tendon -Including Anomalous, Broad Insertion 

2. 4a




Fascial Restrictions



Intrasheath Septae 



Trochlear Entrance Restriction




Inflammation of the Trochlea



Cyst of the Reflected Tendon



Trochlear Trauma* (Canine Tooth) * This causes superior oblique underaction and Brown syndrome



Tuck of the superior oblique tendon is usually done at or near the insertion on globe



Iatrogenic Brown occurs when a tendon of normal length and consistency is shortened. S.O. tendon tuck should be limited to loose/lax - anomalous tendons demonstrated by the S.O. traction test.

Treatment of Brown

The treatment of Brown syndrome is to release the mechanical limitation to elevation in adduction caused by abnormalities in or around, the trochlea/tendon of the superior oblique. As the cause varies, likewise the treatment should. Probably the only fair statement is that no single treatment is effective for all cases; for example,

1. Inflammation around the trochlea tends to be intermittent and self limiting. Injection of steriod in the area of the trochlea can hasten recovery.

2. Brown syndrome after tuck can be relieved, in most cases, by take down of the tuck - particularly if the tuck has been done neatly. This can be avoided if tucking is limited to only lax tendons and the tuck is checked intraoperatively by means of the superior oblique traction test -- with adjustment, i.e., loosening, if the tuck is "too tight".

3. Excision of a cyst of the proximal reflected tendon can relieve Brown in the appropriate case. However, the cyst, and therefore the Brown, can recur.

4. An anomalous insertion of the tendon can be treated successfully in some instances with a partial, posterior 7/8, disinsertion.

5. Fascial restrictions are hard to pin down as a discreet cause of Brown syndrome at the time of surgery. Surgery limited to freeing fascial restrictions is usually unsuccessful in spite of initial apparent success demonstrated by free forced ductions at surgery.

6. Superior oblique tenectomy is the surest way to free elevation in adduction in Brown but it carries the liability of producing a superior oblique palsy in a high percentage of cases.

7. The superior oblique tendon spacer of Wright has been successful in some cases. To be effective, it requires free movement in the trochlea. This procedure which simply lengthens the tendon requires excellent technique on the part of the surgeon.


A silicone spacer (#240 retinal band) approximately 5mm is sewn between -- separating -- cut ends of the S. O. tendon, thereby lengthening it while preserving its "sheath" of fascial surround. 

The canine tooth syndrome which is a combination of superior oblique palsy and Brown is not very fixable. Usually, the best that can be done is relief of the restriction if the Brown is causing diplopia or an objectionable head posture followed by treatment of the superior oblique palsy with antagonist and/or yoke surgery. In cases with eyes aligned in the primary position it may be best to do nothing.

A Suggestion for Approach for Surgery on the Superior Oblique Tendon


Using a superior limbal "cuff" incision, the superior oblique tendon can be visualized from the trochlear cuff to the insertion on the globe, enabling exposure for the surgery of your choice.

The Strabismus Minute, Vol. 1, No. 7 Copyright (C) 1999 Eugene M. Helveston All Rights Reserved

Editor-in-Chief: Eugene M. Helveston, M.D.

Associate Editor: Faruk H. Orge, M.D.

Editorial Board: Bradley C. Black, M.D.

Edward O'Malley, M.D.

David A. Plager, M.D.

Derek T. Sprunger, M.D.

Daniel E. Neely, M.D.

Naval Sondhi, M.D.

Senior Editorial Consultant: Gunter K. vonNoorden, M.D.

Graphics: Michelle L. Harmon

Technical Support: George J. Sheplock, M.D.

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