Parálisis aislada del músculo oblicuo inferior izquierdo

La parálisis aislada del músculo oblicuo inferior constituye la parálisis menos frecuente de todas las que afectan a los músculos extraoculares. Se realiza la presentación de una paciente de seis años de edad con antecedentes de salud que fue traída por su madre a la consulta de oftalmología pediátrica y estrabismo por presentar una desviación ocular desde los primeros meses de nacida. Se planteó como posibles diagnósticos un síndrome de Brown del ojo izquierdo o una parálisis del músculo oblicuo inferior izquierdo, se confirmó el segundo diagnóstico con el test de ducción forzada. Existen varias opciones quirúrgicas para estos pacientes. El objetivo fue determinar si se logra el alineamiento quirúrgico en la posición primaria de mirada con la intervención quirúrgica propuesta de recesión del recto superior derecho 5 mm. La paciente se encuentra alineada en posición primaria de mirada, sin limitación de las versiones y sin tortícoli.

Isolated palsy of the inferior oblique muscle is the least frequent of all palsies affecting the extraocular muscles. We present a six-year-old female patient with a medical history who was brought by her mother to the pediatric ophthalmology and strabismus clinic because she presented an ocular deviation since the first months of her life. A Brown's syndrome of the left eye or left inferior oblique muscle palsy was proposed as possible diagnoses, the second diagnosis was confirmed with the forced duction test. There are several surgical options for these patients. The objective was to determine if surgical alignment in the primary gaze position is achieved with the proposed surgical intervention of right superior rectus recession 5 mm. The patient is aligned in the primary gaze position, without limitation of the versions and without torticollis.

Eficacia en el diagnóstico y tratamiento del síndrome de Brown / Efficacy of the diagnosis and treatment of Brown syndrome

RESUMEN Objetivo: Identificar las características clínicas y los criterios quirúrgicos en el síndrome de Brown. Métodos: Se realizó un estudio descriptivo retrospectivo a 15 pacientes con el diagnóstico de síndrome de Brown, quienes acudieron a la Consulta de Visión Binocular del Hospital Infantil Sur "Dr. Antonio María Béguez César". Se incluyeron los niños con edades entre 2 a 7 años, con el diagnóstico definido de síndrome de Brown; se realizó exploración motora y sensorial completa y se evaluó el ojo afectado, el tipo de síndrome de Brown que tenía el paciente, las características clínicas y los criterios quirúrgicos tenidos en cuenta para resolver una conducta adecuada. Resultados: En la muestra estudiada el 66,5 por ciento de los pacientes tuvo afectado el ojo derecho con un síndrome de Brown leve; el 73 por ciento estuvo en ortotropía y el 73,3 por ciento no fue quirúrgico. Conclusión: Los pacientes con síndrome de Brown leve que permanecen en ortotropía, sin tortícolis y sin depresión en aducción, no requieren intervención quirúrgica(AU)

ABSTRACT Objective: Identify the clinical characteristics of and surgical criteria for Brown syndrome. Methods: A retrospective descriptive study was conducted of 15 patients diagnosed with Brown syndrome attending the binocular vision service at Dr. Antonio María Béguez César South University Children's Hospital. The sample included children aged 2-7 years with a definite diagnosis of Brown syndrome. Complete motor and sensory exploration was done, and evaluation was performed of the affected eye, Brown syndrome type, clinical characteristics and surgical criteria considered to select the appropriate management. Results: 66.5 percent of the study sample had their right eye affected by mild Brown syndrome, 73 percent were orthotropic, and 73.3 percent were not surgical cases. Conclusion: Patients with mild Brown syndrome who remained orthotropic, without torticollis or adduction depression, did not require surgical intervention(AU)

Unilateral acquired Brown’s syndrome in systemic scleroderma: An unusual cause for diplopia.

Brown’s syndrome can be congenital or acquired with multiple causes. It has been described as a ocular complication in various rheumatic and nonrheumatic diseases. We describe a case of 27‑year‑old female patient with 5 years old history of systemic scleroderma who developed vertical diplopia, a left head tilt, and restriction of left eye on elevation in adduction. The patient responded to systemic steroids with resolution of diplopia.

Acquired Simulated Brown Syndrome Combined with Blepharoptosis after Upper Blepharoplasty

PURPOSE: Brown syndrome is motility disorder of the eyeball which shows limited elevation in adduction and occurs very rarely after eye surgery. The authors have experienced a case of strabismus-like Brown syndrome combined with blepharoptosis and report this case with the review of literatures. METHODS: A 28-year-old female suffered from hypotropia in the primary gaze and severe blepharoptosis with diplopia of the right eye after upper blepharoplasty. Rotation showed an inability to elevate the adducted right eye. She underwent extraocular muscle surgery about the 7 mm tucking of the right superior rectus muscle and 6 mm recession of right inferior rectus muscle. Intraoperatively, injury of the superior rectus muscle and foreign body were observed. Seven months after the extraocular surgery, the patient underwent frontalis muscle transfer on the right upper eyelid for the correction of blepharoptosis. RESULTS: Postoperatively, the patient was orthophoric in the primary gaze, and she had improvements in the correction of blepharoptosis and eyeball movement. CONCLUSION: Repeated eyelid surgeries increase the risk of ocular motility disorder. Careful approach is essential for the proper treatment and successful outcome in secondary surgeries.

Treatment of Posttraumatic Facial Deformity Patient with Brown's Syndrome: Case Report

PURPOSE: Brown's syndrome is characterized by the limited elevation in adduction from mechanical causes around the superior oblique tendon trochlea complex. In this particular case, post-traumatic facial deformity accompanied by Brown's syndrome was observed. We would like to report the satisfying cosmetic results obtained by reconstructing orbital roof and superior orbital rim and repositioning of zygoma. METHODS: A 12-year-old patient was observed with facial deformity with strabismus in her right eye and orbital dystopia after the car accident and was eventually diagnosed with traumatic Brown's syndrome. Reconstructive surgeries could not be performed at the time of trauma due to the cerebral hemorrhage. At the second year after the trauma, a depressed fracture of the right orbital roof and superior orbital rim were reconstructed via the intracranial approach, and orbital dystopia was corrected via the zygoma triple ostectomy. In addition, a strabismus surgery was performed one year after her plastic surgery. RESULTS: Facial deformity with orbital dystopia and strabismus was confirmed to be fully reconstructed after the surgery. Moreover, when the patient came in for a follow-up thirteen years after the operation, a developmental imbalance of the facial bones, diplopia, or any other surgical complications were not to be found. CONCLUSION: After the trauma, the patient with Brown's Syndrome accompanied by post-traumatic facial deformity, who went under the corrective surgeries after the meticulous examination and assessment pre-surgically, was able to acquire cosmetic satisfaction via those operations.

A Case of Acquired Brown Syndrome after Surgical Repair of a Medial Orbital Wall Fracture

A case of acquired Brown syndrome caused by surgical repair of medial orbital wall fracture is reported in the present paper. A 23-year-old man presented at the hospital with right periorbital trauma. Although the patient did not complain of any diplopia, the imaging study revealed a blow-out fracture of the medial orbital wall. Surgical repair with a calvarial bone autograft was performed at the department of plastic surgery. The patient was referred to the ophthalmologic department due to diplopia that newly developed after surgery. The prism cover test at distant fixation showed hypotropia of the right eye, which was 4 prism diopters (PD) in primary gaze, 20 PD in left gaze, while orthophoric in right gaze. Eye movement of the right eye was markedly limited on elevation in adduction with normal elevation in abduction with intorsion in the right eye present. Forced duction test of the right eye showed restricted elevation in adduction. Computerized tomography scan of the orbits showed the right superior oblique muscle was entrapped between the autografted bone fragment and posterior margin of the fracture. When repairing medial orbital wall fracture that causes Brown syndrome, surgeons should always be careful of entrapment of the superior oblique muscle if the implant is inserted without identifying the superior and posterior margin of the orbital fracture site.

Bilateral Brown's syndrome associated with nanophthalmos and generalized joint stiffness / 国际眼科杂志(Guoji Yanke Zazhi)

Brown's syndrome is characterized by absence or severe limitation of elevation in adduction with a positive forced duction test and minimal elevation deficit in abduction and primary position. Nanophthalmos is an uncommon congenital ocular malformation characterized by an extremely small eye. In this report,a case with bilateral Brown's syndrome and nanophthalmos combined with generalized joint stiffness was presented.

Surgical Outcomes in Correction of Brown Syndrome

PURPOSE: To evaluate the outcomes of surgery for Brown syndrome. METHODS: We reviewed the charts of 15 patients who underwent surgery for Brown syndrome. The limitation of elevation in adduction (LEA) ranged from -2 to -4 degrees. A superior oblique muscle (SO) tenotomy was performed in 4 patients, a silicone expander was inserted in the SO of 9 patients, and a SO recession was performed in 2 patients. The results of surgery were analyzed with a follow-up period of more than 6 months, 42.3+/-48.42 months on average. RESULTS: Nine female patients and 6 male patients with unilateral Brown syndrome were selected for this study. The left eye was the affected eye in 9 patients. The degree of preoperative LEA was -2 to -4 in 4 patients in whom SO tenotomy was performed, -3 to -4 in 9 patients treated with the silicone expander, and -2 to -4 in 2 patients treated with SO recession. The LEA was released after surgery in all patients without postoperative adhesion. However, unilateral overaction of the inferior oblique muscle due to excessive weakening of the SO occurred in 1 patient with tenotomy (25%) and in 1 patient with insertion of a silicone expander (11%). CONCLUSIONS: LEA was released after tenotomy, insertion of a silicone expander and recession of the SO in 13 of 15 patients with Brown syndrome. SO palsy due to overcorrection and under-correction with postoperative adhesion should be avoided.

Acquired Brown Syndrome After Retinal Detachment Surgery

PURPOSE: To report a case of acquired Brown syndrome found in the left eye of a female patient who had undergone surgery for proliferative vitreoretinopathy. METHODS: A 41-year-old female patient presented with right hypertropia and esotropia. We reviewed her history, conducted an ophthalmic examination and performed surgery. RESULTS: Prior to presentation, the patient experienced a sudden decrease in visual acuity. She was diagnosed with proliferative vitreoretinopathy caused by rhegmatogenous retinal detachment, and underwent scleral buckling. After surgery, with the eye in the primary position, the right hypertropia was 9 prism diopters and the esotropia was 30 prism diopters. The patient was unable to elevate the eye in the adducted position. A forced duction test was performed and we detected a restricted elevation in adduction. By performing a tenectomy of the superior oblique muscle and a recession of the medial rectus muscle, orthophoria was obtained in the primary position, and the elevation in adduction improved. CONCLUSIONS: Herein, we report satisfactory results of a procedure in one case of acquired Brown syndrome following retinal detachment surgery.

A Case of Acquired Brown Syndrome Following Scleral Buckling

PURPOSE: To present a case of the acquired Brown syndrome caused by scleral buckling. METHODS: A 58-year-old man presented with floaters in his right eye which had developed 20days before. Rhegmatogenous retinal detachment with a retinal tear at the location of 2 o' clock was diagnosed. Radial scleral buckling was performed. Ten days after surgery, he was unable to elevate his right eye in adduction, and right superior oblique muscle overaction was presented. RESULTS: Acquired Brown syndrome caused by scleral buckling has not been documented in Korea to our knowledge. Therefore, we report this case with review of related literatures.

Clinical analysis of Superior Oblique Plication Procedure

The purpose of this study is to evaluate retrospectively the surgical results and complications in the patients with unilateral superior oblique palsy using superior oblique plication(SO plication) only or SO plication combined with inferior oblique weakening. Among 22 patients with unilateral superior oblique palsy, there were 13 patients(59.1%) in type III, 5 patients(22.7%) in type IV, 2 patients(9.1%) in type II and 2 patients(9.1%) in type V according to Knapps classification. The mean amount of hypertropia was 18 prism diopters(PD) and 18 of 22 patients(81.8%) showed abnormal head posture(AHP). Nineteen patients (86.4%) showed horizontal strabismus and exotropia was most common. The methods of oblique and vertical rectus operation were SO plication, SO plication combined with inferior oblique weakening, combined with resection of inferior rectus, and combined with recession of contralateral inferior rectus, inferior oblique weakening, and superior rectus weakening. We performed corrective surgery on the patients with horizontal deviation more than 14 PD. Postoperatively the mean amount of hypertropia was 2.6PD. In 7 patients with superior oblique plication only the mean amount of correction in plication was 8.4PD, and hypertropia was corrected 1.2PD per mm. Thirteen of 18 patients(72.2%) with AHP and 15 of 19 patients (78.9%) with horizontal strabismus were corrected after operation. Postoperative complications were residual hypertropia in 7 patients(31.8%) and Brown syndrome in one. We conclude that plication of the superior oblique may be one of the effective procedures for correction of superior oblique palsy and possible its complications may be postoperative undercorrection and Brown syndrom.

Differential Diagnosis of Atypical Brown Syndrome and Primary Inferior Rectus Restriction of Double Elevator Palsy

Both atypical Brown syndrome (ABS) and inferior rectus restriction of double elevator palsy (DEP) are characterized by monocular limitations of upgaze in primary, abducted position as well as abducted position. Futhermore, they exhibit resistance of elevation in adduction during forced duction test and should be considered in the differential diagnosis. We gained several differential points from 6 year-old female with ABS and a 12 year-old female with DEP due to inferior rectus restriction (IRR). In forced duction test under general anesthesia, ABS exhibited resistance of elevation in adduction and IRR of DEP showed resistance of elevation in all upward direction. DEP showed an impairment of Bell`s phenomenon and mild pseudoptosis preoperatively in which ABS never showed. ABS displayed divergence in upgaze producing V-pattern, and further limitation of upgaze in adduction than DEP. Superior oblique lengthening procedure using silicone expander was performed for ABS. Ipsilateral inferior rectus and contralateral superior rectus recession were performed for IRR of DEP. The results for elevation in adduction, primary position and abduction were satisfactory in both diseases. In conclusion, the direction of resistance in forced duction test, Bell` s phenomenon, the degree of elevation in abducted and abducted position, presence of pseudoptosis and divergence in upgaze producing 3 V-pattern may be helpful to differentiate ABS from IRR of DEP.

Superior Oblique Tenotomy with Silicone Expander for Superior Oblique Overaetion and Brown Syndrome

Standard procedures for weakening the superior oblique muscle have been associated with significant complications in the treatment of superior oblique overaction and Brown's syndrome. Authors performed a technique for weakening the superior oblique muscle by lengthening the superior oblique tendon with silicone. Lengthening was accomplished by a nasal superior oblique tenotomy and inserting a segment of silicone 240 retinal band between the cut ends of the tendon. This technique was performed on 6 patients (8 eyes), 2 (4 eyes) with superior oblique overaction (SOOA), and 4 (4 eyes) with Brown's syndrome. Preoperatively patients with SOOA demonstrated A-patterns of 26 and 29 prism dioptersrespectively, and versions of +2 or +3 SOOA. Patients with Brown's syndrome demonstrated version of -3 or -4 elevation on adduction. Postoperatively, the A -patterns disappeared and SOOA was improved to 0 or +1, and underaction on adduction improved to 0 or -0.5 in Brown's syndrome. Based on these results, the superior oblique tenotomy with silicone expander is useful in patients with SOOA and Brown's syndrome.

A Case of Acquired Brown's Syndrome Caused by Tenosynovitis

Brown's syndrome is characterized by inability to elevate the adducted eye and positive forced duction test. It is known as congenital disease but may occur as acquired disease Acquired Brown's syndrome may occur after superior oblique muscle tucking, frontal sinusitis, surgery of frontal sinus or orbit, scleral buckling, and inflammation in trochlear area. Brown's syndrome caused by inflammation of trochlear area is frequently combined with rheumatoid arthritis. The ocular motiliy is improved after systemic corticosteroid treatment or local injection of corticosteroid in trochlear area. An llyear old korean girl was found to have bilateral aquired Brown's syndrome caused by tenosynovitis. There were severe limitation of elevation in adduction and resistance in forced duction test in both eyes. The ocular motility was improved after local injection of dexamethasone in trochlear area.