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Mühlendyck H. [Superior oblique tendon trochlear passage syndrome : Causes, motility findings and treatment of acquired Jaensch-Brown syndrome]. DIE OPHTHALMOLOGIE 2022; 119:1224-1243. [PMID: 36001133 DOI: 10.1007/s00347-022-01649-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 06/15/2023]
Abstract
CLINICAL FEATURES Acquired Jaensch-Brown syndrome is characterized by a mechanical limitation of elevation in adduction, with orthophoria in downward gaze. It was first described by Jaensch in 1928 after orbital trauma in his case and has the same motility pattern as congenital Brown's syndrome. For this reason, in 1973 Brown differentiated between the "true" and "simulated" cases. Further clinical findings of the different etiological factors must be considered in order to differentiate between the two groups. ORIGIN The cause is an acquired restriction of the free passage of the superior oblique tendon through the trochlea. In most cases this is produced by a palpable swelling/nodule of the superior oblique tendon posterior to the trochlea. There are three possibilities to develop a swelling/nodule: 1. Shortly after birth due to an incomplete development at the time of birth of the sliding factors needed for a free passage. 2. An inflammation in combination with a systemic disease, such as rheumatism or idiopathic. 3. A blunt orbital trauma causing a hematoma of the superior oblique tendon. Additionally, the trochlear passage can be narrowed by a severe inflammation involving the trochlea, which is associated with a swelling and marked tenderness of the trochlear area and corresponds to stenosing tenosynovitis of the hand. TREATMENT The therapeutic management of these four variations differs significantly depending on the cause of the swelling. CONCLUSION The swelling of the superior oblique tendon posterior to the trochlea explains the motility disorder in acquired Jaensch-Brown syndrome. There are three different causes for the swelling, which require different therapeutic management.
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Affiliation(s)
- Hermann Mühlendyck
- Augenklinik der Universitätsmedizin Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Deutschland.
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Wadhwani M, Kursange S. Traumatic Gaze Restriction. J Pediatr Ophthalmol Strabismus 2022; 59:430. [PMID: 35611827 DOI: 10.3928/01913913-20220314-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fierz FC, Landau K, Kottke R, Wichmann W, Sturm V, Weber KP, Gerth-Kahlert C. The "Eyelet Sign" as an MRI Clue for Inflammatory Brown Syndrome. J Neuroophthalmol 2022; 42:115-120. [PMID: 33870947 DOI: 10.1097/wno.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brown syndrome is characterized by a restrictive elevation deficit of the affected eye in adduction. Besides the well-known congenital form, different acquired etiologies including inflammation, trauma, and surgery may prevent the superior oblique (SO) tendon from gliding freely through the trochlea on attempted upgaze. We present MRI findings in pediatric and adult patients with inflammatory acquired Brown syndrome. METHODS Retrospective review of clinical and MRI findings of 6 patients (4 children: median age 8.4 years [range 6.1-8.7]; 2 adults: age 46.4 and 51.1 years). Median follow-up was 23 months (range 1-52). RESULTS In all 6 patients, orbital MRI demonstrated inflammatory changes of the SO tendon-trochlea complex. A striking feature was circumferential contrast enhancement of the trochlea with central sparing where the tendon passes, reminiscent of an eyelet. In all cases, the motility restriction improved either spontaneously or with systemic anti-inflammatory treatment. Although both adult patients had a history of known seronegative spondyloarthritis, there was no associated systemic condition in the children in our series. CONCLUSIONS Both in children and in adults, MRI can provide evidence of inflammatory changes located at the trochlea-tendon complex in acquired Brown syndrome here referred to as the "eyelet sign," which may be helpful in confirming the clinical diagnosis and guide appropriate treatment.
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Affiliation(s)
- Fabienne C Fierz
- Department of Ophthalmology (FCF, KL, KPW, CG-K), University Hospital Zurich and University of Zurich, Zurich, Switzerland ; Department of Diagnostic Radiology (RK), University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland ; Institute of Neuroradiology (WW), University Hospital Zurich and University of Zurich, Zurich, Switzerland ; Department of Ophthalmology (VS), Cantonal Hospital St. Gallen, St. Gallen, Switzerland ; and Department of Neurology (KPW), University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Lee SJ, Won JY, Kim M. Ethmoidal sinus mucocele as a cause of acquired brown syndrome. KOREAN JOURNAL OF OPHTHALMOLOGY 2016; 28:428-9. [PMID: 25276088 PMCID: PMC4179123 DOI: 10.3341/kjo.2014.28.5.428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Seung-Jun Lee
- Department of Ophthalmology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jun Yeon Won
- Department of Otolaryngology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Moosang Kim
- Department of Ophthalmology, Kangwon National University School of Medicine, Chuncheon, Korea
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Is Delayed Release of Superior Oblique Muscle Entrapment in Orbital Roof Fracture Worth Correcting? J Craniofac Surg 2016; 27:e491-2. [DOI: 10.1097/scs.0000000000002807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Routt LA. Monocular partial/sector occlusion therapy: a procedure to inhibit diplopia in Brown syndrome. ACTA ACUST UNITED AC 2011; 82:207-11. [PMID: 21216206 DOI: 10.1016/j.optm.2010.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 07/13/2010] [Accepted: 10/04/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brown syndrome is recognized clinically as an absence or restriction of elevation in adduction. It often causes intermittent diplopia. CASE REPORT This article includes discussion of a child, age 3 years, 11 months, who underwent surgery of the right eye for a left hypertropia. By age 5 years, he complained to his mother of daily, intermittent diplopia, eye pain in both eyes (OU), and frontal headaches. Additional strabismus surgeries OU were done at ages 6¾ years and 8¼ years. At age 10½ years, the ophthalmologist first noted suspicion of acquired right Brown syndrome, which was definitively diagnosed at age 14. At that time, the original complaints remained unresolved, and his mother was hesitant to allow a fourth surgery. Thus, a procedure was devised to partially occlude a precise sector of the spectacle lens for the noninvolved eye in Brown syndrome. This successfully inhibited the daily, intermittent diplopia while allowing fusion and normal stereopsis in primary and down gaze. Also, it resolved the associated eye pain OU and headaches. CONCLUSION Monocular partial/sector occlusion therapy to inhibit intermittent diplopia in Brown syndrome offers a sensible alternative to surgery for those with normal or near-normal alignment, fusion, and stereopsis in primary and down gaze. For those who contemplate surgery, had failed surgery, or require treatment of underlying disease, monocular partial/sector occlusion therapy can serve as an excellent adjunct. Also, it may be attempted in other incomitant strabismic deviations with bothersome diplopia limited to specific positions of gaze.
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Affiliation(s)
- A O Garrick
- Department of Ophthalmology, Royal Albert Edward Infirmary, Wigan, UK
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Kiratli H, Tatlipinar S, Sanaç AS, Bilgiç S. Pseudo-Brown's syndrome secondary to a growing conjunctival dermolipoma. J Pediatr Ophthalmol Strabismus 2001; 38:112-3. [PMID: 11310704 DOI: 10.3928/0191-3913-20010301-15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- H Kiratli
- Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, Turkey
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Lacy PD, Rhatigan M, Colreavy MP, Lyons BM, Irani BN, McNab AA. Acquired Brown's syndrome caused by a fronto-ethmoidal mucocoele. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 2000; 70:688-9. [PMID: 10976904 DOI: 10.1046/j.1440-1622.2000.01914.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- P D Lacy
- Department of Otolaryngology, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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Abstract
PURPOSE To describe the clinical features in two patients with superior oblique click syndrome and the pathologic causes of their symptoms. DESIGN Two observational case reports. PARTICIPANTS Two patients. METHODS The clinical histories, results of physical examinations, treatment, and pathologic findings in two patients with superior oblique click syndrome are reviewed and analyzed with reference to the literature. MAIN OUTCOME MEASURES Relief of symptoms. RESULTS Both patients were operated on; one was found to have a schwannoma and the other a giant cell tumor of tendon sheath as causes of their symptoms. Symptoms were relieved by removal of the lesions and have not recurred. CONCLUSION Definite pathologic lesions may cause the superior oblique click syndrome.
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Affiliation(s)
- V A White
- Department of Pathology, Vancouver General Hospital, British Columbia, Canada.
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Wright KW. Brown's syndrome: diagnosis and management. TRANSACTIONS OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY 1999; 97:1023-109. [PMID: 10703149 PMCID: PMC1298285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
PURPOSE To better understand the various etiologies of Brown's syndrome, define specific clinical characteristics of Brown's syndrome, describe the natural history of Brown's syndrome, and evaluate the longterm outcome of a novel surgical procedure: the silicone tendon expander. Also, to utilize a computer model to simulate the pattern of strabismus seen clinically with Brown's syndrome and manipulate the model to show potential surgical outcomes of the silicone tendon expander. METHODS Charts were reviewed on patients with the diagnosis of Brown's syndrome seen at a children's hospital ophthalmology clinic from 1982 to 1997, or seen in the author's private practice. Objective fundus torsion was assessed in up gaze, down gaze, and primary position in 7 Brown's syndrome patients and in 4 patients with primary superior oblique overaction. A fax survey was taken of members of the American Association of Ophthalmology and Strabismus (AAPOS) listed in the 1997-1998 directory regarding their results using the silicone tendon expander procedure for the treatment of Brown's syndrome. A computer model of Brown's syndrome was created using the Orbit 1.8 program by simulating a shortened superior oblique tendon or by changing stretch sensitivity to create an inelastic muscle. RESULTS A total of 96 patients were studied: 85 with Brown's syndrome (38 with congenital and 47 with acquired disease), 6 with masquerade syndromes, 1 with Brown's syndrome operated on elsewhere, and 4 with primary superior oblique overaction in the torsion study. Three original clinical observations were made: 1. Significant limitation of elevation in abduction occurs in 70% of Brown's syndrome cases surgically verified as caused by a tight superior oblique tendon. Contralateral pseudo-inferior oblique overaction is associated with limited elevation in abduction. 2. Traumatic Brown's syndrome cases have larger hypotropias than nontraumatic cases (P < .001). There was no significant hypotropia in primary position in 56 (76%) of 74 congenital and nontraumatic acquired cases despite severe limitation of elevation. 3. Of 7 patients with Brown's syndrome, 6 had no significant fundus torsion in primary position, but had significant (+2 to +3) intorsion in up gaze. Spontaneous resolution occurred in approximately 16% of acquired nontraumatic Brown's syndrome patients. The silicone tendon expander was used on 15 patients, 13 (87%) were corrected with 1 surgery and 14 (93%) with 2 surgeries. The only failure was a Brown's syndrome not caused by superior oblique pathology. Five of the silicone tendon expander patients had at least 5 years follow-up (range, 5 to 11 years). Four (80%) of the 5 patients had an excellent outcome with 1 surgery, final results graded between 9 and 10 (on a scale of 1-10, 10 is best). The fifth patient had a consecutive superior oblique paresis and a good outcome after a recession of the ipsilateral inferior oblique muscle. The AAPOS survey had a mean outcome score of 7.3, with 65% between 8 and 10. There were 9 (6%) complications reported: 4 related to scarring and 5 extrusions of the implant. Three of the 5 extrusions were reported from the same surgeon. The computer model of an inelastic superior oblique muscle-tendon complex best simulated the motility pattern of Brown's syndrome with severe limitation of elevation in adduction, mild limitation of elevation in abduction, minimal hypotropia in primary position, no superior oblique overaction, and intorsion in up gaze. CONCLUSIONS The presence of mild to moderate limitation of elevation in abduction is common, and its presence does not eliminate the diagnosis of Brown's syndrome. The majority of Brown's syndrome patients have a pattern of strabismus consistent with an inelastic superior oblique muscle-tendon complex that does not extend, but can contract normally; not the presence of a short tendon. The presence of inelastic or tethered superior oblique muscle-tendon can be diagnosed without forced duction testing by observing the pattern of strabismus including torsion. Because of the chance for spontaneous resolution, conservative management, not surgery, should be the first line of treatment for acquired Brown's syndrome. If surgery is indicated, a novel procedure, the silicone tendon expander, is an effective option with excellent long-term outcomes.
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Affiliation(s)
- K W Wright
- Department of Ophthalmology, University of California, Irvine College of Medicine, Los Angeles, USA
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Mombaerts I, Koornneef L, Everhard-Halm YS, Hughes DS, Maillette de Buy Wenniger-Prick LJ. Superior oblique luxation and trochlear luxation as new concepts in superior oblique muscle weakening surgery. Am J Ophthalmol 1995; 120:83-91. [PMID: 7611332 DOI: 10.1016/s0002-9394(14)73762-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE We used superior oblique luxation and trochlear luxation as new surgical procedures to treat acquired Brown's syndrome and superior oblique muscle overaction. METHODS We studied nine patients (11 eyes) who underwent trochlear surgery between 1988 and 1993. Four patients had acquired Brown's syndrome and five had superior oblique muscle overaction. In five patients (six eyes) the trochlea was incised to luxate the superior oblique tendon out of the trochlea. In four patients (five eyes) the trochlea was luxated out of its fossa via a periosteal approach without opening the trochlea itself. RESULTS The mean follow-up was 18 months (range, nine to 33 months). Postoperatively, eight patients showed subjective and objective improvement. One patient with painful traumatic acquired Brown's syndrome had no objective improvement but obtained relief of pain. CONCLUSIONS These new techniques are a successful alternative in the treatment of acquired Brown's syndrome and superior oblique muscle overaction.
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Affiliation(s)
- I Mombaerts
- Department of Ophthalmology, Academic Medical Center, University of Amsterdam, The Netherlands
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Bradshaw DJ, Bray VJ, Enzenauer RW, Enzenauer RJ, Truwit CL, Damiano TR. Acquired Brown syndrome associated with enteropathic arthropathy: a case report. J Pediatr Ophthalmol Strabismus 1994; 31:118-9. [PMID: 7912268 DOI: 10.3928/0191-3913-19940301-14] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- D J Bradshaw
- Ophthalmology Service, Fitzsimons Army Medical Center, Aurora, Colo. 80045-5001
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Ilankovan V, al-Qurainy IA, Moos KF, Dutton GN. Acquired Brown's syndrome: iatrogenic causes. J Oral Maxillofac Surg 1990; 48:420-4. [PMID: 2313451 DOI: 10.1016/0278-2391(90)90445-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Two cases of iatrogenic acquired Brown's syndrome are presented, and other causes of this disorder and its treatment are discussed. Care should be taken not to cause damage when operating in the region of the trochlea.
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Abstract
Brown's syndrome is a well-recognized clinical disorder of ocular motility manifesting most notably a restriction of active and passive elevation in adduction. The original name, "superior oblique tendon sheath syndrome," is no longer appropriate, since it has been shown that the tissue surrounding the anterior superior oblique tendon is blameless as a restrictive force. "True" and "simulated" as descriptive modifiers should also be discarded, as they relate to the disproven sheath concept. Brown's syndrome occurs as a congenital or acquired, constant or intermittent condition; the common link is restriction of free movement through the trochlea pulley mechanism. The various etiologic theories are reviewed and the spectrum of medical and surgical treatments are described and evaluated. Evidence suggests that subtypes of Brown's syndrome lie on a single continuum and that spontaneous resolution occurs in each group, probably more often than previously recognized. A simplified classification scheme is encouraged and possible future directions in Brown's syndrome research are introduced.
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Affiliation(s)
- M E Wilson
- Department of Ophthalmology, National Naval Medical Center, Bethesda, Maryland
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Bradbury JA, Martin L, Strachan IM. Acquired Brown's syndrome associated with Hurler-Scheie's syndrome. Br J Ophthalmol 1989; 73:305-8. [PMID: 2496743 PMCID: PMC1041720 DOI: 10.1136/bjo.73.4.305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A 5-year-old Caucasian girl with known Hurler-Scheie's syndrome (mucopolysaccharidosis) developed a right Brown's syndrome while under orthoptic review. There was no evidence of trauma or inflammation of the superior oblique tendon, trochlea, or surrounding tissues. The Brown's syndrome in this case may be due to shortening of the superior oblique tendon, associated with the shortening of long tendons of the arms and feet, which is common in Hurler-Scheie's syndrome.
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Affiliation(s)
- J A Bradbury
- Department of Ophthalmology, University of Sheffield, Royal Hallamshire Hospital
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Folk ER, Miller MT, Mittelman D, Mafee M. Simulated superior oblique tendon sheath syndrome. Graefes Arch Clin Exp Ophthalmol 1988; 226:410-3. [PMID: 3192088 DOI: 10.1007/bf02169998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Three patients with simulated Brown's superior oblique tendon sheath syndrome are presented. With the use of computed tomographic (CT) findings, the site of the pathology could be demonstrated. In all three patients, there were definite abnormal findings in the anterior sheath of the reflected tendon of the superior oblique. The abnormal findings in one case were confirmed at the time of surgery. Therapy in two of the cases was determined by the abnormal findings on the CT scan.
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Affiliation(s)
- E R Folk
- Department of Ophthalmology, University of Illinois, College of Medicine, Chicago 60612
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Al-Qurainy IA, Dutton GN, Moos KF, Reynolds ST, McMillan N. Orbital injury complicated by entrapment of the superior oblique tendon: a case report. Br J Oral Maxillofac Surg 1988; 26:336-40. [PMID: 3166968 DOI: 10.1016/0266-4356(88)90054-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Fractures of the orbital roof are rare. Entrapment of the extraocular muscles in such fractures has not, to our knowledge, been reported previously. A case of acquired Brown's syndrome due to entrapment of the superior oblique muscle tendon in an orbital roof fracture is reported.
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Affiliation(s)
- I A Al-Qurainy
- Tennent Institute of Ophthalmology, University of Glasgow, Western Infirmary
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Olver J, Laidler P. Acquired Brown's syndrome in a patient with combined lichen sclerosus et atrophicus and morphoea. Br J Ophthalmol 1988; 72:552-7. [PMID: 3046656 PMCID: PMC1041525 DOI: 10.1136/bjo.72.7.552] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A 49-year-old woman with generalised lichen sclerosus et atrophicus and morphoea developed bilateral Brown's syndrome. Some of the skin lesions were in the vicinity of the trochlea. A characteristic feature of morphoea is subcutaneous fibrosis, so we postulate that the cause of the Brown's syndrome was mechanical tethering of the superior oblique tendon by deep subdermal fibrosis. Histopathological diagnosis was made from biopsies of similar lesions on the patient's face.
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Affiliation(s)
- J Olver
- Department of Ophthalmology, University Hospital of Wales, Heath Park, Cardiff
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