Case 2
A 5 year-old girl presents with complaints of “double-vision” when she looks up. She says her vision is good.
Following presentation of the clinical photograph and the above brief history, the candidate will be asked to discuss proper handling of the case by discussing at least some of the following:
Data acquisition:
History (any additional information from the history that the candidate might want to know):
- Parents noticed eyes “not tracking together” past 2–3 years. No new changes.
- No history of trauma.
- No other eye problems.
- No family history of eye problems.
Expected findings:
- A left exotropia is evident in upgaze (Y-pattern XT).
- There is limited elevation in adduction of the left eye.
- Patient may demonstrate abnormal head position (chin up most likely).
- Vision is 20/20 OU.
- Stereopsis is 60 sec (normal).
Diagnosis:
Differential diagnosis:
1. Discuss difference between congenital and acquired Brown’s syndrome including various etiologies of acquired (trauma, inflammatory, etc.). Differential may also include double elevator palsy, inferior oblique paresis, and superior oblique overaction.
Additional testing:
- Forced duction testing may be useful for confirmation.
- If traumatic, consider MRI.
- If inflammation suspected, consider autoimmune work up.
Management:
Medical therapy:
Indicated if inflammatory (NSAIDS, steroids, other autoimmune agents).
Surgical therapy:
1. Congenital Brown’s: surgery indicated for abnormal head positioning (usually chin-up). Superior oblique weakening procedure, such as silicone tendon expander or other.
