Brown’s syndrome
Brown’s syndrome is a restriction of elevation of the eye in adduction, with normal or near-normal elevation in abduction.1 The restriction is mechanical and typically involves the superior oblique tendon. The condition is usually congenital but occasionally acquired.2
The main differential diagnosis is paralysis of the inferior oblique muscle.3 Brown’s syndrome shows a positive forced duction test on attempted elevation, no superior oblique overaction and, typically, normal alignment in primary gaze.1 Depression of the adducted eye, normal action of the contralateral superior rectus and a V pattern in upgaze also favor Brown’s syndrome, whereas inferior oblique paralysis tends to produce an A pattern.3
Congenital Brown’s syndrome usually needs no treatment as long as binocular function holds with an acceptable head posture, and spontaneous improvement is often seen toward the end of the first decade.2 Treatment is indicated for a significant hypotropia in primary position, deteriorating control or an unacceptable head posture. The recommended procedure for congenital cases is lengthening of the superior oblique tendon.2
More detail
Congenital Brown’s syndrome has long been attributed to structural abnormalities of the superior oblique muscle, tendon or trochlea that keep the tendon from moving freely through the trochlear pulley.1 Patients may report an audible click or pop, discomfort or pain on attempted upgaze.1 Acquired cases call for treatment of any treatable cause, and depending on that cause, oral steroids or a steroid injection near the trochlea may help.2
Sources (8)
- Liu, Volpe and Galetta, Neuro-Ophthalmology: Diagnosis and Management, ch. 15
- Kanski, Clinical Ophthalmology (2024), ch. 18
- von Noorden and Campos, Binocular Vision and Ocular Motility, ch. 21
- Kanski, J.J. and Bowling, B. (2011) Clinical Ophthalmology: A Systematic Approach. 7th edn. Edinburgh: Elsevier/Saunders.
- Nerad, J.A. (2010) Techniques in Ophthalmic Plastic Surgery. Philadelphia: Saunders/Elsevier.
- Rosenbaum, A.L. and Santiago, A.P. (1999) Clinical Strabismus Management: Principles and Surgical Techniques. Philadelphia: Saunders.
- Von Noorden, G.K. and Campos, E.C. (2002) Binocular Vision and Ocular Motility: Theory and Management of Strabismus. 6th edn. St. Louis: Mosby.
- Wright, K.W. and Strube, Y.N.J. (2012) Pediatric Ophthalmology and Strabismus. 3rd edn. Oxford: Oxford University Press.
Reviewed October 2026