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“Inverted Brown pattern”: A Tight inferior oblique muscle masquerading as a superior oblique muscle underaction – clinical characteristics and surgical management Guyton et al J AAPOS 2006; 10:565-572. Purpose.

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“Inverted Brown pattern”: A Tight inferior oblique muscle masquerading as a superior oblique muscle underaction – clinical characteristics and surgical managementGuyton et alJ AAPOS 2006; 10:565-572
purpose
Purpose
  • To characterize and evaluate surgical management of patients with unilateral deficiency of depression in adduction
  • i.e. SO underaction, without significant ipsilateral IO overaction
methods
Methods
  • Retrospective study
  • Patients with diplopia in downgaze who had
    • Ipsilat IO muscle weakening
    • Contralat IR muscle recession
  • Patients showed unilateral deficiency of depression in adduction, suggesting SO muscle underaction, with no or minimal IO muscle overaction
  • 8PD hypertropia in involved quadrant of downgaze
  • No more than 6-7PD of overelevation in adduction
results
Results
  • 12 pts
    • 3 had prev surgery for Brown syndr
    • 4 had prev orbital floor trauma
  • Exaggerated forced duction testing
    • Recorded for 9 pts (other 3 not recorded)
    • Tight IO muscle recorded for 7pts (78%), with no laxity of SO tendon
results continued
Results continued
  • 12 pts
    • 4 had contralateral IR muscle recession
    • But in all 4, deficiency of depression in adduction recurred
    • Ave FU 16mo (7wks to 5yrs)
    • 8 had IO muscle weakening procedure
      • IO recession (5) or
      • IO denervation & extirpation (3) – for excessive tightness on exaggerated FDT
    • Achieved overall improvement of ocular alignment
  • 9 subsequent patients with similar pattern of misaligment treated with IO weakening
    • Good results
conclusions
Conclusions
  • “Inverted Brown pattern”
    • Caused by tight or inelastic IO muscle
    • Treatment:
      • IO muscle weakening procedure
      • Even though no significant IO muscle overaction
      • Better results than IR muscle recession
discussion
Discussion
  • “Inverted Brown pattern” not the same as “Reverse Brown Pattern”
  • “Reverse Brown Pattern” - Jampolsky coined the term to describe cases of
    • Thyroid myopathy with asymmetric upgaze deficiencies due to asymmetric IR muscle tightening
discussion1
Discussion
  • “Inverted Brown pattern” inverted wrt Brown syndrome
  • Difference:
    • Y pattern sometimes seen in Brown synd
    • No Y pattern in “inverted Brown pattern”
        • Due to less side slip of IO muscle – firmly attached to IR muscle sleeve whilst more slip occurs with SO tendon causing Y pattern
discussion2
Discussion
  • Customary treatment for apparently underacting SO with no or minimal IO overaction
    • Ipsilateral SO tuck or
    • Contralateral IR recession
  • Consider IO muscle weakening
    • Good results (small numbers, no longterm follow-up)
    • Analogous to Brown Syndrome
    • Low complication rate (rare fat adherence syndrome)
ad