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  • 1.  Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 08:53
    Edited by Michel Van Lint 07-03-2025 08:54

    Today, I saw an 8-year-old girl who presented with a sudden unilateral Brown syndrome last week (apologies, not a CN IV palsy, as the title implies).
    She was seen by a colleague who had ordered a CT scan and which is supposed to be normal.

    The orthoptist suspected Brown syndrome, but there is no pain on eye movement or when applying pressure in the supratrochlear region. Because of her young age, I am inclined to request an MRI scan.

    Since I only see children on a less frequent basis, I would like to hear your opinion on this?

    Kind regards,

    Michel



  • 2.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 08:59
    Pain, in my experience is not a common complaint in Brown's syndrome. Do forced ductions to see if the eye cannot elevate in adduction. And a fourth does not look like Brown's regarding measurements, usually.
    +=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
    Scott Forman, MD
    Senior Fellow North American Neuro-ophthalmology Society

    Adult and Pediatric Neuro-ophthalmology
    Comprehensive Ophthalmology
    Functional Medicine













  • 3.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 09:03
    There should be no confusion with the very different Brown syndrome; ask for precise measurements & look @ 9 Gaze photos before ordering MRI. 
    Recent vaccination?
    LK





  • 4.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 09:21

    Acquired Browns syndrome with acute presentation should have some pain or tenderness . Please go ahead with MRI brain and orbit. 
    If it is not an isolated IO palsy ( u can look for SO over action ) and indeed is an acquired Browns, please take a rheumatologists opinion too to r/o the CTD causes of BS

    Dr Shikha Bassi
    Sankara Nethralaya 
    Chennai
    India



    Original Message


  • 5.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 10:12

    Dear all,

    Thank you very much. I can confirm that it is a Brown syndrome and that there is no confusion with a CN IV palsy, but I cannot edit the title anymore. When I have a lack of sleep I become dangerous....

    Michel




  • 6.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 13:57
    Old photos to document if really a new
    Problem




    Original Message


  • 7.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 10:55
    What are the measurements? How could the orthoptist get a Brown's and you got a CN IV? 
    If a variable diplopia, consider MG.
    On the other hand, the 2 can coexist. Would be good to get a dedicated orbit MRI, looking for SO atrophy 
    Floyd Warren





  • 8.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 11:16
    Please tell us why you feel you confirmed that this is Brown's syndrome and not IV no palsy. If this is a fourth nerve palsy, it could very well be congenital and not acquired. Children with congenital fourth nerve palsy often present "acutely". The tip off would be whether it is or has been intermittent, indicating that the patient has large vertical fusion vergences. Are there times where the eyes appear straight, and the  vertical deviation is not present or becomes very small?  Do an alternate cover test and see whether the vertical deviation increases markedly. Also, don't forget to do a head tilt test to see whether it is consistent with fourth nerve palsy rather than browns.
    Hope this helps.
    Joel.
    Sent from my iPhone



    Original Message


  • 9.  RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl

    Posted 07-03-2025 11:26
    Meant to mention in last post, include myasthenia gravis and neurofibromatosis in differential diagnosis if 4th n palsy still a consideration,and include diagnostic tests and exam to rule these out, i.e. check skin for Café au lait spots, etc., check for Lisch nodules, antibodies for MG, and tensilon test with appropriate monitoring.
    Can you post copies of the MRI with cuts in the appropriate area?
    Joel
    Sent from my iPhone



    Original Message


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