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?
Original Message:
Sent: 7/3/2025 11:16:00 AM
From: Joel Weinstein
Subject: RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl
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.
Original Message:
Sent: 7/3/2025 10:55:00 AM
From: Floyd Warren
Subject: RE: Sudden unilateral fourth nerve palsy in 8-year-old-girl
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
Original Message:
Sent: 7/3/2025 8:53:00 AM
From: Michel Van Lint
Subject: Sudden unilateral fourth nerve palsy in 8-year-old-girl
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