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Browns Tendon Sheath Syndrom


Brown’s tendon sheath syndrome is a structural anomaly of ocular motility. The syndrome is characterized by a short superior oblique tendon sheath which restricts elevation of the adducted eye in free space as well as under the forced duction test.


The signs and symptoms associated with Brown’s tendon sheath syndrome may include, but are not limited to, the following:

  1. eye turn, deviation (ICD:H51.9); sensation of monocular viewing; head turn/tilt
  2. defective stereopsis and inaccurate/inconsistent depth judgment
  3. general fatigue after sustained task
  4. diplopia in primary gaze(ICD: H53.2)
  5. inaccurate eye-hand coordination
  6. reduced efficiency and productivity/diminished accuracy/inconsistent work product
  7. asthenopia and diminished performance with increased task time
  8. divergence pattern in upward gaze (i.e. “V-pattern”)
  9. abnormal postural adaptation/abnormal working distance (ICD: R29.3)
  10. spatial disorientation/incoordination/clumsiness (ICD: R27.8)


Brown’s tendon sheath syndrome is characterized by one or more of the following findings:

  1. diplopia in primary gaze
  2. absence of elevation upon adduction
  3. near normal elevation in primary position and abduction
  4. positive forced duction test (i.e. restriction of passive elevation)
  5. occasional over-action of the ipsilateral superior oblique muscle.


The doctor of optometry determines appropriate diagnostic and therapeutic modalities, and frequency of evaluation and follow-up, based on the urgency and nature of the patient’s conditions and unique needs. Vision disorders that are not totally cured through vision therapy may still be ameliorated with significant improvement in visual function and quality of life. In cases of Brown’s syndrome, co-management with medicine (i.e. internists, neuro-ophthalmology and/or ophthalmology) is often in order due to systemic complications. The management of the case and duration of treatment would be affected by:

  1. the severity of symptoms and diagnostic factors, including onset and duration of the problem
  2. the complications of associated visual conditions
  3. implications of patient’s general health, cognitive development, physical development, and effects of medications taken
  4. etiological factors
  5. extent of visual demands placed upon the individual
  6. patient compliance and involvement in the prescribed therapy regimen
  7. type, scope, and results of prior interventions


Some cases are successfully managed by the prescription of therapeutic lenses and/or prisms. Many Brown’s syndrome cases benefit from optometric vision therapy, which incorporates the prescription of specific treatments in order to:

  1. develop adequate fusional vergence ranges and stability in all positions of gaze at distance and near
  2. enhance accommodative/convergence relationships
  3. enhance depth judgments and/or stereopsis
  4. integrate binocular function with information processing
  5. enhance fusional vergence facility and flexibility
  6. integrate binocular skills with accurate motor responses
  7. integrate binocular skills with other sensory skills (vestibular, kinesthetic, tactile, and auditory)
  8. increase visual stamina/integrate newly established skills with information processing


The following treatment ranges are provided as a guide. Treatment duration will depend upon the particular patient’s condition and associated factors. When duration of treatment beyond these ranges is required, documentation of the medical necessity for additional treatment services may be warranted for third-party claims processing and review purposes.

  1. Full treatment requires resolution of associated visual conditions.
  2. The most commonly encountered Brown’s Syndrome usually requires 32 to 40 hours of office
  3. Associated factors such as cerebral vascular accident, head trauma, and/or systemic conditions may warrant an increase in treatment period.


At the conclusion of the active treatment regimen, periodic follow-up evaluation is required. Should signs, symptoms, or other diagnostic factors recur, further therapy may be medically necessary. Therapeutic lenses may be prescribed during or at the conclusion of active vision therapy to assist in the maintenance of long-term stability.