Brown Syndrome Treatment & Management

Spontaneous resolution of Brown syndrome rarely occurs; if it does, it is more likely in nontraumatic acquired cases. Because of the possibility for late spontaneous recovery, a conservative approach to management is justified, especially for patients with nontraumatic acquired cases.

• Patients with acquired Brown syndrome should be evaluated medically for coexisting systemic disease.

  • If a disorder, such as rheumatoid arthritis or sinusitis, is identified, treat accordingly.
  • Once systemic disease is excluded, patients who have acquired Brown syndrome with signs of inflammation can be treated with anti-inflammatory medication. Oral ibuprofen is a good first-line choice. Local steroid injections in the area of the trochlea and oral corticosteroids can be used for inflammation.
  • Once the inflammatory disease process is controlled, patients with inflammatory Brown syndrome may show spontaneous resolution.
• Congenital Brown syndrome is unlikely to improve spontaneously; therefore, surgery is important to consider as an option.

The most important indications for surgery are the presence of chin elevation and severe limitation of elevation in adduction, which significantly interferes with the quality of life. Acquired nontraumatic cases should be observed conservatively, because spontaneous resolution may occur. Consider surgery for long-standing cases.

The treatment of superior oblique Brown syndrome is to lengthen the tendon and release the restriction without causing a superior oblique palsy. The first phase is to identify the restriction's cause, inelastic superior oblique tendon or no superior oblique tendon (eg, fat adhesion). The most important signs of inelastic tendon etiology include positive forced duction that is worse with retropulsion, intorsion in upgaze, and negative forced duction after transecting the superior oblique tendon. The best surgical procedures lengthen the tendon rather than severing the tendon. The old procedure of tenotomy was associated with 50-80% risk for iatrogenic superior oblique palsy. The surgically caused superior oblique palsy is worse than the Brown syndrome in many cases.

• Wright silicone tendon expander technique (preferred method)

  • This technique consists of elongating the superior oblique tendon by performing a tenotomy and then of inserting a segment (about 5 mm) of medical-grade silicone 240 retinal band between the cut ends of the tendon.
  • Silicone must be placed within the tendon capsule without disrupting the floor of the tendon capsule; otherwise, complications, such as postoperative adherence of the silicone to the sclera or spontaneous extrusion of the implant, may occur.
  • This technique has been effective.
  • The silicone tendon expander procedure is not easy to perform because tenotomy or tenectomy requires special surgical techniques.
  • Preoperative and postoperative images of a patient who underwent the silicone tendon expander procedure are shown below.This patient has the longest follow-up in the silicone tendon expander group at 11 years. A. Preoperative composite photograph of eye movements, showing right Brown syndrome. The patient underwent silicone tendon expander, 6 mm right eye. B. Postoperative photograph 3 years after surgery, showing full ocular motility. C. Postoperative photograph 11 years after surgery, showing continued normal ocular motility. Courtesy of Kenneth Wright, MD.
• Superior oblique split tendon lengthening technique

  • This technique splits the tendon on the nasal side of the superior rectus muscle. The halves of the tendon are removed and then joined to lengthen the tendon.
  • The function of the superior oblique tendon remains intact and the cut tendon ends are separated in a controlled manner.
• Suture bridge

  • A nonabsorbable suture is placed to connect the cut ends of the superior oblique tendon, thus preventing a consecutive superior oblique palsy.
  • The suture bridge can act as a scaffold for scar that can reunite the cut tendon ends, thus resulting in an undercorrection with a significant residual Brown syndrome.
• Tenotomy

  • This treatment has been relatively successful for primary superior oblique overaction in nonfusing patients. However, patients with bifoveal fusion do not tolerate induced postoperative cyclovertical deviations.
  • A major problem with this technique is the uncontrolled separation of tendon ends.
  • The incidence of postoperative superior oblique paresis is reported to be 50-80%.
  • Parks and Eutis added a simultaneous ipsilateral inferior oblique recession with a superior oblique tenotomy to reduce the incidence of a secondary superior oblique palsy.^[6]
  • Use of a 5-6 mm suture bridge can keep the cut tendon ends from separating too much. Unfortunately, this suture bridge can act as scaffolding for fibrosis to reunite the cut tendon ends, resulting in undercorrections.
• Superior oblique recession

  • This procedure produces a graded slackening of the tendon.
  • The results are mixed, because undercorrections are common.
  • The problem with recessing the superior oblique tendon is that it dramatically changes the characteristics of the superior oblique tendon insertions and alters its functional mechanics. This results in the postoperative complication of limited depression.
• Superior oblique and trochlear luxation consists of removing the tendon from the trochlea by luxating the trochlea. This procedure has been abandoned.
• Sheathectomy has been abandoned.

Consult a rheumatologist in acquired nontraumatic cases.