Seminars in Ophthalmology, 23:291–293, 2008
Copyright

c Informa Healthcare USA, Inc.
ISSN: 0882-0538
DOI: 10.1080/08820530802505971
Management of Brown Syndrome
John Lee
Moorfields Eye Hospital
London, UK
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For personal use only.
Declaration of interest: The author
reports no conflicts of interest. The
author alone is responsible for the
content and writing of the paper.
Address correspondence John Lee,
FRCS, MRCP, FCOphth
Moorfields Eye Hospital
City Road, London
UK, EC1V 2PD.
E-mail: john.lee@moorfields.nhs.uk
ABSTRACT Brown syndrome is a challenging management problem. Con-
genital Brown syndrome may show sontaneous resolution, and conservative
management is successful in around 75% of cases. Inflammatory acquired
Brown syndrome may respond to peri-trochlear injection of steroids or oral
non-steroidal inflammatory agents. Post-traumatic acquired Brown syndrome
is not as common as it was in the “pre-seat belt” era. Surgical management can
be undertaken, but results are disappointing.
KEYWORDS Brown Syndrome, eye muscle surgery
INTRODUCTION
Harold Brown described his eponymous syndrome in 19501 , ascribing it to an
underaction of the inferior oblique muscle, but identifying the classical clinical
features of limited elevation of the affected eye in adduction, downdrift in
adduction, a “V” pattern and a positive forced duction test for passive elevation
in adduction.
The pathology is now generally agreed to be in the superior oblique ten-
don/trochlear complex, and the syndrome is subdivided into primary congen-
ital, and acquired. Acquired cases may be further classified as inflammatory,
traumatic and iatrogenic, but many other secondary causes have been reported.
This paper sets out some of our experience with primary and acquired Brown
syndrome.
PRIMARY CONGENITAL BROWN SYNDROME
Although most textbooks advocate surgical management of this condition,
it is generally agreed that surgery is unpredictable, and there is a high risk of
subsequent surgery, typically for an iatrogenic superior oblique palsy induced
by superior oblique tenectomy or tenotomy.
However, there are some reports suggesting that conservative management
may result in spontaneous improvement in some cases, thereby avoiding surgery
for either the primary motility defect or consecutive deviations.
The first of these was by Waddell, in 19822 , who reported 36 cases, followed
over a period of 1–14 years. Twenty -four (67%) showed partial or complete im-
provement. However, 14 patients underwent surgery, so the true spontaneous
improvement rate is not clear from the data reported, although clearly sponta-
neous improvement occurred.
Gregersen, in 19933 , reported 10 cases followed over 13 years. Nine improved,
and in 3 cases improvement was complete. Kaban et al.,4 also in 1993, reported
full recovery in 10 of 60 cases with a follow-up period of 48 months.
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 We have recently reviewed our own patients and
experience.5 Our management philosophy has been to
practice a conservative approach, with careful monitor-
ing but with surgery withheld unless the patient clearly
showed no sign of recovery over many years observa-
tion, or requested surgery themselves. It has been our
experience that most children with Brown syndrome are
remarkably unconcerned by their compensatory head
posture, and our main task has been to reassure their
parents that all was well, and that their child was main-
taining good control of its eye position and good binoc-
ular vision.
We retrospectively reviewed all cases referred to us of
primary congenital Brown syndrome, without previous
surgical treatment, seen between 1992 and 2002. There
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were 32 patients, 22 female and 10 male. The age at
first attendance was from 1 to 14 years, with a mean
of 6 years. This wide range reflects the nature of our
institution, with many of the older children being re-
ferred for second opinions. The age at last attendance
was from 4 to 16 years, mean 10 years.
Twenty-nine had demonstrable stereopsis on first at-
tendance, ranging from gross stereopsis to 30 arc sec-
onds. Nineteen had an abnormal head posture docu-
For personal use only.
mented at first attendance. Limitation of elevation in
adduction ranged from -5 to -2 a first visit.
Over the study period, 24 cases (75%) showed spon-
taneous improvement in ocular motility. In three cases
with bilateral Brown syndrome, both sides improved. In
eleven of these, we also documented an improvement
in stereopsis. Follow up was from 6 months to 9.5 years
with a mean of 4 years.
Five patients who failed to improve underwent
surgery. Three had superior oblique tendon expanders,
and two had superior oblique tenotomies. One of these
developed some iatrogenic superior oblique underac-
tion and required a subsequent contralateral inferior
rectus posterior fixation procedure. Long-term results
were good in all cases.
These results confirm us in our current management
plan of careful observation while awaiting spontaneous
improvement, which we anticipate in around three-
quarters of our patients. The remainder are likely not to
improve, and may require surgery, although we warn all
parents that more than one procedure may be necessary.
ACQUIRED BROWN SYNDROME
Here are many reports of acquired Brown syndrome
due to a wide variety of causes. The excellent review
J. Lee
article by Wilson, Eustis and Parks6 lists many of the
references.
Presumed inflammatory Brown syndrome is charac-
terized by typical ocular motility findings of Brown syn-
drome typically associated with pain which patients lo-
calize very accurately to the region of the trochlea of
the affected eye. There is usually local tenderness to
palpation as well. The condition does not seem to be
associated with any other systemic disorders, and may
resolve spontaneously, although relapses are common.
Some time ago we reviewed our experience with 9
cases of acquired Brown syndrome seen between Jan-
uary 1994 and December 1999. Six had a characteris-
tic presumed inflammatory etiology; three were post-
traumatic. We treated all of them with peri-trochear
injections of Dexamethasone (4 mg in 1 ml.) to
the affected side. In two cases, a second injection
was performed, followed by a short course of non-
steroidal anti-inflammatory drugs such as Flurbiprofen
by mouth.
Three of six presumed inflammatory cases obtained
good relief of both pain and restricted motility after one
injection. Three others failed to improve. None of the
post-traumatic cases showed any improvement.
It has been our experience that post-traumatic Brown
syndrome is a disappointing entity to treat. It occurred
much more frequently in the era when car windscreens
were made of toughened, not laminated glass. In ad-
dition campaigns to increase seat belt usage, and leg-
islation to make it compulsory (passed in the UK in
January 1993), markedly changed the incidence of this
problem.
In 1992, we reported6 13 cases of post-traumatic
Brown syndrome, of which 12 followed road traffic acci-
dents, and one a fronto-ethmoidectomy. The age range
was from 18 to 46 with a mean of 34. Eight were male.
All had symptomatic diplopia due to restriction of ele-
vation in the affected eye. Three also showed superior
oblique underaction on ocular rotations. Twelve of the
cases had been observed for spontaneous improvement
for a period of 9 to 30 months before surgery. One case
presented 10 years after the trauma.
All cases were initially managed with confirmation of
forced duction testing, exploration of the trochlea and
superior oblique tendon, removal of any glass foreign
bodies and superior oblique tenotomy. Post-operatively
patients were asked to do vigorous ocular rotation ex-
ercises. In 4 of 13 cases, this strategy worked fairly well,
and further intervention was not required. However,
292
 seven cases underwent a second procedure, and 2 had
a total of three operations.
These involved procedures on ipsilateral and con-
tralateral vertical rectus and oblique muscles. Patients
reported symptomatic improvement in 7 cases, no
change in 3 cases, and worsening in 3 cases. Percent-
age scored fields of diplopia-free vision improved in 8,
were not recorded in 2, and were worse in 3 at final
follow-up.
CONCLUSIONS
In primary congenital Brown syndrome, a policy of
observation will allow a substantial majority of children
to show spontaneous improvement. Surgery can be re-
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served for those who do not improve, but may require
multiple surgical procedures. Presumed inflammatory
Brown syndrome may respond to local injection of solu-
For personal use only.
293
ble steroids, but may also improve spontaneously. Post-
traumatic Brown syndrome is happily much rarer than
it was in the days before laminated windscreens and
compulsory seat belts. Management is difficult and dis-
appointing.
REFERENCES
Brown H. Congenital structural anomalies, in Allen JH (ed): Strabismus
Ophthalmic Symposium II. St Louis, Mosby, 1950, p391.
Waddell E. Brown’s syndrome revisited. Br Orthoptic J. 1982;39:17–21.
Gregersen, Rindziunski E. Brown’s Syndrome. Acta Ophthalmologica.
1993;71:371–76.
Kaban TJ, et al. Natural history of presumed congenital Brown Syndrome.
Arch. Ophthalmol.1993;111:943–46.
Dawson, EM, Barry J-S, Lee JP. Spontaneous improvement in patients with
congenital Brown syndrome. JAAPOS. In press.
Wilson ME, Eustis HS, Parks MM. Browns syndrome. Major review. Surv
Ophthalmol 1989;34:153–72.
Aylward GW, Lawson J, McCarry B, Lee JP, Fells P. The surgical treatment
of traumatic Brown syndrome. J Pediatr Ophthalmol Strabismus.
Sep-Oct;29(5):276–83.
Management of Brown Syndrome