Surgical outcomes in correction of Brown syndrome

Abstract

Purpose: To evaluate the outcomes of surgery for Brown syndrome.

Methods: We reviewed the charts of 15 patients who underwent surgery for Brown syndrome. The limitation of elevation in adduction (LEA) ranged from -2 to -4 degrees. A superior oblique muscle (SO) tenotomy was performed in 4 patients, a silicone expander was inserted in the SO of 9 patients, and a SO recession was performed in 2 patients. The results of surgery were analyzed with a follow-up period of more than 6 months, 42.3 +/- 48.42 months on average.

Results: Nine female patients and 6 male patients with unilateral Brown syndrome were selected for this study. The left eye was the affected eye in 9 patients. The degree of preoperative LEA was -2 to -4 in 4 patients in whom SO tenotomy was performed, -3 to -4 in 9 patients treated with the silicone expander, and -2 to -4 in 2 patients treated with SO recession. The LEA was released after surgery in all patients without postoperative adhesion. However, unilateral overaction of the inferior oblique muscle due to excessive weakening of the SO occurred in 1 patient with tenotomy (25%) and in 1 patient with insertion of a silicone expander (11%).

Conclusions: LEA was released after tenotomy, insertion of a silicone expander and recession of the SO in 13 of 15 patients with Brown syndrome. SO palsy due to overcorrection and under-correction with postoperative adhesion should be avoided.

Fig. 1

Case 1. (A) Before surgery. This patient experienced -4 limitation of upward movement of the left eye in adduction and up-gaze. Elevation in abduction was normal. The movement of the right eye was normal. She presented with 10 PD ET and 6PD LHOT at distance and 35PD ET' and 6PD LHOT' at near primary gaze. A diagnosis of Brown's syndrome and accommodative esotropia with high AC/A ratio was made. (B) FDT at surgery revealed -4 limitation of elevation in adduction and -3 limitation in upgaze of the left eye. SO tenotomy was performed in the left eye. After SO tenotomy, LEA was eliminated and normal ocular rotation was obtained on postoperative day 1. (C) Seven years after tenotomy. Ipsilateral overaction of the IO (+3) and SO underaction (-1.5) developed with 20PD of esotropia. A 3-mm recession of the MR and IO extirpation without denervation were performed in the left eye. (D) After the 2^nd operation. Upward and downward movement in adduction of the left eye were normal. Esotropia of 8PD was seen in the primary gaze.

Fig. 2

Case 5. (A) Befor surgery. A 20-month-old female presented with limitation of the left eye in adduction (LEA) with esotropia of 40PD. She also experienced an inability to elevate the left eye in adduction and primary gaze. A forced duction test revealed -4 LEA. (B) After surgy. Insertion of a 5.5-mm silicone expander in the SO muscle of the left eye, a 4.5-mm recession of the right medial rectus and a 5-mm recession of the left medial rectus were performed. Orthophoria was obtained in primary gaze with -1 LEA in the left eye. (C) Five years and four months after operation, LEA was completely relieved. The patient obtained orthophoria in all gazes.

Fig. 3

Case 15. (A) Before surgery. The six-year-old boy had -4 limitation of elevation in adduction (LEA) and -4 limitation of elevation in the primary gaze of the right eye. He had 8° esophoria and 13° hypotropia of the right eye. He preferred left head turning of 10°. (B) After surgery. LEA -4 was confirmed by a forced duction test at the time of surgery. Recession of 8 mm of the SO, combined with a 5-mm Mersilene loop-suture was performed to lengthen the tendon of the SO by 13-mm. One day after surgery, the LEA had disappeared and normal ocular movement was obtained in all gazes.