Brown Syndrome: Treatment Options
For Brown syndrome causing hypotropia in primary position or significant abnormal head posture, surgical intervention with superior oblique tenectomy is the most effective treatment, while observation is appropriate for mild cases without functional impairment. 1
Initial Management Strategy
Observation is the first-line approach for most cases, as spontaneous resolution occurs more frequently than previously recognized across all subtypes of Brown syndrome 2. This conservative approach is particularly appropriate when:
- No hypotropia exists in primary position 1
- Abnormal head posture is minimal or absent 1
- The patient maintains functional binocular vision 2
Non-Surgical Treatment Options
For acquired Brown syndrome, particularly when associated with inflammation or trauma:
- Systemic corticosteroids may be administered to address underlying inflammatory causes 1
- Intra-trochlear steroid injections can be considered for localized inflammatory processes 1
- These approaches target the pathophysiology of restricted superior oblique tendon movement through the trochlea 1
Surgical Indications
Surgery becomes necessary when functional impairment occurs, specifically:
- Hypotropia present in primary gaze position 1
- Significant abnormal head posture affecting quality of life 1
- Persistent symptoms despite conservative management 2
Surgical Techniques
Superior Oblique Tenectomy (Most Effective)
Complete tenotomy of the superior oblique tendon just medial to the superior rectus muscle provides the best surgical outcomes 3. The procedure works because:
- The cut tendon retracts only 8-10 mm medially due to capsular attachments to the trochlea 3
- This limited retraction prevents excessive weakening while relieving the restriction 3
- The underlying pathophysiology involves a fibrotic strand in the superior oblique muscle tendon that creates the elevation deficit 1
Critical Surgical Caveat
Iatrogenic superior oblique paralysis is a frequent complication, occurring in approximately two-thirds of patients (8 of 12 in one series) 4. This complication:
- Often requires additional corrective surgery 4
- Presents special clinical management challenges 4
- Must be discussed during informed consent 4
Alternative Surgical Approaches
Other techniques with variable success include:
- Silicon tendon expander placement for cases requiring controlled lengthening 1
- Z-tenotomy or split tendon lengthening (historically less successful than complete tenectomy) 3
- Traction/manipulation of the superior oblique tendon during surgical exploration, which has shown success in select acquired cases following trauma 5
Clinical Pearls
The restriction in Brown syndrome results from impaired movement of the superior oblique tendon through the trochlea pulley mechanism, not from the tendon sheath itself 2. This understanding has led to abandoning the original terminology "superior oblique tendon sheath syndrome" 2.
V-pattern strabismus commonly accompanies Brown syndrome and should be assessed during examination 1.