Treatment of Brown
The treatment of Brown syndrome is to release the mechanical limitation to elevation in adduction caused by abnormalities in or around, the trochlea/tendon of the superior oblique. As the cause varies, likewise the treatment should. Probably the only fair statement is that no single treatment is effective for all cases; for example,
1. Inflammation around the trochlea tends to be intermittent and self limiting. Injection of steriod in the area of the trochlea can hasten recovery.
2. Brown syndrome after tuck can be relieved, in most cases, by take down of the tuck - particularly if the tuck has been done neatly. This can be avoided if tucking is limited to only lax tendons and the tuck is checked intraoperatively by means of the superior oblique traction test -- with adjustment, i.e., loosening, if the tuck is "too tight".
3. Excision of a cyst of the proximal reflected tendon can relieve Brown in the appropriate case. However, the cyst, and therefore the Brown, can recur.
4. An anomalous insertion of the tendon can be treated successfully in some instances with a partial, posterior 7/8, disinsertion.
5. Fascial restrictions are hard to pin down as a discreet cause of Brown syndrome at the time of surgery. Surgery limited to freeing fascial restrictions is usually unsuccessful in spite of initial apparent success demonstrated by free forced ductions at surgery.
6. Superior oblique tenectomy is the surest way to free elevation in adduction in Brown but it carries the liability of producing a superior oblique palsy in a high percentage of cases.
7. The superior oblique tendon spacer of Wright has been successful in some cases. To be effective, it requires free movement in the trochlea. This procedure which simply lengthens the tendon requires excellent technique on the part of the surgeon.
A silicone spacer (#240 retinal band) approximately 5mm is sewn between -- separating -- cut ends of the S. O. tendon, thereby lengthening it while preserving its "sheath" of fascial surround.
The canine tooth syndrome which is a combination of superior oblique palsy and Brown is not very fixable. Usually, the best that can be done is relief of the restriction if the Brown is causing diplopia or an objectionable head posture followed by treatment of the superior oblique palsy with antagonist and/or yoke surgery. In cases with eyes aligned in the primary position it may be best to do nothing.
A Suggestion for Approach for Surgery on the Superior Oblique Tendon
Using a superior limbal "cuff" incision, the superior oblique tendon can be visualized from the trochlear cuff to the insertion on the globe, enabling exposure for the surgery of your choice.
The Strabismus Minute, Vol. 1, No. 7 Copyright (C) 1999 Eugene M. Helveston All Rights Reserved
Editor-in-Chief: Eugene M. Helveston, M.D.
Associate Editor: Faruk H. Orge, M.D.
Editorial Board: Bradley C. Black, M.D.
Edward O'Malley, M.D.
David A. Plager, M.D.
Derek T. Sprunger, M.D.
Daniel E. Neely, M.D.
Naval Sondhi, M.D.
Senior Editorial Consultant: Gunter K. vonNoorden, M.D.
Graphics: Michelle L. Harmon
Technical Support: George J. Sheplock, M.D.