Case Report: Idiopathic Bilateral Sequential Brown Syndrome

Objective: To report a rare case of idiopathic Brown syndrome in the left eye first, then followed by Brown syndrome in the right eye after free tenotomy and inferior oblique anteriorization of the left eye. Case Report: A 5-year old girl presented with ocular misalignment. The prism cover test at distant fixation showed hypotropia of the left eye, and chin up position which was 25 prism diopters (PD) in forced primary gaze, while in near fixation 35 prism diopters (PD). Eye movement of the left eye was markedly limited on elevation in adduction with normal elevation in abduction and markedly depression in adduction. Forced duction test of the left eye showed restricted elevation in adduction. Six months after surgical correction by free superior oblique tenotomy and inferior oblique anteriorization of the left eye, the girl showed hypotropia of the right eye, which was 35 prism diopters (PD) in primary gaze and markedly limited on elevation in adduction and limitation in elevation. Computerized tomography scan of the orbits ruled out any evolving local pathology. The right eye was managed conservatively for 6 months. Then, 10mm right superior oblique spacer was done combined with posterior fibers tenotomy and removal of the spacer in the left eye. Postoperatively, the patient was able to fix both eyes centrally with no misalignment, reasonable extra-ocular muscle movements and excellent vision. Conclusion: Cases of BS can be identified by positive forced duction test. Management of BS is a real challenge to ophthalmologists. Nevertheless, conservative management for several months may prove effective in some cases of BS among children.