MRI of acquired Brown syndrome: a report of two cases

The "Eyelet Sign" as an MRI Clue for Inflammatory Brown Syndrome

BACKGROUND

Brown syndrome is characterized by a restrictive elevation deficit of the affected eye in adduction. Besides the well-known congenital form, different acquired etiologies including inflammation, trauma, and surgery may prevent the superior oblique (SO) tendon from gliding freely through the trochlea on attempted upgaze. We present MRI findings in pediatric and adult patients with inflammatory acquired Brown syndrome.

METHODS

Retrospective review of clinical and MRI findings of 6 patients (4 children: median age 8.4 years [range 6.1-8.7]; 2 adults: age 46.4 and 51.1 years). Median follow-up was 23 months (range 1-52).

RESULTS

In all 6 patients, orbital MRI demonstrated inflammatory changes of the SO tendon-trochlea complex. A striking feature was circumferential contrast enhancement of the trochlea with central sparing where the tendon passes, reminiscent of an eyelet. In all cases, the motility restriction improved either spontaneously or with systemic anti-inflammatory treatment. Although both adult patients had a history of known seronegative spondyloarthritis, there was no associated systemic condition in the children in our series.

CONCLUSIONS

Both in children and in adults, MRI can provide evidence of inflammatory changes located at the trochlea-tendon complex in acquired Brown syndrome here referred to as the "eyelet sign," which may be helpful in confirming the clinical diagnosis and guide appropriate treatment.

Late recurrence of idiopathic Brown's syndrome successfully treated with oral corticosteroids

INTRODUCTION

Idiopathic Brown's syndrome is a restrictive strabismus of the superior oblique tendon that often presents in pediatric populations and rarely occurs in adults.

CASE DESCRIPTION

We present here a case of a 41-year-old man with an idiopathic left Brown's syndrome that recurred after presenting with similar symptoms 14 years prior that was originally treated with oral corticosteroids. This patient had a negative work up for connective tissue disease and only exhibited subtle left trochlear thickening on orbital MRI with contrast. Since he had a good response to oral corticosteroids in the past, this repeat occurrence was treated with oral Prednisone and he promptly responded. His double vision resolved within 2 weeks and he continued to have a normal examination 6 months after presentation.

CONCLUSION

We suspect this case was related to a subclinical inflammatory process resulting in the MRI findings and response to steroids. This case demonstrates that idiopathic Brown's syndrome can recur more than a decade later in adults and oral corticosteroids are an effective treatment option even in the absence of an underlying rheumatological condition.

Brown Syndrome from Local Anesthesia for Inferior Orbital Fat Decompression

Patient: Female, 36-year-old

Final Diagnosis: Acquired Brown syndrome

Symptoms: Diplopia • vertical diplopia

Medication: —

Clinical Procedure: Local anesthesia • orbital fat decompression

Specialty: Ophthalmology

A case of acquired Brown syndrome treated with adalimumab

We present the case of a 4-year-old boy with acquired Brown syndrome of inflammatory origin. Without evidence of systemic inflammation, the disease typically resolves with oral steroids or nonsteroidal anti-inflammatory drugs. Refractory cases can be treated with local steroid injections or surgery. The present case of inflammatory Brown syndrome did not respond to conservative therapy, and parental concerns and wishes precluded more invasive treatments. Adalimumab was initiated and led to complete resolution of the disease.