Acquired Brown Syndrome

A 51-year-old male presented with complaints of diplopia for 1 month. The patient was a hepatitis B carrier. His vision was normal with an acuity of 6/6 in both eyes. A prism cover test showed 8 prism diopters of left hypertropia, which increased to 14 prism diopters on left gaze and decreased to 2 prism diopters on right gaze. The left hypertropia was 4 prism diopters on right head tilt and increased to 10 prism diopters on left tilt. Extraocular movements revealed limited supero-nasal movement in the right eye (Fig. 33.1). Anterior segments were normal with clear lens in both eyes. Fundoscopic examination showed normal posterior poles (Fig. 33.2). A Maddox double rod test found a 3° of intorsion in the right eye. A Worth four-dot test disclosed diplopia on both near and far targets. The patient could identify the fly only in the Titmus stereoacuity test. Antinuclear antibody was found to be 1:160× positive, while immunoglobulins and complements were normal. Tenderness over the right trochlear region was also noticed. MRI showed enhancement over the right superior oblique tendon (Fig. 33.3). Under the impression of right trochlear tendonitis, we gave him an injection of 10 mg triamcinolone acetonide over the right trochlear region. One month later, the patient felt much improved with better vision and relief of pain and diplopia. His range of movement improved in the supero-nasal direction of the right eye (Fig. 33.4).