Eye muscle surgery in persistent bilateral trochlear paralysis and concomitant Brown phenomenon after indirect craniocerebral trauma

Background: Rarely, an additional Brown's syndrome develops spontaneously in cases of posttraumatic bilateral superior oblique palsy. Surgical measures are controversial and problematic.

Methods: We here report on a 40-year-old patient who, 2 years after blunt head trauma, presented with residual bilateral VIth nerve palsy with 12 degrees excyclotropia in downgaze, abnormal head postures of 20 degrees chin down position in binocular viewing and reduced elevation in adduction. His binocular field of gaze ranged from 10 degrees upgaze to 25 degrees upgaze. After thorough discussion of the situation we suggested bilateral superior oblique tucking, depending on interoperative findings. In a forced duction test under general anesthesia both eyes showed restricted elevation in adduction. Both superior oblique tendons seemed stiff. A 2.5-mm tuck (right) and a 3.0-mm tuck (left) of the anterior part of the tendon were performed. After operation the patient showed a central field of binocular fusion ranging from 10 degrees upgaze to 25 degrees downgaze, in right gaze up to 30 degrees and in left gaze unrestricted. Excyclotropia was present only in downgaze and not more than 6 degrees.

Conclusions: A low-dosage anterior tuck of the superior oblique tendon was successful in eliminating excyclotropia sufficiently and enlarging the binocular field of fusion.