Sir,

Brown's syndrome is a rare but serious complication of cosmetic blepharoplasty.

Case report

A 56-year-old male presented in 2006 with vertical diplopia, which had developed immediately after routine bilateral, upper-lid blepharoplasties performed as part of a ‘medical tourism’ package. The patient had a best-corrected visual acuity of 6/5 OD and 6/6 OS, with no previous ophthalmic history. Clinically, there was marked limitation of both dextroelevation and elevation of the left eye. Orthoptic measurements showed orthophoria in the primary position, but a manifest left hypotropia measuring 10 Prism Diopters in dextroelevation. Orbital palpation revealed no tenderness in the trochlea region. The patient had symptomatic diplopia in right gaze, which extended close to the primary position. Lees screen testing showed a mechanical limitation of ocular motility typical of an acquired Brown's syndrome (Figure 1). MRI imaging indicated normal and symmetrical extraocular muscles.

Figure 1
figure 1

Hess chart showing left Brown's syndrome.

Full size image

The clinical situation remained unchanged over a 4-year follow-up period. Peri-trochlear steroid injection was performed, to no effect. The patient was unwilling to have surgery on the contralateral eye to match the motility defect. The patient copes with the diplopia by using occlusion and has been discharged from clinical care.

Comment

Complications of blepharoplasty are generally mild, but acquired strabismus is a rare, serious complication. Both horizontal1 and vertical strabismus2, 3, 4 have been described. Previous case reports of acquired Brown's syndrome following blepharoplasty are scarce. Bhola et al2 reported on one case where MRI revealed scarring of the reflected superior oblique tendon. Kushner and Jethani3 reported one case where the superior oblique tendon could not be identified as a distinct structure following blepharoplasty. Syniuta et al4 reported on one case with concurrent superior oblique weakness and Brown's syndrome.

Surgery is indicated with either vertical diplopia in the primary position or severe compensatory head posture. Surgical correction is difficult and rarely successful in achieving binocular single vision in the primary position. In most cases, surgery is not indicated and patients are managed conservatively.

Blepharoplasty is the second most common cosmetic surgical procedure performed,5 and with the popularity of such procedures increasing alongside the increasing ease of access to such procedures, the public, media and professionals should be aware of the potential serious risks.