Brown Syndrome Secondary to SARS-CoV-2

A 51-year-old Caucasian man developed vertical binocular diplopia 2 days before consultation. On ocular examination, the patient was found to have 10-prism diopter left hypotropia in primary gaze, an inability to elevate the left eye in an adducted position (Fig. 1).

Photo and Video Essay Section Editors: Melissa W. Ko, Dean M. Cestari, Peter Quiros, Kimberly M. Winges, MD MD MD MD Brown Syndrome Secondary to SARS-CoV-2 Patricia Fernández Tezanos, MD, Adalgisa Corona Peralta, MD FIG. 1. Initial presentation of the patient. Evidenced limitation to elevation in adduction of the left eye and 10-prism diopter hypotropia of the left eye in primary gaze. A 51-year-old Caucasian man developed vertical binocular diplopia 2 days before consultation. On ocular examination, the patient was found to have 10-prism diopter left hypotropia in primary gaze, an inability to elevate the left eye in an adducted position (Fig. 1). Forced duction testing was positive for restriction of up gaze in the adducted position. No limitation of depression of the left eye in adduction was found, and no restriction of elevation of the left eye in abduction was noted. During examination, he also referred tenderness to palpation over the superonasal bony orbit. Axial and coronal computed tomography scans of the orbits showed an enlargement of superior oblique tendon and trochlea of the left side, respectively, (Figs. 2 and 3). Two days after the first visit the patient referred high fever, fatigue, myalgia, arthralgia, headache, and dry cough, and test for Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2) was performed and it was positive. The patient received treatment with zinc, vitamin C, vitamin D, remdesivir, and 800 mg of ibuprofen were administered three times daily. Three weeks later the patient returned referring significant improvement, with mild diplopia exclusively in up gaze in adducted positions (Fig. 4). FIG. 2. Axial computed tomography of the orbit showing marked left superior oblique tendon inflammation (arrow). Department of Neuroopthalmology, Hospital Doctor Elías Santana, Calle Duarte, Santo Domingo, Dominican Republic. The authors report no conflicts of interest. Address correspondence to Patricia Fernández Tezanos, MD, Hospital Dr. Elías Santana, Prolongación Duarte, Esq. Hato Nuevo, Los Alcarrizos 10801; E-mail: [e-mail]. e600 FIG. 3. Coronal computed tomography of the orbit showing marked left trochlear inflammation (arrowhead). Fernández Tezanos and Corona Peralta: J Neuro-Ophthalmol 2022; 42: e600-e601 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay FIG. 4. Almost 1 month posterior to the initiation of treatment. No limitation to elevation in adduction or hypotropia. Brown syndrome is a rare form of strabismus that affects slightly more women than men. Typical presentation is the inability to elevate the eye in adduction, along with vertical diplopia, primarily in supraduction and to the contralateral side of the affected eye. This occurs because of tightening of the posterior fibers of the tendon, impeding correct pulleylike movement. They might adopt chin elevation and face turn to compensate for diplopia. Guyton exaggerated forced duction testing will reveal restriction on inward and upward movements, confirming the diagnosis of restrictive strabismus (1). It can be congenital or acquired and is generally unilateral at presentation (2). Acquired Brown syndrome has been described to arise secondary to trauma, inflammation, sinusitis, or eyelid surgery, even autoimmune diseases such as psoriatic arthritis. For instance, orbital imaging and blood panel should be indicated on presentation. Congenital Brown syndrome can be self-limited, and others may require surgery (sheathectomy with inferior oblique tuck) (3). Acquired disease might have a recurrent course and can be treated using oral anti-inflammatory therapy. Bone, joint, and muscle involvement in SARS-CoV-2 infection has been widely documented since 2020 (4). Even reduced bone mineral density independent of the corticosteroid therapy has been reported. Secondary trochleitis and tendinitis is just proof to how far can it go. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: P. Fernández Tezanos; b. Acquisition of data: A. Corona Peralta; c. Analysis and interpretation of data: A. Corona Peralta. Category 2: a. Drafting the manuscript: P. Fernández Tezanos; b. Revising it for intellectual content: P. Fernández Tezanos and A. Corona Peralta. Category 3: a. Final approval of the completed manuscript: A. Corona Peralta. REFERENCES 1. Wright K. Alphabet Patters and Oblique Muscle Dysfunctions: Brown Syndrome. 2nd ed. Verlag, New York: Springer, 2003: 245–248. 2. Hoyt C, Taylor D. Special Forms of Vertical Strabismus: Brown Syndrome. 4th ed. Amsterdam, Netherlands: Elsevier Saunders, 2013: 807–808. 3. Brown syndrome. (2015, February 11). NORD (National Organization for Rare Disorders). Available at: https:// rarediseases.org/rare-diseases/brown-syndrome/. 4. Disser NP, De Micheli AJ, Schonk MM, Konnaris MA, Piacentini AN, Edon DL, Toresdahl BG, Rodeo SA, Casey EK, Mendias CL. Musculoskeletal consecuences of COVID. J Bone Joint Surg. 2020;102:1197–1204. Fernández Tezanos and Corona Peralta: J Neuro-Ophthalmol 2022; 42: e600-e601 e601 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.