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Dacryocystorhinostomy (DCR) has been a primary treatment for adults with nasolacrimal duct obstruction, while the optimal approach and technique remain controversial. With the advancement of endoscopic DCR and the silicone stents, an update of the surgical outcomes and preferable approaches is required. This study aims at comparing the surgical outcomes of endoscopic DCR using pushed bicanalicular intubation (BCI) to pulled monocanalicular intubation (MCI) in adults with primary acquired nasolacrimal duct obstruction (PANDO). Forty five eyes of 45 patients were enrolled, including 22 eyes of 22 patients treated with endoscopic DCR with pulled MCI and 23 eyes of 23 patients with pushed BCI from January 2014 to June 2021. The success rates at stent removal, 1 month and 3 months after removal were 95, 91, and 82%, respectively, in the MCI group, and 100, 87, and 87% in the BCI group. The BCI group had better success rates but failed to reach a significant difference (p = 0.49, p = 0.67, p = 0.24, respectively). After analyzing with binary logistic regression, the implant material was demonstrated as the predictive of surgical success (p = 0.045). There was no significant difference in success rates between patients with dacryocystitis and those without dacryocystitis. We conclude that endoscopic DCR with pushed BCI is easily manipulated and has a promising surgical outcome over pulled MCI. Stent indwelling duration as well as history of dacryocystitis have less influence on the success rates.

BackgroundLagophthalmos with exposure keratopathy is a potential vision-threatening complication following surgery for blepharoptosis. We report three cases successfully treated with botulinum toxin-A (Botox®, Allergan, Irvine, USA) for this complication.CasesThree patients presented with severe blepharoptosis after surgery for orbital and frontal base tumors. They obtained good appearances after frontalis-orbicularis oculi muscle (FOOM) flap shortening. However, exposure keratopathy developed after the surgery despite frequent use of topical lubricants and autologous serum eye drops. We injected 5-10 units of botulinum toxin-A around the central supra-brow area, which was near the origin of the FOOM flap. One week later, they developed ptosis and could close the eye completely. The corneal defect gradually resolved. They recovered from ptosis 3 months later and never required a second injection.ObservationsLagophthalmos with exposure keratopathy is a potential vision-threatening complication following FOOM flap surgery. In severe cases, surgical revision should be considered to partially or totally release the FOOM flap attachment, which also decreases its function permanently. In this case series, we demonstrated that injecting botulinum toxin-A may be a promising method to manage this complication without permanently affecting the function of the FOOM flap.ConclusionsA botulinum toxin-A injection may be an effective treatment for patients developing exposure keratopathy after FOOM flap surgery.