Fig. 16. A 63-year-old man presented with a 6-month history of left inferomedial canthal swelling, epiphora, and recurrent ectropion (history of ectropion repair 4 years prior). On examination, he had a visible mass below the level of the medial canthal ligament associated with medial ectropion, local conjunctival injection, and minimal decreased abduction (A). CT scan with contrast revealed a mass lesion in the region of the lacrimal sac on axial (B) and coronal (C) views, with no evidence of bony erosion or infiltration into the nose or paranasal sinuses. Biopsy revealed a low-grade transitional carcinoma of the lacrimal sac (D) (H & E, × 200). He underwent radiotherapy with 52.5 Gy in 15 fractions over 3 weeks with regression of the tumor and no evidence of recurrence in 7 years of follow-up. He remains with good visual function and persistent epiphora due to punctal stenosis, atrophy of the lacrimal drainage system, scarring, and contracture of the medial lower lid with persistent ectropion. He has refused to undergo conjunctival dacryocystorhinostomy or excision of scar tissue with skin graft.