Although malignancies of the lacrimal sac are rare, malignant melanoma of the lacrimal sac is an exceedingly rare occurrence. Patients with abnormalities of the nasolacrimal system may come to otolaryngologists for evaluation. Treatment of lacrimal sac malignancies will necessitate consultation of a head and neck surgeon. The triad of symptoms commonly found in these patients includes epiphora, bloody reflux from the lacrimal punctum, and a medial canthal mass. Early local recurrence occurs frequently. Radical surgical treatment, including wide-field en bloc resection of the entire nasolacrimal system, affords the best protection against local recurrence and provides the best opportunity for enhanced patient survival. Adjunctive therapy in this disorder remains controversial.