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In summary, some differences between the lacrimal systems of males and females and those of different races have been well documented, such as the smaller nasolacrimal canal diameter of women as compared with men. However, further comparative studies are needed to fully address the anatomic differences, which would provide better surgical guidelines. Variations exist even within each gender and race. The key to being a successful lacrimal surgeon lies in the awareness of such nuances and the ability to adjust surgical technique when an anatomic variation is encountered in any patient.

The etiologies of nasolacrimal outflow obstruction are multifactorial. They can be the result of external forces causing clefts in the outflow pathway or of pressure causing occlusion of the system, as seen with nasal cysts or masses. Genetic factors may have a role in the embryogenesis of syndromic entities that are associated with epiphora. Obstruction to outflow must be distinguished from other causes of tearing such as lid malpositions, abnormal or misdirected lashes, or a poor lacrimal pump mechanism. An understanding of the various etiologies can help in better appreciating the anatomic sites of dysfunction and in the selection of the most appropriate medical and surgical solutions.