# Primary Malignant Melanoma of the Nasolacrimal Duct Presenting Without Hemolacria: A Case Report and Literature Review

## TL;DR

A rare case of nasolacrimal duct melanoma without bloody tears was diagnosed early using imaging and biopsy, leading to successful treatment with surgery and radiation.

## Contribution

This case report challenges the assumption that bloody tears are essential for diagnosing nasolacrimal duct melanoma and emphasizes early diagnosis and treatment.

## Key findings

- Early diagnosis via imaging and biopsy prevented tumor spread in a patient without hemolacria.
- Combining surgery and radiation therapy led to two years of disease-free survival.
- The absence of hemolacria should not rule out malignancy in persistent lacrimal obstruction.

## Abstract

Nasolacrimal duct melanoma is an extremely rare and aggressive cancer affecting the tear drainage system. Because its early symptoms—such as tearing and eye discharge—look exactly like common benign infections, doctors often miss the diagnosis until the tumor has grown large. It is widely believed that “bloody tears” are a key warning sign of this cancer. However, we report a case of an elderly woman who had this cancer but never experienced bloody tears; she only had persistent tearing and discharge. By using advanced imaging and biopsy early, we diagnosed the cancer before it spread. She was treated with a combination of surgery and radiation therapy and remains cancer-free after two years. This report is important because it warns doctors not to wait for bloody tears to suspect cancer. It suggests that early diagnosis followed by complete surgical resection, with consideration of adjuvant radiotherapy, may provide durable local control in selected patients.

Primary malignant melanoma of the nasolacrimal duct is a rare and aggressive mucosal neoplasm. Its diagnosis is frequently delayed because early symptoms often mimic benign inflammatory conditions like chronic dacryocystitis. While hemolacria is considered a hallmark sign, it is not universally present. We present a case of a 78-year-old woman with a 1-year history of persistent epiphora and discharge from the left eye, without hemolacria. Initial lacrimal irrigation suggested obstruction. Computed tomography (CT) revealed a soft tissue lesion with widening of the lacrimal bony canal but without gross destruction. An incisional biopsy confirmed malignant melanoma. The patient underwent wide surgical resection, including medial maxillectomy, followed by adjuvant intensity-modulated radiotherapy (50 Gy). The tumor was BRAF wild-type. At 24 months post-treatment, the patient remains disease-free with no evidence of recurrence or metastasis. This case highlights that the absence of hemolacria should not preclude the suspicion of malignancy in refractory lacrimal obstruction. Early cross-sectional imaging and biopsy are essential for accurate diagnosis. Furthermore, this case suggests that a multimodal approach combining wide surgical excision and adjuvant radiotherapy may contribute to durable local control in selected patients.