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

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.