The management of dacryolithiasis is driven by the goal of resolution of secondary obstruction and/or inflammation. Although a large number of dacryoliths are incidentally found during dacryocystorhinostomy, certain clinical features such as unilateral sac distension, particularly those with a palpable firm medial canthal mass, might lead one to have a high index of suspicion. It remains unclear if the incidental finding of a dacryolith during a dacryocystorhinostomy has a favorable prognostic value.