For nearly a century the gold standard treatment for epiphora and nasolacrimal duct obstruction has been dacryocystorhinostomy (DCR). The definitive treatment of severe canalicular stricture remains conjunctivodacryocystorhinostomy. Although the high success rate of open external approaches continues to be confirmed in the literature, there have been promising advances for endocanalicular surgery and endonasal DCR. Despite a significant narrowing of the gap in outcomes, external DCR may hold the advantage in its ease of performance and lower economic impact. A minor controversy exists over the role of routine postoperative antibiotics. Intraoperative intravenous antibiotic dosing may be as effective as postoperative systemic antibiotics for patients at high risk of infection.