We treated ten eyes in six pediatric patients with epiphora and punctal and canalicular atresia in one or both lids. Attempted probing and irrigation had failed to improve the epiphora. Nine out of ten of the lacrimal systems had additional anomalies, such as cutaneous lacrimal fistulas (anlage ducts), small sacs, and nasolacrimal duct stenosis or obstruction. A surgical plan is described for the exploration and reconstruction of these markedly abnormal nasolacrimal drainage systems, including a new method of performing bicanalicular intubation. Four of the five eyes with at least part of one canaliculus present have had resolution of epiphora.