Exact etiopathogenesis of PANDO has remained a big question for quite some time now. Inflammation, disturbances in helical structure of NLD, and cavernous bodies have been implicated; however, the accurate understanding is still elusive [1]. Future directions in this regard include careful studies of the vascular plexus surrounding the NLD, the possible protective role of tear-duct-associated lymphoid tissue, cytokine expression in obstructed ducts, developing diagnostic modalities to recognize early inflammation, and possible specific pharmacological blockers.

Recanalization of obstructed lacrimal passage under guidance is one of the current hot topics [2–6]. It is now recognized as a major therapeutic challenge. Although good success rates are occasionally reported, the long-term results are unclear and skepticism is well-justified at this stage. The major hurdle is our understanding of the etiopathogenesis. The future directions include characterizing the cytokine expressions during a scar formation, understanding the complete tissue response to recanalization and possibly developing pharmacological blockers of undesirable molecular communications.

Mitomycin-C is commonly used to reduce the cicatrix in DCR, especially the high-risk ones and thus may prevent failures. The MMC meta-analysis has shed good light on the role of MMC in DCR surgery [7]. Possible optimal concentration and duration have recently been identified in vitro [8]. The future direction is to standardize the appropriate concentration and duration by further basic studies like collagen contractility assays and clinical validation of these results. Standardized treatments of MMC will to a large extent make the clinical results comparable and objectively assessable and this would further help in knowing the clinical benefits of MMC in DCR.

The major question on lacrimal intubation is: “Does it really help?” It has been a controversial topic although a recent meta-analysis has helped straighten a few curves [9]. Major questions to explore with the use of intubation include the appropriate retention duration, significance of biofilms on stents, and the feasibility of anti-proliferative drug-coated stents.

LDALT is a term used to describe the specific lymphoid tissue of the lacrimal drainage system. It is known to possibly influence the local immunity as well as ocular surface immune integrity [10]. Numerous derangements of LDALT have been noted in dacryocystitis [11]. The future directions would be to study LDALT in well-established ovine models of lymphocyte homing and recirculation. Changes in conjunctival-associated lymphoid tissues (CALT) following dacryocystectomy could be studied to decipher CALT and LDALT interactions and how the ocular surface influences lacrimal system and vice versa. LDALT of the nasolacrimal duct should be further investigated to assess whether it confers any protective effect against symptomatic dacryostenosis.

Dacryoendoscopy is gaining firm ground and increasing popularity for expanding indications in lacrimal disorders, thus having many diagnostic and potential therapeutic implications [12–14]. Today, we can study every part of the lacrimal system in detail and it has helped us in some cases to avoid more cumbersome diagnostic techniques like DCG and CT or MR-DCG. The future directions possibly include improved instrumentation for better clarity of images, better intraluminal mobility, less traumatic adjunctive instruments, and newer minimally invasive intraluminal surgical techniques.

A thorough insight of lacrimal embryology is essential for advancing lacrimal science in terms of fundamental reasoning and developing minimally invasive interventions. Newer terminologies and description of embryonic conditions have been noted recently [15, 16]. The future direction is to study the cellular mechanism of mesenchymal condensation around the lacrimal primordium during Carnegie stage of embryonic development and create models to assess the effects of its dysregulation.

The microbes involved in acute and chronic lacrimal passage inflammation are well-known [17, 18]. However, their exact roles are unknown. The concept of microbiome is picking up, which essentially studies the microbial diversity and its abundance in a specified environment using molecular biology techniques [19]. The future is to establish the microbiome of the lacrimal system in detail, study the secretomes of the suspects and its mucosal barrier effects, biofilms on stents and their significance, and the role of appropriate antibiotics if any.

Transmission electron microscopy (TEM) is being increasingly used to study the subcellular effects in lacrimal disorders and pharmacological response of tissues to medications [20, 21]. However, the normative data are inadequate. The future direction would be to map the entire lacrimal system with both the TEM and scanning microscopes, establish a large normative data, and subsequently study the ultrastructural changes in common lacrimal disorders.

Current trends and studies in cadavers had a paradigm shift effect in our understanding of lacrimal anatomy with regard to topography, Horner’s muscle, medial canthal structures, and canalicular–lacrimal sac mucosal folds (CLS-MF) [22–24]. The crucial studies should be replicated across various races to validate their significance. The future directions perhaps should direct toward studying the embryos and stillborn cadavers up to cellular level to unravel the pathogenesis of congenital anomalies. It would also be interesting to take the CLS-MF concept further and study its characteristics and implications on dacryocystitis and DCR surgery.

Stem cells is a buzz word across the specialties. The possibilities of managing lacrimal disorders through stem cells should definitely be a long-term goal. Stem cells have been isolated and characterized within the lacrimal gland earlier [25]. The future direction could be to explore the stemness within the lacrimal system, followed by its characterization, the cell–cell interactions, and the distant goal of regrowing the entire lacrimal system in vitro!

Most of the questionnaires used so far in lacrimal surgery are general in nature and most are administered postoperatively [26]. The morbidity with lacrimal obstructions should ideally not be assessed using questionnaires that were designed for more general conditions where systemic morbidity may change a lot of parameters. This need for lacrimal-specific questionnaires has resulted in two new models, the NLDO symptom score or the NLDO-SS questionnaire and “Lac-Q” questionnaire for DCR [27, 28]. The future direction would be to validate these in more clinical studies and add lacrimal-disorder-specific morbidities and specific psychosocial impacts.