This is a retrospective review of 22 patients with inverted papilloma, including nine cases confined to the nasolacrimal system and 13 involving into the orbit. This is a rare disease and the report is the largest published series of periocular inverted papillomas. Medial canthal swelling and epiphora were the commonest presenting symptoms and were present for an average of 33 months prior to presentation. Associated risk factors were smoking, dust or aerosol exposure and human papilloma virus. Smoking was also associated with a higher recurrence rate. Of those with orbital invasion, 69% were from the nose or sinuses, and 31% via the nasolacrimal system. All cases were treated with surgical excision. Four of the 22 had malignant pathology at presentation and a further two underwent later malignant transformation up to five years after surgery. Five cases recurred (23%) only one of which was from the group initially confined to the nasolacrimal system. Overall mortality was 9%. The authors suggest the disease involving the orbits may be inherently more aggressive than those confined to the lacrimal system. They have produced an algorithm for the management of inverted papillomas based on the presence of orbital involvement, bony erosion on CT, histology on biopsy and a history of smoking. The outcomes of the algorithm are excision with clean margins, or excision with a wide margin with or without adjunctive chemotherapy / radiotherapy. Unfortunately, there is a lack of clarity over the definitions of wide and clean margins. As disease can recur late, longer follow-up periods are justified with a recommendation of five to seven years, but longer in higher risk patients.