Endocrine orbitopathy is a common feature of autoimmune thyroid disease. The increase of pressure within the eye socket leads to proptosis and compression of the optic nerve. This results in cosmetic impairment as well as loss of vision. Apart from the medical treatment surgical decompression of the crowded orbit offers a valid therapeutic option.142 patients (264 orbits) were treated at the interdisciplinary orbital center, Johannes Gutenberg University Hospital, Mainz, Germany. The medial orbital wall was removed, followed by lipectomy. Indications for decompression included cosmetic reasons (196 orbits, 74.2%), dysthyroid optic neuropathy (67 orbits, 25.4%), and in one case corneal ulceration.A median reduction of the severity score according to the NOSPECS classification from 7 points preoperatively to 4 points 3 months after surgery was achieved (p < 0.001). Median proptosis decreased from 23 to 20 mm (p < 0.001). Intraocular pressure in upgaze dropped from 23 mmHg by 3 mmHg during the first postoperative 3 months (p < 0.001). Additionally, the influence of age, sex and smoking behavior on the operation outcome was examined. Diplopia was present in 100 patients before surgery. Of the remaining 42 patients, two patients (4.8%) complained about new-onset constant diplopia 3 months after decompression, while 22 patients (52.2%) reported inconstant/intermittent motility disorders. Squint surgery corrected diplopia.The combined transnasal-endoscopic/transpalpebral approach represents a safe and efficient method for severe endocrine orbitopathy.