AT A BASIC LEVEL, orbital decompression surgery, as compared with a field like, say, molecular biology, has advanced very little in the past 100 years. It still represents a lot of hammering and chiseling on a disease that would be better treated immunologically. To the credit of orbit surgeons, however, advancement of the field has not been stationary. A number of philosophical and technical advances have coalesced to evolve the surgical management of thyroid-related orbitopathy. I know that I personally have a substantially different approach to the surgical management of my own patients than I did 10 years ago. I will focus on 3 areas in which significant changes have occurred: the indications for orbital decompression, the bony surfaces that are selected for removal, and the incisions that are used to gain access to the orbital cavity.