Over the past century, orbital decompression surgery has evolved considerably, and balancing the techniques of orbital decompression surgery has become critical, not only to achieve effective improvement of the protruding eye, but also, and most importantly, to ensure the safety of the procedure. In the early 1980s, the transsinus approach to septal sinus decompression surgery, described by Walsh and Ogura in 1957, became the dominant technique. The greatest disadvantage of transnasal sinus medial orbital wall decompression is its tendency to cause uneven eye movements, as high as 52%. Therefore, different orbital decompression procedures have been attempted to avoid orbital decompression surgery-induced diplopia as much as possible. For mild proptosis, orbital decompression via the medial wall of the eyelid is a viable option, with an incidence of medically induced diplopia of only 4.6%. For severe proptosis, medial inferior orbital decompression combined with lateral wall orbital decompression can be performed, and the incidence of persistent diplopia is also relatively low. in 1989, in an effort to reduce the incidence of medically induced diplopia, Leone introduced the concept of balanced orbital decompression surgery, which involves medial and lateral orbital wall decompression without inferior orbital wall decompression. Current orbital wall decompression procedures focus on three walls: the medial, inferior, and lateral walls, and the orbital apex has been abandoned because of the minimal improvement in orbital cavity volume and the potential complications and sequelae associated with parietal wall decompression. Although infraorbital wall decompression is no longer preferred in North America, EUGOGO shows that infraorbital wall decompression is still the most common procedure in Europe. Depending on the severity of the protrusion, infraorbital wall decompression is the usual option, either in combination with lateral orbital wall decompression or orbital fat removal, most commonly in the outer lower quadrant. To avoid the occurrence of diplopia, the first step of the relative protocol is to perform lateral orbital wall decompression, which can be combined with orbital fat removal, and then consider decompression of the medial and inferior orbital walls as a second step if needed. In contrast to the traditional orbital decompression protocol, in which the medial and inferior walls are preferred for decompression, the lateral orbital wall and its deeper parts are preferred for decompression. Lateral orbital wall decompression, with its very low surgical risks, including complications such as persistent diplopia and cerebrospinal fluid fistulas, is extremely well suited to meet the needs of a growing cosmetic population. Studies have confirmed that deep lateral orbital wall decompression as part of a coronal incision triple wall decompression procedure can increase the improvement of orbital prominence by 32% compared to conservative traditional triple wall decompression surgery and does not increase the risk of diplopia. There is, however, a very large individual variation in the depth of the lateral orbital wall. Therefore, deep lateral orbital wall decompression is an effective decompression option, but one that is not always possible to perform. While lateral orbital wall decompression surgery alone is appropriate to improve proptosis, combined with medial wall decompression may increase the risk of persistent diplopia. Lateral orbital wall decompression surgery combined with orbital lipectomy may increase the degree of improvement in ocular proptosis and, without increasing the risk of medial strabismus, conversely, lateral orbital wall decompression combined with orbital lipectomy may improve preexisting gaze diplopia. Any type of orbital wall decompression surgery is expected to provide maximum pressure relief at the orbital apex and effectively improve optic neuropathy. The existing accepted view is that the more extensive the expansion of the bony orbital cavity volume at the orbital apex, the greater the relief of pressure at the orbital apex. The most effective modality is medial orbital wall decompression surgery. In exceptional, severe patients, prophylactic removal of the lateral orbital wall or even the lateral orbital rim can facilitate medial orbital wall decompression. Forced traction using a pulling hook to reach the orbital apex for decompression through the medial orbital wall can result in already high retrobulbar pressures that may even exceed the upper tolerance limit of the optic nerve fibers and vascular system. Prophylactic lateral orbital wall decompression allows the surgeon to reach the deepest part of the medial orbital wall with great ease, avoiding the pathophysiologic effects of medically induced high orbital pressure on the optic neuropathy. There are several options for incision of the medial orbital wall for decompression, but a transconjunctival approach is the most appropriate, avoiding the cosmetic effects of scarring. A transnasal endoscopic approach is also an option, allowing easy access to the orbital apex without causing high orbital pressure.