A very active 45 year old presented with severe thyroid eye disease accompanied by eye bulging, double vision, inability to close eyes during sleep and orbital ache /pain. She was formerly very active (biking, running) but had to give up those activities due to double vision and pain. She underwent bilateral customized medial lateral and fat decompressions, achieving a symmetric result and 7mm reduction in proptosis. She underwent strabismus surgery, but no eyelid or revision surgery was required. She subsequently completed her first triathlon.