Pretibial myxedema (thyroid dermopathy), an uncommon autoimmune manifestation of Graves' disease, is almost always associated with significant ophthalmopathy and may be a marker for an unusually prolonged or different course for the ophthalmopathy. However, it is not known if the response to therapy for eye disease is different in patients with pretibial myxedema. We compared the results of orbital decompression in 385 patients without and 52 patients with pretibial myxedema operated on between 1969 and 1989. Preoperative and postoperative characteristics of severe Graves' ophthalmopathy did not differ in patients with or without pretibial myxedema except for slightly, but not significantly, more proptosis and diplopia in the pretibial myxedema group. In response to a 1989-1990 questionnaire (83% response rate, n = 364), 89.1% without (n = 319) and 88.9% with (n = 45) pretibial myxedema reported satisfactory or acceptable appearance of the eyes. Self-assessment of visual acuity, eye comfort, diplopia, and overall rate of satisfaction with the status of the eyes did not differ between the groups. The presence of pretibial myxedema does not herald an unsatisfactory response to transantral orbital decompression.