The level of evidence is low for the treatment of patients with dysthyroid optic neuropathy (DON) and there is no consensus on the treatment of DON with intravenous high-dose glucocorticoids (ivGC) or direct surgical decompression.To compare the efficacy of glucocorticoid treatment and orbital decompression (OD) in DON.PubMed, EMBASE, and Cochrane Library were searched along with other sources.A total of 17 studies met the inclusion criteria.Standard methodological guidance of the Cochrane Handbook was used and data were independently extracted by multiple observers. The primary outcomes were the improvement of best corrected visual acuity (ΔBCVA). Secondary outcomes were proptosis reduction, change in diplopia, visual field defects, and intraocular pressure (IOP).The ΔBCVA in the ivGC + OD group was improved 0.26 LogMAR more than in the ivGC group (p = 0.007). The ΔBCVA in the OD group was better than in the ivGC group (p = 0.008). Post-treatment proptosis in the ivGC + OD and OD groups were improved further by 3.54 mm and 3.00 mm, respectively, than in the ivGC group (p < 0.01). The mean deviation (MD) in the ivGC + OD group was improved by an additional 5.33 dB than in the ivGC group (p = 0.002). The IOP in the ivGC + OD group was improved further than in the ivGC group (p = 0.03).Based on the results of the present meta-analysis, OD or ivGC + OD may be more effective in improving BCVA and MD and reducing proptosis compared with ivGC. Compared with ivGC alone, ivGC + OD is more effective in improving IOP than ivGC. Although this study improves the hierarchy of evidence in the treatment of DON, additional RCTs are needed to confirm this conclusion.© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.