A 57-year-old man demonstrated thyroid-associated orbitopathy with active inflammation, eyelid retraction with a left corneal ulcer, exophthalmometry of 25 OD and 27 mm OS, restrictive myopathy in all directions of gaze with constant diplopia, and bilateral compressive optic neuropathy (best-corrected visual acuity, 20/50 OU). His VISA (vision, inflammation, strabismus, and appearance) score1 was as follows: visual acuity: bilateral optic neuropathy; inflammation: 6 of 8; strabismus: 3 of 3; and appearance: severe. A course of 3 boluses of intravenous corticosteroids followed by radiation therapy did not resolve his optic neuropathy, and bilateral 2-wall orbital decompression was performed through a Lynch incision, removing the medial wall posteriorly to the sphenoid sinus and superiorly to the level of the ethmoid vessels and inferiorly along the orbital floor to the infraorbital nerve. The day after surgery, his visual acuity was 20/20 OU, and he had no afferent pupillary defect. Two days later after returning to his home in a remote community, he contacted us and reported clear fluid draining from his right nostril, particularly when leaning forward. With a suspected diagnosis of CSF leak, he was prescribed bed rest for a week and was asked to immediately report the development of fever or neurologic complaints. Headache and fluid leakage persisted during the next week, and he returned by airplane to the hospital. During the flight, his headache dramatically worsened, and he developed right leg weakness. On admission to the hospital, he was noted to have CSF rhinorrhea, while computed tomographic scan (CT) confirmed dehiscence on the floor of the anterior cranial fossa posterolateral to the cribriform plate anda small collection of intracranial air over the right middle cranial fossa. The expansion of this air during the flight was assumed to have worsened his headache and caused the paresis. Surgical repair was performed using an abdominal fat graft and tissue adhesive (Tisseal; Baxter Healthcare Corporation, Glendale, California) placed directly over the leaking spot through the original Lynch incision. There was no recurrence of the leakage, and paresis on the right side resolved.