Background Thyroid eye disease (TED) is the most common autoimmune disease of the orbit. Management includes conservative measures, medical therapy, surgery, and targeted biologic therapy. Aim To compare the efficacy of repeated peribulbar triamcinolone injections with surgical orbital decompression in patients with moderate to severe TED. Patients and methods A prospective nonrandomized, noncontrolled comparative interventional study was conducted that included 30 eyes with moderate to severe inactive TED, which were divided into two groups: group A included 15 eyes that were enrolled for surgical orbital decompression and group B included 15 eyes that underwent repeated peribulbar triamcinolone injections. Patients were subjected to preoperative and postoperative ophthalmological examination, including visual acuity, intraocular pressure measurement, and degree of proptosis. Results Hertel's exophthalmometer measurements showed mean±SD difference between preoperative and postoperative values in group A of 6.20±1.32, whereas group B had 2.53±0.92, revealing high statistically significant differences between preoperative and postoperative results in each group as well as between both groups. Differences in intraocular pressure values between preoperative and postoperative periods in group A were 1.73±1.39 and in group B were 1.13±0.92, showing a highly statistically significant difference. Concerning refraction, the mean difference between preoperative and postoperative periods in sphere, cylinder, and axis in group A showed a highly statistically significant difference in cylinder and axis, whereas only cylinder and not axis in group B. Conclusion Both repeated peribulbar injection of triamcinolone and surgical orbital decompression are effective modalities for management of moderate and severe inactive TED, with surgical orbital decompression having the upper hand in providing better results in reduction of proptosis.