Optic nerve sheath fenestration (ONSF) is an important procedure in the management of patients with idiopathic intracranial hypertension (IIH) who do not respond to medical treatment. Traditional surgical approaches for fenestration have limitations. Furthermore, when tumors in the intraconal space medially and superiorly are encountered, complex surgical approaches with significant morbidity have been used. We present our surgical approach to these conditions with a technique that is quick, safe and efficient.