Significance statement: This case report demonstrates a novel approach to treating a rare indirect carotid cavernous fistula (CCF) and associated abducens palsy. Although endovascular treatment is the standard of care in the management of CCFs, it was contraindicated in this patient. Instead, she underwent an endoscopic endonasal approach (EEA) with decompression of the medial orbital apex, including the cavernous sinus and optic nerve, with complete resolution of headache, lateral gaze palsy, and diplopia within 2 months.