Acquired sixth nerve palsy usually results in bothersome symptomatic diplopia. Botulinum toxin injection of the ipsilateral medial rectus is an effective treatment to prevent contracture of this muscle and may provide the patient a functional area of single binocular vision. If recovery of lateral rectus function does not occur in six months, surgery may be required. Transposition of the ipsilateral superior and inferior rectus muscles combined with botulinum injection of the medial rectus may create a large central area of single binocular vision. This procedure avoids surgery on three rectus muscles of the same eye.