Severe trauma is a common cause of multiple ocular motor palsies, involving traction at the skull base or fracture of the bones of the orbit or skull base. Although there is good prognosis for recovery following traumatic ocular motor palsies, there is a high incidence of secondary third nerve aberrant regeneration.

Combination of third and sixth third and nerves  is most likely and is not difficult to perceive. In addition to the third nerve palsy, there is a failure of abduction of the same eye.

The cardinal symptom is binocular diplopia, this is usually a combination of horizontal and cyclovertical deviations.

Ptosis is also common, as the third nerve is frequently a component of multiple nerve palsies.

In contrast with isolated mononeuropathies, which are often benign and vasculopathic in nature, involvement of more than one ocular motor nerve rarely results from vasculopathic lesions. It is very important to ascertain that multiple nerves are involved, because establishment of this enables localization of the lesion responsible.

The treatment of diplopia may include monocular patching or prisms. If the misalignment remains fairly stable, then prisms may reduce diplopia in primary gaze. However, given the incomitance of these deviations, prisms are unlikely to alleviate diplopia in eccentric gaze, and patient satisfaction may vary.

The risks of surgery should be weighed carefully in the decision to treat patients with multiple ocular motor palsies. Patients should be warned that more disabling diplopia may occur following strabismus surgery, as the images from each eye become perceived much closer together. The ultimate goal for surgery in these cases is to establish single binocular vision in the primary position. Correction of ptosis is usually easily accomplished but carries some risk of corneal exposure.

This patient is treated with simple Recession / Resection with up shift of the insertions of the horizontal recti this corrects the esotropia in the primary position and the hypotropia caused by 3rd nerve palsy. The ptosis is treated with undercorrected frontalis sling . Patients like these could not regain perfect versins , still they could be made better with multiple surgical procedures.