---
title: "Double vision and ocular motor nerve palsy"
url: "https://acuiq.com/wiki/evidence/diplopia-and-ocular-motor-palsy"
updated: 2026-10-22
last_verified: 2026-10-22
license: CC-BY-4.0
license_url: "https://creativecommons.org/licenses/by/4.0/"
section: "evidence"
basis: "Modern research"
audience: "Anyone"
published: "2026-10-22"
reading_minutes: 10
sources: 15
---

# Double vision and ocular motor nerve palsy

_What the one systematic review, two unreported review protocols, the small trials since and the American Academy of Ophthalmology’s strabismus guideline report on acupuncture for double vision from third, fourth and sixth nerve palsy._

Double vision, which doctors call diplopia, follows when one of the three nerves that move an eye stops working and the two eyes no longer point at the same spot. The American Academy of Ophthalmology’s EyeWiki pages describe the [oculomotor nerve](https://eyewiki.org/Acquired_Oculomotor_Nerve_Palsy), the third cranial nerve, as supplying four of the six eye muscles, the muscle that lifts the upper eyelid and the muscle that constricts the pupil, and the [abducens nerve](https://eyewiki.org/Abducens_Nerve_Palsy), the sixth, as supplying the lateral rectus, the muscle that turns the eye outward. The third of the three, the trochlear or fourth cranial nerve, gets little attention in the sources on this page. The same pages list the causes as diabetic or hypertensive damage to the nerve’s small blood vessels, head injury, compression by an aneurysm or tumour, infection and drug toxicity, state that most microvascular abducens palsies recover under observation within 3 to 6 months, and describe the standard management of the double vision as prisms, covering one eye, botulinum toxin or surgery once the deviation has been stable for 6 months. One systematic review covers acupuncture for any of these palsies. It pooled 18 trials, most of them from China, and rated the certainty of every result low or very low; the trials published since are small and either add needling to drugs or compare two needling schemes.

## Is there a Cochrane review?

No. The Cochrane Library holds no review of acupuncture for oculomotor, trochlear or abducens nerve palsy, for ophthalmoplegia (the general term for weakness of the eye muscles) or for diplopia, and a search of PubMed and Europe PMC in October 2026 found one completed systematic review, described below, and two protocols that have not reported.

## The 2022 systematic review

The [2022 review](https://doi.org/10.1016/j.ctim.2022.102888) by Zhang, Cui and colleagues in _Complementary Therapies in Medicine_ searched PubMed, the Cochrane Library, Medline and three Chinese databases for randomised trials that compared acupuncture alone with no treatment, sham acupuncture or another active therapy, or acupuncture added to a therapy with that therapy alone. It included 18 trials with 1,150 participants, which its abstract describes as comparing acupuncture with other therapies, and assessed them with the Cochrane risk of bias tool and GRADE, the system that rates how far a pooled result can be trusted. Its full text sits behind the publisher’s paywall; this page reports the abstract.

| Outcome | Result |
| --- | --- |
| Clinical efficiency rate | Risk ratio 1.30 (95% CI 1.23 to 1.37) |
| Diplopia score | Mean difference 0.78 points lower |
| Palpebral fissure, the opening between the eyelids | 1.04 mm wider (95% CI 0.41 to 1.68) |
| Pupil diameter | 0.56 mm smaller (95% CI 0.70 to 0.42) |
| Quality of life score | 8.96 points higher (95% CI 6.79 to 11.13) |
| Adverse effects | Risk ratio 0.52 (95% CI 0.22 to 1.22), no significant difference |

The clinical efficiency rate is the share of people a trial classes as improved; the abstract does not say how the trials defined it. The abstract prints the confidence interval for the diplopia score as 1.39 to 0.77, which does not contain its own point estimate, so the table gives the estimate alone. The authors rate the GRADE certainty of the evidence as low or very low, note that most of the trials were run in China, and conclude that most of the included studies reported acupuncture ahead of its control.

## Two review protocols without results

A protocol is the published plan for a review: what will be searched, which trials will count and which outcomes will be pooled, registered in advance so that the finished review can be checked against it. Two have been published for this condition and neither has reported. [Ji, Qin and colleagues](https://doi.org/10.1097/MD.0000000000011065) registered a review of acupuncture for ophthalmoplegia with PROSPERO, the international register of systematic reviews, as CRD42018091536 and published the protocol in _Medicine_ in 2018. It planned to search to 31 March 2018 and to take the distance the eye can move, the size of the palpebral fissure and the degree of strabismus (misalignment of the eyes) as its primary outcomes. [Huang, Miao and colleagues](https://doi.org/10.1097/MD.0000000000028456) published a protocol in the same journal in 2022, registered as CRD42021266447, for a review of acupuncture combined with tuina, Chinese manual therapy applied to the body surface and to acupuncture points, for oculomotor paralysis; its primary outcomes were to be diplopia scores, the pupil’s response to light and the size of the palpebral fissure. The protocol states that in a third of cases the cause is unknown and names aneurysm, tumour, head injury, infection and diabetic neuropathy among the rest. A search of PubMed and Europe PMC in October 2026 found no completed review under either registration.

## Trials since the review

The trials published after the review’s search are small and compare regimens rather than needling with no needling. [Fahmy and colleagues 2025](https://doi.org/10.1002/pri.70074), physiotherapists in Cairo writing in _Physiotherapy Research International_, randomised 40 eyes with diplopia from oculomotor or abducens palsy to four weeks of electroacupuncture, needling with a current passed between the needles, plus standard medication, or to the medication alone, and measured the deviation with the Hess screen test, a chart on which the patient marks where a light appears to each eye. The abstract reports a post-test difference in favour of the electroacupuncture group, with p values printed as 0.38 and 0.003, and names no points. [Electroacupuncture](/wiki/techniques/electroacupuncture) describes the technique.

Two trials in _Acupuncture Research_ (_Zhen Ci Yan Jiu_) tested point selection by Biaoben Genjie theory, which the trials describe as the distribution, connection and gathering of channel qi in the body, and which picks points at four named sites on a channel. [Wang and colleagues 2025](https://pubmed.ncbi.nlm.nih.gov/39961763/) randomised 62 people with oculomotor nerve palsy, all on conventional medical treatment, to that scheme or to routine acupuncture, six courses of six daily sessions, and reported lower diplopia and strabismus degrees in the scheme group and an effective rate of 29 of 31 against 26 of 31. [Guan and colleagues 2026](https://pubmed.ncbi.nlm.nih.gov/41566739/) ran the same design in 60 people with abducens nerve palsy. Its scheme group was needled at [`TB23`](/points/tb23) (Sizhukong), [`TB03`](/points/tb03) (Zhongzhu), [`GB44`](/points/gb44) (Zuqiaoyin) and [`GB01`](/points/gb01) (Tongziliao), with [`GB20`](/points/gb20) (Fengchi), [`XH05`](/points/xh05) (Taiyang), [`XH07`](/points/xh07) (Qiuhou) and [`GB37`](/points/gb37) (Guangming), and the trial reported an effective rate of 29 of 30 against 26 of 30 with routine acupuncture. Because both arms were needled, neither trial measures what acupuncture adds to medical treatment.

Earlier trials in _Chinese Acupuncture and Moxibustion_ (_Zhongguo Zhen Jiu_) compared needling with drugs. [Liu and colleagues 2020](https://pubmed.ncbi.nlm.nih.gov/32869586/) randomised 46 people with oculomotor nerve palsy after a stroke to mecobalamin injections with oral citicoline, or to the same drugs plus four weeks of needling at [`ST03`](/points/st03) (Juliao) and [`GB04`](/points/gb04) (Hanyan) on the unaffected side, [`BL01`](/points/bl01) (Jingming), [`ST02`](/points/st02) (Sibai), [`GB14`](/points/gb14) (Yangbai), [`BL02`](/points/bl02) (Cuanzhu), Shangming, TB23 and GB01 on the affected side, and [`LI11`](/points/li11) (Quchi), [`LI06`](/points/li06) (Pianli), [`TB05`](/points/tb05) (Waiguan), [`LI04`](/points/li04) (Hegu) and GB20 on both sides. It reported a wider eye opening, a smaller pupil and more movement in three of the muscles in the needled group, and an effective rate of 19 of 23 against 15 of 23. [Zhang and colleagues 2009](https://pubmed.ncbi.nlm.nih.gov/19873915/) allocated 100 people with paralytic strabismus to needling at BL01, GB01 and Shangming or to oral methylcobalamin and vitamin B1, and reported an effective rate of 95% against 86%, with the needled group ahead for the muscles the oculomotor and abducens nerves supply and no difference for the superior oblique muscle.

## Needling near the eye

Several of these points lie on the rim of the orbit. A [2023 review in the _Korean Journal of Ophthalmology_](https://doi.org/10.3341/kjo.2022.0111) by Lee, Wu and Hwang collected 14 case reports, covering 15 eyes, of serious injury after acupuncture around the eye published between 1982 and 2020; ten eyes were perforated, and six of those needed vitrectomy, an operation to remove the gel inside the eye. The review counts six classical points in the periorbital area, BL01, BL02, GB01, ST01, ST02 and TB23, and lists ophthalmoplegia among the conditions for which needling there has been reported. A [2026 case report](https://doi.org/10.1016/j.ajem.2026.08.023) in the _American Journal of Emergency Medicine_ describes orbital compartment syndrome, bleeding behind the eye that raised the pressure in the orbit to 79 mmHg, 90 minutes after periocular acupuncture; the eye saw nothing on arrival, emergency decompression within two hours restored vision to 20/25 by three months, and imaging at six months showed permanent thinning of the retina’s inner layers.

## What guidelines say

The guideline nearest this subject is the American Academy of Ophthalmology’s [Adult Strabismus Preferred Practice Pattern](https://doi.org/10.1016/j.ophtha.2019.09.023), written in 2019 and published in _Ophthalmology_ in January 2020, which covers misalignment of the eyes in adults, including that left by nerve palsies. The [Academy’s page for it](https://web.archive.org/web/20230921101316/https://www.aao.org/education/preferred-practice-pattern/adult-strabismus-ppp), which carries the abstract and highlighted recommendations, does not mention acupuncture; this page could not open the full text. No later edition is indexed in Europe PMC as of October 2026. NICE’s [Clinical Knowledge Summaries](https://cks.nice.org.uk/topics/), the topic guides for English general practice, list Bell’s palsy and squint in children but no topic for diplopia or ocular motor nerve palsy. [Clinical guidelines](/wiki/evidence/clinical-guidelines) sets out other bodies’ positions on acupuncture.

## What the reviews could not settle

The one review pooled trials whose comparators its abstract calls other therapies, and it reports no result against sham acupuncture, so the pooled estimates cannot separate needling from the attention that comes with it. Its effective rate is a category whose definition the abstract does not give, its certainty is low or very low on every outcome, and most of its trials were run in one country. The trials since have randomised 40 to 62 people each and compared one needling scheme with another, or needling plus drugs with drugs, never needling with none. Because the EyeWiki pages describe most microvascular palsies as recovering on their own within months, a trial without an untreated or sham arm cannot show that acupuncture shortened that recovery. The two registered reviews have not reported, and nothing in the sources here covers trochlear nerve palsy on its own.

AcuiQ’s [diplopia](/symptoms/diplopia), [oculomotor nerve palsy](/symptoms/oculomotor-nerve-palsy), [abducens nerve palsy](/symptoms/paralysis-abducens-nerve), [paralytic strabismus](/symptoms/paralytic-strabismus) and [eyelid ptosis](/symptoms/ptosis-eyelid) pages list the protocols individual studies prescribed, each with its citation. [Bell’s palsy](/wiki/evidence/bells-palsy) covers palsy of the seventh cranial nerve, which moves the face, and [hemifacial spasm](/wiki/evidence/hemifacial-spasm) its overactivity.

### Sources

1. Zhang X, Cui H, Liu Y, et al., Acupuncture for oculomotor nerve palsy: a systematic review and meta-analysis, Complementary Therapies in Medicine 2022 — https://doi.org/10.1016/j.ctim.2022.102888
2. Ji M, Qin Y, Zi Y, et al., Acupuncture for ophthalmoplegia: protocol for a systematic review, Medicine 2018 — https://doi.org/10.1097/MD.0000000000011065
3. Huang Y, Miao Z, Lai C, et al., Acupuncture combined tuina for oculomotor paralysis: a protocol for systematic review and meta-analysis, Medicine 2022 — https://doi.org/10.1097/MD.0000000000028456
4. Fahmy S, Wadee AN, Elshinnawy AM, et al., Influence of electro-acupuncture on diplopia in patients with oculomotor and abducens nerves palsy, Physiotherapy Research International 2025 — https://doi.org/10.1002/pri.70074
5. Wang T, Chen YH, Yuan N, Guo LY, Observation on the clinical efficacy of acupuncture in treatment of oculomotor nerve palsy guided by Biaoben Genjie theory, Zhen Ci Yan Jiu 2025 — https://pubmed.ncbi.nlm.nih.gov/39961763/
6. Guan XR, Chen YH, Sun W, et al., Observation on the clinical effect of acupuncture on abducens nerve palsy guided by Biaoben Genjie theory, Zhen Ci Yan Jiu 2026 — https://pubmed.ncbi.nlm.nih.gov/41566739/
7. Liu XX, Wu JY, Zhao Y, Clinical observation on post-stroke oculomotor nerve palsy treated with the interaction of twelve meridian muscle regions and contralateral needling therapy, Zhongguo Zhen Jiu 2020 — https://pubmed.ncbi.nlm.nih.gov/32869586/
8. Zhang SJ, Li SR, Li JS, Liu J, Song RX, Clinical observation on acupuncture for treatment of paralytic strabismus, Zhongguo Zhen Jiu 2009 — https://pubmed.ncbi.nlm.nih.gov/19873915/
9. Lee SM, Wu J, Hwang DD, Severe adverse events of periocular acupuncture: a review of cases, Korean Journal of Ophthalmology 2023 — https://doi.org/10.3341/kjo.2022.0111
10. Wong TH, Chen YY, Wang HC, Huang CH, Orbital compartment syndrome after periocular acupuncture: vision preserved by emergent decompression, American Journal of Emergency Medicine 2026 — https://doi.org/10.1016/j.ajem.2026.08.023
11. Dagi LR, Velez FG, Archer SM, et al., Adult Strabismus Preferred Practice Pattern, Ophthalmology 2020 — https://doi.org/10.1016/j.ophtha.2019.09.023
12. American Academy of Ophthalmology, Adult Strabismus PPP 2019 (abstract and highlighted recommendations), aao.org page as archived 21 September 2023 — https://web.archive.org/web/20230921101316/https://www.aao.org/education/preferred-practice-pattern/adult-strabismus-ppp
13. NICE Clinical Knowledge Summaries, Health topics A to Z, accessed October 2026 — https://cks.nice.org.uk/topics/
14. American Academy of Ophthalmology EyeWiki, Acquired oculomotor nerve palsy, last edited October 2026 — https://eyewiki.org/Acquired_Oculomotor_Nerve_Palsy
15. American Academy of Ophthalmology EyeWiki, Abducens nerve palsy, last edited August 2026 — https://eyewiki.org/Abducens_Nerve_Palsy