Management is described for 13 patients who received inferior rectus botulinum toxin (BT) injection for vertical strabismus due to orbital pathology. Patients were aged 19-86 years, eight were female and seven were right eye injections. Orbital pathology included six with idiopathic orbital inflammatory syndrome, three with orbital wall fracture, one optic nerve sheath schwannoma post resection, one lymphoma and one spontaneous superior ophthalmic vein haemorrhage. Each patient had diplopia. Benefit from BT was noted in nine (69%). Follow-up was from three months to three years. A functional cure was achieved in five (38%) with a single BT dose. Benefit was independent on the angle of deviation.