Patients aged over 50 presenting with isolated nerve palsies of the third (pupil sparring), fourth or sixth nerves, are often described as having microvascular extraocular palsies. This review looks critically at the evidence surrounding these microvascular non-arteritic extraocular palsies and suggests practical ideas on diagnosis and management of suspected cases. The condition itself and its management provoke divergent opinions. The review covers a wide range of features including incidence, pathology, causes, clinical presentation, and yield of imaging, progression, recovery as well as management options. The literature review demonstrates that the clinical presentation is more diverse than often thought. According to the authors, the two crucial differential diagnoses that must be considered immediately in an isolated ocular motor palsy are giant cell arteritis and posterior communicating artery aneurysm. Overall the authors suggest a pragmatic approach to diagnosis, investigation and management from initial presentation.