The authors of this article explore the factors associated with successful surgical outcomes in third nerve palsy, which is known to be difficult to treat. A number of case notes were reviewed for patients who underwent surgery or botulinum toxin for third nerve palsy between 1988 and 2012. Treatment was deemed to be successful if there was absence of diplopia, vertical deviation ≤2 prism dioptres (PD) and horizontal deviation ≤10 PD. Fifty-six patients from four surgeons were included. Surgical success was achieved in 50% of the patients. The success rate for patients was unaffected by aetiology, degree of palsy, pupillary involvement, presence of aberrant regeneration or number of other cranial nerves involved. The aetiology and degree of third nerve palsy does not appear to affect the surgical success rate, as is apparent with sixth nerve palsies. However, there was a trend towards a higher success rate when adjustable sutures were used, versus non-adjustable sutures. In this study, patients who underwent surgery with adjustable sutures were more likely to have a successful outcome (adjustable 63%, non-adjustable 38%), however, this difference did not quite reach significance, possibly due to the small sample size. Further validation of these preliminary findings would be beneficial, using a multicentre trial approach to increase sample size.