Acute sixth nerve palsy (abducens nerve palsy) is characterized by weakness or paralysis of the lateral rectus muscle, resulting in impaired eye abduction. Current treatments for sixth nerve palsy, such as prism glasses and surgical interventions, may have limitations in achieving satisfactory outcomes. Objective: This prospective observational study aims to evaluate the efficacy of botulinum toxin injections in improving ocular motility and visual acuity in patients with acute sixth nerve palsy. Methods: Consecutive patients diagnosed with acute sixth nerve palsy at Saveetha Medical College & Hospital, Chennai, were enrolled after obtaining institutional review board approval and written consent. Patients aged 18 years or older underwent clinical evaluation and neuroimaging to confirm the diagnosis. Exclusion criteria included prior ocular surgery, significant comorbidities affecting vision, contraindications to botulinum toxin injections, or inability to adhere to follow-up visits. A total of 49 patients were included, with allocation into intervention (botulinum toxin injections) or control (standard care) groups based on patient preference and clinical suitability. Botulinum toxin injections were administered by experienced ophthalmologists targeting lateral rectus muscle involvement. Outcome measures, including ocular motility, visual acuity, diplopia severity and adverse events, were assessed at baseline and follow-up intervals (1 week, 1 month, and 3 months) using standardized methods. Results: Significant improvements in ocular motility and visual acuity were observed in the intervention group compared to the control group over a one-month follow-up period. At baseline, there were no statistically significant differences in ocular measurements between groups. However, at 1-week follow-up, the intervention group showed a significant reduction in Hess screen measurements (p = 0.041) and improved visual acuity (p = 0.012) compared to controls. These improvements were sustained and enhanced at 1-month follow-up (p < 0.001). Conclusion: Botulinum toxin injections demonstrate promise as an effective therapeutic intervention for acute sixth nerve palsy, with significant improvements in ocular alignment and visual function compared to standard care. Larger studies with longer follow-up are needed to validate these findings and establish clinical guidelines for botulinum toxin use in managing acute sixth nerve palsy. Further research in this area will contribute to optimizing treatment strategies and improving outcomes for patients with this condition