OBJECTIVE To compare unilateral versus bilateral surgical treatment of esotropia associated with high myopia. METHODS This retrospective study comprised patients who underwent surgery for esotropia with high myopia performed by the first author (Y.M.) between 2003 and 2008. Surgical results and complications were compared between patients who underwent unilateral versus bilateral surgery. RESULTS Nine patients were identified with average age of 44.9 years (range 8-70 years). All had bilateral high myopia (average -13.35 D, range -9.00 to -17.50 D) and esotropia of 20-75 diopters, together with hypotropia in 5 cases. Bilateral displacement of the lateral rectus inferiorly and superior rectus medially was demonstrated in each patient by computed tomography scan of the orbits and by observation during surgery. Five patients underwent bilateral surgery and 4 underwent unilateral surgery. After an average follow-up of 29 months (range 4-47 months), 4/5 patients who underwent bilateral myopexy achieved good results with postoperative esotropia of less than 8 diopters, as opposed to 2/4 patients who underwent unilateral surgery. No complications were noted. CONCLUSIONS Bilateral superior and lateral rectus myopexy is the preferred method of surgical correction of esotropia associated with high myopia. Additional unilateral or bilateral medial rectus recession is probably not indicated in most cases. Patients who prefer unilateral surgery can benefit from unilateral superior and lateral rectus myopexy together with medial rectus recession. This unilateral approach may yield good results particularly in young patients without markedly restricted and tight extraocular muscles.