The authors present a retrospective case review to compare bimedial rectus recession and botulinum toxin injection to the medial recti. This study was possible due to the different first-line preferences of the individual surgeons within the team. Inclusion criteria were a partially accommodative esotropia, aged 14 years or younger, no previous ocular surgery and minimum of three months follow-up. Moderate inferior oblique overactions, neurological disorders, developmental delay, nystagmus and other ocular pathology were all reasons for exclusion. Two hundred and twenty-four met the inclusion criteria, 121 in the botulinum toxin group and 103 in the bimedial rectus recession group. Statistically significant differences were identified in the demographics of the two groups; the botulinum toxin group were significantly younger, earlier onset, larger refractive error, and longer follow-up. The overall success rate was higher in the bimedial rectus recession group (71%) compared with the botulinum toxin group (54%), this being a greater difference for males. The botulinum toxin group had a greater number fail the first procedure compared to the bimedial rectus recession group. The authors report this is the first study to directly compare bimedial rectus recession and botulinum toxin. The authors report several limitations including it being a single site study and being unable to report any measure of binocular vision. This direct comparison of these management technique may pave the way to establishing which is the preferrable first line treatment for which patient groups.