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To compare the surgical outcomes of the plication technique with the resection method to treat exotropic patients. In this prospective randomized clinical trial, a total of 52 exotropic patients (27 females and 25 males) who were candidates for medial rectus resection were randomly classified into the plication (n = 24) and resection (n = 28) groups. Comprehensive ophthalmic examination included cyclorefraction, assessment of the best corrected visual acuity (BCVA), evaluation of the extraocular muscle, ocular deviation measurement and stereopsis measured using a Titmus test. Ocular anterior and posterior segments were examined using slit-lamp and indirect ophthalmoscopy. Patients were randomly divided to medial rectus plication and medial rectus resection groups. The plication technique was the same as for resection, but in the last step the muscle was folded. Examinations were repeated at the 1- and 3-day as well as 1-, 2-, 3- and 6-month follow-ups. If the postoperative ocular deviation was in the range of 5 PD esotropia to 10 PD exotropia, it was considered a successful surgical outcome. Results show that there was no statistically significant difference between the two groups regarding near and far deviations (PN = 0.298, PF = 0.103), surgical dose response (P = 0.904) and postoperative success rate (plication, 87% and resection, 89.3%, P > 0.99). Reoperation was needed in 13% and 10.7% of the plication and resection groups, respectively (P > 0.05). Medial rectus plication is an effective and appropriate alternative option for medial rectus resection in exotropic patients.