A variety of surgical techniques have been described for surgical management of variable angle esotropia and high AC/A ratio, such as augmented medial rectus recession using the average of the preoperative smallest and largest angles, Faden operation, slanted medial rectus recession, medial rectus recession with Y-splitting, and most recently, the medial rectus posterior pulley fixation. With significant advantages such as fornix based incision, minimal dissection, and avoidance of orbital fat injury, pulley posterior fixation seems to be a very tempting and effective alternative to augmented medial rectus recession in patients with variable angle esotropia and high AC/A ratio ET. The main downside of this surgery being that it requires a limbal incision, an excessive dissection, longer learning curve and more time consuming. But once it’s learned, the surgery is not technically difficult.