AIM: To assess metrics of diffusion tensor imagining (DTI) in evaluating microstructural abnormalities of horizontal extraocular muscles (EOM) in esotropia. METHODS: Six adult concomitant esotropia patients, 5 unilateral abducent paralysis patients and 2 healthy volunteers were enrolled. Conventional magnetic resonance imaging (MRI) and DTI were performed on all subjects using 3T MR scanner. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) of medial and lateral rectus muscles were measured and compared between patients group and control group. RESULTS: Medial rectus MD and RD within the adducted eye of concomitant patients was significantly greater than that in unilateral abducent paralysis patients (0.259×10-2 mm2/s vs 0.207×10-2 mm2/s, P=0.014; 0.182×10-2 mm2/s vs 0.152×10-2 mm2/s, P=0.017). Both strabismus patients showed a significantly decreased MD and AD than that obtained in normal controls for lateral rectus muscles (P<0.05). Medial rectus MD of the adducted eye in concomitant strabismus patients was significantly decreased than that in healthy controls (0.259×10-2 mm2/s vs 0.266×10-2 mm2/s, P=0.010). Lateral rectus AD of the adducted eye in concomitant strabismus patients was significantly decreased as compared with that in healthy controls (0.515×10-2 mm2/s vs 0.593×10-2 mm2/s, P=0.013). No statistically significant differences were present between the adducted and fixating eyes in concomitant strabismus patients. CONCLUSION: DTI represents a feasible technique to assess tissue characteristics of EOM. The effects of eye position changes on DTI parameters are subtle. Decreased MD and RD could be evidence for remodeling of the medial rectus muscle contracture. Lower medial and lateral recuts MD of concomitant esotropia patients indicates a thinner fibrous structure of the EOM. Lower MD and AD should be general character of esotropia.