Background We aimed to determine the impact of the preoperative prism adaptation test (PAT) on surgical outcomes in patients with primary exotropia. Methods Thirty‐eight consecutive patients with primary exotropia were enrolled. Pre‐operative PAT was performed in 18 randomly selected patients (Group 1). Surgery was based on the angle of deviation at distance measured after PAT. The remaining 20 patients in whom PAT was not performed comprised Group 2. Surgery was based on the angle of deviation at distance in these patients. Surgical success was defined as ocular alignment within eight prism dioptres (PD) of orthophoria. Results Satisfactory motor alignment (± 8 PD) was achieved in 16 Group 1 patients (88.9 per cent) and 16 Group 2 patients (80 per cent) one year after surgery (p = 0.6; chi‐square test). There were no statistically significant differences in demographic parameters, pre‐operative and post‐operative angle of deviation between the two groups (p > 0.05; Mann‐Whitney U and chi‐square tests). Nine patients in Group 1 (50 per cent) and two patients in Group 2 (10 per cent) had increased binocular vision one year post‐operatively. A statistically significant difference was determined in terms of change in binocular single vision between the two groups (p = 0.01; chi‐square test). Conclusion Although the prism adaptation test did not lead to a significant increment in motor success, it may be helpful in achieving a more favourable functional surgical outcome in patients with primary exotropia.