To investigate the predictive value of the complete ophthalmic examination at first presentation in foreseeing the need for surgery in patients with pediatric orbital cellulitis.

Retrospective observational case series.

We reviewed 136 cases of radiographically confirmed orbital cellulitis between 2004 and 2012 at Children's Hospital Colorado. The presenting ophthalmic examinations, imaging results, medical and surgical interventions, and clinical complications were recorded. The main outcome measures were ophthalmic examinations on presentation, medical or surgical interventions, and complications.

The median age was 6.5 years. Of the patients, 56 (41%) underwent surgical intervention, and 80 patients (59%) were managed medically. Patients requiring surgery had higher rates of extraocular motility (EOM) restriction (78.6% vs 38.8% P < 0.01), proptosis (64.3% vs 21.2%, P < 0.01), elevated intraocular pressure (IOP) (35.7% vs 12.5%, P < 0.01), and age over 9 years (58.9% vs 20.0%, P < 0.01). Using any combination of the above risk factors at presentation, the probability of surgical intervention increases from 7% (95% confidence interval [CI] 1%–13%) with zero risk factors to 95% (95% CI 89%–100%) with 4 risk factors.

In pediatric orbital cellulitis, the likelihood of surgical intervention can be estimated accurately based on the ophthalmic examination on initial presentation to the hospital. Risk factors for surgery include age older than 9 years, proptosis, EOM restriction, and elevated IOP. These factors may be used to identify patients at high risk for failure of medical management early in the clinical course.