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Daniel Gealy, Michael Migliori; The role of the specialist in directing judicious imaging in children with periorbital cellulitis. Invest. Ophthalmol. Vis. Sci. 2018;59(9):5631.
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© ARVO (1962-2015); The Authors (2016-present)
Preseptal and orbital cellulitis can present similarly and represent a diagnostic challenge. Because pediatric patients who undergo CT are at higher lifetime risk for malignancy, it is important to minimize the use of CT in children with suspected orbital cellulitis. We performed a retrospective chart review to assess the role of specialist evaluation in the diagnosis of orbital cellulitis, evaluate the diagnostic utility of clinical findings known as orbital signs, and characterize cases where medical treatment fails.
Retrospective chart review of children (<18 years of age) who presented to a tertiary hospital emergency room with periorbital cellulitis from 2011-2016. 281 charts were reviewed, and 32 were excluded for trauma or recent sinus surgery. We evaluated presenting signs and symptoms, radiographic imaging and clinical course.
Of 249 children presenting with periorbital cellulitis, 58 (23%) had CT scans; 22/58 (38%) were diagnosed with orbital cellulitis while 36 (62%) had no orbital involvement. Of 36 cases where imaging was performed with no orbital process, 31/36 (86%) did not have ophthalmology evaluation prior to imaging. Specialist involvement was less likely to lead to imaging in cases of preseptal cellulitis (OR: 0.28), whereas patients who underwent CT without prior specialist input were more likely to have a preseptal infection (OR: 3.59). We show that on average patients with preseptal cellulitis presented with 0.41 orbital signs, whereas patients with orbital cellulitis presented with 2.14 orbital signs. Patients with an orbital cellulitis are much more likely to present with at least 1 orbital sign compared to patients with a preseptal process (OR: 10.78). Finally, we examined 9 patients who were initially treated for preseptal cellulitis with PO antibiotics but worsened and were subsequently found to have an orbital component. Virtually all patients with an orbital cellulitis had coexisting sinus disease.
Orbital signs can reliably indicate the presence or absence of orbital cellulitis, and ophthalmologists are effective at using these clinical markers to diagnose orbital infections. Specialist evaluation may be utilized in the pediatric emergency setting to prevent unnecessary imaging and radiation exposure in this vulnerable population. Even with appropriate treatment, close follow-up is essential to identify treatment failures.
This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.
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