We read with interest the recent article by Smith and associates, who investigated the relation between ophthalmic clinical signs at first presentation and the need for surgical treatment in children with orbital cellulitis. They concluded that extraocular motility restriction (EOM), proptosis, and raised intraocular pressure (IOP) are predictive of worse prognosis and need for surgical intervention.

It is well known that orbital infections are rare and potentially blinding conditions, and we would therefore add that the presence of an afferent pupillary defect should also alert the treating physicians and prompt surgical intervention if imaging examination shows consistent findings.

Although we understand that all patients included in the study had a concurrent sinusitis, which constitutes the leading cause for orbital infections in pediatric patients, it needs highlighting that different types of orbital infections were observed in the reported series; in fact, the majority of the 136 children enrolled (83) presented with either an orbital or a subperiosteal abscess.

Orbital infections are historically classified by a 5-tier system, as described by Smith and Spencer and subsequently modified by Chandler and associates. Besides this descriptive classification, a recent review suggested a newer classification that would take into account the severity of the condition and the need for a less or more aggressive management.

Hence, it might perhaps be more appropriate to differentiate the patients enrolled into 3 different groups, and evaluate if the conclusions reached by Smith and associates prove to hold true in each of the 3 different clinical scenarios. In any case, the authors might certainly agree that performing an adequate imaging assessment in all cases presenting with any sign of possible orbital infection remains imperative.

We also read how proptosis was considered “a more telling risk factor for surgery than EOM restriction,” and we call for a clarification regarding the grade of proptosis: in fact, the grade rather than the presence or absence of proptosis seems to be important.

We accepted with skepticism that IOP was manually checked as a globe “soft or firm to palpation” in some cases; it would have been better to exclude those cases from the study and avoid an additional source of bias.

We also believe that details regarding antibiotic treatment algorithm should be provided, so that the reader could understand when the efficacy or inefficacy of medical treatment was assessed, and surgery indicated. Lastly, given that the surgical option is to be pursued, we would be interested to understand when the authors recommend endoscopic approach alone and when instead they choose the combined endoscopic and external approach that was often used in this series.