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Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p 0.05).The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management.• Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management.• Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.