Orbital Imaging and Vision Loss-Child

Variant: 1 Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
CT orbits without IV contrast	Usually Appropriate	☢☢☢
MRI head without IV contrast	May Be Appropriate	O
MRI orbits without IV contrast	May Be Appropriate	O
CT head without IV contrast	May Be Appropriate	☢☢☢
Radiography orbit	Usually Not Appropriate	☢
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI orbits without and with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Child. Nontraumatic acute vision loss without papilledema. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head and orbits without and with IV contrast	Usually Appropriate	O
MRI complete spine without and with IV contrast	May Be Appropriate	O
MRI head and orbits without IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI orbits without and with IV contrast	May Be Appropriate	O
CT head without IV contrast	May Be Appropriate	☢☢☢
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI complete spine without IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
CT head and orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT head and orbits without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head and orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Child with isolated nystagmus. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head and orbits without and with IV contrast	May Be Appropriate	O
MRI head and orbits without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI orbits without and with IV contrast	May Be Appropriate	O
MRI orbits without IV contrast	May Be Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
CT head and orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT head and orbits without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head and orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head and orbits without IV contrast	Usually Appropriate	O
MRI head and orbits without and with IV contrast	May Be Appropriate (Disagreement)	O
MRI head without IV contrast	May Be Appropriate	O
MRI orbits without IV contrast	May Be Appropriate	O
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI orbits without and with IV contrast	Usually Not Appropriate	O
CT head and orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT head and orbits without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head and orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head and orbits without and with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
MRI orbits without and with IV contrast	May Be Appropriate (Disagreement)	O
Radiography orbit	Usually Not Appropriate	☢
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI head and orbits without IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
CT head and orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT head and orbits without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head and orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 6 Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head and orbits without and with IV contrast	Usually Appropriate	O
MRI head and orbits without IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRV head with IV contrast	May Be Appropriate	O
MRV head without and with IV contrast	May Be Appropriate	O
MRV head without IV contrast	May Be Appropriate	O
CT head without IV contrast	May Be Appropriate	☢☢☢
CTV head with IV contrast	May Be Appropriate	☢☢☢☢
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI orbits without and with IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
CT head and orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT head and orbits without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head and orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 7 Child. Suspected orbital or periorbital infection. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
CT orbits with IV contrast	Usually Appropriate	☢☢☢
MRI head without and with IV contrast	May Be Appropriate	O
MRI orbits without and with IV contrast	May Be Appropriate	O
CT head with IV contrast	May Be Appropriate	☢☢☢
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
MRV head with IV contrast	Usually Not Appropriate	O
MRV head without and with IV contrast	Usually Not Appropriate	O
MRV head without IV contrast	Usually Not Appropriate	O
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢
CTV head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 8 Child. Leukocoria or suspected intraocular mass. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head and orbits without and with IV contrast	Usually Appropriate	O
MRI orbits without and with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
MRI orbits without IV contrast	May Be Appropriate	O
CT head and orbits with IV contrast	May Be Appropriate	☢☢☢
CT head with IV contrast	May Be Appropriate	☢☢☢
CT orbits with IV contrast	May Be Appropriate	☢☢☢
CT orbits without IV contrast	May Be Appropriate	☢☢☢
MRA head without and with IV contrast	Usually Not Appropriate	O
MRA head without IV contrast	Usually Not Appropriate	O
MRI head and orbits without IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
CT head and orbits without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head and orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Mohit Maheshwari, MD^a; Mai-Lan Ho, MD^b; Thangamadhan Bosemani, MD^c; Hisham Dahmoush, MBBCh^d; Douglas Fredrick, MD^e; Carolina V. Guimaraes, MD^f; Edwin Gulko, MD^g; Camilo Jaimes, MD^h; Madeline M. Joseph, MDⁱ; Summer L. Kaplan, MD, MS^j; R Christopher Miyamoto, MD^k; Helen R. Nadel, MD^l; Sonia Partap, MD, MS^m; Cory M. Pfeifer, MDⁿ; Sumit Pruthi, MD, MBBS^o.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
A. CT head

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
B. CT Orbits

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
C. CT head without IV contrast

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
D. MRA Head

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
E. MRI Head

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
F. MRI Orbits

Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging.
G. Radiography Orbit

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
A. CT head and orbits

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
B. CT head and orbits without and with IV contrast

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
C. CT Orbits

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
D. CTA Head and Neck

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
E. CT head without and with IV contrast

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
F. MRA Head

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
G. MRI Head

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
H. MRI Head and Orbits

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
I. MRI Orbits

Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging.
J. MRI Complete Spine

Variant 3: Child with isolated nystagmus. Initial imaging.

Variant 3: Child with isolated nystagmus. Initial imaging.
A. CT head and orbits

Variant 3: Child with isolated nystagmus. Initial imaging.
B. CT head

Variant 3: Child with isolated nystagmus. Initial imaging.
C. CT orbits

Variant 3: Child with isolated nystagmus. Initial imaging.
D. CTA Head

Variant 3: Child with isolated nystagmus. Initial imaging.
E. MRA Head

Variant 3: Child with isolated nystagmus. Initial imaging.
F. MRI Head and Orbits

Variant 3: Child with isolated nystagmus. Initial imaging.
G. MRI Head

Variant 3: Child with isolated nystagmus. Initial imaging.
H. MRI Orbits

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
A. CT head and orbits

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
B. CT head

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
C. CT orbits

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
D. CTA Head

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
E. MRA Head

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
F. MRI Head and Orbits

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
G. MRI Head

Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging.
H. MRI Orbits

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
A. CT head and orbits

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
B. CT head

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
C. CT orbits

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
D. CTA Head

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
E. MRA Head

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
F. MRI Head and Orbits

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
G. MRI Head

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
H. MRI Orbits

Variant 5: Child. Vision loss and suspected optic pathway tumor, with or without a history of neurofibromatosis type 1. Initial imaging.
I. Radiography Orbit

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
A. CT head and orbits

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
B. CT head

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
C. CT orbits

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
D. CTA Head

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
E. CTV Head

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
F. MRA Head

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
G. MRI Head and Orbits

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
H. MRI Head

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
I. MRI Orbits

Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
J. MRV Head

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
A. CT head with IV contrast

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
B. CT Orbits

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
C. CTA Head

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
D. CTV Head

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
E. MRA Head

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
F. MRI Head

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
G. MRI Orbits

Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging.
H. MRV Head

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
A. CT head and orbits with IV contrast

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
B. CT head

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
C. CT Orbits

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
D. CTA Head

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
E. MRA Head

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
F. MRI Head and Orbits

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
G. MRI Head

Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging.
H. MRI Orbits

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Graves JS, Galetta SL. Acute visual loss and other neuro-ophthalmologic emergencies: management. Neurol Clin 2012;30:75-99, viii.
2.	Vachha BA, Robson CD. Imaging of Pediatric Orbital Diseases. Neuroimaging Clin N Am 2015;25:477-501.
3.	Goh PS, Gi MT, Charlton A, Tan C, Gangadhara Sundar JK, Amrith S. Review of orbital imaging. Eur J Radiol. 2008; 66(3):387-395.
4.	Acar U, Tok OY, Acar DE, Burcu A, Ornek F. A new ocular trauma score in pediatric penetrating eye injuries. Eye (Lond) 2011;25:370-4.
5.	Stotland MA, Do NK. Pediatric orbital fractures. [Review]. J Craniofac Surg. 22(4):1230-5, 2011 Jul.
6.	Betts AM, O'Brien WT, Davies BW, Youssef OH. A systematic approach to CT evaluation of orbital trauma. [Review]. Emergency Radiology. 21(5):511-31, 2014 Oct.EMERG. RADIOL.. 21(5):511-31, 2014 Oct.
7.	Hink EM, Wei LA, Durairaj VD. Clinical features and treatment of pediatric orbit fractures. Ophthal Plast Reconstr Surg. 30(2):124-31, 2014 Mar-Apr.
8.	Barh A, Swaminathan M, Mukherjee B. Orbital fractures in children: clinical features and management outcomes. J AAPOS. 22(6):415.e1-415.e7, 2018 12.
9.	Roth FS, Koshy JC, Goldberg JS, Soparkar CN. Pearls of orbital trauma management. Semin Plast Surg 2010;24:398-410.
10.	Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: A review of the literature. J Emerg Trauma Shock 2015;8:216-23.
11.	Mashriqi F, Iwanaga J, Loukas M, D'Antoni AV, Tubbs RS. Penetrating Orbital Injuries: A Review. Cureus 2017;9:e1725.
12.	Kubal WS. Imaging of orbital trauma. [Review] [25 refs]. Radiographics. 28(6):1729-39, 2008 Oct.
13.	Patel SN, Langer PD, Zarbin MA, Bhagat N. Diagnostic value of clinical examination and radiographic imaging in identification of intraocular foreign bodies in open globe injury. Eur J Ophthalmol. 22(2):259-68, 2012 Mar-Apr.
14.	Lescher S, Wickmann V, Hofstetter P, Porto L. Paediatric patients with sudden vision impairment - An overview of MRI findings. European Journal of Paediatric Neurology. 20(4):616-24, 2016 Jul.
15.	Daniel MC, Coughtrey A, Heyman I, Dahlmann-Noor AH. Medically unexplained visual loss in children and young people: an observational single site study of incidence and outcomes. Eye (Lond) 2017;31:1068-73.
16.	Toldo I, Pinello L, Suppiej A, et al. Nonorganic (psychogenic) visual loss in children: a retrospective series. J Neuroophthalmol 2010;30:26-30.
17.	Filippi M, Rocca MA, Ciccarelli O, et al. MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines. [Review]. Lancet neurol.. 15(3):292-303, 2016 Mar.
18.	Mushlin AI, Detsky AS, Phelps CE, et al. The accuracy of magnetic resonance imaging in patients with suspected multiple sclerosis. The Rochester-Toronto Magnetic Resonance Imaging Study Group. JAMA 1993;269:3146-51.
19.	Al Othman B, Raabe J, Kini A, Lee AG. Neuroradiology for ophthalmologists. Eye (Lond) 2020;34:1027-38.
20.	Kim HJ, Paul F, Lana-Peixoto MA, et al. MRI characteristics of neuromyelitis optica spectrum disorder: an international update. [Review]. Neurology. 84(11):1165-73, 2015 Mar 17.Neurology. 84(11):1165-73, 2015 Mar 17.
21.	Cotton F, Weiner HL, Jolesz FA, Guttmann CR. MRI contrast uptake in new lesions in relapsing-remitting MS followed at weekly intervals. Neurology 2003;60:640-6.
22.	Tillema JM, Pirko I. Neuroradiological evaluation of demyelinating disease. Ther Adv Neurol Disord 2013;6:249-68.
23.	Papageorgiou E, McLean RJ, Gottlob I. Nystagmus in childhood. Pediatr Neonatol 2014;55:341-51.
24.	Bertsch M, Floyd M, Kehoe T, Pfeifer W, Drack AV. The clinical evaluation of infantile nystagmus: What to do first and why. Ophthalmic Genet 2017;38:22-33.
25.	Ehrt O. Infantile and acquired nystagmus in childhood. Eur J Paediatr Neurol 2012;16:567-72.
26.	Lavery MA, O'Neill JF, Chu FC, Martyn LJ. Acquired nystagmus in early childhood: a presenting sign of intracranial tumor. Ophthalmology 1984;91:425-53.
27.	Reginald AY, Tandon A, Donelyl J, Bartel U, Buncic R. Nystagmus as a presenting sign in optic nerve glioma: The last decade. J Am Assoc Pediatr Ophthalmol Strabismus 2010;14:e6.
28.	Shaw FS, Kriss A, Russel-Eggitt I, Taylor D, Harris C. Diagnosing children presenting with asymmetric pendular nystagmus. Dev Med Child Neurol 2001;43:622-7.
29.	Batmanabane V, Heon E, Dai T, et al. The role of MR imaging in investigating isolated pediatric nystagmus. Pediatr Radiol. 46(12):1721-1727, 2016 Nov.
30.	Garone G, Suppiej A, Vanacore N, et al. Characteristics of Acute Nystagmus in the Pediatric Emergency Department. Pediatrics 2020;146.
31.	Benson JC, Nascene D, Truwit C, McKinney AM. Septo-optic Dysplasia : Assessment of Associated Findings with Special Attention to the Olfactory Sulci and Tracts. Clin Neuroradiol. 29(3):505-513, 2019 Sep.
32.	Qian X, Fouzdar Jain S, Morgan LA, Kruse T, Cabrera M, Suh DW. Neuroimaging and endocrine disorders in paediatric optic nerve hypoplasia. Br J Ophthalmol. 102(7):906-910, 2018 07.
33.	Ramakrishnaiah RH, Shelton JB, Glasier CM, Phillips PH. Reliability of magnetic resonance imaging for the detection of hypopituitarism in children with optic nerve hypoplasia. Ophthalmology. 121(1):387-391, 2014 Jan.
34.	Lenhart PD, Desai NK, Bruce BB, Hutchinson AK, Lambert SR. The role of magnetic resonance imaging in diagnosing optic nerve hypoplasia. Am J Ophthalmol. 158(6):1164-1171.e2, 2014 Dec.
35.	Park ES, Park JB, Ra YS. Pediatric Glioma at the Optic Pathway and Thalamus. J Korean Neurosurg Soc 2018;61:352-62.
36.	Rasool N, Odel JG, Kazim M. Optic pathway glioma of childhood. Curr Opin Ophthalmol 2017;28:289-95.
37.	Cassina M, Frizziero L, Opocher E, et al. Optic Pathway Glioma in Type 1 Neurofibromatosis: Review of Its Pathogenesis, Diagnostic Assessment, and Treatment Recommendations. Cancers (Basel) 2019;11.
38.	Maloney E, Stanescu AL, Perez FA, et al. Surveillance magnetic resonance imaging for isolated optic pathway gliomas: is gadolinium necessary? Pediatr Radiol 2018;48:1472-84.
39.	Marsault P, Ducassou S, Menut F, Bessou P, Havez-Enjolras M, Chateil JF. Diagnostic performance of an unenhanced MRI exam for tumor follow-up of the optic pathway gliomas in children. Neuroradiology 2019;61:711-20.
40.	Inger HE, Rogers DL, McGregor ML, Aylward SC, Reem RE. Diagnostic criteria in pediatric intracranial hypertension. Journal of Aapos: American Association for Pediatric Ophthalmology & Strabismus. 21(6):492-495.e2, 2017 Dec.
41.	Rook BS, Phillips PH. Pediatric pseudotumor cerebri. [Review]. Current Opinion in Ophthalmology. 27(5):416-9, 2016 Sep.
42.	Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology. 81(13):1159-65, 2013 Sep 24.
43.	Gilbert AL, Heidary G. Update on the evaluation of pediatric idiopathic intracranial hypertension. [Review]. Curr Opin Ophthalmol. 27(6):493-497, 2016 Nov.
44.	Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging?. Pediatrics. 125(4):e719-26, 2010 Apr.
45.	Suhaili DN, Goh BS, Gendeh BS. A ten year retrospective review of orbital complications secondary to acute sinusitis in children. Med J Malaysia. 65(1):49-52, 2010 Mar.
46.	Mathew AV, Craig E, Al-Mahmoud R, et al. Paediatric post-septal and pre-septal cellulitis: 10 years' experience at a tertiary-level children's hospital. Br J Radiol. 87(1033):20130503, 2014 Jan.
47.	Chawla B, Sharma S, Sen S, et al. Correlation between clinical features, magnetic resonance imaging, and histopathologic findings in retinoblastoma: a prospective study. Ophthalmology. 119(4):850-6, 2012 Apr.
48.	Galluzzi P, Hadjistilianou T, Cerase A, et al. MRI helps depict clinically undetectable risk factors in advanced stage retinoblastomas. Neuroradiol. j.. 28(1):53-61, 2015 Feb.
49.	Heran F, Berges O, Blustajn J, et al. Tumor pathology of the orbit. [Review]. Diagnostic and Interventional Imaging. 95(10):933-44, 2014 Oct.
50.	Radhakrishnan V, Sharma S, Vishnubhatla S, Bakhshi S. MRI findings at baseline and after neoadjuvant chemotherapy in orbital retinoblastoma (IRSS stage III). Br J Ophthalmol. 97(1):52-8, 2013 Jan.
51.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.