12-phase flow (12)

1. 1FRAME
   Frame as a SIGHT-THREATENING ophthalmic emergency masquerading as a systemic illness — the trap is mislabelling severe eye pain + headache + vomiting as acute abdomen, migraine, or gastroenteritis (Weinreb JAMA 2014 PMID 24825645). IOP reduction is the only proven means of preventing irreversible optic-nerve damage; chronic open-angle management, the migraine pathway, and the SAH pathway are routed OUT, not authored here.
   advance: AACG-emergency scope confirmed; not-this-engine pathways routed by engine_id
2. 2ENTRY
   Recognise the classic triad (severe unilateral eye/brow pain + blurred vision + coloured halos) OR the systemic-mimic presentation (red eye + frontal headache + nausea/vomiting) OR a precipitant-drug entry; capture laterality and halos up front
   inputs: eye_pain_laterality_and_severity, coloured_halos_around_lights
   actions: workup.acute_red_eye
   advance: entry trigger present; laterality + halos recorded
3. 3CONTEXT
   Build the AACG prior: the cardinal sign cluster (mid-dilated fixed/oval pupil, steamy cornea, shallow AC, IOP often 40-80 mmHg), the nausea/vomiting that misdirects and precludes oral CAI, anatomic/demographic predisposition (hyperopia, Asian ancestry, prior episode), and the precipitant-drug review (bilateral simultaneous → secondary/ciliochoroidal-effusion mechanism)
   inputs: nausea_vomiting_with_eye_pain, pupil_shape_and_reactivity, corneal_clarity_and_anterior_chamber_depth, intraocular_pressure, precipitant_drug_review, hyperopia_or_prior_angle_closure
   actions: workup.acute_red_eye
   advance: cardinal cluster + IOP + pretest prior + mechanism (pupillary-block vs secondary) assigned
4. 4RED_FLAGS
   Time-critical screen: IOP at the level/duration that risks irreversible optic-nerve damage → STAT ophthalmology + immediate medical IOP-lowering bundle; thunderclap/worst-headache/focal-neurology → recognise then route OUT to neuro.sah.core.v1; sulfonamide allergy → gate carbonic-anhydrase inhibitors before they are ordered
   inputs: thunderclap_or_worst_headache_features, sulfonamide_allergy
   actions: protocol.angle_closure, calc.news2
   advance: optic-nerve-damage time window flagged + STAT ophtho activated; SAH mimic screened/routed; CAI allergy gate set
5. 5INITIAL_WORKUP
   Confirm by IOP (tonometry) + slit-lamp/penlight (cornea, pupil, AC depth); baseline electrolytes, glucose, renal function to deliver acetazolamide/mannitol safely; CBC/CMP if systemic toxicity or admission anticipated; ECG/vitals if mannitol volume load planned in cardiac patients
   inputs: electrolytes_and_glucose, creatinine
   actions: panel.cmp, panel.renal
   advance: IOP + anterior-segment exam documented; baseline labs sent; medical bundle initiated
6. 6BRANCHING_WORKUP
   Mechanism decision: pupillary-block primary closure (LPI definitive) vs plateau iris (iridoplasty) vs lens-vault/phacomorphic (lens extraction — EAGLE) vs ciliochoroidal-effusion drug-induced secondary closure (STOP drug + cycloplegia + topical steroid — iridotomy does NOT help). Gonioscopy ± AS-OCT/UBM once cornea clears; route precipitant-drug review out to gim.deprescribing.core.v1
   inputs: gonioscopy_or_anterior_segment_imaging
   actions: workup.acute_vision_loss
   advance: mechanism classified; secondary/drug-induced separated from primary pupillary-block; precipitant review routed
7. 7DIFFERENTIAL
   Terminal differential of the red painful eye with headache/vomiting, with named pivots: AACG (mid-dilated fixed pupil + steamy cornea + raised IOP + shallow AC + halos pivot) vs acute anterior uveitis (small/miotic pupil + hypopyon/cells + normal-or-low IOP pivot) vs migraine/cluster headache (normal eye exam + normal IOP + photophobia-without-corneal-oedema pivot) vs conjunctivitis (discharge + normal pupil + normal IOP + no pain pivot) vs scleritis (boring pain + scleral violaceous hue + normal IOP pivot) vs subarachnoid haemorrhage (thunderclap + neurology + normal IOP → route to neuro.sah.core.v1 pivot)
   actions: workup.acute_headache
   advance: single best diagnosis selected; SAH/secondary-cause mimics excluded or routed
8. 8RISK_STRATIFICATION
   Severity by IOP magnitude × duration of attack × optic-nerve/visual-field status × bilateral or fellow-eye anatomic risk × refractoriness to the medical bundle; very high IOP for prolonged duration or non-response within ~1 h of the bundle → surgical/laser urgency upgrade and inpatient/transfer disposition
   inputs: intraocular_pressure
   actions: calc.news2
   advance: IOP-duration severity + fellow-eye risk + refractoriness assigned
9. 9TREATMENT
   STEPWISE medical IOP-lowering bundle as a temporising bridge to definitive laser: (1) supine positioning + corneal indentation; (2) topical timolol + brimonidine + pilocarpine (pilocarpine ineffective if IOP >40-50 mmHg due to iris-sphincter ischaemia — give after IOP partly lowered) + topical prednisolone; (3) systemic/topical acetazolamide/dorzolamide (sulfonamide-allergy and renal gating); (4) hyperosmotic IV mannitol if refractory (cardiac/renal/pregnancy gating); then DEFINITIVE laser peripheral iridotomy of the affected eye once cornea clears, PROPHYLACTIC LPI of the anatomically-narrow fellow eye, and consider EAGLE early-lens-extraction. Drug-induced secondary closure → STOP precipitant + cycloplegia + topical steroid (NOT pilocarpine, NOT iridotomy).
   inputs: pregnancy, creatinine, cardiac_pulmonary_comorbidity, sulfonamide_allergy
   actions: protocol.angle_closure
   advance: medical bundle delivered + IOP trending down; definitive laser PI arranged; fellow-eye prophylaxis planned; precipitant stopped if secondary
10. 10DISPOSITION
    STAT same-day ophthalmology is mandatory in all cases. Refractory IOP, prolonged attack, bilateral/secondary closure needing systemic therapy, or vomiting precluding oral therapy → admit/transfer for IV mannitol + urgent laser/surgery; responsive primary pupillary-block with arranged same-day LPI and reliable follow-up → may complete laser as urgent outpatient (ophthalmology-directed). Pure migraine/conjunctivitis/SAH-mimic confirmed → exit AACG pathway, route by engine_id.
    inputs: intraocular_pressure
    advance: disposition documented; definitive laser timing and fellow-eye plan confirmed
11. 11MONITORING
    Recheck IOP at 30-60 min intervals during the bundle; expect a meaningful fall within ~1 h on an effective bundle — failure to break the attack mandates escalation to mannitol then urgent laser/surgery, not silent continuation; monitor for acetazolamide hypokalaemia/acidosis and mannitol volume overload/electrolyte shift; post-LPI IOP check and patency confirmation
    inputs: intraocular_pressure, electrolytes_and_glucose
    actions: panel.cmp
    advance: IOP broken and trending to safe range OR escalation triggered
12. 12FOLLOWUP
    Definitive LPI of the affected eye and PROPHYLACTIC LPI of the anatomically-narrow fellow eye (untreated fellow-eye attack risk is substantial in symptomatic angle closure — distinct from screen-detected ZAP suspects where prophylaxis benefit is modest, He Lancet 2019 PMID 30878226); EAGLE early-lens-extraction discussion in lens-driven disease (Azuara-Blanco Lancet 2016 PMID 27707497); lifelong glaucoma surveillance for residual optic-nerve damage / chronic angle closure; permanent documentation + deprescribing of the precipitant drug and patient warning card; route chronic IOP care and precipitant medication review out by engine_id
    inputs: precipitant_drug_review, hyperopia_or_prior_angle_closure
    advance: definitive + fellow-eye laser plan documented; precipitant deprescribed/flagged; chronic glaucoma surveillance arranged