12-phase flow (12)

1. 1FRAME
   Frame as a VISION-DESTROYING intraocular-infection EMERGENCY whose prognosis is measured in hours — the EVS tap-and-inject spine, NOT undifferentiated red-eye triage (that is ophtho.acute-red-eye.core.v1, which routes here). Set the five-category partition (post-cataract / post-injection / post-trauma / bleb-associated / endogenous) and the hard rules: empiric intravitreal vancomycin + ceftazidime BEFORE culture; vitrectomy if light-perception-only; no routine systemic abx for post-cataract; systemic therapy + source hunt for endogenous. Orbital/panophthalmitis extension is recognised then routed OUT.
   advance: endophthalmitis emergency scope confirmed; upstream-triage and orbital concerns delineated by engine_id
2. 2ENTRY
   Recognise the four exogenous entries (post-cataract, post-injection, post-trauma, bleb) vs the endogenous entry (candidemia/bacteremia/IVDU/line/liver-abscess/endocarditis with ocular symptoms); capture vision-loss tempo and severity up front (presenting acuity is the EVS treatment fork).
   inputs: vision_loss_tempo_and_severity
   advance: entry trigger present; vision-loss tempo + severity recorded
3. 3CONTEXT
   Build the category + pathogen prior: latency from surgery/injection/trauma/bleb-surgery; pain disproportion (Bacillus/strep); hypopyon + AC reaction; vitritis + red-reflex status; filtering bleb; systemic infective source; immunocompromise/IVDU. This phase assigns post-cataract vs post-injection vs post-trauma vs bleb vs endogenous and separates infection from sterile post-op inflammation/TASS.
   inputs: recent_intraocular_surgery_or_injection_or_trauma, pain_severity_and_disproportion, hypopyon_and_anterior_chamber_reaction, vitritis_and_red_reflex_status, glaucoma_filtering_bleb, systemic_infection_source_candidemia_bacteremia, immunocompromise_or_ivdu
   actions: workup.acute_vision_loss
   advance: category + pretest pathogen prior assigned; TASS/uveitis pivot considered
4. 4RED_FLAGS
   The whole disease is a red flag — stratify the within-hours actions: light-perception-only vision → emergent vitrectomy (EVS); fulminant post-trauma → Bacillus cover + IOFB removal; bilateral / endogenous → systemic work-up + route to sepsis/candidemia/endocarditis engines; bleb-associated → virulent-strep cover; orbital/panophthalmitis extension → route OUT to ophtho.orbital-cellulitis.core.v1. These mandate same-hour vitreoretinal ophthalmology and tap-and-inject.
   inputs: bilateral_ocular_involvement, visual_acuity_each_eye, orbital_or_panophthalmitis_features
   actions: calc.qsofa, workup.acute_vision_loss, workup.endocarditis
   advance: vision-criterion, fulminant, endogenous, bleb and orbital red flags screened and routed by engine_id if positive
5. 5INITIAL_WORKUP
   TAP-AND-INJECT NOW: vitreous (± aqueous) tap for Gram/Giemsa/KOH + bacterial & fungal culture obtained AT the same sitting as immediate empiric intravitreal vancomycin + ceftazidime — do NOT await culture. For endogenous/unexplained disease in parallel: blood cultures, source hunt (urine, line, abdomen, echocardiography), CBC/inflammation/CMP baseline, creatinine for systemic dosing. B-scan if the fundus is obscured.
   inputs: vitreous_tap_gram_stain_and_culture, blood_cultures_and_systemic_workup, creatinine
   actions: panel.cbc, panel.inflammation, panel.cmp, workup.candidemia
   advance: tap obtained AND empiric intravitreal antibiotics injected; systemic cultures sent if endogenous
6. 6BRANCHING_WORKUP
   Category-driven branch: post-trauma → CT/B-scan for retained IOFB, add Bacillus-active cover; endogenous → blood/urine/line cultures, abdominal imaging for Klebsiella liver abscess, transthoracic→transoesophageal echo for endocarditis, fungal markers (β-D-glucan); bilateral/chorioretinal lesion → systemic Candida work-up; bleb → bleb-leak (Seidel) assessment. Send vitreous PCR / fungal culture when smear negative but course atypical/non-resolving.
   inputs: b_scan_ultrasound
   actions: workup.candidemia, workup.endocarditis, workup.acute_vision_loss
   advance: category-specific source/organism work-up dispatched and routed
7. 7DIFFERENTIAL
   Terminal differential with pivot findings: endophthalmitis vs sterile post-op inflammation / TASS (latency + pain + vitritis pivot — TASS = early <24-48 h, limbus-to-limbus corneal oedema, AC reaction WITHOUT significant vitritis, painless, steroid-responsive) vs severe anterior uveitis (cell/flare WITHOUT vitritis or red-reflex loss pivot) vs microbial keratitis with hypopyon (sterile reactive hypopyon over a corneal infiltrate, no true vitritis — route reciprocally to ophtho.microbial-keratitis.core.v1) vs retained lens fragment (post-cataract granulomatous reaction, indolent, lens material in AC/vitreous pivot) vs masquerade (intraocular lymphoma / necrotic tumour / old vitreous haemorrhage — indolent, steroid-refractory, no source).
   advance: single best diagnosis selected; infectious-vs-sterile pivot documented; co-existence (keratitis → endophthalmitis) flagged
8. 8RISK_STRATIFICATION
   Stratify by the EVS vision criterion (light-perception-only → vitrectomy; hand-motions-or-better → tap-and-inject), organism virulence (EVS microbiologic spectrum — coag-neg staph favourable; strep/enterococci/gram-negative/Bacillus/fungal unfavourable), category (post-trauma/bleb/endogenous worse than post-cataract coag-neg-staph), bilaterality, and systemic illness severity (qSOFA for the septic endogenous patient).
   inputs: visual_acuity_each_eye, bilateral_ocular_involvement
   actions: calc.qsofa, calc.news2, calc.sirs
   advance: EVS vision tier + organism/category/systemic-severity overlay assigned
9. 9TREATMENT
   IMMEDIATE intravitreal vancomycin 1 mg/0.1 mL (gram-positive incl. MRSA) + ceftazidime 2.25 mg/0.1 mL (gram-negative incl. Pseudomonas) at the tap; amikacin 0.4 mg/0.1 mL only if ceftazidime unsuitable (macular-infarction caution). Pars-plana VITRECTOMY if presenting vision is light-perception only (EVS — 3× the ≥20/40 rate). NO routine systemic antibiotics for post-cataract disease (EVS null). Intravitreal dexamethasone DEBATED — withhold if fungal/atypical. ENDOGENOUS: systemic antibacterial (bacteraemia/Klebsiella) or antifungal (Candida — systemic ± intravitreal voriconazole/amphotericin B) + SOURCE CONTROL, and route the systemic arm to sepsis/candidemia/endocarditis engines. Trauma: add Bacillus-active cover (vancomycin covers; ± systemic) + IOFB removal. Pregnancy: voriconazole teratogenic — substitute amphotericin B.
   inputs: vitreous_tap_gram_stain_and_culture, creatinine, pregnancy
   advance: tap-and-inject delivered; vitrectomy decision by EVS vision criterion; endogenous systemic therapy + source control + route-out initiated
10. 10DISPOSITION
    Every endophthalmitis is admitted or managed under same-hour vitreoretinal ophthalmology with capacity for repeat tap/inject and possible vitrectomy. Endogenous → admit under medicine/ID with the eye co-managed; route the systemic arm to id.sepsis.core.v1 / workup.candidemia / workup.endocarditis. Orbital/panophthalmitis extension → route OUT to ophtho.orbital-cellulitis.core.v1. A confirmed sterile look-alike (TASS / retained lens fragment / reactive keratitis hypopyon / masquerade) is taken off empiric anti-infectives and managed/routed accordingly.
    inputs: visual_acuity_each_eye, bilateral_ocular_involvement
    advance: disposition + route-out/route-back engine_id documented; repeat-tap/vitrectomy capability confirmed
11. 11MONITORING
    Re-examine within 24-48 h: hypopyon/AC reaction, vitritis density, red reflex, B-scan, and acuity vs the baseline map. Worsening or non-improvement at 48-72 h → repeat tap + re-inject, reconsider fungal/atypical/Bacillus, and escalate to vitrectomy. Endogenous: track blood-culture clearance, source control, and systemic-therapy response with the medicine/ID team.
    inputs: vitreous_tap_gram_stain_and_culture
    actions: panel.inflammation
    advance: objective improvement by 48-72 h, OR repeat-tap/vitrectomy/re-evaluation triggered
12. 12FOLLOWUP
    Track final visual outcome (EVS prognostic anchors), retinal/vitreous sequelae (RD, epiretinal membrane, macular damage), and silicone-oil/secondary-surgery needs. PREVENTION (a core deliverable): povidone-iodine antisepsis + intracameral cefuroxime for cataract surgery (ESCRS ~5-fold reduction); meticulous injection antisepsis (antibiotic prophylaxis does NOT help); prompt open-globe repair + IOFB removal; bleb-leak surveillance and patient education on the bleb-endophthalmitis lifetime risk; treat the systemic source and screen the fellow eye in endogenous disease.
    inputs: recent_intraocular_surgery_or_injection_or_trauma
    advance: visual-outcome + sequelae tracked; category-specific prevention plan documented; systemic source treated for endogenous