12-phase flow (12)

1. 1FRAME
   Frame SCH as the BENIGN PIVOT of the acute red eye: a self-limited extravasation of blood between conjunctiva and sclera with intact vision, no pain, no discharge — but a presentation that must be CONFIRMED isolated and screened for the situations where it is a flag (significant trauma → open globe; spontaneous on anticoagulant; recurrent/bilateral → bleeding diathesis / HTN / occult trauma-NAI / neoplasm). This engine OWNS confirmation + reassurance + the danger screen; definitive management of trauma/globe-rupture and of the systemic drivers is routed OUT by engine_id (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690; Wills Eye Manual).
   advance: SCH framed as benign-pivot; danger-screen + route-out targets flagged by engine_id
2. 2ENTRY
   Recognise the painless bright-red flat patch with normal vision, OR the escalation entries (spontaneous-on-anticoagulant, recurrent/bilateral, post-trauma/Valsalva, neonatal). Up front elicit the two hard pivots — is there genuine ocular PAIN, and is visual ACUITY normal? Either pain or reduced acuity means this is NOT isolated SCH and re-triages (Wills Eye Manual; Tarlan & Kiratli 2013 PMID 23843690).
   inputs: ocular_pain_present, visual_acuity_change
   actions: workup.acute_red_eye
   advance: SCH entry recognised; pain + acuity pivots screened
3. 3CONTEXT
   Build the benign-vs-flag prior: presence/absence of discharge, photophobia, itch (all absent in isolated SCH); antithrombotic use; recurrent or bilateral pattern; blood pressure; mucocutaneous bleeding tendency; Valsalva/birth/paediatric context; contact-lens wear; pregnancy. This phase decides whether the case stays in the reassurance lane or enters the danger/work-up lane (Tarlan & Kiratli 2013 PMID 23843690; Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065).
   inputs: discharge_or_photophobia_or_itch, antithrombotic_use, recurrent_or_bilateral_pattern, blood_pressure, bleeding_tendency_or_easy_bruising, valsalva_or_birth_or_pediatric_context, contact_lens_wear, pregnancy
   actions: workup.acute_red_eye, workup.secondary_htn
   advance: benign-vs-flag pre-test prior assigned
4. 4RED_FLAGS
   Hard danger screen, each recognised then routed OUT by engine_id: (1) significant blunt/penetrating trauma → exclude open/ruptured globe BEFORE attributing to benign SCH; (2) bullous / 360° circumferential SCH, SCH with no posterior limit, marked haemorrhagic chemosis, reduced acuity, peaked/irregular pupil, hyphema (layered AC blood), shallow AC or hypotony → suspected globe rupture / hyphema → route to ophtho.ocular-trauma.core.v1 (shield, no pressure, NPO, do NOT manipulate); (3) any true pain / photophobia / discharge / vision change → it is NOT isolated SCH → return to ophtho.acute-red-eye.core.v1. These are recognised here, NOT managed here (Philip Am J Ophthalmol Case Rep 2021 PMID 33732947; Wills Eye Manual red-eye triage).
   inputs: trauma_mechanism_and_severity, sch_extent_bullous_or_360_or_no_posterior_limit, pupil_cornea_iop_anterior_chamber_normal
   actions: workup.acute_vision_loss
   advance: open-globe / hyphema / not-SCH red flags screened and routed by engine_id if positive
5. 5INITIAL_WORKUP
   For CONFIRMED isolated benign SCH: NO routine bloods — the most common error is over-investigating a single benign event (Jeon Ophthalmic Epidemiol 2021 PMID 34793286 — SCH itself is not a stroke/AMI risk factor; Hong Sci Rep 2023 PMID 38097669 — not associated with increased ICH/GI bleed). Targeted only: a single BP reading for every patient; INR if on warfarin/with a spontaneous bleed; CBC + coagulation panel + CMP ONLY when recurrent/bilateral WITH other bleeding, on anticoagulation with a spontaneous event, or when a systemic driver is clinically suspected (Tarlan & Kiratli 2013 PMID 23843690; Fierro/Gresele 2016 PMID 26087065).
   inputs: inr
   actions: panel.cbc, panel.coag, panel.cmp
   advance: BP recorded; INR sent if anticoagulated; targeted panels only if a flag is present (no reflex bloods for isolated SCH)
6. 6BRANCHING_WORKUP
   Decision tree off CONTEXT/RED_FLAGS: trauma + any open-globe sign → ophtho.ocular-trauma.core.v1 (open-globe arm); spontaneous + anticoagulant + supratherapeutic INR → anticoagulation-indication / dose review (do NOT reflexively stop); recurrent/bilateral + other mucocutaneous bleeding → bleeding-disorder / heme work-up (panel.cbc + panel.coag); markedly elevated BP / resistant or young HTN → workup.secondary_htn + BP management; elderly recurrent unilateral SCH or a fleshy/atypical lesion behind the blood → conjunctival-neoplasm / Kaposi inspection + biopsy referral; paediatric SCH with an inconsistent history → NAI safeguarding pathway; otherwise → isolated benign SCH, reassurance lane (Redzuwan Cureus 2023 PMID 37846262; Tarlan & Kiratli 2013 PMID 23843690).
   inputs: elderly_unilateral_recurrent_or_fleshy_mass
   actions: workup.secondary_htn, workup.acute_vision_loss
   advance: single best arm selected; dangerous / systemic-driver arm routed by engine_id
7. 7DIFFERENTIAL
   Terminal differential with explicit pivot findings — ISOLATED BENIGN SCH: painless + normal acuity + flat + sharply demarcated + bright-red + no discharge + normal pupil/cornea/IOP + posterior limit visible pivot. DANGEROUS / NOT-SCH look-alikes: open / ruptured globe (significant trauma + bullous/360° SCH + reduced acuity + peaked pupil + hypotony + Seidel pivot — route to ophtho.ocular-trauma.core.v1); hyphema (layered red blood in the anterior chamber, not under conjunctiva, after trauma pivot); conjunctivitis (discharge + itch + bilateral + diffuse injection NOT a discrete blood patch pivot); episcleritis / scleritis (sectoral/violaceous injected vessels that blanch (epi) or boring pain (scleritis), not extravasated blood pivot); conjunctival laceration (focal trauma + Seidel/fluorescein + foreign-body pivot); conjunctival neoplasm / Kaposi sarcoma (fleshy/feeder-vessel/recurrent in elderly or immunocompromised + persistent beyond expected resolution pivot — biopsy). Co-existence flagged (e.g., SCH overlying an occult rupture; SCH plus a small hidden conjunctival mass) — the blood must not hide the lesion (Redzuwan Cureus 2023 PMID 37846262; Wills Eye Manual).
   advance: isolated benign SCH vs a dangerous/neoplastic look-alike selected; co-existence flagged
8. 8RISK_STRATIFICATION
   Stratify to a disposition tier: TIER 1 (route OUT, urgent) — any trauma with an open-globe sign, reduced acuity, bullous/360° SCH, hyphema → ophtho.ocular-trauma.core.v1; TIER 2 (work-up, non-urgent) — spontaneous on anticoagulant with supratherapeutic INR, recurrent/bilateral with other bleeding, severe/symptomatic HTN, elderly recurrent unilateral or fleshy lesion (neoplasm), paediatric inconsistent history (NAI); TIER 3 (reassure) — isolated benign SCH, normal vision/pain-free, no flags → primary-care reassurance + return precautions. qSOFA/NEWS2 only when a systemic-bleed or sepsis context co-exists (rare) (Jeon Ophthalmic Epidemiol 2021 PMID 34793286; Tarlan & Kiratli 2013 PMID 23843690).
   inputs: visual_acuity_change, recurrent_or_bilateral_pattern
   actions: calc.qsofa, calc.news2
   advance: tier assigned; route-out target identified by engine_id
9. 9TREATMENT
   NO specific treatment for isolated benign SCH — this is an explicit guardrail, not an omission. Supportive only: reassure (self-limited, resolves 1-2 weeks, up to ~3 wk for large bleeds; colour evolves red → orange/yellow like a bruise); COLD compress for the first 24-48 h to limit extension, then WARM compress to speed clearance; preservative-free artificial tears ONLY if surface irritation; no antibiotics, no patch. The only therapeutic actions are routed OUT: anticoagulation-INR/dose review (do NOT reflexively stop the agent for an isolated benign SCH — the thrombotic risk of stopping usually outweighs a benign self-limited bleed), BP management, bleeding-disorder work-up, and the trauma/open-globe pathway. Drug-safety gating: any systemic agent screened against pregnancy (Tarlan & Kiratli 2013 PMID 23843690; Leiker Optometry 2009 PMID 19410227; Jeon 2021 PMID 34793286).
   inputs: pregnancy, antithrombotic_use
   advance: reassurance + compress guidance given; no specific Rx for benign SCH; systemic-driver / trauma actions routed by engine_id
10. 10DISPOSITION
    Tier 3 isolated benign SCH → discharge to primary care with explicit eye-specific return precautions (any new pain, vision change, discharge, photophobia, recurrence, or failure to resolve by 3 weeks → re-present). Tier 1 trauma/open-globe → route to ophtho.ocular-trauma.core.v1 same-hour (shield, no pressure, NPO). Tier 2 → arrange the targeted work-up (anticoagulation review, BP management, heme work-up, conjunctival-lesion / neoplasm referral, paediatric safeguarding) with the relevant engine/service; document why bloods were or were NOT sent (Tarlan & Kiratli 2013 PMID 23843690; Wills Eye Manual).
    inputs: visual_acuity_change
    advance: disposition + route-out engine_id documented; benign cases given vision-specific return precautions
11. 11MONITORING
    Isolated benign SCH needs no active monitoring beyond expected colour evolution; counsel that the patch often looks WORSE / spreads over the first 24-48 h before clearing — this is expected and prevents needless re-presentation. Re-evaluate only if NEW pain, vision change, discharge or photophobia emerge (re-triggers RED_FLAGS / re-triage to ophtho.acute-red-eye.core.v1) or if it has not resolved by ~3 weeks (prompts re-examination for an underlying lesion). For routed cases, confirm the receiving engine has carryover state (Jeon Ophthalmic Epidemiol 2021 PMID 34793286; Tarlan & Kiratli 2013 PMID 23843690).
    inputs: visual_acuity_change, ocular_pain_present
    actions: workup.acute_red_eye
    advance: expected-evolution counselling given OR re-triage triggered; route-out carryover confirmed
12. 12FOLLOWUP
    Education + return precautions are the core deliverable for benign SCH — explicit RED-FLAG return: new true ocular pain, any vision drop, discharge, severe photophobia, recurrence, bilateral involvement, or non-resolution by 3 weeks → re-present. Modifiable-driver follow-up where flagged: optimise BP, review/optimise (do not reflexively stop) anticoagulation with the prescribing clinician, contact-lens hygiene, treat the Valsalva source (e.g., antitussive / pertussis management). Recurrent/bilateral or persistent → ensure the bleeding-disorder / conjunctival-neoplasm / paediatric-safeguarding pathway is closed. For routed dangerous cases, ownership transfers to the receiving engine (Tarlan & Kiratli 2013 PMID 23843690; Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065).
    inputs: recurrent_or_bilateral_pattern, antithrombotic_use
    advance: return-precaution + modifiable-driver counselling documented; recurrent/persistent work-up routed if applicable