ophtho.acute-conjunctivitis.core.v1PRODUCTION

ophtho.acute-conjunctivitis.core.v1

Acute conjunctivitis (viral / bacterial / allergic, with red-flag red-eye routing)

general_internal_medicineacutesubacuteadultpediatric

Hard-required inputs

0 / 10

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as ACUTE CONJUNCTIVITIS subtyping (viral vs bacterial vs allergic) layered on a mandatory sight-threatening-red-eye screen. Most acute infective conjunctivitis is self-limited (Sheikh Cochrane 2012; Everitt BMJ 2006), so the engine is a discriminator + antibiotic-stewardship + red-flag-routing tool. Gonococcal/chlamydial/neonatal/contact-lens cases are NOT simple conjunctivitis and are escalated. Keratitis, uveitis, angle-closure, scleritis are recognised then routed OUT by engine_id.

Inputs

Actions

Advance rule

Set

Advance when

conjunctivitis scope confirmed; not-this-engine sight-threatening concerns routed by engine_id

Patient inputs (16)

discharge_character*symptom • CONTEXT

Watery → viral; mucopurulent/glued lids → bacterial; hyperacute copious purulent → gonococcal emergency; ropy/mucoid → allergic — the single highest-yield subtype discriminator (Azari JAMA 2013; Rietveld BMJ 2004)

itch_dominance*symptom • CONTEXT

Itch is the most consistent sign of ALLERGIC conjunctivitis and argues AGAINST a bacterial cause (Rietveld BMJ 2004 — itch lowers bacterial probability; Azari JAMA 2013)

morning_glued_eyelids*symptom • CONTEXT

Bilateral lids glued on waking is the strongest single positive predictor of a bacterial cause (Rietveld BMJ 2004 — early-morning glued eye raises bacterial probability)

laterality_and_spread*symptom • CONTEXT

Unilateral→fellow-eye spread + watery favors adenoviral; strictly bilateral itchy favors allergic; persistent unilateral favors chlamydial/atypical (Azari JAMA 2013; AAO PPP Varu 2018)

preauricular_lymphadenopathy*symptom • CONTEXT

A tender preauricular node strongly favors viral (esp. adenoviral/EKC) or gonococcal/chlamydial over simple bacterial/allergic (Azari JAMA 2013)

contact_lens_use*history • CONTEXT

not present

Contact-lens wear raises the microbial-keratitis prior ~5-10x and changes the pathogen spectrum (Pseudomonas); a contact-lens red eye is keratitis until excluded — never patch, urgent referral (Seal 1999; Truong 2018)

ocular_pain_severity*symptom • RED_FLAGS

Significant/deep pain is a RED FLAG against simple conjunctivitis (grittiness is expected; true pain → keratitis/uveitis/scleritis/angle-closure) — route OUT (AAO PPP Varu 2018; Azari JAMA 2013)

photophobia*symptom • RED_FLAGS

True photophobia suggests corneal involvement or anterior uveitis, not conjunctivitis — route OUT to keratitis/uveitis (AAO PPP Varu 2018)

visual_acuity_change*symptom • RED_FLAGS

Reduced visual acuity not clearing with a blink is a RED FLAG — conjunctivitis does not reduce acuity; route OUT to sight-threatening red-eye pathway (AAO PPP Varu 2018; Azari JAMA 2013)

ciliary_flush_or_corneal_opacity*symptom • RED_FLAGS

Ciliary/limbal (perilimbal) flush, corneal opacity/infiltrate, fixed or irregular pupil → keratitis / uveitis / angle-closure; route OUT — NOT managed here (AAO PPP Varu 2018)

sexual_history_or_genital_symptomshistory • CONTEXT

not present

Sexually active adult / concurrent urethritis-cervicitis or partner STI → gonococcal or chlamydial conjunctivitis (systemic Rx + partner treatment + STI workup) (CDC STI 2021; Azari JAMA 2013)

neonate_age_daysdemographic • CONTEXT

Age in days stratifies ophthalmia neonatorum etiology and Rx (chemical day 1; gonococcal days 2-5; chlamydial days 5-14) — systemic, not topical-only (CDC STI 2021)

immunocompromisehistory • CONTEXT

not present

Atypical/severe presentation, herpetic risk, and lower referral threshold; avoid empiric steroids without ophthalmology (AAO PPP Varu 2018)

recent_sick_contact_or_institutional_exposurehistory • CONTEXT

not present

Adenoviral/EKC is highly contagious — sick contact / school / clinic / military exposure drives infection-control measures and the outbreak severity trigger (Hamada J Hosp Infect 2008; Liu Cochrane 2022)

fluorescein_corneal_stainingsymptom • INITIAL_WORKUP

Fluorescein staining (dendrite → HSV; diffuse punctate/ulcer → keratitis) gates the steroid-avoidance and route-out decisions; pseudodendrite vs true dendrite pivot (AAO PPP Varu 2018)

pregnancyhistory • TREATMENT

not present

Antibiotic-safety gating for chlamydial conjunctivitis (doxycycline contraindicated in pregnancy → azithromycin; CDC STI 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement

informationallife_threateninggonococcal_hyperacute_conjunctivitis_emergency
Hyperacute copious purulent discharge over hours, marked lid edema, rapid progression ± Gram-negative intracellular diplococci — gonococcal conjunctivitis (CDC STI 2021; Azari JAMA 2013)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningneonatal_ophthalmia_neonatorum
Neonate ≤28 days with conjunctivitis/discharge — ophthalmia neonatorum (gonococcal days 2-5, chlamydial days 5-14, chemical day 1) (CDC STI 2021)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverecontact_lens_associated_keratitis_risk
Contact-lens wearer with red eye + pain/photophobia/corneal infiltrate or fluorescein staining — microbial (Pseudomonas/Acanthamoeba) keratitis until excluded (Seal 1999; Truong 2018)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverevision_threatening_red_flags_route_out
Significant deep pain, true photophobia, reduced visual acuity, ciliary/limbal flush, corneal opacity/infiltrate, fixed/irregular pupil — NOT simple conjunctivitis (AAO Conjunctivitis PPP, Varu 2018)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereherpetic_keratoconjunctivitis_no_steroids
Unilateral red eye + corneal dendrite on fluorescein ± vesicular lid rash / decreased corneal sensation — HSV/VZV keratoconjunctivitis (AAO Conjunctivitis PPP, Varu 2018)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateepidemic_keratoconjunctivitis_outbreak_infection_control
Adenoviral/EKC with institutional exposure (school, clinic, military, hospital) — highly contagious, environmental contamination, outbreak potential (Hamada J Hosp Infect 2008; Liu Cochrane 2022)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatechlamydial_conjunctivitis_systemic_and_partner_rx
Chronic follicular conjunctivitis, sexually active adult or neonate day 5-14, refractory to topical therapy — chlamydial/inclusion conjunctivitis (CDC STI 2021; Azari JAMA 2013)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatenon_response_at_48_72h_reassess
No improvement or worsening at 48-72 h despite subtype-appropriate management (Sheikh Cochrane 2012; AAO PPP Varu 2018)
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives screening

Loading…

Recommended regimen

Acute conjunctivitis — subtype-stratified (stewardship-first; emergencies systemic + ophthalmology)

axis: acute_conjunctivitis_subtype_stratifiedstep 1 - Step 1 — Sight-threat / emergency gate before any conjunctivitis treatment

Selected step "Step 1 — Sight-threat / emergency gate before any conjunctivitis treatment" — Every red eye: significant pain, photophobia, reduced acuity, ciliary flush, corneal opacity/infiltrate, fixed/irregular pupil, hyperacute copious purulent discharge, contact-lens wearer, or neonate

sight_threat_screen_route_out_if_positive
first line
decision_gate
triggers: ocular_pain, photophobia, reduced_visual_acuity, ciliary_flush, corneal_involvement, contact_lens_wearer, hyperacute_purulent, neonate
AAO Conjunctivitis PPP (Varu 2018) — these features mean it is NOT simple conjunctivitis; route OUT to ophtho.acute-red-eye / keratitis / anterior-uveitis / acute-angle-closure-glaucoma by engine_id before treating as conjunctivitis. Contact-lens red eye: discontinue lens, NEVER patch.

outpatient playbook — drug actions (4)

1. supportive care only (viral/adenoviral)
cool compress + lubricants • topical • PRN + strict hygiene
trigger: Watery + preauricular node + sick contact = adenoviral/EKC (AAO PPP Varu 2018; Liu Cochrane 2022)
No antibiotic for viral; infection control is the intervention
2. delayed/short topical antibiotic (non-gonococcal bacterial)
rxcui 4053
erythromycin 0.5% ointment ~1 cm • ophthalmic • QID × 5-7 d (or delayed prescription)
trigger: Mucopurulent + glued lids, no red flag (Sheikh Cochrane 2012; Everitt BMJ 2006)
Most self-limited; delayed prescribing preferred — cuts antibiotic use without medicalisation
3. olopatadine (allergic)
rxcui 135391
0.1-0.2% 1 drop • ophthalmic • once-twice daily
trigger: Bilateral itch-dominant + chemosis + seasonality (Azari JAMA 2013)
Dual antihistamine/mast-cell stabilizer relieves the cardinal itch; allergen avoidance adjunct
4. ceftriaxone (gonococcal — emergency, refer same-day)
rxcui 2193
1 g • IM • single dose + same-day ophthalmology
trigger: Hyperacute copious purulent discharge (CDC STI 2021)
Ophthalmic emergency; systemic Rx + lavage + ophthalmology; co-treat chlamydia + STI/partner workup

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute red eye with discharge or crusting/glued lids — the conjunctivitis presentation; subtype not yet assigned (Azari JAMA 2013; AAO Conjunctivitis PPP, Varu 2018); Bilateral itchy, watery, chemotic eyes ± seasonality / atopy — allergic conjunctivitis entry (Azari JAMA 2013 — itch is the most consistent allergic sign); Unilateral (then fellow-eye) watery red eye, follicular reaction, tender preauricular node — adenoviral / EKC entry, infection-control flag (Liu Cochrane 2022; AAO PPP Varu 2018).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute conjunctivitis (viral / bacterial / allergic, with red-flag red-eye routing)** (ophtho.acute-conjunctivitis.core.v1).
Phenotype framing: Terminal differential with pivot findings — within conjunctivitis: bacterial (glued lids + mucopurulent + no itch pivot — Rietveld BMJ 2004) vs viral/adenoviral (watery + preauricular node + fellow-eye spread + sick contact pivot) vs gonococcal (hyperacute copious purulent + rapid corneal threat pivot) vs chlamydial (chronic follicular + STI/neonate pivot) vs allergic (itch + bilateral + chemosis + seasonality pivot). Against look-alikes: keratitis (pain + photophobia + fluorescein staining + contact-lens pivot → route OUT), anterior uveitis (ciliary flush + photophobia + cells/flare + miotic pupil pivot → route OUT), acute angle-closure glaucoma (severe pain + haloes + fixed mid-dilated pupil + hard globe pivot → protocol.angle_closure / route OUT), scleritis (deep boring pain + violaceous non-blanching scleral injection pivot → route OUT).
Scope: Frame as ACUTE CONJUNCTIVITIS subtyping (viral vs bacterial vs allergic) layered on a mandatory sight-threatening-red-eye screen. Most acute infective conjunctivitis is self-limited (Sheikh Cochrane 2012; Everitt BMJ 2006), so the engine is a discriminator + antibiotic-stewardship + red-flag-routing tool. Gonococcal/chlamydial/neonatal/contact-lens cases are NOT simple conjunctivitis and are escalated. Keratitis, uveitis, angle-closure, scleritis are recognised then routed OUT by engine_id.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute conjunctivitis — subtype-stratified (stewardship-first; emergencies systemic + ophthalmology)** — step "Step 1 — Sight-threat / emergency gate before any conjunctivitis treatment".
1. sight_threat_screen_route_out_if_positive (decision_gate, first line) — AAO Conjunctivitis PPP (Varu 2018) — these features mean it is NOT simple conjunctivitis; route OUT to ophtho.acute-red-eye / keratitis / anterior-uveitis / acute-angle-closure-glaucoma by engine_id before treating as conjunctivitis. Contact-lens red eye: discontinue lens, NEVER patch.

Setting playbook (outpatient) — Subtype the conjunctivitis, run the sight-threatening red-flag screen, apply antibiotic stewardship for infective disease, escalate gonococcal/chlamydial/neonatal/contact-lens cases, and counsel contagion/return-to-activity (Azari JAMA 2013; Sheikh Cochrane 2012; Everitt BMJ 2006; AAO PPP Varu 2018)
2. supportive care only (viral/adenoviral) cool compress + lubricants topical PRN + strict hygiene — Watery + preauricular node + sick contact = adenoviral/EKC (AAO PPP Varu 2018; Liu Cochrane 2022) (No antibiotic for viral; infection control is the intervention)
3. delayed/short topical antibiotic (non-gonococcal bacterial) erythromycin 0.5% ointment ~1 cm ophthalmic QID × 5-7 d (or delayed prescription) — Mucopurulent + glued lids, no red flag (Sheikh Cochrane 2012; Everitt BMJ 2006) (Most self-limited; delayed prescribing preferred — cuts antibiotic use without medicalisation)
4. olopatadine (allergic) 0.1-0.2% 1 drop ophthalmic once-twice daily — Bilateral itch-dominant + chemosis + seasonality (Azari JAMA 2013) (Dual antihistamine/mast-cell stabilizer relieves the cardinal itch; allergen avoidance adjunct)
5. ceftriaxone (gonococcal — emergency, refer same-day) 1 g IM single dose + same-day ophthalmology — Hyperacute copious purulent discharge (CDC STI 2021) (Ophthalmic emergency; systemic Rx + lavage + ophthalmology; co-treat chlamydia + STI/partner workup)

Non-pharmacologic actions:
- Discontinue contact-lens wear and DO NOT patch; route to ophtho.keratitis.core.v1 if any keratitis suspicion (Seal 1999; Truong 2018)
- Strict hand hygiene, separate towels, no eye-makeup/lens sharing; counsel ~10-14 d contagion for adenoviral (Hamada J Hosp Infect 2008)
- Saline lavage of copious purulent discharge before/with gonococcal Rx (CDC STI 2021)
- Patient education: natural history + antibiotic-stewardship rationale (Everitt BMJ 2006)

AVOID / contraindication checks:
- Doxycycline contraindicated pregnancy and young children use azithromycin (CDC STI 2021 — chlamydial conjunctivitis in pregnancy/pediatric → azithromycin)
- No empiric topical corticosteroid without ophthalmology and HSV exclusion (AAO Conjunctivitis PPP Varu 2018 — steroid worsens HSV keratitis, raises IOP)
- Never patch a contact lens red eye route to keratitis (Seal 1999; Truong 2018 — Pseudomonas microbial keratitis risk; route to ophtho.keratitis.core.v1)
- Do not antibiotic treat viral or allergic conjunctivitis (Azari JAMA 2013; Sheikh Cochrane 2012 — antibiotic stewardship; most infective conjunctivitis is self limited)
- Gonococcal conjunctivitis is an emergency systemic ceftriaxone not topical only (CDC STI 2021 — corneal perforation risk)

Monitoring

Regimen monitoring:
- typical infective conjunctivitis expect improvement 5-7d else reassess (Sheikh Cochrane 2012)
- adenoviral EKC watch subepithelial infiltrates pseudomembrane vision drop (Liu Cochrane 2022)
- gonococcal daily corneal exam until clear perforation risk (CDC STI 2021; Azari JAMA 2013)
- allergic steroid course IOP and HSV surveillance if used (AAO PPP Varu 2018)
- reassess for red flag or wrong subtype at 48-72h if not improving (AAO PPP Varu 2018)

Setting (outpatient) monitoring:
- Improvement expected within 5-7 d for typical infective disease (Sheikh Cochrane 2012)
- Return precautions: increasing pain, photophobia, vision change, no improvement at 48-72 h, hyperacute purulent discharge (AAO PPP Varu 2018)

Follow-up plan: Stewardship + contagion + chronicity: counsel natural history and antibiotic-stewardship rationale (Everitt BMJ 2006 — immediate prescribing increases re-attendance and antibiotic belief); hygiene/return-to-activity guidance (adenoviral sheds ~10-14 d); ensure gonococcal/chlamydial partner treatment + STI follow-up + reporting; recurrent/chronic or treatment-refractory conjunctivitis → ophthalmology (chronic chlamydial, atopic/vernal keratoconjunctivitis, mucous membrane pemphigoid, or ocular surface malignancy mimic — AAO PPP Varu 2018); vernal/atopic → long-term ophthalmology (cyclosporine 0.1% per updated PPP).
- Close-out criterion: natural-history + hygiene counselling done; STI partner/follow-up arranged; chronic/refractory referred to ophthalmology

Monitoring phase: Typical infective conjunctivitis: expect improvement within 5-7 d (Sheikh Cochrane 2012 — 65% placebo improved by d2-5 in earlier edition); if NOT improving or worsening at 48-72 h reassess for wrong subtype, red flag, or look-alike (keratitis/uveitis) and re-screen — do not silently continue. Adenoviral/EKC: watch for subepithelial infiltrates / pseudomembrane / vision drop (Liu Cochrane 2022) → ophthalmology. Gonococcal: daily corneal exam until clear (perforation risk). Allergic: reassess steroid course IOP/HSV if used.

Disposition

Current setting: outpatient — Subtype the conjunctivitis, run the sight-threatening red-flag screen, apply antibiotic stewardship for infective disease, escalate gonococcal/chlamydial/neonatal/contact-lens cases, and counsel contagion/return-to-activity (Azari JAMA 2013; Sheikh Cochrane 2012; Everitt BMJ 2006; AAO PPP Varu 2018)

Disposition criteria:
- Discharge with self-care + return precautions for typical viral/allergic/non-gonococcal bacterial (Azari JAMA 2013)
- Same-day ophthalmology / route OUT for any red flag, gonococcal, contact-lens, neonatal, herpetic (AAO PPP Varu 2018; CDC STI 2021)

Escalation triggers (move to higher acuity):
- Any sight-threatening red flag → same-day ophthalmology, route to ophtho.acute-red-eye.core.v1 / keratitis / uveitis / angle-closure (AAO PPP Varu 2018)
- Hyperacute purulent (gonococcal) / contact-lens keratitis suspicion / neonatal ophthalmia / herpetic → emergency ophthalmology + systemic Rx (CDC STI 2021)
- Adenoviral/EKC outbreak in an institution → infection-control notification (Hamada 2008)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hyperacute copious purulent discharge over hours, marked lid edema, rapid progression ± Gram-negative intracellular diplococci — gonococcal conjunctivitis (CDC STI 2021; Azari JAMA 2013)
- [LIFE_THREATENING] Neonate ≤28 days with conjunctivitis/discharge — ophthalmia neonatorum (gonococcal days 2-5, chlamydial days 5-14, chemical day 1) (CDC STI 2021)
- [SEVERE] Contact-lens wearer with red eye + pain/photophobia/corneal infiltrate or fluorescein staining — microbial (Pseudomonas/Acanthamoeba) keratitis until excluded (Seal 1999; Truong 2018)

Citations

- AAO Conjunctivitis Preferred Practice Pattern (Varu et al, Ophthalmology 2018; updated as Conjunctivitis PPP 2023, republished Ophthalmology 2024 — substance unchanged, confirmed current 2026-05-17) + Azari & Barney JAMA 2013 systematic review + Sheikh et al Cochrane 2012 (antibiotics vs placebo for acute bacterial conjunctivitis) + Rietveld et al BMJ 2004 (bacterial-cause clinical prediction rule) + Everitt et al BMJ 2006 (delayed-prescribing RCT) + CDC STI Treatment Guidelines 2021 (gonococcal/chlamydial/ophthalmia neonatorum) + Liu et al Cochrane 2022 (EKC topical therapy) [PMID:30366797](https://pubmed.ncbi.nlm.nih.gov/30366797/)
- Cited evidence (PMID 24150468) [PMID:24150468](https://pubmed.ncbi.nlm.nih.gov/24150468/)
- Cited evidence (PMID 22972049) [PMID:22972049](https://pubmed.ncbi.nlm.nih.gov/22972049/)
- Cited evidence (PMID 16625540) [PMID:16625540](https://pubmed.ncbi.nlm.nih.gov/16625540/)
- Cited evidence (PMID 10796757) [PMID:10796757](https://pubmed.ncbi.nlm.nih.gov/10796757/)

Last reconciled with current guidelines: 2026-05-17.

References

AAO Conjunctivitis Preferred Practice Pattern (Varu et al, Ophthalmology 2018; updated as Conjunctivitis PPP 2023, republished Ophthalmology 2024 — substance unchanged, confirmed current 2026-05-17) + Azari & Barney JAMA 2013 systematic review + Sheikh et al Cochrane 2012 (antibiotics vs placebo for acute bacterial conjunctivitis) + Rietveld et al BMJ 2004 (bacterial-cause clinical prediction rule) + Everitt et al BMJ 2006 (delayed-prescribing RCT) + CDC STI Treatment Guidelines 2021 (gonococcal/chlamydial/ophthalmia neonatorum) + Liu et al Cochrane 2022 (EKC topical therapy) — PMID:30366797
Cited evidence (PMID 24150468) — PMID:24150468
Cited evidence (PMID 22972049) — PMID:22972049
Cited evidence (PMID 16625540) — PMID:16625540
Cited evidence (PMID 10796757) — PMID:10796757