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ophtho.acute-red-eye.core.v1PRODUCTION
ophtho.acute-red-eye.core.v1

Acute red eye (undifferentiated triage)

general_internal_medicineacutesubacuteadultpediatric
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12/12 authored

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

Current phase

Frame

Detailed

Frame the acute red eye as a TRIAGE problem: the dominant task is separating the ~80-95% benign self-limited red eye (conjunctivitis, subconjunctival hemorrhage, episcleritis, blepharitis, dry eye, pterygium) from the sight-threatening can't-miss set (microbial keratitis, anterior uveitis, scleritis, acute angle-closure glaucoma, endophthalmitis, orbital cellulitis, chemical burn, globe rupture, hyphema). This engine OWNS the triage + routing; definitive management of each dangerous cause is routed OUT by engine_id, not re-authored here (AAO PPP Conjunctivitis 2024; Wills Eye Manual red-eye triage).

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triage scope confirmed; definitive-management concerns flagged for route-out by engine_id

Patient inputs (16)

True photophobia + perilimbal ciliary (circumcorneal) injection indicates corneal/anterior-chamber pathology (keratitis, uveitis, AACG) rather than superficial conjunctival disease (AAO PPP Anterior Uveitis 2023)

Watery/serous → viral; mucopurulent → bacterial; stringy/ropy + itch → allergic — drives the benign-conjunctivitis arm and antibiotic-stewardship decision (Johnson JAMA 2022 PMID 35699701 — mucopurulent discharge LR+ 2.1 for bacterial)

Contact-lens wear is THE dominant preventable microbial-keratitis risk; overnight wear escalates risk ~10-25× — converts a red eye into a sight-threat until keratitis excluded (Stapleton Ophthalmology 2008 PMID 18538404)

TRUE ocular pain (deep ache/boring, photophobic) vs gritty/itchy foreign-body sensation is the single strongest benign-vs-dangerous pivot — itch favours allergic/viral conjunctivitis, deep pain favours keratitis/uveitis/scleritis/AACG (Wills Eye Manual; Beaver Compr Ther 2001 PMID 11569323)

Reduced/blurred acuity not clearing with blink is a danger sign that excludes uncomplicated conjunctivitis and mandates corneal/uveal/glaucoma/endophthalmitis work-up (AAO PPP Bacterial Keratitis 2024; Perumal NZ Med J 2011 PMID 21952383)

Fluorescein staining: dendrite → HSV (do NOT give steroid); geographic/ulcerated infiltrate → microbial keratitis; diffuse punctate → dry eye/exposure; abrasion → uncomplicated (AAO PPP Bacterial Keratitis 2024; HEDS Ophthalmology 1994 PMID 7997323)

Globe rupture / penetrating injury / chemical (esp. alkali) burn are immediate sight-threats; chemical exposure mandates irrigate-FIRST before any other step (Beal J Pediatr Health Care 2016 PMID 26948259)

Fixed mid-dilated pupil + cloudy/steamy cornea → acute angle-closure; small/irregular pupil + flush → uveitis; corneal opacity/infiltrate → keratitis — the core danger-exam triad (Wills Eye Manual red-eye triage)

IOP markedly raised (often >40-50 mmHg) with a red painful eye + halos + fixed pupil = acute angle-closure glaucoma — a true ocular emergency routed OUT for immediate lowering (AAO PPP Primary Angle Closure 2020)

Proptosis, painful/restricted eye movement, lid erythema/edema → orbital cellulitis (vs preseptal) — vision- and life-threatening, IV antibiotics + imaging, routed OUT (Papier Am Fam Physician 2007 PMID 18217520)

Slit-lamp (anterior chamber cells/flare/hypopyon, infiltrate, hyphema) is the definitive triage tool; orbital CT when orbital cellulitis/occult rupture/foreign body suspected (AAO PPP Anterior Uveitis 2023; Papier Am Fam Physician 2007 PMID 18217520)

V1 dermatome vesicular rash + Hutchinson sign (nasociliary nasal-tip involvement) → herpes-zoster ophthalmicus; HZO/HSV alters work-up and contraindicates empiric steroid (HEDS Arch Ophthalmol 2000 PMID 10922194)

Immunosuppression → atypical, fulminant, fungal/Acanthamoeba/HSV presentations; lowers the threshold for urgent ophthalmology and broadens the differential (Stapleton Eye 2011 PMID 22134592)

Bilateral watery red eye with sick contacts and normal vision strongly favours benign viral conjunctivitis; strict unilateral painful red eye raises the dangerous prior (Johnson JAMA 2022 PMID 35699701 — contact with red-eye person LR+ 2.5 for viral)

Acute red painful eye after cataract surgery / intravitreal injection / glaucoma surgery → post-procedural endophthalmitis — sight-threatening emergency routed OUT (EVS Arch Ophthalmol 1995 PMID 7487614)

Drug-safety gating for any analgesic/antimicrobial started here and for routed definitive Rx (aminoglycoside/fluoroquinolone/tetracycline considerations) (AAO PPP Bacterial Keratitis 2024)

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

Severity triggers (8)

8 need judgement
  • informationallife_threateningacute_angle_closure_glaucoma
    Red painful eye + fixed mid-dilated pupil + steamy/hazy cornea + IOP markedly raised (often >40-50 mmHg) + halos/headache/nausea/vomiting (AAO PPP Primary Angle Closure 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmicrobial_keratitis_contact_lens_or_HSV
    Painful red eye + corneal infiltrate/ulcer with fluorescein uptake ± hypopyon, esp. contact-lens wearer or dendritic (HSV) pattern (Stapleton Ophthalmology 2008 PMID 18538404; HEDS Ophthalmology 1994 PMID 7997323)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningendophthalmitis_post_procedure
    Acute red painful eye + rapidly falling vision + hypopyon, within days-weeks of cataract surgery / intravitreal injection / glaucoma surgery / penetrating trauma (EVS Arch Ophthalmol 1995 PMID 7487614)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningorbital_cellulitis
    Red eye + proptosis + painful/restricted ocular motility + lid erythema/edema ± fever ± diplopia ± reduced acuity (post-septal — distinct from preseptal cellulitis) (Papier Am Fam Physician 2007 PMID 18217520)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningchemical_burn_globe_rupture_or_hyphema
    Chemical/alkali splash, penetrating/blunt trauma with a soft eye / peaked pupil / Seidel-positive / 360° subconjunctival hemorrhage, or layered blood in the anterior chamber (hyphema) (Beal J Pediatr Health Care 2016 PMID 26948259)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanterior_uveitis_iritis
    Deep ache + photophobia + perilimbal ciliary flush + small/irregular pupil + anterior-chamber cells/flare on slit-lamp; consensual photophobia positive (AAO PPP Anterior Uveitis 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverescleritis
    Severe boring/deep pain (often waking from sleep, radiating to brow/jaw) + violaceous deep scleral vessels that do NOT blanch with topical phenylephrine; frequent systemic vasculitis association (Tabbut J Emerg Med 2019 PMID 31353264)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildbenign_red_eye_confirmed_no_reflex_antibiotic
    Danger triad negative: normal acuity, no true pain (gritty/itch only), no photophobia, diffuse conjunctival injection, watery/itchy discharge, no contact-lens/trauma/surgery context (Johnson JAMA 2022 PMID 35699701)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RED_FLAGSrequiredDrives screening
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Recommended regimen

Acute red-eye triage — immediate-harm-prevention + benign symptomatic care (definitive Rx routed by engine_id)
axis: red_eye_triage_immediate_harm_preventionstep 1 - Step 1 — Chemical exposure: irrigate FIRST (overrides all other steps)
Selected step "Step 1 — Chemical exposure: irrigate FIRST (overrides all other steps)" — Any history of chemical/alkali/acid splash — irrigation precedes visual acuity, history, and examination
  • immediate_copious_ocular_irrigation_to_neutral_pH
    first line
    decontamination
    triggers: chemical_exposure, alkali_splash, acid_splash
    Wills Eye Manual / AAO — alkali chemical injury is a true ocular emergency; immediate copious irrigation (≥1-2 L, e.g. saline/LR via Morgan lens) to neutral pH minimises stromal penetration and is the single highest-yield action; topical anaesthetic facilitates irrigation only.
  • topical_proparacaine_for_examination_only_not_dispensed
    add on
    topical_anaesthetic
    triggers: exam_required, severe_blepharospasm, irrigation
    AAO PPP Bacterial Keratitis 2024 — topical anaesthetic enables exam/irrigation but is NEVER dispensed (epithelial toxicity, masking of progression); single in-clinic instillation only.

outpatient playbook — drug actions (3)

  1. 1. preservative-free artificial tears (benign viral/dry/SCH)
    1 drop • ophthalmic • q1-4h PRN
    trigger: Confirmed benign viral conjunctivitis / dry eye / subconjunctival hemorrhage, danger triad negative (AAO PPP Conjunctivitis 2024)
    Self-limited; supportive only; NO reflex topical antibiotic (stewardship — Johnson JAMA 2022 PMID 35699701)
  2. 2. ketotifen (allergic conjunctivitis)
    rxcui 6146
    0.025% 1 drop • ophthalmic • BID
    trigger: Bilateral itch-dominant ropy-discharge red eye with atopy (AAO PPP Conjunctivitis 2024)
    Dual-action antihistamine/mast-cell stabiliser, first-line allergic conjunctivitis
  3. 3. acetaminophen (analgesia bridge to referral)
    rxcui 161
    500-1000 mg • PO • q6h PRN
    trigger: Severe ocular pain awaiting urgent ophthalmology for a Tier-1/2 sight-threat (Wills Eye Manual)
    Systemic analgesia while definitive cause-specific Rx delivered by the routed engine

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute ocular redness ± discharge, the undifferentiated chief complaint — the highest-yield primary-care/ED ophthalmic triage decision (Johnson JAMA 2022 PMID 35699701; AAO PPP Conjunctivitis 2024); Red eye with TRUE ocular pain (deep ache/boring vs gritty foreign-body) — pain is the strongest single danger discriminator vs benign conjunctivitis (Wills Eye Manual red-eye triage; AAFP Beaver Compr Ther 2001 PMID 11569323); Red eye with reduced visual acuity and/or photophobia — the danger triad with pain; sight-threatening until excluded (AAO PPP Bacterial Keratitis 2024; AAO PPP Anterior Uveitis 2023).

Objective

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

Assessment

**Acute red eye (undifferentiated triage)** (ophtho.acute-red-eye.core.v1).
Phenotype framing: Terminal red-eye differential with explicit pivot findings — BENIGN: viral conjunctivitis (bilateral watery + preauricular node + sick contact + normal vision pivot), bacterial conjunctivitis (mucopurulent + lids stuck pivot), allergic conjunctivitis (bilateral itch + ropy + atopy pivot), subconjunctival hemorrhage (painless flat blood + normal vision pivot), episcleritis (sectoral, blanches with phenylephrine, no photophobia pivot), blepharitis/dry eye (chronic gritty + lid-margin pivot), pterygium. SIGHT-THREATENING: microbial keratitis (contact-lens + corneal infiltrate + pain pivot), anterior uveitis (ciliary flush + AC cells + photophobia + miosis pivot), scleritis (severe boring pain + violaceous deep vessels not blanching pivot), acute angle-closure glaucoma (fixed mid-dilated pupil + IOP↑ + halos + headache/vomiting pivot), endophthalmitis (post-op/injection + hypopyon + rapid vision loss pivot), orbital cellulitis (proptosis + painful motility + fever pivot), chemical burn / globe rupture / hyphema (history + exam pivot). Co-existence flagged (e.g., keratitis with secondary uveitis).
Scope: Frame the acute red eye as a TRIAGE problem: the dominant task is separating the ~80-95% benign self-limited red eye (conjunctivitis, subconjunctival hemorrhage, episcleritis, blepharitis, dry eye, pterygium) from the sight-threatening can't-miss set (microbial keratitis, anterior uveitis, scleritis, acute angle-closure glaucoma, endophthalmitis, orbital cellulitis, chemical burn, globe rupture, hyphema). This engine OWNS the triage + routing; definitive management of each dangerous cause is routed OUT by engine_id, not re-authored here (AAO PPP Conjunctivitis 2024; Wills Eye Manual red-eye triage).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute red-eye triage — immediate-harm-prevention + benign symptomatic care (definitive Rx routed by engine_id)** — step "Step 1 — Chemical exposure: irrigate FIRST (overrides all other steps)".
1. immediate_copious_ocular_irrigation_to_neutral_pH (decontamination, first line) — Wills Eye Manual / AAO — alkali chemical injury is a true ocular emergency; immediate copious irrigation (≥1-2 L, e.g. saline/LR via Morgan lens) to neutral pH minimises stromal penetration and is the single highest-yield action; topical anaesthetic facilitates irrigation only.
2. topical_proparacaine_for_examination_only_not_dispensed (topical_anaesthetic, add on) — AAO PPP Bacterial Keratitis 2024 — topical anaesthetic enables exam/irrigation but is NEVER dispensed (epithelial toxicity, masking of progression); single in-clinic instillation only.

Setting playbook (outpatient) — Triage the undifferentiated red eye: confirm benign self-limited cause with the danger triad NEGATIVE → supportive care + explicit return precautions; danger triad POSITIVE → urgent ophthalmology referral routed by engine_id (Johnson JAMA 2022 PMID 35699701; Konstantakopoulou BMJ Open 2016 PMID 27515757; Wills Eye Manual)
3. preservative-free artificial tears (benign viral/dry/SCH) 1 drop ophthalmic q1-4h PRN — Confirmed benign viral conjunctivitis / dry eye / subconjunctival hemorrhage, danger triad negative (AAO PPP Conjunctivitis 2024) (Self-limited; supportive only; NO reflex topical antibiotic (stewardship — Johnson JAMA 2022 PMID 35699701))
4. ketotifen (allergic conjunctivitis) 0.025% 1 drop ophthalmic BID — Bilateral itch-dominant ropy-discharge red eye with atopy (AAO PPP Conjunctivitis 2024) (Dual-action antihistamine/mast-cell stabiliser, first-line allergic conjunctivitis)
5. acetaminophen (analgesia bridge to referral) 500-1000 mg PO q6h PRN — Severe ocular pain awaiting urgent ophthalmology for a Tier-1/2 sight-threat (Wills Eye Manual) (Systemic analgesia while definitive cause-specific Rx delivered by the routed engine)

Non-pharmacologic actions:
- Chemical splash → irrigate copiously to neutral pH BEFORE anything else, then refer (AAO)
- Contact-lens red eye → stop lens wear, never patch, urgent ophthalmology (Stapleton Ophthalmology 2008 PMID 18538404)
- Suspected globe rupture → rigid shield, no pressure/drops, NPO, ED (Wills Eye Manual)
- Withhold any topical steroid; document a vision-specific return-precaution safety-net (HEDS Ophthalmology 1994 PMID 7997323)

AVOID / contraindication checks:
- Never dispense topical anaesthetic (AAO PPP Bacterial Keratitis 2024 — proparacaine is exam only; outpatient use causes epithelial toxicity/melt)
- Never patch contact lens associated red eye (Stapleton Ophthalmology 2008 PMID 18538404 — occlusion accelerates pseudomonal keratitis)
- Withhold topical steroid until HSV and microbial keratitis excluded (HEDS Ophthalmology 1994 PMID 7997323 — steroid on HSV/microbial keratitis → geographic ulceration/perforation)
- No pressure no drops NPO if suspected globe rupture (Wills Eye Manual — manipulation can extrude intraocular contents)
- Irrigation precedes all steps in chemical injury (AAO — alkali burn outcome is irrigation time dependent)
- No reflex topical antibiotic for undifferentiated conjunctivitis (Johnson JAMA 2022 PMID 35699701 — most acute conjunctivitis is viral; stewardship)

Monitoring

Regimen monitoring:
- re-evaluate benign red eye at 48-72h for danger conversion (AAO PPP Conjunctivitis 2024)
- counsel viral conjunctivitis may worsen days 3-5 before improving (Johnson JAMA 2022 PMID 35699701)
- confirm route out engine received carryover state for sight threats (Wills Eye Manual)
- contact lens hygiene reinforced no overnight no tap water (Stapleton Ophthalmology 2008 PMID 18538404)

Setting (outpatient) monitoring:
- Re-evaluate benign red eye at 48-72 h if not improving (AAO PPP Conjunctivitis 2024)
- Return precautions: new pain, vision drop, photophobia, halos, contact-lens symptoms → immediate re-present

Follow-up plan: Benign causes: education + return precautions are the core deliverable — explicit "RED-FLAG return": new true pain, any vision drop, severe photophobia, halos, contact-lens-associated symptoms → immediate re-present. Contact-lens hygiene counselling (no overnight wear, no tap-water/showering in lenses, replace case) — the dominant preventable microbial-keratitis driver (Stapleton Ophthalmology 2008 PMID 18538404). Allergic: allergen avoidance + mast-cell stabiliser bridge. Recurrent HSV: suppression decision routed to keratitis engine (HEDS Arch Ophthalmol 2000 PMID 10922194). For routed dangerous cases, ownership transfers to the receiving engine.
- Close-out criterion: return-precaution + prevention counselling documented; recurrent/HSV/contact-lens prevention routed if applicable

Monitoring phase: For benign causes retained here: re-evaluate at 48-72 h if not improving — any emergent pain, falling acuity, photophobia, or corneal change converts a presumed-benign red eye into a sight-threat and re-triggers RED_FLAGS routing. Counsel that viral conjunctivitis can worsen over the first 3-5 days before improving (prevents premature antibiotic escalation). Confirm route-out engines received carryover state for the dangerous cases (Johnson JAMA 2022 PMID 35699701; AAO PPP Conjunctivitis 2024).

Disposition

Current setting: outpatient — Triage the undifferentiated red eye: confirm benign self-limited cause with the danger triad NEGATIVE → supportive care + explicit return precautions; danger triad POSITIVE → urgent ophthalmology referral routed by engine_id (Johnson JAMA 2022 PMID 35699701; Konstantakopoulou BMJ Open 2016 PMID 27515757; Wills Eye Manual)

Disposition criteria:
- Benign + danger triad negative → discharge with supportive care + return precautions (Konstantakopoulou BMJ Open 2016 PMID 27515757)
- Sight-threatening → urgent/emergency ophthalmology, route by engine_id (Wills Eye Manual)

Escalation triggers (move to higher acuity):
- Any danger-triad positive → same-day/same-hour ophthalmology routed by engine_id (Wills Eye Manual)
- Fixed pupil + IOP↑ + halos → emergency, route ophtho.acute-angle-closure-glaucoma.core.v1 (AAO PPP Primary Angle Closure 2020)
- Corneal infiltrate / contact-lens keratitis → route ophtho.microbial-keratitis.core.v1 (Stapleton Ophthalmology 2008 PMID 18538404)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Red painful eye + fixed mid-dilated pupil + steamy/hazy cornea + IOP markedly raised (often >40-50 mmHg) + halos/headache/nausea/vomiting (AAO PPP Primary Angle Closure 2020)
- [LIFE_THREATENING] Painful red eye + corneal infiltrate/ulcer with fluorescein uptake ± hypopyon, esp. contact-lens wearer or dendritic (HSV) pattern (Stapleton Ophthalmology 2008 PMID 18538404; HEDS Ophthalmology 1994 PMID 7997323)
- [LIFE_THREATENING] Acute red painful eye + rapidly falling vision + hypopyon, within days-weeks of cataract surgery / intravitreal injection / glaucoma surgery / penetrating trauma (EVS Arch Ophthalmol 1995 PMID 7487614)

Citations

- AAO Preferred Practice Pattern — Conjunctivitis (2024) + AAO PPP Bacterial Keratitis (2024) + AAO PPP Anterior Uveitis (2023) + AAO PPP Primary Angle Closure (2020) + Wills Eye Manual red-eye triage algorithm + JAMA Rational Clinical Examination (Johnson, Liu, Simel — Does This Patient With Acute Infectious Conjunctivitis Have a Bacterial Infection?, JAMA 2022) + Stapleton contact-lens microbial-keratitis incidence (Ophthalmology 2008 / Eye 2011) + Endophthalmitis Vitrectomy Study (Arch Ophthalmol 1995) + Herpetic Eye Disease Study (Ophthalmology 1994 / Arch Ophthalmol 2000) [PMID:35699701](https://pubmed.ncbi.nlm.nih.gov/35699701/)
- Cited evidence (PMID 18538404) [PMID:18538404](https://pubmed.ncbi.nlm.nih.gov/18538404/)
- Cited evidence (PMID 22134592) [PMID:22134592](https://pubmed.ncbi.nlm.nih.gov/22134592/)
- Cited evidence (PMID 35912449) [PMID:35912449](https://pubmed.ncbi.nlm.nih.gov/35912449/)
- Cited evidence (PMID 33775382) [PMID:33775382](https://pubmed.ncbi.nlm.nih.gov/33775382/)

Last reconciled with current guidelines: 2026-05-17.
References
  • AAO Preferred Practice Pattern — Conjunctivitis (2024) + AAO PPP Bacterial Keratitis (2024) + AAO PPP Anterior Uveitis (2023) + AAO PPP Primary Angle Closure (2020) + Wills Eye Manual red-eye triage algorithm + JAMA Rational Clinical Examination (Johnson, Liu, Simel — Does This Patient With Acute Infectious Conjunctivitis Have a Bacterial Infection?, JAMA 2022) + Stapleton contact-lens microbial-keratitis incidence (Ophthalmology 2008 / Eye 2011) + Endophthalmitis Vitrectomy Study (Arch Ophthalmol 1995) + Herpetic Eye Disease Study (Ophthalmology 1994 / Arch Ophthalmol 2000) — PMID:35699701
  • Cited evidence (PMID 18538404) — PMID:18538404
  • Cited evidence (PMID 22134592) — PMID:22134592
  • Cited evidence (PMID 35912449) — PMID:35912449
  • Cited evidence (PMID 33775382) — PMID:33775382