Built on the chapter structure of the Academy’s The Physician’s Guide to Eye Care and its red, yellow, and green referral lights, with the visual vital signs added to every diagnosis. Acute persistent visual loss is built out in full to show what a collaborative product could look like. The other tabs hold draft triage summaries. All clinical content is a working draft for review.
Arm one · Symptom & Triage Support
What is the eye complaint?
Pick the symptom the team is calling about. Each diagnosis shows its visual vital signs pattern, the findings that separate it, what to start on site, and a red, yellow, or green light for how soon ophthalmology needs to see the patient.
Eye consults are already remote
Fewer ophthalmologists cover hospitals, so more consults happen by phone, photo, or telemedicine.
Visual vital signs make remote triage possible
Acuity, pressure, and pupils, recorded and passed on with the consult request, let a remote ophthalmologist sort most presentations before seeing the patient.
Care stays local when it can
Patients who can be managed where they are stay there, rather than every eye complaint going to the same handful of academic centers.
Referral lightsRed, emergent: within 24 hoursYellow, urgent: within 48 hoursGreen, non-urgent: within 30 daysImmediatelyminutes matter, do not wait out the 24 hours
Windows as defined in Trobe, The Physician’s Guide to Eye Care, chapter 3. The Immediately marker is our addition for hospital teams.
Built out in the proposed format. Other tabs hold draft triage summaries.
Acute persistent visual loss
Vision loss persisting more than 1 hour
Sudden loss of vision that has lasted longer than an hour. Start with the visual vital signs: together with pain, they separate most of the causes before anyone looks inside the eye.
Visual vital signs pattern
What the bedside team can report, and what it points to. Select a diagnosis for the full card.
Sudden, painless loss of vision, often noticed on waking from sleep or from surgery, and more common after prone procedures such as spine surgery. The loss may be complete or partial.
Visual vital signs
AcuityOften severely reduced. Parts of the field may be spared in a branch occlusion.
PressureUnaffected.
PupilsAPD often present.
Exam findings
Normal front of the eye. On dilated exam, the retina looks whitish and opaque where it is ischemic, with a cherry red spot in a central occlusion. The retina can look normal if the embolic event has just happened or the occlusion is proximal.
On-site treatment
Treat it as a stroke. Activate the stroke pathway and look for other cerebral ischemia with the facility’s stroke imaging. Manage vascular risk factors. Consider thrombolysis where the stroke team judges it appropriate. Arrange ophthalmology follow up.
Urgency
Emergent. Time from onset matters for any vascular treatment, and a wider stroke has to be ruled out and treated on site.
Endophthalmitis
EmergentImmediately
Symptoms
Pain, often severe. A red eye, often with swelling of the conjunctiva and periorbital tissues, and tenderness of the globe or lid. Early cases can show little redness. Ask about recent eye surgery or trauma, and consider seeding from a recent systemic infection.
Visual vital signs
AcuitySignificantly reduced, often quickly.
PressureSlightly raised early, significantly raised in advanced infection.
PupilsAPD usually absent.
Exam findings
Reduced red reflex, red eye, swelling of the conjunctiva or lids, pain when the periorbital tissues are touched, marked light sensitivity, headache, and nausea.
On-site treatment
Emergent intravitreal tap and injection by ophthalmology to identify and control the infection. If that is not available at the treating facility, transfer to a facility with ophthalmology services.
Urgency
Emergent. The timing of injection therapy drives the visual outcome.
Acute glaucoma
EmergentImmediately
Symptoms
Pain and pressure around the eye or head, nausea, and vomiting. Blurred vision may be present and significant.
Visual vital signs
AcuityModerately or significantly reduced.
PressureSignificantly raised.
PupilsMid-dilated with minimal reactivity. An APD may be present in chronic cases.
Exam findings
Hazy cornea, a poorly reactive pupil, injected or swollen conjunctiva and periorbital tissues, and significant pain with light or on palpation.
On-site treatment
Topical pressure-lowering drops. Consider acetazolamide 500 mg by mouth or IV. In severe cases that do not respond, consider IV mannitol 1.5 to 2 g/kg over at least 30 minutes when it is systemically appropriate.
Decreased vision, often starting suddenly or over hours to days, which may come with flashes, floaters, or a shade or veil moving in from any direction.
Visual vital signs
AcuityModerately or severely reduced. If central acuity seems normal, check confrontation fields, since part of the field may be missing.
PressureUnaffected or slightly raised.
PupilsAPD if the detachment is large or long-standing. None in early cases.
Exam findings
External exam often normal. On dilated exam the view is poor if a vitreous hemorrhage is also present. Otherwise a whitish, billowing retina may be visible. Ultrasound may show a bright, billowing retinal membrane, but it can be confused with vitreous hemorrhage, so treat ultrasound as supportive rather than diagnostic.
On-site treatment
Arrange same day or next morning ophthalmology. Ask the patient to avoid high-impact activity until examined. Control uncontrolled systemic conditions that may contribute.
Urgency
Emergent. Same day, or an early morning appointment when seen overnight. Restoring vision depends on treatment before the macula detaches.
Vitreous hemorrhage
Urgent
Symptoms
Decreased vision, with red, grey, or black floaters or a haze. Flashes are usually absent, and so are pain and redness.
Visual vital signs
AcuityModerately to severely reduced.
PressureUnaffected or slightly raised.
PupilsNo APD unless another problem is present.
Exam findings
The front of the eye is often normal, though new vessels may be visible on the iris. The view to the back of the eye is poor even with dilation. Ultrasound may show debris in the vitreous cavity.
On-site treatment
Manage hypertension, diabetes, blood dyscrasias, or vascular abnormalities. Arrange outpatient follow up with ophthalmology and primary care when systemic findings call for it. See the quick reference.
Urgency
Urgent. Ophthalmology within 1 to 2 days. Push for sooner if retinal detachment is a concern, usually signaled by flashes or a shade or veil over the vision.
Keratitis
Urgent
Symptoms
Pain and foreign body sensation.
Visual vital signs
AcuityMildly or moderately reduced.
PressureUnaffected.
PupilsNo APD.
Exam findings
The cornea may look hazy and stains with fluorescein. The conjunctiva is injected.
On-site treatment
Start treatment and secure ophthalmology follow up within 1 to 2 days.
Urgency
Urgent. Early treatment may prevent further damage to the corneal epithelium and prevent superinfection.
Still to writeRetinal vein occlusionMacular abnormalityIschemic optic neuropathy, including giant cell arteritisOptic neuritisStroke affecting the visual pathwaysPsychogenic visual loss
Quick referencesVitreous hemorrhageRetinal vascular occlusionRetinal detachmentAcute glaucomaPostoperative vision loss
Transient visual loss
Went dark, then came back
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
Vision dimmed or blacked out and has returned, usually within minutes. The exam is often normal, so the history carries this one.
History
One eye or both? Did they cover each eye during the episode?
How long did it last?
A dark curtain, or shimmering zigzag lines?
Atrial fibrillation or vascular risk factors? Over 50: giant cell arteritis symptoms?
Examination
Acuity and pupils, then look at the optic discs if you can. Swollen discs change the workup.
Painless loss lasting minutes, now resolved, in one eye or bothTransient ischemic attack until proven otherwise. Retinal ischemia counts. Start the same workup as any TIA today.
Over 50 with headache, jaw claudication, or scalp tendernessImmediatelyGiant cell arteritis. ESR and CRP, and steroids without waiting for a biopsy.
Greying out for seconds when standing or bending, with headacheTransient obscurations from papilledema. Look at the discs and work up raised intracranial pressure.
Green light non-urgent, within 30 days
Shimmering zigzag that spreads over 5 to 20 minutes and fades within an hour, often before a headache, with the same past episodesMigraine aura. A first episode after 50 deserves a TIA workup instead.
Blur that clears with blinkingDry eye.
Chronic progressive visual loss
Faded over months
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
Rarely an emergency, but an admission is a good moment to make sure it is being followed.
History
One eye or both?
Blurry everywhere, or a part of the vision missing?
To be built. Part of the full symptom list for the collaborative version.
Diplopia
Double vision
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
Cover one eyeIf the double image disappears when either eye is covered, the eyes are misaligned and the cause is neurologic, muscular, or orbital. If it persists with one eye covered, the problem is in that eye’s optics and is rarely urgent.
History
Side by side, or one image above the other?
Worse at the end of the day? Trouble swallowing or breathing?
Weakness, numbness, slurred speech, unsteadiness?
Recent injury to the face or orbit?
Examination
Pupils and eyelids first. A large pupil or a droopy lid with double vision changes everything.
New third nerve palsy: droopy lid, eye down and out, with or without a large pupilImmediatelyCompressive aneurysm until proven otherwise. CTA or MRA. A dilated pupil makes it an emergency.
Any other neurologic signImmediatelyStroke pathway.
Fluctuating double vision or ptosis with trouble swallowing, speaking, or breathingImmediatelyMyasthenia gravis. Check respiratory function now.
After orbital trauma, restricted eye movement with nausea, slow heart rate, or pain looking up, especially in a childImmediatelyEntrapped extraocular muscle. Urgent surgical consult.
Double vision with headache and swollen optic discsRaised intracranial pressure.
Yellow light urgent, within 48 hours
Isolated fourth or sixth nerve palsy, over 50 with diabetes or hypertension, nothing else abnormalLikely microvascular. Close observation is one accepted approach, with imaging if it does not improve or anything new appears.
Fluctuating ptosis or double vision, breathing and swallowing normalMyasthenia workup.
Green light non-urgent, within 30 days
Persists with one eye covered and improves through a pinholeOptical cause: refractive error, cataract, or dry eye.
New flashes with a curtain, a field defect, or loss of visionRetinal detachment. See acute persistent visual loss.
Yellow light urgent, within 48 hours
New or worsening flashes, or flashes with new floaters, vision normalPosterior vitreous detachment, which can tear the retina. Needs a dilated retinal exam.
Green light non-urgent, within 30 days
Zigzag lines in both eyes for 5 to 60 minutes, then a headacheMigraine aura. A first episode after 50 deserves a TIA workup.
Long-standing flashes, unchanged in frequency or intensityClinic referral.
Floaters
Spots, cobwebs, haze
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
History
New, or unchanged for months?
A shadow or curtain? Any loss of vision?
Recent eye surgery, injection, or injury?
Bacteremia, candidemia, IV drug use, or a long-term line?
Examination
Acuity in each eye, fields, pupils, and the red reflex.
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
Most red eyes are benign. The job is to catch the few that are not, and the warning signs are reduced vision, real pain, light sensitivity, and contact lens use.
Chemical exposure: irrigate firstStart copious irrigation before the history, the vision check, or any imaging, and continue until the pH is neutral. Then call.
No topical steroidsNot before an ophthalmologist has looked. They worsen herpes and fungal infections.
No anesthetic drops homeUse them to examine. Repeated use damages the cornea.
Red light emergent, within 24 hours
Chemical splashImmediatelyIrrigate, then call.
Reduced vision, halos, nausea, a mid-dilated pupil, a rock-hard eyeImmediatelyAcute angle closure glaucoma.
Red, painful eye after recent surgery or an intravitreal injectionImmediatelyEndophthalmitis.
Fever, a bulging eye, painful or limited eye movementImmediatelyOrbital cellulitis. See proptosis.
After trauma, a large or ring-shaped subconjunctival hemorrhageImmediatelyTreat as an open globe until examined.
Heavy pus that reforms within minutes of wipingGonococcal conjunctivitis. It can perforate the cornea quickly.
Contact lens wearer with pain, light sensitivity, or a white spot on the corneaMicrobial keratitis. Remove the lenses and do not patch.
Stevens-Johnson syndrome or TEN, with or without eye symptomsStevens-Johnson syndrome. Call ophthalmology now, per the quick reference.
Zoster rash with reduced vision, high pressure, or an afferent pupillary defectHerpes zoster ophthalmicus, red flags. Per the quick reference.
Yellow light urgent, within 48 hours
Any other new zoster on the forehead, including vesicles on the tip of the noseHerpes zoster ophthalmicus. Start oral antivirals now. Every new case goes to ophthalmology.
Branching staining pattern with fluorescein, or a cloudy corneaHerpes simplex keratitis. Same or next day, per the quick reference.
Light sensitivity, aching, a small pupil, redness around the corneaAnterior uveitis.
Deep, boring pain that wakes them at night, tender eyeScleritis.
Painful red swelling at the inner corner of the eyeDacryocystitis. Needs antibiotics.
Green light non-urgent, often managed by the primary team
Flat, bright red patch, painless, normal visionSubconjunctival hemorrhage. Check blood pressure, and anticoagulation if it recurs.
Watery, gritty, recent cold, tender node in front of the earViral conjunctivitis. Very contagious. Hand hygiene.
Itching is the main complaintAllergic conjunctivitis.
Sticky discharge, none of the warning signs aboveBacterial conjunctivitis.
Crusted lid margins, burning, worse in the morningBlepharitis.
Patch of redness, mild discomfort, normal visionEpiscleritis.
Diagnosis cards to buildBlepharitisStyeChalazionDacryocystitisOrbital cellulitisAutoimmune orbital inflammationOrbital tumorKeratitisAnterior uveitisAcute angle closure glaucomaEpiscleritisScleritisPingueculaPterygiumSubconjunctival hemorrhageBacterial or viral conjunctivitisAllergic conjunctivitisContact dermatoconjunctivitisAutoimmune conjunctivitisAV fistula of the cavernous sinusEndophthalmitis
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
One drop of topical anestheticRelief points to the surface: abrasion, foreign body, keratitis. No relief points deeper: uveitis, scleritis, angle closure, or the orbit. Use it to examine, never to send home.
History
Scratchy and foreign body like, or a deep ache?
Pain when moving the eye?
Hammering, grinding, or drilling metal?
Contact lenses? Recent eye surgery?
Examination
Acuity and pupils. Pressure only if no open globe is suspected.
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
Compare in dim light and bright lightA bigger difference in the dark means the small pupil is abnormal because it fails to dilate, as in Horner syndrome. A bigger difference in bright light means the large pupil is abnormal because it fails to constrict, as with a third nerve palsy, a drug, a tonic pupil, or iris injury.
History
Is it new? An old photo or ID settles it fast.
Headache, neck pain, double vision, droopy lid?
Ipratropium nebulizers, a scopolamine patch, or eye drops?
Head or eye injury?
Examination
Pupils in both lighting conditions, the eyelids, and eye movements.
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
The pupil and the eye movements decide the urgency, not the lid.
Red light emergent, within 24 hours
Ptosis with a large pupil or limited eye movementImmediatelyThird nerve palsy. Emergent CTA or MRA.
Ptosis with a small pupil and neck pain or headacheImmediatelyHorner syndrome from carotid dissection.
Fluctuating ptosis with trouble swallowing, speaking, or breathingImmediatelyMyasthenia gravis. Check respiratory function now.
Swollen, red lid with a bulging eye, painful eye movement, or reduced visionImmediatelyOrbital cellulitis, not preseptal.
Yellow light urgent, within 48 hours
Fluctuating ptosis, breathing and swallowing normalMyasthenia workup.
Adult with a swollen, red lid, normal vision and eye movements, no bulgingPreseptal cellulitis. Treat and recheck.
Green light non-urgent, within 30 days
Slowly progressive over years, normal pupil and eye movementsAge-related or contact lens related ptosis.
Proptosis
Bulging eye
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
A bulging eye is an orbital problem until shown otherwise.
Red light emergent, within 24 hours
After trauma: tense orbit, proptosis, vision loss, high pressureImmediatelyRetrobulbar hemorrhage. Lateral canthotomy and cantholysis without waiting for imaging.
Fever with painful or limited eye movementImmediatelyOrbital cellulitis. CT of the orbits with contrast and IV antibiotics.
Ketoacidosis or immunosuppression, sinus disease, black eschar in the nose or palateImmediatelyMucormycosis. ENT and ophthalmology now.
Thyroid eye disease with reduced vision, washed-out colors, or an afferent pupillary defectCompressive optic neuropathy.
Yellow light urgent, within 48 hours
Red eye with corkscrew vessels, a bruit, or pulsation, often after head traumaCarotid-cavernous fistula. Red light if vision is falling or pressure is high.
New proptosis without pain or vision changeOrbital imaging for a mass or thyroid eye disease.
Lids that no longer close over the eyeExposure. Lubricate now.
Green light non-urgent, within 30 days
Known, stable thyroid eye disease with normal visionClinic follow up.
Quick referencesThe polytrauma patientRetrobulbar hemorrhage and canthotomyOrbital cellulitisOrbital mass
Tearing
Watery eye
Draft triage summary. Diagnosis cards to follow in the acute persistent visual loss format.
Yellow light urgent, within 48 hours
Painful red swelling at the inner corner of the eyeDacryocystitis. Needs antibiotics.
Green light non-urgent, within 30 days
Watery eye without redness or painDry eye or a blocked tear duct.
Sources
Organization and referral windows follow the book. The text here was written for this mockup and is not taken from it.
Trobe JD. The Physician’s Guide to Eye Care. American Academy of Ophthalmology. Chapters 3, Common Symptoms and Signs, and 4, The Red Eye.
Trobe JD. The Eyes Have It. Kellogg Eye Center, University of Michigan. Licensed CC BY 3.0 except where noted. kellogg.umich.edu/theeyeshaveit
Mac Grory B, Schrag M, Biousse V, et al. Management of central retinal artery occlusion: a scientific statement from the American Heart Association. Stroke. 2021;52(6):e282-e294.
Maz M, Chung SA, Abril A, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis. Arthritis Rheumatol. 2021;73(8):1349-1365.
Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack. Stroke. 2009;40(6):2276-2293.
Flaxel CJ, Adelman RA, Bailey ST, et al. Posterior vitreous detachment, retinal breaks, and lattice degeneration Preferred Practice Pattern. Ophthalmology. 2020;127(1):P146-P181.
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
Acetazolamide and mannitol (Osmitrol) doses as in the FDA prescribing information, DailyMed.