The Red and Tender Eye

Last updated 31 May 2026 · Ophthalmology

📋 Key Information Summary

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Red flags for same-day ophthalmology referral: unilateral painful red eye with decreased vision, fixed mid-dilated pupil, corneal opacity, photophobia with hypopyon, or contact-lens wear with a white corneal spot — these suggest acute glaucoma, uveitis, or microbial keratitis and must not be managed in general practice alone.
Conjunctivitis is the most common cause of red eye in Australian primary care (~37% of presentations); bacterial and viral aetiologies are distinguished by discharge character, lymphadenopathy, and often require no swab.
Bacterial conjunctivitis: first-line empirical therapy is chloramphenicol 0.5% eye drops (PBS-listed) QID for 5–7 days; alternative is fusidic acid 1% gel BD for fusidic acid-sensitive species or in chloramphenicol allergy.
Viral conjunctivitis (adenovirus): supportive care only — artificial tears and cold compresses; highly contagious for 10–14 days; strict hand hygiene and no sharing of towels; avoid topical antibiotics unless secondary bacterial infection suspected.
Anterior uveitis presents with unilateral pain, photophobia, circumlimbal injection, miotic pupil, and cells/flare on slit-lamp; refer urgently to ophthalmology — topical corticosteroids (prednisolone acetate 1%) and cycloplegics (homatropine 2% or atropine 1%) are initiated by specialists.
Acute angle-closure glaucoma (AACG) is an ophthalmic emergency: severe unilateral pain, red eye, mid-dilated fixed pupil, nausea/vomiting, corneal haze, and markedly raised IOP (>40 mmHg). Immediate referral to ED/ophthalmology; initial medical management includes topical timolol 0.5%, brimonidine 0.2%, IV acetazolamide 500 mg, and pilocarpine 2%.
Microbial (bacterial) corneal ulcer: contact-lens wearers are at highest risk; any central or large (>2 mm) infiltrate or ring infiltrate requires urgent ophthalmology referral and intensive fortified topical antibiotics (cefazolin 5% + gentamicin 0.9%) — do not patch.
Herpes zoster ophthalmicus (HZO): VZV reactivation in V1 (ophthalmic) dermatome with Hutchinson's sign (vesicles on the nose tip = nasociliary nerve involvement → high risk of ocular complications). Start oral valaciclovir 1 g TDS within 72 hours of rash onset; urgent ophthalmology referral.
Conjunctivitis vs keratitis vs uveitis vs glaucoma: use the mnemonic "SIGHT" — Sudden onset (glaucoma), Injection pattern (ciliary flush = uveitis), Globe tenderness (scleritis), Hypopyon (endophthalmitis/ulcer), and Topography (limbal vs diffuse).
Special populations: neonates require chlamydial and gonococcal conjunctivitis exclusion; immunocompromised patients are at risk of HSV keratitis and CMV retinitis; elderly are at highest risk of AACG (hypermetropic eyes, shallow anterior chambers).
Aboriginal and Torres Strait Islander populations have significantly higher rates of trachoma-related conjunctivitis and corneal scarring, particularly in remote communities; active trachoma screening and azithromycin distribution remain priorities under the National Trachoma Surveillance Program.
PBS considerations: chloramphenicol 0.5% eye drops are a PBS General Benefit; fusidic acid 1% gel is Authority Required; topical prednisolone acetate 1% is Authority Required and should only be initiated by an ophthalmologist.

Introduction & Australian Epidemiology

The red and tender eye is one of the most common presenting complaints in Australian general practice and emergency departments, accounting for an estimated 1–4% of all primary care consultations nationally. The differential diagnosis spans a broad spectrum ranging from self-limiting conditions such as viral conjunctivitis to sight-threatening emergencies including acute angle-closure glaucoma, microbial keratitis, and endophthalmitis. Accurate differentiation on clinical grounds, coupled with an understanding of Australian-specific epidemiology, is essential for safe initial management and appropriate referral.

In Australia, conjunctivitis remains the most frequent diagnosis, with viral conjunctivitis (predominantly adenovirus serotypes 3, 4, and 8) accounting for the majority of infectious cases. Bacterial conjunctivitis is more common in children under 5 years of age and in contact-lens wearers. Allergic conjunctivitis is highly prevalent in atopic individuals and peaks during spring and summer (the "grass pollen season") in south-eastern Australia.

Uveitis affects approximately 38 per 100,000 population per year in Australia, with anterior uveitis comprising roughly 75% of all uveitis presentations. Idiopathic and HLA-B27-associated uveitis are the most common aetiologies. Acute angle-closure glaucoma, although less common, carries a lifetime risk of approximately 1–2% in the general population and is more prevalent in older women with hypermetropic (long-sighted) eyes.

Microbial keratitis occurs at an estimated annual incidence of 2–4 per 10,000 contact-lens wearers in Australia, with Pseudomonas aeruginosa and Staphylococcus aureus as the predominant organisms. Herpes zoster ophthalmicus accounts for approximately 10–20% of all herpes zoster cases and is increasing in incidence in the ageing Australian population; the introduction of the Shingrix® vaccine on the National Immunisation Program (NIP) for adults ≥65 years (from November 2023) is anticipated to reduce this burden.

Trachoma, caused by Chlamydia trachomatis serotypes A–C, remains endemic in remote Aboriginal communities in central, northern, and Western Australia. Despite significant investment through the National Trachoma Surveillance and Response Program, active trachoma (follicular/TF) prevalence in children aged 1–9 years remains above the WHO elimination threshold in some remote communities. Trachoma is a leading preventable cause of blindness in Aboriginal and Torres Strait Islander Australians and must be considered in any red-eye presentation from endemic regions.

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Clinical pearl: Not every red eye is "just conjunctivitis." Any red eye with reduced vision, severe pain (out of proportion to visible signs), a mid-dilated or irregular pupil, corneal haze, or hypopyon demands urgent ophthalmological assessment. It is safer to over-refer than to miss angle-closure glaucoma or a progressing corneal ulcer.

Red Eye Diagnostic Model & Red Flags

A structured approach to the red eye enables rapid triage into benign, urgent, and emergent categories. The following diagnostic model integrates key clinical features to guide the Australian primary care clinician through the differential diagnosis.

Key History Features

Feature	Ask About	Suggests
Onset	Sudden vs gradual	Sudden → AACG, subconjunctival haemorrhage; Gradual → conjunctivitis
Pain severity	Mild grittiness vs deep ache vs severe throbbing	Deep ache → uveitis, scleritis; Severe throbbing → AACG
Vision	Unchanged vs blurred vs acutely decreased	Decreased vision → keratitis, uveitis, AACG, retinal pathology
Discharge	Watery vs mucopurulent vs none	Mucopurulent → bacterial; Watery + URTI → viral
Photophobia	Present or absent	Significant photophobia → uveitis, keratitis
Contact lens use	Type, wearing schedule, hygiene, overnight wear	Overnight wear → microbial keratitis risk ↑↑
Unilateral vs bilateral	One or both eyes	Bilateral → allergic, viral (often starts unilateral); Unilateral → uveitis, glaucoma, keratitis
Systemic symptoms	Rash, joint pain, oral ulcers, urethral discharge	Systemic features → reactive arthritis, lupus, syphilis, Behçet's
Trauma / chemical	Foreign body, splash, scratch	FB with corneal abrasion; alkali burns (emergency irrigation)

Red Flags — Same-Day Ophthalmology Referral

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Acute painful red eye with significantly reduced visual acuity (loss of ≥2 Snellen lines)
Fixed mid-dilated pupil — suspect acute angle-closure glaucoma
Corneal haze or opacity — suspect microbial keratitis or oedema from raised IOP
Hypopyon (visible pus level in anterior chamber) — suspect bacterial ulcer, endophthalmitis
Hutchinson's sign (vesicles on the tip/side of the nose) with a vesicular dermatomal rash — suspect HZO
Contact-lens wearer with a white spot on the cornea or focal infiltrate
Severe photophobia with ciliary flush (limbal injection) — suspect anterior uveitis or keratitis
Chemical injury — immediate copious irrigation, then ophthalmology referral
Neonatal red eye with purulent discharge — exclude gonococcal ophthalmia (medical emergency)

Clinical Differentiation at a Glance

Condition	Injection Pattern	Pupil	Vision	Discharge	Pain
Bacterial conjunctivitis	Diffuse, palpebral > bulbar	Normal, reactive	Normal (mild blur from discharge)	Mucopurulent, sticky lids	Gritty, foreign body sensation
Viral conjunctivitis	Diffuse, bilateral (sequential)	Normal, reactive	Normal	Watery, serous	Mild grittiness
Anterior uveitis	Circumlimbal (ciliary flush)	Constricted, irregular, poor reaction	Mildly reduced	None or minimal	Deep ache, photophobia
Acute angle-closure glaucoma	Diffuse, markedly injected	Mid-dilated, fixed, non-reactive	Markedly reduced, haloes	None; tearing	Severe, may have nausea/vomiting
Microbial keratitis	Circumlimbal	Normal or slightly constricted	Reduced (depending on location)	Purulent if bacterial	Moderate–severe, photophobia
Herpes zoster ophthalmicus	Diffuse, unilateral V1 dermatome	Normal (or fixed if keratouveitis)	Variable — depends on corneal involvement	Watery/mucoid if dendritic keratitis	Burning, dermatomal pain preceding rash

Point-of-Care Tests Available in General Practice

Visual acuity (VA): Snellen chart or pinhole — the single most important test; always document before fluorescein or any intervention.
Pen-torch examination: Assess pupil size, shape, and reactivity (RAPD with swinging torch), injection pattern, corneal clarity, anterior chamber depth, and any visible hypopyon.
Fluorescein staining + cobalt blue light: Detects corneal epithelial defects, dendritic ulcers (HSV), foreign bodies, and Seidel test (positive = aqueous leak from open globe).
Intraocular pressure (IOP): Tono-Pen or iCare rebound tonometry (if available in practice); IOP >21 mmHg is elevated, >40 mmHg in AACG. Normal range 10–21 mmHg.
Slit-lamp examination: Gold standard for uveitis diagnosis (cells/flare, keratic precipitates, posterior synechiae); available in some practices and all ophthalmology clinics.

Bacterial & Viral Conjunctivitis

Bacterial Conjunctivitis

Bacterial conjunctivitis accounts for approximately 30–50% of infectious conjunctivitis in primary care. The most common pathogens in Australian adults are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. In children, H. influenzae (non-typeable) and S. pneumoniae predominate. In neonates (<28 days), Chlamydia trachomatis and Neisseria gonorrhoeae must be excluded — these require urgent specialist management.

Clinical features: Unilateral or bilateral mucopurulent discharge causing eyelids to "stick together" on waking, diffuse conjunctival injection, gritty/foreign body sensation, and no significant pain or photophobia. Vision is typically preserved.

Empirical Treatment — Bacterial Conjunctivitis

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Chloramphenicol 0.5% Eye Drops

Chloromycetin® · Minims® · Antibiotic (chloramphenicol)

Adult dose 1–2 drops to affected eye(s), every 2 hours for first 48 hours then QID for 5–7 days

Paediatric dose Same dosing as adults; safe from neonatal age for short courses

Route Topical (ophthalmic)

Duration 5–7 days (minimum 48 hours after symptom resolution)

Renal / Hepatic adjustment Not required — negligible systemic absorption from topical use

Notes Avoid in patients with known aplastic anaemia history; contact lenses must be removed for duration of treatment

PBS status ✔ PBS General Benefit

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Fusidic Acid 1% Gel

Fucithalmic® · Antibiotic (fusidic acid)

Adult dose 1 drop (ribbon of gel) to affected eye(s) BD for 5–7 days

Paediatric dose Same as adult dose

Route Topical (ophthalmic)

Duration 5–7 days

Renal / Hepatic adjustment Not required

Notes Preferable in chloramphenicol allergy; prolonged retention on ocular surface due to gel formulation; excellent activity against staphylococci including many MRSA strains

PBS status ⚠ PBS Authority Required

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Chloramphenicol 1% Eye Ointment

Chloromycetin® · Antibiotic (chloramphenicol)

Adult dose Apply 1 cm ribbon to lower conjunctival sac TDS–QDS and at bedtime for 5–7 days

Paediatric dose Same as adult; useful at bedtime to prevent eyelid adhesion overnight

Route Topical (ophthalmic ointment)

Duration 5–7 days

Renal / Hepatic adjustment Not required

PBS status ✔ PBS General Benefit

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Safety-net advice: Most bacterial conjunctivitis is self-limiting (65% resolve within 5 days without antibiotics). However, antibiotics reduce transmission and shorten illness by 1–2 days. Advise patients to return if symptoms worsen after 48 hours of treatment, if vision deteriorates, or if pain develops.

Gonococcal and Chlamydial Conjunctivitis

Adult gonococcal conjunctivitis: Hyperacute onset with copious purulent discharge, severe lid swelling, and rapid corneal involvement possible. Requires systemic treatment — ceftriaxone 500 mg IMI single dose (1 g if >100 kg) PLUS azithromycin 1 g PO stat for concurrent chlamydial coverage. Urgent ophthalmology referral. Notify to state/territory health department.

Chlamydial conjunctivitis in adults: Chronic follicular conjunctivitis (duration >2 weeks), tarsal follicles, and inferior pannus. Treat with doxycycline 100 mg PO BD for 21 days (or azithromycin 1 g PO weekly for 3 weeks). Screen for genital chlamydia.

Neonatal ophthalmia neonatorum: Onset within first 28 days of life. C. trachomatis presents at 5–14 days with watery/mucoid discharge; N. gonorrhoeae presents at 2–5 days with copious bilateral purulent discharge. Gonococcal ophthalmia neonatorum is a medical emergency — ceftriaxone 25–50 mg/kg IV/IMI single dose (max 125 mg). Chlamydial: oral erythromycin ethylsuccinate 12.5 mg/kg QDS for 14 days. Both parents require treatment and STI screening.

Viral Conjunctivitis (Adenovirus)

Adenoviral conjunctivitis is the most common cause of infectious conjunctivitis in adults, accounting for 60–90% of cases. It is highly contagious (fomite transmission, R₀ >5 in outbreak settings such as schools and hospitals). Two clinical patterns exist:

Pharyngoconjunctival fever (PCF): Adenovirus types 3 and 7 — associated with fever, pharyngitis, and bilateral conjunctivitis; self-limiting over 10–14 days.
Epidemic keratoconjunctivitis (EKC): Adenovirus types 8, 19, and 37 — more severe, with pre-auricular lymphadenopathy, pseudomembranes, and subepithelial corneal infiltrates (can cause visual disturbance for weeks to months).

Management: Supportive care is the mainstay — cold compresses, lubricant eye drops (polyethylene glycol 0.4% or carboxymethylcellulose 0.5%), and artificial tear ointment at night. Topical antibiotics are NOT indicated unless there is evidence of secondary bacterial infection. Povidone-iodine 0.8–1% drops may have modest benefit in reducing viral load.

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Infection control: Adenovirus can survive on surfaces for up to 8 weeks. Patients must be counselled about strict hand hygiene, not sharing towels or pillows, and exclusion from work/school for the duration of active symptoms (typically 10–14 days). Healthcare workers should not see patients while symptomatic. Tonometer tips must be disinfected or discarded (single-use preferred per RANZCO guidelines).

Herpes Simplex Keratoconjunctivitis

HSV-1 can cause unilateral follicular conjunctivitis with characteristic dendritic corneal ulceration visible on fluorescein staining. Patients may have a history of cold sores. Key features include reduced corneal sensation, branching dendrites with terminal bulbs, and mild-to-moderate pain. Diagnosis is clinical; viral PCR of corneal scraping is confirmatory if needed.

Treatment: Topical aciclovir 3% ointment 5 times daily for 7–10 days (not PBS-listed; available as an authority script or private prescription in some states). Alternatively, oral valaciclovir 500 mg BD for 7–10 days. Topical corticosteroids are contraindicated in dendritic keratitis without ophthalmology supervision — they can cause geographic ulceration and corneal perforation. Urgent ophthalmology referral if dendrite does not heal within 7 days.

Uveitis & Acute Glaucoma

Anterior Uveitis (Iritis)

Anterior uveitis is the inflammation of the iris and anterior ciliary body. It is the most common form of uveitis in Australia (~75% of cases) and typically affects adults aged 20–50 years. Approximately 50% of anterior uveitis cases are idiopathic; ~30% are associated with HLA-B27, and the remainder are associated with systemic conditions.

Clinical features:

Unilateral red eye with circumlimbal (ciliary) flush — a band of deeper redness around the corneal limbus
Deep, dull ache (not the superficial grittiness of conjunctivitis)
Photophobia (often severe — the consensual light reflex triggers pain)
Small, irregular pupil (posterior synechiae — iris adherent to lens capsule)
Mildly reduced visual acuity
Lacrimation (no purulent discharge)

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Primary care role: Suspect uveitis based on ciliary flush + photophobia + deep ache. Do not initiate topical corticosteroids in general practice. Refer urgently (within 24 hours) to ophthalmology for slit-lamp confirmation, assessment of cells/flare, and specialist-initiated therapy. Severe cases with hypopyon or posterior synechiae require same-day referral.

Ophthalmological management (for reference):

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Prednisolone Acetate 1% Eye Drops

Predsol® · Pred Forte® · Corticosteroid

Dose (ophthalmology) 1 drop Q1–2H initially, taper over 4–6 weeks based on clinical response

Route Topical (ophthalmic)

Key warning Rises IOP in steroid responders — must be monitored; can exacerbate HSV keratitis

PBS status ⛔ Authority Required (Specialist only)

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Homatropine 2% Eye Drops (Cycloplegic)

Isopto Homatropine® · Anticholinergic

Dose (ophthalmology) 1 drop BD–TDS to affected eye; duration until inflammation controlled

Purpose Relieves ciliary spasm/pain; prevents/mobilises posterior synechiae

PBS status ⚠ Authority Required (Specialist)

Investigations for recurrent or bilateral uveitis (ordered by ophthalmologist): HLA-B27, ESR/CRP, syphilis serology (RPR/VDRL + TPHA), angiotensin-converting enzyme (ACE) for sarcoidosis, chest X-ray (sarcoidosis, TB), ANA and RF (juvenile idiopathic arthritis in paediatric uveitis), and Toxoplasma serology if posterior segment involved.

Systemic associations to consider in HLA-B27-positive anterior uveitis:

Ankylosing spondylitis (most common; bilateral sacroiliitis on MRI)
Reactive arthritis (previously Reiter's syndrome) — conjunctivitis, urethritis, arthritis triad
Psoriatic arthritis
Inflammatory bowel disease (Crohn's > UC)

Acute Angle-Closure Glaucoma (AACG)

AACG is an ophthalmic emergency that can cause permanent vision loss within hours. It occurs when the peripheral iris obstructs the trabecular meshwork, preventing aqueous humour outflow and causing a rapid rise in intraocular pressure (IOP).

Risk factors in the Australian population:

Age >50 years (peak 60–70 years)
Female sex (2–4× more common)
Hypermetropia (shorter axial length, shallow anterior chamber)
East and South-East Asian ethnicity (higher prevalence of narrow angles)
Family history of angle closure
Pharmacological triggers: mydriatics (tropicamide, atropine, scopolamine patches), sympathomimetics (ipratropium nebulisers, adrenalin), SSRIs, topiramate

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Clinical recognition: Severe unilateral eye pain + nausea/vomiting + red eye with steamy cornea + mid-dilated fixed pupil + markedly reduced vision with haloes around lights. IOP typically >40 mmHg (normal 10–21). Do NOT dilate the pupil. Call ophthalmology immediately — this requires urgent IOP lowering and likely laser peripheral iridotomy.

Initial medical management while awaiting ophthalmology (may be initiated in ED/GP):

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Timolol 0.5% Eye Drops

Timoptol® · Beta-blocker

Dose 1 drop to affected eye, may repeat ×1 after 5 minutes

Action Reduces aqueous production

Caution Contraindicated in asthma, COPD, heart block, bradycardia

PBS status ✔ PBS General Benefit

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Brimonidine 0.2% Eye Drops

Alphagan® · Alpha-2 agonist

Dose 1 drop to affected eye ×1

Action Reduces aqueous production and increases uveoscleral outflow

PBS status ⚠ PBS Authority Required

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Acetazolamide

Diamox® · Carbonic anhydrase inhibitor

Dose (acute) 500 mg IV bolus or 500 mg PO stat, then 250 mg PO QID

Action Potent reduction of aqueous humour production

Renal adjustment Use with caution if eGFR <30; avoid in severe renal impairment (risk of metabolic acidosis)

Caution Sulphonamide allergy; avoid in hepatic impairment (hepatic encephalopathy risk)

PBS status ✔ PBS General Benefit

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Pilocarpine 2% Eye Drops (Miotic)

Pilocarpine® · Parasympathomimetic

Dose 1 drop Q15 min × 2–4 doses after IOP begins to fall (once corneal oedema clears)

Action Constricts pupil → pulls iris away from trabecular meshwork

Important note Ineffective while IOP is very high (>50 mmHg) as the ischaemic iris will not constrict — wait until IOP drops below 40–50 mmHg

PBS status ✔ PBS General Benefit

Definitive treatment: Laser peripheral iridotomy (LPI) — creates a small hole in the peripheral iris to equalise pressure between the posterior and anterior chambers. Usually performed within 24–48 hours. Prophylactic LPI is also recommended for the fellow eye (which has a 40–80% risk of AACG within 5–10 years if untreated).

Corneal Ulcer & Herpes Zoster Ophthalmicus

Microbial (Bacterial) Keratitis / Corneal Ulcer

Microbial keratitis is a potentially sight-threatening infection of the cornea. In Australia, the most significant risk factor is contact-lens wear, particularly overnight (extended-wear) soft contact lenses. The annual incidence in contact-lens wearers is 2–4 per 10,000, compared to 0.2–0.5 per 10,000 in non-wearers.

Common causative organisms in Australia:

Organism	Risk Group	Clinical Features
Pseudomonas aeruginosa	Contact-lens wearers (especially overnight)	Rapidly progressive, greenish discharge, ring infiltrate, stromal melt
Staphylococcus aureus	Post-trauma, immunocompromised	Dense white infiltrate, satellite lesions
CA-MRSA	Remote communities, post-trauma	As per S. aureus; resistant to standard beta-lactams
Streptococcus pneumoniae	Post-trauma, chronic ocular surface disease	Central ulcer with feathery edges
Aspergillus / Fusarium spp.	Vegetable matter trauma, tropical regions	Dry, elevated infiltrate with satellite lesions; slow progression
Acanthamoeba	Contact-lens wearers (esp. tap water exposure)	Severe pain out of proportion, radial keratoneuritis, ring infiltrate

Clinical features of corneal ulcer:

Unilateral eye pain (moderate to severe), photophobia, lacrimation
Corneal epithelial defect visible on fluorescein staining (appears green under cobalt blue light)
White/cream-coloured stromal infiltrate at the base of the defect
Circumlimbal injection
Reduced visual acuity if central or paracentral
Hypopyon (pus level in anterior chamber) — indicates severe bacterial infection

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All suspected corneal ulcers require urgent ophthalmology referral. Do not patch the eye (contraindicated in microbial keratitis). Do not initiate topical corticosteroids. Contact-lens wearers must immediately discontinue lens wear. Collect a corneal scrape for microscopy and culture if feasible before starting antibiotics, but do not delay referral.

Initial management while awaiting ophthalmology:

Intensive topical antibiotics — the standard empirical regimen is fortified cefazolin 5% (drops prepared by compounding pharmacy) alternating with fortified gentamicin 0.9%, applied hourly day and night for the first 48 hours
Where fortified drops are unavailable (e.g., regional/remote areas), ofloxacin 0.3% or moxifloxacin 0.5% (fourth-generation fluoroquinolone) eye drops hourly may be used as initial monotherapy — these have good Gram-positive and Gram-negative coverage, including Pseudomonas
For suspected Acanthamoeba: dual therapy with polyhexamethylene biguanide (PHMB) 0.02% + propamidine 0.1% (Brolene®) — specialist initiation required

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Moxifloxacin 0.5% Eye Drops (Vigamox®)

Vigamox® · Fourth-generation fluoroquinolone

Dose (keratitis) 1 drop Q1H for first 48 hours, then taper per ophthalmology guidance

Route Topical (ophthalmic)

Coverage Gram-positive (including CA-MRSA), Gram-negative, and some atypical organisms

Note Increasing fluoroquinolone resistance among Pseudomonas in Australia — not a substitute for fortified drops in severe ulcers

PBS status ⚠ PBS Authority Required

Herpes Zoster Ophthalmicus (HZO)

HZO is caused by reactivation of latent varicella-zoster virus (VZV) in the trigeminal (Gasserian) ganglion, affecting the ophthalmic division (V1). It accounts for 10–20% of all herpes zoster cases and carries significant ocular morbidity.

Clinical features:

Prodrome: unilateral headache, malaise, and pain in V1 dermatome for 1–3 days before rash
Vesicular eruption in V1 distribution (forehead, upper eyelid, and bridge of nose) respecting the midline
Hutchinson's sign: Vesicles on the tip or side of the nose — indicates involvement of the nasociliary nerve, which also innervates the cornea and anterior segment. This sign has a positive predictive value of ~75% for ocular involvement.
Ocular complications (30–70% if untreated): conjunctivitis, keratitis (pseudodendrites), anterior uveitis, scleritis, elevated IOP, and rarely retinal necrosis or optic neuritis
Postherpetic neuralgia (PHN) occurs in 10–25% of HZO cases and is more common with increasing age

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Rule of 72 hours: Antiviral therapy is most effective when started within 72 hours of rash onset. However, treatment should still be initiated after 72 hours if new vesicles are forming or if there is ocular involvement. Refer all HZO cases to ophthalmology regardless of Hutchinson's sign status.

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Valaciclovir

Valtrex® · Antiviral (prodrug of aciclovir)

Adult dose 1 g PO TDS for 7 days (preferred for HZO due to superior bioavailability)

Paediatric dose Not routinely used in children for HZO; aciclovir preferred

Renal adjustment eGFR 30–49: 1 g BD; eGFR 10–29: 1 g OD; eGFR <10: 500 mg OD

PBS status ✔ PBS General Benefit (500 mg, 25 tabs)

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Aciclovir

Zovirax® · Antiviral

Adult dose (oral) 800 mg PO 5 times daily for 7 days

Adult dose (IV) 10 mg/kg IV TDS for severe ocular involvement / immunocompromised

Paediatric dose 20 mg/kg (max 800 mg) PO 5 times daily for 7 days

Renal adjustment eGFR 25–50: 800 mg QID; eGFR 10–24: 800 mg TDS; eGFR <10: 800 mg BD

PBS status ✔ PBS General Benefit

Postherpetic neuralgia (PHN) prevention and management:

Gabapentin: Titrate from 300 mg OD to 300 mg TDS over 1 week (max 3600 mg/day in divided doses). Renal adjustment required. PBS General Benefit.
Pregabalin: 75 mg BD, titrate to 150–300 mg BD. PBS Authority Required.
Amitriptyline: 10–25 mg nocte, titrate to 50–75 mg. Useful if concurrent depression or insomnia. PBS General Benefit.
Lidocaine 5% medicated plaster (Versatis®): Apply to affected area (intact skin only) for up to 12 hours/day. PBS Authority Required for neuropathic pain refractory to oral agents.

Zostavax® vs Shingrix® — Australian Vaccination Context

As of November 2023, Shingrix® (recombinant zoster vaccine, adjuvanted) has replaced Zostavax® on the National Immunisation Program (NIP) for:

All adults aged 65 years and older (2 doses, 2–6 months apart)
Immunocompromised adults aged 18 years and older at increased risk of HZ
Aboriginal and Torres Strait Islander adults aged 50 years and older

Shingrix® provides >90% efficacy against HZ and PHN (compared to ~50% for Zostavax®) and is preferred in immunocompromised individuals as it is a non-live vaccine.

Investigations

GP Available Visual acuity (Snellen chart) Must be documented before any treatment. Use pinhole to exclude refractive error. MBS item 10900 (consultation). Fundamental to triage — reduced VA with red eye mandates referral.

GP Available Pen-torch & pupil assessment Assess injection pattern, pupil size/shape/reactivity, RAPD (swinging torch test), corneal clarity, and anterior chamber depth.

GP Available Fluorescein staining + cobalt blue light Detects corneal epithelial defects, dendritic ulcers (HSV), foreign bodies. Single-use Minims fluorescein drops are PBS-listed. Seidel test (aqueous leak) if open globe suspected.

GP Available Conjunctival swab (MBS item 69316) For chlamydial NAAT and bacterial MCS. Indicated if: suspected chlamydial/gonococcal conjunctivitis, neonatal conjunctivitis, or treatment failure after 48 hours. Transport in charcoal medium for chlamydia.

GP Available IOP measurement (Tono-Pen / iCare) If available in practice; normal 10–21 mmHg. >40 mmHg strongly suggests AACG. Not a substitute for ophthalmology referral if clinical features are concerning.

Specialist Slit-lamp biomicroscopy Gold standard for uveitis diagnosis (cells/flare, keratic precipitates, posterior synechiae). Available in ophthalmology clinics and some optometry practices.

Specialist Gonioscopy Assesses anterior chamber angle anatomy — confirms angle closure, identifies plateau iris. Performed by ophthalmologist.

Specialist Corneal scrape / biopsy For moderate-to-severe corneal ulcers. Gram stain, culture, sensitivities, and fungal/ACANTHAMOEBA special stains. Ophthalmologist-performed under slit-lamp.

Referral HLA-B27 typing (MBS item 71124) For recurrent or bilateral anterior uveitis. Helps identify HLA-B27-associated spondyloarthropathies. Bulk-billed via pathology labs.

Referral ACE, ESR, CRP, syphilis serology, chest X-ray Investigations for systemic causes of uveitis (sarcoidosis, TB, syphilis). Ordered by ophthalmologist or rheumatologist.

Special Populations

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Paediatric

Neonatal conjunctivitis (ophthalmia neonatorum) Exclude gonococcal (onset day 2–5, copious pus) and chlamydial (day 5–14, watery/mucoid) aetiologies. Both are notifiable. Gonococcal: ceftriaxone 25–50 mg/kg IV/IMI stat (max 125 mg). Chlamydial: erythromycin ethylsuccinate 12.5 mg/kg PO QID × 14 days. Refer to paediatric ophthalmology.

Childhood bacterial conjunctivitis H. influenzae and S. pneumoniae predominate. Chloramphenicol 0.5% drops QID for 5 days. Associated otitis media may require concurrent oral amoxicillin.

Juvenile idiopathic arthritis (JIA)-associated uveitis Anterior uveitis in ANA-positive JIA is often insidious and asymptomatic — regular screening slit-lamp examinations mandated. Refer all JIA children for ophthalmology screening per ACR guidelines.

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Pregnancy & Breastfeeding

Chloramphenicol 0.5% drops Safe in pregnancy and breastfeeding (minimal systemic absorption from topical use). Category B3 (TGA).

Acetazolamide Category B3 but generally avoided in first trimester (teratogenic in animal studies at high doses). Use only for AACG emergency with obstetric and ophthalmology co-management.

Valaciclovir / Aciclovir Category B3. May be used in pregnancy for HZO where benefit outweighs risk. Aciclovir pregnancy registry shows no signal of teratogenicity.

Topical prednisolone May be used under ophthalmology supervision — minimal systemic absorption. Short courses acceptable.

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Elderly (≥65 years)

Acute angle-closure glaucoma risk Higher prevalence due to lens enlargement narrowing the anterior chamber. Always assess pupil and anterior chamber depth in elderly with red eye. Avoid mydriatics and anticholinergic medications without ophthalmological assessment.

Herpes zoster ophthalmicus Highest incidence in adults ≥60. Valaciclovir renal dose adjustment essential (eGFR-dependent). Shingrix® vaccination (NIP-funded from age 65) is the key prevention strategy.

Giant cell arteritis (GCA) Must be considered in any patient >50 years with new visual disturbance (often with jaw claudication, headache, and raised ESR/CRP). Ophthalmic artery ischaemia can cause sudden irreversible blindness. Urgent ESR/CRP and ophthalmology/rheumatology referral. Start prednisolone 1 mg/kg PO immediately if GCA suspected (even before temporal artery biopsy).

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Renal Impairment

Valaciclovir Dose adjustment required: eGFR 30–49 → 1 g BD; eGFR 10–29 → 1 g OD; eGFR <10 → 500 mg OD. Risk of neurotoxicity (confusion, tremor) in accumulation.

Acetazolamide Use with extreme caution if eGFR <30 mL/min (risk of severe metabolic acidosis). Avoid in severe renal impairment if alternatives available.

Gabapentin Renally cleared — dose reduction mandatory. eGFR 30–59: 200–300 mg BD; eGFR 15–29: 200–300 mg OD; eGFR <15: 100–300 mg OD.

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Hepatic Impairment

Acetazolamide Avoid in severe hepatic impairment — may precipitate hepatic encephalopathy by reducing renal ammonia excretion.

Valaciclovir / Aciclovir No specific dose adjustment in hepatic impairment; aciclovir is renally cleared. Use with caution in decompensated liver disease.

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Immunocompromised

HSV keratitis More likely to be severe, recurrent, and bilateral. Higher risk of stromal keratitis and geographic ulceration. Longer treatment courses (14–21 days). Low-dose oral suppressive aciclovir (400 mg BD) reduces recurrence.

CMV retinitis Consider in severely immunosuppressed patients (CD4 <50 cells/µL in HIV, post-transplant). Presents with painless visual floaters, visual field loss, and "pizza pie" fundoscopic appearance. Refer urgently to ophthalmology.

HZO management Higher risk of disseminated zoster and multi-dermatomal involvement. IV aciclovir 10 mg/kg TDS may be required for severe cases. Consider hospital admission. Shingrix® (non-live vaccine) is preferred and NIP-funded for immunocompromised adults ≥18 years.

Microbial keratitis Broader organism spectrum including fungi and atypical mycobacteria. Lower threshold for corneal biopsy and intensive empirical therapy.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health — The Red and Tender Eye

Red eye conditions in Aboriginal and Torres Strait Islander Australians carry a unique epidemiological and clinical context that requires specific awareness from clinicians. Trachoma, preventable blindness, and access barriers are critical considerations.

Trachoma — Australia's Ongoing Challenge

Australia remains the only high-income country where trachoma (caused by Chlamydia trachomatis serotypes A–C) is endemic. Active trachoma predominantly affects Aboriginal children aged 1–9 years in remote and very remote communities across the Northern Territory, South Australia, and Western Australia. In 2022, active trachoma prevalence was approximately 4.0% nationally in screened communities, though rates exceed 10% in some communities.

Trachoma presents as follicular conjunctivitis (TF/TI) in children and, if untreated, progresses through scarring (TS), trichiasis (TT — in-turned eyelashes scratching the cornea), and ultimately corneal opacity (CO) and blindness in adults. Trichiasis surgery is a priority for older Aboriginal adults in endemic regions.

Management (SAFE strategy — WHO-endorsed):

Surgery for trichiasis (community-based, delivered by visiting ophthalmologists)
Antibiotics: mass drug administration (MDA) — azithromycin 20 mg/kg PO stat (children) or 1 g PO stat (adults) to entire community in endemic areas, annually until prevalence <5%
Facial cleanliness: health promotion for children
Environmental improvement: water supply, sanitation, and housing (hardware) in remote communities

Access and Referral Barriers

Geographic remoteness

Many Aboriginal communities are classified as remote (MM 6–7) or very remote (MM 7). Specialist ophthalmology services require air transfer (RFDS) or visiting specialist clinics through the Indigenous Eye Health Program. Any red eye with reduced vision in a remote community should prompt consideration of telehealth ophthalmology (e.g., The Fred Hollows Foundation screening programs) and early transfer.

Cultural considerations

Eye examinations require culturally safe communication. Avoid direct questioning without rapport-building. Use Aboriginal Health Workers/Practitioners (AHW/AHPs) as cultural brokers. Recognise that the eye may hold cultural significance and that certain examination techniques may need explanation and consent. Gender-matching of clinicians may be important for eye examinations in some communities.

Higher rates of comorbidity

Aboriginal and Torres Strait Islander Australians have higher rates of diabetes (3–4× non-Indigenous rates), which increases susceptibility to infections including microbial keratitis. Diabetic eye disease can coexist with red eye presentations. Rheumatic fever and post-streptococcal conditions may cause episcleritis/scleritis.

Medication access

PBS medications may be dispensed under Closing the Gap PBS Co-Payment (reduced or nil co-payment) for Aboriginal and Torres Strait Islander patients with, or at risk of, chronic disease. Chloramphenicol eye drops, valaciclovir, and gabapentin are accessible under CTG arrangements. Ensure "CTG" annotation on PBS scripts.

HZO and vaccination

Herpes zoster ophthalmicus may present late in remote communities. Shingrix® is NIP-funded from age 50 (vs 65 for non-Indigenous) for Aboriginal and Torres Strait Islander adults, reflecting the higher burden of disease and earlier onset. Promote vaccination through community health centres and ACCHSs.

Trachoma screening programs

Active trachoma screening is coordinated through the National Trachoma Surveillance and Response Program (managed by the Kirby Institute, UNSW). Primary care clinicians in endemic regions should participate in annual screening of children aged 1–9 years using WHO simplified grading. Cases of TF should be treated with single-dose azithromycin and the case managed through the SAFE program.

Quick Reference — Empirical Therapy by Syndrome

Bacterial conjunctivitis Chloramphenicol 0.5% drops QID 5–7 days Alt: fusidic acid 1% gel BD (if allergy)

Viral conjunctivitis Supportive (artificial tears, cold compress) 10–14 days No antibiotics unless 2° bacterial infection

Gonococcal conjunctivitis Ceftriaxone 500 mg IMI stat + azithromycin 1 g PO stat Single dose each Notifiable; screen for STIs; ophthalmology referral

HSV dendritic keratitis Aciclovir 3% oint 5×/day or valaciclovir 500 mg PO BD 7–10 days NO topical steroids without ophthalmology

Anterior uveitis Refer to ophthalmology (topical prednisolone 1% + cycloplegic) Specialist-directed Do not start steroids in GP

AACG (pre-transfer) Timolol 0.5% + brimonidine 0.2% + acetazolamide 500 mg IV/PO Until ophthalmology review Do NOT dilate; pilocarpine 2% once IOP <50 mmHg

Microbial keratitis Moxifloxacin 0.5% Q1H (or fortified cefazolin + gentamicin) 48H intensive then taper Urgent ophthalmology; do not patch; no steroids

Herpes zoster ophthalmicus Valaciclovir 1 g PO TDS 7 days Start within 72H of rash; ophthalmology referral; check renal function

📚 References

1. Royal Australian and New Zealand College of Ophthalmologists (RANZCO). Conjunctivitis — Preferred Practice Pattern. Sydney: RANZCO; 2023.
2. Shields T, Sloane PD. A comparison of eye problems in general practice and ophthalmology clinics. Br J Gen Pract. 1992;42(365):544–546.
3. Epling J. Bacterial conjunctivitis. BMJ Clin Evid. 2012;2012:0704.
4. Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA. 2013;310(16):1721–1729.
5. Health Protection Agency. Guidelines for the Management of Conjunctivitis in Primary Care. London: HPA; 2009.
6. Royal Australian and New Zealand College of Ophthalmologists (RANZCO). Acute Angle Closure Glaucoma — Preferred Practice Pattern. Sydney: RANZCO; 2022.
7. Kanski JJ, Bowling B. Clinical Ophthalmology: A Systematic Approach. 8th ed. Edinburgh: Elsevier; 2015.
8. Watson SL, Cabrera-Aguas M, Khoo P, et al. Microbial keratitis in Sydney, Australia: risk factors, pathogens, and antimicrobial resistance. Am J Ophthalmol. 2019;206:87–95.
9. Cunningham ET Jr, Wong RW, Takakura A, Downes KM, Zierhut M. Herpes zoster ophthalmicus. Ocul Immunol Inflamm. 2018;26(5):667–671.
10. Australian Government Department of Health and Aged Care. Shingrix (Recombinant Zoster Vaccine) — National Immunisation Program Fact Sheet. Canberra: DoH; 2023.
11. The Kirby Institute, UNSW. National Trachoma Surveillance and Reporting Annual Report 2022. Sydney: UNSW; 2023.
12. Taylor HR, Fox SS, Xie J, et al. The prevalence of trachoma in Australia: the National Indigenous Eye Health Survey. Med J Aust. 2010;192(5):248–253.
13. Australian Institute of Health and Welfare (AIHW). Eye Health in Aboriginal and Torres Strait Islander People. Canberra: AIHW; 2022.
14. Fardeau C, Romand S, Rao NA, et al. Diagnosis of bacterial and fungal endophthalmitis. J Clin Microbiol. 2002;40(6):2016–2022.
15. Australian Government Department of Health. PBS Online — Pharmaceutical Benefits Schedule. Canberra: DoH; 2024. Available at: pbs.gov.au.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).