angle closure glaucoma beware of the unilateral red eye · 4/27/12 1 beware of the unilateral red...
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BewareoftheUnilateralRedEye
Mark T. Dunbar, O.D., F.A.A.O. Bascom Palmer Eye Institute University of Miami, Miller School of Med Miami, FL
Jill Autry, OD, RPH Optometric Physician/Partner/Pharmacist Eye Center of Texas 6565 West Loop South, Suite 650 Bellaire, TX 77401
AngleClosureGlaucoma
• Agroupofdisordersallrelatedbyafinalcommonpathway
• 1ststepisirisapposiContotheTMblockingouGlowofaqueoushumor
PrimaryAngleClosureGlaucoma(PACG)
StaggeringStaCsCcs• 5.2to6.7millionpeopleworldwideblindfromglaucoma
• PACGisthemostcommonformofglaucomainMongolians,Singaporean,ChineseandSouthIndians
AngleClosureGlaucoma
• PACGinChina– Affects3.5millionpeople– 28millionhaveoccludabledrainageangles
• ChineseandIndianpopulaConrepresent2billionpeople– LargeminoriCesinmanycountries
• Greatestcauseofvisualmorbiditythananyotheroculardisease– Exceptcataractsandtrachoma
PrimaryAngleClosureGlaucoma
• Theleadingformofglaucomaworldwide!
• PACGblinds10XmorepeoplethanPOAG
PACGPresentaCon
• AcutesymptomaCcangleclosureisnotthemostcommonform
• ChronicasymptomaCcPACGismostpredominant
• 58%ofangleclosureglaucomaptshadchronicformofthedisease
BonomiLetal.Egna‐NeumarketglaucomastudyOphthalmol2000,107:998‐1003.
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PACGPresentaCon
• Lackofsymptomsmakeitdifficulttodetect• PACGis#1causeofbilateralglaucomablindnessinMongolia,SingaporeandChina
• India41%withPACGwereblindononeorbotheyes
ACUTEANGLECLOSURE
• CharacterizedbyapposiConoftheiristothetrabecularmeshwork
• MechanicalblockageofaqueousouGlow
• ProgressivetrabeculardysfuncCon• Canleadtosynechialclosure
WWW.GONIOSCOPY.ORGCHARACTERISTICS
• 90%ofcasesarerelaCvepupillaryblock• Hyperopiceyes,Asians,andEskimos• Anterioririsbowing• Shallowanteriorchamber• Olderage• Ageinducedlensthickening• Angleclosedongonioscopy;narrowinothereye
CHARACTERISTICS
• IOPin40‐60mmHgrange• Corneacloudy;mayhavemicrocysCcedema• Pupilogenmid‐dilatedwithlihlereacContolight
• ConjuncCvalhyperemia• PaCentogenwithpain,nausea,vomiCng,and/orheadache
• PercepConofhalosaroundlights
TREATMENT
• Putinalltypesofdropsincludingpilo,prostaglandin,AlphaganP,CAI,beta‐blockers
• Diamox500mgand/orosmoCcagents
• PredForteq1‐2hforinflammaCon• DoindenCongonioscopyifpossible‐maybreakahack
• Getperipheraliridotomy(PI)ininvolvedeyefirst• KeeppilocarpineonOUunClPIdoneinbotheyes
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NEOVASCULARGLAUCOMA
• OcularischemiacausesneovascularizaCon• NeovascularizaConoftheanteriorsegmentleadstoincreasedIOP
• DirectobstrucConofthetrabecularmeshworkbyaneovascularmembrane
• SeenmoreogenwithcertainischemicocularcondiCons– CRVO– ProliferaCvediabeCcreCnopathy(PDR)– Ocularischemicsyndrome(OIS)
CHARACTERISTICS
• IrisneovascularizaCon(NVI)• AngleneovascularizaCon(NVA)• Spontaneoushyphema
• Historyofpoorvisualacuityinaffectedeyeformonthstoyears
• OlderpaCents• VasculopathiccondiCons
TREATMENT
• AhempttocontrolIOP– Prostaglandins,AlphaganP,CAIs,Diamox
• NeedpanreCnalphotocoagulaCon(PRP)ASAP• AnteriorsegmentvesselsregresswithanC‐VEGFinjecConsintoanteriorchamber
• TranscleralcyclophotoablaCon(TCP)
PSEUDOEXFOLIATIVEGLAUCOMA
• ExfoliaCvematerialfromlens• AbrasiveacConcausespigmentrelease• ExfoliaCvematerialandpigmentdecreasetrabecularmeshworkflow
• Unilateralorbilateral• ZonularfibersareweakenedmakinglensdislocaConpossible,especiallyduringcataractsurgery
• Irisalsodilatespoorly
CHARACTERISTICS
• CaucasianpaCents• SeeexfoliaCvegrayish‐white,flakymaterialonanteriorlenssurface
• Materialsehlesinaringonperipheraledgeoflens
• SeepupillarytransilluminaCngdefects• Seelossofpupillarypigmentedruff• SeenbestwithdilatedlensexaminaCon
TRAUMATICGLAUCOMA
• AlsoknownasAngleRecessionGlaucoma• Unilateral• Historyoftraumainaffectedeye• Blunttraumawithmicrohyphema/hyphema• IOPmaybeelevatedordecreasediniCallydependingonavarietyoffactors
• Long‐termriskofglaucomaisusuallysecondarytoanglerecession(maynotpresentfor20years)
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LONGTERMEVALUATION
• Signsofprevioustrauma– PoorpupillaryconstricConsecondarytosphinctertear
– Iridodialysis– Cyclodialysis– Anglerecessionongonioscopy• Comparewithgonioonunaffectedeye
– Weakortornzonules– Cataract
TREATMENT
• Prostaglandins• AlphaganP• Beta‐blockers• CAIs• SLT/ALTrarelyeffecCve
UVEITICGLAUCOMAS
• InflammaConcancauseiniCaldecreaseinIOP– ReducConinaqueoussecreCon– IncreaseinuveoscleralouGlow
• OverCme,however,inflammatorymaterialcanobstructthetrabecularmeshwork
• TrabeculiCscanalsoincreaseIOP• IncreasedIOPmaybetransientormaypersistwithpermanentstructuralchanges
POSNER‐SCHLOSSMAN
• AlsoknownasGlaucomatocycliCccrisis• UveiCcglaucoma
• Unilateral• Youngtomiddle‐agedmen
• MilduveiCsinassociaConwithveryhighIOP
• OgenfoundonrouCneexam
• OgenwithexacerbaConsandremissions
CHARACTERISTICS
• Mildcellandflare,someCmesflareonly• FinekeraCcprecipitates(KP)oncornealendothelium
• Nopain,eyeiswhite• Milddecreaseinvisualacuity• IOPogen50‐60mmHg• PaCentogendevelopschronicallyelevatedIOPrequiringlong‐termtreatmentorsurgery
TREATMENT
• StartPredForte1%q1‐2h• IniCallyaddmulCpledropsprn– Prostaglandin,AlphaganP,beta‐blocker,CAIs
• MayneedDiamoxorally• Removeprostaglandinfirstifused• Tapersteroidanddropsover1‐2weeks• WatchforchronicincreaseinIOP– FollowmonthlyiniCally,thenevery3monthsforlife
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FUCH’SHETEROCHROMICIRIDOCYCLITIS
• UveiCcglaucoma(chronic,low‐grade)• GenerallyasymptomaCc
• Unilateral(90%),bilateral(10%)• CharacterisCctriad– Heterochromia– Glaucoma– Cataract
CHARACTERISTICS
• Lighteririscolorininvolvedeye• Fine,stellatekeraCcprecipitatesonenCrecornealendothelium(notjustinferior)
• Posteriorsynechiaeisnotseenbutmayseeperipheralanteriorsynechiae
• Frailanglevesselscancausespontaneoushyphemaorsurgicallyinducedhyphema
• PureneovascularizaConofirisand/orneovascularglaucomarare
TREATMENT
• Poorresponsetosteroidtreatment– Onlyuseshort‐termforsymptomaCcepisodes– ChronictherapyonlyworsenscataractandglaucomaassociaCons
• PoorresponsetoALT/SLT• Avoidprostaglandinuse• ConsiderAlphaganP,beta‐blockers,CAIs• Trabeculectomyorshunt
HERPETICUVEITICGLAUCOMA
• UveiCsandiniCalhighIOP• SimplexinduceduveiCs– Mayormaynotseedendrite
– Askifhistoryofrecurrent,unilateralredeye• ZosterinduceduveiCs– CharacterisCclesionsononesideofupperface
TREATMENT
• Simplex– ViropCcfortreatmentofepithelialdisease
– ViropCcforprevenConofepithelialdiseasewiththeuseoftopicalsteroids
– Topicalsteroidtotreatstromaldisease– AlphaganP,beta‐blockertodecreaseIOP– CanuseoralanCviralagentsinplaceofViropCcfortreatmentandsteroidcoverage
HSV• ConjuncCviCs• EpithelialKeraCCs– Dendrite– Geographic
• StromalKeraCCs– Non‐necroCzingvsNecroCzing
• KeratouveiCs• EndotheliaCs
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HSVDendriCcKeraCCs
• Thin,linear,branchingulceraCvelesion• Terminalbulbs• Heaped‐upedges• DecreasedcornealsensiCvity• CentralstainswithNaFl,edgesstainwrose• Workupusuallynotnecessary• Geographiculcers‐>largeramourphousdefect
HSVEpithelialKeraCCs
Treatment• TopicalAnCvirals– Zirgan(topicalganciclovir)– ViropCc(Trifluorothymidine)9X/d– Idoxuridineung(Vidarabine3%5X/d– Toxicity:IDU>TF3>ViraA>Acyclovir
• OralAcyclovir:muchlesstoxicandequivalentresults400mg5X/d
• NoSteroids
Zirgan
• AtopicalanCviralusedforherpeCckeraCCs
• GelformulaConallowsforlongerresidenceCmeoncornea
• AseffecCveasacyclovir,withbehertolerabilityprofile
Zirgan
• Dosedlessfrequentlythantrifluridine—5xdayversus9xdayforViropCc
• Onlyaffectsinfectedcells,TFTtargetsallcells– ThisresultsinlesstoxicitytoepithelialcellswithZirgan
• AcCveagainst2ofthe3mostprevalentadenovirusspecies– TFThasnosuchacCvity
ZirganDosing
• RecommendeddosingregimenforZirganis1drop5XperdayunCltheulcerheals,andthen1drop3Xperdayfor7days
HSVOralTreatment
• Acyclovir(Zovirax)– Adults:2g/day– Children:20mg/kg/day
• Valacyclovir(Valtrex)1000mgTID
• Famciclovir(Famvir)500mgTID
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HSVDisciformKeraCCs
• Involvementofdeeperstromaandendothelium
• Non‐necroCzing• Disc‐shapedstromaledema• Stromalcells• MaybefromcellmediatedimmunereacCon– KaufmanbelievesslowstromalviralreplicaCon
HERPESSIMPLEX
• InplaceofViropCc®topically– Acyclovir400mg5xdayx10days– Famvir®250mgCdx7days– Valtrex®500mgCdx7days
• ForprevenConofrecurrences– Acyclovir400mgqd‐bid– Famvir®250mgqd– Valtrex®500qd
HERPESZOSTER
• Unilateral• OlderpaCent• Withsame‐sided,vesicularfaciallesions
– LesionsonCpofnosesuggesCveofimpendingorcurrentocularinvolvement
• ConjuncCviCs/iriCs/cornealpseudodendrites– Mayappearbeforeskinlesions
ZOSTERTREATMENT
– ViropCcNOTusedinHerpeszoster– MakesureoralanCviralsonboard– IfseverekeraCCsormoderatetosevereACreacCon• StartPForDurezolq2htoqid
– IfmildACreacCon/hyperemiaonly• Considerwatchingwithcycloplegiconly
– WatchIOP!!Avoidprostaglandins
HERPESZOSTER
• Muststartwithin72hrsforbesteffect;preferablywithin24hrs
• Acyclovir800mg5Xday
• Famvir500mgCd
• Valtrex1gramCd
IRITIS/AnteriorUveiCs
• Women>Men• Unilateralpain,circumcornealinjecCon,photophobia,decreasedVA
• C/FinAC,KPoncornealendothelium,posteriorsynechiae,decreased/increasedIOP
• TraumaCc,postoperaCve,idiopathic,systemicassociaCons
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AnteriorUveiCs:ECologies
• Idiopathic:mostcommon• Exogenous– InfecCons– Non‐infecCous
Surgical TraumaCc Chemical Allergic
• Endogenous:immunologicalreacCon
UveiCsECology
• HLA‐B27relatedacuteanterioruveiCsisthemostcommoncause– 15.2ofalluveiCscases
• IntermediateuveiCsaccountsfor7.9%ofallcases
• ToxoplasmosisofthemostcommontypeofposterioruveiCs– 4.6%ofallcases
AcuteAnteriorUveiCs
ClinicalSigns• Redness/ciliaryinjecCon
• ACreacCon– Cells&Flare
• KP’s• Bandkeratopathy• Irisnodules(Koeppe,Busacca)
AcuteAnteriorUveiCs
ClinicalSigns• Synechia– Peripheralanterior– Posterior
• IOP↑or↓• Cataract• Vitreouscells• ReCnal/choroidallesion
UveiCsClassificaCon
• Granulomatous– Indicatesdiseasemaybesystemicinnature– Muhon‐fatKP– Koeppenodules,Busaccanodules– Cellandflare– Posteriorsynechia
• GranulomatousdiseasemaypresentinanongranulomatousmannerwithfineKPandnoirisnodules‐nongranulomatousdiseasewillnotpresentinagranulomatousfashion
AcuteAnteriorUveiCs
• VariablepresentaCon• Granulomatous– Insidiousonset– Eyemorewhite
• Nongranulomatous– Acuteonset– Redeye– Nonodules– Moresymptoms
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TreatmentofUveiCs
• Dependsofseverity• TypicallyRxtopicalsteroids
• Cycloplegics• MayneedIOPloweringmedicaCons
TreatmentforMild/ModerateAnteriorUveiCs
• OpConaldependingonsymptoms• Prednisoloneacetate,1%qid• CycloplegiadependingonSx• Oralaspirinoribuprofen(2tabq4h)• BetablockersifIOPelevated• Re‐evaluate3‐7days– Orprnifworsening
TreatmentforSevereAnteriorUveiCs
• Prednisoloneacetate,1%q2toq3h• Durezolq2htoq3h–morepotent
• Homatropine5%orScopolamine0.25%bid
• Oralaspirinoribuprofen(2tabq4h)• Darkglasses• BetablockersifIOPelevated• Re‐evaluate1‐2days
HowLongtoUseMedicaCons?
• DependsontheiniCalseverity:– IfA/CreacConisimproving,medicaConcanbeconCnuedorreduced
• D/ccycloplegicswhencellularreacConissubsidingandflareisabsent
• ConCnuesteroidsunClcellularreacConisminimalorabsent
• Steroidshouldbetaperedslowly–onedropperweek
HowLongtoUseMedicaCons?
• MostanterioruveiCswillclearwithin6weeks• ChronicanterioruveiCsmayrequirelong‐termuseoflow‐dosetopicalstreroid
• Ifptisasteroidresponder,addbeta‐blocker(unlesscontra‐indicated)
• Follow‐upshouldbeevery1‐6monthsdependingonfindings
Whendoyoudoamedicalworkup?
• 1stCme:unilateral,nongranulomatousuveiCsandnoothersignificantclinicalfinding,
laboratorywork‐upisnotindicated• Bilateralgranulomatous,oranyrecurrentuveiCs(otherwiseunremarkableexam)work‐upshouldbeconducted
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MANAGEMENT
• Treataggressivelywithq1‐2hoursteroidthentaper• CycloplegictoreducesynechiaeformaConanddecreasepain
• TreatIOPwithnon‐prostaglandinagentsprn• Referforbloodwork/x‐raysifrepeatepisodesorbilateral
• Referifunresponsivetotopicaltherapy– MayneedsubconjuncCvalsteroidinjecCon– MayneedMedroldosepack
• ReferifposterioruveiCspresent
LUPUS
• Systemiclupuserythematosus(SLE)• Chronic,autoimmuneinflammatorydisorderofconnecCveCssue
• Joints,skin,kidneys,heart,bloodcells,lungs• 9:1Women:Men• BlacksandAsiansmorecommonlyaffected• Malarrash“buherflyrash”onface,jointpain,skinlesions,faCgue,mouthulcers
• Dryeye,iriCs,opCcneuriCs
SARCOID
• Chronic,autoimmuneinflammatorydisordercharacterizedbyinflammatorygranulomas
• Lungs,lymphnodes,eyes,skin• Women>Men• 2:1BlackWomen:BlackMen• Persistantcough,shortnessofbreath,weightloss,jointpain,redskinbumps
• Dryeye,iriCs
RHEUMATOIDARTHRITIS
• InflammatoryformofarthriCsthatcausesjointpainanddamage
• Damagestheliningofthejoints(synovium)
• 3:1Women:Men
• Jointpain,swelling,morningsCffness,faCgue
• Dryeye(Sjogren’s),iriCs
HLA‐B27AssociatedAnteriorUveiCs
• CanoccuraloneasadisCnctenCty• Acute• Unilateral• Pain,redness• 1to2dayprodrome
• Men>women
• Nongranulomatous
HLA‐B27AssociatedAnteriorUveiCs
• Recurrent• Oneeyethentheother• Abundantfibrin(noM&FKP)
• Posteriorsynechia• Maylast2‐3monthswithTx
• History:Backpain,Arthropathies,Bowldisease
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OtherDiseasesAssocwithHLA‐B27+UveiCs
• UlceraCveColiCs/Crohn’sDisease• AnkylosingSpondyliCs
ANKYLOSINGSPONDYLITIS
• ChronicinflammatoryarthriCs• Affectsthevertebralandsacroiliacjoints• Men>Women,16‐40yo,AmericanIndian
• LowerbackpainandsCffness• Stooping,restrictedrangeofmoCon,inflexiblespine
• IriCs
REITER’S
• AlsoknownasReacCvearthriCs• TriggeredbyaninfecCon,ogenurogenital• Ankles,knees,feetandhips• ArthriCs,urethriCs,conjuncCviCstriad• Increasedurgency,• 7:1Male:Female,15‐35yearsofage
• ConjuncCviCs,iriCs
PSORIATICARTHRITIS
• AutoimmunediseasecharacterizedbyinflammaConoftheskin(psoriasis)andjoints(arthriCs)
• ArthriCsfollowspsoriasisdiagnosis• Canalsoaffecteyes,skin,heartandkidneys• Women=Men
INFLAMMATORYLABS
• Lupus(ANA)• Sarcoid(ACE,if+runChestX‐ray)• RheumatoidarthriCs(RF,anC‐CCP)• AnkylosingspondyliCs(HLA‐B27,if+runsacroiliacspinalfilms)
• Reiter’s(HLA‐B27,jointx‐rays)• ParsplaniCs(HLA‐B27)• PsoriaCcarthriCs(ESR‐Sedrate)• Syphilis(RPR,FTA‐ABS)• CBC
IndicaConsforCulturing
• Involvingthevisualaxis• Size>3mm• SignificantCssuedestrucConorlocalizedcornealectasia
• MulCplelesions
• SuspectFungioracanthamoeba
• OneeyedpaCent• SuspectedinfecConinthepresenceof:– Filteringbleb– PenetraCngtrauma
– Woundleak– Exposedbuckleorseton
• ImmunocompromisedpaCent
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PredicCngVisualLossagerHealingofBacterialCornealInfecCon
1. Cells>1+intheanteriorchamber(10cellsorgreaterin1‐mmbeam)
2. Denseinfiltrate>2mminsizeingreatestlineardimension
3. Edgeofinfiltrate<3mmfromthecenterofcornea
1‐2‐3Rule
Vital,MC,BellosoM,PragerTCetal.Cornea.26(1):16‐20,January2007.
October2011
CorCcosteroidsforBacterialKeraCCsTheSteroidsforCornealUlcersTrial(SCUT)
• 9/1/2006–2/22/2010,1769paCentswerescreenedforthetrialand500paCentswereenrolled
• Nosignificantdifferencewasobservedinthe3‐monthBSCVA,Cmetore‐epithelializaCon,orcornealperforaCon
• AsignificanteffectofcorCcosteroidswasobservedinsub‐groupsofbaselineBSCVA,andulcerlocaCon– At3months,paCentswithvisionofcounCngfingersorworseatbaselinehad0.17logMARbehervisualacuitywithcorCcosteroids(95%CI,−0.31to−0.02;P=.03)comparedwithplacebo,– PaCentswithulcersthatwerecompletelycentralatbaselinehad0.20logMARbehervisualacuitywithcorCcosteroids
Guidelines:TheUseofTopicalSteroidsinBacterialKeraCCs
PrinciplesforsuccessfuluseofcorCcosteroids:• Scrapingsforstainandculture• UseofadequatelydosedbactericidalanCbioCcs• DelayiniCaConofsteroidsunClaclearlybeneficialeffecttoanCbioCchasbeendetermined
• ConCnueconcurrentuseofanCbioCcwithsteroids
• DelayuseofsteroidsifcausaCveorganismisnotidenCfied
ACANTHAMEOBA
• Contactlenswearers• Irregularepithelium
• Lotsofpain• NoimprovementwithanCbioCcs/anCvirals
EARLYACANTHAMOEBAPRESENTATION
• ContactlenspaCentpresentswithirregular,disruptedepithelium– Punctateerosions– PseudodendriteformaCon– Smallinfiltrates
– Ogenmistakenforherpessimplex
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EARLYACANTHAMOEBAPRESENTATION
• PainisdisproporConatetoclinicalpresentaCon– Subepithelialinfiltratesalongradialcornealnerves– RadialperineuriCs
LATEACANTHAMOEBAINFECTION
• Delayeddiagnosisistypical,avg.6weeks• Ringinfiltrate– Seeninonly6%ofearlycases– Seeninonly16%oflatecases
• Hypopyon• Progressivecornealthinning• RiskofperforaCon
VIRALCONJUNCTIVITIS
• VirusiniCatesinflammatoryresponse– Redness– Pain– Follicular/papillarypalpebralconjuncCvalresponse
• Watery,mucousdischarge
• Subepithelialinfiltrates• Pseudomembranes
AllergicKeratoconjuncCviCs
• Seasonalallergies• Vernal• Atopic• GPC
VernalKeratoconjuncCviCs(VKC)
• Chronicimmunemediatedinflammatorydisease
• Seasonalrecurrences(spring/summer)
• Teens,earlyadulthood• Historyofatopy
VernalKeratoconjuncCviCs
• Thickropydischarge• “Cobblestone”Papillae• LimbalchangesincludinggelaCnousthickening,
• Trantasdots• Shieldulcers(sterile)
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ShieldUlcers
• MorecommonlyseeninVernal• Exactcauseisunknown• Mechanical• EnzymereleaseofinflammatorymediatorsresulCngcornealdecompensaConanddestrucCon
• Canresultinscarringandvisionloss• Treatment:TopicalSteroidsand/orCyclosporineA,lubricants
AtopicKeratoconjuncCviCs
• IgE‐mediatedallergickeratoconjuncCviCs• H/OatopiceczematoiddermaCCs
• OlderpaCents20to60’s(vernal<20)• Slightlyredlidmargins
• Papillaeupperandlowertarsus– smalltomedium
• CornealneovascularizaConandscarring
AtopicLidInvolvement• Ophthalmicbrandtopicalsteroidointment:FML,Dexamethasone
• AristocortAcream
• Triamcinolone0.1%ointment
• Calcineurininhibitors(immunosuppressive)– Protopic(Tacrolimus):0.1or0.03%– Elidel(Pimecromilus1%)
• Coolcompresses
• SystemicBenadrylPOOT