Giant Papillary Conjunctivitis Medication
- Author: Barry A Weissman, OD, PhD, FAAO; Chief Editor: Hampton Roy, Sr, MD more...
Pharmacologic management is a mildly to moderately effective, adjunctive treatment when patients with giant papillary conjunctivitis cannot or will not discontinue wearing contact lenses. Giant papillary conjunctivitis is a Gel-Coombs type 1 disease with degranulated conjunctival mast cells as the chief histologic feature; therefore, drugs that inhibit mast cell degranulation are effective.
Classic treatment usually includes the use of topical sodium cromolyn 0.4% ; this has been quite effective, although the most commonly used topical medications include combination, dual-acting H1 receptor antagonists and inhibitors of histamine release from mast cells (ie, olopatadine hydrochloride, ketotifen fumarate). These are more ideal for patient compliance because of their once-daily to twice-daily dosing.
Topical mast cell stabilizers, NSAIDs, and antihistamines are also used.
Steroids can be useful for severe cases.[23, 24] Mild steroids such as loteprednol would be more ideal than stronger steroids because of their low risks of inducing glaucoma. More recently, topical immunomodulators have been used with results as efficacious as those of corticosteroids but without the side effects of corticosteroids.[25, 26]
Topical ophthalmic medications should be used cautiously with contact lens wear, because these medications are commonly preserved with benzalkonium chloride (BAK). BAK is associated with corneal epithelial toxicity episodes (a greater concern with hydrogel contact lenses).
If medication must be administered concomitantly with hydrogel contact lenses, application should be restricted to a maximum of 3 times a day (ie, one drop just prior to contact lens wear, one drop immediately upon contact lens removal, and one drop before going to bed). Once-daily and twice-daily ophthalmic medications are now available (eg, Pataday, Zaditor, Elestat, Lastacaft) for increased patient compliance and convenience, especially for contact lens wearers. Patients should wait at least 10 minutes after medication instillation before contact lens insertion.
Mast cell stabilizers
Giant papillary conjunctivitis primarily appears to be a Gel-Coombs type 1 hypersensitivity disease. The primary pathological event is inappropriate degranulation of the conjunctival mast cells, which release many inflammatory mediators, such as histamine (resulting in itch). Pure mast cell stabilizers are indicated for long-term use after the acute phase of symptoms is abated.
Nedocromil inhibits the release of various inflammatory cell mediators (mast cell stabilizer).
Mast cell stabilizer; inhibits histamine and SRS-A from mast cell.
These agents are used for the temporary relief of the signs and symptoms (itching) of allergic conjunctivitis.
Emedastine difumarate is a relatively selective H1 receptor antagonist that appears to be devoid of effects on adrenergic, dopaminergic, and serotonin receptors.
Azelastine ophthalmic is a selective H1-receptor competitor with H1-receptor sites on effector cells. It also exhibits H2-blocking properties. It inhibits the release of histamine and other mediators involved in the allergic response.
Antihistamine (H1 antagonist); inhibits release of histamine from mast cells and histamine induced effects on conjunctival epithelial cells.
Epinastine is a direct histamine-1 receptor antagonist. It is indicated for symptoms due to allergic conjunctivitis.
These agents inhibit many aspects of the inflammatory response to inciting agents: edema, capillary dilation and proliferation, leukocyte migration, and fibroblast proliferation. Loteprednol has been specifically shown to be effective in giant papillary conjunctivitis with minimal to low risks of increasing ocular pressures.
Modulates the activity of prostaglandins and leukotrienes. Placebo-controlled studies have demonstrated that loteprednol reduces the signs and symptoms of giant papillary conjunctivitis after 1 week of treatment, continuing for up to 6 weeks while on treatment.
Antihistamines/Mast Cell Stabilizers
These agents are used to treat symptoms of itching and to prevent future symptoms by controlling the degranulation of mast cells. Mast cell-stabilizing medications/antihistamine combination drops are most likely to achieve the therapeutic effect with minimal complications.
Ketotifen is a relatively selective, non-competitive H1 receptor antagonist and inhibitor of histamine release from mast cells. This is an over-the-counter product.
Alcaftadine is an H1-receptor antagonist. It inhibits histamine release from mast cells, decreases chemotaxis, and inhibits eosinophil activation.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Ophthalmic
The inhibition of prostaglandin synthesis results in vasoconstriction, a decrease in vascular permeability, leukocytosis, and a decrease on intraocular pressure (IOP). However, these agents have no significant effect on IOP. Topical NSAIDs (especially a generic version of Voltarin) have been associated with rare corneal melting as a severe complication.
Bromfenac ophthalmic solution is an NSAID for ophthalmic use. It blocks prostaglandin synthesis by inhibiting cyclooxygenase 1 and 2. It is indicated to treat postoperative inflammation and reduce ocular pain after cataract extraction.
This agent inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclo-oxygenase, which results in decreased formation of prostaglandin precursors, which, in turn, results in reduced inflammation.
Immunomodulators are indicated for the treatment of severe and chronic ocular allergies without the side effects of corticosteroids.
Inhibits T-cell activation by binding to intracellular protein FKBP-12 and complexes with calcineurin dependent proteins.
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