Giant Papillary Conjunctivitis Medication

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.^[27]

The most commonly used topical medications are combination, dual-acting H1 receptor antagonists and inhibitors of histamine release from mast cells (ie, olopatadine hydrochloride, ketotifen fumarate). Topical mast cell stabilizers, NSAIDs, and antihistamines are also used. Steroids can be useful for severe cases.^{[24, 25]}

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, 1 gtt just prior to contact lens wear, 1 gtt immediately upon contact lens removal, 1 gtt hs). 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.

Class Summary

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.^[27]

Nedocromil ophthalmic (Alocril)

Nedocromil inhibits the release of various inflammatory cell mediators (mast cell stabilizer).

Pemirolast ophthalmic (Alamast)

This agent is a mast cell stabilizer that inhibits the antigen-induced release of inflammatory mediators (eg, histamine, leukotriene C4, D4, E4) from human mast cells.

Cromolyn (Opticrom, Crolom)

Cromolyn inhibits the release of various inflammatory cell mediators (mast cell stabilizer). It is a first-generation mast cell stabilizer.

Class Summary

These agents are used for the temporary relief of the signs and symptoms (itching) of allergic conjunctivitis.

Emedastine difumarate (Emadine)

Emedastine difumarate is a relatively selective H1 receptor antagonist that appears to be devoid of effects on adrenergic, dopaminergic, and serotonin receptors.

Azelastine ophthalmic (Optivar)

Azelastine ophthalmic competes with H1-receptor sites on effector cells and inhibits the release of histamine and other mediators involved in the allergic response.

Class Summary

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.

Loteprednol etabonate (Lotemax)

Placebo-controlled studies have demonstrated that Lotemax reduces the signs and symptoms of giant papillary conjunctivitis after 1 week of treatment, continuing for up to 6 weeks while on treatment.

Class Summary

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.

Olopatadine (Patanol)

This is a relatively selective H1 receptor antagonist and inhibitor of histamine release from mast cells.

Ketotifen (Zaditor, Alaway)

Ketotifen is a relatively selective H1 receptor antagonist and inhibitor of histamine release from mast cells. This is an over-the-counter product.

Epinastine (Elestat)

Epinastine is a direct histamine-1 receptor antagonist. It is indicated for symptoms due to allergic conjunctivitis.

Alcaftadine ophthalmic (Lastacaft)

Alcaftadine is an H1-receptor antagonist. It inhibits histamine release from mast cells, decreases chemotaxis, and inhibits eosinophil activation. It is available as a 0.25% ophthalmic solution.

Class Summary

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.

Ketorolac ophthalmic (Acular)

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.

Diclofenac (Voltaren Ophthalmic)

Diclofenac is one of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. It is believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins.

It may facilitate the outflow of aqueous humor and decrease vascular permeability. Any equivalent topical NSAID also can be used.

Flurbiprofen (Ocufen)

Flurbiprofen facilitates the outflow of aqueous humor by inhibiting prostaglandin synthesis, causing a subsequent decrease in vascular permeability.