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Conjunctivitis, Giant Papillary
Updated: Nov 2, 2007
Introduction
Background
Giant papillary conjunctivitis (GPC) is a common complication of contact lens (CL) wear. Spring first described GPC in association with CL use in 1974.1 Papillary changes can occur in the ocular tarsal palpebral conjunctivae as part of an immunoglobulin E (IgE)-mediated hypersensitivity reaction.
Prior to the popularization of hydrogel (soft) CLs in the past 4 decades, this reaction primarily was seen as allergic conjunctivitis (AC) or vernal keratoconjunctivitis (VKC). VKC is a seasonal atopic disease in young people (more common in boys), which occasionally becomes severe and leads to shield corneal ulcers and other complications. GPC related to CL wear never leads to the severe tissue morbidity of VKC.
Papillary changes in the tarsal conjunctiva have been associated with the use of all types of CLs (eg, rigid, hydrogel, scleral, prosthetic). Similar reactions have been noted with ocular prostheses, extruding scleral buckles, exposed ocular sutures, and even elevated corneal scars. When the small papillae coalesce with expanding internal collections of inflammatory cells and when the lesions reach a diameter of at least 1.0 mm, the condition is referred to as giant.
Pathophysiology
The antigens responsible for GPC have not been identified. From circumstantial evidence, the initiating event is believed to be mechanical irritation of the tarsal conjunctiva of the upper lids, followed by histologic changes in the tissue (mast cell degranulation and typical secondary inflammatory cascade).
Frequency
United States
Hydrogel CLs appear to result in an overall prevalence of GPC of approximately 20%. Silicone hydrogel CLs may be more prone to GPC development, perhaps because of their mechanical stiffness or their higher propensity for deposition. Heat sterilization, poor cleaning, rough CL edges, and extended wearing times favor development of GPC. Increased frequency of CL replacement (especially daily disposables), rigorous cleaning (particularly with enzymes), peroxide disinfection, and decreased wear times appear to reduce the prevalence of GPC among users of hydrogel CLs. Rigid CL wear appears to result in a prevalence of approximately 5%; increased enzyme cleaning appears prophylactic.
International
No differences are reported; the prevalence is similar to that in the United States.
Mortality/Morbidity
GPC is not associated with any mortality.
- Ptosis of the upper lids and decreased CL tolerance can occur.
- GPC has been a common cause for permanent CL intolerance.
Race
No racial differences have been described.
Sex
Both sexes develop GPC.
Age
GPC can be more aggressive in children who wear CLs.
Clinical
History
Patients often report decreasing CL tolerance and mechanical stability, ocular itching, and mucous discharge in the tears, as well as blurred vision and conjunctival injection.
Physical
- Clinicians commonly note protein-laden CLs. Also, CLs appear to ride more under the upper lids than expected.
- With eversion of the lids, inflammation of the vasculature (hyperemia) and papillary hypertrophy are noted.
- Mucous strands are seen both in the tears and between the papillae.
- Papillae can range from small uniform lesions (uniform cobblestone appearance [UCA]) to irregular changes (nonuniform cobblestone appearance [NUCA]) to clusters of giant lesions with whitish centers that can ulcerate and stain with sodium fluorescein dye.
- Originally, the papillae of the upper tarsal conjunctiva were thought to have to be at least 1 mm to diagnose GPC.
- Today, the clinical sign is generally accepted as follows: the papillae are at least 0.3 mm diameter on the upper palpebral conjunctiva in association with the classic symptoms.
- GPC that is associated with hydrogel CLs appears more commonly at the fold of the everted lid, spreading over the entire tarsal conjunctival surface.
- GPC that is associated with rigid CL wear shows an opposite pattern, corresponding to the position of the CL edge meeting the lid tissues. This is evidence for the mechanical etiological hypothesis.
Causes
All forms of ocular prostheses, including rigid and hydrogel CLs, artificial glass eyes, extruding scleral buckles, exposed portions of sutures, filters, and knots (even corneal scars), can cause GPC.
- Other diagnostic considerations
- Distinguish from other diseases that cause conjunctivitis and ocular itching/mucus - Typically ocular allergies (hay fever conjunctivitis) but also viral and bacterial conjunctivitis and blepharitis
- Distinguish from other diseases that cause papillary changes in the tarsal conjunctiva of the lids, especially vernal and atopic conjunctivitis
- Distinguish from other giant papillary forming disorders by the creamy white appearance of the giant papillae center/top (a clinical pearl)
- Distinguish from other diseases that cause follicular changes, which can easily be confused with papillary changes, in the palpebral conjunctivae of the lids - Viral conjunctivitis (adenovirus and herpes); chlamydial infections; and Gel-Coombs type IV hypersensitivity and toxic reactions, particularly to CL solutions
- Distinguish from other causes of CL intolerance, such as poor fit, dry eyes, and blepharitis
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References
Spring TF. Reaction to hydrophilic lenses. Med J Aust. Mar 23 1974;1(12):449-50. [Medline].
Aakre BM, Ystenaes AE, Doughty MJ, Austrheim Ø, Westerfjell B, Lie MT. A 6-month follow-up of successful refits from daily disposable soft contact lenses to continuous wear of high-Dk silicone-hydrogel lenses. Ophthalmic Physiol Opt. Mar 2004;24(2):130-41. [Medline].
Allansmith MR, Korb DR, Greiner JV. Giant papillary conjunctivitis induced by hard or soft contact lens wear: quantitative histology. Ophthalmology. Aug 1978;85(8):766-78. [Medline].
Allansmith MR, Korb DR, Greiner JV, Henriquez AS, Simon MA, Finnemore VM. Giant papillary conjunctivitis in contact lens wearers. Am J Ophthalmol. May 1977;83(5):697-708. [Medline].
Chang WJ, Tse DT, Rosa RH, Huang A, Johnson TE, Schiffman J. Conjunctival cytology features of giant papillary conjunctivitis associated with ocular prostheses. Ophthal Plast Reconstr Surg. Jan 2005;21(1):39-45. [Medline].
Donshik PC, Ballow M. Tear immunoglobulins in giant papillary conjunctivitis induced by contact lenses. Am J Ophthalmol. Oct 1983;96(4):460-6. [Medline].
Donshik PC, Ballow M, Luistro A, Samartino L. Treatment of contact lens-induced giant papillary conjunctivitis. CLAO J. Oct-Dec 1984;10(4):346-50. [Medline].
Korb DR, Greiner JV, Finnemore VM, Allansmith MR. Treatment of contact lenses with papain. Increase in wearing time in keratoconic patients with papillary conjunctivitis. Arch Ophthalmol. Jan 1983;101(1):48-50. [Medline].
Further Reading
Keywords
giant papillary conjunctivitis, GPC, CL GPC, contact lens giant papillary conjunctivitis, contact lens wear, contact lenses, hydrogel contact lenses, soft contact lenses, allergic conjunctivitis, AC, vernal keratoconjunctivitis, VKC, CLPC
