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Giant Papillary Conjunctivitis Treatment & Management

  • Author: Barry A Weissman, OD, PhD, FAAO; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jan 08, 2016
 

Approach Considerations

Topical steroids can be used in the treatment of giant papillary conjunctivitis but are not necessary, especially in mild cases. Contact lens hygiene is an important component in the disease’s deterrence.

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Lens Use and Pharmacologic Management

If severe giant papillary conjunctivitis develops, patients who wear contact lenses purely for cosmesis should discontinue contact lens wear for 2-4 weeks (the interval during which symptoms may begin to reverse and signs improve).

Steroids can be used in these cases.[23, 24] Short-term low-potency topical corticosteroid use concurrently with a combination mast cell stabilizer/antihistamine ophthalmic solution is a more effective treatment for papillary conjunctivitis than mast cell stabilizer/antihistamine monotherapy and topical steroid monotherapy alone.[24] However, combination mast cell stabilizers and antihistamine ophthalmic medications generally suffice without exposing the patient to the known risks of topical steroids. Most patients do not require more aggressive treatment.

Long-term use of topical steroid drops, especially for more than a few weeks, is associated with glaucoma, cataracts, and decreased ocular resistance to infection. Topical steroid use is a particular concern in patients with a history of herpetic eye disease. Although topical corticosteroid use is not associated with induction or facilitation of viral recurrence, a fulminant infection could occur if the herpes virus recurs during topical corticosteroid treatment. Increased concerns exist regarding de novo fungal and other viral infections and potentiating bacterial infections.

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) have limited immediate hypersensitivity responses but can be effective with giant papillary conjunctivitis. NSAIDs have rarely been associated with corneal melting.

More recently, immunomodulatory drugs such as tacrolimus 0.05% have been found comparable to fluorometholone 0.1% in efficacy without the side effects of steroids in the treatment of giant papillary conjunctivitis. More studies need to be conducted for this recent development.[25, 26]

Contact lens use can often resume after improvement in symptoms, but refit wearers of hydrogel contact lenses into disposable contact lenses, especially daily disposable contact lenses.

If daily disposable contact lenses are not available, wearers of hydrogel contact lenses should use peroxide disinfecting solutions with their frequently disposable contact lenses.

Reemphasize contact lens cleaning techniques, especially rubbing with "no-rub"–labeled contact lens solutions; also, educate patients about the nature of this allergic disease.

For mild to moderate giant papillary conjunctivitis, patients can often continue contact lens wear but with the same change in contact lens design and materials, care regimens, and education.

Wearers of rigid and hydrogel contact lenses should use some form of enzyme cleaning, at least twice per week or as frequently as every night.[27] This measure, of course, is unnecessary for patients who use daily disposable hydrogel contact lenses.

Topical mast cell stabilizers (eg, sodium cromolyn 0.4%) and antihistamine combination solutions (eg, olopatadine, Elestat) may offer a pharmacologic adjunctive treatment for these patients, although contact lens cessation is the most effective initial treatment.

Topical steroid and antihistamines may be used synergistically.[24]

Cool compresses can be added to improve symptoms.

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Refractive Surgery

Considering the efficacy and safety of most modern keratorefractive procedures (eg, LASIK), patients who refuse conservative management may consider refractive surgery. This treatment may enable them to avoid contact lenses.

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Prevention

Increased frequency of contact lens replacement (especially daily disposables), rigorous cleaning (particularly with enzymes), peroxide disinfection, decreased wear times, and appropriate/timely professional supervision appear to reduce the prevalence of giant papillary conjunctivitis among users of hydrogel contact lenses.

Increased enzyme cleaning also appears to be prophylactic for wearers of rigid lenses.[1, 2, 3]

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Long-Term Monitoring

Approximately 80% of patients who develop giant papillary conjunctivitis (GPC) with contact lens use can return to comfortable contact lens wear with appropriate treatment.[8] Frequent encouragement by the clinician can be essential, because the symptoms may take a while to subside.

The patient should be frequently monitored while giant papillary conjunctivitis is active, perhaps every few weeks to few months.

Once giant papillary conjunctivitis successfully is managed, patients should receive follow-up care as indicated by other aspects of their ophthalmic and medical situation.

Symptoms may be more important than signs.

Therapeutic effect is evidenced by the subjective return of contact lens tolerance, suppression of ocular itching, decreased objective hyperemia of the tarsal conjunctivae, decreased inflammation of the giant papillae, and lessened mucus in the tears.

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Complications

GPC can lead to lid ptosis.

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Contributor Information and Disclosures
Author

Barry A Weissman, OD, PhD, FAAO Professor of Optometry, Southern California College of Optometry; Professor Emeritus of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, International Society for Contact Lens Research

Disclosure: Nothing to disclose.

Coauthor(s)

Karen K Yeung, OD, FAAO Senior Optometrist, Arthur Ashe Student Health and Wellness Center, University of California, Los Angeles

Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References
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Very large papillae in the everted upper lid of a patient who wears hydrogel (soft) contact lenses.
Giant papillary conjunctivitis (GPC) response (slightly out of focus) seen in the upper lid of a young patient recovering from cataract extraction with an exposed suture barb (in focus).
 
 
 
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