eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Giant Papillary: Treatment & Medication

Author: Barry A Weissman, OD, PhD, FAAO, Chief of Contact Lens Service, Professor, Department of Ophthalmology, Jules Stein Eye Institute, University of California at Los Angeles
Coauthor(s): Karen K Yeung, OD, FAAO, Director of Optometry, Arthur Ashe Student Health and Wellness Center, University of California at Los Angeles
Contributor Information and Disclosures

Updated: Nov 2, 2007

Treatment

Medical Care

  • For severe GPC, patients who wear CLs purely for cosmesis should discontinue CL wear for 2-4 weeks (the interval during which symptoms may begin to reverse and signs improve).  Steroids can be used for these cases.  Combination mast cell stabilizers and antihistamine ophthalmic medications can sometimes suffice. Most patients do not require more aggressive treatment.
  • For mild-to-moderate GPC or when CL wear is resumed after discontinuing CL wear in severe cases, refit patients into new CLs. Refit wearers of hydrogel CLs into disposable CLs, especially daily disposable CLs. If daily disposable CLs are not available, wearers of hydrogel CLs should use peroxide disinfecting solutions with their frequently disposable CLs. Reemphasize CL cleaning techniques, especially rubbing with "no-rub" labeled solutions; also educate patients about the nature of this allergic disease.  
  • Wearers of rigid and hydrogel CLs should use some form of enzyme cleaning, at least twice per week or as frequently as every night. This measure is unnecessary for patients who use daily disposable hydrogel CLs.
  • Topical mast cell stabilizers and antihistamine combination solutions (eg, olopatadine, Elestat) may offer a pharmacological alternative for these patients, although CL cessation is the most effective treatment.
  • Cool compresses can be added to improve symptoms.
  • Considering the efficacy and safety of most modern keratorefractive procedures (eg, LASIK), patients who refuse conservative management may consider refractive surgery to avoid CLs.
  • Symptoms may be more important than signs.
    • Therapeutic effect is evidenced by the subjective return of CL tolerance, suppression of ocular itching, decreased objective hyperemia of the tarsal conjunctivae, decreased inflammation of the giant papillae, and lessened mucus in the tears.
    • The lids of some patients return to normal appearance, while other lids retain small, white, capped scars of the giant papillary lesions for long periods of time, sometimes indefinitely.

Medication

Pharmacological management is a mildly to moderately effective, adjunctive treatment when patients with GPC cannot or will not discontinue wearing CLs. GPC 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.

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, nonsteroidal anti-inflammatory drugs (NSAIDs), and antihistamines are also used. Steroids can be useful for severe cases.

Topical ophthalmic medications should be used cautiously with CL wear, because these medications are commonly preserved with benzalkonium chloride (BAK). BAK is associated with corneal epithelial toxicity episodes (a greater concern with hydrogel CLs).

If medication must be administered concomitantly with hydrogel CLs, application should be restricted to a maximum of 3 times a day (ie, 1 gtt just prior to CL wear, 1 gtt immediately upon CL removal, 1 gtt hs).  Once-daily and twice-daily ophthalmic medications are now available (eg, Pataday, Zaditor) for increased patient compliance and convenience, especially for CL wearers. Patients should wait at least 10 minutes after medication instillation before CL insertion.

Mast cell stabilizers

GPC 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 (Alocril)

Inhibits release of various inflammatory cell mediators (mast cell stabilizer).

Adult

2% ophthalmic solution: 1-2 gtt OU bid

Pediatric

<3 years: Not established
>3 years: 1-2 gtt OU bid

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Common reactions may include burning, dry eye, foreign body sensation, headache, rhinitis, flu symptoms, respiratory symptoms, photophobia, unpleasant taste


Pemirolast (Alamast)

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

Adult

0.1% solution: 1 gtt OU qid for 1 mo, then bid prn

Pediatric

<3 years: Not established
>3 years: 1 gtt OU qid for up to 4 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For topical ophthalmic use only (not for injection or oral use); instruct patients who wear soft contact lenses and whose eyes are not red to wait >10 min, after applying drops, to insert contact lenses; adverse reactions include burning, dry eye, foreign body sensation, hyperemia, keratitis, lid edema, pruritus, headaches, cold syndrome, rhinitis, sinusitis


Cromolyn (Opticrom, Crolom)

Inhibits the release of various inflammatory cell mediators (mast cell stabilizer). First-generation mast cell stabilizer.

Adult

4% ophthalmic solution: 1 gtt OU 4-6 times/d

Pediatric

<4 years Not established
>4 years: 1 gtt OU 4-6 times/d

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Common reactions include burning, dry, puffy, watery, itchy eyes, chemosis, hyperemia, contact dermatitis

Antihistamines

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


Emedastine difumarate (Emadine)

Relatively selective H1 receptor antagonist that appears to be devoid of effects on adrenergic, dopaminergic, and serotonin receptors.

Adult

0.05% ophthalmic solution: 1 gtt OU up to qid

Pediatric

<3 years: Not established
>3 years: 1 gtt OU qid

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for injection or oral use; caution in breastfeeding (effects unknown)

Corticosteroids

These agents inhibit many aspects of the inflammatory response to inciting agents: edema, capillary dilation and proliferation, leukocyte migration, and fibroblast proliferation.


Loteprednol etabonate (Lotemax)

Placebo-controlled studies have demonstrated that Lotemax reduces signs and symptoms of GPC after 1 week of treatment, continuing for up to 6 wk while on treatment.

Adult

0.5% ophthalmic solution: 1-2 gtt OU qid or up to q1h depending upon severity of disease; monitor IOP if used greater than 10 d

Pediatric

Not established

Documented hypersensitivity; any corneal infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Shake bottle vigorously prior to use; adverse reactions include glaucoma, elevated IOP, secondary ocular infection, cataract formation, visual field defect, optic nerve damage, corneal perforation, blurred visual acuities, burning of eyes

Antihistamine/Mast Cell Stabilizer

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)

Relatively selective H1 receptor antagonist and inhibitor of histamine release from mast cells.

Adult

0.2% ophthalmic solution: 1 gtt OD/OS qd

Pediatric

<3 years: Not established
>3 years: 1 gtt OD/OS qd

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not for conjunctival injection; adverse reactions include burning or stinging, dry eye, foreign body sensation, hyperemia, keratitis, lid edema, pruritus, headaches, asthenia, cold syndrome, pharyngitis, rhinitis, sinusitis, and taste perversion


Ketotifen (Zaditor, Alaway)

Relative selective H1 receptor antagonist and inhibitor of histamine release from mast cells. OTC.

Adult

0.025% solution: 1 gtt OU bid

Pediatric

<3 years: Not established
>3 years: 1 gtt OU bid

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common reactions include conjunctival injection, headache, rhinitis, allergic reactions, burning/stinging, conjunctivitis, dry eyes, ocular discharge, ocular pain, ocular pruritus, keratitis, lacrimal problems, mydriasis, photophobia, rash, flu symptoms, and pharyngitis

Nonsteroidal Anti-inflammatory Drug (nsaid), 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.


Ketorolac ophthalmic (Acular)

Inhibits cyclooxygenase and lipoxygenase and reduces prostaglandin synthesis.

Adult

0.5% solution: 1 gtt OU qid for 1-2 wk, then prn

Pediatric

<3 years : Not established
>3 years: 1 gtt OU qid

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Perform ophthalmologic studies in patients who develop eye complaints during therapy; discontinue therapy if changes are noted; changes may include blurred or diminished vision, corneal deposits and retinal disturbances, scotomata, changes in color vision, and macular degeneration; common reactions include burning, stinging, hyperemia, corneal infiltrates, headache, ocular edema, ocular pain, allergic edema, iritis, keratitis, and ocular infection

More on Conjunctivitis, Giant Papillary

Overview: Conjunctivitis, Giant Papillary
Differential Diagnoses & Workup: Conjunctivitis, Giant Papillary
Treatment & Medication: Conjunctivitis, Giant Papillary
Follow-up: Conjunctivitis, Giant Papillary
Multimedia: Conjunctivitis, Giant Papillary
References
[ CLOSE WINDOW ]

References

  1. Spring TF. Reaction to hydrophilic lenses. Med J Aust. Mar 23 1974;1(12):449-50. [Medline].

  2. 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].

  3. 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].

  4. 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].

  5. 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].

  6. Donshik PC, Ballow M. Tear immunoglobulins in giant papillary conjunctivitis induced by contact lenses. Am J Ophthalmol. Oct 1983;96(4):460-6. [Medline].

  7. 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].

  8. 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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Barry A Weissman, OD, PhD, FAAO, Chief of Contact Lens Service, Professor, Department of Ophthalmology, Jules Stein Eye Institute, University of California at Los Angeles
Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Karen K Yeung, OD, FAAO, Director of Optometry, Arthur Ashe Student Health and Wellness Center, University of California at Los Angeles
Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry
Disclosure: Nothing to disclose.

Medical Editor

Anastasios J Kanellopoulos, MD, Assistant Program Director, Clinical Associate Professor, Department of Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, New York University
Anastasios J Kanellopoulos, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Eye Bank Association of America, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

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, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.