eMedicine Specialties > Ophthalmology > Conjunctiva
Conjunctivitis, Giant Papillary: Treatment & Medication
Updated: Feb 10, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- If severe giant papillary conjunctivitis (GPC) develops, patients who wear contact lenses (CL) 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.20 However, combination mast cell stabilizers and antihistamine ophthalmic medications sometimes suffice without exposing the patient to the known risks of topical steroids (eg increased risk of glaucoma, cataracts, and decreased resistance to microbial infection). Most patients do not require more aggressive treatment.
- 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 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 and 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.21 This measure is unnecessary for patients who use daily disposable hydrogel contact lenses.
- Topical mast cell stabilizers and antihistamine combination solutions (eg, olopatadine, Elestat) may offer a pharmacological adjunctive treatment for these patients, although contact lens cessation is the most effective initial 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 contact lenses.
- 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.
- The lids of some patients return to normal appearance, whereas 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 giant papillary conjunctivitis (GPC) cannot or will not discontinue wearing contact lenses (CLs). 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.22
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.20
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) 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 (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
None known
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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 PO 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
None reported
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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 has been specifically shown to be effective in giant papillary conjunctivitis.
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
None reported
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
None reported
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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
None reported
Documented hypersensitivity
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 |
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Further Reading
Keywords
giant papillary conjunctivitis, GPC, contact lens giant papillary conjunctivitis, contact lens wear, contact lenses, hydrogel contact lenses, soft contact lenses, allergic conjunctivitis, vernal keratoconjunctivitis, symptoms
