Giant Papillary Conjunctivitis

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

Background

Giant papillary conjunctivitis is a common complication of contact lens wear. It has also been called contact lens–induced papillary conjunctivitis (CLPC). Spring first described giant papillary conjunctivitis in association with contact lens use, [1, 2, 3] which is hypersensitivity-related inflammation of the ocular tarsal palpebral conjunctivae. [4] (See Etiology, History, and Physical Examination.)

Prior to the popularization of hydrogel (soft) contact lenses over the past 4 decades, such reactions were primarily seen as immunoglobulin E (IgE)–mediated ocular allergies: allergic conjunctivitis (AC) or vernal keratoconjunctivitis (VKC). VKC is a seasonal, atopic disease in young people (more common in boys) that occasionally becomes severe and leads to shield corneal ulcers and other complications. Giant papillary conjunctivitis related to contact lens wear, however, never leads to the severe tissue morbidity of VKC. (See Prognosis.)

Giant papillary conjunctivitis symptoms and signs, such as papillary changes in the tarsal conjunctiva, have been associated with the use of all types of contact lenses (eg, rigid, hydrogel, silicone hydrogel, piggyback, [5] scleral, prosthetic). (See History and Physical Examination.)

Similar reactions have been noted with ocular prostheses, extruding scleral buckles, exposed ocular sutures, and even elevated corneal scars. The initially small papillae eventually coalesce with expanding internal collections of inflammatory cells. When the lesions reach a diameter of more than 0.3 mm, often approaching or exceeding 1 mm, the condition is referred to as giant papillary conjunctivitis. Images of eyelid papillae appear below. (See Etiology.)

Very large papillae in the everted upper lid of a Very large papillae in the everted upper lid of a patient who wears hydrogel (soft) contact lenses.
Giant papillary conjunctivitis (GPC) response (sli 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).

Because of the high prevalence of giant papillary conjunctivitis in contact lens wearers, every patient who wears contact lenses should be considered as a potential patient with giant papillary conjunctivitis.

See the following for more information:

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Etiology

The antigen(s) responsible for giant papillary conjunctivitis have yet to be identified. From circumstantial evidence, the initiating event is believed to be mechanical irritation and/or antigenic stimulus of the tarsal conjunctiva of the upper lids, perhaps by a contact lens surface or edge (rigid or flexible) or deposit, followed by histologic changes in the tissue (mast cell degranulation and typical secondary inflammatory cascade). This leads to conjunctivitis and further tissue changes and increasing inflammatory markers in the tears.

Debris on the surface of contact lenses may be a cause as well as a result, leading to a spiral of inflammation that causes more lens deposits to form, leading to additional inflammation. [1, 2, 3]

All forms of ocular prostheses, including rigid and hydrogel contact lenses and artificial glass eyes, as well as extruding scleral buckles, exposed portions of sutures, filters, knots, and even corneal scars, can cause giant papillary conjunctivitis. [6]

Heat sterilization, poor cleaning, thick or rough contact lens edges, and extended wearing times favor the development of giant papillary conjunctivitis.

First-generation silicone hydrogel contact lenses may be more prone to giant papillary conjunctivitis development, perhaps because of their mechanical stiffness or their higher propensity for lipid deposition. Silicone hydrogel lenses tend to induce more local giant papillary conjunctivitis (similar to the changes seen with rigid lenses), whereas hydrogel lenses tend to induce more generalized giant papillary conjunctivitis reactions in the palpebral conjunctiva. [7]

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Epidemiology

In the United States, hydrogel contact lenses appear to result in an overall prevalence of giant papillary conjunctivitis of approximately 20%, whereas rigid contact lens wear appears to result in a prevalence of approximately 5%. One study found that 85% of 221 patients with giant papillary conjunctivitis had been wearing soft (hydrogel) lenses, whereas only 15% used rigid lenses. [7] With an increased frequency of contact lens replacement from more than four weeks to less than four weeks, the incidence of giant papillary conjunctivitis has dropped from 36% to 4.5%.

The international prevalence of giant papillary conjunctivitis is similar to that in the United States.

Both sexes develop giant papillary conjunctivitis.

Giant papillary conjunctivitis can be more aggressive in children who wear contact lenses.

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Prognosis

The prognosis in giant papillary conjunctivitis is good. Approximately 80% of patients can return to comfortable contact lens wear with appropriate treatment. [8]

Ptosis of the upper lids and decreased contact lens tolerance can occur. Giant papillary conjunctivitis has been a common cause for temporary and permanent contact lens intolerance.

The lids of some patients return to normal appearance following the resolution of giant papillary conjunctivitis, whereas other lids retain small, white, capped scars of the giant papillary lesions for long periods, sometimes indefinitely.

Giant papillary conjunctivitis is not associated with mortality.

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Patient Education

Patients should be educated about appropriate contact lens cleaning and follow-up care. Patients should be advised to return for regular professional evaluations (perhaps once or twice a year if no other complications) and to make additional appointments if they experience any increasing ocular itching, mucous discharge, or dirty contact lenses.

Patients should also be educated about the chronic nature of this disease and its symptoms (eg, ocular itch, mucous discharge, contact lens intolerance) and should be counseled to present within a week of any relapsing symptoms.

For patient education information, see the Eye and Vision Center, as well as Pinkeye and Contact Lenses.

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