Approach Considerations
Combination mast cell stabilizers/antihistamines and modification of contact lens type/hygiene are the primary treatments for giant papillary conjunctivitis (GPC). Topical steroids can be used in the treatment of severe GPC but are not always necessary, especially in mild cases. Patients should be refitted into more disposable contact lenses, ideally one-day disposable contact lenses. If one-day disposable contact lenses are not available, then improved contact lens hygiene with hydrogen peroxide based cleaning solutions and more disposable contact lenses will help prevent future occurances.
Lens Use and Pharmacologic Management
For any degree of GPC, the contact lens modality, type, and cleaning need to be addressed. Refitting patients into one-day disposable contact lenses is most ideal for patients who choose to continue contact lens wear. If daily disposable contact lenses are not available in the patients’ prescription parameters, wearers of hydrogel contact lenses should use peroxide disinfecting solutions with their frequently disposable contact lenses.
In patients who cannot be refit into one-day disposable contact lenses and cannot use hydrogen peroxide–based cleaning solutions, reemphasize contact lens–cleaning techniques, especially rubbing with "no-rub"–labeled multipurpose contact lens solutions.
For mild to moderate GPC, patients can often continue contact lens wear but with a change in contact lens design and materials, care regimens, and education.
Wearers of rigid contact lenses should use some form of enzyme cleaning, at least twice per week or as frequently as every night. [30] This measure, of course, is unnecessary for patients who use daily disposable hydrogel contact lenses.
If severe GPC develops in patients who wear contact lenses purely for cosmesis, they 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. [31, 32]
Short-term low-potency topical corticosteroid used 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. [33] 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 herpes virus infection recurs during topical corticosteroid treatment. Increased concerns exist regarding de novo fungal and other viral infections and potentiating bacterial infections. Contact lenses should not be worn while the patient is being treated with steroids.
Although contact lens cessation is the most effective initial treatment for GPC, some patients may still need to wear contact lenses during treatment (eg, patients with keratoconus). Topical antihistamine/mast cell stabilizer combination solutions are the primary choice of treatment because of the drug efficacy and low frequency of dosing to improve patient compliance.
Topical mast cell stabilizers (eg, sodium cromolyn 0.4%) and antihistamines also may be used.
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) have limited immediate hypersensitivity responses but can be effective in patients with GPC. NSAIDs rarely have 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 adverse effects of steroids in the treatment of GPC. More studies need to be conducted for this recent development. [34]
Cool compresses can be added to improve symptoms.
Refractive Surgery
Given the efficacy and safety of most modern keratorefractive procedures (eg, LASIK), refractive surgery may be a good alternative for patients who refuse conservative management by enabling them to avoid contact lenses.
Prevention
Increased frequency of contact lens replacement (especially one-day disposables), rigorous cleaning, hydrogen peroxide disinfection, decreased wear times, and appropriate/timely professional supervision appear to reduce the prevalence of GPC among users of hydrogel contact lenses.
Increased enzyme cleaning also appears to be prophylactic for wearers of rigid lenses. [2, 3, 4]
Long-Term Monitoring
Approximately 80% of patients who develop GPC with contact lens use can return to comfortable contact lens wear with appropriate treatment. [14] Frequent encouragement by the clinician can be essential, because the symptoms may take some time to subside.
The patient should be frequently monitored while GPC is active, perhaps every few weeks to few months.
Once GPC is successfully 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 decreased mucus in the tears.
Surgical Care
Surgical care is extremely rare, although there have been limited cases when surgery is used when medical therapy was not effective. GPC is surgically removed and a free autologous conjunctival graft is used to cover the tarsal conjunctival defect. [34]
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Very large papillae in the everted upper lid of a patient who wears hydrogel (soft) contact lenses.
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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).
