Giant Papillary Conjunctivitis

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Giant papillary conjunctivitis (GPC), also called contact lens–induced papillary conjunctivitis (CLPC), is a common complication of contact lens wear. First described by Spring, [1, 2, 3, 4] GPC is characterized by hypersensitivity-related inflammation of the ocular tarsal palpebral conjunctivae. [5] It is associated with the use of all types of contact lenses (eg, rigid, hydrogel, silicone hydrogel, piggyback, [6] scleral, prosthetic), although similar reactions have been noted with ocular prostheses, extruding scleral buckles, exposed ocular sutures, and even elevated corneal scars.

GPC was once considered an allergic disease similar to other immunoglobulin E (IgE)–mediated ocular allergy such as allergic conjunctivitis and vernal keratoconjunctivitis because of the similar clinical symptoms seen in allergic diseases (eg, itchiness, tearing, mucous hyperproduction, increase in symptoms during allergy season). The mechanical irritation of contact lenses and sutures that causes GPC supports the classification of GPC into a group of nonallergic hypersensitivity disorders. [7]

Initially, small papillae coalesce with expanding internal collections of inflammatory cells. When the lesions reach diameters of more than 0.3 mm, often approaching or exceeding 1 mm, the condition is referred to as GPC. Images of eyelid papillae appear below.

Because of the high prevalence of GPC among contact lens wearers, GPC should be considered in every patient with characteristic symptoms who wears contact lenses.

See the following for more information:

The antigen(s) responsible for GPC 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 by a contact lens surface or edge (rigid or flexible) or deposit. Histologic changes in the tissue occur with mast cell degranulation and a secondary inflammatory cascade. This leads to conjunctivitis and further tissue changes with increasing inflammatory markers in the tears.

GPC can be caused by all forms of ocular prostheses, including rigid and hydrogel (soft) contact lenses, prosthetic eyes, extruding scleral buckles, exposed portions of sutures, filters, knots, and even corneal scars. [8] Heat sterilization, poor cleaning, thick or rough contact lens edges, and extended wearing times also predispose to the development of GPC.

Lipid and protein deposits from the tears, as well as debris coating the surface of contact lenses, may also lead to a spiral of inflammation. This, in turn, causes even more lens deposits to form, leading to additional inflammation. [1, 2, 3] The level of coating on the lenses varies among individuals and the polymer of the contact lenses.

High-water hydrogel (HEMA) contact lenses tend to coat more than lower-water HEMA contact lenses. Silicone contact lenses tend to accumulate more lipid deposits than HEMA lenses. First-generation silicone hydrogel contact lenses may be more prone to GPC development, perhaps because of their mechanical stiffness or their higher propensity for lipid deposition. Silicone hydrogel lenses tend to induce more local GPC (similar to the changes seen with rigid lenses), whereas hydrogel lenses tend to induce more generalized GPC reactions in the palpebral conjunctiva. [9]

In the United States, the prevalence of GPC is highest among wearers of hydrogel contact lenses—approximately 20%. Rigid gas-permeable contact lens wearers constitute approximately 5% of all cases. One study found that 85% of 221 patients with GPC had been wearing hydrogel lenses, whereas only 15% used rigid lenses. [10] With an increased frequency of contact lens replacement from more than four weeks to less than four weeks, the incidence of GPC has dropped from 36% to 4.5%. [11] This rate should drop even lower with the greater availability and popularity of one-day disposable contact lenses.

The international prevalence of GPC is similar to that in the United States.

Both sexes develop GPC.

GPC can be more aggressive in children who wear contact lenses.

The prognosis of GPC is good. Approximately 80% of patients can return to comfortable contact lens wear with appropriate treatment. [11]

GPC has been a common cause of temporary and permanent contact lens intolerance. It can also cause ptosis of the upper lids.

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

GPC is not associated with mortality.

Patients should be educated about appropriate contact lens cleaning and follow-up care. Regular professional evaluations (perhaps once or twice a year in the absence of other complications) and additional appointments are recommended if they experience any increasing ocular itching, mucous discharge, or dirty contact lenses.

Patients should also be educated about the chronic nature of GPC and its symptoms (eg, ocular itch, mucous discharge, contact lens intolerance). Patients 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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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.

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.

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, Sidney Kimmel 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, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, AAO, OMIC, Allergan; Avedro; Bio-Tissue; GSK, Novartis; Shire; Sun Ophthalmics; TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Avedro; Bio-Tissue; Shire.

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.

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