Giant Papillary Conjunctivitis

Giant papillary conjunctivitis (GPC) is an inflammatory reaction of the upper tarsal conjunctiva to chronic mechanical irritation and deposits.

Causes: soft contact lenses (about 5 to 10 percent of wearers, more with extended wear and infrequent replacement), rigid lenses, ocular prostheses, exposed sutures (after cataract or corneal surgery), scleral buckles, filtering bleb, and cyanoacrylate glue.

Mechanism: combination of mechanical trauma and immune response to protein deposits on the foreign material, with mast cell and eosinophil involvement.

Not a true IgE-mediated allergy; not related to atopy in many.

• Itching (especially after lens removal), mucus discharge, blurred vision due to lens coating, lens intolerance and excess lens movement.
• Giant papillae (over 0.3 to 1 mm) on the upper tarsal conjunctiva with a cobblestone appearance, tarsal hyperaemia and thickening.
• Mild ptosis, mucous strands in the morning.
• Cornea is usually clear; limbal changes are absent (unlike vernal disease).

• Clinical with lid eversion showing papillae; fluorescein staining highlights tops of papillae.
• Examine the lens surface for deposits and the edge for damage; review lens material, wear schedule, solution and cleaning habits.
• For prosthesis or suture related disease, locate the exposed foreign body.
• Differentiate from vernal and atopic keratoconjunctivitis (limbal involvement, age, atopy), and from infectious conjunctivitis.

• Remove the cause: stop lens wear for 2 to 4 weeks, remove or trim exposed sutures, polish or exchange the prosthesis.
• Contact lens modification on return: switch to daily disposable lenses (best), reduce wearing time, use silicone hydrogel with high oxygen permeability, use peroxide based or preservative free care systems, enzymatic cleaning, and replace the case regularly.
• Topical mast cell stabilisers or dual action agents: olopatadine 0.1 percent twice daily, ketotifen 0.025 percent twice daily, lodoxamide 0.1 percent four times daily, for 4 to 8 weeks.
• Short course topical steroid (loteprednol 0.5 percent four times daily for 1 to 2 weeks) for severe disease.
• Preservative free lubricants and lid hygiene.
• Persistent: change to a rigid gas permeable lens or use spectacles; some patients cannot continue lens wear.