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Giant papillary conjunctivitis

Giant papillary conjunctivitis
Literature review current through: Jan 2024.
This topic last updated: Jul 07, 2022.

INTRODUCTION — There are five main types of ocular allergy: seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and giant papillary conjunctivitis (GPC). GPC is a noninfectious inflammatory disorder that represents a reaction to lid movement over a foreign substance, such as contact lenses. It is characterized by foreign-body sensation on the upper tarsus, associated with formation of "giant" (>1 mm) papillae. GPC is reviewed here. Other contact lens-related complications are discussed separately. (See "Complications of contact lenses".)

VKC and AKC are chronic, bilateral, and severe forms of allergic inflammation affecting the ocular surface. These two relatively uncommon types of allergic eye disease can cause severe damage to the ocular surface, leading to corneal scarring and vision loss if not treated properly. VKC and AKC are discussed in detail separately. (See "Vernal keratoconjunctivitis" and "Atopic keratoconjunctivitis".)

SAC and PAC, the most common forms of ocular allergy, are also discussed separately. (See "Allergic conjunctivitis: Clinical manifestations and diagnosis".)

Toxic conjunctivitis is not allergic in nature, but it is frequently confused with allergic ocular disease. It develops with protracted use of topical medications, mostly due to preservatives. Toxic conjunctivitis is discussed separately. (See "Toxic conjunctivitis".)

EPIDEMIOLOGY — GPC is most commonly associated with wearing of contact lenses and is seen more frequently with soft, hydrogel lenses rather than rigid, gas-permeable (RGP) lenses [1-3]. Approximately 1 to 5 percent of soft contact lens wearers have clinical signs of GPC, and the prevalence is approximately 10-fold less in rigid lens wearers [1]. This difference in prevalence is probably because allergens adhere more readily to the surface of soft contact lenses. Additional factors that influence the incidence of GPC in contact lens wearers include wearing time of contact lenses, cleaning routine (frequency and types of solutions), and duration of contact lens wear [4]. The average onset of GPC after start of contact lens wear is 10 to 20 months for soft contact lenses and 22 to 90 months for rigid lenses [2,3]. However, symptoms may occur as early as three weeks after the start of contact lens wear.

Other foreign substances that can trigger GPC include:

Ocular prostheses [5]

Extruded scleral buckles [6]

Glaucoma filtering blebs [7]

Cyanoacrylate glue [8]

Band keratopathy [9]

Exposed sutures [10]

GPC affects predominantly young adults because of the association with contact lenses. There is no sex predilection. A history of atopy is also associated with GPC [11]. The peak distribution of GPC is in the spring and fall, possibly due to increased pollen allergens in the air during this time of the year [12].

PATHOGENESIS — The pathogenesis of GPC involves both mechanical and immunologic mechanisms [13]. Debris that can build up on the contact lens surface over time is associated with GPC. This debris may be recognized as foreign to the mucous membranes of the conjunctiva, thereby initiating an immunologic reaction (a combination of type I and type IV hypersensitivity) with repeated antigen presentation. Additionally, trauma from blinking over a foreign substance (such as a contact lens, prosthesis, or suture barb) can provide a port of entry for antigens and induce an immune response.

The combination of mechanical trauma and immune reaction with release of inflammatory mediators leads to increased lymphocytes, papillary formation, fibroblast proliferation, and collagen production. These factors lead to giant papillae formation.

The total number of inflammatory cells in the conjunctiva is elevated in GPC [13]. Mast cells, eosinophils, and basophils are increased in biopsies of papillae and are found in both the conjunctival epithelium and the substantia propria [14]. Cells similar to membranous epithelial cells (M cells) in mucosa-associated lymphoid tissue are found in elevated numbers in the conjunctiva of patients with GPC [15]. These cells are involved in the binding, uptake, and translocation of antigens to underlying lymphocytes and antigen-presenting cells.

Tear levels of immunoglobulin E (IgE) and, in some cases, immunoglobulin M (IgM) and immunoglobulin G (IgG) are elevated in patients with GPC compared with contact lens wearers without GPC and with normal controls. The IgE is produced locally and recognizes the lens material or allergic material contaminants that have adhered to the lens. In addition, levels of leukotriene C4 levels are elevated in tears of GPC patients [16]. Increased numbers of CD4+ T cells and levels of inflammatory cytokines, particularly interleukin (IL) 4, IL-6, soluble IL-6 receptor, and eotaxin, are also seen [17-20].

SIGNS AND SYMPTOMS — Symptoms may precede overt signs of GPC and are initially mild at onset. Early symptoms include mild irritation and itching, as well as slight mucus production. If untreated, symptoms gradually progress and may include mucus overproduction (most often noted first thing in the morning), more intense itching, foreign-body sensation, discomfort upon insertion of lenses, blurry vision, and increased awareness of contact lenses [3]. Complete intolerance to wearing contact lenses can develop in severe cases. (See 'Diagnosis' below.)

Signs include enlarged papillae on the upper tarsus, mucus production, conjunctival hyperemia, eyelid thickening, and sometimes ptosis [3]. In the early stages, papillae are rarely larger than 0.3 mm. The papillae often reach 1 to 2 mm in size as the disease progresses (picture 1 and picture 2). Protein deposits of unknown origin are often visible on the contact lens surface. Frequently, signs and symptoms do not perfectly correlate and vary depending on the inciting stimulus. Dryness and blepharitis may exacerbate GPC, as with other allergic conditions affecting the eye. (See 'Diagnosis' below.)

HISTOLOGY — The typical histology of GPC is thickened and irregular conjunctival epithelium covering giant papillae [21]. Epithelial cells show polymorphism and polymegathism. There are a greater number of conjunctival goblet cells, which appears to be due to the increased conjunctival surface area covering the papillae. GPC is characterized by increased numbers of eosinophils, basophils, mast cells, lymphocytes, and plasma cells in the substantial propria and, to a lesser degree, in the epithelium. The infiltration of these cells demonstrates the immune-mediated features of GPC. (See 'Pathogenesis' above.)

DIAGNOSIS — Diagnosis is made by eliciting a history of contact lens (or prosthesis, suture knot, etc) intolerance and by everting the upper lid and observing enlarged papillae. Both the size and pattern of papillae can vary, as noted previously. (See 'Signs and symptoms' above.)

GPC can be classified into four stages [2], although symptoms and signs do not always correlate, and there is much variation among patients [2]:

In stage I, symptoms include mild mucus discharge after sleeping and mild itching after lens removal. There are no signs or papillae at this stage.

In stage II, there is an increase in mucus production and itching, an awareness of the lens, blurred vision, and the development of upper tarsal papillae.

In stage III, there is severe mucus production and itching. The contact lens itself becomes coated with debris. The papillae are increased in number and size. The contact lens may have excessive movement caused by blinking and "grabbing" of the lens by the enlarged papillae. At this stage, there is a reduction in contact lens wearing time.

In stage IV, all signs and symptoms are severe, and the contact lenses are worn only briefly.

Environmental allergens do not cause GPC, and, therefore, there is no role for testing for environmental allergies.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis includes the other types of allergic conjunctivitis and toxic conjunctivitis (see 'Introduction' above). The main differentiating feature of GPC is that there is presence of a foreign substance in the eye, such as contact lenses. GPC can be differentiated from seasonal and perennial conjunctivitis in that giant papillae do not form in those types of conjunctivitis. Papillary hypertrophy is seen in vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and occasionally in toxic conjunctivitis. However, it typically occurs in the inferior fornix in patients with AKC, it occurs in a different patient population in patients with VKC (boys living in warm, dry, subtropical climates rather than young adult contact lens wearers), and it is associated with use of ocular medications in patients with toxic conjunctivitis. (See "Allergic conjunctivitis: Clinical manifestations and diagnosis" and "Vernal keratoconjunctivitis" and "Atopic keratoconjunctivitis" and "Toxic conjunctivitis".)

TREATMENT — The primary treatment is removal of the source of mechanical irritation. In patients with GPC triggered by contact lenses, improving cleaning and storage of the lenses to prevent protein adherence, reducing the wearing time, increasing the frequency of lens replacement, and changing the type and/or design of the lenses may help. Artificial tears and topical antihistamines, mast cell stabilizers, or dual-acting agents are common adjunctive therapies. Topical corticosteroids are reserved for severe, acute cases. There is no role for allergen immunotherapy since environmental allergens do not cause GPC.

Contact lens wear should be discontinued for two to four weeks to allow the inflammation to resolve [3,21]. Old contact lenses and storage/cleaning solutions containing preservatives should be thrown out. When possible, the patient should restart contact lens usage with a new pair of lenses. Lens-cleaning agents, along with storing and rinsing solutions, should all be preservative free since hypersensitivity reactions to preservatives can contribute to the inflammatory reaction. However, homemade saline solutions are not advised, due to the risk of bacterial contamination. Daily disinfection with 3% hydrogen peroxide is recommended over other types of disinfection. Enzymatic cleaning of lenses should be performed three times a week or even daily to reduce lens debris [22].

Lenses should be replaced at least every three weeks [23]. Changing the type and design of contact lenses may also be beneficial. A switch from extended wear to daily wear (or daily wear to disposable wear) may help to decrease the accumulation of debris and allergens on the contact lens [24,25]. Changing from soft contact lenses to rigid, gas-permeable (RGP) contact lenses may help if other approaches do not succeed.

A longer contact lens "holiday" should be initiated if symptoms persist or recur. Lenses can be reintroduced approximately two to three weeks after symptoms resolve.

Frequent use of preservative-free artificial tears can provide relief of mild symptoms. (See "Dry eye disease", section on 'Artificial tears'.)

Topical antihistamines, mast cell stabilizers, and dual-acting agents (eg, olopatadine, azelastine hydrochloride, epinastine, pemirolast potassium, and ketotifen fumarate) can all provide relief of acute itching and reduce eye rubbing by reducing histamine release. Cromolyn sodium has been shown in observational studies to promote resolution of early GPC signs and symptoms when combined with improved lens hygiene [21,26-28]. However, advanced GPC does not respond to cromolyn sodium alone. Olopatadine is the primary treatment of choice among most clinicians, although there are no observational studies or randomized trial of olopatadine in GPC.

It may be necessary to use topical "soft" corticosteroids that have a lower risk of causing side effects, such as increased intraocular pressure, than other corticosteroids. Loteprednol etabonate was shown to be effective in improving signs and symptoms of GPC in most patients in several randomized trials [29-32]. Topical corticosteroids should only be used in severe, acute cases of GPC, such as in patients who fail to respond to several weeks of the therapies mentioned previously. In addition, they should be used judiciously and for no longer than four to six weeks. Tapering of corticosteroids is usually done over a two-week period. If the corticosteroid drops have been used for longer than six weeks, they should be tapered more slowly and in correlation with the duration of their usage. Patients on topical corticosteroids should be managed by an ophthalmologist or optometrist because of the risk of side effects.

PROGNOSIS — Signs and symptoms of GPC usually resolve in less than one week if the source of mechanical irritation is removed. The vast majority of patients who comply with treatment will be able to successfully resume contact lens use.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Allergic eye disease".)

SUMMARY AND RECOMMENDATIONS

Epidemiology and pathogenesis – Giant papillary conjunctivitis (GPC) is a noninfectious inflammatory disorder that represents a reaction to lid movement over a foreign substance, such as contact lenses. The pathogenesis of GPC involves both mechanical trauma and immune reaction to debris that can build up on the contact lens surface. (See 'Introduction' above and 'Epidemiology' above and 'Pathogenesis' above.)

Clinical manifestations – GPC is characterized by foreign-body sensation on the upper tarsus, associated with formation of "giant" (>1 mm) papillae (picture 1 and picture 2). Patients often have intense pruritus and increased mucus production. (See 'Signs and symptoms' above.)

Diagnosis – Diagnosis is made by eliciting a history of intolerance of contact lenses or another foreign substance in the eye and by everting the upper lid and observing enlarged papillae. (See 'Diagnosis' above.)

Treatment – Signs and symptoms of GPC usually resolve in less than one week if the source of mechanical irritation is removed. In patients with GPC triggered by contact lenses, improving cleaning and storage of the lenses to prevent protein adherence, reducing the wearing time, increasing the frequency of lens replacement, and changing the type and/or design of the lenses may help. The vast majority of patients who comply with treatment will be able to successfully resume contact lens use. (See 'Treatment' above.)

We suggest a trial of a topical mast cell inhibitor or dual-acting mast cell inhibitor and antihistamine for patients who do not improve with removal of the inciting agent and other nonpharmacologic measures (Grade 2C). We recommend a short course of topical corticosteroids in patients who do not respond to mast cell inhibitors and who have severe disease (Grade 1B). (See 'Treatment' above.)

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