Understanding Giant Papillary Conjunctivitis

Understanding Giant Papillary Conjunctivitis: Causes, Symptoms, and Management

Giant Papillary Conjunctivitis (GPC) is a chronic, inflammatory condition affecting the superior tarsal conjunctiva. Most commonly seen in contact lens wearers and individuals with ocular prostheses, GPC is characterized by the presence of large papillae on the upper eyelid’s palpebral conjunctiva. Though not infectious, it can severely impact comfort and vision quality if left untreated.

Pls note : Although GPC usually affects the upper tarsal conjunctiva, in severe or chronic cases it can involve the lower lid. it can be seen in a cobblestone arrangement.

Etiology and Risk Factors

According to Samar Basak’s Comprehensive Ophthalmology, GPC is not a true allergic conjunctivitis but rather a form of mechanical irritation and hypersensitivity reaction. The causes and contributing factors include:

• Contact lenses (particularly soft lenses worn for extended periods)
• Exposed sutures, especially post-surgery
• Ocular prostheses
• Scleral buckles or filtering blebs post glaucoma surgery
• Protein deposits on lenses triggering hypersensitivity
• Poor lens hygiene or fitting

Kanski also emphasizes the role of mechanical trauma combined with an immune-mediated response to foreign materials on the ocular surface.

Pathophysiology

GPC is essentially a mixed Type I and Type IV hypersensitivity reaction. Repeated mechanical friction (e.g., from contact lenses) leads to epithelial trauma, allowing allergens like lens deposits or denatured proteins to interact with immune cells.

This interaction promotes:

• Mast cell degranulation
• Eosinophilic infiltration
• Pro-inflammatory cytokine release
• Fibroblast activation and collagen deposition, resulting in hypertrophied papillae

Clinical Feature

Symptoms:

• Foreign body sensation
• Itching
• Excessive mucous discharge
• Blurry vision (due to unstable tear film or lens deposits)
• Difficulty in contact lens tolerance
• Photophobia

Signs:

• Giant papillae (>1.0 mm) on the superior tarsal conjunctiva
• Hyperemia of the palpebral conjunctiva
• Mucous strands
• Ptosis or lid heaviness in chronic cases
• Contact lens intolerance due to increased lens movement and discomfort

Diagnosis

Diagnosis is largely clinical, supported by patient history and slit-lamp examination.

Key clinical clues include:

• History of prolonged contact lens use
• Presence of giant papillae with central vascular cores
• No signs of infectious conjunctivitis (no follicles or preauricular lymphadenopathy)

Differential Diagnosis:

• Vernal conjunctivitis
• Atopic keratoconjunctivitis
• Trachoma (especially in endemic areas)
• Mechanical irritation from sutures or exposed implants

Management

1. Elimination of Mechanical Cause

• Discontinue contact lens wear temporarily
• Switch to daily disposable or rigid gas permeable lenses
• Improve lens hygiene and lens replacement schedules
• Remove exposed sutures or adjust prosthesis if implicated

2. Medical Treatment

• Topical mast cell stabilizers (e.g., lodoxamide, nedocromil)
• Antihistamine eye drops (e.g., olopatadine)
• Combination antihistamine + mast cell stabilizer agents
• Topical steroids (short-term, e.g., loteprednol or fluorometholone) in moderate to severe casesSteroid use should be limited due to the risk of elevated intraocular pressure and cataracts.

3. Supportive Measures

• Cold compresses
• Lubricant eye drops to relieve mechanical irritation
• Education on contact lens hygiene and wearing schedule

Prognosis

GPC typically resolves with elimination of the causative factor and proper medical management. However, recurrence is common if poor contact lens hygiene or improper lens type continues.

Prevention

• Use of daily disposable contact lenses
• Regular cleaning and replacing of lenses and lens cases
• Avoiding extended wear of soft lenses
• Early treatment of minor irritation before giant papillae form

Conclusion

Giant Papillary Conjunctivitis is a common but preventable condition among contact lens users. While it may resemble allergic conjunctivitis, its underlying cause is mechanical irritation compounded by immune response. Proper lens hygiene, early identification of symptoms, and prompt medical intervention ensure long-term ocular health and comfort.

References

1. Samar K. Basak. Comprehensive Ophthalmology, 6th Edition. Chapter: Diseases of the Conjunctiva.
2. Kanski, J.J. Clinical Ophthalmology: A Systematic Approach, 9th Edition.
3. American Academy of Ophthalmology (AAO) Preferred Practice Guidelines
4. Contact Lens Spectrum Journal – GPC and lens care updates
5. PubMed Clinical Review: “Giant Papillary Conjunctivitis in Contact Lens Users”