Living Library

Giant Papillary Conjunctivitis (GPC)

CLINICAL DESCRIPTION: Giant Papillary Conjunctivitis (GPC)
Giant papillary conjunctivitis is an inflammatory condition commonly seen in soft contact lens wearers, patients with ocular prosthesis and patients with exposed sutures, secondary to surgery.  Initial presentation may occur month or even years after lens wear has been initiated.  Clinical findings such as hyperemia of the upper palpebral conjunctiva and mucous strands could be early signs of the condition.  The presence of papillae, 0.3mm in diameter or larger on the upper tarsal conjunctiva in combination with other ocular symptoms is generally required for the diagnosis of GPC.
Early symptoms of GPC may be subtle and usually appear before signs. Itching immediately upon lens removal, accumulation of mucus in the nasal canthus, and mild blurring of vision from coatings on the lens after few hours of wear are common early indicators of GPC.1 In many occasions patients failed to report them because they assume they are normal signs of contact lens wear. In later stages, symptoms of foreign body sensation, lens displacement, blurred vision and large amounts of mucous secretion  make contact lens wear intolerable.  This will bring the patient back looking for medical attention.
Although incidence of GPC in contact lens wearers has not been fully determined, it has been clearly shown that risk of developing the condition will increase with prolonged lens wear.  Several studies comparing the frequency of contact lens replacement is a key factor in the development of GPC.  Porazinski and Donshik showed that patients on a 1-day to 3-week lens replacement cycle had a significantly lower risk of developing GPC than patients who replaced lenses at longer intervals.2 Boswell showed higher incidence of GPC in patients wearing extended conventional lenses (35%) than patients wearing extended disposable lenses (5%).
The etiology of GPC is complex and multi-factorial. Not a true allergic condition, GPC is probably a form of hypersensitivity reaction to mechanical trauma of the lid, combined with an autoimmune response by the lymphoid tissue of the upper lid to the allergens embedded on the lens surface.3 These allergens could be mucus, protein, bacteria, cell and cell debris and airborne pollutants deposited on the surface of the lens.4
GPC patients have been demonstrated to have degranulated mast cells in the epithelium, combined with basophils and eosiniphils in the conjunctiva. Tear histamine levels are not elevated in GPC patients, while IgE levels are significantly elevated. The clinical and histopathological features of GPC indicate that the disease represents both IgE mediated (Type I) and delayed hypersensitivity reactions (Type IV).5 
Recent evidence demonstrates that tear fluid leukotrienes (LTs) are substantially increased in those with GPC (potentially serving as a marker of predictor for diagnosing purposes).  LTs may contribute to the pathogenesis of GPC in that they have been shown to increase conjunctival microvascular permeability.  The prolonged exposure to LTs , contrary to other released inflammatory mediators like histamine, may produce redness, conjunctival edema, and increased mucoid secretions.7
Treatment of GPC will be dependent on the severity of the condition.  In early cases, management is aimed on reducing ocular symptoms.  In more severe cases management should be guided to prevent ocular tissue damage, caused by inflammation.
Mild cases of the condition will require a number of modifications to bring about improvement of the symptoms. Changing lens materials, like more deposit resistant (FDA group I) or moving to disposable lenses (daily or weekly) can bring marked improvements.4 Improving lens hygiene, and using preservative free disinfectants and lubricants may also control the condition. In patients who are at high risk for GPC, replacing lenses at intervals of 1-day to 2-weeks appears to offer a better strategy in avoiding GPC than incorporating enzymatic cleaning into their care system.2 
In moderately severe cases of GPC the use of mast cell stabilizers and antihistamines will be necessary to treat the condition. The use of new dual acting medications, like olopatadine and ketotifen, which combine a mast cell stabilizer effect with an antihistamine used twice a day for 8 to 12 weeks will be an alternative therapeutic option. In situations were lens wear cannot be discontinued, the use of daily disposable lenses in combination with these twice daily dosing medications will be a good alternative of treatment.
More severe cases of GPC may require the use of non-steroidal or steroidal anti-inflammatory medications.  Steroids will be chosen over non-steroidal in recalcitrant cases, because of the effectiveness it has in controlling the acute stages of inflammation. The introduction of loteprednol, a "soft", safer steroid, with rapid therapeutic response combined with a low incidence of intraocular pressure increase, makes it an appropriate treatment for more severe cases of GPC.6   Steroid may be used as a short-term control for  acute inflammation, and then the other treatment options mentioned above   should be employed.
Allansmith MR, Ross RN.  Giant Papillary Conjunctivitis. Int.  Ophthalmo Clinics 1988; 28(4): 309-316.
Porazinski AD, Donshik PC.  Giant Papillary Conjunctivitis in Frequent Replacement Contact Lens Wearers:  A Retrospective Study. Trans Am Ophthalmo Soc 1999; 97: 205-216.
Shovlin J, DePaolis M, Abelson M, Bolard M. Ocular Allergies in Contact Lens Wearers: Signs, Symptoms and Solutions. Contact Lens Spectrum 1998; April: 23.
Katelaris CH. Giant Papillary Conjunctivitis- A Review. Acta.
Opththalmo Scand. 1999; 77: 17-20.
Allansmith MR. Pathology and Treatment of Giant Papillary
Friedlaender MH, Howes J. A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. The Loteprednol Etabonate Giant Papillary Conjunctivitis Study Group I. Am J Ophthalmo 1997 Apr; 123(4): 455-464.
Irkec MT, Orhan M, Erdener U.  Role of Tear Inflammatory Mediators in Contact Lens-Associated Giant Pappillary Conjunctivitis in Soft Contact Lens Wearers.  Ocular Immunology and Inflammation.  1999;7:35-38.
Begley CG, Riggle A, Tuel JA. Association of Giant Papillary Conjunctivitis with Seasonal Allergies. Optom. Vis. Science 1990; 67(3):  192-195.
Allansmith MR, Baird RS. Percentage of Degranulated Mast Cells in Vernal Conjunctivitis and Giant Papillary Conjunctivitis Associated with Contact Lens Wear. Am J Opthalmo 1981; 91: 71-75.
Abelson MB, Richard KP. What We Know and Don’t Know About GPC. Rev. Optom. 1994 Aug. 

Cornea and Contact Lens Living Library
Giant Papillary Conjunctivitis (GPC)

Edited by:
Chris Lievens, O.D., Souther College of Optometry
Manuel Conde Seijo, O.D.,  Inter American University of Puerto Rico School of Optometry