Immunol Allergy Clin N Am
28 (2008) 83–103
Giant Papillary Conjunctivitis
Peter C. Donshik, MDa,*, William H. Ehlers, MDa,
Mark Ballow, MDb
aUniversity of Connecticut Health Center, 263 Farmington Avenue, Farmington,
CT 06030, USA
bDivision of Allergy and Immunology, Department of Pediatrics, State University of New York at Bu alo (SUNY Bu alo), Women and Children’s Hospital of Bu alo, 219 Bryant Street, Bu alo, NY 14222, USA
Giant papillary conjunctivitis (GPC) was first noted by Spring [1] in 1974. He reported a papillary reaction, similar to that seen in allergic conditions, on the upper tarsal conjunctiva in soft contact lenses wearers. The condition has been described in detail by Allansmith and coworkers [2]. This syndrome, although predominantly associated with soft contact lens wear, has been reported in patients with rigid lenses, ocular prostheses, exposed sutures following ocular surgery, extruded scleral buckle, filtering blebs, band keratopathy, corneal foreign bodies, limbal dermoids, and cyanoacrylate tissue adhesives [2–13]. This condition is also known as ‘‘contact lens–induced papillary conjunctivitis.’’
Signs and symptoms
Contact lens wearers with GPC report a variety of symptoms, including decreased lens tolerance, increased lens awareness, excessive lens movement, increased mucus production associated with ocular irritation, redness, burning, and itching. These patients almost invariably have coated contact lenses, and they often report mucus accumulating in the inner canthus on awakening in the morning. On examination, the upper tarsal conjunctiva may show inflammation and papules, which are usually larger than 0.3 mm. It is important to note that in the very early stages of GPC, the
Portions of this article appeared in Donshik DC. Giant papillary conjunctivitis. Trans Am Ophthalmol Soc 1994;92:687–744; with permission; and Donshik PC, Ehlers WH. Giant papillary conjunctivitis. Immunology and Allergy Clinics 1997;17:53–73; with permission.
* Corresponding author. 47 Jolley Drive, Bloomfield, CT 06002. E-mail address: pdonshik@drdonshik.com (P.C. Donshik).
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symptoms may precede the signs, with only tarsal injection being present. It is essential to question patients at each visit to elicit reports of symptoms consistent with GPC that they may consider to be normal contact lens discomfort.
Biomicroscopy of the normal tarsal conjunctiva reveals a moist, pink mucous membrane with a vascular arcade that appears as fine vessels radiating perpendicular to the tarsal margin. This appearance has been described as a satin appearance in which the surface is smooth and devoid of papillae. One may also see a fine, uniform papillary appearance with small papules (4–8 per milliliter) that are best detected after the instillation of fluorescein. In some normal individuals, the papules may not be uniform in size, but even the larger papules are less than 0.3 mm [2].
Allansmith and coworkers [2] quantified the distribution of normal findings and reported that in non–contact lens wearers 24% of subjects had a tarsal conjunctiva that could be classified as having a satin appearance, 69% had a uniform papillary appearance, and 7% had a nonuniform appearance. Papules greater than 1 mm were not present in normal non– contact lens wearers (Fig. 1). Korb and colleagues [14], however, reported that a small number (0.6%) of normal individuals who do not wear contact lenses did have a papillary reaction of 0.3 mm on the upper tarsal conjunctiva. On the basis of these findings, a papillary reaction greater than 0.3 mm
Fig. 1. Classification of tarsal changes. (A) Satin. (B) Uniform papillary appearance. (C) Nonuniform papillary appearance. (D) Giant papillary appearance. (From Allansmith MR, Korb DR, Greiner JV, et al. Giant papillary conjunctivitis in contact lens wearers. Am J Ophthalmol 1977;82:697–708; with permission.)
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is generally considered abnormal and consistent with the diagnosis of GPC when accompanied by the appropriate symptoms.
In patients with GPC, the upper tarsal conjunctiva undergoes progressive changes that begin with nonspecific signs of inflammation and progress to the development of the characteristic papillary reaction that give this entity its name. For convenience of classification and treatment, this progression has been divided into stages, described later. The best method of examining a patient with suspected GPC is to have them remove their lenses and examine the conjunctiva and cornea under low and high power at the slit lamp biomicroscope. The presence of bulbar conjunctival injection, superior corneal pannus, or corneal opacities should be noted. The upper lid is then inverted for examination of the tarsal conjunctiva. The presence and location of hyperemia, abnormal tarsal vascular patterns, and papules should be recorded, along with any evidence of subconjunctival scarring. Fluorescein is then instilled into the cul-de-sac, and the patient is asked to blink several times to distribute the dye. The lid is again everted, and using the blue cobalt filter of the slit lamp, the tarsal conjunctiva is re-examined for the presence of a papillary reaction. The fluorescein-stained tear film outlines the presence of the papillary reaction, and the sterile 2% solution seems to give the best definition of the papules. One can then easily appreciate the pattern of the papillary reaction and estimate the size of the papules.
It is important to note the size of the papules and their location, and the presence of apical scarring or apical staining. This process is facilitated by dividing the redundant upper tarsal conjunctiva into three zones (Fig. 2). Zone 1 is the area along the tarsal border, zone 3 is the area along the lid margin, and zone 2 is the central area of the tarsal plate. The area
Fig. 2. Zones of the superior tarsal conjunctiva. (From Donshik PC, Elhers WG. Giant papillary conjunctivitis. Immunology and Allergy Clinics of North America 1997;17:53–73; with permission.)