along the medial and temporal aspects of the tarsal plate and the area along the superior border of the plate have been called transitional zones because one often sees a papillary reaction in normal individuals in these areas that can be quite large, and they are not considered pathologic and should be disregarded in assessing the condition of the upper tarsal plate.

Stages of giant papillary conjunctivitis

For purposes of classification and treatment, the signs and symptoms of GPC can be classified into four stages [2].

Stage 1: preclinical giant papillary conjunctivitis

In this early stage, the symptoms consist of minimal mucus discharge, usually noted on awakening, and occasional itching noted after lens removal. The lenses are often mildly coated. Examination of the upper tarsal conjunctiva may reveal a normal appearance, or there may be mild hyperemia, but a normal vascular pattern is usually visible (Fig. 3).

Stage 2: mild giant papillary conjunctivitis

This stage is characterized by increased mucus production with associated itching, increased lens awareness, and coating of the contact lenses. Occasionally, patients may note mild blurring of vision. Examination of the upper tarsal conjunctiva reveals mild to moderate injection and thickening of the conjunctiva with some loss of the normal vascular pattern. Although the superficial vessels are typically obscured, the deeper vessels are still visible. A papillary reaction is observed, and although there is variability in size, some of the papules measure 0.3 mm or more. At this stage some of the papules may begin to coalescence because several adjacent papules are

Fig. 3. Stage 1 giant papillary conjunctivitis. (A) Minimal hyperemia of the upper tarsal plate. (B) Papillary reaction in same patient (fluorescein instilled and photographed with cobalt filter).

elevated by thickening of the underlying tissue. These early changes may be di cult to detect with white light alone; however, the use of fluorescein dye and cobalt illumination greatly enhances the ability to detect these changes (Fig. 4).

Stage 3: moderate giant papillary conjunctivitis

As this condition progresses, itching and mucus formation have increased and lens coating is more prominent. Patients may find it di cult to keep their lenses clean and lens awareness is also increased, often resulting in a significant reduction in wearing time. There may be excessive lens movement with each blink that often results in fluctuating and blurred vision. At this stage, examination of the upper tarsal conjunctiva shows marked injection and thickening, and the normal vascular pattern is further obscured (Fig. 5). The papules on the tarsal conjunctiva have increased in size and number and are now becoming elevated. The apices of the papules may appear whitened from subconjunctival scarring and fibrosis and often exhibit staining with fluorescein dye.

Stage 4: severe giant papillary conjunctivitis

At this stage patients are usually completely unable to wear their lenses. Discomfort begins shortly after insertion of their lenses, which quickly become coated and cloudy. In addition to excessive lens movement, the lenses often fail to center properly. Mucus secretion is increased, sometimes so that the patients’ eyelids can occasionally stick together in the morning. The thickening of the upper tarsal conjunctiva has progressed to the point where the normal vascular pattern is totally obscured (Fig. 6). Papules on

Fig. 4. Stage 2 giant papillary conjunctivitis. (A) Injection and thickening of the conjunctiva. (B) Enlargement and elevation of papillary reaction (fluorescein instilled and photographed with cobalt filter).

Fig. 5. Stage 3 giant papillary conjunctivitis. (A) Marked injection, thickening, and obscuration of the normal vascular pattern of the upper tarsal plate. (B) Papules are between 0.5 and 1 mm in size (fluorescein instilled and photographed with cobalt filter).

the upper tarsal conjunctiva are large (sometimes 1 mm or larger) and may have flattened apices. Fluorescein staining and subconjunctival scarring may also be present.

Although four stages have been described that illustrate the progression of both the signs and symptoms of GPC, individual variation is very common, and there may be a discrepancy between the severity of the signs and the symptoms. Some patients may have fairly severe symptoms with only early tarsal changes, whereas some asymptomatic patients or patients with minimal symptoms are found to have impressive inflammatory changes

Fig. 6. Stage 4 giant papillary conjunctivitis. (A) Marked injection, thickening, and total obscuration of the normal vascular pattern. (B) Large papules with apical staining (fluorescein instilled and photographed with cobalt filter). (From Donshik PC, Ehlers WH. Giant papillary conjunctivitis. Immunology and Allergy Clinics of North America 1997;17:53–73; with permission.)

on examination of the tarsal conjunctiva. GPC is usually bilateral, but approximately 10% of patients have unilateral or markedly asymmetric signs and symptoms. In approximately 50% of the unilateral cases, an obvious reason for the asymmetry can be found, such as asymmetric coating of the lenses or a poor fit to explain the disparity between the manifestations of the disease in the two eyes; however, in the other half, no specific cause can be found [15].

The signs and symptoms of GPC can be present in both soft hydroxyethyl methacrylate (HEMA)–based hydrogels and rigid contact lens wearers; however, both the signs and symptoms occur sooner in patients wearing soft lenses than those wearing rigid lenses [2,16,17]. The tarsal conjunctival findings are usually similar in patients wearing soft or hard contact lenses. Korb and colleagues [18,19] have shown that in wearers of soft contact lenses the papules usually form first in the zones of the tarsal conjunctiva that are nearest the upper margin of the tarsal plate (zones 1 and 2) and then progress to all 3 zones. In rigid gas-permeable contact lens wearers, however, the papules usually form in the zones nearest the eyelid margin (zone 3 and then zone 2) and tend to remain more localized.

Silicone hydrogel contact lenses were introduced into the United States in 1999. Presently, there are six di erent silicone hydrogel contact lenses available in the United States. These contact lenses have high oxygen transmissibility compared with conventional HEMA-based contact lenses, which is a benefit to the cornea. In addition to di erences in their oxygen transmissibility, these lenses also vary in their modulus or sti ness, and their surface characteristics. GPC has been associated with use of these lenses, especially the first-generation silicone hydrogel contact lenses. In addition to the typical generalized pattern seen in HEMA-based contact lenses, a localized GPC presentation has been reported with silicone hydrogel lenses, and occurs more frequently than the generalized form [20]. The localized presentation involves the presence of papillae in one or two areas of the tarsal conjunctiva (Fig. 7), whereas in the generalized condition, the papillae

Fig. 7. Localized giant papillary conjunctivitis in a patient wearing silicone hydrogel contact lenses. (A) White light showing the localized papillary reaction. (B) Localized reaction with fluorescein and cobalt filter.