History

Patients with giant papillary conjunctivitis (GPC) often report an increase in contact lens soilage, ocular itching, and mucous discharge in tears, as well as blurred vision and conjunctival injection. This can be accompanied by decreased contact lens tolerance and mechanical stability. Patients often report that the contact lenses move noticeably with each blink.

GPC can follow a seasonality pattern similar to that of environmental allergies. Environmental allergens may exacerbate contact lens–induced GPC in patients with atopy.^[16]GPC development does not correlate with ocular bacterial bioburden.^[16]

Physical Examination

Clinicians commonly note increased deposition on contact lenses. In addition, contact lenses appear to ride higher under the upper lids than expected. Rigid lenses, in particular, show deposits around the lens edge.

With eversion of the lids, inflammation of the vasculature (hyperemia) and papillary hypertrophy are noted.

Mucous strands can be seen in the tears and between the papillae.

Papillae can range from small uniform lesions (uniform cobblestone appearance [UCA]) to irregular changes (nonuniform cobblestone appearance [NUCA]) to clusters of giant lesions with whitish centers that can ulcerate and stain with sodium fluorescein dye.^[17]Originally, the papillae of the upper tarsal conjunctiva were thought to have to be at least 1 mm to diagnose GPC. Today, the clinical sign is generally accepted as follows: the papillae are at least 0.3 mm in diameter on the upper palpebral conjunctiva in association with classic symptoms.

GPC that is associated with hydrogel contact lenses is more commonly at the fold of the everted lid, spreading over the entire tarsal conjunctival surface.

GPC that is associated with rigid contact lens wear shows an opposite pattern, corresponding to the position of the contact lens edge meeting the lid tissues. This provides evidence for the mechanical etiology hypothesis.

Silicone hydrogel lenses tend to induce more local than general GPC responses, similar to those seen with rigid lens wear.

Attending eye doctors should routinely invert and visually inspect lids, especially in patients who wear contact lenses for any ocular complaints.

Subjective ocular itching, mucus, contact lenses with significant protein deposits, and contact lenses that become less comfortable, more mobile, or ride higher underneath the upper lids should all raise suspicion for GPC.

Differential Diagnoses

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Media Gallery

Very large papillae in the everted upper lid of a patient who wears hydrogel (soft) contact lenses.
Giant papillary conjunctivitis (GPC) response (slightly out of focus) seen in the upper lid of a young patient recovering from cataract extraction with an exposed suture barb (in focus).

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Author

Karen K Yeung, OD, FAAO Senior Optometrist, UCLA Arthur Ashe Student Health and Wellness Center; Clinical Assistant Professor, College of Optometry, Western University of Health Sciences

Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry

Disclosure: Nothing to disclose.

Coauthor(s)

Barry A Weissman, OD, PhD, FAAO Retired Professor of Optometry, Southern California College of Optometry at Marshall B Ketchum University; Professor Emeritus of Ophthalmology, Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, International Society for Contact Lens Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University; Director of the Cornea Service, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AAO; OMIC; American Society of Ophthalmic Trauma (ASOT); Avellino, Bio-Tissue; Celularity; Dompe; Glaukos; Kala; Oyster Point; Sun Ophthalmics; Tarsus; TearLab Serve(d) as a speaker or a member of a speakers bureau for: Glaukos; Dompe; Bio-Tissue Received research grant from: Glaukos Received income in an amount equal to or greater than $250 from: AAO; OMIC; Bio-Tissue; Cellularity; Dompe; Glaukos; Kala; Sun Ophthalmics; TearLab.

Chief Editor

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, Association for Research in Vision and Ophthalmology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: 1-800-DOCTORS; AbbVie; Alcon; Aldeyra; Allergan; Alphaeon; ArcScan; Baush+Lomb; Bio-Tissue; Clearside; EyeGate; Hovione; Mededicus; NovaBay; Omeros; Pentavision; Portage; Santen; Science Based Health; Senju; Shire; Sun Pharma; TearLab;TearScience;Topivert Serve(d) as a speaker or a member of a speakers bureau for: AbbVie; Alcon; Allergan; Bausch+Lomb; Bio-tissue; EyeGate;Hovione;LayerBio; NovaBay;Omeros;Portage; Santen; Shire; Stemnion; Sun Pharma;TearLab;TearScience; Topivert Received research grant from: Alcon; Aldeyra; allergan; Baush+ Lomb; EyeGate; Hovione; Kala; Ocular Therapeutix;Pfizer; RPS; Santen;Senju;Shire;Topcon; Xoma.

Giant Papillary Conjunctivitis Clinical Presentation

History

Physical Examination

References

Tables

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