Giant papillary conjunctivitis (GPC) is a non-infectious immune inflammatory reaction that primarily involves the upper lid conjunctiva. It can occur at any age and does not differ by gender. It is most often associated with hydrophilic contact lenses, rigid gas permeable contact lenses, prosthetic eyes, glaucomatous follicles, exposed corneal sutures, scleral buckle protrusion, and band keratopathy. It can be cured with termination of lens wear and with medication.
(I) Clinical manifestations
Initial symptoms are mild and manifest with mild irritation, thin mucous discharge and mild scratching sensation. Without appropriate treatment, the condition will gradually worsen. Blurred vision and a persistent foreign body sensation during lens wear may occur due to the mucousy discharge and protein covering the lens surface.
Allansmith classifies GPC into four stages according to its clinical manifestations.
Stage I: a small amount of mucous discharge in the morning; itching sometimes when the lens is removed; deposits on the surface of the lens; normal appearance of the lid conjunctiva, which may be accompanied by mild to moderate congestion.
Stage II: increased mucus discharge and itching, and increased sensation of contact lenses; deposits on the lens surface; mild decrease in visual acuity; symptoms often occur a few hours after lens wear, and the patient’s ability to wear lenses is reduced or limited. On slit lamp examination, the upper lid conjunctiva is mildly congested and thickened, and papillae of varying sizes (0.3 mm or less) are visible on the lid conjunctiva; several adjacent papillae are fused and elevated due to tissue thickening, which becomes clearer with fluorescent staining.
Stage III: Significantly increased mucus discharge and scratchiness; frequent deposits on the lens surface, making it difficult to keep the lenses clean; sensation of the presence of contact lenses with each transient, excessive lens displacement, resulting in fluctuating blurred vision; significantly reduced lens wear time; marked congestion and thickening of the upper lid conjunctiva, blurred blood vessels, increased papillae size and number, and bulging papillae. The top of the papillae appear white with fluorescein staining due to subconjunctival scarring.
Stage IV: The patient is completely intolerant of wearing the lenses and feels discomfort very shortly afterwards; deposits and staining soon form on the lens surface, the lenses are greatly displaced, mucous discharge is considerable, and in severe cases the eyelids stick together in the morning; the conjunctival papillae of the upper lid are further enlarged (greater than 1 mm), the papillae are flattened at the top, and fluorescein staining is present.
(B) Diagnostic points
1. The patient wears corneal contact lenses or is fitted with a prosthetic eye; has ocular conditions such as glaucomatous follicles, exposed corneal sutures, and protruding scleral buckles.
2, with clinical manifestations of different periods.
3.Conjunctival scrapings can be seen with a large number of eosinophils or eosinophilic granules.
4, pay attention to the differentiation point with spring conjunctivitis.
Treatment】
The treatment principles of GPC are: reduce the formation of contact lens surface deposits; reduce the wearing time; choose the right size and type of contact lens; drug treatment.
(I) Reduce deposition
Contact lenses or prostheses should be cleaned regularly, usually once a day, using a surfactant; adequately cleaned in sterile, unpreserved saline; and then, placed in a sterile system. Periodically, the technician should use enzyme preparations to clean the precipitated proteins. Hygienic habits are also an important factor in preventing GPC from occurring.
(ii) Reduce contact time
The symptoms of GPC are often time-dependent, i.e., the longer the conjunctival surface is in contact with the foreign body, the more severe the symptoms become. Therefore, for most contact lens wearers, the amount of time spent wearing lenses during the day can be reduced. For example, myopic wearers should be asked to remove their contact lenses on the way home from work and wear regular glasses instead; for those who wear contact lenses for social or sports activities, they should also be encouraged to minimize the time spent wearing them in various settings. Sometimes, 1 pair of lenses can be used for the first half of the day and another pair for the second half of the day. For those who wear prosthetic eyes, the patient should be asked to remove them at night instead of considering the problem purely from the cosmetic point of view.
(C) Contact lens wear and its type optimization
Wearing unsuitable contact lenses can cause or promote the occurrence of GPC. Appropriate attention should be paid to the shape of the lenses, especially the edges of the lenses. Lenses with excessively curved edges can easily cause trauma to the conjunctiva of the upper eyelid. Larger diameter lenses are also more likely to cause this condition than smaller diameter lenses.
Replacement of other products with different materials and designs, such as rigid gas permeable contact lenses, disposable contact lenses and low water content methyl methacrylate lenses, can also contribute to disease improvement. Some studies have shown that certain patients are prone to GPC when wearing lenses made of standard PMMA materials, while switching to other materials is less likely to develop the disease.
(iv) Drug treatment
1. Mast cell stabilizer: For mild and moderate cases, 2% to 4% sodium cromoglycate eye drops can be used. For severe advanced cases, sodium cromoglycate does not have significant efficacy. Sodium cromoglycate inhibits the activation of neutrophils, eosinophils and macrophages. The new drug nalidoxomib sodium also reduces scratchiness and mucus secretion. Sodium nalidomide also has the effect of blocking the release of inflammatory mediators and the activation of inflammatory cells. Lodoxamide (lodoxmide) is another class of mast cell stabilizer that is 2,500 times more effective than sodium cromoglycate in vitro. It has the same effect as sodium cromoglycate in vivo, but has a faster onset of action.
2, non-steroidal anti-inflammatory drugs: such as thiamphenicol (suprofen), for the treatment of GPC has a certain benefit. Its main effect is to inhibit prostaglandin synthesis.
3.Topical glucocorticoid: It has certain efficacy for the treatment of GPC. Its main effect is to reduce the congestion and inflammation of the eyelids, and it has no special therapeutic effect on other parts of GPC. Its application is generally limited to the acute phase. However, long-term application can cause many potential complications, such as glaucoma, cataract and prompt infection, so its use is generally contraindicated. However, for GPC induced by wearing prostheses or other items, it can be used topically if necessary because it does not involve damage to vision.
The prognosis for GPC is good, and permanent visual impairment does not usually occur. The outcome is flattening of the papillae, subepithelial fibrosis and disappearance of symptoms. All patients improve their symptoms after discontinuation of contact lenses. Mild cases can be cured simply by changing the type and design of the lens and the cleaning procedure. In severe cases, contact lens wear should be discontinued and aggressive medication should be given.