Giant Papillary Conjunctivitis

Symptoms and Signs

Symptoms of GPC are low grade at their onset, consisting of mild irritation, scant mucous discharge, and occasionally mild itching. Many patients take only passing notice of the disease at this early stage and rarely present for evaluation because of these symptoms alone. Undetected and untreated, GPC progresses with gradual development of more significant symptoms. Blurring of vision due to lens surface debris, the accumulation of mucus in the medial canthal region, and a persistent foreign body sensation while wearing lenses inevitably leads to decreased contact lens wearing time. Itching of the eyes even when the lenses are removed is a frequent complaint. As these problems intensify, patients cease wearing their contact lenses altogether or seek ophthalmologic evaluation.

The slow, progressive character of GPC has been described in detail by Allansmith et al. Mild hyperemia of the upper tarsal conjunctiva is the earliest finding and is frequently accompanied by subtle conjunctival thickening. Conjunctival translucency is unaltered during this early phase, but gradually, as the disease progresses and increased inflammatory cell infiltrates develop, conjunctival thickening and increased opacification become evident ( Fig. 44.1 ). Small strands of mucus are frequently evident early in the course of GPC. A ropy, whitish, mucoid discharge develops ( Fig. 44.2 ) as the condition worsens and is usually concentrated medially and in the inferior fornix.

Persistent contact lens wear or continued exposure to the inciting material leads to increased conjunctival hyperemia and inflammation. Opacification of the conjunctiva and the development and enlargement of tarsal conjunctival papillae ensue. Papillae normally measure less than 0.3 mm in diameter. In GPC, papillae greater than 0.3 mm (often ranging from 0.6 to 1.75 mm) in diameter can be seen ( Fig. 44.3 ). The presence of giant papillae, defined as papillae greater than 1.0 mm in diameter, gives GPC its name ( Fig. 44.4 ).

The appearance and location of papillae may vary considerably. The upper tarsal conjunctiva may be covered by a uniform pattern of small to medium papillae proximally and distally, a nonhomogeneous-zonal pattern may develop, or large, cobblestone-like giant papillae may be seen ( Fig. 44.5 ). One must be careful when evaluating the superior tarsal surface to “ignore” the far lateral, medial, and superior borders of the tarsal plate since these areas respond unpredictably to adverse stimuli and may confuse the picture. Allansmith et al. have divided the superior tarsal surface into three zones ( Fig. 44.6 ). Zone 1 is located proximally along the uppermost edge of the tarsal plate; zone 3 is located distally adjacent to the lid margin. Papillae associated with soft contact lens-related GPC first appear in zone 1 and progress toward zones 2 and 3. The pattern is reversed in GPC related to rigid gas-permeable contact lenses. Papillae associated with rigid gas-permeable contact lens wear are typically seen in zone 3, adjacent to the lid margin or the distal half of the lid. These papillae are usually fewer in number and crater-like or flattened in appearance. The topographic variation between GPC associated with large-diameter soft contact lenses and smaller-diameter rigid gas-permeable lenses is consistent with current theories related to a mechanical and/or immunologic stimulus for GPC.

GPC associated with exposed suture material, elevated band keratopathy, and filtering blebs is usually characterized by large clusters of giant papillae overlying the inciting area ( Fig. 44.7 ). The topographic character of these changes suggests that chronic mechanical trauma may be a strong factor in the development of GPC in these cases. Large clusters of papillae are seen on the tarsal surface and in the superior fornix when scleral lenses or prosthetic shells are the stimulus ( Fig. 44.8 ). A granulomatous-like thickening may occasionally be seen in the superior fornix. Fluorescein staining of the apex of the papillae is not uncommon. It is not uncommon to see a white cap covering larger papillae ( Fig. 44.9 ). These changes regress as the conjunctival inflammation resolves, suggesting that inflammatory infiltrates may be partially responsible for these findings. Horner-Trantas dots have been reported in some patients with GPC. Rarely, the disease may be confined to the limbus with no inflammation of the tarsal surface. An association between GPC and meibomian gland dysfunction has been described, with increased meibomian gland dropout and an increased viscosity of the meibomian gland excreta being noted.