What is the best approach to manage giant papillary conjunctivitis?

Management of Giant Papillary Conjunctivitis

The primary treatment for giant papillary conjunctivitis (GPC) is discontinuation of contact lens wear until symptoms resolve, combined with modification of the causative entity and appropriate medical therapy based on severity. 1

Etiology and Clinical Features

• GPC is characterized by papillary hypertrophy of the superior tarsal conjunctiva, often with mucoid discharge
• Primary causes:
  • Contact lens wear (most common)
  • Exposed sutures
  • Ocular prostheses
• Risk factors for contact lens-related GPC:
  • Soft contact lenses
  • Infrequent lens replacement
  • Prolonged wearing time
  • Poor lens hygiene
  • Allergenic contact lens solutions
  • High water content lenses
  • Poor contact lens fit 2

Treatment Algorithm

Step 1: Discontinue Contact Lens Wear

• Immediate discontinuation until cornea normalizes 1
• This alone may resolve mild cases

Step 2: Address the Underlying Cause

• For contact lens wearers:
  • Replace lenses more frequently
  • Decrease wearing time
  • Use preservative-free lens care systems
  • Refit contact lenses
  • Switch to daily disposable lenses (preferred)
  • Change contact lens polymer 2
• For non-contact lens causes:
  • Remove or replace protruding suture knots
  • Clean, polish, or replace ocular prostheses 2

Step 3: Pharmacological Management (Based on Severity)

Mild GPC:

• Mast cell stabilizers (e.g., cromolyn sodium) 2, 3
• Treat associated conditions (aqueous tear deficiency, MGD) 2

Moderate to Severe GPC:

• Short course (1-2 weeks) of topical corticosteroids
  • Loteprednol etabonate is effective for GPC 4
  • Monitor IOP and pupillary dilation to evaluate for glaucoma and cataract 2
• Consider topical cyclosporine 0.05% for longer-term treatment 1

Follow-up and Monitoring

• Frequency based on disease severity and treatment used
• Each visit should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 2
• Monitor for potential complications:
  • Tarsal scarring
  • Ptosis
  • Corneal abrasions/erosions 2
  • Glaucoma and cataracts (if using corticosteroids) 1

Prevention Strategies

• Proper contact lens care:
  • Rub and rinse lenses in disinfecting solution
  • Clean and rinse case with fresh solution
  • Replace case every 3 months
  • Follow prescribed wearing and replacement schedule
  • Never "top off" solution; always use fresh disinfecting solution
  • Avoid water exposure when wearing lenses 1

Prognosis

With proper management, GPC has an excellent prognosis. Most cases resolve with lens abstinence and appropriate treatment, though symptoms may be prolonged in some cases 1, 5.

Common Pitfalls to Avoid

1. Using topical corticosteroids for extended periods without monitoring IOP
2. Failing to address the underlying cause (especially continuing with the same contact lens regimen)
3. Inadequate follow-up to ensure resolution
4. Overlooking associated conditions like aqueous tear deficiency and MGD
5. Returning to contact lens wear too quickly before complete resolution 2, 1