Giant papillary conjunctivitis from contact lenses

 
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Giant Papillary Conjunctivitis

Giant Papillary conjunctivitis has been recognized as a complication of contact lens wear since the 1970’s. In 1974, Giant Papillary conjunctivitis or GPC was defined as an “allergic reaction” and is considered to be the cause of a combination of allergic and mechanical stimuli that affected the upper tarsal conjunctival surface in a certain group of people who wore contact lenses. Therefore it is caused secondarily by the auto immune reaction to the patients’ micro proteins on the lens.

Giant Papillary conjunctivitis is also known as contact lens papillary conjunctivitis (CLPC). Its occurrence can be attributed to all types of contact lens wear as well as ocular prosthesis, protruding surtura after anterior segment surgery, plaques in the cornea and tumors.

The Rate of Occurrence

The occurrence of GPC in contact lens wearers can be further defined as generalized and local contact lens induced papillary conjunctivitis. The incidence of GPC ranges between 2% and 18%. In a study it has been found that in people using disposable and frequent replacement contact lenses, 4% of that group which replaced their contact lenses 3 weeks or less suffered from GPC whereas 36% of that group which replaced their contact lenses after 4 weeks or more suffered from this problem.

Therefore, we can come to the conclusion that prolonging the wearing time period of disposable contact lenses directly increased the incidence of GPC and that the problem occurs more in the case of those using soft contact lenses. The latter point is supported further by the data that the onset of GPC occurs approximately within 19.86 months in case of soft lenses whereas in case of rigid gas permeable lenses the onset averages at 21.56 months and 90 months with hard PMMA lenses.

The Symptoms of Giant Papillary Conjunctivitis

The symptoms include discomfort while wearing contact lenses, increased shifting of contact lenses, decreased wearing time, itching, blurred vision and coating of the contact lens. There may be cases where mucus discharge is present on the inner canthus on opening the eyes. In extreme conditions patients sometimes may have to discontinue wearing their lenses.

Observation shoes the presence of injection of the superior tarsal conjunctiva in addition to the loss of the ability to identify the tarsal vessel due to thickening and hyperemia of the conjunctiva. Normal micro papillae have a diameter of less than 0.3 mm whereas giant micro papillae have a diameter of 1 mm or more. In GPC, the papillary reaction is usually present and the sizes of the papules vary from .3mm to more than 1 mm. These enlarged papillae are collections of lymphocytes and plasma cells. The papillary reactions may be restricted to a specific area (localized) or may spread on the total tarsal surface. These signs and symptoms increase directly with the severity of papillary conjunctivitis.

Mast cell stabilizers may be used to reduce the symptoms but elimination of the cause is necessary. This requires improved lens care of the lenses more frequent lens replacement and reduced wearing time.


The Pathophysiology of GPC

The physiological processes involving the abnormalities of GPC is complex and it has been proved that the condition is a result of immune mediation. The reaction is started when deposits that are formed on the contact lenses instigate an antigen stimulus. As a result of this tear, immunoglobulins such as IgE and IgG are released and the complement system is activated and C3 anaphylatoxin is formed. As this builds up an associated problem of the coating of the contact lens leads to trauma in the conjunctiva, which in turn releases a neutrophilic chemotatic factor that starts the creation of inflammatory cells like lymphocytes, bosophils, eosinophils as well as mast cells. These complement system and tear immunoglobulins act together with the mast cells, which are degranulated and produce a release of vasoactive amines which manifest as inflammation, itching, mucus build up, fibrovascular changes i.e. all the signs and symptoms of GPC.

In a study conducted on 120 subjects who used high-Dk silicone lenses, 13 showed signs of contact lens papillary conjunctivitis. The average onset of the disorder was about 6 months. In about 70% of the subjects the disorder was quite severe as to necessitate the discontinuation of contact lens wear. It is found that the initial clinical experience with high Dk - silicone contact lens are less susceptible to coating than conventional extended wear contact lenses. However, the silicone lenses are found to be stiffer than the non-silicone hydrogel lenses. This stiffness of the silicone lenses causes conjunctival trauma in some patients. Recent reports document that generalized CPLC is more frequent in low Dk-lens wearers whereas local CPLC is more frequent with high Dk materials. The trauma induced GPC manifests itself in a more localized fashion.