Aetiology

Contact Lens-associated Papillary Conjunctivitis (CLAPC) presents withhyperaemia and roughnessof the palpebral surface in response to contact lens wear. A similar response may also be seen with ocular prosthetics, exposed sutures,filtration blebs, and in floppy eyelid syndrome. Its multifactoral aetiology is not fully understood

Type I immediate hypersensitivity mediated by IgE

• Possible antigens:
  • altered host protein on lens surface
  • bacterial cell wall constituents
  • other lens contaminants
• Reaction causes degranulation of mast cells
• Products of degranulation stimulate recruitment of basophils and eosinophils to conjunctival epithelium

Type IV delayed hypersensitivity mediated by T-cells

• Amplifies the inflammatory response

Trauma to the tarsal conjunctival surface releases chemotactic factors for a variety of inflammatory cells including eosinophils and neutrophils

Predisposing factors

Commoner in soft compared to rigid lenses

• occurs in silicone hydrogel, as well as hydrogel, lens wearers

Lens deposits
Thick or poorly designed or manufactured lens edges
Meibomian gland dysfunction
Atopy

Symptoms of contact lens-associated papillary conjunctivitis (CLAPC)

Itching and non-specific irritation

• may increase after lens removal (manipulation of lids mechanically stimulates mast cell degranulation)

Mucus discharge
Increased lens movement
Loss of lens tolerance
Decreasing comfort (may abandon wear)
Blurred vision
(NB: poor correlation of severity with symptoms and signs) 

Signs of contact lens-associated papillary conjunctivitis (CLAPC)

Almost always bilateral
Upper tarsal conjunctiva (lower usually not affected)

• papillae
  • macropapillae (diameter between 0.3 and 1 mm) or giant papillae (diameter > 1 mm)
  • apices of papillae may stain with fluorescein when inflammation active
  • apices may be whitish due to scarring in chronic cases
• hyperaemia
• stringy mucus in tear film and on conjunctival surfaces
• conjunctival oedema

Differential diagnosis

Vernal Keratoconjunctivitis, Atopic Keratoconjunctivitis, Seasonal Allergic Conjunctivitis, Superior Limbic Keratoconjunctivitis 

• contact lens history will aid diagnosis

Distinguish papillae from follicles:
Follicles:

• hyperplasia of lymphoid tissue
• generally seen in viral or chlamydial conditions
• smooth, pale, pink-to-yellow, elevated lesions
• surrounded by displaced vessels

Papillae: 

• hyperplasia of epithelium
• usually more discrete and more red than follicles
• side walls of papillae appear perpendicular to tarsal plate
• contain vascular core visible at apex as vascular tuft

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere.

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Removal of lens deposits

• replace soft lenses more frequently
• improve hygiene – more rigorous surfactant cleaning, more frequent enzyme use
• polish or replace rigid lenses

Reduce exposure time

• abandon extended wear
• reduce daily wearing time to minimum possible
• cease wear for a period in some cases

Optimise lens fit, material and wearing regime

• rigid lens: alter overall diameter (repositions lens edge relative to tarsus), reduce edge clearance and edge thickness
• soft lens: change material to one with improved deposit resistance, and/or lower modulus
• change to daily disposable soft lenses

Ocular prostheses

• polish, adjust or replace prosthesis

(GRADE*: Level of evidence=low; Strength of recommendation=strong)
 

Topical mast cell stabilisers (gutt. sodium cromoglicate 2% qds, gutt. lodoxamide 0.1%) can be used while lens wear continues but preserved drops should not be instilled with soft lenses in situ

(GRADE*: Level of evidence=low; Strength of recommendation=strong)
 

Topical combined anti-histamine/mast cell stabilizer e.g. gutt. olopatadine 0.1%, gutt. ketotifen 0.025% (both off-licence use)

(GRADE*: Level of evidence=low; Strength of recommendation=strong)
 

In cases that do not respond to other treatment, consider a six-week treatment period of a ‘non-penetrating’ topical steroid such as gutt. loteprednol 0.5% or gutt. fluorometholone 0.1% (both off-license use). Monitor IOP at beginning, at two weeks, and at end of treatment period (see Clinical Management Guideline on Glaucoma [Steroid]).

(GRADE*: Level of evidence=moderate; Strength of recommendation=strong)

Wherever preservative-free eye drops are available, these should be used when continuation of soft lens wear is deemed appropriate during the treatment period

Management category

B3: management to resolution
(normally no referral) 

Possible management by ophthalmologist

A range of topical steroids in recalcitrant cases that do not respond to other treatment, especially where contact lens wear is medically indicated

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
 

Sources of evidence

Asbell P, Howes J. A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. CLAO J. 1997;23(1):31-6

Elhers WH, Donshik PC. Giant papillary conjunctivitis. Curr Opin Allergy Clin Immunol. 2008;8:445-9

Friedlaender MH, Howes J. A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. The Loteprednol Etabonate Giant Papillary Conjunctivitis Study Group I. Am J Ophthalmol. 1997;123(4):455-64

Khurana S, Sharma N, Agarwal T, Chawla B, Velpandian T, Tandon R, Titiyal JS. Comparison of olopatadine and fluorometholone in contact lens-induced papillary conjunctivitis. Eye Contact Lens 2010;36:210-4

Kenny SE, Tye CB, Johnson DA, Kheirkhah A. Giant papillary conjunctivitis: A review. Ocul Surf. 2020;18(3):396-402

Matter M, Rahi AHS, Buckley RJ. Sodium cromoglycate in the treatment of contact lens-associated giant papillary conjunctivitis. Proc VII Congress of Europ Soc Ophthalmol, Helsinki 1985: 383-4 

Meisler DM, Berzins UJ, Krachmer JH, Stock EL. Cromolyn treatment of giant papillary conjunctivitis. Arch Ophthalmol. 1982 Oct;100(10):1608-10

CL-associated Papillary Conjunctivitis (CLAPC)
Giant Papillary Conjunctivitis (GPC)
Version 9
Date of search 15.06.21
Date of revision 27.08.21
Date of publication 05.04.22
Date for review 14.06.23
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