CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology 

Multifactoral aetiology 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 tarsal conjunctival surface releases neutrophil chemotactic factor

  • Sources of trauma
    • contact lenses
    • ocular prostheses
    • protruding sutures, extruding scleral buckles, filtration blebs
    • elevated corneal deposits

Predisposing factors

  • Commoner in soft compared to rigid lenses
    • reported in silicone hydrogel, as well as hydrogel, lens wearers
  • Lens deposits
  • Thick or poorly designed or manufactured lens edges
  • Meibomian gland dysfunction
  • Atopy

Symptoms

  • 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

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

Non pharmacological

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
  • change soft lens material to one with improved deposit resistance
  • change to daily disposable soft lenses

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

Pharmacological 

Topical mast cell stabilisers (gutt. sodium cromoglicate 2%, gutt. lodoxamide 0.1%, gutt. nedocromil sodium 2%):

  • can be used while lens wear continues but preserved drops should not be instilled with soft lenses in situ
  • nedocromil sodium is yellow and may discolour soft lenses

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

Topical combined anti-histamine/mast cell stabilizer e.g. gutt. olopatadine 0.1% (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 trial of a ‘non-penetrating’ topical steroid such as gutt. loteprednol 0.5% qds (off-licence 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)

 

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

Bailey CS, Buckley RJ. Nedocromil sodium in contact lens-associated papillary conjunctivitis. Eye 1993;7(suppl):29-33

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

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 

Lay summary

Contact lens-associated papillary conjunctivitis (CLAPC) is an inflammatory condition affecting the transparent membrane which lines the back of the upper eyelid (tarsal conjunctiva). It can occur in people wearing soft or rigid contact lenses or an ocular prosthesis (artificial eye). People suffering from this condition experience eye irritation, which may lead them to abandon contact lens wear. The vision may be blurred intermittently. The eyes are often red and the underside of the upper lid shows minute cobblestone-like swellings called papillae. Treatment for CLAPC initially consists of improving contact lens hygiene and replacing lenses more frequently. Eye drops such as anti-histamines or mast cell stabilisers are often required to relieve symptoms and improve clinical signs. In more severe cases it may be necessary to use steroid eye drops for short periods.

CL-associated Papillary Conjunctivitis (CLAPC)
Giant Papillary Conjunctivitis (GPC)
Version 7
Date of search 21.04.17
Date of revision 21.04.17
Date of publication 05.12.17
Date for review 20.04.19
© College of Optometrists 

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