Aetiology

Contact lens-associated papillary conjunctivitis (CLAPC) is an inflammatory condition of the upper tarsal conjunctiva, presenting with hyperaemia and roughness of the conjunctival surface in response to contact lens wear. A similar response may also be seen with ocular prosthetics, exposed sutures, extruded scleral buckle, filtration blebs, and in floppy eyelid syndrome. Its multifactoral aetiology is not fully understood. CLAPC is thought to be immunological in origin but mechanical factors may also play a role. Both Type 1 and Type IV hypersensitivity reactions have been implicated.

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

Localised mechanical trauma to the tarsal conjunctival surface caused by contact lens movement and lens edge releases chemotactic factors for a variety of inflammatory cells including eosinophils and neutrophils.

Predisposing factors

Risk of CLAPC increases with duration of contact lens wear. More common in reusable soft lens wear compared to disposable soft or rigid lens wear.

High modulus silicone hydrogel (SiH) lenses may contribute to the mechanical aspect of the disease due to increased frictional irritation of the tarsal conjunctival surface.

Overnight contact lens wear
Lens deposits
Thick or poorly designed or manufactured lens edges
Preservatives in contact lens care products
Meibomian gland dysfunction
Atopy

Symptoms of contact lens-associated papillary conjunctivitis (CLAPC)

Itching and non-specific irritation e.g. burning, foreign body sensation.

• 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
  • may be localised or generalised
  • in the localised form (more common in SiH wearers) the papillae are confined to one or two areas of the tarsal conjunctiva. In the generalised form, papillae are present over the entire tarsal conjunctiva
  • 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: 

• thickened irregular 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

Initial management of CLAPC should focus on addressing predisposing factors relating to contact lenses or their care products.

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 (e.g. 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

Stapleton F, Bakkar M, Carnt N, Chalmers R, Vijay AK, Marasini S, Ng A, Tan J, Wagner H, Woods C, Wolffsohn JS. CLEAR - Contact lens complications. Cont Lens Anterior Eye. 2021;44(2):330-367.

CL-associated Papillary Conjunctivitis (CLAPC)
Giant Papillary Conjunctivitis (GPC)
Version 10
Date of search 25.07.23
Date of revision 26.10.23
Date of publication 23.01.24
Date for review 24.07.25
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