contact lens care

GP Lens Care for Giant Papillary Conjunctivitis

BY MICHAEL A. WARD, MMSC, FAAO

A 59-year-old male presented with complaints of ocular itching, mucous discharge and cloudy vision. All complaints are longstanding, for more than 10 years. His ocular history is significant for giant papillary conjunctivitis (GPC), keratoconus and postpenetrating keratoplasty with aphakia in his right eye. He has primary open angle glaucoma managed with Alphagan-P (Allergan) OU. He's wearing GP lenses OU. Lens care consists of Boston Original Formula Cleaner and Conditioning solutions (Bausch & Lomb) with occasional enzymatic cleaning.

External examination shows bilateral ptosis, and slit lamp evaluation reveals giant (>1.0mm) papillae and superior palpebral conjunctiva thickening in all zones of both eyelids. The keratoconus in his left eye is relatively mild and without scarring. The graft in his right eye is clear.

His refractions are OD +7.75 –1.75 x50 =>20/50; OS –3.75 –2.75 x30 =>20/30, indicating a significant anisometropia. Therefore, discontinuing contact lens wear and wearing spectacles is not an option.

Giant Papillary Conjunctivitis

Contact lens-associated GPC is the result of an immunologic reaction to the presence of a foreign body (lens) and the coating of the foreign body with tear proteins (lysozyme, lactoferrin, lipocalin, immunoglobulins), which may be denatured. Histopathologically, GPC patients exhibit one of the following abnormalities: mast cells in the conjunctival epithelium; eosinophils in the epithelium or substantia propria; and/or basophils in the epithelium or substantia propria.

Figure 1. Chronic giant papillary conjunctivitis.

Maximum Contact Lens Care

The key to contact lens-associated GPC management is to keep the lenses clean. Because single use disposable lenses aren't an option here, we need to maximize cleaning of the GP lenses, which will decrease the body's immune response and therefore the patient's symptoms.

We prescribed the following lens care regimen:

• On alternate days use Boston Advance Daily Cleaner (B&L) and Optimum Extra Strength Cleaner (Lobob) to clean lenses.
• Disinfect with UltraCare (Advanced Medical Optics) peroxide system overnight.
• Enzyme cleaning with Ultrazyme (AMO) every other day.
• Wet the lens with preservative-free artificial tears.

Discussion

By alternating surfactant cleaners between an abrasive (Boston) and a strong solvent (Optimum), we get the best of both worlds. The oxidizing action of peroxide disinfection cleans GP lenses thoroughly and isn't affected by organic load. Proteolytic enzymes act to reduce protein accumulation on the lens surfaces.

An alternative to Ultrazyme could be daily use of SupraClens (Alcon). This lens care regimen is preservative-free.

In addition to this daily cleaning regimen, his lenses are to be regularly cleaned and polished manually or treated with Progent (Menicon) to reduce protein and debris build-up. We also prescribed a mast cell stabilizer in a maintenance dose of twice a day.

This maximum contact lens care system has allowed our keratoconic-aphake patient to comfortably continue his lens wear. CLS

Mr. Ward is an instructor in ophthalmology at Emory University School of Medicine and Director, Emory Contact Lens Service.