Contact lens-induced papillary conjunctivitis (CLPC), more generically known as giant papillary conjunctivitis (GPC), is associated with mechanical trauma of the tarsal plate from blinking over a contact lens that leads to an immunological response resulting in the proliferation of conjunctival papillae (Kenny et al, 2020). CLPC was common with soft lens wearing patients, especially with patients who have less frequent lens replacement, but also occurs with rigid contact lenses and ocular prostheses (Chin, 2006). The case presented is of a keratoconus patient who developed CLPC while wearing scleral lenses.

Case Details

A 59-year-old keratoconus patient was referred after previous failure of scleral lenses secondary to discomfort. Manifest refraction OD –4.50 –100 x 090, 20/250; and OS –4.50 –1.00 x 004, 20/200. The patient was refit with free-form 16.5mm scleral lenses in both eyes (Figure 1) that had monovision per his request.

Initially, the patient had acceptable comfort but started to complain of irritation OD with lens wear at an initial follow-up examination. Slit lamp exam revealed CLPC of his right eye (Figure 2) but not his left. His scleral lenses were remade adding a polyethylene glycol (PEG) coating to minimize deposits and lessen friction between his lids and scleral lens.

A short trial of olopatadine was recommended for his right eye. The patient followed up with his ophthalmologist who recommended the following protocol: loteprednol etabonate drops for two weeks with no scleral lens use, bepotastine besilate ophthalmic solution PRN, and tacrolimus drops. After restarting lens wear, he preferred his lenses without PEG and began biweekly usage of a deposit and protein remover and cleaner.

At his eventual return to our office six months later, he reported that he had acceptable comfort with his scleral lenses. The patient was now using tacrolimus two times per week in both eyes and bepotastine besilate ophthalmic solution every morning in both eyes. Slit lamp exam now shows non-inflammed upper tarsal plate papillae of both lids.

Impact of CLPC

The development of CLPC results in irritation with lens wear, which can decrease wear time. For scleral lens patients, temporary discontinuation to help reduce acute inflammation is not always ideal, especially if the patient requires scleral lenses for functional vision. Steroids and mast cell stabilizers have a limited role in promoting resolution (Chin, 2006). Topical tacrolimus drops can be an effective steroid alternative for the management of CLPC (Diao et al, 2012).

Addressing the source of mechanical trauma is the key for resolution. Eliminating any superior edge lift with customized landing zones will decrease lid trauma that can be a primary cause of CLPC. Using a PEG coating may help some patients reduce friction and deposits that can be the causative source of CLPC. For this case, the patient preferred using a biweekly cleaner. CLS

REFERENCES:

1. Kenny SE, Tye CB, Johnson DA, Kheirkhah A. Giant papillary conjunctivitis: A review. Ocul Surf. 2020 Jul;18:396-402.
2. Chin T. GPC: Don’t Call it An Allergic Reaction. Rev Optom. 2006 Oct 24. Available at reviewofoptometry.com/article/gpc-dont-call-it-an-allergic-reaction . Accessed Sept. 4, 2022.
3. Diao H, She Z, Cao D, Wang Z, Lin Z. Comparison of tacrolimus, fluorometholone, and saline in mild-to-moderate contact lens-induced papillary conjunctivitis. Adv Ther. 2012 Jul;29:645-653.