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Clinicians address increased incidence of GPC with aggressive treatment
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A sampling of optometrists finds an increase in the incidence of the inflammatory condition giant papillary conjunctivitis, primarily associated with contact lens wear. While this contact lens complication may be multifactorial in nature, relatively simple treatment protocols have shown impressive results in nearly all patients.
“Over the last 5 or 6 years, I feel giant papillary conjunctivitis (GPC) has become a more prevalent issue at our practice,” Derek N. Cunningham, OD, FAAO, director of optometry at Dell Laser Consultants in Austin, Texas, said in an interview.
GPC and silicone hydrogels
Patients most at risk of developing GPC at Dell Laser Consultants are likely those who are extended-wear silicone hydrogel lens users primarily for a week at a time. “This might be attributed to market share penetration of silicone lenses over conventional lenses,” Dr. Cunningham said. “The stiffer material of silicone (as opposed to hydrogel) may also have a mechanical component that increases the amount of GPC we are seeing.
“It is also easy to make the conclusion that extended wearing times will increase GPC,” he continued. “As our understanding of GPC evolves, we are learning that there are not only chemical and immune reactions occurring, but physical irritation as well.”
 Figure 1. Typical GPC from soft contact lens wear under cobalt blue light with the use of fluorescein dye.  Figure 2. Clinicians attribute GPC to contact lens over wear and allergy. Images: Cunningham DN |
Patients with poor lens compliance are also at a much higher risk of GPC, Dr. Cunningham said. However, as for a detrimental solution-lens material interaction, “this has been difficult to elicit,” he said. “All the studies I’ve reviewed have some deficiencies, such as just taking one aspect of a disease process that may not be correlated to anything else.”
I. Ben Gaddie, OD, owner of Gaddie Eye Centers in Louisville, Ky., said he has also seen a “huge increase” in incidence of GPC. “I’m putting all the blame on silicone hydrogel lenses,” he told Primary Care Optometry News. “Published clinical trials and anecdotal evidence indicate that silicone hydrogel lenses cause an increase in GPC. Silicone hydrogels are more lipophilic, so they like lipids and proteins, which can certainly contribute to the cycle that leads to GPC. In addition, some of the first-generation silicone lenses had a stiffer or more abrasive modulus, which I think contributes to GPC from a mechanical standpoint.”
Dr. Gaddie is perplexed as to why the industry has “pushed” so many patients into silicone hydrogel lenses. “These lenses were originally designed for patients who desire to sleep in their lenses,” he said. “I spend most of my time taking people out of silicone lenses and putting them back into traditional HEMA material or into 1-day disposables.”
Dr. Gaddie also does not place much credence in the debates that point fingers at the lens edge or solution-material interaction as being the cause of GPC. “Any interaction is transient and does not lead to infections or inflammation,” he said.
Terry F. Hawks, OD, FAAO, a private practitioner in Overland Park, Kan., told PCON in an interview, “There’s no question we’ve seen an increase in GPC. We used to see very little, but now we’re seeing several cases a month over the past few years. It is mostly silicone hydrogel wearing patients and it seems to be more prevalent in some brands than others.”
Dr. Hawks speculated that a number of factors could be responsible for the GPC increase: seasonal allergies, solution incompatibility with the lens, the modulus of the lens material itself or even the logos that are pressed onto the lens.
“Some patients may also be sleeping more in their silicone lenses, causing more build-up on the lens,” he said. “Poor compliance might be a factor, too.”
Lens abuse, allergy
Mel A. Friedman, OD, a private practitioner in Memphis, Tenn., who specializes in hard-to-fit contact lenses, agrees that GPC is on the rise. “We notice it more in patients who are fairly abusive with their lenses and have some history of allergy,” he said in an interview. “We are always fighting GPC during the spring and fall.”
Dr. Friedman has observed GPC across the board among contact lens users. “Silicone lenses are not the panacea everyone thinks they are,” he said. “Many doctors thought edge design contributed to GPC, but we now find abuse in lens wear and environment are major factors.”
Improper cleaning is another contributing factor, such as the left-eye syndrome or left-handed syndrome, he said.
“Why is it that a patient will have a right-eye tarsal plate that is clear and a left-eye tarsal plate that has GPC?” Dr. Friedman said. “The reason is because the right-eye lens is removed first and cleaned a lot better and more energetically than the left-eye lens; hence, there is more irritation in the left eye.
“Cleaning has a tremendous effect; we emphasize to our patients all the time that they should be rubbing and cleaning,” he continued. “The fact that no-rub solutions are advertised at all is a problem.”
Furthermore, GPC can be caused by wearing lenses past their recommended life span, he said.
Aggressive treatment with steroids
Dr. Cunningham’s preferred method for treating GPC among lens wearers is to discontinue lens usage and treat the patient extremely aggressively with an ester steroid eye drop, for safety reasons. “I honestly believe that in most cases, you cannot get a foot up on immune response unless you use an aggressive steroid,” he said.
Patients refrain from lens wear for a minimum of 2 weeks.
“Results are good,” he said. “Patients can return to lenses much quicker than with a traditional antihistamine or the complete discontinuation of lenses.”
An alternative therapy for those patients who absolutely need to wear lenses or are asymptomatic is to prescribe a topical steroid to be used pre- and post-daily wear, along with an antihistamine drop that can be used with contact lens wear.
“But leaving a lens in the eye when you are trying to cure GPC takes exponentially longer for the process to be rectified, if at all,” Dr. Cunningham said. “Being mindful of subclinical comorbidities is also important, including dry eye and blepharitis. In numerous cases, I find mild levels of dry eye or blepharitis that could very well be the primary instigator of eventual GPC.”
Dr. Hawks’ treatment protocol for GPC consists of discontinuing lens wear and prescribing Pred Forte (prednisolone acetate, Allergan) eye drops four times a day for 1 week. “By then, a lot of patients are considerably better,” he said.
If so, patients can usually start wearing their lenses again while tapering off the Pred Forte, twice a day, for 2 or 3 more weeks. However, patients often end up in a daily wear lens after awhile, he said.
“I don’t recall a single incident of GPC with daily disposable lenses,” he said.
Antihistamine/mast-cell stabilizers
For mild-to-moderate cases of GPC, Gaddie Eye Centers usually discontinues lens wear for about 1 month, during which time a topical antihistamine/mast-cell stabilizer is prescribed; for example, Patanol (olopatadine, Alcon), Elestat (epinastine ophthalmic, Allergan/Inspire) or Bepreve (bepotastine besilate ophthalmic solution 1.5%, Ista). A topical nonsteroidal anti-inflammatory drug (NSAID) is dispensed as well.
“Many times, we will also add a soft steroid such as Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb) because patients will be on it for a month,” Dr. Gaddie said. “I feel Lotemax has a little less propensity to raise the intraocular pressure.”
After 1 month, if the condition has begun to resolve, the steroid and NSAID usually will be discontinued and the patient can begin wearing a daily disposal while continuing the allergy eye drop.
“This protocol seems to work really well,” Dr. Gaddie said.
Off-label therapy
Dr. Friedman is enthused about using Bepreve with contact lenses as an off-label therapy to treat GPC. “Bepreve is H1-specific, with H2 properties, and a cell masking stabilizer, so it inhibits the histamine reaction,” he said. “GPC is an irritation of the tarsal plate, so we are trying to reduce the infection or inflammation of the tarsal plate.”
Combining cromolyn with Bepreve or a steroid or combining Bepreve with a steroid “also seems to work well to reduce GPC in the attack form,” Dr. Freidman said. Environmental factors may also play a role, such as “air quality, along with heat and air conditioning, causing people to have drier eyes, which may lead to more irritation and exacerbate allergies.”
Dr. Friedman noted that for patients who refuse to discontinue contact lens wear, he will consider allowing them to wear daily disposables, “as long as they’re not causing damage to the cornea and we’re getting good results.” – Bob Kronemyer
- Derek N. Cunningham, OD, FAAO, can be reached at (512) 347-0255; dcunningham@dellvision.com.
- Mel A. Friedman, OD, can be reached at (901) 737-4393; dfried007@aol.com.
- I. Ben Gaddie, OD, is a Primary Care Optometry News Editorial Board member. He can be reached at (502) 423-8500; ibgaddie@bellsouth.net.
- Terry F. Hawks, OD, FAAO, is a PCON Editorial Board member. He can be reached at (913) 341-4508; (913) 856-6360; tfhawks@aol.com.
- Disclosures: Drs. Cunningham, Friedman, Gaddie, and Hawks have no direct financial interest in the products mentioned in this article. Dr. Cunningham is a consultant for Bausch + Lomb and Ista Pharmaceuticals. Dr. Friedman is a national consultant for Ista. Dr. Gaddie is a consultant for Bausch + Lomb, Ista and Allergan. Dr. Hawks is not a paid consultant for any of the companies mentioned.