Giant Papillary Conjunctivitis Revisited
BY TIMOTHY T. MCMAHON, OD, FAAO
Grading the severity of GPC varies among clinicians. The complicated parts are treatment decisions and follow-up management. Let's look again at clinical markers of severity in GPC.
Signs to focus on include superior and inferior tarsal papillae with or without apical staining, conjunctival edema, mucus discharge, tarsal conjunctival injection and ptosis. Removing the causal agent results in a rapid resolution of symptoms. Physical findings are always slower to resolve than symptoms, so following GPC by symptoms alone is inadequate. Let's look at the important findings.
Papillae. As GPC develops, inflammatory cells and immunoglobulins invade and expand these structures. With sufficient cellular invasion, hypertrophic papillae coalesce to form giant papillae 0.8 to 1.0 mm or larger in size. The papillae are round or oval early on and tend to flatten at the top with time and as they grow in size, giving the "cobblestone" appearance. Papillae remain present for months after GPC is no longer active.
Apical staining. Staining can be seen in active moderate to severe GPC and uncommonly in active mild GPC. This is the first to resolve.
Conjunctival edema and hyperemia. These are valuable markers of GPC activity. When inflammatory cells are invading the conjunctival tissue releasing their mediators, the conjunctiva becomes edematous. The mild to moderate boggy appearance leads to obscuration of the conjunctival microvasculature. Hyperemia can be helpful as a tracking tool but is unimpressive in the majority of cases. In suture-induced cases, conjunctival hue is a very useful physical feature to track.
Mucus discharge. Tracking patient reports about higher than usual levels of mucoid debris, particularly recovered upon awakening, is more valuable than tracking itching symptoms.
Ptosis. Ptosis found with GPC is no more than 1 to 2 mm and presents in moderate to severe cases.
I separate GPC into causal agent, initial severity and current degree of activity. GPC carries one cause and two grades such as Suture GPC/3+/2+. This GPC is caused by a suture, has a grade three severity and a current level of activity of 2+. The next column will address treatment strategies for GPC.
TABLE 1: GPC Grades of Severity and Level of Activity
Fine velvety to smooth appearance
|Papillary Hypertrophy||Papillae clinically visible and <.40 mm
0 to 1+ injection
Conjunctival microvasculature visible (no edema)
No or minimal mucous discharge evident
Macro papillae .40 to .80 mm
Macro papillae 0.40 to 0.80 mm
Giant papillae >0.80 mm
Giant Papillae >0.80 mm
|Normal||No obscuration of conjunctival microvasculature|
|Papillary Hypertrophy||No obscuration of conjunctival microvasculature|
|1+ Active||Trace obscuration of conjunctival microvasculature|
Mild obscuration of the conjunctival
Moderate to severe obscuration of the
Severe edema and obscuration of the
Dr. McMahon is an associate professor and Director of the Contact Lens Service at the University of Illinois at Chicago Dep. of Ophthalmology & Visual Sciences.
Dr. Gerber is the president of the Power Practice a company offering consulting, seminars and software solutions for optometrists. He can be reached at 800-867-9303 or DrGerber@PowerPractice.com