Giant papillae visible on upper eyelid eversion

ICD-10 Diagnosis Codes:

H10.411–Chronic giant papillary conjunctivitis, right eye
H10.412–Chronic giant papillary conjunctivitis, left eye
H10.413–Chronic giant papillary conjunctivitis, bilateral


Giant Papillary Conjunctivitis


Disorders Of The Conjunctiva


Giant papillary conjunctivitis (GPC) is a form of chronic conjunctivitis that is characterized by giant papillae on the superior tarsal conjunctiva. 

Giant papillary conjunctivitis (GPC) is a form of chronic conjunctivitis that can be seen in patients with the following conditions:

  • Patients who wear contact lenses
  • Patients with exposed sutures after intraocular surgery
  • Patients with a prosthetic eye
  • Patients with hay fever or animal allergies

Giant papillary conjunctivitis is a result of the body’s over reaction to immunogen or allergen and is usually innate or acquired after multiple exposures to an antigen, however it has no seasonal variations. 

Cytologic scraping from the conjunctiva exhibit lymphocytes, plasma cells, mast cells, eosinophils and basophils which suggest an antigen-antibody mechanism.  In general the allergic response causes phopholipase A2 to cause the release of histamine from the mast cells.
DG37211Pic09   Papillary Hypertrophy of the Palpebral Conjunctiva

  • This mast cell degranulation increases capillary permeability and produces lymphocyte circulation such as T-cells, eosinophils and monocytes
  • The degranulation also initiates the liberation of arachidonic acid, which is the catalyst for cyclooxygenase and lipoxygenase pathways
  • These two pathways produces inflammatory mediators such as thromboxanes, leukotrienes and prostaglandins which cause ocular discomfort and the formation of papillae

More recently, GPC is being seen in patients wearing silicone-hydrogel (SiHi) lenses.  SiHi lenses can have a higher predisposition to deposit formation creating a roughened surface on the contact lens.  The resultant GPC is considered more of a mechanical response to the frictional contact lens surface.  

Structural Damage to the Eye 

  • Structural damage to the eye occurs from mechanical irritation of the tarsal conjunctiva of the upper lids resulting in histological changes in the tissue such as mast cell degranulation and the secondary inflammatory cascade
  • There will also be an inflammation of the vasculature and superior lid hypertrophy
  • Last, repetitive mechanical irritation can result in corneal abrasions with infiltrates


Functional Damage to the Eye 

Giant papillary conjunctivitis can cause decreased vision as result of excessive lens deposits on the lens from the inflammatory response.  Also, decreased vision can occur from displacement of the lens with blinking because of the superior lid hypertrophy. 

DG37211Pic11 Contact Lens-Induced Giant Papillary Conjunctivitis

  • Excessive protein coating on contact lens
  • High-riding contact lens
  • Mild conjunctival hyperemia
  • Secondary ptosis
  • Reduced visual acuity secondary to coated lens

The main goal of the diagnostic evaluation in a patient with giant papillary conjunctivitis is to accomplish the following:

  • Determine the underlying etiology of the giant papillary conjunctivitis
  • Relieve ocular pain and discomfort
  • Explain the condition to the patient
  • Prescribe a treatment plan to treat the underlying condition
  • Attempt to make changes that will lessen or prevent recurrence of the condition

Patient History

Patients with giant papillary conjunctivitis will present with the following signs and symptoms:

  • Blurred vision
  • Episodic tearing
  • Blepharospasm
  • Photophobia
  • Conjunctival injection
  • Mild foreign body sensation to severe pain
  • Ocular itching that worsens with contact lens removal
  • Increase mucous discharge in the tears especially in the morning

Contact lens intolerance characterized by any of the following clinical findings:

  • Decreased wear time
  • Increased lens awareness
  • Excessive contact lens coating
  • Excessive upward lens movement (typically, although can be random movement) 


Clinical Appearance of the Conjunctiva

  • Look for conjunctival injection 
  • Perform upper eyelid eversion 
DG37211Pic02 Giant Papillary Conjunctivitis

  • Eyelid eversion shows hyperemia and papillary hypertrophy 
  • Mechanical irritation of the tarsal conjunctiva of the upper lids results in histological changes in the tissue
  • Chronic inflammation results in a giant paillae formation


Clinical Appearance of the Tear Film

  • Mucus strands can be seen in the tears in mild cases
  • Mucus can be seen between the papillae in moderate-to-severe cases
  • Papillae can be small uniform cobblestone lesions to irregular clusters of giant lesions with whitish centers that can ulcerate and stain with fluorescein
DG37211Pic07 DG37211Pic08 DG37211Pic10


External Ocular Photography

  • Document the progression or lack of progression of giant papillary conjunctivitis
  • To help plan a treatment program
  • Document the delivery and response to medical treatment

There is no official classification system for giant papillary conjunctivitis.  It is often described based upon severity of the condition with mild, moderate, or severe descriptors.  The severity of the condition determines the aggressiveness of the treatment. 

This would include any other disease that presents with papillary response and/or ptosis.

Allergic Conjunctivitis

Patients with allergic conjunctivitis will present with symptoms of redness, watery eyes, mild discharge and the hallmark symptom of itchy eyes and conjunctival injection.  Patients with allergic conjunctivitis usually do not describe a foreign body sensation like patients with giant papillary conjunctivitis do. 

DG37211Pic12 Allergic Conjunctivitis

  • For patients with allergic conjunctivitis, there is some contact lens intolerance, but not to the extent of those with giant papillary conjunctivitis
  • Allergic conjunctivitis can give the eye an overall edematous appearance
  • Patients with allergic conjunctivitis tend to have seasonal occurrence and will report an allergy to something versus patients with giant papillary conjunctivitis do not
  • Giant papillary conjunctivitis patients have symptoms as long as the mechanical irritation is still present.

Vernal Conjunctivitis 

The symptoms of discomfort or eye pain, redness, photophobia, foreign body sensation.  The clinical signs are some what different and the case history is very important.

DG37211Pic13 Vernal Conjunctivitis

  • The papillae take on a large, more cobblestone appearance
  • The symptoms are the hallmark differential, with symptoms in vernal being almost always severe in nature
  • The itching in vernal can be so intense that patients create abrasions or sores on their peri-orbital skin
  • The most common demographic for vernal conjunctivitis is a pre-teen African-American male, although any young atopic individual can be at risk

Viral Keratoconjunctivitis 

The symptoms of discomfort or eye pain, redness, photophobia, foreign body sensation are the same except viral conjunctivitis patients also have watery eyes and the palpebral conjunctival redness is more of a diffuse pinkish color.

DG0771AB Viral Keratoconjunctivitis

  • Patients with a viral keratoconjunctivitis will often have swollen preauricular lymph nodes
  • The clinical signs are some what different and the case history is very important
  • The presentation is almost always more acute and the symptoms less severe 

Congenital Ptosis

Giant papillary conjunctivitis can cause a ptosis that may be mistaken for a patient who has a congenital ptosis.  In these cases ask the patient whether their eyelid has always looked droopy or smaller most of their life. 

Treatment is based on the severity of the giant papillary conjunctivitis.  The severity of the condition determines the aggressiveness of the treatment.  In addition, the patient should be educated on the potential need for long-term treatment and/or recurrent therapy.

Pharmacological Treatment 

Mild giant papillary conjunctivitis – Topical mast cell stabilizer 

  • Alocril b.i.d 
  • Alamast q.i.d 
  • Alomide q.i.d 
  • Crolom q.i.d

Moderate giant papillary conjunctivitis – Topical anti-histamine/mast cell stabilizer and NSAID

  • Pataday q.d 
  • Patanol b.i.d
  • Bepreve b.i.d.
  • FML 0.1% t.i.d.
  • Lotemax Gel t.i.d.

Severe giant papillary conjunctivitis – Topical anti-inflammatory and anti-histamine/mast cell stabilizer

  • Pred forte t.i.d.

Mechanical Treatment

Discontinue contact lens wear and change contact lens treatment options:

  • Change to daily wear disposables
  • Decrease wearing time
  • Change from soft contact lenses to gas permeable contact lenses
  • If the patient is wearing a SiHi lens, change to hydrogel material with hydrogen peroxide disinfection and digital cleaning
  • Prescribe bandage contact lens to cover exposed sutures after intraocular surgery
  • Increase the frequency of cleaning a prosthetic eye

In all cases of giant papillary conjunctivitis, resolution of the disease can be highly variable.  Giant papillary conjunctivitis from contact lens wear (especially extended wear lenses or when poor compliance is involved) may take several months of aggressive treatment to resolve.  Resolution of giant papillary conjunctivitis induced by SiHi lenses can be fairly rapid, often as little as a week or two.

Surgical Treatment

  • Remove exposed sutures

1.  Brujic M.  Kading D.  Allergies and contact lens wear: finding the successful balance.  Contact Lens Spectrum. 2013 March: 27-31