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Papillary hypertrophy: Clinical research helps define your treatment
William J. Benjamin, OD, PhD, contributing editor
ClinicalR & D
Papillary Hypertrophy: Clinical Research Helps Define Your Treatment An Interview with Susan E. Marren, OD, of the Pennsylvania
Dr. Susan E. Marren gave a presentation before the Association of Optometric Contact Lens Educators (AGCLE) in Philadelphia, Pennsylvania, during the summer of 1989. Among a “whirlwind” of activity arranged by the Pennsylvania College of Optometry (the group encountered a tornado on the Delaware River at a reception the night before), Dr. Marren indicated that soft lenses and rigid lenses have been associated with giant papillary conjunctivitis (GPC). Furthermore, she stated that the probable cause of the GPC should be analyzed in order to best manage the patient. Immediately after Dr. Marren’s presentation, I interviewed her to ascertain more fully what she had meant.
contact lenses. The appearances of papillary hypertrophy induced by chronic ocular surface exposure to such “soft” and “rigid” foreign bodies are different and are probably indicative of separate primary causes of papillary hypertrophy in humans. When wearing soft contact lenses, papillary hypertrophy generally develops along a zone of palpee bra1 conjunctiva near the fold in the everted superior eyelid. Papillae rarely are present next to the lid margin, but may spread away from the fold as the number of papillae and severity of the hypertrophy increase. In “soft lens GPC,” the papillae are numerous, are rounded with flattened tops, and are contig
However, papillary hypertrophy and its end-stage GPC can also be associated with the wear of rigid
Figure 1. Papillary hypertrophy induced by wear of soft contact lenses. (Photo courtesy Dr. Shelley Cutler.)
0 1990 Buttetworth
Publishers
College of Optometry
uous across the conjunctival surface (see Fig. 1). Papillary hypertrophy seen with the wear of rigid lenses, on the other hand, develops across the conjunctival surface of the tarsal plate (see Fig. 2). Papillae are fewer in number than those seen with the wear of soft lenses and may be scattered with craterlike tops that collect fluorescein. Isolated papillae may be seen near the margin of the superior eyelid in “rigid lens GPC.” Dr. Benjamin: Why would a rigid lens induce a different papillary appearance than would a soft lens? Dr. Marren: Soft lenses contact more surface area of the superior palpebra1 conjunctiva than do rigid
Figure 2. Papillary hypemophy induced by the wear of rigid contact lenses. (Photo courtesy Dr. Joel Silbert.)
ICLC, Vol. 17, MarIApr
1990
103
Clinical R B D lenses and are thought to carry a larger antigenic load. Rigid lenses have a mechanical interaction with the upper lid at the lens edge, and because they are smaller than soft lenses, this interaction is positioned at the tarsal plate. Rigid lenses are more easily cleaned free of coatings and deposition. Thus, soft lenses have been thought to primarily induce GPC by providing antigens to which the eyelids become hypersensitive with chronic exposure. Rigid lenses have been thought to primarily induce a similar physiological response by creating chronic microtrauma to the superior palpebral conjunctiva. There is histological evidence to support hypersensitivity and mechanical trauma as causative of papillary hypertrophy. Allansmith and co-workers stated that soft lens GPC was most probably a cutaneous basophil hypersensitivity, a type of delayed sensitivity or cellmediated sensitivity, with lens coatings acting as antigens for an additional humoral (immediate) response mediated by IgE, plasma cells, and mast cells. Whereas basophils are indicative of a delayed hypersensitivity, neutrophils and eosinophils have been found in GPC induced by soft and rigid lenses. Allansmith and co-workers further noted that GPC induced by nylon sutures, considered biologically inert, was accompanied by neutrophils and eosinophils but not basophils or plasma cells and, therefore, that this papillary hypertrophy must have been primarily of traumatic origin. Greiner described giant papillae with no mucus or itching that occurred surrounding an epithelialized foreign body and suggested that papillogenesis may have been the result of trauma alone. Most cases of papillary hy
104
ICLC, Vol. 17, Mar/Apr 1990
Table 1. Differential Diagnosis and Treatment of Papillary Hyperrrophy Associated with Wear of Soft and Rigid Contact Lenses Soft Lenses Papillae Distribution
Typically near fold of
Pattern Shape Number Probable Cause Primary Treatment
Options
everted lid, rarely at lid margin Contiguous Flattened Many
Typically over tarsal plate, occasionally near lid margin Scattered Craterlike Fewer
Primarily a hypersensitive allergenic response
Primarily a mechanical traumatic response
Discontinue wear Reduce wearing time Cold compresses Lubricant/decongestant Enhance cleaning Alter lens material Try disposable lenses Change to rigid lenses Topical steroid Antihistamine Mast cell inhibitor
Discontinue wear Reduce wearing time Cold compresses Lubricant/decongestant Reduce edge lift and/or thickness Polish surface/edge Change rigid lens fit’ Topical steroid Antihistamine
’ For example, interpalpebral
to lid attachment
pertrophy, however, are probably the result of all three causative routes (delayed sensitivity, immediate antigenic response, and trauma). One route plays a predominant role in each case of hypertrophy because of characteristics of the particular foreign body involved. Dr. Benjamin: Why should the practitioner be aware of the different causes of papillary hypertrophy?
Dr. Marren:
Rigid Lenses
The causes of papillary hypertrophy and differentiation of these causes are important for the contact lens practitioner. It is on these causes that his or her treatment of the condition is predicated. For instance, sodium cromolyn is a mast cell inhibitor that will reduce papillary responses induced by the humoral (immediate) route, but may not be particularly effective for GPC induced by rigid
fit.
lenses or for hypertrophy that is primarily basophilic in nature. As “soft lens GPC” may be a combination of “delayed” and “immediate” hypersensitivities, with only a minor role played by trauma, treatment with sodium chromolyn may best work in cases when GPC develops quickly after an exposure to antigen. Please keep in mind, though, that all of this is still not perfectly understood and I would not advise against the use of sodium cromolyn as well in cases of GPC due to chronic exposure. Other treatments of GPC, listed in Table 1, have been designed with reduction of ocular hypersensitivity and/ or trauma in mind. It is up to the practitioner, with his knowledge of the patient’s condition and the prescribed contact lens and care regimen, to ascertain which of the various treatments are most justified for each individual case of GPC.
ClinicalR & D
Papillary Hypertrophy: Clinical Research Helps Define Your Treatment An Interview with Susan E. Marren, OD, of the Pennsylvania
Dr. Susan E. Marren gave a presentation before the Association of Optometric Contact Lens Educators (AGCLE) in Philadelphia, Pennsylvania, during the summer of 1989. Among a “whirlwind” of activity arranged by the Pennsylvania College of Optometry (the group encountered a tornado on the Delaware River at a reception the night before), Dr. Marren indicated that soft lenses and rigid lenses have been associated with giant papillary conjunctivitis (GPC). Furthermore, she stated that the probable cause of the GPC should be analyzed in order to best manage the patient. Immediately after Dr. Marren’s presentation, I interviewed her to ascertain more fully what she had meant.
contact lenses. The appearances of papillary hypertrophy induced by chronic ocular surface exposure to such “soft” and “rigid” foreign bodies are different and are probably indicative of separate primary causes of papillary hypertrophy in humans. When wearing soft contact lenses, papillary hypertrophy generally develops along a zone of palpee bra1 conjunctiva near the fold in the everted superior eyelid. Papillae rarely are present next to the lid margin, but may spread away from the fold as the number of papillae and severity of the hypertrophy increase. In “soft lens GPC,” the papillae are numerous, are rounded with flattened tops, and are contig
However, papillary hypertrophy and its end-stage GPC can also be associated with the wear of rigid
Figure 1. Papillary hypertrophy induced by wear of soft contact lenses. (Photo courtesy Dr. Shelley Cutler.)
0 1990 Buttetworth
Publishers
College of Optometry
uous across the conjunctival surface (see Fig. 1). Papillary hypertrophy seen with the wear of rigid lenses, on the other hand, develops across the conjunctival surface of the tarsal plate (see Fig. 2). Papillae are fewer in number than those seen with the wear of soft lenses and may be scattered with craterlike tops that collect fluorescein. Isolated papillae may be seen near the margin of the superior eyelid in “rigid lens GPC.” Dr. Benjamin: Why would a rigid lens induce a different papillary appearance than would a soft lens? Dr. Marren: Soft lenses contact more surface area of the superior palpebra1 conjunctiva than do rigid
Figure 2. Papillary hypemophy induced by the wear of rigid contact lenses. (Photo courtesy Dr. Joel Silbert.)
ICLC, Vol. 17, MarIApr
1990
103
Clinical R B D lenses and are thought to carry a larger antigenic load. Rigid lenses have a mechanical interaction with the upper lid at the lens edge, and because they are smaller than soft lenses, this interaction is positioned at the tarsal plate. Rigid lenses are more easily cleaned free of coatings and deposition. Thus, soft lenses have been thought to primarily induce GPC by providing antigens to which the eyelids become hypersensitive with chronic exposure. Rigid lenses have been thought to primarily induce a similar physiological response by creating chronic microtrauma to the superior palpebral conjunctiva. There is histological evidence to support hypersensitivity and mechanical trauma as causative of papillary hypertrophy. Allansmith and co-workers stated that soft lens GPC was most probably a cutaneous basophil hypersensitivity, a type of delayed sensitivity or cellmediated sensitivity, with lens coatings acting as antigens for an additional humoral (immediate) response mediated by IgE, plasma cells, and mast cells. Whereas basophils are indicative of a delayed hypersensitivity, neutrophils and eosinophils have been found in GPC induced by soft and rigid lenses. Allansmith and co-workers further noted that GPC induced by nylon sutures, considered biologically inert, was accompanied by neutrophils and eosinophils but not basophils or plasma cells and, therefore, that this papillary hypertrophy must have been primarily of traumatic origin. Greiner described giant papillae with no mucus or itching that occurred surrounding an epithelialized foreign body and suggested that papillogenesis may have been the result of trauma alone. Most cases of papillary hy
104
ICLC, Vol. 17, Mar/Apr 1990
Table 1. Differential Diagnosis and Treatment of Papillary Hyperrrophy Associated with Wear of Soft and Rigid Contact Lenses Soft Lenses Papillae Distribution
Typically near fold of
Pattern Shape Number Probable Cause Primary Treatment
Options
everted lid, rarely at lid margin Contiguous Flattened Many
Typically over tarsal plate, occasionally near lid margin Scattered Craterlike Fewer
Primarily a hypersensitive allergenic response
Primarily a mechanical traumatic response
Discontinue wear Reduce wearing time Cold compresses Lubricant/decongestant Enhance cleaning Alter lens material Try disposable lenses Change to rigid lenses Topical steroid Antihistamine Mast cell inhibitor
Discontinue wear Reduce wearing time Cold compresses Lubricant/decongestant Reduce edge lift and/or thickness Polish surface/edge Change rigid lens fit’ Topical steroid Antihistamine
’ For example, interpalpebral
to lid attachment
pertrophy, however, are probably the result of all three causative routes (delayed sensitivity, immediate antigenic response, and trauma). One route plays a predominant role in each case of hypertrophy because of characteristics of the particular foreign body involved. Dr. Benjamin: Why should the practitioner be aware of the different causes of papillary hypertrophy?
Dr. Marren:
Rigid Lenses
The causes of papillary hypertrophy and differentiation of these causes are important for the contact lens practitioner. It is on these causes that his or her treatment of the condition is predicated. For instance, sodium cromolyn is a mast cell inhibitor that will reduce papillary responses induced by the humoral (immediate) route, but may not be particularly effective for GPC induced by rigid
fit.
lenses or for hypertrophy that is primarily basophilic in nature. As “soft lens GPC” may be a combination of “delayed” and “immediate” hypersensitivities, with only a minor role played by trauma, treatment with sodium chromolyn may best work in cases when GPC develops quickly after an exposure to antigen. Please keep in mind, though, that all of this is still not perfectly understood and I would not advise against the use of sodium cromolyn as well in cases of GPC due to chronic exposure. Other treatments of GPC, listed in Table 1, have been designed with reduction of ocular hypersensitivity and/ or trauma in mind. It is up to the practitioner, with his knowledge of the patient’s condition and the prescribed contact lens and care regimen, to ascertain which of the various treatments are most justified for each individual case of GPC.