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Soft Contact Lenses from Patients with Giant Papillary Conjunctivitis
SOFT CONTACT LENSES FROM PATIENTS W I T H GIANT PAPILLARY CONJUNCTIVITIS S H E R R Y A. F O W L E R , M.S., JACK V. G R E I N E R , P H . D . , AND M A T H E A R. A L L A N S M I T H , M.D. Boston,
Patients with contact lens-associated giant papillary conjunctivitis usually have deposits on their lenses. However, deposits do not invariably lead to the disease because we have seen many sub jects with deposit-coated lenses and no conjunctival changes. We previously pre sented the hypothesis that giant papillary conjunctivitis was associated with an immunologic mechanism, that the deposits contained the antigen, and that some per sonal characteristic of the patient was essential for the disease to develop. 1 If this is true, and the capacity to develop giant papillary conjunctivitis is influ enced by individual differences more than by differences in lens deposits, per haps deposits from lens wearers with giant papillary conjunctivitis would ap pear the same as deposits from lens wear ers without giant papillary conjunctivitis. We report herein a study of surface de posits from asymptomatic contact lens wearers and those who have developed giant papillary conjunctivitis.
Massachusetts
lenses for two months to two years. All five lenses had surface deposits as seen by gross and biomicroscopic examination. Also examined were five lenses from normal, asymptomatic subjects that also had heavy surface coating, and five new, never-worn soft lenses hydrated in 0.9 NaCl solution. Lenses were removed from subjects by the finger pinch method or forceps. The contact lenses studied were from various manufacturers. The degree of deposits, on a 0 to 4 + scale, was determined after lens removal (Fig. 1) by allowing the lenses to air-dry for about one minute and examining them under fluorescent room light. All lenses were rated 3 to 4 + on this scale. Lenses were fixed in 4% glutaraldehyde in 0.15 M sodium phosphate buffer (pH 7.2) for one hour at room tempera ture. They were then postfixed in cold 1% osmium tetroxide in the same buffer for 90 minutes, followed by dehydration in graded ethyl alcohols and drying in a critical point drying apparatus using CO2
METHODS
Five lenses from one eye of each of five subjects with contact lens-associated giant papillary conjunctivitis were select ed for this study. Subjects ranged in age from 19 to 60 years, and had worn contact From the Department of Ophthalmology, Harvard Medical School and the Department of Cornea Re search, Eye Research Institute of Retina Founda tion, Boston, Massachusetts. This study was sup ported by grant EY-02099 and Institutional National Research Service Award EY-07018, National Eye Institute, National Institutes of Health, and by a grant from Allergan (Dr. Allansmith). Reprint requests to Sherry A. Fowler, M.S., Eye Research Institute of Retina Foundation, 20 Stam ford St., Boston, MA 02114. 1056
Fig. 1 (Fowler, Greiner, and AllmiMiiilli). Contact lens with heavy surface coating (arrow).
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:1056-1061, 1979
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GIANT PAPILLARY CONJUNCTIVITIS
as a critical point transitional fluid. Lens es were mounted on aluminum sample stubs and coated with gold-palladium (60 to 40%) in a Hummer sputtering device. Both anterior and posterior lens surfaces were examined with a scanning electron microscope operated at 40 kV. RESULTS
New, never-worn soft contact lenses, when inspected with approximately x 1,200 magnification, showed a homoge neous dark background with linear mark ings. These were probably the result of either lathing or polishing manufacturing steps (Fig. 2). When the entire lens was examined, the linear marks appeared con centric and had small white particles that
1057
appeared to be unattached. Other white particles were also scattered randomly over the lens surface. When the magnifi cation was increased approximately five fold to x 6,380, these pronounced grooved markings resembled furrows. The surfaces of all worn lenses were strikingly different from those of new, never-worn lenses (Fig. 3). The worn lenses were covered with deposits, some forming thickened coatings, although a few areas, however, resembled the sur face of never-worn lenses. The interface between the coating and uncoated surface were evident (Fig. 3). There was no sig nificant difference between the morpho logic appearance of the lenses from sub jects with giant papillary conjunctivitis
Fig. 2 (Fowler, Greiner, and Allansmith). New, never-worn hydrophilic contact lens shows polishing marks with white particulate debris on homogenous, smooth, dark background (bar gauge = 10 (jun, x 1,280). Inset, High magnification shows furrowed surface (bar gauge = 5 |xm, x6,330).
1058
AMERICAN JOURNAL OF OPHTHALMOLOGY
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rfP*^*^\
Fig. 3 (Fowler, Greiner, and Allansmith). Coated surface of hydrophilic contact lens from subject with giant papillary conjunctivitis. Note peeling of surface (arrow) (bar gauge = 100 |xm, X28.000). Inset, Mosaic-like, mottled surface with areas of peeling (arrows) (bar gauge = 10 (ji,m, x 2,780).
and those lenses from asymptomatic lens wearers. Worn lenses showed mucus debris and particles scattered randomly over the lens surface. This mucus debris was morpho logically similar to that seen previously on the upper tarsal conjunctiva of normal patients 2 and patients with giant papillary conjunctivitis. 3 Occasionally seen were structures with a cylindrical morphology (2 to 4 u.m in length) that resembled bacteria. 4 Smooth cell-membrane-like structures, which appeared to be desquamated cells, adhered to the anterior contact lens sur face (Fig. 4). Large clumps of mucus material and small mounds of coating were commonly seen. Also present were areas of plaque-like formations of debris, some of which
seemed to be peeling from the lens sur face (Fig. 4). High magnification of sur face deposits revealed a diffuse trabeculated material (Fig. 4). The posterior surfaces of the new, never-worn lenses were smooth and free of debris (Fig. 5). The posterior surface of the coated lenses showed coatings but these were markedly smoother than the anterior surface. DISCUSSION
Deposits on soft contact lenses from patients with giant papillary conjunctivi tis appear the same as deposits on lenses from asymptomatic lens wearers. This finding supports our idea that giant papil lary conjunctivitis is more likely to be related to a difference among persons than among deposits. Soft contact lenses
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GIANT PAPILLARY CONJUNCTIVITIS
i. .
s (r f
Fig. 4 (Fowler, Greiner, and Allansmith). Heavily coated hydrophilic contact lens. Top left, Membrane like material on lens surface (bar gauge = 50 am, x500). Top right, High magnification of surface mounds along groove marks, and mucus clump (bar gauge = 5 am, x 6,430). Bottom left, Surface shows peeling and granular appearance (bar gauge = 1 am, x 12,770). Bottom right, Surface shows trabeculated mesh coating (bar gauge = 1 am, X 12,100).
Fig. 5 (Fowler, Greiner, and Allansmith). Top, High magnification of posterior surface of contact lens of new, never-worn lens (bar gauge = 10 n-m, x24,000). Inset, Low magnification of same lens (bar gauge = 10 (xm, x 1,200). Bottom, High magnification of posterior surface of worn coated lens from subject with giant papillary conjunctivitis (bar gauge = 10 u.m, x24,000). Inset, Low magnification of same area (bar gauge = 10 ^m, x 1,200).
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GIANT PAPILLARY CONJUNCTIVITIS
from all subjects showed deposits that covered most of the anterior lens surface and a coating of deposits covered all of the posterior lens surface. Our study focused on the anterior lens surface because the presence of deposits on this surface was in direct contact with the upper tarsal conjunctival surface in volved in giant papillary conjunctivitis. Deposits on a contact lens surface may act as a nondesquamating glue to which materials can attach. This hypothesis is supported by the finding of two types of structures on or in the lens deposits: (1) bacteria 4 and (2) structures that resem bled cells or their membranes alone. The cell types of structures were similar to those shown by Kaufman and Katz 5 on the surface of used intraocular lenses. The coating that covered the posterior surface of our uncleaned lenses showed similarities to the scanning electron micrographic appearance reported by Matas, Spencer, and Hayes. 6 They showed the wearing (posterior) surface of samples of wedge-shaped segments cut from two worn soft contact lenses that had been cleaned according to the manufacturer's recommendation. Deposits appeared to adhere to the lens surface and in parts existed as a thick coating. Few areas re mained that resembled the surface of new, never-worn lenses. We have defined the morphologic detail of lens surface deposits and compared surface coatings from those with and without conjunctival disease associated with lens wear. Our findings do not elimi nate the possibility that there may be an immunologic difference in the deposits on contact lenses, but our morphologic findings do show that deposits are the same in all contact lens wearers. SUMMARY
We used scanning electron microscopy to study the surfaces of five coated soft
1061
contact lenses from subjects with giant papillary conjunctivitis. Findings were compared to the surfaces of five coated lenses from normal, asymptomatic wear ers and five new, never-worn lenses. Lenses were from various manufacturers. All worn contact lenses differed strik ingly from new, never-worn lenses. The anterior surface of worn lenses was cov ered with apparently adherent deposits. In only a few areas was the surface simi lar to new, never-worn lenses. Thick coat ings on lenses from patients with giant papillary conjunctivitis and asymptomat ic wearers were similar. High magnifica tion of the coatings revealed a trabeculated morphology. Also seen was debris that resembled mucus-like material in both strand and particulate forms. On some lenses bacterial-shaped structures were scattered randomly over the surface. Smooth structures resembling cells were also seen. The posterior lens surface of all worn lenses was smoother than the anteri or lens surface. The findings support our idea that the capacity to develop giant papillary con junctivitis is influenced by individual dif ferences more than by differences in lens deposits. REFERENCES 1. Allansmith, M. R., Korb, D. R., Greiner, J. V., Henriquez, A. S., Simon, M. A., and Finnemore, V. M.: Giant papillary conjunctivitis in contact lens wearers. Am. J. Ophthalmol. 83:697, 1977. 2. Greiner, J. V., Covington, H. I., and Allansmith, M. R.: Surface morphology of the human upper tarsal conjunctiva. Am. J. Ophthalmol. 83: 892, 1977. 3. : Surface morphology of giant papillary conjunctivitis in contact lens wearers. Am. J. Oph thalmol. 85:242, 1978. 4. Fowler, S. A., Greiner, J. V., and Allansmith, M. R.: Attachment of bacteria to soft contact lenses. Arch. Ophthalmol. 97:659-660, 1979. 5. Kaufman, H. E., and Katz, J. I.: Endothelial damage from intraocular lens insertion. Invest. Ophthalmol. 15:996, 1976. 6. Matas, B. R., Spencer, W. H., and Hayes, T. L.: Scanning electron microscopy of hydrophilic con tact lenses. Arch. Ophthalmol. 88:287, 1972.
Patients with contact lens-associated giant papillary conjunctivitis usually have deposits on their lenses. However, deposits do not invariably lead to the disease because we have seen many sub jects with deposit-coated lenses and no conjunctival changes. We previously pre sented the hypothesis that giant papillary conjunctivitis was associated with an immunologic mechanism, that the deposits contained the antigen, and that some per sonal characteristic of the patient was essential for the disease to develop. 1 If this is true, and the capacity to develop giant papillary conjunctivitis is influ enced by individual differences more than by differences in lens deposits, per haps deposits from lens wearers with giant papillary conjunctivitis would ap pear the same as deposits from lens wear ers without giant papillary conjunctivitis. We report herein a study of surface de posits from asymptomatic contact lens wearers and those who have developed giant papillary conjunctivitis.
Massachusetts
lenses for two months to two years. All five lenses had surface deposits as seen by gross and biomicroscopic examination. Also examined were five lenses from normal, asymptomatic subjects that also had heavy surface coating, and five new, never-worn soft lenses hydrated in 0.9 NaCl solution. Lenses were removed from subjects by the finger pinch method or forceps. The contact lenses studied were from various manufacturers. The degree of deposits, on a 0 to 4 + scale, was determined after lens removal (Fig. 1) by allowing the lenses to air-dry for about one minute and examining them under fluorescent room light. All lenses were rated 3 to 4 + on this scale. Lenses were fixed in 4% glutaraldehyde in 0.15 M sodium phosphate buffer (pH 7.2) for one hour at room tempera ture. They were then postfixed in cold 1% osmium tetroxide in the same buffer for 90 minutes, followed by dehydration in graded ethyl alcohols and drying in a critical point drying apparatus using CO2
METHODS
Five lenses from one eye of each of five subjects with contact lens-associated giant papillary conjunctivitis were select ed for this study. Subjects ranged in age from 19 to 60 years, and had worn contact From the Department of Ophthalmology, Harvard Medical School and the Department of Cornea Re search, Eye Research Institute of Retina Founda tion, Boston, Massachusetts. This study was sup ported by grant EY-02099 and Institutional National Research Service Award EY-07018, National Eye Institute, National Institutes of Health, and by a grant from Allergan (Dr. Allansmith). Reprint requests to Sherry A. Fowler, M.S., Eye Research Institute of Retina Foundation, 20 Stam ford St., Boston, MA 02114. 1056
Fig. 1 (Fowler, Greiner, and AllmiMiiilli). Contact lens with heavy surface coating (arrow).
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:1056-1061, 1979
VOL. 88, NO. 6
GIANT PAPILLARY CONJUNCTIVITIS
as a critical point transitional fluid. Lens es were mounted on aluminum sample stubs and coated with gold-palladium (60 to 40%) in a Hummer sputtering device. Both anterior and posterior lens surfaces were examined with a scanning electron microscope operated at 40 kV. RESULTS
New, never-worn soft contact lenses, when inspected with approximately x 1,200 magnification, showed a homoge neous dark background with linear mark ings. These were probably the result of either lathing or polishing manufacturing steps (Fig. 2). When the entire lens was examined, the linear marks appeared con centric and had small white particles that
1057
appeared to be unattached. Other white particles were also scattered randomly over the lens surface. When the magnifi cation was increased approximately five fold to x 6,380, these pronounced grooved markings resembled furrows. The surfaces of all worn lenses were strikingly different from those of new, never-worn lenses (Fig. 3). The worn lenses were covered with deposits, some forming thickened coatings, although a few areas, however, resembled the sur face of never-worn lenses. The interface between the coating and uncoated surface were evident (Fig. 3). There was no sig nificant difference between the morpho logic appearance of the lenses from sub jects with giant papillary conjunctivitis
Fig. 2 (Fowler, Greiner, and Allansmith). New, never-worn hydrophilic contact lens shows polishing marks with white particulate debris on homogenous, smooth, dark background (bar gauge = 10 (jun, x 1,280). Inset, High magnification shows furrowed surface (bar gauge = 5 |xm, x6,330).
1058
AMERICAN JOURNAL OF OPHTHALMOLOGY
DECEMBER, 1979
rfP*^*^\
Fig. 3 (Fowler, Greiner, and Allansmith). Coated surface of hydrophilic contact lens from subject with giant papillary conjunctivitis. Note peeling of surface (arrow) (bar gauge = 100 |xm, X28.000). Inset, Mosaic-like, mottled surface with areas of peeling (arrows) (bar gauge = 10 (ji,m, x 2,780).
and those lenses from asymptomatic lens wearers. Worn lenses showed mucus debris and particles scattered randomly over the lens surface. This mucus debris was morpho logically similar to that seen previously on the upper tarsal conjunctiva of normal patients 2 and patients with giant papillary conjunctivitis. 3 Occasionally seen were structures with a cylindrical morphology (2 to 4 u.m in length) that resembled bacteria. 4 Smooth cell-membrane-like structures, which appeared to be desquamated cells, adhered to the anterior contact lens sur face (Fig. 4). Large clumps of mucus material and small mounds of coating were commonly seen. Also present were areas of plaque-like formations of debris, some of which
seemed to be peeling from the lens sur face (Fig. 4). High magnification of sur face deposits revealed a diffuse trabeculated material (Fig. 4). The posterior surfaces of the new, never-worn lenses were smooth and free of debris (Fig. 5). The posterior surface of the coated lenses showed coatings but these were markedly smoother than the anterior surface. DISCUSSION
Deposits on soft contact lenses from patients with giant papillary conjunctivi tis appear the same as deposits on lenses from asymptomatic lens wearers. This finding supports our idea that giant papil lary conjunctivitis is more likely to be related to a difference among persons than among deposits. Soft contact lenses
VOL. 88, NO. 6
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GIANT PAPILLARY CONJUNCTIVITIS
i. .
s (r f
Fig. 4 (Fowler, Greiner, and Allansmith). Heavily coated hydrophilic contact lens. Top left, Membrane like material on lens surface (bar gauge = 50 am, x500). Top right, High magnification of surface mounds along groove marks, and mucus clump (bar gauge = 5 am, x 6,430). Bottom left, Surface shows peeling and granular appearance (bar gauge = 1 am, x 12,770). Bottom right, Surface shows trabeculated mesh coating (bar gauge = 1 am, X 12,100).
Fig. 5 (Fowler, Greiner, and Allansmith). Top, High magnification of posterior surface of contact lens of new, never-worn lens (bar gauge = 10 n-m, x24,000). Inset, Low magnification of same lens (bar gauge = 10 (xm, x 1,200). Bottom, High magnification of posterior surface of worn coated lens from subject with giant papillary conjunctivitis (bar gauge = 10 u.m, x24,000). Inset, Low magnification of same area (bar gauge = 10 ^m, x 1,200).
VOL. 88, NO. 6
GIANT PAPILLARY CONJUNCTIVITIS
from all subjects showed deposits that covered most of the anterior lens surface and a coating of deposits covered all of the posterior lens surface. Our study focused on the anterior lens surface because the presence of deposits on this surface was in direct contact with the upper tarsal conjunctival surface in volved in giant papillary conjunctivitis. Deposits on a contact lens surface may act as a nondesquamating glue to which materials can attach. This hypothesis is supported by the finding of two types of structures on or in the lens deposits: (1) bacteria 4 and (2) structures that resem bled cells or their membranes alone. The cell types of structures were similar to those shown by Kaufman and Katz 5 on the surface of used intraocular lenses. The coating that covered the posterior surface of our uncleaned lenses showed similarities to the scanning electron micrographic appearance reported by Matas, Spencer, and Hayes. 6 They showed the wearing (posterior) surface of samples of wedge-shaped segments cut from two worn soft contact lenses that had been cleaned according to the manufacturer's recommendation. Deposits appeared to adhere to the lens surface and in parts existed as a thick coating. Few areas re mained that resembled the surface of new, never-worn lenses. We have defined the morphologic detail of lens surface deposits and compared surface coatings from those with and without conjunctival disease associated with lens wear. Our findings do not elimi nate the possibility that there may be an immunologic difference in the deposits on contact lenses, but our morphologic findings do show that deposits are the same in all contact lens wearers. SUMMARY
We used scanning electron microscopy to study the surfaces of five coated soft
1061
contact lenses from subjects with giant papillary conjunctivitis. Findings were compared to the surfaces of five coated lenses from normal, asymptomatic wear ers and five new, never-worn lenses. Lenses were from various manufacturers. All worn contact lenses differed strik ingly from new, never-worn lenses. The anterior surface of worn lenses was cov ered with apparently adherent deposits. In only a few areas was the surface simi lar to new, never-worn lenses. Thick coat ings on lenses from patients with giant papillary conjunctivitis and asymptomat ic wearers were similar. High magnifica tion of the coatings revealed a trabeculated morphology. Also seen was debris that resembled mucus-like material in both strand and particulate forms. On some lenses bacterial-shaped structures were scattered randomly over the surface. Smooth structures resembling cells were also seen. The posterior lens surface of all worn lenses was smoother than the anteri or lens surface. The findings support our idea that the capacity to develop giant papillary con junctivitis is influenced by individual dif ferences more than by differences in lens deposits. REFERENCES 1. Allansmith, M. R., Korb, D. R., Greiner, J. V., Henriquez, A. S., Simon, M. A., and Finnemore, V. M.: Giant papillary conjunctivitis in contact lens wearers. Am. J. Ophthalmol. 83:697, 1977. 2. Greiner, J. V., Covington, H. I., and Allansmith, M. R.: Surface morphology of the human upper tarsal conjunctiva. Am. J. Ophthalmol. 83: 892, 1977. 3. : Surface morphology of giant papillary conjunctivitis in contact lens wearers. Am. J. Oph thalmol. 85:242, 1978. 4. Fowler, S. A., Greiner, J. V., and Allansmith, M. R.: Attachment of bacteria to soft contact lenses. Arch. Ophthalmol. 97:659-660, 1979. 5. Kaufman, H. E., and Katz, J. I.: Endothelial damage from intraocular lens insertion. Invest. Ophthalmol. 15:996, 1976. 6. Matas, B. R., Spencer, W. H., and Hayes, T. L.: Scanning electron microscopy of hydrophilic con tact lenses. Arch. Ophthalmol. 88:287, 1972.