Giant Papillary Conjunctivitis (GPC): Complete NCLE Exam Guide

Your patient returns complaining of itchy eyes, stringy mucus in the morning, and contact lenses that won't stay clear past lunchtime. You flip their upper eyelid and see it—rows of bumps lining the tarsal conjunctiva like a cobblestone street. That's giant papillary conjunctivitis, or GPC, and it's the single most common complication you'll see with contact lens wear.

GPC affects somewhere between 1-5% of soft contact lens wearers every year. It's less common with RGPs (under 1%), but when it shows up, it can end a patient's contact lens career if you don't catch it early and treat it properly. The NCLE knows how important this is—expect 15+ questions about what causes GPC, how to recognize it, grading systems, and most critically, how to treat and prevent it.

In this guide, you'll learn exactly what GPC is and why it develops, the classic signs and symptoms (itching is king), how to grade severity from mild to severe, treatment protocols that actually work, and prevention strategies to keep your patients lens-tolerant long-term. By the end, you'll be able to spot GPC before it becomes a problem and know exactly what to do when it shows up.

Giant papillary conjunctivitis is an inflammatory condition of the upper tarsal conjunctiva (the inside of the upper eyelid). It's characterized by the formation of giant papillae—raised bumps that are 0.3mm or larger in diameter. These papillae give the eyelid interior a distinctive cobblestone appearance.

The mechanism is two-fold:

1. Allergic/immune response (Type I hypersensitivity): Protein deposits on the lens surface act as antigens. The immune system recognizes these foreign proteins and mounts an allergic response. Mast cells degranulate, releasing histamine and other inflammatory mediators.
2. Mechanical irritation (Type IV hypersensitivity): The lens edge, deposits, or rough lens surface physically traumatizes the upper tarsal conjunctiva with each blink. Over time, this repetitive mechanical trauma triggers inflammation and papillae formation.

Think of it as a combination of allergy and friction injury. The deposits make your immune system angry, and the mechanical rubbing keeps irritating the tissue. Eventually, the conjunctiva forms these raised bumps (papillae) as a defensive response.

Other names you might see: Contact lens papillary conjunctivitis (CLPC), contact lens-induced papillary conjunctivitis. They all refer to the same condition.

GPC can also occur with anything that chronically rubs the upper lid: exposed sutures after eye surgery, ocular prostheses (artificial eyes), and even scleral buckles. But for the NCLE exam, focus on contact lens-related GPC—that's what they test.

Understanding what causes GPC helps you prevent it. Here are the primary culprits:

1. Protein Deposits (Most Important)

This is the #1 cause. Tear proteins (lysozyme, lactoferrin, immunoglobulins, lipocalin) adhere to the lens surface over time. These proteins denature (change shape) and become antigenic—meaning your immune system sees them as foreign invaders. The longer you wear lenses without proper cleaning or replacement, the more deposits accumulate.

High-risk lens types for deposits: Soft lenses, especially high water content lenses (Group II and IV), attract more protein deposits than low water lenses. RGP lenses resist deposits better due to their hard, non-porous surface.

2. Mechanical Irritation from Lens Edge

Every blink drags the lens edge across the tarsal conjunctiva. If the lens edge is damaged, rough, or poorly designed, it causes microtrauma with each blink. Over thousands of blinks per day, this adds up to significant mechanical irritation.

3. Poor Lens Hygiene

Patients who don't clean their lenses properly, reuse solution, or skip enzyme cleaning allow deposits to build up faster. Non-compliant patients are at much higher risk for GPC.

4. Extended Lens Replacement Schedule

Monthly lenses worn for 3 months. Two-week lenses stretched to 6 weeks. The longer lenses are used beyond their intended replacement schedule, the more deposits accumulate and the more lens material degrades.

5. Tight Lens Fit

A tight-fitting lens doesn't move well with blinking, which reduces tear exchange. Poor tear exchange means deposits aren't flushed away effectively. Plus, tight lenses create more mechanical friction against the upper lid.

Risk Factors Summary

• Soft lenses > RGP lenses (soft lenses accumulate more deposits)
• Extended wear > daily wear (more lens exposure time)
• Poor compliance with replacement schedule
• Inadequate cleaning
• High water content lenses (Group II and IV more deposit-prone)
• Patients who are heavy protein depositors (individual variation in tear chemistry)

Signs are what you observe during examination. Here's what to look for:

Papillae on Upper Tarsal Conjunctiva

This is the hallmark sign. You must evert the upper eyelid to see them—they won't be visible without eversion. The papillae appear as raised, dome-shaped bumps with a cobblestone or pebbled appearance. They're typically located on the central third of the upper tarsal conjunctiva.

Size matters: By definition, giant papillae are ≥0.3mm in diameter. In severe cases, they can reach 1mm or larger.

Mucus Production

Excess mucus is a key sign. It's typically stringy or ropy (not watery). You'll see mucus strands on the lens surface or at the canthi. Patients often describe waking up with crusty eyes or mucus threads.

Conjunctival Hyperemia (Redness)

The tarsal conjunctiva appears red and inflamed. In severe cases, you might see injection (blood vessel dilation) and even limbal redness.

Lens Deposits

The lenses themselves show protein and/or lipid deposits. Protein deposits appear as white, cloudy patches. Lenses may look hazy or filmy even after cleaning.

Reduced Lens Movement

With each blink, the lens should move 1-2mm (soft lens) or 2-3mm (RGP). In GPC, lens movement is often reduced due to increased friction from papillae and mucus.

Ptosis (Severe Cases)

In very severe GPC, the upper eyelid can droop slightly due to the weight and inflammation of the enlarged papillae. This is uncommon but can occur.

GPC Grading System

GPC severity is graded on a 1-4 scale based on papillae size and symptoms:

Symptoms are what the patient reports. Here's what they'll tell you:

Itching (Hallmark Symptom)

This is THE classic symptom of GPC. Patients describe intense itching, especially under the upper eyelid. The itching is often worse at the end of the day or after lens removal. If a contact lens patient complains of itching, GPC should be high on your differential diagnosis list.

Excess Mucus Discharge

Patients notice stringy, ropy mucus—especially upon waking. They might describe "glue-like" or "spider web" strands. The mucus coats the lenses and makes them cloudy.

Lens Awareness/Discomfort

Lenses that were once comfortable now feel like they're there. Patients become aware of the lens sensation, especially with blinking. It's not sharp pain—more like a foreign body sensation or general discomfort.

Reduced Wearing Time

Patients who used to wear lenses 12-14 hours now can only tolerate 6-8 hours. They start taking lenses out earlier and earlier in the day.

Blurred Vision

Mucus and deposits coat the lens, causing variable blur. Vision might be clear in the morning but progressively degrade throughout the day. Blinking temporarily clears vision but blur returns quickly.

Increased Lens Coating

Lenses get cloudy or filmy faster than they used to. Even freshly cleaned lenses might feel "gunky" within hours.

Symptom Pattern

• Symptoms are typically worse at the end of the day (cumulative irritation)
• Often worse after lens removal (when you stop, you notice the irritation more)
• May be seasonal variation (worse during allergy season if patient has allergies)
• Gradual onset—doesn't happen overnight. Usually develops over weeks to months

Diagnosing GPC requires upper eyelid eversion and slit lamp examination. Here's the process:

1. Evert the upper eyelid—this is essential! You cannot diagnose GPC without looking at the tarsal conjunctiva. Ask the patient to look down, grasp the lashes, pull the lid margin out and up, then flip it over a cotton swab or your finger.
2. Examine with slit lamp—look for papillae (raised bumps with cobblestone appearance), hyperemia, and mucus.
3. Measure papillae size—estimate diameter. Are they ≥0.3mm (giant)?
4. Inspect the contact lenses—look for deposits, coating, or damage.
5. Assess lens fit—check movement and centration.

Differential Diagnosis

You need to distinguish GPC from other conditions that cause upper lid papillae:

• Vernal keratoconjunctivitis (VKC): Seasonal (spring/summer), seen in children/young adults, severe itching, limbal involvement. NOT related to contact lens wear.
• Atopic keratoconjunctivitis (AKC): Year-round, associated with atopic dermatitis/eczema, bilateral, affects lower lids too.
• Bacterial conjunctivitis: Purulent discharge (yellow-green, not stringy), no papillae, acute onset.
• Allergic conjunctivitis: Bilateral, seasonal, itching and tearing, but no giant papillae.

The key distinguishing feature of GPC is the contact lens history plus giant papillae on the upper tarsal conjunctiva. If they're wearing contact lenses and have giant papillae, it's GPC until proven otherwise.

Treating GPC requires addressing both the cause (deposits, mechanical irritation) and the inflammation. Here's the step-by-step approach:

Step 1: Discontinue Contact Lens Wear (Most Important!)

This is non-negotiable. The patient must stop wearing contact lenses for a minimum of 1-4 weeks (depending on severity). Mild cases might need only 1-2 weeks. Severe cases may require 4-6 weeks or longer.

Why? You need to eliminate the source of irritation (deposits and mechanical trauma) and give the conjunctiva time to heal. Papillae won't resolve if you keep wearing the same lenses.

Step 2: Lens-Related Changes (When Resuming Wear)

Once the GPC has resolved, you need to prevent recurrence. Here are your options:

Step 3: Improve Cleaning Regimen

If not using daily disposables, cleaning becomes critical:

• Hydrogen peroxide systems (like Clear Care)—these are better than multipurpose solutions for removing deposits. More effective cleaning = less antigen buildup.
• Enzyme cleaners weekly—enzyme tablets or solutions break down protein deposits that regular cleaning misses. Use once a week.
• Avoid preserved solutions if possible—preservatives can irritate sensitive eyes and worsen GPC.
• Never reuse solution—fresh solution every time.
• Replace lens case monthly—old cases harbor bacteria and biofilm.

Step 4: Medical Treatment (If Needed)

For moderate to severe GPC, you might need medical intervention:

• Mast cell stabilizers (cromolyn sodium, lodoxamide)—prevent mast cell degranulation, reducing the allergic response. Takes 1-2 weeks to work. Used for moderate GPC.
• Antihistamines (olopatadine, ketotifen)—reduce itching and inflammation. Work faster than mast cell stabilizers.
• Mild steroid drops (short-term only)—for severe cases, a brief course (1-2 weeks) of loteprednol or fluorometholone can knock down severe inflammation. Use with caution—steroids have risks (increased IOP, cataract, infection). Not for long-term use!

Step 5: Follow-Up

Monitor the patient closely after resuming lens wear:

• 1-week follow-up after resuming lenses
• 1-month follow-up to ensure no recurrence
• Evert upper lid at every visit to check for papillae
• If symptoms return, discontinue lenses immediately and reassess

Preventing GPC is much easier than treating it. Here's how to keep your patients GPC-free:

• Recommend daily disposables from the start—especially for new wearers or patients with allergy history. Best prevention strategy.
• Enforce strict replacement schedules—educate patients that "two-week lenses" means 14 days, not "until they feel uncomfortable."
• Teach proper cleaning technique—rub and rinse, don't just soak. Many patients don't clean effectively.
• Regular enzyme cleaning—weekly for reusable lenses.
• Avoid overwear—extended wear increases GPC risk. Limit wearing time to 10-12 hours if possible.
• Annual check-ups with lid eversion—catch early GPC before it becomes symptomatic.
• Address allergies proactively—patients with seasonal allergies are at higher risk. Consider treating allergies during peak season.

Good news: If caught early and treated properly, GPC resolves completely in most patients. Mild to moderate GPC usually responds well to lens discontinuation and switching to daily disposables.

The challenge: Papillae can take weeks to months to fully resolve, even after stopping lens wear. A patient might feel better in 1-2 weeks, but the papillae might still be visible for 4-8 weeks.

Recurrence risk: If you resume lenses without addressing the underlying cause (deposits, poor hygiene, extended replacement schedule), GPC will come back. Recurrence rates are lowest with daily disposables (5-10%) and highest with monthly lenses worn beyond schedule (30-40%).

When patients can't return to lenses: Some patients with severe, recurrent GPC cannot tolerate contact lenses long-term, even with daily disposables. This is rare but can happen. These patients need to stay in spectacles or consider refractive surgery.

The NCLE tests GPC extensively. Here's what they focus on:

• Definition: Giant papillae ≥0.3mm on upper tarsal conjunctiva
• Primary cause: Protein deposits (not mechanical trauma—that's secondary)
• Hallmark symptom: Itching
• Key sign: Stringy, ropy mucus
• Most common complication: GPC is #1 contact lens complication
• Treatment priority: Discontinue lens wear (most important step)
• Best prevention: Daily disposable lenses
• Diagnosis requires: Upper lid eversion (can't diagnose without it)