Giant Papillary Conjunctivitis Caused by a Fibroepithelial Polyp of the Lower Eyelid

A 9-year-old girl presented to the ophthalmological clinic with a 6-month history of asymmetrical injection of the eyes, more prominent on the right side. She had no history of medical illness other than a small polyp of her right lower eyelid that developed 8 months ago. Around 2 months later, her parents noted her asymmetrical pink eyes (Figure 1, A); however, the patient reported no other eye symptoms, such as itching or a foreign-body sensation. Parents denied potential eye rubbing of the patient through careful daytime and overnight observation. Clinical examination showed a 2-mm round fibroepithelial polyp on her right lower eyelid (Figure 1, A, B, arrows). When the eye was closed, the polyp was slightly in touch with the tarsal conjunctival surface with some involution, such that the polyp was barely seen from the outside. Eversion of the lower eyelid revealed hyperemia of the bulbar conjunctiva and numerous giant (>1 mm) papillae with clear discharge on the right palpebral conjunctiva but not on the left side (Figure 1, B). Slit-lamp examination revealed no obvious complication of the conjunctivitis such as corneal abrasion or keratitis. Visual acuity was 20/20 on both eyes and the intraocular pressure was within normal range. Under the tentative diagnosis of giant papillary conjunctivitis (GPC) associated with unknown allergic reactions, antihistamines and mast cell stabilizers were prescribed but were not effective. The multiple allergen simultaneous test with a panel of 61 inhalant allergens, including perennial (eg, Dermatophagoides pteronyssinus and D. farinae) and seasonal (eg, dandelion and pigweed) allergens, showed negative results. Administration of ocular steroid or cyclosporine was effective during its use; however, the unilateral conjunctivitis recurred after the discontinuation of the treatments. The asymmetry of conjunctivitis with the absence of pruritus and seasonal variation over the course of the disease suggested mechanical stimulation from the fibroepithelial polyp as the cause of the conjunctivitis. After surgical removal of the polyp, the congestion of the right eye disappeared without any further treatment (Figure 1, C). The GPC is a noninfectious inflammatory disorder usually triggered by a foreign substance (eg, contact lenses) and is characterized by the formation of giant papillae on the conjunctiva.1Kenny S.E. Tye C.B. Johnson D.A. Kheirkhah A. Giant papillary conjunctivitis: a review.Ocul Surf. 2020; 18: 396-402Crossref PubMed Scopus (16) Google Scholar,2Allansmith M.R. Korb D.R. Greiner J.V. Henriquez A.S. Simon M.A. Finnemore V.M. Giant papillary conjunctivitis in contact lens wearers.Am J Ophthalmol. 1977; 83: 697-708Abstract Full Text PDF PubMed Google Scholar A diagnosis of GPC caused by an eyelid fibroepithelial polyp was made and there was no recurrence of conjunctivitis at a follow-up visit 6 months later. The exact pathophysiology of GPC remains incompletely understood. It is likely to be developed from the combination of mechanical trauma to the tarsal conjunctiva and an immunological response by the conjunctiva. Because the GPC has excellent prognosis after appropriate management of underlying causes,1Kenny S.E. Tye C.B. Johnson D.A. Kheirkhah A. Giant papillary conjunctivitis: a review.Ocul Surf. 2020; 18: 396-402Crossref PubMed Scopus (16) Google Scholar,2Allansmith M.R. Korb D.R. Greiner J.V. Henriquez A.S. Simon M.A. Finnemore V.M. Giant papillary conjunctivitis in contact lens wearers.Am J Ophthalmol. 1977; 83: 697-708Abstract Full Text PDF PubMed Google Scholar in the case of asymmetrical conjunctivitis, efforts for differential diagnosis to investigate potential causes such as mechanical stimulation are warranted, particularly when the conventional treatments for allergic conjunctivitis are not effective. Here we identified and reported a GPC that developed unilaterally, which is attributed to mechanical stimulation from the precedent development of a fibroepithelial polyp of the lower eyelid. Informed consent was obtained from the parents of the patient to publish the case report along with all accompanying visual elements. J. H. Roh contributed to conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, resources, supervision, visualization, and writing original draft. K. H. Kim contributed to data curation, investigation, supervision, and visualization. All authors read and approved the final version of the clinical picture. This study was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2021R1I1A1A01049566) and grants from Korea University (K2123751 and K2125871). The ethics committee of the Korea University Anam Hospital approved the study protocol (2022AN0219) and informed consent for participation was obtained from the patient’s parents.