Chapter 154. Contact Lens Removal

The Emergency Physician must be familiar with the proper technique of removing both soft and hard contact lenses from patients who are unable to do so on their own for various reasons. Patients with altered mental status are at particular risk of corneal damage if contact lenses are allowed to remain in place. Healthy individuals who wear contact lenses overnight experience a 4- to 15-fold increase in the risk of corneal injury over those who remove their contact lenses daily.1 The explanation for this increased risk of injury is based on the development of corneal hypoxia and an immune response to antigens present on the lens surface, both of which lead to an inflammatory response and susceptibility to infectious organisms.1 This results in an increased incidence of ulcerative keratitis, Pseudomonas aeruginosa infection, and corneal neovascularization.2,3

Contact lenses rest on a three-layer tear film (outer lipid, middle aqueous, and inner mucus layer) that covers the corneal and conjunctival epithelium. This tear layer provides oxygen and nutrients to the avascular cornea. The cornea also receives nutrition from blood vessels at the limbus and the aqueous humor. It is believed that contact lenses increase tear evaporation and disrupt the three-layer tear film, leading to the lack of corneal oxygenation and the symptoms of dry eye.4 A dry eye causes discomfort and corneal edema with resultant hazy vision. The normal blinking action initiates contact lens movement and a “fresh” flow of oxygenated tears over the cornea in an awake patient. This blinking action is not present in the sleeping or comatose patient.

The normal resting position of the contact lens is over the cornea. It may occasionally drift from the center of the eye and relocate over the sclera or in various parts of the eye, including under the upper eyelid. Thorough exploration of all aspects of the eye is essential when evaluating an individual for the presence of contact lenses prior to their removal. This evaluation should include inspection under the lower eyelid margin as well as eversion of the upper eyelid. Failure to adequately perform this examination can lead to the mistaken belief that a contact lens does not exist. In turn, a contact lens that remains in place acts as a foreign body and can lead to chronic irritation, inflammation, and development of a mass. Mass development from a retained contact lens typically occurs in the upper fornix of the eyelid and requires double eversion of the eyelid for identification and retrieval.5

Contact lenses must be removed from any patient who is unconscious or suffers an ocular injury. Contact lenses should not be left in place if fluorescein stain is to be used to examine the eye. Fluorescein can permanently stain the contact lens material. Give patients the opportunity to remove their own contact lenses if there are no contraindications (i.e., immobilization or ocular trauma). Patients are usually quite adept at removing their own contact lenses. Remove the contact lenses if the patient is unable to remove them or cannot remove them.

The only absolute contraindication to removing a contact lens would be in the case of a ruptured globe. Leave the contact lens in place for the Ophthalmologist to remove at the time of their examination and/or surgical repair. Extreme caution must be exercised to avoid unnecessary pressure on the eye itself so as not to complicate the injury when severe ocular damage has occurred. Place an eye shield and not an eye patch to avoid pressure on the globe with resultant exacerbation of the injury (Chapter 161).

• Normal saline
• Two cups, labeled “left” and “right”
• Hard lens remover suction cup device, optional
• Soft lens remover device, optional
• Cotton-tipped applicators

Explain to the patient, if they are awake, that their contact lenses must be removed. A signed consent is not required to remove a contact lens. Place the patient sitting or supine, whichever is most appropriate for the current clinical situation. Place several drops of a saline solution onto the eye and wait 5 to 10 minutes to allow the saline to penetrate the lenses. This maximally moistens the contact lenses to the point where they can be seen to slide easily over the surface of the eye when the patient blinks.

All contact lenses should be centered over the cornea for ease of removal by gentle manipulation of the eyelids. The lenses may often become displaced from the cornea. Care must be taken to search for the lens in other parts of the eye. Shine a penlight at an angle to the eye to aid in the search. A common location for a displaced contact lens to migrate is under the upper eyelid. Evert the upper eyelid if a contact lens cannot be found elsewhere to complete the search before assuming either that the lens fell out or the patient is not wearing contact lenses. Instill fluorescein into the eye if the patient still insists that it is present. The fluorescein will pool around the edges of the contact lens and make it easy to locate. Warn the patient that fluorescein may permanently stain their contact lens.

Prepare the equipment. Locate the equipment required to remove the contact lenses. Label two cups, “left” and “right,” to place the lenses in after they are removed. Fill the cups with enough saline to cover the contact lenses. The person performing the procedure should wear powderless gloves to prevent the powder from irritating the eye. Wipe powdered gloves clean with a saline or a water-moistened towel to remove the powder. Powdered gloves can also be placed under running water to flush away the powder.

A hard contact lens can be identified by its small size (6 to 10 mm). It is smaller than the cornea. Center the hard contact lens on the cornea. Place the index finger (or thumb) of one hand at the base of the eyelashes of the upper eyelid and the index finger (or thumb) of the opposite hand at the base of the eyelashes of the lower eyelid (Figure 154-1A). Gently, but firmly, approximate the eyelids by moving them toward the center of the cornea until the margins of the eyelids touch the edges of the hard contact lens (Figure 154-1B). Press slightly harder on the lower eyelid until the bottom edge of the hard contact lens lifts off the cornea utilizing the edge of the lower eyelid as a fulcrum (Figures 154-1C & D). Continue to push the eyelids together until the hard contact lens is lifted completely off the cornea and can be easily grasped.6,7

The patient who is awake and alert may not like the Emergency Physician's fingers near their eyes. Pull the skin of the lateral margin of the eyelids laterally with an index finger (Figure 154-2A). Alternatively, place one finger on the lateral edge of the upper eyelid and one finger on the lateral edge of the lower eyelid and pull laterally (Figure 154-2B). Instruct the patient to look downward and inward toward their nose. The hard contact lens will pop off the cornea. Grasp and remove the contact lens. This technique does not put as much pressure on the globe as the previous technique, an advantage if the patient has ocular trauma.

A commercially produced suction cup-like rubber device, resembling a golf tee, can be used to remove hard contact lenses if available (Figure 154-3). Moisten the surface of the device with a drop of saline. Gently touch the suction cup to the center of the hard contact lens. Suction will form and result in the hard contact lens adhering to the device. Lift the device and the attached contact lens from the cornea. Slide the hard contact lens sideways to remove it from the suction cup. Do not attempt to pull the hard contact lens off the suction cup as this may damage the contact lens.

A final technique involves the use of a cotton-tipped applicator (Figure 154-4). Moisten the cotton with saline. Place the-cotton-tipped applicator over the lower edge of the hard contact lens (Figure 154-4A). Carefully and gently slide the hard contact lens off the cornea and onto the sclera with the moistened cotton-tipped applicator. Gently press the cotton-tipped applicator into the sclera and under the edge of the hard contact lens (Figure 154-4B). Lift the hard contact lens from the sclera. Do not use the cotton-tipped applicator to elevate the hard contact lens from the cornea as this can result in a corneal abrasion.8

Soft contact lenses can be identified by their larger sizes (12 to 14 mm). They usually extend to, or just beyond, the corneal-scleral junction. There are numerous techniques to remove a soft contact lens (Figures 154-5, 154-6 and 154-7). The easiest and simplest method is to remove it manually (Figure 154-5). To remove the contact manually, retract the lower eyelid with the nondominant index finger (Figure 154-5A). The soft contact lens will slide partially onto the conjunctival surface of the lower sclera. Gently grasp the soft contact lens between the thumb and index finger of the dominant hand. Pinch the fingers together and remove the soft contact lens.

A second technique to remove soft contact lenses is illustrated in Figure 154-5B. Gently place the index finger and thumb of the nondominant hand on the upper and lower eyelids, respectively. Retract the eyelids. Gently grasp the soft contact lens between the thumb and index finger of the dominant hand. Slide the soft contact lens inferiorly. Gently pinch the fingers together to pull the soft contact lens from the eye.6

A third technique to manually remove a contact lens uses the patient's eyelids (Figure 154-5C). Place the thumb of the nondominant hand and dominant hand on the upper and lower eyelid, respectively. Retract the eyelids until the edges of the contact lens are fully visible. Close both eyelids against the superior and inferior edges of the soft contact lens. Continue to close the eyelids until the contact lens pops off the eye. Grasp and remove the soft contact lens with the dominant hand.

A commercially available rubber tweezer-like device can be used to remove soft contact lenses. Place the rubber tips of the device onto the center of the soft contact lenses (Figure 154-6). Gently squeeze the tweezers closed using minimal pressure. The soft contact lens will fold and lift off the eye. Remove the soft contact lens from the eye.

A commercially available rubber disc on a stick can be used to remove soft contact lenses. Place the rubber disc over the center of the soft contact lens (Figure 154-7). Apply gentle pressure to slide the soft contact lens onto the sclera. Lift the stick to remove the attached soft contact lens. The rubber disc may occasionally not stick to the soft contact lens. Apply a drop of saline to the rubber disc and repeat the procedure. The drop of liquid will form a seal between the rubber disc and the soft contact lens.

The scleral lens is essentially a very large, soft contact lens. It is approximately the size of a quarter and covers the cornea and sclera. Remove the scleral lens using the same techniques described to remove a soft contact lens.

Place removed contact lenses in the appropriately marked container. Ensure that the contact lenses are covered completely with saline solution. Perform an eye examination using fluorescein eye drops if the patient complains of eye pain after contact lens removal. The procedure may have resulted in a corneal abrasion.

Any attempt to remove contact lenses with fingernails or other solid objects not approved for the removal of contact lenses can cause corneal abrasions. Their use must be avoided. Proper contact lens removal techniques can also result in corneal abrasions. Do not patch corneal abrasions resulting from contact lens removal in order to prevent an infectious process.8 The suction cup of the hard contact lens remover may occasionally be inadvertently placed on the cornea. Do not pull it off the cornea. Slide it to the lateral corner of the sclera and remove it with a twisting motion.

Never remove a contact lens if there is concern for a potential globe perforation. The techniques described in this chapter are gentle yet put pressure on the globe while removing a contact lens. This pressure on the globe may result in extrusion of the intraocular contents (i.e., lens or vitreous) and cause permanent blindness. Use a suction cup device (hard contact lens) or a rubber disc (soft contact lens) if the contact lens must be removed before the Ophthalmologist arrives.

Additional complications include the inability to remove the lens and damage to the contact lens itself.8 Consult an Ophthalmologist or Optometrist if a contact lens cannot be removed from the cornea. Desiccated lenses that are not properly rehydrated prior to removal can result in the removal of the corneal epithelium and a corneal abrasion.8 A properly hydrated lens will slide easily over the surface of the eye. Apply saline drops onto the eye to hydrate the contact lens prior to removal.

Removal of contact lenses is a procedure that all Emergency Physicians must be able to perform on any patient who is unconscious, who has ocular trauma, or who cannot remove their own lenses. Failure to perform this simple procedure appropriately can result in serious ocular damage. The removal of a contact lens is easy, quick, simple, and straightforward. Never remove a contact lens if a globe perforation is suspected unless absolutely necessary.