Contact Lens Removal

Although most patients are capable of removing their own contact lenses, proficiency in contact lens removal is a useful skill for any clinician. Patients may present to the emergency department because of difficulty removing their own lenses or with acute ophthalmological complications of contact lens wear. In some instances, contact lens removal is necessary for examination purposes. Consideration should also be given as to whether patients with altered mental status (eg, comatose) may be wearing contact lenses.

Prolonged contact lens wearing times are associated with an increased risk for corneal hypoxia and edema, infection, and corneal vascularization. Contact lens removal also is necessary following ocular trauma; however, in severe trauma, where globe rupture is suspected, an ophthalmologist should be involved before any ocular examination or intervention.

The technique of contact lens removal varies slightly depending on the type of contact lens. Two main types of contact lenses are available: soft contact lenses or hydrophilic lenses, and rigid gas-permeable lenses (RGPs). A 2021 analysis of international contact lens prescribing habits revealed 86% of patients wear soft lenses, whereas the remaining patients either wear rigid gas-permeable lenses (11%) or orthokeratology lenses (3%). ^[1]

Soft contact lenses

These lenses are made from oxygen-permeable material and are generally the most tolerated.

Types of soft contact lens include the following:

• Disposable contact lenses: These lenses are designed for short-term use. These lenses are not suitable for wear while asleep and need to be cleaned carefully and stored. Daily disposable lenses have increased in popularity over the past decade and make up 36% of US contact lenses worn. ^{[1, 2]}
• Extended-wear contact lenses: Superpermeable silicone hydrogel lenses may be worn up to 30 days continuously, even while asleep, although wearing contact lenses overnight is not recommended. Overnight wearing of contact lenses increases the risk for infectious corneal ulcers by 10 to 15 times over daily wear. ^[3]

Rigid gas-permeable lenses

RGP lenses are made of synthetic materials that do not contain water. The most popular material for their manufacture is fluorosilicone acrylate. The rigidity of hard lenses means they are generally easier to handle than soft contact lenses.

The typical RGP lens diameter is 9.8 mm (the typical soft lens diameter is 14.0 mm). Rigid lenses cover only 50% of the area covered by a soft contact lens and are smaller than the cornea.

RGP lenses are more mobile on the eye than are soft contact lenses; therefore, they allow increased tear circulation beneath the lens. Increased tear circulation allows the transfer of more oxygen to the corneal surface.

RGP lenses have been shown to be less likely than hydrogel materials to cause corneal infections. In one study comparing the relative risk of soft contact lens types to RGP lenses, extended-wear soft contact lenses had a relative risk for any complication of 2.7, compared with a relative risk of 1.3 for daily-wear soft contact lenses. ^[4]

Soft or rigid contact lens in the eye that cannot be removed by the patient.

Corneal infection or inflammation associated with use of a contact lens.

Necessity of ocular irrigation due to chemical injury. 

Generally, no contraindications exist to the removal of a contact lens from the eye. However, there is one potential exception to this which might include a patient who is wearing a soft contact lens applied to the eye to act as a “bandage lens” used to heal a poorly healing corneal epithelial defect. This is a special indication and these lenses may be kept in for several days or up to a week in this special situation. ^[5]

Caution is advised if the patient is uncooperative (eg, intoxicated).

If the patient has had a serious eye injury while wearing a contact lens and globe perforation is suspected, removal should not be attempted as any attempt to remove the contact lens in this emergency situation should be deferred to the ophthalmologist. An eye shield (not a pad) should be placed over the eye to minimize or avoid any external compression of the globe.

Anesthetic drops typically are not required but a topical anesthetic ophthalmic solution (eg, proparacaine 0.5% [Alcaine, Ophthetic]) may facilitate contact lens removal in some cases.

Required equipment

Required equipment includes the following:

• Saline solution

• Contact lens case or 2 small cups labeled left and right

Optional equipment

Optional equipment includes the following:

• Cotton-tipped applicator

• Fine, nontoothed forceps

• Anesthetic drops (eg, proparacaine 0.5% [Alcaine, Ophthetic])

• Hard lens remover suction cup

• Slit lamp biomicroscope

The patient may be seated or supine.

Preparation

Before starting, the clinician should wash his or her hands. The procedure may be performed wearing powderless gloves or with clean hands.

Ask the patient whether he or she wears hard or soft contact lenses. Rigid gas-permeable (RGP) lenses are smaller in diameter (smaller diameter than the cornea) than soft contact lenses. RGP lenses are more difficult to remove than soft contact lenses because they do not fold.

Add a few drops of saline solution to each eye prior to removal. For RGP lenses, this helps further separate the corneal surface from the lens to increase removal success rate and decrease chances of corneal abrasion. Saline solution also hydrates soft lenses, making removal easier.

While waiting, prepare the equipment needed for lens removal. Label 2 small cups left and right and fill each with enough saline to cover the lenses.

Localization of lens

Now examine the eye with a torch, ophthalmoscope, or slit lamp, as shown below.

Ensure the contact lens is on the cornea before attempting to remove it. Attempting to remove a contact lens that is not there may result in a corneal abrasion. The contact lens should be centered on the cornea. If it is not, the lens can be moved gently into the correct position by a fingertip.

If the lens is not visible in the eye, it may have become displaced (most commonly, under the upper eyelid). As depicted in the image below, the upper lid should be everted and the fornix examined.

To evert the lid, ask the patient to look down. Place the tip of a cotton-tipped applicator on the upper lid, 1 cm above the lid margin. This is the upper edge of the tarsal plate. Grasp the lid margin and lashes with the forefinger and thumb of the other hand then evert the lid using the tip of the cotton applicator as a fulcrum.

If the lens still is not visible, it probably already fell out.

The lens is easier to identify if fluorescein eye drops are instilled, as shown below.

Fluorescein drops permanently stain soft contact lenses. This should be explained to the patient before proceeding. Fluorescein may be instilled using a floret or with drops. If using a floret, add 2 drops of saline to the tip of the floret, shake it to remove excess liquid, then lightly touch the flat side of the floret to the lower palpebral conjunctival surface.

Technique for removal of soft contact lenses

A soft contact lens can be removed in several ways. The pinch method is described here; other methods are described below in the discussion of techniques for removal of hard or soft contact lenses. ^{[6, 7, 8]}

Pinch method

Make sure the lens is centered correctly on the eye, as depicted below.

Hold down the lower lid while having the patient look up. Hold the lower lid down throughout the procedure, as shown in the image below.

As shown below, gently touch an index finger to the center-to-lower surface of the contact lens.

Slowly slide the lens down onto the sclera.

Be careful not to release the lens at this point, as it will slide back to the center of the cornea.

Gently pinch the lens between the thumb and index finger as shown below.

Pull the lens away from the eye, as shown below.

Techniques for removal of hard lenses (rigid gas-permeable lenses or orthokeratology lenses)

Lateral lid method

With the patient in the sitting position, place a finger on the lateral palpebral margin and pull the skin laterally.

Ask the patient to look down and toward his or her nose; the lens should be forced off of the cornea. Another option may be to ask the patient to blink, which helps to dislodge the lens.

Suction cup method

If removal of the lens is problematic, commercially available miniature suction cup plungers can aid the removal of hard contact lenses, as shown below. This device cannot be used for soft contact lenses.

Moisten the suction cup with saline, then gently touch it square to center of the contact lens.

The contact lens adheres to the cup and comes away from the eye.

Remove the lens from the suction cup by sliding it gently sideways.

Alternative techniques for removal of hard or soft contact lenses

Forefinger and thumb method

Place a towel under the eye to catch the contact lens.

Place a forefinger on the center of the upper lid and a thumb on the center of the lower lid.

Press thumb and forefinger together to force a blink.

The contact lens should fall onto the towel or hand.

Cotton applicator method

The technique may be performed using the slit lamp or with the naked eye.

Place a cotton applicator tip on the lower part of the lens and slide the lens down onto the sclera.

Gently press the cotton applicator under the edge of the contact lens and use the applicator to lift the lens from the sclera.

Fine plain forceps

If the contact lens is difficult to remove or an eye injury is suspected, the lens should be removed under direct visualization at the slit lamp.

Instill topical anesthetics, if needed.

Remove the lens using a pair of plain microforceps.

A contact lens cannot become lost in the eye because the scleral conjunctiva is contiguous with the palpebral conjunctiva. If the lens is not visible, it probably is underneath the upper eyelid or has already fallen out.

The main risk of contact lens removal is corneal abrasion. The risks of corneal abrasion can be minimized by ensuring that the contact lens is centered on the cornea, by hydrating a soft lens at the start of the procedure, and by following one of the methods described above. If difficulties are encountered, removal using microforceps and the slit lamp is advisable. If corneal abrasion does occur, instruct the patient to avoid any contact lens wear in the affected eye until the abrasion heals. Prescribe antibiotic drops with pseudomonal coverage and have the patient follow up with an ophthalmologist the next day.

More significant complications are likely to result from contact lenses left in the eyes for prolonged periods. This is especially important to exclude in patients with a reduced level of consciousness. Complications of contact lens wear include lens deposits, allergic conjunctivitis, giant papillary conjunctivitis, peripheral corneal infiltrates, microbial keratitis, corneal de-epithelialization, and corneal neovascularization. All types of contact lenses reduce the amount of oxygen that reaches the cornea. Oxygenation is reduced further if contact lenses are worn when the eyes are closed.