As the number of persons wearing contact lenses steadily increases, so does the chance that a physician in the emergency department (ED) will encounter problems related to contact lens use. Familiarity with indications and techniques for contact lens removal is therefore essential. These skills also may prove valuable for the office-based practitioner.

Contact lens use requires a certain level of maturity, so children do not usually become contact lens wearers until approximately 10 years of age. At that age, children are less likely to be meticulous in regard to the proper wear, removal, and cleaning of their lenses. They are therefore at increased risk of complications such as eye trauma or infection. Children also are less likely to be cooperative with contact lens removal, which can make this procedure much more challenging.

The cornea is a transparent window at the most anterior portion of the eye (see Fig. 45.1). It is a dense layer of tissue that is uniformly about 1 mm thick. Because it has a greater curvature than the sclera, the cornea resembles a watch crystal. The cornea is avascular and receives nutrients from the capillaries associated with the anterior ciliary arteries at its margin. It is well supplied with sensory nerves from the ciliary nerves. Aside from the cornea, the remainder of the visible portion of the anterior eyeball is covered by the conjunctiva. The conjunctiva joins the corneal epithelium at the limbus, or corneal margin. The conjunctiva and cornea are lubricated by mucous-containing secretions from the lacrimal gland and from the conjunctiva itself (1,2).

A contact lens is designed to float on the tear film overlying the surface of the centrally located cornea and to modify its refractive power. When the lens slides out of position and is lost in the eye, it may commonly hide on the undersurface of either eyelid, especially in the fornices, which are the upper and lower recesses where the conjunctiva reflects onto the eyeball. Tinted lenses are usually easy to locate and remove, but localization and recovery of a clear lens may require topical anesthesia and slit lamp examination (1,3,4).

Lack of vascularity of the cornea makes it dependent on the movement of tears beneath the contact lens for oxygen delivery. Both hard and soft contact lenses may, with prolonged wear, cause mechanical irritation, hypotonic tear production, and resultant corneal edema. The subsequent reduction in oxygen-rich tear flow can produce ischemia of segments of the cornea. The symptoms of this overwear syndrome are similar to a foreign body sensation and include eye pain, redness, itching, and tearing. Symptoms may not appear until several hours after removal of the contact lens from the eye as a result of transient anesthesia of the eye caused by buildup of anoxic metabolites over the course of wear. Chemical irritants such as cigarette smoke and anything that decreases blinking and normal tear flow, such as the ingestion of sedatives (e.g., alcohol), also may produce a similar syndrome of corneal edema and ischemic injury.

The cornea is easily abraded by trauma to the eye, whether it is from a fingernail during contact lens insertion or removal, or from foreign material trapped beneath the improperly cleaned lens. Many abrasions and foreign bodies are visible to the naked eye with fluorescein staining and a Wood’s (UV) lamp, although a complete examination should involve using a slit lamp. Mechanical trauma to the cornea may predispose to infection and ulceration if untreated. Few organisms are capable of penetrating an intact corneal epithelium without antecedent injury (1,2,3,4,5).

Soft contact lenses, made of a hydrophilic gel that may contain in excess of 60% water, carry added risk in terms of predisposition to infection. Soft lenses readily absorb water and, along with it, pathogenic organisms. Even minor trauma caused by simple lens insertion and wear may provide a portal of entry for organisms that then invade the cornea and lead to the development of a bacterial or fungal corneal ulcer. In the contact lens wearer who presents with eye pain, tearing, photophobia, and/or decreased vision in the affected eye, a suspicion of a corneal ulcer should be raised. The lens should be removed and a fluorescein slit lamp examination performed. Corneal opacity with shaggy debris and a flocculent stromal infiltrate indicate ulceration. Such a lesion represents an emergency and requires immediate ophthalmologic consultation for appropriate cultures and antimicrobial therapy (5).

Soft contact lenses also may be associated with other forms of nonemergent ocular injury, including corneal neovascularization, giant papillary conjunctivitis, and sensitivity reactions to contact lens solutions (2).

The emergency physician may need to remove a contact lens from a patient’s eye for several reasons. The first is to allow for a more detailed evaluation of the eye. This is especially true for the contact lens wearer who sustains trauma to the eye with a lens in place. The lens should be removed before a more thorough inspection of the patient’s cornea, including instillation of fluorescein. Contact lenses, particularly the soft variety, absorb stains and chemicals and will become permanently stained if fluorescein is instilled before their removal from the eye (1,6).

Complaint of eye pain in a contact lens wearer is a second common indication for lens removal. Because of the cornea’s rich nerve supply, pain is the classic presenting symptom of corneal injury. Photophobia also may be a significant component if the abrasion is large or is present for an extended period of time. As discussed previously, pain may represent traumatic injury to the eye, presence of a foreign body, infection, or “overwear” syndrome (1,6).