12.2 RGP Insertion, Removal & Emergency Responses

RGP Insertion, Removal & Emergency Responses

Quick Answer: RGP lenses are inserted directly onto the cornea with lids held firmly to prevent blink dislodgement. Three removal techniques are commonly used: the lid-spread blink-out, the DMV suction cup, and the lean-forward table method. Emergency responses include massaging a displaced lens from under the upper lid, rewetting a stuck lens, and never doubling up a lost lens.

Rigid gas permeable (RGP) lenses interact with the ocular surface very differently than soft lenses. Because they maintain their shape and sit on the tear film over the cornea, the insertion site, lid control, and emergency responses all differ.

RGP Insertion Technique

1. Wash and dry hands thoroughly (non-cream soap, lint-free towel).
2. Moisten the lens with the prescribed wetting solution — this improves tear-film interaction and cushions the initial touch.
3. Place the lens concave-side up on the tip of the index finger of the dominant hand.
4. With the non-dominant hand, hold the upper lid firmly against the brow. Firm pressure is critical: a blink during placement can launch an RGP across the room.
5. With the dominant middle finger, pull the lower lid down.
6. Have the patient look straight ahead — RGP lenses are placed on the cornea, not the sclera.
7. Place the lens directly on the cornea.
8. Release the lower lid first, then the upper lid slowly.
9. Have the patient blink gently and assess comfort, centration, and movement.

Why Scleral Placement Fails for RGPs

A soft lens drapes over the sclera and migrates onto the cornea. An RGP retains its shape; if placed on the sclera it sits off-axis and immediately decentrates on the first blink. Direct corneal placement is mandatory.

RGP Removal Techniques

Three methods are taught in CLRE curricula, and a competent dispenser should know all three.

Method 1: Lid-Spread (Blink-Out)

The most common in-office removal, requiring no instruments.

1. Have the patient look toward the temple (lateral gaze shifts the lens off the visual axis onto the temporal sclera).
2. Place the index finger of one hand on the upper lid margin and the index finger of the other on the lower lid margin.
3. Spread the lids wide apart, pressing gently against the globe.
4. Have the patient blink — the lid margin catches the lens edge and pops it out.
5. Catch the lens with the free hand or a clean towel.

Method 2: DMV Suction Cup

Useful for small-diameter lenses or patients who cannot master the blink-out.

1. Moisten the suction cup tip with wetting solution or saline.
2. Have the patient look straight ahead.
3. Touch the suction cup to the lens surface — capillary action adheres the lens.
4. Lift straight off — do not slide, which can abrade the cornea.
5. Release the lens from the cup by breaking the seal with a fingertip.

Method 3: Lean-Forward (Table Method)

Ideal for patients at home without tools.

1. Have the patient lean forward over a clean towel on a table.
2. Place fingers on the lid margins as in the blink-out technique.
3. Have the patient blink forcefully — the lens falls onto the towel.

Emergency Responses

Lens Displaced Under the Upper Lid

A common call to the clinic. Removal steps:

1. Have the patient look down — this brings the upper fornix into view.
2. Massage the upper lid gently downward toward the lower fornix.
3. The lens typically drops onto the sclera or cornea; remove normally.
4. If the lens does not reappear, instill rewetting drops and repeat.
5. As a last resort, evert the upper lid and lift the lens off with a moistened cotton-tipped applicator or suction cup.

Lens Stuck (Tight) on the Cornea

A lens can adhere when the tear film thins or the patient falls asleep with the lens in.

1. Instill rewetting drops and wait several minutes.
2. Have the patient blink repeatedly to break the suction.
3. Gently massage through the upper lid.
4. If still adhered, remove with a suction cup after generous wetting — never force a dry lens off, which risks epithelial abrasion.

Lens on the Sclera (Decentration)

1. Have the patient look toward the lens (e.g., look left if the lens is on the nasal sclera of the right eye).
2. Blink — the lens typically recenters.
3. If persistent, gently push the lens through the closed lid toward the cornea with a clean fingertip.
4. Once over the cornea, have the patient blink to seat it.

Lens Lost

• If a lens is lost off-eye, replace it — never allow a patient to wear two lenses in one eye ("doubling up").
• Doubling up induces severe corneal hypoxia, mechanical abrasion, and unpredictable optics.
• For lost lenses, check the patient's glasses as a backup and reorder a replacement.

Key Takeaways

• RGPs are placed directly on the cornea with the upper lid held firmly.
• The blink-out, suction cup, and lean-forward methods are the three accepted removal techniques.
• A displaced upper-lid lens is brought down by having the patient look down and massaging the lid toward the lower fornix.
• Rewet, never force a stuck lens off the cornea.
• Never double up a lost lens — replace it.