12.1 Soft Lens Insertion & Removal Techniques

Soft Lens Insertion & Removal Techniques

Quick Answer: Soft lens insertion follows a fixed sequence: clean hands, verify orientation with the "taco test," control the lids, place the lens on the inferior sclera, release the lower lid first, then the upper lid, and blink. Removal uses a temporal pinch after sliding the lens off the cornea.

Domain VI of the CLRE blueprint expects you to know not just the steps but the why behind each one. Fitters who can explain the rationale teach patients correctly and reduce dropouts.

Pre-Insertion Setup

1. Wash hands with non-cream soap; rinse thoroughly.
2. Dry with a lint-free towel — paper towels and terry cloth shed fibers that cling to hydrogel surfaces.
3. Inspect the lens for nicks, deposits, or inside-out orientation.

Verifying Orientation: The Taco Test

A soft lens can sit on the finger in one of two orientations. Inserting an inside-out lens causes immediate discomfort and poor optics.

Some lenses also feature laser markings (typically "123" or an "OK" engraved mark) that read correctly only in the proper orientation; the taco test remains the fastest bedside check.

Standard Insertion Technique

The textbook method places the lens on the inferior sclera, not directly on the cornea. Scleral placement triggers fewer blink reflexes and lets capillary action seat the lens.

1. Place the lens on the tip of the index finger of the dominant hand (concave side up).
2. With the non-dominant middle finger, hold the upper lid against the brow bone — firm pressure prevents blinking.
3. With the dominant middle finger, pull the lower lid down.
4. Instruct the patient to look up or straight ahead.
5. Place the lens on the inferior sclera, just below the cornea.
6. Release the lower lid first — this anchors the lens against the globe.
7. Have the patient look down, then release the upper lid slowly.
8. Instruct the patient to blink gently a few times and check comfort and centration.
9. Repeat for the left eye (OS).

Alternate: Lateral Canthal Insertion

For patients with a strong blink reflex, hypersensitivity, or ptosis that limits upper lid control, use the lateral canthal method:

• Pull both lids temporally with the index and middle fingers, creating a "stretched" interpalpebral fissure.
• Place the lens on the index finger, look toward the nose, and apply the lens to the temporal sclera.
• Have the patient slowly look toward the lens while releasing the lids.

This technique bypasses the central corneal reflex arc and is often taught to first-time wearers who struggle with the standard method.

Soft Lens Removal Technique

1. Look up — this exposes the inferior sclera and moves the lens off the visual axis.
2. Pull the lower lid down with the dominant middle finger.
3. Slide the lens to the temporal sclera using the index finger pad (never a fingernail).
4. Pinch gently between the thumb and index finger — the lens buckles and lifts off the ocular surface.
5. Place the lens in the appropriate case compartment (right or left).
6. Repeat for the fellow eye.

Common Insertion/Removal Errors to Avoid

• Using fingernails — tears the lens edge; use finger pads only.
• Placing the lens on the cornea directly — provokes an immediate blink reflex and risk of corneal abrasion.
• Releasing the upper lid first — the lid sweeps the lens off the globe before the lower lid can anchor it.
• Pinching too aggressively during removal — can fold the lens tightly and cause micro-tears.

Patient Education Pointers

• Recommend a consistent insertion order (e.g., right eye first) to prevent mixing up lenses with different parameters.
• Have new wearers practice with the non-dominant hand controlling the upper lid — dominant hand steadiness matters more for lens placement.
• Warn patients that eye rubbing over a lens can displace or damage it.

Key Takeaways

• The taco test is the fastest on-eye orientation check; inside-out lenses flare outward like a plate.
• Soft lenses belong on the inferior sclera, not the cornea.
• Release the lower lid first, then the upper lid, to seat the lens.
• For sensitive patients, lateral canthal insertion bypasses the central blink reflex.
• Removal combines a temporal slide with a gentle pinch to lift the lens off the sclera.