17.3 Insertion, Removal, Care Systems, and Wear Schedules

17.3 Insertion, Removal, Care Systems, and Wear Schedules

This is the most heavily tested practical area for the ophthalmic assistant because patient education prevents the complications in the next section. Stems often describe a patient action and ask whether it is safe.

Insertion and removal

Every procedure begins with washing hands with soap and drying with a lint-free towel. That is the universal first step the exam expects — before touching the lens, the case, or the eye. Keep fingernails short and remove any debris, and always work over a clean surface (not an open drain) so a dropped lens is recoverable.

• Soft lens insertion: balance the lens on a dry fingertip (check it is not inverted — a properly oriented lens looks like a bowl with straight edges, not a flared rim), hold both lids open, look steadily, and place on the cornea or lower sclera.
• Soft lens removal: look up, slide the lens down onto the sclera with a finger, then pinch gently between thumb and index finger.
• RGP removal: widen the lids past the lens edges and blink, or use a small suction cup (DMV plunger). Never pinch an RGP off the cornea.

Care solution systems

Water is the enemy

The single most dangerous patient habit is exposing lenses to water. Teach explicitly:

• Never rinse or store lenses in tap water, distilled water, or saliva.
• Never swim, shower, or use a hot tub in lenses without sealed goggles.
• Tap water carries Acanthamoeba, a protozoan that causes a severe, vision-threatening keratitis that is notoriously hard to treat. This is the classic exam link: contact lens + water exposure + severe pain out of proportion to findings + ring-shaped corneal infiltrate = Acanthamoeba.
• Discard and replace solution daily; never "top off" old solution. Replace the case every 3 months and air-dry it face-down.

Replacement vs wear schedule

These are two separate decisions the patient must understand:

• Replacement schedule = how often a fresh lens is opened: daily disposable, two-week, monthly, or quarterly. Overwear past the replacement interval causes deposits, giant papillary conjunctivitis, and reduced oxygen.
• Wear schedule = whether the lens is removed for sleep: daily wear (out every night) vs extended/continuous wear (approved overnight, FDA-cleared up to 6 nights or 30 days for specific silicone hydrogels).

Extended wear multiplies the risk of microbial keratitis several-fold versus daily wear, so the safe default the exam rewards is daily wear with nightly removal unless the prescriber specifically approves otherwise.

Common scenario

A teenager reports sleeping in two-week lenses "a few nights" and topping off solution. The correct teaching is to remove lenses nightly, never top off, discard on schedule, and return if redness or pain develops — addressing the root behaviors, not just one symptom.

The order of operations on the eye

A frequently tested sequencing point: apply makeup after inserting lenses and remove lenses before removing makeup, so cosmetics do not deposit on the lens. Insert contact lenses before applying cosmetics; remove lenses before cleansing the face. Use water-based, non-flaking products and avoid lash-line eyeliner that clogs the meibomian glands.

Hand-off and follow-up cues

Teach patients the warning acronym some clinics use — SEE: Stinging/redness, Excess tearing or discharge, Eye pain or reduced vision — any of which means remove the lens and call. Schedule lens wearers for annual contact-lens evaluations (not just glasses exams) because fit, oxygen needs, and corneal health change over time. The ophthalmic assistant documents wear schedule, replacement schedule, solution brand, and any symptom history at every visit so the prescriber can spot overwear patterns early.

A note on solution mismatches

Never use a soft-lens multipurpose solution to soak RGPs or vice versa without checking the label — surfactants and viscosities differ. Never substitute homemade saline (a salt-tablet practice abandoned decades ago because of fatal Acanthamoeba outbreaks). When a patient switches brands and reports new stinging on insertion, suspect a preservative they tolerated poorly and move them to a hydrogen-peroxide or preservative-free system.

A lost or stuck lens

A soft lens that "disappears" almost always folds and lodges in the upper fornix — it cannot go behind the eye, because the conjunctiva is continuous. Reassure the patient, have them look down, evert the upper lid, and recover the lens; copious preservative-free saline helps a dehydrated, stuck lens release. A dried-out soft lens should be rehydrated in solution before any attempt to remove it, never peeled off dry. These are exactly the calm, accurate instructions a COA is expected to give over the phone or chairside.