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Comprehensive information about diving and undersea medicine for the non-medical diver, the non-diving physician and the specialist.

  


Diving and the Eye
Underwater Optics
Underwater Refractive Correction
Sources for Prescription Dive Masks
Ophthalmic Considerations in Fitness to Dive Evaluations
Contra-indications to diving from Eye Problems
Diving Related Vision Loss
Barotrauma of the Eye
Decompression Sickness Involving the Eye
Arterial Gas Embolism of the Eye
The Effect of Oxygen Toxicity on the Eye
Hyperbaric Oxygenation and the Eye
Diving After Eye Surgery
Recommended Waiting Periods Prior to Diving

Fitness to Dive: Eye Problems for the Dive Instructor

The Effect of Water on Optics
  • Light rays are scattered and absorbed underwater. The deeper underwater - more light is absorbed
  • At 33 fsw [10 meters] about 20% of light is perceived and at 260 fsw, only 1% of light can be seen. 
  • Silt and particulate matter in water greatly reduce this light and even at very shallow depths can reduce visibility to one foot or less.
  • There is selective absorption of light wavelengths occurring at varying depths, causing color perception changes.
  • Red colors disappear first (longer wavelengths). reds disappear at about 30 feet, yellows at 75 feet. 
  • Only blues and greens remain at depths below 100 feet. [Artificial light reverses this effect.]
  • Mask Effects
  • Adjusts the changes that occur with refraction of light by the eye under water. 
  • There is a loss of refracting power underwater due to the water/cornea interface. Air between the mask and cornea preserves the refracting power.
  • However, as light is refracted away by the exit from the water to the eye - there is a magnification of about 30 % - making objects appear closer than reality.
  • The mask decreases the amount of field that is perceived from about 180 degrees to 85 degrees (depending upon the type of mask).
  • The reduction in the downward vision is most significant in that it prevents the diver from appropriate gear management.
  • HydroOptix,  Double-Dome masks

    These masks expand underwater vision almost 5X vs. flat masks and automatically correct for a remarkably broad range of myopia. 

    Contact Source
    Jon Kranhouse,
    HydroOptix LLC
    5631 Mesmer Ave
    Culver City, CA 90230
    PHONE:  310-636-1700 Xt. 209
    FAX:      310-390-8401
    TOLL FREE in USA: (877) WIDE EYE
    <http://www.hydrooptix.com>

    Underwater Refractive Correction

    Contact Lenses

  • Soft contact lenses are preferred. No corneal edema. 
  • Soft contacts more susceptible to marine infection. Use disposable lenses.
  • Hard lenses cause corneal edema during decompression and after dives. [Prevented by the use of a 'fenestrated' hard lens]*
  • Changes are apparently caused by nitrogen bubbles in the pre corneal film of tears resulting in epithelial edema. 
  • A good face mask seal minimizes loss of lens during a dive.
  • Consciously narrowing the palpebral fissure can help in decreasing the possibility of a contact lens floating off of the surface of the eye should the mask become flooded.
  • Reference:

    Cornea-contact lens interaction in the aquatic environment. Brown MS; Siegel IM, Department of Ophthalmology, New York University Medical Center, NY 10016, USA., CLAO J, 23(4):237-42 1997 Oct

    *'Fenestrated' refers to a 0.4 mm hole in the center of the hard lens serving as a channel through which the tears and bubbles can pass.


    Sources for Prescription Dive Masks

    Here is a Google Search for Prescription diving masks


    Considerations in Fitness to Dive Evaluations

          Guidelines have been published on medical standards for divers which include considerations concerning the eye. Visual considerations differ extensively according to the type of diving being contemplated. 

            Fitness to dive evaluations are most often done in one of two settings; either recreational and occupational. The first is an evaluation done for a patient who is a sport diver and asks his or her personal physician "Is it safe for me to dive?" This requires an evaluation and decision based entirely on medical safety considerations for the patient.

            The second type of fitness to dive evaluation is one done in an occupational setting in which a patient who is currently or hopes to be a military or commercial diver is evaluated by a physician who works for the organization in question, with interests of both the organization and the patient to be considered. The physical standards which are established may be quite different depending on the mission to be accomplished by the diver in each setting.

            Obviously additional questions must be considered in occupational settings. Economic, medico legal and liability considerations effect considerations in decisions about diving fitness in the occupation setting.

            The fitness to dive considerations for sport divers should focus only on medical safety and attempt to address three issues:

            (1) Does the condition impair the individual in such a way as to endanger himself or his associates in the hazardous hyperbaric environment (e.g. inadequate visual acuity);

            (2) Is the condition one which may be made worse by hyperbaric exposures (e.g. neurological   residua from DCS);

            (3) Would hyperbaric exposures possibly result in complications from a pre-existing condition (e.g. vision threatening barotrauma from diving with intraocular gas).


    Contra-indications to Diving from Eye Problems
    • Post-operative gas in the eye

    • Diving should not be allowed early in the post-operative period because of the possibility of gas  having been inserted purposefully or inadvertently. Boyle's Law dictates that the air will change in volume inversely in proportion to the depth and the possibility of injury to the eye  would be great.

    • Hollow orbital implant

    • The implant would implode at depth, severely injuring the orbit and endangering the diver.

    • Any acute disorder 

    • Pain, double vision or decrease in visual acuity would interfere with the problem solving and decision making process of the diver.
    • Recent eye surgery within the convalescent period.
    • Visual problems from previous DCS or AGE.
    • Glaucoma
    Where there is loss of vision severe enough as to make it dangerous for them to function in an underwater environment.
    • Functioning filters (Relative contraindication)
    • Divers who have undergone recent glaucoma filtering surgery.  A minimum of two months convalescence is recommended after this procedure.
    • Individuals who have undergone ophthalmic surgical procedures should allow an appropriate period for wound healing before resuming diving. [See chart below]



    Diving Related Vision Loss
     

  • Contact lens adherence due to salt water with resultant irritation and blurred vision.
  • Corneal swelling due to bubbles under a rigid gas permeable contact lens.
  • Displaced contact lens
  • Reaction to commercial mask anti-fog chemicals leading to blurred vision, photophobia, tearing and spasm of the eye muscles. Eye doctors identify this as keratopathy with the slit lamp. This is easily prevented by appropriate rinsing of the mask before use.
  • Ultraviolet keratopathy is caused by failure to protect the eyes from the ultraviolet radiation of underwater welding.

  • Barotrauma of the Eye
     
  • Normally, the eye is protected from barotrauma because the eye is filled with non compressible fluids, the aqueous and vitreous humors. 
  • A mask has air filled space that is compressible, affecting the eye and it's adnexa. 
  • If the diver does not expel gas through the nose into the mask on descent, negative pressure develops inside this space, sucking the eyes and lids toward this space. 
  • This negative pressure results in marked lid edema and bruising as well as bleeding under the conjunctivae of the eyeballs. These changes look a lot worse than they really are but can be disconcerting to the diver and his buddy.
  • Hyphema, a more serious injury, can occur in the eyes if the diver becomes unconscious and sinks to a greater depth without being able to equalize the mask. This can also result in bleeding under the periosteum of the bones of the orbit.
  • Vitreoretinal surgery with air placed in the eye contraindicates diving so long as any of the bubble remains. Pressure induced changes in the volume of these bubbles may result in hemorrhage inside the eye and also may result in partial collapse of the eyeball.

  • Decompression Sickness Involving the Eye

    Signs and Symptoms

  • Nystagmus (flicking of the eyes)
  • double vision
  • blank areas in the vision
  • loss of half the vision in an eye
  • pain in the eye muscles
  • blindness
  • inability to see close up objects
  • inflammation of the optic nerve 
  • blockage of the central retinal artery. 

  •  
    Incidence of Ocular DCS
  • In two large series was found to be 7 and 12 % . 
  • Long-term changes in the retinas is thought to be due to blockage of blood vessels of the choroid plexus. 
  • The incidence of these lesions is directly related to the length of diving and a history of decompression sickness.
  • In altitude DCS the most common neurologic finding is ophthalmologic
  • Increased risk if exposed to altitude too closely after diving.
  • Treatment of Ocular DCS 
  • Recompression to 60 fsw or deeper and hyperbaric oxygen breathing, the sooner the better. 
  • Incomplete response to treatment and recurrence of symptoms following treatment may lead to the infrequent situation where the eye doctor will be called upon to manage the diver in conjunction with the diving medicine specialist. 
  • The diver should be retreated with recompression and hyperbaric oxygen even when there is a considerable delay, since such treatment can be successful up to several weeks after the initial insult.


  • Arterial Gas Embolism (AGE) of the Eye
     

  • Caused by pulmonary barotrauma as the diver ascends, with bubbles getting into the pulmonary venous system and arterial circulation from rupture of alveoli. 
  • This can happen in as little as 4 feet of water if the diver holds the breath while ascending with compressed air
  • Ocular symptoms generally come from cerebral defects posterior to the optic chiasm, leading to hemianopias and cortical blindness. (Brain)
  • The gas emboli can also occlude the ophthalmic or central retinal artery resulting in blindness. (Arteries blocked)
  • The treatment is similar to that given for DCS -  emergent recompression and hyperbaric oxygen in all cases.


  • The Effect of Oxygen Toxicity on the Eye

    Manifestations of oxygen Toxicity

  • Eyelid twitching is the most commonly seen manifestation of O2 toxicity and usually is a warning that a full-blown seizure is imminent. 
  • blurred vision
  • visual field constriction
  • visual hallucinations
  • transient one-sided loss of vision 
  • Reversible after termination of the O2 exposure.
  • Treatment 
  • Removal of the O2 source immediately.
  • No residua unless secondary trauma or near-drowning occur from a convulsion . 

  • Prevented by using appropriate O2 concentrations at proper depths.

    Hyperbaric Oxygenation and the Eye
    Retinitis Pigmentosa
    (Investigative Ophthalmology 38; 5713 Abstract #3296, 1997).
    Researchers in Italy are reporting a breakthrough treatment for retinitis pigmentosa with the use of hyperbaric oxygen therapy. Daily hyperbaric oxygen at 2.2 atmospheres of pressure was employed among 24 RP patients for two years. The electroretinogram readings of RP patients undergoing hyperbaric oxygen treatment improved from 4.86 at the beginning of the study to 14.4 at the end of the study. RP patients who did not undergo oxygen therapy experienced diminished electroretinograms, beginning with an average of 4.92 decreasing to 2.97. Hyperbaric oxygen therapy may rescue retinal photoreceptors.  This report provides encouraging news to RP patients since there is no proven treatment for RP save for vitamin A therapy which only slows down progressive loss of vision as measured by an electroretinogram and does not improve the ERG.

    K.K. Jain, author of The Textbook of Hyperbaric Medicine, indicates the retina has the highest rate of oxygen consumption of any organ in the body. That hyperbaric oxygen treatment is helpful in cases of RP is an anomaly because it has been shown to cause severe constriction (narrowing) of retinal blood vessels. The hallmark of RP is poor retinal circulation. The constriction of the retinal blood vessels however is offset by the greatly increased oxygen carrying capacity of the blood during treatment (oxygen saturation increases by 23 percent).


      Contrast Sensitivity

    (Undersea & Hyperbaric Medicine 21; 387-90, 1994)

    Hyperbaric oxygen treatment improves contrast sensitivity (ability to see shades of gray) when administered to healthy volunteers. Even though patients with non retinal eye disorders have experienced constriction of retinal blood vessels following hyperbaric oxygen treatment, when there is a lack of oxygen supply to the retina narrowing of retinal blood vessels does not occur. 


    Other Reports
    (New England Journal of Medicine 281; 25-30, 1969)
    (Journal French Ophthalmology 10: 381-86, 1987)

    The medical literature reveals that hyperbaric oxygen treatment has been tried on cases of retinitis pigmentosa as early as 1965. A 1987 report in the Journal of French Ophthalmology indicates hyperbaric oxygen treatment improved the visual acuity of a patient with retinitis pigmentosa and macular edema.

    Radiation neuritis, optic nerve
    (Ophthalmology 93; 1083-88, 1986; Journal Clinical Neuro-ophthalmology 113; 98-101, 1993)

    Hyperbaric oxygen treatment has been used as a rescue remedy for optic nerve damage caused by radiation treatment for brain tumors.

    Hyperbaric oxygen improved vision among individuals who experienced a sudden loss of vision due to diminished blood supply to the optic nerve. Oxygen therapy must be administered early following onset of the event before shrinkage of the optic nerve occurs. (Arh Hig Rada Tokaikol 45; 19-24, 1994) 


    Decreased Vision due to multiple sclerosis
    (New England Journal Medicine 308; 181-86, 1983)

    Multiple sclerosis patients undergoing 20 hyperbaric oxygen treatments experienced temporary improvement of their symptoms including visual symptoms.
     

    Recently 100 percent oxygen delivered at 2 times atmospheric pressure did not produce a significant improvement in visual acuity or peripheral vision among patients suffering from a condition known as non arterial anterior ischemic optic neuropathy. (American Journal Ophthalmology 122; 535-41, 1996) 


    Glaucoma

    Among glaucoma patients, hyperbaric oxygen has been shown to expand peripheral vision, an effect which lasted for 3 months. (Acta Ophthalmologica 71; 315-19, 1993)

    The fluid pressure in the eye of humans and animals decreases as atmospheric pressure is raised in a hyperbaric chamber. (Investigative Ophthalmology 19; 43-48, 1980)

    K.K. Jain, author of Textbook of Hyperbaric Medicine, reports that hyperbaric oxygen has been used to
    successfully treat cases of glaucoma. Twenty or more 90 minute treatments at 2 atmospheres of pressure expanded the visual field among all glaucoma subjects tested. There was no change in eye fluid pressure.



     

    Retinal artery and vein occlusion

    Hyperbaric oxygen treatment combined with a blood vessel widening drug (vasodilator) has been shown to improve visual function among individuals experiencing retinal artery occlusion. (European Journal Ophthalmology 3; 89-94, 1993)

    Hyperbaric oxygen treatment has been successfully used to improve vision among patients with retinal swelling (macular edema) and retinal vein occlusion. (Survey of Ophthalmology 39; 347-66, 1995)

    Hyperbaric oxygen treatment has been administered successfully to patients with central retinal swelling (macular edema) resulting from retinal vein occlusion. Among 12 patients who were treated, 10 experienced visual improvement, with median visual acuity improving from 20/100 to 20/25. The hyperbaric oxygen treatment is believed to constrict retinal capillaries and thus decrease leakage of fluid that causes edema. (Ophthalmologica 210; 168-170, 1996)



    Possible ocular side effects HBO2

    It has been known that healthy persons can breathe oxygen at 3 times normal atmospheric pressure for 3 hours without any ocular side effects, but during the fourth hour some begin to experience a narrowing of their visual field.

    One reported side effect of hyperbaric oxygen treatment is the development of myopia (nearsightedness). (Journal Hyperbaric Medicine 1; 69-73, 1987) Myopia was first reported in 1978 among 18 of 26 patients undergoing hyperbaric oxygen treatment at 4 atmospheres of pressure. (Transactions American Ophthalmology Society 76; 118-24, 1976) Note: Italian doctors only used 2.2 atmospheres of pressure in their successful treatment of RP with hyperbaric oxygen.

    Dogs exposed to 3 atmospheres of pressure at 100 percent oxygen developed retinal problems and a reduction in their electro-retinograms. Narrowing of the visual field and impairment of central vision has been recorded among humans undergoing hyperbaric oxygen treatment at 3 atmospheres of pressure for more than 4 hours. (Science 151; 466-68, 1966)

    Captain Frank K. Butler, Jr. of the U.S. Navy reviewed the ocular effects of hyperbaric oxygen treatment in a recent issue of Review of Ophthalmology. Hyperbaric oxygen may induce myopia (nearsightedness) at the rate of one quarter diopter change in eyeglass prescription per week among patients receiving daily hyperbaric oxygen treatment. The myopia reverses slowly over a course of many weeks. Cataracts have been reported to occur among patients undergoing a prolonged course of daily hyperbaric oxygen treatment which may not be reversible following cessation of treatment, particularly among adults of advanced age. (Survey of Ophthalmology 39; 347-66, 1995) K.K. Jain indicates cataracts may occur among patients undergoing hyperbaric oxygen treatment but that these were seldom observed when less than 200 treatments were administered.

    K.K. Jain reports that the most useful role of hyperbaric oxygen in eye care is the relief of blood vessel constriction in central retinal artery occlusion with a success rate as high as 60 percent. Hyperbaric oxygen does not appear to have a useful role in the treatment of diabetic retinopathy. K.K. Jain states "With the pressure and duration of exposures used in clinical practice, ocular complications are not a problem... Hyperbaric oxygen appears to be a safe treatment from the ocular point of view." Confirming its safety, hyperbaric oxygen treatment has been applied in cases of multiple sclerosis with optic neuritis without loss of vision or narrowing of the visual field.


    Free Radicals
    (Free Radical Biology & Medicine 6; 505-12, 1989)

    Hyperbaric oxygen treatment has been shown to adversely affect the electroretinograms (ERGs) of rodents fed a diet deficient in vitamin E and selenium. But rodents fed vitamin E alone or vitamin E plus selenium showed no decreases in their ERGs after 15 weeks of hyperbaric oxygen treatment.


    Diving After Eye Surgery

    Individuals who have undergone ophthalmic surgical procedures should allow an appropriate period for wound healing before resuming diving. 

    Factors increasing the risk of post-operative complications:

  • Marine organisms may cause infections when they contaminate non-epithelialized wound surfaces of the cornea, sclera, conjunctiva, or lid tissues
  • These pathogens may enter the eye through unhealed corneal or scleral wounds and result in vision threatening endophthalmitis

    The risk of infection due to contact of the eye with water is much greater when diving in potentially contaminated ocean, river, or lake water than when showering or bathing in chlorinated city water.
  • Gas in the anterior chamber or vitreous cavity.
  • This may be affected by changes in pressure and result in vision threatening intraocular barotrauma
  • Negative pressure in the air space of a face mask caused by a mask squeeze.
  • This may result in subconjunctival hemorrhage, lid ecchymosis and edema, and could theoretically cause the rupture of incompletely healed corneal or scleral wounds.
  • In chamber dives, only gas in the eye remains a consideration.



  • There are no controlled studies specifically addressing the requisite length of convalescence before a return to diving from any type of eye surgery. The recommendations below are based on the application of wound healing observations in other studies and on clinical experience.

    Also, it is unknown whether scuba has any relationship in causing or contributing to conditions such as retinal detachment in the normal eye. Concerned divers with signs and symptoms of visual problems are advised to seek advice from their eye doctors.



    A. Corneal surgery

    Full thickness incisions

  • Very little healing is noted in the first week, followed by a rapid rise to about 30% of normal strength at 1 month. 
  • Wound strength then gradually increases to approximately 50% of normal by 3 to 6 months.
  • Penetrating keratoplasty in which full thickness incisions are made in the cornea should be followed by a six month convalescent period.
  • Radial and astigmatic keratotomy
    •  Do not entail full thickness corneal incisions or prolonged topical steroid therapy, may be allowed to dive after three months.
    • The possibility of barotrauma induced rupture of a corneal wound is a theoretical possibility after any of the above procedures, but would occur only in the setting of an uncommonly encountered face mask squeeze.

    Photorefractive keratotomy

    • There are no incisions, which permits a return to diving after re-epithelialization of the cornea is complete and acute post-operative symptoms subside.

    Diving after refractive surgery

    There are often inquiries about radial keratotomy [RK], a surgical procedure with long-term implications for diving. RK is currently a widely performed keratorefractive procedure.  Individuals whose myopia has been corrected with this procedure are prohibited from entering diving programs in the Navy.

    Applicants who have had this procedure may not even be allowed to serve in less visually demanding Navy positions. Two recent reviews of RK in the military have recommended that the procedure continue to be disqualifying for Navy divers and for Army aviators. Edmonds, Lowery and Pennefather recommend that no one who has had RK be allowed to dive unless they have face masks designed to equalize the pressure within the mask to that of the ambient pressure. Davis and Bove state that until further data is available, a person who has had RK should be permanently disqualified from diving.

    Complications of RK that impact the diver.

  • halos
  • glare
  • diurnal fluctuations in visual acuity
  • progressive hyperopia
  • irregular astigmatism
  • decrease in best corrected visual acuity
  • recurrent corneal erosions
  • increased susceptibility to traumatic corneal rupture
  • possible barotrauma induced rupture of RK incisions in the hyperbaric environment (No reports)

  • Dr. Frank Butler has seen only one clinically significant case of face mask squeeze in many years of association with Navy and sport diving activities. Most of the reports of corneal rupture following RK have been the result of direct blunt trauma to the eye. Also worthy of note are the reports of blunt trauma severe enough to cause hyphema and facial fractures in which radial keratotomy scars remained intact.

    Photorefractive keratectomy (PRK) is a new refractive surgical procedure. Unlike radial keratotomy, it entails no corneal incisions which may decrease the ability of the cornea to withstand blunt trauma. Published studies of the outcomes of PRK have shown this procedure to be relatively free of post-operative complications when compared to RK.  Individuals who have had this procedure may be allowed to dive two weeks after their surgery, assuming that they have had a normal post-operative course with resolution of pain and photophobia.


    LASIK (laser in situ keratomileusis)

    1. There are no case reports that document diving related complications after LASIK.

    2. There are at least three potential complications that might occur in post-op LASIK patients as a result of diving:

            - Globe rupture from face mask barotrauma (unlikely)
            - Interface keratitis (infection of the flap interface)
            - Flap displacement from interface bubbles

    3. Complications that might impact the safety of divers include;

    Halo
    Glare
    Night diving complaints
    These decrease from 25+% early to about 4% in one year.

    4. It is recommended waiting a minimum of one month before resuming diving after LASIK. [Butler]

    5. This should always be discussed with the personal ophthalmologist, so that he or she will be able to add any special knowledge about your specific situation that would be relevant.


    Central Serous Retinopathy

     -  localized detachment of the retina in the region of the macula.
            - Visual acuity usually ranges from 20/20 to 20/80.
            - Usually occurs in men aged 25 to 50.
            - CSR is often associated with stress and a Type-A personality.
            - In women, it is associated with pregnancy.
            - Resolves spontaneously, permanent deficits may occur.
            - Recurrences are common.

    Laser therapy may hasten resolution and decrease the incidence of recurrences. Indications for therapy include duration beyond 4-6 months, recurrence of CSR in an eye that sustained a permanent deficit from a previous episode, and occurrence in the fellow eye in a patient that suffered a permanent deficit from a previous episode of CSR in the other eye.

    Dr. Frank Butler reports that, as far as is known, this disorder has not been reported to be worsened by diving. In addition, there is no physiological rationale that I am aware of to expect that hyperbaric exposures would have an adverse impact on the natural course of or therapy for this disorder.




    Recommended Waiting Periods Prior to Diving *
    Anterior Segment Surgery
    Penetrating Keratoplasty
    6 months
    Corneal laceration repair
    6 months
    Cataract Surgery
     
    1.  Non corneal valve  incision
    3 months
    2. Corneal valve incisions
     
          A. Clear corneal
    2 months
           B. Scleral tunnel
    1 month


    Radial Keratotomy
    3 months
    Astigmatic keratotomy
    3 months
    Glaucoma filtering surgery (relative contra-indication)
    2 months
     
    Photorefractive keratotomy
    2 weeks
    Lasik
    One month
    Pterygium excision
    2 weeks
    Conjunctival surgery
    2 weeks
    Corneal suture removal
    1 week
    Argon laser trabeculoplasty 
    or iridectomy
    No wait 
    Yag laser capsulotomy
    No wait 
    Vitreoretinal surgery
     
    Vitrectomy 

    (Intraocular air must be 
    absorbed prior to diving)

    2 months
    Retinal detachment repair
    2 months
    Pneumatic retinopexy 

    (Must wait until all air is 
    absorbed before diving)

    2 months
    Retinal cryopexy or laser 
    photocoagulation for breaks
    2 weeks
    Oculoplastic surgery
     
    Sutured wound
    2 weeks
    Skin graft or granulating wound
    Complete 

    epitheliazation

    Enucleation
    2 weeks
    Hollow implants
    Diving contraindicated
     
     
    Strabismus Surgery
    2 weeks
     
     
    References:

    Diving and Hyperbaric Ophthalmology, Captain Frank K. Butler, Jr. MD
    Survey of Ophthalmology Volume 39, No. 5, March-April, 1995, 347-366.

    Diving and Subaquatic Medicine, 4th Edition, Edmonds, Lowery, Pennefather and Walker


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