SCUBA Diving and the Eye

Educational Objectives

The goal of this program is to improve the management of ophthalmic issues related to SCUBA diving. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel patients on strategies to reduce the risk for ophthalmic complications after SCUBA diving.
2. Identify ocular contraindications for SCUBA diving.

Summary

Intraocular gas bubbles: Jackman and Thompson (1995) injected 0.3 mL of gas into the eyes of rabbits and then simulated a SCUBA dive (33 ft) in a bariatric chamber; the intraocular pressure (IOP) decreased to zero as the rabbits descended and atmospheric pressure increased; as they ascended, the IOP increased to 60 mm Hg (much higher than baseline)

Influence of masks: the mask is the most common source of issues during SCUBA diving; issues are most commonly related to barotrauma or changes in optics; at greater depths, longer wavelengths of light (eg, violet, red, yellow) are selectively filtered out; pink or yellow-tinted masks are used to accommodate this; the cornea is responsible for most refractive changes at 45 D, and extreme hyperopia occurs if water enters the mask; the mask makes objects appear closer and larger, and visual fields decrease from 180° to 85° (curved masks are used to accommodate this)

Contact lenses during SCUBA diving: soft contact lenses are universally accepted and generally preferred; formation of gas bubbles beneath a hard contact lens onto the surface of the cornea may occur when rising to the surface, though these bubbles are usually short-lived; while generally discouraged (but not contraindicated), many experts state that hard contact lenses can be worn if divers adhere to conservative events; immediately discard soft contact lenses after diving to prevent contamination; mask should be large and well-sealed; soft lenses are not usually dislocated if fluid enters the mask, but infection is possible; chemicals used to defog masks may adhere to the contact lens and stick to the cornea; individuals <40 yr of age with myopia often have a set of contact lenses with stronger myopic correction that they use for SCUBA diving; individuals with presbyopia need a stronger addition or correction to accommodate the underwater optics; prescription masks are available but expensive; presbyopic correction may also be achieved through use of different contact lenses, bifocals (affixed to the bottom of the mask), stick-on magnifying lenses, or add-ons (eg, drop-ins, inserts, bonding)

Decreased vision after diving: causes include loss of lens, keratitis, barotrauma, choroidal edema, anti-fog keratopathy, and contact lens adherence; goggles used for skin diving can cause trauma to the conjunctival vessels if the pressure is not normalized inside the goggles; deep free-divers use single-plated masks because they need to pre-pressurize the mask (important to prevent barotrauma); severe barotrauma caused by inadequate pressurization may present as hyphema, subperiosteal orbital hemorrhages, diplopia, periocular swelling, optic neuropathy, and conjunctival hemorrhage; patients with Lester-Jones tubes are unable to SCUBA dive because they are unable to pressurize the mask; asymptomatic anatomic anomalies of the vasculature can result in unanticipated injuries after SCUBA diving (eg, vascular insult to the left carotid artery and central retinal artery occlusion that occurred in a patient who had absence of the A1 segment of the left anterior cerebral artery); progressive optic neuropathy can occur from sphenoid sinus barotrauma; sphenoid sinus mucocele may result in inferior hemianopsia; a link between SCUBA diving and carotid artery dissection exists

Contraindications to SCUBA diving: general consensus is that if an individual is able to drive a vehicle, they are capable of SCUBA diving; individuals with unhealed corneal abnormalities should avoid SCUBA diving; enucleation is not a contraindication for diving unless the orbital implant is hollow; glaucoma is only a contraindication if it is accompanied by significant vision loss; vitreoretinal disorders are only problematic if the eye contains a gas bubble or the patient has insufficient visual field or acuity to permit safe diving; silicone oil in the eye is not a contraindication

Wait times after eye surgery: sufficient time for healing (complete healing of the surface) should be given to reduce risk for corneal ulcers; face mask barotrauma can rupture healed wounds, and ≥1 mo should be given to allow for stabilization after sutureless cataract surgery; to enable complete corneal healing, wait 6 mo after penetrating keratoplasty and 3 mo after radial keratotomy; with regard to cataract surgery, wait 1 mo following scleral tunnel incision and 2 mo following clear cornea incision

Readings

Brown MS, Siegel IM. Cornea-contact lens interaction in the aquatic environment. CLAO J. 1997;23(4):237-242; Deleu L, Catherine J, Postelmans L, et al. Effect of SCUBA diving on ophthalmic parameters. Medicina (Kaunas). 2022;58(3):408. doi:10.3390/medicina58030408; Isenberg SJ, Diamant A. Scuba diving after enucleation. Am J Ophthalmol. 1985;100(4):616-617. doi:10.1016/0002-9394(85)90695-6; Jackman SV, Thompson JT. Effects of hyperbaric exposure on eyes with intraocular gas bubbles. Retina. 1995;15(2):160-166. doi:10.1097/00006982-199515020-00013.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Stewart is a consultant for Alkahest, Bayer, and Revana, and received grant/research support from Alexion. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Stewart was recorded at 12th Annual Continuing Medical Education Program: Snowmass Retina & Eye 2023, held March 6-10, 2023, in Snowmass, CO, and presented by the Eye Research Foundation. For information on future CME activities from this presenter, please visit https://www.snowmasscme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

OP611503

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.