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 endophthalmitisThe 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.

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.

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