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Eye Problems - Surgery

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I had an orbital floor fracture repair about 4 months ago to cover a hole that was around 2cm in diameter, and in excess of 50% of the orbital floor. The material used was titanium mesh.

A complication arising from the initial trauma, however, was that it was not possible to correctly reposition a portion of the eye tissue at the back of the orbit. This tissue remains trapped behind the titanium sheet and in the maxillary sinus. It has been decided that any further operation would be too risky to my sight. Can you please advise as to if there would be any contraindications for my diving.

If you need to see CT, or have me take a medical, just let me know.

A - Blimey that’s a big hole. The orbit is the cavity in the skull which accommodates the eye. Orbital floor fractures commonly result from blunt objects (fists, car dashboards, balls) impacting on the eye socket, which then breaks. Over 80% occur in males (funny that). What actually happens is that the object in question, say a well-aimed punch from the gloved fist of Joe Calzaghe, squishes the incompressible eyeball inwards. The rapid increase in pressure in the socket then causes it to “blow out” at its weakest point, the floor. The fatty tissue around the eye then drops through the hole, often pulling a couple of eye muscles with it, resulting in double vision. And a rapid lie-down.

In a victim without visual disturbances, where the fracture covers less than 50% of the floor, and where there’s no trapped fatty or muscle tissue, one option is to leave the area alone and treat with steroids and antibiotics. In your case however, surgery was undertaken, repositioning the disrupted bony fragments and patching up the fracture with a mesh. One issue with this type of repair and diving is whether there is any possibility of trapped gas within the tissues. I would assume that any gas introduced would by now have diffused safely away, but it would be worth checking with your eye surgeons to guarantee this. A second issue is whether the tissue trapped in the maxillary sinus will obstruct your ability to equalise, or make that area more susceptible to barotrauma. I would imagine that as long as the sinus can drain normally you would be OK on that score.

Otherwise I can't see (pardon the pun) any reason you shouldn't dive once you're fully recovered.

Q - I appreciate that you are not an optician, but was wondering whether you could give me any advice at all with my dilemma. I am considering having laser surgery to correct my vision, but as a diving instructor would welcome your opinion on any effect diving may have. Specifically, what duration to remain out of the water, with relation to both fear of infection, and any problems there may be connected to pressure related injuries (if any).

I have been working in the Red Sea over the last couple of years, but am now back in the UK for a few months, and will not be returning to diving until later this summer, at the earliest. So now seems a good idea to go for the surgery.

My prescription is fairly mild (-3.25), which means I can have either type suggested currently.

Lasik - Layer of cornea cut and folded back, laser reshapes cornea and flap is then replaced.

Epi-Lasek - Epithelium parted, laser reshapes (flattens) cornea, epithelium pushed back over flattened cornea.

Is it possible that either is more or less likely to cause problems than the other?

When I mentioned my concerns regarding diving, no-one at Optimax could give me a definitive answer, except I should not go swimming for a month. Obviously swimming and diving are to two different issues. Even just diving and teaching could be separate issues, since unless I am teaching, my mask (hopefully) remains firmly in place.

A - Here's the deal with diving and eye surgery. It's not a case of compression or the eye bursting at depth. It's a solid with some jelly like stuff in the middle. So it wont be affected by pressure. It's all about the abrasion to your cornea, and the chances of infection getting into the eye. The main nasty is called "acanthamoeba". Get it and you can lose your sight in a few days. And the main way it is contracted is by swimming or diving and getting into contact with it in the water.

So if your eye docs say you can swim a month post-op, then in theory you are fine to dive as well. I always used to say 6 weeks though, so an extra 2 wont hurt.

When you dive, hang that mask loose and watch any squeeze.

I don't think it wise to teach before this time, acanthamoeba can lurk
around in pools as well, so stay out of all water for this time.

(other dive medical questions)


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