Ocular Trauma at Sea

Vision is our most critical sense underwater. Yet, a spearfisherman’s environment is at all times hostile towards it. Scouring seascape, our eyes are beaten by sun and wind. Underwater, our eyes are subject to mask pressure, infiltration by salt, sand, and ocean microorganisms. Acute and chronic ocular traumas irritate the tissues of the eye and can insidiously perpetuate vision loss. This article discusses 5 common eye injuries a spearfisherman may encounter: (1) Corneal Sunburn (2) Pterygium (3) Subconjunctival Hemorrhage (4) Pink Eye (5) Corneal Abrasions. These injuries are common, preventable, and treatable. Awareness may decrease complications. 

The takeaway of this article is to remind you to wear sunglasses and to pay attention to your eyes!

 Corneal Sunburn (Photokeratitis):

By far, the number one eye issue divers experience is corneal sunburn. Like a sunburn on your skin, you may not realize it is happening until it’s too late - up to 12 hours after exposure. When on the ocean looking for birds and hopefully foaming tuna, we are exposed to large amounts of strong UV light, this kills the first layers of our cornea. When this occurs, the nerves on our cornea transmit pain. The eye pain can be significant, accompanied by light sensitivity, tearing, some blurring of vision, and eyelid redness. Pus, mucus-like-discharge, or complete vision loss are not symptoms of corneal sunburn. These symptoms can absolutely interrupt the perfect weather conditions you patiently waited so long for.

Oral Tylenol (350mg), aspirin (650mg), ibuprofen (400-800mg), or over the counter artificial tears offer effective relief, as does shade. Dead corneal epithelium should be cleared and renewed within 1-3 days, and symptoms resolve. In some cases, the ravaged cells of the cornea may be inviting for bacteria, so erythromycin antibacterial ointment 4x/day for 2-3 days can be recommended. If your eye is very sensitive, resist the urge to wear an eye patch, it may delay corneal healing. If you wear contact lenses, stick to your glasses until the cornea is healed. Those with past Lasik surgery may have greater sensitivity to the sun. Be cautioned that repeated corneal sunburns can cause progressive scaring that may irreversibly decrease vision and necessitate a corneal transplant.

Pterygium

Depending on who you talk to, pterygiums can be a badge of honor or a cosmetic nightmare. Most people agree it feels like a grain of sand is stuck in your eye. Pterygiums are wedge-shaped, pinkish, scar tissue growths from the corner of your eye. They are associated with persistent UV exposure and are common amongst surfers, sailors, and Nepalese climbers.

Over years, repeated microtrauma via sun, wind, and dryness can lead to pterygiums. They most often occur from the side of your eye closest to your nose and can grow onto your cornea. Dry eye and clogged eyelid oil glands have been correlated with pterygiums. HPV may also pose a risk.

This growth takes a long time to develop, and you will notice it over time. If a pterygium doesn’t interrupt your vision and you don’t mind the cosmetics, then it is totally fine. Other symptoms might include, eye redness, blurred vision, itchiness, or trouble wearing contact lenses. The issue with pterygiums is that it may eclipse the cornea and block vision. It can also progressively tug at the cornea creating an astigmatism (wavy corneal topography).

Expect your doctor to treat mild cases with over-the counter lubricating artificial tears, or prescription steroids to reduce pain and redness. For serious cases (cosmetic or vision compromise) you may elect for a surgical removal of the pterygium. This surgery has many variations, and your doctor likely has their own tried and true method. Ask about it. Generally, the big issue is that the pterygium can grow back quickly, and your money/surgical risk went to waste. Recurrence is most likely to occur within 12 months. The newer graft surgeries tend to avoid this outcome.

You can still dive with a pterygium but probably best to give yourself a few weeks before getting back into the water after a pterygium removal surgery.

Subconjunctival Hemorrhage:

Your wife or dive buddy might freak out, but this is a total non-issue. If you do not equalize your mask pressure on decent, the low pressure in the mask relative to the high pressure at depth can cause bursting of blood vessels just under your conjunctiva. The bleeding is contained in the outer layer of the surface of your eyeball. It is not painful and does not interrupt vision. This blood blister heals spontaneously and does not require medical intervention. Scuba divers likely suffer from a much more serious version of this (subperiosteal hemorrhage) because of their tendency for much more rapid decent and higher amounts of “new-divers”. These may give you a black eye and double vision. Prevent the subconjunctival hemorrhage by using a dive mask instead of swimming goggles and equalizing your mask on descent. The purpose of mentioning this is to prevent unnecessary freak-outs if this happens to you.

Pink Eye

There are limited reports on ocean borne eye infections, however if you are diving and traveling outside of the country, these are important to keep in mind. There are 3 scenarios:

1.     Viral: Both your eyes are red, watering, and you have swollen lymph nodes.

2.     Bacterial: One of your eyes is red, and you have creamy/mucusy discharge.

3.     Allergic: Both your eyes are red; they itch and swell.

If your pink eye is viral or allergic, put a towel soaked with clean cold water over your eyes, take (350mg) Tylenol, and vigorously wash your hands. If you have creamy/mucusy discharge coming from your eye (bacterial), use erythromycin eye ointment. The big concern for bacterial infections is pseudomonas from dirty contact lenses and gonorrhea. If you suspect gonorrhea and have a red eye, get to the hospital, rapid vision loss may ensue. They will give you a systemic antibiotic like ceftriaxone.

Corneal Abrasions

Fortunately, we wear eye protection as part of our sport, but we all are familiar with annoying small particulate ending up on the inside of our masks. Abrasion to the cornea can happen due to infection or trauma – like sand, wind, fingernails, or kelp. This will be very painful but last only 24hrs. Light sensitivity and a foreign body sensation are also common symptoms. Aggressive lubrication is key for management, and with preservative-free eye drops you can use as much as you want. Additionally, patching the eye closed with tape for 24hrs can relieve symptoms. If the pain last longer than 24hrs or patching the eye doesn’t work, then seek urgent medical attention. If you have an abrasion along with signs of a bacterial infection (creamy mucus), this may be an ulcer. Seek immediate medical attention. If out at sea, take the same lubricating measures described for abrasion, which should manage symptoms and encourage healing until you can make your way back from whatever ocean pinnacle you were diving on and see a physician.