Diving and Diabetic Retinopathy?

[jon677]

Hello Everyone...

I have been diving since 1988 and am an SSI certified Master Diver. I have been an insulin dependent diabetic since 1980. I have been unable to dive for the past 3 years due to constant struggling with Diabetic Retinopathy (abnormal growth and rupturing of tiny vessels in the eye leading to internal bleeding, visual obstruction, and if untreated/unlucky, eventual blindness). Pressure changes (both internal/body and external/water) are a concern. Most of the forces would be compressive but I'm concerned about the release of the compressive forces on ascent coupled with the potential blood pressure increase due to exertion. I think I have the condition controlled at this time and want to get back in the water. My eye doctor says to go ahead and try. Are there any others out there who are dealing with stabilized Proliferative Diabetic Retinopathy and diving? Any comments or experience would be welcome.

Thanks,

Jon

 

[Lloyd]

Jon,
I am a clinical prof. at colleges of optometry and medicine. What level of diadetic retinopathy do you have? That will help in making a recommendation. Remember since I have never seen you and am not your Dr. may advice is not as accuarated for your specific condition as your own Dr. I can only give you general knowledge and explainations. If you only have mild NPDR you should be safe.
The most important thing you can do is keep your diabetes under tight control. Always <120. Let me know your specifics for more help.
Lloyd

 

[jon677]

Hi Lloyd, Thanks for responding. I have definitely been battling Proliferative Retinopathy. Both eyes have had all the laser they can take. My left eye has been stable for over a year but I have had trouble with my right eye. My Dr's think it's due to elevated blood pressure and I've been on the ACE Inhibitor Zestril for a few month's. Now my BP is usually around 120/70, sometimes lower. My Ophthalmologist, who is very reputable and highly sought after, says if I want to dive I should give it a shot. I'm "sitting on the fence" with regard to needing a Vitrectomy anyway so I'm inclined to say "What the hell!"...

Thanks again,

Jon

 

[scubadoc]

Hello jon677:

Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with advice from your personal physician.

I'm afraid that I'm not going to be able to give you the information that you want to hear. There is a movement afoot that is giving fairly wide leeway to well controlled insulin dependent diabetics diving. However, a significant degree of retinopathy certainly would indicate that there is poor control of the disease and diving should be avoided. In addition, blood pressure problems usually indicate vascular and/or renal involvement - both possibly adverse to diving.

In the UK, the BS-AC has stated the following:

"A diver with diabetes mellitus may have a hypoglycaemic attack while in the water, which may be fatal to himself or to his diving partner. The hypoglycaemic attack may be brought on by poor control of the diabetic condition or by an increase in physiological stress due to exercise, cold, etc.

The BSAC Medical Committee has decided that diabetics may be allowed to dive provided that they are able to pass the standard BSAC medical examination and in addition, satisfy the following criteria:

1. The diabetic has not experienced any hypoglycaemic attack within the last year.

2. The diabetic has not been hospitalised for any reason connected with diabetes in the last year.

3. The physician in charge of the diabetic at the diabetic clinic must consider the level of control to be satisfactory. This implies that the long-term control of the diabetic condition must be good. A guide to this may be obtained from the HbA or fructosamine level. The physician must also be able to state that he/she considers the potential diabetic diver to be mentally and physically fit to undertake the sport of diving.

4. There must be no microalbuminuria present. Any degree of retinopathy beyond background retinopathy is not allowed. There must be no evidence of neuropathy (sensory, motor or automatic), nor of vascular or microvascular disease beyond the background retinopathy in the eye."

You have posed a problem that is at once complex and difficult to answer, particularly from your doctor's point of view. The main question is - 'Should an individual with diabetes scuba dive?'. Most certification agencies, as well as virtually all textbooks and agencies concerned with diving (such as NOAA and the American Academy of Underwater Sciences) list diabetes (with either oral hypoglycemic agents or insulin therapy) as absolutely disqualifying from scuba diving. An instructor with an agency that excludes diabetics from acceptance for training, risks losing his/her liability insurance coverage if he/she accepts a diabetic as a student as he/she would be in violation of agency standards. Your doctor may be in the same boat re liability - hopefully he/she is mainly considering your well- being.

However, over the last several years, data collected by the Divers Alert Network and others have demonstrated that diabetics can scuba dive safely under carefully controlled conditions. The YMCA Scuba program has developed a particularly comprehensive protocol for the management of diabetics who dive (http://www.traders.co.uk/insulintrust/database/id75.htm).

The principal risk to diabetics who dive is hypoglycemia, which can lead to loss of consciousness and drowning. In addition, the diabetic diver potentially places his/her buddy and other members of the dive party at risk if a rescue is required. Although the specific recommendations for diabetic dive planning are beyond the scope of your question, the key elements are to: insure adequate carbohydrate intake prior to diving (sometimes difficult to accomplish if seasickness is an issue); measure blood sugars several times in the hour before diving (to make sure that blood sugars are not dropping); maintain adequate hydration; and carry a source of glucose underwater. A diabetic who cannot recognize the early symptoms of hypoglycemia and/or who has frequent hypoglycemic episodes unequivocally should not dive.

For more information you may want to visit our web page at http://www.scuba-doc.com/endmet.html#Diabetes_and_Diving

Best regards for safe diving!
scubadoc
Diving Medicine Online
http://www.scuba-doc.com/

 

[jon677]

Wow...ScubaDoc...Thanks for the detailed response. I can't dispute any (?) of it. I can offer a few more details in regard to my particular case that might explain why I'm still personally trying to decide if I am a viable diver.

You're correct that poor control was a factor. It was for the first two decades (horrible, I know) of my diabetic life and that certainly led to the retinopathy.

Now however;

My Hemoglobin a1c level hovers around 6.0 but has been as low as 5.5 (that's almost normal isn't it?)

My average blood sugar (over the past two years, testing 4 to 6 times a day) is 123mg/dL (That "no low blood sugar over the past year" stipulation by the BSAC Medical Committee is completely unrealistic for any diabetic attempting to maintain tight control)

My blood pressure is a respectable 115-120/65-70 (tested nightly)

I have NO kidney concerns (lab work through April 2002)

My eyes are seemingly stable(??? The Big IF...)

Also, I have 11 years of diving (1988 to 1999) with type I Diabetes with no emergencies or significant problems. My comfort in the water and skills are proven time and again. Aside from my retinopathy, I have no doubts that I belong in the water as much or more than any other trained diver.

I expect much, if not all the medical establishment, to attempt to dissuade me from diving and I can't argue with their reasoning.

I guess what I was hoping for was some "old salty dog" in my same situation to tell me "not to worry...he's been doing it for years"... Are you out there somewhere???

Thanks again for your time and detail, ScubaDoc.

Still have one leg in the wetsuit,

Jon

 

[Lloyd]

Jon,
Again on with the legal diclaimer. This is not a diagnosis or treatment plan only information.

I will concentrate on info about your eyes. I agree with your ophth. If you are tightly controlled and have no active retinopathy at this time, diving will probably not hurt your eyes. Your eyes are filled with liquid so compression is not a real concern.

Your retinopathy is an indication that your kidneys and even brain could be similarly affected. It is good that your kidney functions are normal and your A1c is great. So maybe they are ok.

You are correct in stating that your blood sugar can drop low at times if you maintain adequate control. Can you recognise hypoglycemia befor it becomes severe? You can always carry glucose with you. You can even carry liquids in a camel pack.

IMO you should dive in safer areas with a good buddy aware of your condition. You would not want to get in a stressful situation and work hard and crash your BS.

 

[jon677]

Hello again Lloyd...

I think you're right in that if I do decide to get back in the water I should realistically be extra cautious, despite my high level of confidence. Your question about recognizing low blood sugar is a good one. I must concede that after I developed the degree of control that I have now, I noticed that my hypoglycemic symptoms became harder to recognize. Up until now, I still have always realized I was low before there was a serious problem.

In the past I have always had either a tube of glucose gel in my BC or a SKUDA filled with apple juice on my reg.

Thanks Lloyd for bringing up that point (recognition of hypoglycemia). It's something to think about.

Jon