|Year : 2021 | Volume
| Issue : 1 | Page : 97-101
Basics of eye donation
Fayiqa Ahamed Bahkir
Department of Ophthalmology, Karpaga Vinayaga Institute of Medical Sciences and Research, Chengalpet, Tamil Nadu, India
|Date of Submission||14-Sep-2020|
|Date of Decision||21-Sep-2020|
|Date of Acceptance||01-Oct-2020|
|Date of Web Publication||19-Apr-2021|
Dr. Fayiqa Ahamed Bahkir
Department of Ophthalmology, Karpaga Vinayaga Institute of Medical Sciences and Research, Chengalpet, Tamil Nadu
Source of Support: None, Conflict of Interest: None
This writeup deals with the basics of Eye Donation, from who can and cannot donate, how to counsel patients, how to pledge one's eyes, the responsibilities of a donor's family in the donation process. It also touches upon removal of the donor corneal tissue, processing and preservation of donor cornea at the Eye Bank, and the impact of COVID-19 on the eye donation scenario.
Keywords: Corneal storage media, COVID and eye donation, eye donation, pledge eyes
|How to cite this article:|
Bahkir FA. Basics of eye donation. Kerala J Ophthalmol 2021;33:97-101
| Introduction|| |
The concept of replacing a compromised cornea with a clear one has been around for thousands of years. As an experimental procedure, it was performed in animals long before an attempt was made on human eyes. The first reported xenograft corneal transplantation goes back to the year 1838, which was, unsurprisingly, unsuccessful.
The first corneal transplant using an allograft was reported as far back as the year 1905, by Dr. Eduard Zirm, an Ophthalmologist from Austria, on a patient who had sustained severe bilateral alkali burns 15 months earlier. Interestingly, the donor corneas came from a living donor, an 11-year-old male child who had suffered a scleral penetrating injury. The eye was enucleated, and two donor corneal buttons of 5 mm were fashioned. Zirm attempted simultaneous keratoplasty in both the eyes and the intra-operative period was uneventful.
The vision was gradually lost in the right eye due to complications from the surgery (widely believed to be because of wound dehiscence); while the graft in the left eye remained clear, and the patient regained useful vision in that eye. This was a huge milestone in the history of medicine, considering the limitations of knowledge at the time and paucity of surgical equipment capable of such an intricate procedure. However, this procedure almost single-handedly proved the efficiency of using a human donor over a xenograft.
The first corneal transplant in India was performed by Dr. RES Muthiah in 1948, and he is also credited with establishing the first Eye Bank in India. Today, the Eye Bank Association of India is the center for eye donation and eye banking in the country and the main force behind the creation of public awareness regarding the need for donors.
The recent advances in surgical equipment, microscopic precision cutting technology with femtosecond lasers, deeper understanding of corneal microstructural anatomy and immune mechanisms have all led to the possibility of up to four recipients benefiting from a single donor.
| Donor Criteria|| |
- Anyone between the age of two (this is sometimes even reduced to 1 year of age) and seventy can be donors, though donation beyond the age of seventy is not discouraged. The upper limit only exists as a benchmark where corneal decompensation might have started due to the significant fall in the number of endothelial cells by the seventh decade. Corneas from donors less than a year of age are mostly used for research purposes
- Corneal donation from a living donor is seldom encouraged, as it is widely accepted that having good vision in both eyes is a basic human right and necessity. There are, however, very rare instances in which living donors can be considered. In case of a penetrating injury of the eye that does not involve the cornea; the eye undergoing enucleation can be used for corneal donation. In these types of cases, the entire eyeball cannot be preserved, and hence, an in-situ excision of the donor corneal button is done, and the sclero-corneal button alone is preserved
- In some instances of unilateral retinal pathologies, where there is no perception of light in one eye, and the patient has corneal blindness in the other, an autograft procedure can be considered if it ultimately bestows useful vision to the patient.
| Contraindications for Eye Donation|| |
- People who have undergone LASIK cannot be donors since the cornea has already been surgically manipulated, and the shape of the corneal button obtained from such eyes might not be ideal. The question of survival of the delicate corneal tissue after undergoing two surgical procedures has also raised concerns regarding endothelial cell viability
- If death is due to unknown causes, or the person suffered a central nervous system disease of unknown etiology, the person cannot be a donor
- People at high risk for human immunodeficiency virus (HIV) such as intravenous drug use, people with active leukemia, disseminated lymphoma, active septicemia, ocular neoplasms, or other neoplasms that cause ocular seeding cannot be donors
- In the case of pediatric donors, an eye that is < 1 year of age is generally not used for transplantation, and the donated eye is used instead for research purposes
- An eye with active inflammatory disease, any stage of retinoblastoma or malignant melanoma is not acceptable for donation
- Other than these specific restrictions, the same rules that apply to any other organ donation apply here. People with communicable diseases cannot be donors. Rabies, subacute sclerosing panencephalitis (SSPE), Creutzfeldt-Jacob disease, and other suspected prion diseases are contraindications.
The Food and Drug Administration testing requires HIV, Hepatitis B, Hepatitis C, syphilis to be ruled out. At the time of enucleation, a sample of blood is taken from the donor for this reason.
| Responsibilities of a Donor|| |
Anyone above the legal age of 18 can pledge their eyes. This can be done online, on the Eye Bank Association of India website; or, if you wish to donate other organs as well, on the website of the Organ Receiving and Giving Awareness Network. It can also be done in the Department of Motor Vehicles while applying for or renewal of a driving license. Donor information is usually mentioned on the license itself.
In addition to this, it is important for a person to keep their family members informed regarding their pledge.
| Responsibilities of the Family Members of a Donor|| |
In case a person who has pledged their eyes passes away, the family needs to intimate the nearest Eye Bank as soon as possible. The Organ Receiving and Giving Awareness Network, on their website (www.organindia.org) provides the location and contact information of the nearest Eye Bank. If a person, in life, has not pledged their eyes; the next of kin has the right to donate their eyes. The cornea should be harvested within six to eight hours of death; the earlier, the better. This is because the endothelium of the cornea is in apposition to the necrotic and metabolic substances in the stagnant aqueous humor.
The eyes should be kept closed, and a moist cloth is to be applied on the lids. It is advised that the family keep the fans switched off in the room to prevent drying of the ocular surface. If possible, they can keep humidifiers and air conditioners on. The head end should be elevated to prevent edema of the cornea, which might lead to a loss of transparency; and decreases congestion in ocular blood vessels, which in turn reduces blood loss during enucleation.
The Eye Bank team arrives at the residence, and the procedure is carried out at home.
| Harvesting the Corneal Graft|| |
The consent of the next of kin is necessary for the procedure to be carried out. The procedure is either enucleation or an in-situ removal of sclerocorneal button. What is preferred is that the whole globe is removed, but once taken to the Eye Bank, only the corneoscleral button is excised and then preserved. As mentioned before, preserving the whole globe would mean that the endothelium remains in contact with aqueous humor that rapidly fills with metabolic by-products that adversely affect endothelial cell health. Another point in favor of doing a whole globe removal is that enucleation takes less time, and time need not be wasted doing an in-situ corneoscleral button incision in a cornea that is later deemed unacceptable in the preliminary screening itself.
Once the procedure is complete, a gauze ball, ocular prosthesis, or keratoprosthesis is placed, and the lids are sewn shut. A 10 ml sample of blood is also withdrawn to run serological and other tests. The enucleated eyeball is placed, cornea up, in a moist chamber. In the case of in-situ excision of a corneoscleral button, they are stored endothelial cell side up, in either McCarey Kaufman medium, Cornisol, or Optisol GS.
| Donor Cornea Evaluation|| |
Once they are brought back to the Eye Bank, they undergo a donor cornea evaluation process. This starts with the blood sample, and once this is cleared, the cornea itself undergoes evaluation under a microscope, and specular microscopy is done in most cases. This process standardizes and streamlines the quality of donor corneas.
During this process, the cornea may also be precut to be used for the next procedure, either a lamellar keratoplasty or a full-thickness keratoplasty. Doing this in the Eye Bank itself decreases valuable surgical time while the cornea is being transplanted.
| Storage of Donor Cornea|| |
The various storage techniques are classified based on the duration of storage, as listed in [Table 1].
Before the cornea is used for transplantation, make sure that the seal is intact, check the expiry date and look for signs of contamination (pH change, turbidity).
| Eye Donation Counselling and Awareness|| |
Counseling for eye donation yields better results when done in the ward, rather than in the mortuary. The two sources of donated corneas are voluntary pledging by the well-informed public, or the creation of awareness among patients and their families by the Hospital Cornea Retrieval Programme (HCRP), wherein potential donors are identified and recruited by a combination of motivation and grief counseling. The team can include hospital staff, doctors, and grief counselors, who are usually stationed near critical care complexes of the hospital (intensive care unit, critical care unit). Trained eye donation counselors are available round the clock, and this way, the option of donating one's eyes reaches even those without prior knowledge of eye donation.
The formation of an HCRP team can help ease the donation process since a detailed history of the patient's medical profile is already known, and as it is done in a hospital setup, there is a shorter interval time between death and corneal harvesting. The individuals in the team should have a sound knowledge about eye donation, should be able to dispel any myths about eye donation, and should be able to motivate and counsel the family through the entire process while giving due respect to the deceased.
It always helps if the following points are touched upon during the counseling or awareness programs. No religion is against eye donation, though this is the single largest argument against eye donation people have even today. Donating your eyes does not cause disfiguration of the face or body in any way. Two donated corneas can help up to four people. It must be made clear that eyes, once donated, or any other organ for that matter, cannot be bought or sold. It is a humanitarian act that no one can put a price on. The eye, once donated, cannot be tracked. There is no way of knowing who the eye goes to or comes from, and everything is kept anonymous (except in the few rare cases mentioned above).
| Impact of COVID-19 on Eye Donation|| |
The number of elective surgeries has drastically dropped since the pandemic rolled in, but keratoplasty is not always an elective procedure. With reports that the COVID-19 virus has been isolated from tear samples, it remains prudent that corneal harvesting be kept to a minimum as of now, considering that the procedure might endanger the health of the collection team and the fact that it is too early to comment on COVID transmission through transplanted organs. Usage of alternative methods to preserve the globe in case of emergencies until such time as a vision-restoring procedure can be performed has been proposed.
On May 8, the Ministry of Health and Family Welfare had declared that Eye Banking activities could be done only in non-COVID hospitals. As of August 19, 2020, the Ministry suspended voluntary eye donation and strictly advised against eyeball retrieval from homes. However, they have stated that HCRP can be continued in hospitals for corneal retrieval from non-COVID cadavers for therapeutic purposes.
On September 1, the EBAI published its revised guidelines for cornea retrieval and eye banking activities during the COVID era. Numerous precautions have been advised during the retrieval and transport of donor corneas.
All staff and technicians involved in the counseling and retrieval process should be equipped with a full personal protective equipment kit. Enucleation is not advised, and only the excision of the corneoscleral button is advocated. Before the procedure, double contact with povidone-iodine is advised. All collected tissues are to be quarantined for 48 hours prior to usage for transplantation.
Exclusion criteria for eye donation during the COVID-19 era have been enumerated.
- If the person has tested positive for COVID-19
- If the individual has reported or experienced any symptom known to be associated with COVID-19 (acute respiratory illness, fever, cough, shortness of breath, diarrhea)
- Individuals who have been exposed to a confirmed or suspected case of COVID-19 within the last 14 days
- Persons who have visited the containment zone within 14 days of death
- If the deceased had evidence of conjunctivitis, acute respiratory distress syndrome, pneumonia, or computed tomography scan showing ground glass opacities (regardless of whether another organism has been identified).
Collection of a nasal swab of the deceased donor for COVID-19 reverse transcription-polymerase chain reaction can be done, though this is solely under the discretion of the Medical Director of the institution. Eye banks throughout the country have been advised to follow their respective local state government guidelines regarding their extent of activities.
| PG Pearls on Eye Donation|| |
Bioengineered corneas are corneal equivalents made of cellular scaffolds from recombinant human collagen and synthetic phosphorylcholine polymer. They have been proposed for usage in anterior lamellar keratoplasty procedures rather than full-thickness grafts. However, the consensus remains that a cornea from a donor remains superior to anything made under laboratory conditions
- Isolated endothelial cell injections have been done, and recent advances have shown their efficacy in cases of corneal edema
- Most of the rejection reactions are due to the presence of donor corneal endothelium, and this is the reason anterior lamellar keratoplasty has a much lower failure rate than a graft that involves donor endothelium
- In the case of congenital corneal opacities, the child should be operated on as soon as possible to prevent the development of strabismus or amblyopia. It is always better to use age-matched corneas, especially in young children. In adults, a slightly younger donor than the recipient is preferred, but this is not a strict criterion
- There are a few rare instances where eyes can be donated before death, as enumerated above.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Armitage WJ, Tullo AB, Larkin DF. The first successful full-thickness corneal transplant: A commentary on Eduard Zirm's landmark paper of 1906. Br J Ophthalmol 2006;90:1222-3.
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Gupta N, Tandon R. Eye Banking. Zia Chaudhuri, Murugesan Vanathi. Postgraduate Ophthalmology. Vol. 1., Ch. 6.11. New Delhi: Jaypee Brothers Medical Publishers Limited; 2012. p. 723.
Chaurasia S, Sharma N, Das S. COVID-19 and eye banking. Indian J Ophthalmol 2020;68:1215-6.
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Sachdev Writing Committee MS; Composition of the All India Ophthalmological Society (AIOS)- Eye Bank Association of India (EBAI) Expert Group for COVID-19 Practice Guidelines for Cornea and Eyebanking includes the Writing Committee (as listed) and the following members - in alphabetical order: Arun Kumar Jain -Post Graduate Institute of Medical Education & Research, Chandigarh; Atul Kapoor - Sightlife, New Delhi; Geetha Iyer- Sankara Nethralaya, Chennai; Hemant Kumar - Abhinav Drishti Eye Hospital, Lucknow; Himanshu Matalia - Narayana Nethralaya, Bangalore; Hitendra Ahooja - Ahooja Eye and Dental Institute, Gurugram; J.K.S. Parihar - Centre for Sight, New Delhi; Jnanankar Medhi - The Retina Centre, Guwahati, Assam; Mandeep Jot Singh - Centre for Sight, New Delhi; Manisha Acharya - Dr. Shroff Charity Eye Hospital, New Delhi; Nilesh Mohan - Regional Institute of Ophthalmology, Igims, Patna; Paras Mehta - Sameep Eye Hospital & Corneal Centre, Vadodara; Prafulla Maharana - Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; Praveen K. Vadavalli - LV Prasad Eye Institute, Hyderabad; Promila Gupta - National Programme for Control of Blindness; Radhika Tandon - Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India; Rajib Mukherjee - Mukherjee Eye Clinic, New Delhi; Rajiv Garg - Directorate General of Health Services; Rakesh Shah- Swaraashi Netralaya, Thane; Rishi Mohan - MM Eyetech Institute, New Delhi; Ritika Sachdev - Centre for Sight, New Delhi; Ritu Arora - Guru Nanak Eye Centre, New Delhi; Samar Basak -Disha Eye Hospital, Barrackpore; Shakeen Singh - Sri Guru Ram Das Hospital, Amritsar, Punjab; Srinivas K Rao - Darshan Eye Care, Chennai; Sujata Das - L.V.Prasad Eye Institute, Bhubaneshwar; Sunita Chaurasia - L.V.Prasad Eye Institute, Hyderabad; Swati Tomar - Swanetra Eye Hospital, Jaipur; Vikas Mittal - LJ Eye Institute, Ambala. All India Ophthalmological Society - Eye Bank Association of India consensus statement on guidelines for cornea and eyebanking during COVID-19 era. Indian J Ophthalmol. 2020;68:1258-62. doi: 10.4103/ijo.IJO_1554_20. PMID: 32587148; PMCID: PMC7574107.