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Demolishing a corneal donation waitlist

Published: 07.06.2023
Dr Prashant Garg Executive Chair
L V Prasad Eye Institute
Demolishing a corneal donation wait list

I head the L V Prasad Eye Institute network and have the formidable responsibility of steering this wonderful organization towards a new future. I am also a cornea specialist, and I have an abiding interest in advocating for ‘eye banks’. You need an eye bank to successfully tackle a key cause of vision impairment: corneal opacity. If one looks at the causes of vision loss in the IAPB Vision Atlas, the third biggest cause, after refractive errors and cataract, is the catch-all “other vision loss” impairing close to an estimated 60 million people. Corneal opacities sit in this residual category, and it has been my life’s ambition to tackle this form of vision impairment. Corneal opacities are the second major cause of blindness in India among those who are 50 years and older—and the primary cause in those younger.

The cornea waitlist

Tranfering tissue to MK
Tranfering tissue to MK

A cornea refracts light into the eye, and so, it must be a clear and transparent portal. Infection or scarring can make it opaque, impairing a person’s vision. A corneal transplant makes it possible to remove the opaque cornea and replace it with a ‘donated’ cornea, i.e., a cornea retrieved from a generous individual after their death.

Back in the 1990s, LVPEI maintained a waitlist for cornea recipients. The would-be recipients and their families would wait for months on end, enquiring each day about the availability of a cornea. As soon as we received the precious tissues we would launch into surgeries. I still have memories of those days when we would perform graft surgeries late into the night. The corneal tissues had to be used immediately, within 24 hours after retrieval, as there was no preservative medium to store them.

Those days are in the past. Today, there is no waitlist for any cornea specialist in the three Indian states where LVPEI is present. In fact, LVPEI’s eye banking network meets the corneal supply needs of many partners across India. Here’s our story.

The beginning

When we started patient care services at the institute in the mid-80s, our globally acclaimed team of corneal surgeons were hampered by a severe shortage of transplantable corneas. For the first few years we had to import corneas, sometimes from USA, and mostly from the pioneering Gautam Mazumdar-run eye bank in Ahmedabad in Gujarat. In 1989, after struggling for two years, we decided to set up an eye bank. The decision was not easy, and most people were sceptical. However, a donor, Gunnam Ramayamma’s family, came forward to support us. Frederick N Griffith of the International Federation of Eye and Tissue Banking (IFETB), Baltimore, USA agreed to provide us with technical support and help with training. Dr Verinder Nirankari, a successful corneal surgeon from Maryland, USA, was the catalyst who made this partnership possible. Mr. Mahmood Farazdaghi, also of IFETB, was a pillar of support and helped us institute international quality standards at our eye bank.

Starting with 20 corneas in 1989, LVPEI’s Ramayamma International Eye Bank (RIEB) has come a long way. Today, it is the largest eye bank in Asia and one of the largest in the world. LVPEI’s network has grown to 4 eye banks and several eye collection centres, collecting more than 10,000 corneas each year and supplying close to 7,500 corneas for surgeries to a vast network of surgeons across the country (the remaining corneas may be unsuitable for grafts, but can help with research). The eye bank network also keep pace with advancements in surgery techniques. They have started preparing and supplying partial thickness tissues, for example, for an advanced and novel technique.

Breaking the waitlist

So, how did we break out of the waitlist rut? There are three parts to the breaking: procuring adequate corneas, storing them for as long as possible, and enabling an ecosystem where corneal donations can happen smoothly.

In 1990, we started our hospital-based cornea retrieval program (HCRP) in partnership with a major health care facility in Hyderabad. As hospitals handle a lot of mortality, they are potential sites for motivating eye donations. We would post trained grief counsellors at a large hospital, and they would handle the delicate and difficult job of encouraging an eye donation. The counsellor approaches the kin of the deceased and initiates a conversation on eye donation. The kin maybe grieving, and eye donation may be the last thing on their minds. Some may worry about defiling the dead, others may even be angry. The counsellor works with them through all this, always mindful of their grief and pain. All this may sound impossible to execute, and it is very hard, but our counsellors have been miracle workers. By 2023, the Ramayamma International Eye Bank has collected over 100,000 corneas. Today, HCRP runs in several large hospitals and accounts for nearly two-thirds of corneal tissues procured in our network. Other eye banks in India run successful HCRPs as well.

In 1991, we set up a laboratory for manufacturing cornea storage medium in collaboration with IFETB, USA. The medium allowed us to store excised corneal tissues for 96 hours – a gain of 3 days compared to a few hours. Last year, we produced and distributed nearly 25,000 vials of this cornea storage medium to various eye banks in and outside our country. Do note, the procurement and preservation happen at LVPEI to the highest standards. All our eye banks are accredited by international agencies and the Eye Bank Association of India.

Finally, we advocate for eye banking. This is important because we must make eye donations a natural and voluntary choice after death. To achieve that, the public must be convinced that we do everything to the highest clinical and ethical standards. So, we led efforts to establish the Eye Bank Association of India as a resource centre for other eye banks and as a supporter of India’s eye donation movement. We played a leadership role in drafting medical standards for eye banking in India.

All of this was possible because of visionary leadership, a committed team, and support from many individuals and organisations. Dr Gullapalli ‘Nag’ Rao, LVPEI’s founder, conceived and built RIEB. The late Dr Paul Dubord of Eyesight International (ESI) was a big supporter. Sightlife, a major eye bank on the West coast of USA, Rotary club of Hyderabad and Rotary International are our major supporters.