Corneal Surgery, Transplant Tissue, and Eye Banking

Sutured eye

Sutured eye/ Courtesy: Lions Eye Donation Service/Centre for Eye Research Australia

Corneal transplant surgery is an effective option for some people affected by corneal disease (Wang et al. 2016) and it is the most frequently performed type of transplant worldwide (Gain et al, 2015). There is a global need for corneal transplant surgery – with an est. 12.7 million waiting for a transplant (Gain et al, 2015) – across all age groups (Solomon, 2005).

One of the biggest barriers to corneal transplantation is access to ethically donated and allocated human corneal tissue (HCT) – which is managed through a service called Eye Banking. Worldwide, there is a shortage of HCT – with 53.3% of countries without practical access, and another 35.7% with satisfactory access (Gain et al, 2015).

Countries without eye bank services are mostly located in Low and Middle Income Countries (LMIC) – where an estimated 90% of the world’s vision impaired reside. (WHO, 2010).

The reasons for poor access to HCT and eye bank services vary from country to country, although in LMIC poor access is due to a lack of trained manpower (clinicians and eye bankers); no existing donation-on-death programme; no local Tissue Acts; limited prioritisation within the wider health system to support service development; suboptimal quality of surgical supplies; and inequities in allocation.

Corneal tissue is unique, as it is neither a manufactured tissue nor an organ. It’s position, as a tissue which is “living” like an organ but managed like a tissue (AAO statement, 2016) – means it needs to be classified differently. Unfortunately, legislative policy in some countries does not make this distinction – resulting in limitations to service development.

Addressing Corneal Surgery – by addressing tissue access

Access to corneal tissue remains a challenge in many parts of the world. This can be addressed by including corneal needs, and eye banking, within the short term and long term National or Regional Eye Health Plans. Such plans, need to be inclusive of:

  • Confirmation/agreement from the ophthalmology community and stakeholders to develop corneal services long term (i.e. corneal surgical training programs/fellowships)
  • Seeking a clear distinction between human tissue for ocular application, and other tissues, organs (AAO statement, 2016) and human biologicals.
  • Process planning, to obtain corneal tissue ethically via adherence to a national Tissue Act, sector standards and technical recommendations, bioethical frameworks and WHO guiding principles regarding human tissues (biologicals).
  • Long term donor-community education programmes and donor registries (often done in combination with other tissues and organ education programs) to promote eye and organ donation.
  • Development of national self-sufficient eye bank systems, through capacity development methods (or short-term importation until such time – with feasible ‘exit-plans’ in place). (Martin et al, 2017).
  • Equitable distribution of tissue to the community through policy and practice.
  • Examining the appropriateness of alternative tissue and engineering methods – if financially viable and appropriate, and evidence-based-research suggests these alternatives as viable.
Two bottles containing corneas in organ culture

Cornea in organ culture / Photo credit: Lions Eye Donation Service, Centre for Eye Research Australia

Resources

Global Resources:

For Surgeons:

For Eye Banks:

For Operating Theatre Surgeons, Nurses and Technicians on the care and handling of tissue:

Journals:

Information consolidated by: Global Alliance of Eye Bank Associations, International Council of Ophthalmology, World Council of Optometry, and eye tissue providers: Eversight International, Lions NSW Eye Bank-AU, LV Prasad Eye Institute Eye Bank -India, Keralink International and SightLife.

References

  1. American Academy of Ophthalmology. Position Statement: Tissue for Corneal Transplantation. February 2016. https://www.aao.org/clinical-statement/tissue-procurement-corneal-transplantation Accessed 05.05.2017
  2. Doughman, D, J., & Rogers, C, C. Eye Banking in the 21st Century: How far have we come? Are we prepared for what’s ahead? International Journal of Eye Banking. Sept. 2012: 1:1-15.
  3. Philippe Gain, MD, PhD; Rémy Jullienne, MD; Zhiguo He, PhD; Mansour Aldossary, MD; Sophie Acquart, PhD; Fabrice Cognasse, PhD; Gilles Thuret, MD, PhD. (2015). Global Survey of Corneal Transplantation and Eye Banking. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2015.4776 Published online December 3, 2015
  4. Eye Bank Association of Australia and New Zealand (EBAANZ). Community and FAQ page. http://www.ebaanz.org/faqs/ As seen on 20.03.2017
  5. Eye Bank Association of America (EBAA) Description of Diseases page. http://restoresight.org/cornea-donation/descriptions-of-diseases/ As seen on 20.03.2017
  6. European Eye Bank Association (EEBA). Donation and Transplantation page. http://www.eeba.eu/article/Donation%2B%2526%2BTransplantation/c/89 As seen on 20.03.2017
  7. Martin, D, Kelly, R, Jones, G, Machin, H., & Pollock, G. (2017). Ethical Issues in Transnational Eye Banking. Cornea. 36. (2). 252-257.
  8. Pineda R. Corneal Transplantation in the Developing World: Lessons Learned and Meeting the Challenge. 2015 Oct;34 Suppl 10: S35-40.
  9. Solomon, A. State of the World’s Sight. Vision2020: the Right to Sight 1999-2005. Geneva: World Health Organization. WHO Press, 2005.
  10. Wang, X, Jin, L, Wang, J, Garrett, E, H, Shuman, J, Yang, K, Schottman, T, Chen, T, Wang, J, Wang, C, Congdon, N. Attitudes and knowledge concerning corneal donation in a population-based sample of urban chinsed adults. Cornea. 35: 10. 1362-1367.
  11. World Health Organization (2010). Action plan for the prevention of avoidable blindness and visual impairment 2009 – 2013.