Eye banking: an introduction

Gullapalli N Rao and Usha Gopinathan

Gullapalli N Rao, Chairman, LV Prasad Eye Institute (LVPEI), LV Prasad Marg, Banjara Hills, Hyderabad, 500 034 India. Email: gnrao@lvpei.org; Contributor Information. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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While prevention is the most desirable way to control corneal blindness, once a cornea has lost its transparency, a corneal transplant, or graft, is a patient's best chance to regain vision in the affected eye(s). However, the biggest limiting factor is the worldwide shortage of donated corneas. In low- and middle-income countries, where the magnitude of corneal blindness is greatest, the availability of donated corneas is very low. This is due in large part to the lack of local eye banks. Efforts are under way to develop eye banks of optimal standards in many lowand middle-income countries, with countries like India and Philippines making notable progress. Myanmar, Ethiopia (see box right), and Kenya are examples where high quality eye banks have been established. However, this is still not enough to meet the need for corneas.

The Eye Bank of Ethiopia

A group of children on a visit to the Eye Bank of Ethiopia

Eye Bank of Ethiopia

The Eye Bank of Ethiopia in Addis Ababa has been in existence since 2003. It is associated with Menelik II Referral Hospital, a tertiary referral centre, where most of the transplants are done. The eye bank also sends corneas to two university referral hospitals in northwestern and southern Ethiopia. Between 130 and 150 corneas are harvested (using in situ corneal excision) and used in 90120 transplants every year. There are five corneal transplant surgeons in Ethiopia. Cornea donation is encouraged in a variety of ways, including media campaigns with well-known personalities such as the president of Ethiopia and athlete Haile Gabreselassi. So far, 6,000 Ethiopians, including Mr Gabreselassi, have pledged their corneas, and next-of-kin consent is being used increasingly. The eye bank is funded by ORBIS International Ethiopia and Addis Ababa City Government Health Bureau; it also raises funds locally. (Elmien Wolvaardt Ellison)
A technician at work in the Eye Eye Bank of Ethiopia

Eye Bank of Ethiopia

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What is an eye bank?

Eye banks are the institutions responsible for collecting (harvesting) and processing donor corneas, and for distributing them to trained corneal graft surgeons. 1 Eye banks are regulated and part of the local health system; they may be attached to a hospital or housed in a separate building. Cornea harvesting is the surgical removal from a deceased person of either the whole eye (enucleation) or the cornea (in situ corneal excision). This can be done by appropriately trained eye care personnel (eye bank technicians, ophthalmology residents, ophthalmologists, or general practitioners) in a variety of settings, including hospitals, homes, and funeral grounds.

Before harvesting
Corneas can be harvested up to twelve hours after death, but ideally within six hours. The person who will harvest the cornea must first do the following:

Obtain written consent from the senior next of kin of the deceased. Verify the death certificate and ensure there is a stated cause of death. Review the donor's medical and social history to ensure they have no contraindications to donation. (This is done by studying medical records, interviewing the physician under whose care the donor was, and interviewing close family members. Each eye bank must have a list of such contraindications, which are available from other well-established eye banks.) Obtain information about any blood loss occurred prior to and at time of death, and whether the donor received infusion/transfusion of crystalloids, colloids, and blood; these are used to calculate plasma dilution.

During harvesting
Aseptic methods must be adhered to, including maintaining a sterile field while performing enucleation or in-situ corneal excision.2 Standard protocols include:

pen torch examination of the eyes for foreign objects and other defects preparing the face and eyes of the donor using povidone iodine employing aseptic techniques for in situ corneal excision or enucleation immediate preservation of the excised eye or cornea in an appropriate cornea preservation medium drawing blood to screen the donor for infectious diseases. Each eye bank must decide the most appropriate serological tests needed but at a minimum they must test for HIV, hepatits B, and syphilis.

Storing donated corneas

Whole eyes can be stored in a moist chamber at two to eight degrees Celsius. This is the simplest and least expensive way to store whole eyes, but the eyes have to be used within 48 hours. Such a storage method may be suitable for some eye banks with limited resources. Excised corneas can be stored in intermediate-term preservation media, such as McCary Kaufman medium (MK medium) or Optisol, both maintained at four degrees Celsius. Corneas can be stored for 96 hours in the MK medium and ten days in Optisol. With the availability of MK medium and Optisol, eye banks should ideally switch over from enucleation to in situ corneal excision procedures. This will enable better viability of donated corneas during storage. With increased resistance to the antibiotics used in preservation media, inclusion of alternative antibiotics must be considered.3

After corneas reach the eye bank, they are examined using a slit lamp to check for corneal and stromal pathology. The endothelial cell density is also examined by specular microscope; this is necessary as donor corneas with a low number of endothelial cells are likely to fail soon after surgery. The processing of whole eyes must be done within a laminar flow hood maintained in sterile conditions. The suitability of a cornea for transplantation is assessed by the corneal surgeon, who will consider the donor screening report, slit lamp and specular microscopic results, and serology reports. Following processing and evaluation of corneas and serological testing, transplantable corneas are transported to hospitals individually sealed and packaged, maintaining the cold chain at four degrees Celcius. The vial containing the cornea must be labelled properly with the eye bank name, tissue number, name of the preservative medium, medium lot number, expiry date of the medium, and date and time of the donor's death. The surgeon must also be provided with the donor screening, tissue evaluation, and serology reports. It is important that the eye bank follows a fair and equitable system of tissue distribution.

Standards
Eye banks should develop and adhere to acceptable standards. This reduces the risk that grafts will fail or that infection will be transmitted. It may help to refer to the technical guidelines and acceptable minimum medical standards of the European Eye Banking Association (see Useful Resources, page 38).

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Finding donors
Even with an effective eye bank, finding enough people willing to donate their corneas can be difficult. Public awareness programmes play an important role. They must emphasise that corneas can be donated by anyone, whatever their age, religion, or gender, and that neither enucleation nor in situ corneal excision causes disfigurement of the face or any delays in funeral arrangements. Family pledging is also becoming more important as family consent is usually needed before eyes or corneas can be removed. Some of these problems may be circumvented by favourable legislation for eye donation, such as a required request' law. This law requires hospital authorities to identify potential cornea donors and obtain consent from bereaved family members. Another law employed in some countries, such as the United States and Ethiopia, is a presumed consent' law. Under

this law, every person who dies while in hospital is presumed to be an eye donor unless this is actively rejected by their next of kin.
An eye donation counsellor speaks to family members of a deceased person. INDIA

Ramayamma International Eye Bank, LVP

Hospital cornea retrieval programmes can meet some of the immediate need. In these programmes, trained eye donation counsellors approach family members of the deceased and motivate them to consider eye donation. Training these counsellors in the art of grief counselling assists them in approaching family members at an appropriate time, sharing their grief, and preparing them to take the positive step of giving permission for eye donation on behalf of their loved one.

Contributor Information
Gullapalli N Rao, Chairman, LV Prasad Eye Institute (LVPEI), LV Prasad Marg, Banjara Hills, Hyderabad, 500 034 India. Email: gnrao@lvpei.org. Usha Gopinathan, Associate Executive Director, LVPEI and Vice President, Eye Bank Association of India. Email:usha@lvpei.org.

References
1. Rao GN. What is eye banking? Indian J Ophthalmol. 1996;44:12. [PubMed] 2. Mannis MJ, Reinhart WJ. Medical standards for eye banks. In: Brightbill F, editor. Corneal surgery, theory, technique and tissue. St Louis: CV Mosby; 1993. pp. 531548. 3. Gopinathan U, Agarwal V, Sharma S, Rao GN. Donor corneoscleral rim contamination by gentamicin resistant organisms. Indian J Ophthalmol. 1994;42:7174. [PubMed]

Articles from Community Eye Health are provided here courtesy of International Centre for Eye Health

Stunning Facts of Eye Donation in India

AWAKE, ARISE!
1.

There are 12 million+ blind people in India, out of which about 4 million+ are corneally blind. There is a huge backlog of the number of corneal blind people waiting to get their sight.

2.

3.

As of today, Eye collection figures stand at around 20000+ eyes per year, from around 400+ eye banks across India. This number itself is not sufficient for the freshly added corneal blind. One startling fact of this is we still import eyes from Sri Lanka, which is 1/4th or even less size than India. Sri Lanka, besides catering to its own requirement, sends the eyeballs to several other countries. Over the last quarter of the century, it has flown over 20000+ eyeballs to 135 centres in the various countries of the world.

Looking at the above facts, dont you think that we should make a difference? If yes, please go and pledge yourself for eye donation or if their is a death in your family / friends circle, motivate the people to donate the eyes of the deceased so that a blind person can see this world thru the donated eyes! A well worked stategy to increase Eye Donation awareness called HCRP Hospital Corneal Retrieval Program (HCRP) is a proactive program initiated in some hospitals across the country. In this programme, a specially trained social worker, called Eye Donation Counselor (EDC) [or Grief Counselor] is positioned at a hospital round the clock at the ICUs, Trauma units, Nephrology centers and so on, to build up rapport with the attendants, staffs and doctors. When the death occurs, after the bereaved family has reconciled itself to the tragic reality, the EDC makes a sensitive request for the donation of the eyes. It has been found out by the EBAI (Eye Bank Association of India) that the success rate is good and has been effective.

How much you know about your Eyes?

Here, one can know the importance of their eyes and the important part of their eye that helps us in seeing this beautiful world. Don't you think the blind folks also deserve to see this beautiful world in their life?

Anatomy of an Eye, giving out details of the placements of Cornea, Pupil, Iris and other Major parts. Pic Courtesy: National Eye Institute, US. (More can be found @http://www.nei.nih.gov/photo/eyean/index.asp) What is cornea? The cornea is the clear outer layer at the front of the eye. The colored part of the eye (called Iris) and the round opening in it (called Pupil) can be seen through the cornea. The cornea helps to focus and transmit light as it passes to the lens and on to the Retina at the back of the eye. (When light reaches the retina, it is converted into impulses which are transmitted via the Optic nerve to the visual centre in the brain) Why does the cornea get damaged? Some people are born with abnormalities of the cornea. In a condition known asKeratoconus, the cornea develops an abnormal curvature that makes normal vision impossible. Some childhood infections like measles can also cloud the cornea, often causing permanent blindness throughout the persons life. In later years, infection or traumas to the eye are the main causes for the cornea to become cloudy and this can reduce the vision. In older people, Degenerative diseases, often caused by excessive exposure to harsh sunlight can cause the cornea to become dull and hence loss of vision. What is Corneal Blindness? Corneal blindness means that ones cornea, which is the transparent and thin outer layer of the eye becomes clouded due to Injuries Infections Nutrition deficiency especially in Childhood Chemical burns Post operative complications & infections. How can the eyesight in these patients be restored? Persons who have lost their sight because of corneal damage can hope to regain their sight through the Corneal Grafting (also called Corneal Transplantation) procedure. So, What is Corneal Grafting/Transplantation? This is a procedure to replace the damaged Cornea or part of it, with an healthy Corneal tissue. The new Cornea is obtained from donated Corneas, which undergo thorough testing before being used for transplantation. Who is eligible for Corneal Grafting? Be an young child or an Adult or an Old person, everybody can be operated on to replace the dull and opacified Cornea with a new cornea, so that they may be able to see and enjoy this beautiful world! From where do hospitals get the Corneas for transplantation? Corneas are removed from the eyes of people who have died, with the consent from the individual or his family. This is collected and kept in the respective eye banks. Corneas are not taken from donors known to have infectious conditions. All donors are screened for carriers of AIDS or Hepatitis viruses before their corneas are used.

Eye Donation and its Importance

Here, you will get to know more about Eye donation, its Importance and the procedure involved. What is Eye Donation and How is this helpful? Netram Pradhanam Servendriyanam (Translation: Eyes are the precious gift given to the humans by the Almighty) - Lord Krishna to Arjuna (Shrimad Bhagwat Geeta, Chapter 15, Shloka 8.1) Eye donation is donating the eyes after a persons death. Eyes are very valuable part of a human being, which should not be wasted either by burning or burying the body. Donation of the eyes gives sight to TWO Corneally blind persons, enabling them to come out of their dark and dreary life into a life full of colors, a life where they can see and enjoy this beautiful world! Eyes are a precious gift to a person. But the same eyes bring misery when misused or when they are lost. A wise man utilizes that gift while alive and on death too. - A famous poet. So, Why should my eyes be donated? There is no substitute for human tissue. The transplantation process depends upon the priceless gift of Cornea donation from one human to the next. The use of artificial tissue for transplantation has been unsuccessful. We know that we are not going to live permanent here but after our death, let our eyes live in this world by giving a new life to blind! Who all can donate their eyes? Age does not matter while making this precious donation. Person suffering from Diabetics, Hypertension, Systemic disorders like Asthma and Tuberculosis CAN ALSO donate their eyes. Cataract surgery patient can also be a happy donor. Above all, all Religions endorse the practice of eye donations and its one great valuable service a person can do in his/her life.

Who all CANNOT donate their eyes? Eyes will not be collected if death has occured due to the following diseases.

AIDS / Hepatitis B

Septicemia / Sepsis: Viral Infection spread thru bloodstream affecting vital organs Leukemia: Disease related to Bone Marrow Rabies: Fatal viral disease, transmitted by the bite of warm-blooded animals like dogs Cancer with Metastasis to Head and Neck: Transmission of pathogenic microorganisms/cancerous cells thru blood vessels. Encephalitis: Inflammation of the brain Hodgkins Lymphoma: Cancerous growth of cells in the Lymph system of the body.

So, i want to donate the eyes but What is the procedure? Donation can happen in either of these two ways.
1.

S/He can walk in to a nearest Eye Bank and PLEDGE their eyes for donation. For this, a pledge form needs to be filled, signed by a witness (can be your

2.

relative/friend) and given back to the eye bank. In the time of that persons death, his/her relative/friend, who was a witness for the pledge form or any other family member/friend who had the knowledge that the person who passed away intended to donate the eyes, should call the nearest eye bank. One important aspect to be noted here that it is not sufficient if a person pledges for donating his/her eyes after the death. His/her relatives and friends should be well informed and be well aware to call the nearest eye bank, for donating the eyes after their death. After death, a relative or a friend of the deceased person can inform the eye bank and tell them that they wish to donate the eyes of their bereaved folk.

Steps to take care for donation of the eyes

Call the nearest eye bank within SIX HOURS of the death of the person. Switch off fans & keep AC on, if you have one. Close the eye lids gently and keep a moist cloth over eyes. Raise head with a pillow.

Points worth to be noted

1. 2. 3. 4. 5. 6. 7. 8.

Persons of any Age/Sex can donate their eyes Persons who have undergone surgery for Cataract, Glaucoma or using Spectacles can also pledge and donate their eyes. Eyes should be donated preferably within SIX hours after the death. Nobody is charged for making eye donation. The only cost to encounter is one local telephone call. Face will NOT get disfigured after eye donation. As per the new procedures, only Cornea portion is removed and hence face disfigurement does not happen. Immediate family members or relatives can donate the eyes of the deceased even if the deceased had not pledged for eye donation during his/her life time. Eyes can be donated to any eye bank in India but preferably to the nearest eye bank to avoid delays. TWO Corneally blind persons can get sight due to a single person's eye donation.

Stunning Facts of Eye Donation in India

AWAKE, ARISE!
1.

2.

3.

There are 12 million+ blind people in India, out of which about 4 million+ are corneally blind. There is a huge backlog of the number of corneal blind people waiting to get their sight. As of today, Eye collection figures stand at around 20000+ eyes per year, from around 400+ eye banks across India. This number itself is not sufficient for the freshly added corneal blind. One startling fact of this is we still import eyes from Sri Lanka, which is 1/4th or even less size than India. Sri Lanka, besides catering to its own requirement, sends the eyeballs to several other countries. Over the last quarter of the century, it has flown over 20000+ eyeballs to 135 centres in the various countries of the world.

Looking at the above facts, dont you think that we should make a difference? If yes, please go and pledge yourself for eye donation or if their is a death in your family / friends circle, motivate the people to donate the eyes of the deceased so that a blind person can see this world thru the donated eyes! A well worked stategy to increase Eye Donation awareness called HCRP Hospital Corneal Retrieval Program (HCRP) is a proactive program initiated in some hospitals across the country. In this programme, a specially trained social worker, called Eye Donation Counselor (EDC) [or Grief Counselor] is positioned at a hospital round the clock at the ICUs, Trauma units, Nephrology centers and so on, to build up rapport with the attendants, staffs and doctors. When the death occurs, after the bereaved family has reconciled itself to the tragic reality, the EDC makes a sensitive request for the donation of the eyes. It has been found out by the EBAI (Eye Bank Association of India) that the success rate is good and has been effective.

Myths associated with Eye Donation

Here, you can get to know some MYTHS associated with Eye donation, in India, that may be preventing many people from donating their eyes... Some people think that if they donate their eyes, it will leave holes in the place where their eyes existed. Wrong. Only the Cornea portion of the eye is removed and hence the appearance of the face of the deceased remains the same. Some other people are of the opinion that if they donate their eyes in this life, they shall be born blind in the next life. Wrong. There is no written rule about this and nobody has experienced this! Eye donation is truly a good deed and a good deed always begets good. All religions and their institutions support eye donation and consider it as one of the best donation a person can make. Some people hesitate to pledge their eyes for donation worrying about how their relatives will react. Such people should keep in mind that a little resistance should not hinder the good deed that one is performing. In fact, they should try to motivate their relatives and friends for donating the eyes, by describing the good effects of this donation movement. Person with eye problem like Cataract or Glaucoma cannot donate their eyes. Also, the person is very old and hence cannot donate his/her eyes. Wrong. A Person who HAS Cataract or Glaucoma CANNOT donate their eyes, But a person OPERATED for Cataract or Glaucoma can BE considered for eye donation. Also, Age will not come into picture while donating the eyes. As long as the person or his/her family/friends have a good mindset of doing some good to blind, can donate their eyes. I was reading an article in the Newsletter of EBAI where i found that the eyes of an 105 year old lady of Mysore district was donated (in 2002) and now, her eyes is used by two blind persons to see this beautiful world! How amazing it could be... Hopefully, in this 21st century, people will not yield to these myths and hence come out and volunteer themselves for donating their eyes, to make this world a 'blind-free' world!!

Once again, ARISE, AWAKE, SPREAD THE WORD and HELP THE NEEDY!

Quick look at the procedure for pledging/donating the eyes

Pledging procedure:
Any person can walk into the nearest Eye Bank and PLEDGE their eyes for donation. Once you are in eye bank, ask for the Eye Pledge form available there.
1. 2. 3. 4.

This form needs to be filled with the correct contact details, signed by 1/2 witness/es (can be your relative/friend) and given back to the eye bank. Once done, the eye bank people will issue a DONOR card that has contact details of the eye bank. Please place this card in a place of your home where all the family members has access to it. At the time of that persons death, his/her relative/friend, who was a witness for the pledge form or any other family member/friend who had the knowledge that the person who passed away intended to donate the eyes, should call the nearest eye bank.

One important aspect to be noted here that it is NOT sufficient if a person pledges for donating his/her eyes after the death. Pledging is just 20% of the work done and the rest lies with the actual eye donation. His/her relatives and friends should be well informed and be well aware to call the nearest eye bank, for donating the eyes after their death.

Donating procedure:
Irrespective of whether a person has pledges his/her eyes OR not, eye donation can happen. Pledging is for creating awareness and acts as a reminder to do this job. Once a death of a person happens in your family or in your friend's family, pick up the phone and dial to the nearest eye bank. Please note that this should be done WITHIN 6 hours of the death. Give the eye bank officials the location of the house along with a landmark so that they can come soon and collect the eyes.

giving a new life for 2 blind people!!

These eyes will be

Important points to be taken care after a person's death, before eye donation:
After the death of a person... Call the nearest eye bank within SIX HOURS of the death of the person. Switch off fans & keep AC on, if you have one. Close the eye lids gently and keep a moist cloth over the eyes. Raise head with a pillow.

Please act upon, keeping in mind the above points and pledge/donate the eyes and Gift Sight.
Removal of Cornea from a Donor's eye

Recepient's Eye after Cornea Transplantation

ome of the famous Indian Personalities who have come forward and pledged their eyes are: 1. Kannada Screen Idol, Dadasaheb Phalke Winner, Dr. Rajkumar (who passed away recently and Donated his eyes!) 2. "Big B" - Amitabh Bachchan and his wife, Bollywood yester years "guddi" Jaya Bachchan. 3. "Beauty Queen" Aishwarya Rai 4. "Table King" Ustad Zakir Hussain. 5. "Master of Bansuri" Pandit Hari Prasad Chaurasia. 6. Bharatnatyam Dancer, Alarmelvalli 7. Sri Sri Chinna Jeer Swamigal, Andra Pradesh And many more...Dont you think it is time to pledge your eyes too? Pledge and Donate Eyes :: GIFT YOUR SIGHT :: Make It Your Wish!

ye Banks/Hospitals in Bangalore
Please find useful contact numbers of some eye banks in Bangalore (STD code: 080). The source of this is from the BSNL website (http://www.bangaloretelecom.com) Please utilize these numbers so as to make a healthy contribution to the soceity.

1. 2. 3.

4.

5. 6.

7. 8. 9. 10. 11.

12.

LION INTERNATIONAL EYE BANK, Lions Eye Hospital Road (Off J C Road), Bangalore - 560 002. Ph # 2223 5005 / 2212 1255 NETRA JYOTHI INTERNATIONAL EYE BANK, 56/2, Hs Rd, Bangalore - 560 002. Ph # 2224 3974 / 2224 3974 PRABHA EYE CLINIC & RESEARCH CENTRE / Vittala International Institute of Opthalmolotgy: 504, Cross 40, Block 8, Jayanagar, Bangalore - 560 070. Ph # 2663 7041 / 2244 4141 / 2672 2213 NARAYAN EYE FOUNDATION P LTD 121/c, Chord Rd, Block 1r, Rajajinagar, Bangalore - 560010. Ph # 2357 6855 / 2357 2633 / 2290 2927 / 2347 9366 / 2357 7355 / 2337 0122 / 2357 7776 / 2357 8530 BG WEST LIONS EYE HOSPITAL 56/2, Eye Hosp Rd, Jc Road, Bangalore - 560002. Ph # 2212 1253 / 2597 0657 / 2212 1255 DR AGARWAL'S EYE HOSPITAL LTD 15, Eagle St Tn, Richmond Town, Bangalore 560025. Ph # 2212 6732 / 2222 1242 / 2229 3040 / 2229 8175 / 2229 8215 / 2224 0200 NETHRADHAMA SUPER SPECIALITY EYE HOSPITAL 256/14, Nethradhama, Kp Rd, Block 7, Jayanagar, 560082. Ph # 2663 4202 / 2663 3770 HAWKEYE INSTITUTE FOR BETTER VISION 312/17, Cross 27, Main 10, Block 3, Jayanagar, Bangalore - 560011. Ph # 2655 7223 SURANA PROJECT DRISHTI EYE INSTITUTE 2, Sirur Park Rd, Seshadripuram, Bangalore - 560020. Ph # 2334 7042 / 2334 7027 BHAGWAN MAHAVEER JAIN NETRALAYA 3, Rly Platform Rd, Bangalore - 560020. Ph # 2356 5384 VITTALA INTERNATIONAL INST OF OPTHALMOGY, Hosakerehalli, Cross 2, Main 2, Stage 3, Block 7, Banashankari, Bangalore - 560085. Ph # 2672 2213 / 2672 2214 / 2672 2215 / 2672 2219 NETRA JYOTHI MOBILE OPTHALMIC HOSPITAL. Ph # 2223 2562

Also, I recently found out that there is a 4 digit Telephone number to reach the Eye Banks across Bangalore. I am not sure how effective or how the working procedure of this number is, but still, please note it down for quick access. The number is

1053 / 1919

As per the small information i got, dialing this number will connect to a centralized eye bank desk, where they will ask the area of your residence (the place where the dead body is kept) and then divert your call / assist you in reaching the eye bank that is nearest to your residence so that the doctors belonging to that eye bank can act quickly.