Eye donation - a perspective

THE cornea is the transparent tissue in front of the eye. When removed from the eye, it looks like a small glass button. One loses vision when this transparent cornea becomes opacified due to injury (mechanical or chemical); infections; diseases like rheumatoid arthritis, and leprosy and inherited disorders.

Why a corneal transplantation is unique:

The cornea is a unique organ - essentially it has no blood vessels and derives nourishment from other sources in the eye. It is this inherent property of the cornea, which makes it excellent graft material with minimal chances of rejection. Corneal transplant or keratoplasty is an operation in which an abnormal or a diseased cornea is replaced by donor corneal tissue and sutured. The other parts of the eye cannot be transplanted. The graft may be partial thickness (lamellar) or full thickness (penetrating). Of all the organ transplants, corneal transplantation is unique since:

- It is easy to harvest from the donor, it can be done anywhere and does not require theatre facilities or costly surgical implements and does not involve any significant monetary factor.

- With the availability of advanced storage media, it is possible to store the cornea for a long period of time. Thus transplantation need not be done as an emergency procedure but can be elective. The surgical technique is simple and can be performed even under local anaesthesia in most cases.

Settings of transplantation:

Corneal transplantation is usually done on an elective basis. It can be performed for optical purposes (to restore vision) or a tectonic purpose (to restore the structural integrity of the eye). Patients are usually wait listed. Priority is given to patients who are bilaterally blind, with very low vision, and those who are young. In certain circumstances, corneal transplantation is done on an emergency basis, such as a severe corneal ulcer and an impending or frank corneal perforation. In such circumstances the availability of reserve corneal tissue is of help.

Corneal blindness: the reality:

In India, approximately 1,90,000 persons are blind in both eyes and 5,90,000 persons in one eye with corneal disorders. There is an inherent demand for nearly one million eyes and an estimated 20,000 persons are added to this backlog each year. On the contrary only around 8,000 corneal transplants are being done every year in India. There are significant numbers of corneal blind children.

Transplantation: myths and facts: Organ donation is a sensitive issue all over the world. In many Asian countries, strong cultural and religious beliefs of rebirth and reincarnation have a negative influence on eye donation. However, no major religion bans it.

Many of us are not even aware of the needs and benefits of eye donation. On the contrary there are many myths that are disseminated rapidly. A lack of awareness becomes a major obstacle to convince and obtain consent. Ironically, the impact of the shortage of donor eyes is most glaring in developing conservative countries like India, where corneal blindness accounts for a large proportion of curable blindness. Collection of donor eyes is, therefore, a priority in any organised effort to alleviate the needless scourge of blindness.

The first "successful" human to human corneal transplant was done in 1903 in present day Czechoslovakia by Zirm to visually rehabilitate a patient who had suffered a burn. Since then, the technique of corneal transplantation has undergone changes and been transformed into a clinically acceptable procedure benefitting the corneal blind. The eye banking movement, since 1944, has spread world wide. In India, the first eye bank was started in Chennai in 1945. There are over 150 eye banks, of which only 27 collect more than 50 eyes a year. Most of these banks are not fully developed and functional.

Functions of an eye bank:

In the West, eye banks have become ideal organisations, well equipped and manned for fulfilling the functions of an eye bank. The functions of bank are:

- Collect donor eyes, process them and make them available to eye surgeons for corneal transplant surgery.

- Educate people to donate eyes.

- Motivate people to consent for the removal of eyes after the death of a relative or friend.

- Research different ways and means to prolong viability of cornea with particular reference to environmental factors.

In circumstances as in India, the first of these four is the primary functions of eye banks, as they exist at present. The second and third are better undertaken by social and voluntary organisations and service clubs in cooperation with an eye bank. The last of the functions should be an installation in a well- established eye bank laboratory.

Social and voluntary organisations collect, store and distribute eyes for corneal transplantion. Eye banks usually get the eye through donors, enlightened relatives of the deceased and medico legal/pathological postmortem from unclaimed bodies.

Facts about eye donation:

Almost anyone of any age or sex can pledge to donate eyes after death, even if he or she has undergone eye surgery or has cataract or wears lenses.

The eyes of the deceased can be donated whether the person had pledged eye or not.

The eyes have to be removed within six hours of death. So inform the nearest eye bank or collection centre. The eye bank will send a doctor and trained ancillary staff.

The removal takes only 10 to 15 minutes, is simple and does not lead to any disfigurement.

The eyes are used for a corneal transplant operation within 72 hours, but with present day availability of special storage media the eyes can be stored for a longer time before being transplanted.

The donated corneas are transplanted following the waiting list. The procedure is confidential.

The eyes can be pledged to any eye bank preferably the nearest one.

Eye donation is never refused.

Donation gives sight to two blind persons. The hospital does not levy any charge for the donor cornea but charges only for the surgical procedure.

There are a few conditions when the eye from the donor cannot be used. Conditions potentially hazardous to eye bank personnel and fatal if transmitted are:

AIDS; Rabies; Hepatitis; Creutzfeldt-Jacob disease (Mad cow disease)

Other relative contraindications for corneal transplantation are:

Death due to an unknown cause; Congenital rubella; Encephalitis and subacaute scleral panencephalities; Septicemia; Snake bite; Pre-existing eye diseases like conjunctivitis, other infective conditions and tumours; Tumours like Leukemia Lymphoma and lymphosarcoma; Tetanus; Reyes syndrome; Progressive multifocal leukoencephalopathy.

The next of kin can donate the eyes of the dead person who had not pledged to donate his eyes. At the same time, eyes cannot be removed without the consent of the next of kin, even if the deceased has already pledged his eyes. Pledge forms obtained from your nearest eye bank can be filled and deposited in the eye bank. Now-a-days facilities are available to pledge your eyes online. You will be given an eye donor card to carry with you. Inform family and friends, lawyers and a family doctor of your desire to donate your eyes.

The role of next-of-kin:

Inform the nearest eye bank, as early as possible. The eyes have to be collected within six hours.

Eyelids should be closed immediately after death. The head end should be elevated. A wet piece of cloth can be placed over the covered eyes. Antibiotic drops, if available may be applied to keep the eye moist.

Co-operation should be given to those when they come to remove the eyes including details of death and any other information as may be solicited by the medical professional and in the various formalities such as signing the consent forms for removal of eyes (which is mandatory to collect the eyes).

Eye donation - the procedure:

The doctor usually makes a few enquires about the cause of death, the time of death and other details as and when necessary. Consent forms for removal of eyes and blood sample are duly got signed.

The family members are motivated to include the message that eyes have been donated when they notify the obituary in the media. The nearest relative of the deceased usually gets a certificate stating the details of eye donation and there are social workers who call on these families to thank them at a later date. The person on the waiting list is intimated by telephone/telegram and is operated upon.

Methods of improve awareness:

Eye donation pamphlets and consent forms can be distributed to general practitioners.

Particulars of an eye bank can be displayed in major hospitals, nursing homes, clinics and public places.

The rural population can be motivated by creating an awareness of corneal blindness and eye donation through school teachers, social workers and rural medical staff.

The media

The available laws can be grouped along a spectrum based on the level of consent needed. At one end of the spectrum, unless an objection is registered prior to the death, corneas can be removed as needed. This is called presumed consent. On the other hand, reflecting customs and heritage, the serving family has the controlling authority to donate the deceased one's cornea. Most Asian countries belong to the later group, which have the greatest difficulty in obtaining donors eyes compared to Anglo American and European countries, which constitutes most of the presumed consent nations.

In the hour of grief, it is possible that the family might ignore the pledge for eye donation, at the time of the death of their beloved one. Grief counselling programmes can play a major role in such situations and persuade the family to donate eyes.

Donate your eyes and continue to see the world even after you leave it.

DR. CHOCKALINGAM

DR. SUJATHA MOHAN

DR. MOHAN RAJAN

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