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    1. STATISTICS ON...
    2. IMPEDIMENTS T...
    2.1 Inability to...
    2.2 Inadequate a...
    3. NEW STRATAGIE...
    3.1 Public Educa...
    3.2 Initiate Pro...
    3.3 Grief Counse...
    3.4 Enhance the ...
    4 EYE BANK
    4.1 Structure
    4.2 Equipment ne...
    4.3 Record maint...
    5. TISSUE RETRIEVAL
    5.1 Preliminary ...
    5.2 Collection o...
    5.3 Preparation
    5.4 Enucleation
    5.5 For in-suit ...
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OPHTHALMOLOGY PRACTICE
Year : 1996  |  Volume : 44  |  Issue : 1  |  Page : 47-55
 

Perspectives in eye banking


1 Postgraduate Institute of Medical Education and Research Chandigarh, India
2 L.V. Prasad Eye Institute, Hyderabad, India
3 Netra Jyothi Eye Hospital and Research Foundation, Bangalore, India
4 Eye Bank Coordination and Research Centre, Bombay, India
5 Eye Bank Association of India, Hyderabad, India

Correspondence Address:
Jagjit S Saini
Dept. of Ophthalmology, PGIMER, Chandigarh 160 012.
India
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How to cite this article:
Saini JS, Reddy MK, Jain A K, Ravindra M S, Jhaveria S, Raghuram L. Perspectives in eye banking. Indian J Ophthalmol 1996;44:47-55

How to cite this URL:
Saini JS, Reddy MK, Jain A K, Ravindra M S, Jhaveria S, Raghuram L. Perspectives in eye banking. Indian J Ophthalmol [serial online] 1996 [cited 2014 Dec 18];44:47-55. Available from: http://www.ijo.in/text.asp?1996/44/1/47/24609


Corneal transplantation is the most successful among all forms of organ transplant procedures. Organ donation is a sensitive issue all over the world. Ironically the impact of shortage of donor eyes is most glaring in the developing conservative Asian countries where corneal diseases account 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. There are several impediments to collection of donor eyes. An understanding of strategies that may be useful in overcoming these constrains is helpful. Properly organised eye banks will be able to optimise our efforts and scientifically retrieved tissue will be safer and less often liable to be rejected for use. It is our endeavour to summarise in this work issues related to constraints in collection of donor eyes and strategies to overcome them, structure of eye banks and safe tissue retrieval techniques.


   1. STATISTICS ON EYE DONATION AND RELATED ACTIVITIES Top


The first 'successful' human to human corneal transplant was done in 1903 in present day Czechoslovakia by Zirm to visually rehabilitate a patient of alkali burn.[1] Since then the technique of corneal transplantation underwent various changes and transformed into a clinically acceptable procedure benefiting the corneal blind.

In response to the demand for corneal tissue by increasing number of ophthalmologists, the first 'Eye Bank for Sight Restoration' was started in 1944 in the State of New York by Paton. The objective of this bank was to collect and distribute eyes for corneal transplantation. In 1961 ten such eye banks in the United States of America joined to constitute the 'Eye Bank Association of America' (EBAA) to establish and certify uniform standards and promote the various objectives of eye banks.[2]

During the year 1994, the member eye banks of EBAA collected about 96,700 eyes of which about 41,300 corneas were used for transplantation. The major source of this tissue were hospitals.[3]

In the USA, progessively liberal legislative sanctions to facilitate eye donation were enacted. These legal provisions besides the public awareness efforts, have helped in increasing the supply of corneal tissue in the USA. The development of eye banking was aided by advances in corneal tissue storage which permitted storage of upto 4 days with McCarey Kaufman, 5 to 10 days with Dexsol, upto 2 weeks with Optisol and 4 weeks with Organ culture storage procedure.

The eye banking movement since 1944 has spread world wide and in India the first eye bank was started in Madras in 1945.[4] According to available statistics in India 12,746 eyes were collected in 1992 and approximately 8,400 corneal transplants performed.[5] In 1993, there were 166 eye banks in India, of which approximately 27 eye banks collected more than 50 eyes per year and 6413 corneal grafts were done as reported by 104 eye banks.[6] Most eye banks in the developed countries have adopted storage media for cornea preservation. In 1994, 96% of donor corneas in Australia and in 1993, 100% of donor corneas in USA were preserved in storage media.[7], [8] Choindroitin sulphate containing media are often employed by 33% and 99% eye banks in Australia and USA respectively.[7],[8] Moist chamber preservation is rarely practiced in developed countries. Post inflammatory corneal disorders account for only 11.5% to 14% of corneal transplants done in the developed world.[9] In India approximately 190,000 persons are blind in both eyes and 590,000 persons are blind in one eye with corneal disorder according to the National programme for control of blindness - World Health Organisation Survey (1986-89).There is an inherent demand for nearly one million eyes and an estimated 20,000 persons are added to this backlog each year.[5] These statistics, however, may not reflect the actual magnitude of the problem. A significant number of the corneal blind happen to be children. As emphasized by these statistics there is a great need for eye donations in India.

In India legislation was first passed by the then Bombay state in 1957 to regulate eye donation.[10] The Transplantation of Human Organs bill which includes corneal transplantation in its purview, enacted in 1994 does not help eye donation significantly as it does not liberalise the law to include 'presumed consent' and 'required request' aspects which increased the availability of corneal tissue in the USA nearly five fold. Tissue Banks International (TBI) has initiated eye banking projects in Egypt, Saudi Arabia, India, Czechoslovakia and Myanmar.[2],[11] An association of eye banks named as the Eye Bank Association of India (EBAI) with its head quarters in Hyderabad was established in 1989 to promote eye donation, advance eye banking and co-ordinate the activities of various eye banks in India.[12] A facility to produce McCarey Kaufman corneal storage medium was started in 1994 at the Ramayamma International Eye Bank in Hyderabad.


   2. IMPEDIMENTS TO COLLECTION OF DONOR EYES Top


There is worldwide shortage of transplantable corneas. Fortunately corneas can be procured for several hours after death. The procurement of cadaveric tissues is in turn, significantly influenced by the technical, financial and social requirements, public support and numerous legal issues.[13] Our inability to reduce demand-supply gap of donor corneas falls into either of the two categories [Table - 1].


   2.1 Inability to fully employ existing avenues for cornea procurement and use Top


2.1.1 Soliciting for eye donation by health care professionals

Despite social and legal approval, procurement rates of donor corneas remains dismal. It occurs partly because of the reluctance of health care professionals to employ the provisions of existing social and legal approvals. Unwillingness of health care professionals to facilitate donations results from presumed fears of liability, lack of initiative and inability to ask for donations of cornea of decedent. All legal provisions incorporate immunity to health care professionals involved in eye donation and courts have upheld this repeatedly unless there are charges of malpractice.[13] Studies have demonstrated that wherever provisions of existing legal approval are enthusiastically applied, donations of corneas have substantially improved. For example, legal provisions which empower forensic pathologists to authorize eye donations have helped many eye banks to raise donations of eyes by as much as 60%.[14] While careful management by local morgue and eye bank is needed to ensure that law is carried out in all of its requirements, the resulting yield has been overwhelming and has also helped obtain more of younger tissue. Similarly even the most restrictive laws provide for obtaining eye donations with consent of family or next of kin. Health professionals have generally failed to organize trained teams who would make a request for eye donations. It has been demonstrated that mere asking for permission to obtain eye donation has helped significantly in improving the number of eye donations.[15]

2.1.2 Inadequate availability and practice of corneal preservation

Currently it is possible to prolong the viability of corneal endothelium which helps to maximize the use of donor eyes. Employing methods to preserve cornea helps enlarge geographical area of procurement of donor eyes because it gives more time to overcome the operational time constrains of providing usable corneas to the surgeons. Longer preservation allows better donor tissue screening for contraindications and more effective organised elective surgical use. Prolonging the viablility of corneal tissue by preservation media has significantly enhanced the supply of corneal tissue.[16] Unfortunately because of constrains of finances, trained manpower and infrastructure, many eyes banks are not able to practice intermediate term cornea preservation.

2.1.3 Operational constraints

There is a significant scope to optimise and involve professionals in improving inadequacies in operational organisation for eye donation. Lack of transport, inadequate availability of trained manpower, communication problems, inadequate processing facilities are limiting eye donations in many parts of the world. The organisational efficiency should be such as to be able to collect consented eye donations quickly within the stipulated time from feasible geographical area.[17]

2.1.4 Lack of finances

For good reasons, efficiency in eyebanking needs adequate trained manpower and funds. Sale of donated eyes is prohibited legally and is unethical. Eye Banks have to look for funds from Governments or social organisations. Several eye banks now charge a processing fee to sustain their working. Lack of funds is a major constraint in organising and sustaining efficiency in eye banks in many parts of the world. It is not possible to recruit, retain and motivate manpower, overcome basic operational constraints or employ preservation of cornea or sustain publicity on meager funds.


   2.2 Inadequate awareness and acceptability for organ donations and related legislation Top


2.2.1 Inadequate public awareness

In many parts of the world, large number of people are not even aware of the need and benefits of eye donations.[17] On the contrary there are many myths that are disseminated rapidly.[17-19] To the extent consent of decedent or his family is crucial to initiate the process of eye donation, lack of awareness becomes a major obstacle to convince and obtain consent. In many Asian countries strong cultural and religious beliefs of rebirth and reincarnation have a negative influence on eye donations. No major religion however bans eye donation.[20] Although in some Muslim countries there is religious controversy over use of cadaver organs and tissues, many countries including Syria, Iraq, Kuwait and Egypt have enacted laws to help eye donations.[13] Some other countries including India, Greece, Finland, United Kingdom and Hungary exempt those with known strong philosophical or religious views opposed to cadaver donations. Even those who are aware of eye donation do not often know of operational procedures.[17] Publicity such as occasional posters in limited area and number does not creat necessary impact.

Another reason for public ambivalence in donating cadaver eyes is the reluctance of individuals to contemplate their own deaths and the disposition of their bodies after death.[21] Public opinion polls show that even though when individuals support the concept of eye donation, there is widespread reluctance to consider one's own death and the prospect of bodily mutilation that harvesting of eyes would entail.[22]

In public opinion polls, individuals reluctant to donate eyes have expressed a fear that becoming a donor would encourage physicians to prematurely decrease the level of care.[22] We need to expressly address the fears of premature termination of care and reinforce religious sanction.

Reluctance of health care professionals to solicit eye donation is an important obstacle.[13] Reorientation publicity to change attitudinal factors and the fear of presumed liability of health care workers is required in most parts of the world. In light of estimates that approaching all families might at least double the yield of eye donation,[15] many countries have established protocols to ask families of patients attached to life-support equipment about donation.[13]

2.2.2 Legislaton

State legislation has enabled eyebanks to proactively apply societal approval regarding the use of cadaveric tissues for surgical procedures. Progressive legislation favoring corneal donation has prevented a far more serious shortage of donations. Legislation also enforces ethical and orderly donations.

Enacted laws governing organ or tissue procurement all over the world have incorporated one of the two general approaches. Both philosophies incorporate the notion of consent but express consent by opposing methods. One philosophy requires prior to tissue removal voluntary, affirmative consent by the decedent before death or the survivors in legal possession of the body after death. The second approach presumes consent and allows tissue removal in the absence of prior objections. The approach in each country is to a large extent determined by its need for organs, legal and social heritage and the public support for such laws. The choice of law and its enthusiastic application by health care workers in turn, influence the success of efforts to develop a sufficient supply of corneas.

There are 160 countries where it is legal to procure cadaveric eyes.[13] Countries with 'voluntary consent' or 'opt-in' structure depend heavily on the surviving family consent to facilitate eye donation (Uniform-Anatomical Gift Act 1969, USA or its variants).[23][24][25][26][27] Most Asian countries including India have legal "Opt-in" system.[13] Even within this "Opt-in" system, to facilitate consenting, some countries including USA have refined "mandated choice consent"[22] and "Routine Inquiry laws".[28] Individuals are required under "mandated choice consent" to indicate along with some other state requirements like Income Tax return filing or driver's license, if they will want to be listed by choice as voluntary eye donors. Under the provisions of 'Routine inquiry' health care workers are mandated to compulsorily ask for cadaveric eye donation. (Routine Inquiry law, 1986, USA) These legal provisions have helped improve procurement of voluntary donor corneas.[14] In many countries there are separate legal provisions authorizing eye donations by forensic pathologist without the requirement of obtaining consent. (The justice of Peace of 1975, USA or its variants). Hospitals, physicians, and tissue banks are authorized under presumed consent laws to remove eyes in the absence of a known objection to donation by the decedent or surviving family in 24 Countries.[13] To facilitate easier operational procedures, legal provisions permit removal of cadaveric eyes by non-ophthalmologists also.[16] (Cornea Tissue ACT 1986, U.K. and its variants).

The available laws can be grouped along a spectrum based on the level of consent needed. At one end of the spectrum, reflecting customs and heritage, the surviving family has controlling authority to donate a decreased one's cornea. At the other end, unless an objection is registered prior to death, corneas can be removed as needed. Geographically, culturally and philosophically, Asian and Latin American countries are concentrated in the former group while Continental European nations constitute most of the 'presumed consent' nations. Countries with strong English or American legal heritage tend to follow a more middle course. Not coincidentally, Asian Countries have the greatest difficulty in obtaining donor eyes compared to Anglo-American and European countries.[29] Both non facilitatory legislation as well as ineffective implementation of existing provisions have been shown to be among the major impediments to enhance donor eyes procurement.[13],[14]


   3. NEW STRATAGIES TO IMPROVE DONOR TISSUE COLLECTION Top


Eye banking, is in its infancy in many Asian countries including India. It would be ideal to have a four-way approach to improve the collection of donor tissues [Figure - 1]


   3.1 Public Education Programmes Top


All effforts are required to increase the supply of transplantable corneal tissue with a variety of "Public Education" programmes. It involves working with several organisations to reach all segments of the population [Figure - 2].

(a) Public Lectures

Ophthalmologists and eye bankstaff can give lectures with the aid of audio-visual materials giving all the details about the concepts related to eye donation. The audience could range from school and college students to health care personnel. The other could be organisations such as Pensioner's Associations, Voluntary organisations, Mahila Mandals, Trade Union Members, Spiritual Groups and employees of large organisations.

(b) Driver's Licence

Since it is known that very little or no awareness exists about eye donation even among the literate class, driver's licence may be another useful medium to disseminate the message on eye donation. The reverse side of the driver's licence can carry information about the drive of the person holding the licence to donate eyes, along with the telephone number of the eye bank. As the vehicular traffic is increasing, the message on eye donation will reach a larger group of people. This is a common practice in the developed countries, and has been found to be successful, especially when the licence holder meets with an accident.

Credit cards and identity cards issued by the large organisations to employees, and railway season ticket holders may also have pledge card on the reverse.

3.1.1 One-minute video education programme

A one minute programme carrying messages on eye donation can be publicised through television network. Prominent social and religious personalities may be requested to talk on eye donation in such programmes. However, it is important that this short presentation is made effectively to have an impact. This should be televised at regular intervals and at prime time.

3.1.2 Pledge/Registration

A pledge is, "conveying one's wish to the eye bank to make donation after the death". While pledge is good medium to create awareness, it has been found to have several practical constraints.

Many eye banks even found it difficult to store large quantity of pledge cards collected over long period of time, due to paucity of storage space.

To overcome these constraints, and to make the wish of the eye donor translate into an actual eye donation, it is suggested to have a uniform, country-wide "Certificate of Pledge", filled by the prospective eye donor himself/ herself (without any records maintained by the eye bankers) and have it placed in a prominent place in their home.[Figure - 3] A simple "Facts about Eye Donation" may also be given to the person pledging his eyes and to the family.

3.1.3. Posters

Posters in all languages with effective message on "Eye Donation " may be made and put up in the public places. The idea is to attract the attention of as many people as possible.

3.1.4. Cinema Slides

Vernacular cinema slides carrying the message on eye donation may be fixed in movie theaters at no charge with the help of city police authorities. As the people coming to watch the movie will be in a relaxed mood, it would be the best opportunity to appeal to them for their participation.

3.1.5. Documentary of Eye Donation

A ten-minute documentary demonstrating all aspects of eye donation can show the need for eye donation. This could include interviews with blind patients waiting for corneal transplantion, especially children, along with the highlights of procedure of whole eye enucleation and corneal excision. Help from the government will be vital in this area, in that it can be televised at regular intervals. Hoardings, listing phone numbers of eye banks in the telephone directory and yellow pages, sending newsletters to the donors, and publishing news item in the dailies and magazines are some of the other on-going public education programmes.


   3.2 Initiate Progressive Legislation Top


In order to overcome the problem of reducing the gap between demand and supply of corneas, passing progressive legislation is recommended. Statistics from developed countries reveal that the passage of progressive legislation have lead to increased availability of surgically suitable corneas.

A simple perforated appendix to the death certificate (Fig. 4) giving the details of the potential donor will help in increasing eye donation. Significant contribution by the social workers, doctors and nurses in the hospital will bring about a boost in the availability of donor corneas. It only requires professional handling of the family coupled with consistent effort by eye bankers.


   3.3 Grief Counselling Programmes Top


In the hour of grief, it is possible that the family might lose sight of the pledge for eye donation. In such a situation, there has to be a reminder to the family to donate eyes, so that they may act in that direction. Hence there is a need for more concrete and result oriented approach to harvest more number of eyes.


   3.4 Enhance the Image of Eye Banks Top


As we are gradually stepping into the 21st century, eye banks have to undergo transition and become more professional and maintain unique identity for itself. Many eye banks have started with lot of enthusiasm, without paying attention to the long term commitment it has to the society. Poor understanding of effective functioning of eye banks has thus lead to the notion that establishing an eye bank is a simple affair.


   4 EYE BANK Top



   4.1 Structure Top


Modern eye banks have developed into professional operations with highly trained staff and certified technicians, round the clock coverage and growing public interaction. It must have autonomy of function, run smoothly technically and financially and have strong public relations and professional education programmes.

4.1.1 Objectives



  1. 1. Procure, process and distribute corneal tissue of the highest quality for transplantation.


  2. 2. Provide and process eye tissue for research or teaching as needed.


  3. 3. Provide families of potential donors the mechanism and operational process to donate a decedent's eyes.


  4. 4. Provide support and grief counselling to donor families.


  5. 5. Provide for soliciting eye donation from potential donors.


  6. 6. Promote public relation activities.




4.1.2 Location

Ideally an eyebank should be autonomous. The eye bank must have space dedicated solely to the eye bank's technical activities and have limited access to eye bank personnel. There must be running water, stable electrical source, adequate counter space for working of staff, storage of supplies, equipment and donor records. It should be located close to the main medical facilities for easy access and interaction with other support services including a microbiology laboratory and potential donors. It could benefit from location within a hospital but derive strength from independence of working.

4.1.3 Regulatory staff

An eye bank is headed by the Medical Director, advised by Board of Directors. The Medical Director should preferably be a well trained corneal surgeon who maintains good communication with the Board of Directors, technicians, enucleators, eye bank personnel, procurement coordinators and public. The Directors of the Board are selected from public and can usually serve for 3 years. It can have three approximately equal classes, with one class appointed each year on a rotating basis by the board at the annual meeting. They can be reelected. The number can be decided by the local eye bank which may be 9 to 15. They represent a cross section of the community such as Philanthopists, Social workers, Judges, Hospital administrators, Public relation officers, Industry, non-corneal Ophthalmologists, President of local IMA, Medical Directors of non-Ophthalmic hospitals, Legislators, Superintendent of Nursing, representative from EBAI, media personnel, recipient of cornea transplants and their relatives etc. It is useful to choose board members carefully and only those deeply committed will do justice.

Medical Director has to oversee crucial areas including laboratory establishment and working policies, procedures for procurement, screening, grading and distribution of eyes. Since the medical director is responsible for day to day activities and is required to inspire confidence in staff and public, he should be a trained senior corneal surgeon.

The Administrator (or an Executive Director) can be appointed by the board. This person works closely with the Medical Director, Board Members, staff and community. The Community includes Surgeons, civic groups, news media, hospitals and service organizations. The administrator also looks after the day to day function of the eye bank.

4.1.4 Communication system

The main key to a successful eye banking program is its effective public communication. The eye bank should have facility and specific manpower to receive round the clock telephone calls. The staff should be accessible to meet public courteously during office hours. At least in the initial period, invitations for lectures on eye donation can be actively sought for. Industrial groups, Service clubs, Ladies and Youth associations, College functions etc. are good target platform for public lectures.

4.1.5 Organization of an eye bank

Each Eye Bank should have a Policy manual with details of all the policies and functions. These policies should include the job description of the personnel employed by the Eye Bank. A Technical manual should be prepared or adapted which describes the technical operations of the Eye Bank. The Eye bank Technician reports to the Medical Director and is responsible for performing day to day operation. The Technician must be familiar with the procedures and policies of the Eye Bank, with the aseptic techniques of enucleation, tissue handling, corneal excision and preservation procedures.

Most importantly, the person should be fully aware of the biohazards of the profession and should take all safety precautions to protect himself and other staff from possible contagious diseases. Certified and trained technicians with preferably medical laboratory work background are suitable and are encouraged to remain updated with refresher courses. Similarly a driver and a vehicle should be at the disposal of the eye bank round the clock. If the eye bank is situated within the premises of a hospital, the general reception and the ambulance services of the hospital could be utilized. Paging system currently available are extremely useful to save time.

4.1.6 Distribution

If the eyebank is responsible for distribution of the corneal tissue, all attempts made to contact some one to receive the tissue should be documented. Records should be kept of the names of those contacted, the date and time of contact, the outcome and any reasons why the tissue was not accepted.

In distributing the tissue to the receiving surgeon, the entire medical history of the donor should be described. The information can help the surgeon make a well-informed decision as to acceptance or refusal of the tissue offered.


   4.2 Equipment needed for eye bank Top


The equipment needed for an eye bank is listed in [Table - 2]. Some of these are mandatory and each eye bank should have acess to them while others such as specular microscopy are not absolutely essential. These can be added where resources permit development of a major eye bank.


   4.3 Record maintenance Top


The need for documenting, storing and retrieving vast amount of data mandates the use of a computer. Each eye bank should have custom made software necessary to store eye donors and recipient records, eye pledge details, the results of tissue screening and general correspondence. A printer is necessary to obtain hard copies.


   5. TISSUE RETRIEVAL Top


Tissue can be retrieved for transplantation either by performing an enucleation i.e. surgical removal of the whole eye or by an in-situ corneo-scleral excision (i.e.: globe retained in the orbit).[30]

Donor eye enucleation is technically easier and requires less time to perform than in-situ corneo-scleral excision. While enucleating donor eyes, however, there may be occasional significant blood ooze. Corneal endothelium quality in enucleated eyes deteriorates in 24-36 hours, which can be prolonged only on preservation of excised corneo-scleral buttons in tissue culture medium. Many eye banks now recommend enucleation of whole donor eyes and corneo-scleral excision in the eye bank laboratory. In -situ excision of corneo-scleral button is also in practice.[8] Both these procedures, should be carried out meticulously with utmost respect to the donor.[31]

The equipment and supplies required for tissue collection are given in [Table - 3].


   5.1 Preliminary procedures Top


Before starting any preparation for tissue collection, check the death certificate and take legal permission from the next of kin for donation. If everything is in order, read the donor's history and medical records and check for ocular and medical contraindications. Wash hands with alcohol or similar disinfectant solution. Put on protective clothing - surgical gown, cap, mask, eye protection and non sterile or prep gloves. Identify the donor either by a toe tag or some other form of identification label on the body of the donor. Elevate and position the head so that it is straight and in one line with the rest of the body. Elevation of the head allows minimal seepage of fluids into orbital area and positioning helps during cleaning and surgical procedure thereafter. Discard used gloves into biohazard bag. Open a clean drape to cover an area close to the donor for the supplies and equipment. Prior to draping, if possible, decontaminate the area with alcohol or similar solution. Set up the supplies and equipment in the sequence required.


   5.2 Collection of blood Top


The best sites for post mortem blood collection are the femoral vein, subclavian vein, heart or the jugular vein. Use a 10 cc syringe and a spinal needle for collection of blood from the heart, or a 10 cc syringe and a 1" X 18 g needle for other sites. Choose the site for collection and clean the area with 70% alcohol. Collect 5-10 ml of blood. From the time of collection till the blood sample tube is delivered to the eye bank and serum is separated, keep the tube upright.


   5.3 Preparation Top


In this step we prepare the donor as per operating room standards. Wear sterile gloves and then open the right eye with the help of a sterile cotton tipped applicator or sterile haemostat and copiously irrigate the conjunctival sac with sterile saline. This decreases the microbial flora. Repeat the same procedure on the left eye using a new cotton tipped applicator or haemostat. After irrigation, clean both sides of orbital area with an alcohol swab/alcohol gauze held in a sterile haemostat. Make sure alcohol does not enter the eyes.


   5.4 Enucleation Top


Insert the eyelid speculum and put 5 to 10 drops of antibiotic solution on the cornea to further decrease the microbial flora and keep the cornea moist during enucleation. With the help of the toothed forceps, grasp the conjunctiva close to the limbus and make a small cut in the conjunctiva with the conjunctival scissors. Introduce the scissors with their blades closed into the space between the conjunctiva and the sclera and make a blunt dissection so as to separate the conjunctiva as close to the limbus as possible. Cut the conjunctiva from the limbus 360 degrees around the cornea. Make two or more relaxing slits radially in the conjunctiva. This prevents conjunctiva from coming in the way during isolation of the muscles and enucleation. Isolate and clamp the lateral rectus (temporal) muscle with a haemostat. Cut the muscle distal to the eye and the haemostat. Leave the haemostat in place so that at the end of the procedure, it can be used to lift the eye out of the socket. With the help of the muscle hook and scissors, isolate and cut the superior rectus, inferior rectus, and medial rectus muscles close to their point of attachment to the eye. Isolate the inferior and superior obliques and cut them. Hold the haemostat and rotate the eye to check that all muscles have been cut. With the haemostat, gently raise the eye ball and simultaneously introduce the optic nerve scissors into the orbital cavity till you come in contact with the orbital bone and cut the optic nerve. Try to obtain at least a 4mm stump of the optic nerve. Gently dissect away the adherent tissue and put the eye ball in the eye cage so that the optic nerve passes through the hole in the bottom of the cage and the cornea faces upwards. Pull the optic nerve with the Allis forceps to secure it firmly in socket with sterile cotton ball or gauze. All disposables should be discarded in an appropriate biohazard bag and carried back to the eye bank to be disposed off properly.


   5.5 For in-suit cornea-scleral excision Top


Carefully open the wrapper of the #15 blade and clamp it with the mosquito forceps. Place a piece of sterile 4x4 gauze on the cap of each media vial. Open the right eye and without touching the cornea insert the eyelid speculum. With the help of the toothed forceps, grasp the conjunctiva close to the limbus and make a small cut with the conjunctival scissors. Introduce the scissors with their blades closed into the space between the conjunctiva and the sclera and make a blunt dissection so as to separate the conjunctiva as close to the limbus as possible. Cut the conjunctiva from the limbus 360 degrees around the cornea. Make two or more relaxing slits radially in the conjunctiva. This prevents conjunctiva from coming in the way during excision. Put 5 to 10 drops of antibiotic solution on the cornea. Make an incision through the sclera, 2 to 3 mm from the limbus, and 4 to 5 mm in length into the suprachoroidal space. Using the right and left Castroviejo corneo scissors, cut the sclera 360 degrees evenly with the blades of the scissors. If excision has been performed correctly, the cornea will be attached to the ciliary body- choroid (uvea) only at the scleral spur. With the unused toothed forceps, hold the cornea by its scleral rim and with the iris forceps, gently pull away the iris. If excision has been performed correctly, an air bubble will appear in the anterior chamber.

Gently put the cornea into the medium. The epithelial side should touch the bottom of the vial. Without touching the donor, remove the speculum and proceed similarly with the left eye.

 
   References Top

1.Zirm EK. (V.Graefe's Archiv Fur Ophthalmologie, 1906) Eine erfolgreiche totale keratoplastik (A successful total keratoplasty). Refractive and corneal surgery. 258-261,1989.  Back to cited text no. 1    
2.Brightbill FC. (ed). Corneal surgery. Theory, Technique and tissue. 2nd Ed. St.Louis. 1993.  Back to cited text no. 2    
3.Eye Bank Association of America, 1994 statistics, ARVO news letter, Summer 1995, PP. 21.  Back to cited text no. 3    
4.Atri AP. Sociomedical aspects of eye donation. Punor jyoti. News letter of the Eye Bank Association of India, November, 1994.  Back to cited text no. 4    
5.Bharti IJ Eye Donation, National handicapped welfare council (Haryana unit), Karnal: India, 1994.  Back to cited text no. 5    
6.Statement of the Minister of state of health and family Welfare, Dr. C. Silvera in Rajya Sabha dated 27th April,1995. India.  Back to cited text no. 6    
7.Williams KA, Muehlberg SM, Lewi's RF et al. The Australian Corneal Graft Registry, 1994 Report.  Back to cited text no. 7    
8.Eye bank Association of America. 1993 Statistical Report.  Back to cited text no. 8    
9.Mamlis N, Anderson CW, Kreisler KR, et al. Changing trends in the indications for penetrating Keratoplasty. Arch Ophthalomol. 110:1409-1411, 1992.  Back to cited text no. 9    
10.Atri AP. Human Organs Transplantation Act 1994 and its effect on eye donation. Punarjyoti, News letter of Eye Bank Association of India, February, 1995.  Back to cited text no. 10    
11.Griffith NF. The promise of 'international eye banking' Ophthalmology 14:205-210,1990.  Back to cited text no. 11    
12.The Eye Bank Association of India, Constitution and bye laws.  Back to cited text no. 12    
13.Lee PP. Yang JC, Me Donnel PJ, et al.'Worldwide legal requirements for obtaining corneas-1990. Cornea 11:102-107, 1992.  Back to cited text no. 13    
14.Farge EJ, Silverman LM, Khan MM, et al. The impact of state legislation on eye banking. Arch Ophthalmol 112:180-185, 1994.  Back to cited text no. 14    
15.Diamond GA, Campion M, Mussoline JF, et al. Obtaining consent for eye donation. Am J Ophthalmol 103:198-203, 1987.  Back to cited text no. 15    
16.Armitage WJ, Moss SJ, Easty DLB, et al. Supply of corneal tissue in the United Kingdom. Br J Ophthalmol 74:685-687,1990.  Back to cited text no. 16    
17.Proceedings of National workshop on eye banking. Govt. of India. New Delhi 1986.  Back to cited text no. 17    
18.Mannieu DV, Evans RW. Public attitudes and behaviour regarding organ donation. JAMA 253:3111-3115, 1995.  Back to cited text no. 18    
19.Basu PK. Hazariwala KM. Chipman ML. Public Attitudes towards donation of body parts, particularly the eye. Can J Ophthalmol 24:216-220,1989.  Back to cited text no. 19    
20.May WF. Religious justification for donating body parts. Hastings cent Rep 15:38-42,1985.  Back to cited text no. 20    
21.Veraina JR, Nora LM, Bone RC. Issues in biomedical ethics, in Disease-a-Month 39:884-889,1993.  Back to cited text no. 21    
22.Strategies for cadaveric organ procurement - Council on ethical and Judicial Affairs of American Medical Association. Council Report.JAMA 272:809-812,1994.  Back to cited text no. 22    
23.Uniform Anatomical Gift Act. 8A ULA 16,1989 (suppl.)  Back to cited text no. 23    
24.The Transplantation of Human Organs Act. 1994. Govt. of India.  Back to cited text no. 24    
25.The Eyes. (Authority for use for theraveutic purposes), Act 1982, Govt. of India.  Back to cited text no. 25    
26.The Goa, Daman and Diu (Authority for use of eyes for therapeutic purposes) Act, 1980.  Back to cited text no. 26    
27.The Punjab Anatomy Act, 1963, Govt. of Punjab State, India.  Back to cited text no. 27    
28.Andersen KS, Fox KM. The impact of routine inquiry law on organ donation. Health Att. 7:65-78, 1988.  Back to cited text no. 28    
29.De Cock R: Penetrating keratoplasty in the West Bank and Gaza Eye: 8:29-34,1994.  Back to cited text no. 29    
30.Lane S.S. et al, Whole globe enucleation versus in situ corneal excision, Cornea 13:305-309,1994.  Back to cited text no. 30    
31.Tissue Banks Internatoonal, Eye Banking Manual of Technical Policies and Procedures, 1994.  Back to cited text no. 31    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

    Tables

[Table - 1], [Table - 2], [Table - 3]



 

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2005 - Indian Journal of Ophthalmology
Published by Medknow

Online since 1st April '05