Role of Eye Bank beyond Cornea - Sclera

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The EBAI CME 2013 - 21st and 22nd of September 2013, Golden Valley Resort, Ghodbunder Road, Thane West, Mumbai.

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Role of Eye Bank beyond Cornea - Sclera

  1. 1. Dr Vandana Jain MS,DNB,MNAMS,FLVPEI, FICO,MBA Fellow L.V. Prasad Eye Institute FICO( Massachusetts Eye & Ear Infirmary) MBA( Stanford Business School) Cornea, Cataract and Refractive Surgeon Managing Director, Advanced Eye Hospital & Institute
  2. 2. Age Visual Acuity Previous history/Durati on Findings Serology Surgery Followup Visual Acuity Outcome Complications 6220/400 Pterygium excision/ 9 months Necrotizing scleritis with cataract Negative SPG with AMG 18 months HMCF Stable ocular surface Cataract progression
  3. 3. Age Visual Acuity Previous history/Duration Findings Serology Surgery Followup 22 20/400 Cataract surgery and transcleral cyclophotocoagulati on/ 4 years Aphakic glaucoma with ciliary staphyloma with uveal exposure with corneal edema Negative SPG with conj. Flap 36 months
  4. 4. Age Visual Acuity Previous history/Duration Findings Serology Surgery Follow up Visual Acuity Outco me 48 20/20 Pterygium excision twice/7 months Necrotizing scleritis with uveal exposure Negative SPG with AMG 13 months 20/20 Stable
  5. 5. Age VA Previous history/Duration Findings Organism Medical therapy surgery Visual Acuity Outcome Complicat ions 76 20/400 Pterygium excision with MMC/ 3 years Scleral abscess, AC reaction GPC/ Staph epidermidis Systemic Steroids/ Topical gatifloxacin Scleral debride ment/ Scleral patch graft FCCF Resolved Cataract
  6. 6. Our Study  A total of 13 eyes underwent scleral patch grafting for scleral defects of varying etiologies  Necrotizing scleritis following pterygium surgery (40%) was the most common cause  Tectonic success was achieved in 10 eyes (76.9%)  Scleral grafting with overlying conjunctival or amniotic membrane graft is an effective and simple measure to preserve globe integrity both structurally and functionally Eye (2007) 21, 930–935
  7. 7. Oculoplasty colleagues
  8. 8. Br J Ophthalmol. 2006 July; 90(7): 924–925 •42 year old lorry driver •Traumatic corneal perforation >1.5 mm •Glue BCL failed
  9. 9. •77-year-old white female with retinal detachment •Planned for scleral buckling procedure •Converted into a scleral graft procedure, as extreme scleral thinning was found intraoperatively. •An alcohol-preserved donor sclera graft was used Indian J Ophthalmol. 2011 May-Jun; 59(3): 235–238
  10. 10. Ophthalmology 2012;119:2631–2636
  11. 11. Advantages of Scleral Implants  Readily available  Can be easily preserved for months  Strong, flexible and easy to handle  Natural curvature allowing it to neatly blend with host sclera  Avascular ,well tolerated with little inflammatory reaction
  12. 12. Scleral Grafts  Human sclera grafts are widely used in ophthalmic surgery  Processing of sclera grafts in an eye bank is easy to handle compared to the complexity of cornea transplants
  13. 13. Preparing the Graft  Demand for sclera grafts can be covered without a lot of trouble  For the preparation of sclera grafts  All other tissues removed from donor bulb including retina, choroid, cornea, corpus vitreum and lens  The sclera graft can be stored dry or in ethanol until transplantation  HIV infection, syphilis, hepatitis C, hepatitis A, tuberculosis, HTLV-1 and -2 infection, active leprosy, active typhoid, smallpox and active malaria are also contraindication
  14. 14. Contraindications for Sclera preservation  Active viral Hepatitis  Acquired immunodeficiency syndrome (AIDS) or HIV  Active viral encephalitis or encephalitis of unknown origin  Creutzfeldt-Jakob disease  Rabies  Instrinsic eye disease  Retinoblastom  Malignant tumors of the anterior ocular segment
  15. 15. Unlike Cornea Preservation!  Laser photo ablation surgery  Corneas from patients with anterior segment surgery and poor cornea  Donor age or death to enucleation time is not important
  16. 16. Sclera Preservation  Glycerine Preservation (Dehydration)  Tissue may be stored at room temperature up to 3 months  Surgical utilization requires hydration-  15 to 30 minutes immersion in BSS with antibiotics  Absolute Ethanol  Ethanol conc above 70%  Room temperature,  Maintain up to 5-day full validity  Before utilization the tissue washed in BSS containing antibiotics
  17. 17. Sclera Preservation  Freezing  At -20 degrees for 3 mnths  Thawing at room temperature after which kept refrigerated at 2 - 6ºC for utilization  Should never undergo refreezing and its storage time limit, once unfrozen, should never exceed 24 hours
  18. 18. Sclera Preservation  Freeze Dried  Rapid freezing followed by dehydration of the material under high pressure.  Superior method for sclera preservation as compared to 95% ethanol.  Provides an easy method to manipulate tissue,  Longer shelf life,
  19. 19. Indications of Scleral Transplant  Ocular implantation after enucleation  Synthetic eye implant is wrapped in sclera.  Muscles are then attached to the sclera, which allows artificial eye to move with companion eye  Lid retraction  Sclera is used to reconstruct eyelid  Glaucoma surgery –  Ahmed valve is inserted into the eye to reduce intraocular pressure. The valve is covered with a piece of sclera to allow movement of the eyelids across the implant.
  20. 20. Indications of Scleral Transplant  Scleral thinning  Well-reported complication following pterygium excision, retinal detachment repair, systemic vasculitis, high myopia or trauma  Reinforcement of thin or perforated sclera is necessary, especially when choroid is exposed to prevent prolapse of ocular contents and secondary infection
  21. 21. •Scleral thinning with exposure of residual tumor beneath conj •Choroidal Melanoma Large, hand-crafted scleral graft beneath the conjunctiva Ophthalmology 2012;119:2631–2636
  22. 22. 9 months later showing evidence of absorption and thinning of the graft with uveal pigment at the edge Ophthalmology 2012;119:2631–2636
  23. 23. Need to be careful about!  Need to keep a close watch on epithelialisation and vascularisation  Risk of graft necrosis, graft dehiscence and endophthalmitis  Scleral graft should be well covered with vascular conjunctival layer
  24. 24. To Conclude  Preparation in the eye bank and storage are less stringent compared to cornea preservation  Scleral grafts are well accepted and have multiple indications  Need to pay attention to the epithelialisation and vascularisation
  25. 25. THANK YOU THANK YOU

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