AN OVERVIEW OF EYE BANKING DEFINITION, LEVELS OF EYE BANKS, HARVESTING, EVALUATION AND COVID 19 ASPECTS OF EYE BANKING

1. EYE BANKING & COVID 19
DR.GAGANDEEP SINGH

2. OVERVIEW
 INTRODUCTION
 FUNCTIONS
 INDICATIONS
 CONTRAINDICATIONS
 STEPS OF DONATION – PROTOCOL
 RATING OF CORNEA
 STORAGE
 DISTRIBUTION
 CORNEAL TRANSPLANTATION
 LEGAL

3. WHAT IS AN EYE BANK ??

4. Eye bank is a non-profit community based
organisation which deals with the collection , storage
and distribution of cornea for the purpose of corneal
grafting ,research and supply of the eye tissues for
several purposes.
It is managed by a board of directors with the
objective of increasing the quality and quantity of eye
tissue.

5. FUNCTIONS OF EYE BANK
EYE BANK
TISSUE
HARVESTING
TISSUE
PRESERVATION
TISSUE
DISTRIBUTION
RESEARCH
PUBLIC
AWARENESS
TISSUE
EVALUATION

6. Magnitude of the problem
 Approximately 11 Lakh blind population of our country are waiting
for corneal transplantation and approximately 25,000 new cases are
being reported.
 Mostly children and young adults.
 As against an annual requirement of 75,000 to 1,00,000 corneas, only
22,000 corneas are donated in India at present.
 Vast gap between demand and supply

8. INDICATIONS
 OPTICAL – Pseudophakic Bullous Keratopathy(mc in India,
Fuch's keratopathy(mc in western world),keratoconus , corneal dystrophies
and degenerations
 TECTONIC – Descemetocele , perforated cornea
 THERAPEUTIC – Resistant to medications conditions
 COSMETIC – Rare

9. Eye banking in
India
 1945 –First eye bank established at
RIO,Madras.
 1960-First successful corneal transplant
performed by Dr.R.P .Dhanda and
Dr.Kalevar.
 1999-Eye Bank association of India (EBAI)
established.
Medical standards of Eye banking in India.

10.  Eyes should be donated within 6-8 hrs of death
 Anyone can be donor, irrespective of age, sex, blood group or religion.
 Eyes can be donated even if the deceased had not formally pledged their eyes during
their lifetime, if there is consent of the next of kin.
 Eye Bank team will rush over to the donor’s home or any other place where the body is
available after death. This is free service in public interest.
 Eye banks come under Human Organ Transplantation Act. Donated ayes cannot be brought
or sold as it is a crime under the act.
FACTS

11. THREE TIER ORGANIZATION
 It is an integrated system involving
three tier of organisational work
based on the infrastructure and
manpower at all the levels.
1. EYE DONATION CENTRES (EDC)
2. EYE BANKS (E B)
3. EYE BANK TRAINING CENTRES (EBTC)
5 EBTC
45 EB
2000 EDC

12. EYE BANK
TRAINING
CENTRE (EBTC)
 Tertiary centre of eye banking system
 It involves:
1. Tissue harvesting, processing and
distribution
2. Training and skill upgradation of eye
bank personnel
3. Creating Public Awareness
4. conducting research

13. EYE BANK (EB)
A strong network of 45 EB ;constitute the middle tier of
the eye banking integrated system.
 These are closely linked with the EDC (suggested ratio -
1:50)
 Provide a round the clock public response system over
telephone and conduct awareness program for eye
donation.
 Co-ordinate with donor families and hospitals to
motivate eye donation .
 Caters to a population of 20 MILLION each.

14. EYE DONATION
CENTRES (EDC)
 Affiliated to registered eye bank
 Give public and professional awareness
about eye donation'
 Co-ordinate with donor families and
hospitals to motivate eye donation.
 To harvest corneal tissue and blood for
serology
 To ensure safe transportation of tissue to
the parent eye bank.
 CATERS TO A POPULATION OF 50,000
TO 1,00,000

15. Cornea as transplant
Immune privileges of cornea
 Absence of blood and lymphatic channel in the graft and its bed .
 Absence of MHC class II APCs in the graft.
 Reduced expression of MHC coded alloantigen on graft cells
 Immunosuppressive environment of aqueous.

16. CONTRAINDICATIONS
Do not use for keratoplasty:
 Septicemia
 Extensive burns
 Death from an unknown cause
 Death with CNS disease of unestablished diagnosis
 Subacute sclerosing panencephalitis
 Progressive multifocal leucoencephalopathy.

17. Intrinsic eye diseases:
 Retinoblastoma
 Malignant tumors of anterior ocular segment.
 Active inflammation at the time of death.
 Congenital or acquired diseases of the eye that would preclude
a successful outcome.

18.  Endothelial density below 2000 cells per square millimeter
 Laser photoablation surgery
 Corneas from patients with anterior segment surgery can be used if
screened by specular microscopy and meet the Eye banks endothelial
standards.
 Laser surgical procedures such as argon laser trabeculoplasty, retinal and
panretinal photocoagulation donot necessarily preclude use
for penetrating keratoplasty but should be cleared by the medical
director.

19.  Viral infections are the greatest hazard.
Viruses with proven transmission –Rabies,CJ disease,Hepatitis B
Possible transmission-HIV,HSV,CMV,adenovirus,Ebstein-barr,rubella
Transmission unlikely-Varizella zoster virus.
All prion diseases are contraindications
Snake bite specific for neurotoxins.

20. Interval between death ,enucleation and
preservation.
 If ambient temperature is hot (e.g. summer weather), then eyes must be
preserved or refrigerated within six (6) hours of death
 If ambient temperature is not hot (e.g. winter weather), then eyes must be
preserved or cooled within eight (8) hours of death
 If ocular area including eyes, or the entire body, or enucleated eyes are
continuously cooled within the above constraints of 6 or 8 hours, respectively,
then tissue can be preserved no later than 24 hours from time of death

21. STEPS OF EYE
DONATION
 DONOR SELECTION
 TISSUE RETRIEVAL
 CORNEAL EXAMINATION
 TISSUE TRANSPORTATION
 STORAGE OF THE TISSUE
 DISTRIBUTION

22. 1.
A. DONOR SELECTION

23. STEPS

24. INFORMATION TO BE OBTAINED AT
TELEPHONE REFERRAL
 Date and time of referral
 Origin of referral (funeral home,hospital)
 Full name of person providing information
 Name and age of donor
 Name of hospital/facility where the donor expired
 Time and cause of death
 Phone number and location

26. EQUIPMENT & SUPPLIES FOR TISSUE
RETRIVAL
GENERAL SUPPLIES
 Donor info sheet
 Consent form
 Pen torch
 Moist chamber
 Supplies for blood collection
 Non sterile preparatory gloves
 Safety googles,shoe covers
 Broad spectrum antibiotic solution
 Disinfectant solution
 2 small closed containers – gauze pads
soaked in 70%alcohol,5% betadine
 Gauze and cotton pads
 Biohazard disposable bag
 Ocular prosthesis

27. AUTOCLAVED AND STERILE MATERIALS
 Sterile maintenance cover /barrier drape
 Moisture impermeable surgical gown, mask,cap
 Cotton tipped applicator/hemostat
 0.9% sterile saline
 Sterile gloves
 Two eye jars (labelled R. & L.)with eye stands & a piece
of 2*2gauze
 Cotton balls ,gauze

28. ENUCLEATION
 Solid blade eye speculum – 1
 Toothed forceps – 1
 Conjunctival scissors – 1
 Muscle hook – 1
 Hemostats – 2
 Enucleation spoon
 Enucleation / optic nerve scissors – 1
 Allis forceps – 1
 Surgical tray – 1
 Needle holder
 Sutures

29. CORNEO SCLERAL EXCISION
 Solid blade eye speculum – 1
 Toothed forceps – 2
 Conjunctival scissors – 1
 Trephine
 Iris forceps – 1
 Hemostat – 2
 Surgical tray – 1
 B.P. blade handle & surgical blade no. 11 &15

30. 2.MEDICAL HISTORY
Medical/travel/socail/infection/previous ocular history
Cause of death
Medical records
Medications
Laboratory reports
Visual head to toe inspection
Eye banks must have consistent policies on the examination and selection
criteria and documentation for the donors

31. ENUCLEATION -

32. Donor eye
examination before in
situ corneoscleral rim
excision-
 A) ADNEXA- Dacrocystitis, styes,
pustules, discharge(conjunctivitis)
 B) CORNEA- 1. EPITHELIUM-
odema, defects, exposure, trauma
and foreign bodies.
2. STROMA- arcus
senilis, corneal scars, infiltrates,
abnormal shape, size
3. ENDOTHELIUM-
keratic precipitates,central guttata.
 ANTERIOR CHAMBER-
Shallow/flat, hyphema, abnormal
anatomy.

33. IN SITU CRNEOSCLERAL BUTTON
EXCISION-

35. COMPARISON
BETWEEN GLOBE
ENUCLEATION AND IN
SITU CORNEOSCLERAL
DISC EXCISION ON
CORNEAL
CULTIVATION AND
CLINICAL OUTCOME
OF GRAFTS AFTER
TRANSPLANT-
 Study was conducted by Filip Filev et al.
Cornea . 2018 Aug
 It was a retrospective study performed on
Hamburg eye bank database using compaative
statistics in 2929 cases.
 RESULT- 1) Once the retrieval method was
changed from enucleation to in
situ CD, donation number increased
significantly.
2) Slightly lower endothlial cell density after
retrival in coreas obtained by in situ CD excision
compared with tose from enucleated eyes, whereas
endothelial loss during cultivation was similar.
CONCLUSION- In situ CD excision has similar
cultivation performance and clinical result
compared to enuleation.

36. EVALUATION OF DONOR TISSUE
 GROSS EXAMINATION-
 Whole Globe: eyes with excessive stromal
hydration should be discarded unless
specular microscopy can be done for
endothelial cell count
 Corneoscleral button: colour of the tissue
storage is noted. Yellowish colour-acidic
media- Contamination.

37. BIOMICROSCOPIC
EXAMINATION
 EPITHELIUM – location , extent & depth
dry area, haze, exposure, sloughing
 BOWMAN’S MEMB. – corneal lacerations
 STROMA – edema by making a hairline slit
 DESCEMET’S MEMB – folds
 ENDOTHELIUM – specular microscopy
 ARCUS SENILIS

38. SPECULAR MICROSCOPY
ENDOTHELIAL CELL COUNT
- Minimum count should be
1500 cells / sq. mm
- For penetrating keratoplasty
min. count should be 2000
cells / sq. mm
- DSEK –2200 cells/sq.mm
- DMEK –2400 cells/sq.mm

39. Cornea with specular endothelial patterns
unfit for transplantation
 Cell density less than 1500 cells/mm2
 Severe polymegathism or pleomorphism of endothelial cells
 Central cornea guttata
 Abnormally shaped cells
 Abnormal single cell defects
 Severe edema
 Presence of inflammatory cells

40. Donor serologic testing
 A blood sample from the donor must be tested - this sample may be either:
 1. a post-mortem sample drawn as soon as practicable after the time of death, or
at the time of tissue recovery, or
 2. a pre-mortem sample drawn within 7 days prior to death
 A hard copy of serological results shall be received and assessed by the Eye Bank
prior to release of tissue designated for surgical use.
 If the approved testing methodology is only approved for pre-mortem serology
samples and no post mortem testing kits are approved for use, these pre-mortem
test kits may be utilized for testing cadaveric samples.

41.  Minimum Testing: Blood (serum or plasma)
must test non-reactive to the following
required infectious diseases:
 1. Human Immunodeficiency Virus Types 1
and 2: anti -HIV-1 , anti-HIV-2
 2. Hepatitis C Virus (HCV): anti-HCV
 3. Hepatitis B Virus (HBV): HBsAg
 4. Syphilis
 All tissue intended for transplantation shall
be stored in quarantine until results of all
serology testing are complete.

42. GRADING

43. SNAIL TRACKS, STESS STRIAE
 Careless folding of the corneal
cap while removing causes
snail track lesions.
 Image shows the snail tracks
in varying degree of
magnification

44. STORAGE OF DONOR TISSUE
STORAGE
INTERMEDIATE 7-10
DAYS K-SOL, OPTISOL
LONG TERM 30 DAYS
ORGAN CULTURE MEDIUM ,
VERY LONG TERM 1 YEAR
CRYOPRESERVATION
SHORT TERM 2-3 DAYS
MOIST CHAMBER (24 HRS) , MK
MEDIA

45. MOIST
CHAMBER
• Storage of whole globe
• 4 c
• 24 hrs
• Simple to use
• Drawback- sometimes
stromal edema occurs

46. M.K. MEDIUM
 Base medium – Tc 199
 5% dextran
 Bicarbonate buffer
 Phenol red as indicator
 Stored at 4 c for 4 days

47. INTERMEDIATE STORAGE
 TISSUE MEDIA –
 Provides a chemically defined and stable environment
 Helps support and enhances metabolic activities
 Reduces the stromal swelling
 Keeps the tissue under sterile condition till use.
 Provides time for EB to screen the donor.

48. INGREDIENTS
-
 Dextran
 Chondroitin sulphate
 Electrolytes
 Ph buffer system
 Antibiotics
 Essential aminoacids
 Antioxidants
 ATP precursors
 Insulin
 EGF
 Antiproteases and
anticollagenases

49. DEXTRAN
• Keeps the Cornea
thin
• Conc. 1% of 40,000
mol. wt is used
CHONDROITIN
SULPHATE
• Similar to GAG in
cornea
• Low mol. Wt. keeps
endothelium viable
• Also acts as
antioxidant
ANTIBIOTICS
• Penicillin
• Polymyxin
• Gentamicin

52. CORNISOL
• CORNISOL is an intermediate type of
medium
• 20 ml buffered corneal preservation
medium chondroitin sulfate (Membrane
stabilizer), recombinant human insulin
(Metabolism enhancer), Dextran (Osmotic
agent),
• stabilized L-glutamine,
• ATP precursors,
• vitamins, trace elements,
• gentamicin, streptomycin
• pH indicator.

53. ORGAN CULTURE METHOD
 Upto 35 days
 Earl’s salts
 L- glutamine
 Decomplemented calf serum
 1.5% chondroitin sulphate

54. CRYOPRESERVATION
 Corneal rim is passed through a
series of solutions containing
increasing concentrations of
dimethyl sulphoxide (DMSO) upto
7.5%
 Tissue is frozen at controlled rate
upto -80 c.
 Stored indefinitely at -160 c

55. DISTRIBUTION OF CORNEA
 Distributed only to those hospitals
and ophthalmologist registered
under HOTA
 Maintaining the waiting list
 Distribution Record

56. HOSPITAL CORNEA RETRIEVAL PROGRAM
 It is a revolutionary program Initiated in 1990 to concentrate on deaths
that occur in hospitals and encourage eye donation in their families and
relatives.
 Grief counsellor should motivate the family to donate
 ADVANTAGES-
• Availability of all the records at hospital
• Reduction in time interval between death and corneal excision
• Increased availability of stronger and younger corneal tissues resulting in
more optical and successful grafts.

58. LEGAL ASPECT OF EYE DONATION
 UNDER THE Transplantation of Human Organs Act , 1994
 A special provision was included in the Amendment Bill of the THOT,2008
• The qualification of the doctor permitted to perform enucleation was
reduced from M.S. (ophthalmology) to M.B.B.S
• Eye donation in INDIA is always decided by the donor’s surviving relatives and not
the actual donor.
• Enucleating doctors always have to legally obtain a written consent from the
relatives of the deceased before they remove the eyes.
• Donor and recipient of the corneal tissue should be unknown to each other.

59. EYE BANKING AND COVID-19
Advisory for resuming the Eye Banking Activities
 The Eye Banking activities to be resumed through hospital cornea retrieval
program (HCRP) and to be from a hospital which is declared as non-COVID
 No eye banking activities to be started in the containment areas of Red zones.
 Containment zones shall be demarcated within Red (Hotspots) and Orange Zones by
State/UTs and District Administration based on the guidelines of MoHFW

60. • The Recovery Technician/ doctor to use PPE ( including N95 mask, cap,
face shield/visor, gloves, gown) while recovering the donor tissue.
• Eye Bank Association of India recommends that the collection of a nasal
swab of the deceased donor for RT-PCR COVID19 testing can be done
and sent to the laboratory
immediately.
• All collected tissues should be quarantined for 48 hours prior to the
release of the tissue for usage for transplantation. Avoid immediate
usage.

61. EXCLUSION CRITERIA (EBAI)
 Tested positive for or diagnosed with COVID -19.
 Acute respiratory illness or fever 100.4°F (38°C) or at least one severe or common
symptom known to be associated with COVID -19
 Individuals who have been exposed to a confirmed or suspected COVID-19 patient
within the last 14 days, who have returned from nations with more than 10 infected
patients and those whose cause of death was unexplained respiratory failure should
not be accepted as deceased donors.
 Evidence of conjunctivitis
 ARDS, Pneumonia or pulmonary computed tomography (CT) scanning showing
“ground-glass opacities”

62. Close contact is defined as
A) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of
time; close contact can occur while caring for, living with, visiting, or sharing a health care
waiting for area or room with a COVID-19 case;
B) having direct contact with infectious secretions of a COVID-19 case

63.  Document the risk assessment of the deceased by taking a relevant history from attender
or family members
 only corneal scleral rim excision be performed and avoid the whole eyeball enucleation.
 Use Intermediate preservative media
 Donor corneas in intermediate preservation media if not utilised should be shifted
to glycerol on the last day of preservation
 Entire disposable PPE kit to be removed immediately after tissue retrieval, properly
packaged to avoid cross infection and disposed off after reaching the hospital.
 Non-disposable parts of the PPE like goggles/visor to be cleaned with spirit or
sodium hypochlorite immediately after returning to the hospital

64.  Clean all external surfaces of MK Medium/Cornisol bottles, Flask, ice Gel packs,
Instrument tray, SS Bin with Surgical spirit, alcohol wipes or freshly prepared
sodium hypochlorite after recovery and repeat it at Eye Bank.
CLEANING THE EYE BANK -
● The floor of the eye bank and laboratory areas MUST be cleaned with 1% Sodium
Hypochlorite every 2 hourly
● Deep Cleaning to be done anytime there is any contamination
● Door handles, side rails on stairs, high touch surface like- reception counter with
1 % Sodium Hypochlorite ( 4 Times /Day)

66. THANK YOU…..