This document discusses eye donation and corneal transplantation. It begins by noting that corneal blindness affects over 1.5 million Indians and is increasing by 30,000 people per year. However, only about 15,000 corneas are collected annually, leaving a major shortage. The document then discusses what eye donation entails, who can donate, common myths, and the legal aspects. It also provides details on the enucleation procedure, storage and transportation of donated corneas, and different types of corneal transplantation surgeries like penetrating keratoplasty and lamellar keratoplasty.

1. GOOD AFTERNOON

7. WHAT DO ALL THESE PEOPLE HAVE
IN COMMON?
Lets find out…

8. EYE DONATION AND
KERATOPLASTY
PRESENTER: DR. KHALIL
MODERATOR: DR. CHARUDATT (M.S.)

9. • The EYE is wonderful creation
of nature and masterpiece of
perfection.
• And sight is one of
the most precious possessions.
• To lose vision – total or partial –
is a tragedy.
WONDERFUL EYE

10. CORNEAL BLINDNESS
• About 1.5 Million Indians suffer from
Corneal Blindness
• Increasing at the rate of 30000 every year.
• Corneal blindness mainly affects children
and young adults who have long life ahead
of them.

11. IS THERE ENOUGH?
• On an average around 1
lakh corneas are
needed in India every
year.
ONLY about 15000
usable corneas are
collected every year.

12. We burn or we bury…
We Burn Or Bury
75 Lakh Pairs
Of Eyes……
1.5 Million EYES…
Leaving The 1.5
Million Corneal
Blind Persons To Live
In Darkeness

13. WAITING FOR THE GIFT
Because of this huge
shortfall of donor
eyes in India there
is a long list of
waiting patients.

14. EYE DONATION FORTNIGHT
Aug 25th – Sept 8th

15. CAUSES OF CORNEAL BLINDNESS
• Injuries
• Malnutrition
• Infections
• Chemical Burns
• Congenital Disorders
• Post operative complications

16. WHAT IS EYE DONATION?
• Only the cornea is used for transplant.
• Eyes should be donated within 6-8 hrs. of death.
• Total removal time is about 15-20 minutes.
• More than two Corneally blind persons can get
sight due to a single person's eye donation

17. • Nobody is charged for making eye donation.
• The only cost to encounter is one local telephone call.
• It is replaced by artificial eyes to prevent
disfigurement
• The cornea is free of cost to the recipients
• The identity of both donor and recipient is kept secret
• It does not delay the funeral

18. LEGAL ASPECTS OF ORGAN
DONATION
Under the Transplantation of Human Organs Act, 1994
(THOA)
• The qualification of doctors permitted to perform
enucleation (surgical eye removal) has been
reduced from MS (Ophth.) to MBBS
• Eye donation in India is always decided by the
donor’s surviving relatives and not by the actual
donor,
• Enucleating doctors always have to legally obtain
a written consent from the relatives of the
deceased before they actually remove the eyes.

19. • Any Gender can donate eyes
• All religions endorse the practice of eye donation
• Willing donation of one’s own eye during life
• Eyes from medico legal post mortem cases
• Eyes from unclaimed bodies
• A good donor cornea
• Healthy cornea
• Removal of cornea soon after death (within 6 hrs)
WHO CAN DONATE EYES?

20. HOW TO DONATE EYES?
• Donation can happen in either of these ways:
1. S/He can walk Eye Bank and PLEDGE their eyes
for donation pledge form signed by a witness
given back to the eye bank.
• In the time of that person’s death, his/her
relative/friend, who was a witness should call
the nearest eye bank.

21. • Donors relatives and friends should be well
informed and be well aware to call the nearest eye
bank, for donating the eyes after their death.
2. 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.

22. Age/Sex - NO BAR for Eye Donation

23. MYTHS ABOUT EYE DONATION
• Face/ Body will be disfigured.
• Will be born blind in next birth.
• Will not be able to see GOD.

24. WHAT IS
NEEDED?

25. 1. GENERAL SUPPLIES
a. Donor information sheet, consent forms, etc
b. Torch for gross examination of eyes
c. Insulated container with water ice and special foam to
transport the tissue
d. Supplies for blood collection
e. Non sterile gloves
f. Broad spectrum antibiotic solution
g. Eye protection (safety goggles), shoe covers
h. Disinfectant solution
i. Eye caps/prosthesis
j. Biohazard disposable bag
k. Gauze and cotton pads

26. 2. AUTOCLAVED AND STERILE
MATERIALS
• A double holed drape
• Surgical gown (preferably moisture impermeable) cap,
mask, etc.
• Sterile balanced salt solution or 0.9 percent sterile
saline to irrigate the eyes
• Two sterile hemostats .
• Sterile gloves
• 8–10 pieces of gauze.
• Two eye jars with eye cages and a piece of 2" × 2"
gauze. Eye jars should be labeled left and right.

27. 3. EQUIPMENT FOR ENUCLEATION
The following equipment is required for enucleation
• Eye speculum;
• Muscle hook;
• Haemostat
• Enucleation spoon
• Sharp dissecting scissors;
• Forceps
• Large curved scissors (non-pointed);
• Metal bowl
• Cotton tip
• Blood samples are taken from the donor that is serologically tested for
human immunodeficiency virus 1 and 2, Hepatitis B surface antigen and
Hepatitis C virus.

28. ENUCLEATION PROCEDURE

29. AFTER DONATION
• The donor’s family receive a certificate of
appreciation from the Eye Bank.
• Eyes are evaluated at the Eye Bank and only the
ones deemed suitable are used for transplant.
Others are used for research and education.
• Recipients are notified on a first come first serve
basis from the registry.

30. GRADING OF GRAFT CLARITY
(R.P. CENTRE GRADING SYSTEM)
4+ : Graft absolutely clear; all details of AC and
iris visible
3+ : Graft clear but some details of iris and AC
obscured.
2+ : Graft hazy;iris and AC visible but no
details discernible.
1+ : Graft very hazy; iris and AC just visible.
0 : Graft opaque

31. CONTRAINDICATIONS FOR USE OF
DONOR TISSUE
Systemic Causes :
• Death of unknown cause
• Death from CNS disease of unestablished diagnosis
• Creutzfeldt-jacob disease or risk factor
• Subacute sclerosing panencephalitis
• Progressive multifocal leukoencephalopathy ,hepatitis-c seropositive
donors
• HTLV-1 or HTLV II infection
• HIV
• Active leukemia
• Septicemia
• Active disseminated lymphomas

32. OCULAR CAUSES
• Intrinsic eye disease
• Retinoblastoma
• Malignant tumors of the anterior segment
• Active ocular or intra ocular inflammation
• Prior intra ocular surgery or anterior segment
surgery
• Refractive corneal procedures
• Laser photo ablation surgery

33. STORAGE OF DONOR GRAFT
TISSUE
Many methods of corneal preservation have
been proposed.
• Short term storage (24 to 96 hours)
• Intermediate term storage (up to 2 weeks)
• Long term preservation (up to 4 weeks)
• Very long term preservation (>4 weeks).

34. SHORT TERM STORAGE-
Moist chamber storage
• Enucleated eye in a sealed chamber together with
gauze, usually moistened by glycerine placed at
40c.
• Storage time 24 hours

35. INTERMEDIATE-TERM STORAGE-
• In the intermediate-term corneal storage, as in
the M-K medium storage, excised corneoscleral
buttons are kept in biochemically defined
tissue culture medium
• They are incubated at 4°C e.g. Chondroitin
sulfate storage medium (CSM), dexsol, optisol
and likorol, storage time 7 to 14 days.

36. LONG-TERM CORNEAL STORAGE
The organ culture method of cornea.
Human cornea stored at 34°C for at least five
weeks.

37. VERY LONG-TERM CORNEAL STORAGE
• Cryopreservation of the Cornea
• Stored at –160C
• preservation of donor cornea for periods up to
one year

38. OPTIMAL PERIOD TO MAINTAIN CORENAL
ENDOTHELIAL VIABILITY
MEDIUM OPTIMAL TIME
• Moist chamber 24 hrs.
• MK 72 hrs.
• CPTES Solution 72 hrs.
• EP II 96 hrs.
• RPC (Modified M-K) 96 hrs.
• Dexol 1 wk
• Likorol 1 wk
• Optisol 1 wk
• Organ culture 4-5 wks.
• Cryopreservation 1 year on more

40. WHAT IS AN EYE BANK?

41. EYE BANK
IT IS A NON PROFIT COMMUNITY
ORGANIZATION WHICH DEALS
WITH THE COLLECTION , STORAGE ,
& DISTRIBUTION OF CORNEA FOR
THE PURPOSE OF CORNEAL
GRAFTING , RESEARCH & SUPPLY OF
THE OTHER EYE TISSUES FOR THE
OTHER PURPOSES.

42. Functions of an Eye Bank :
• Promotion
• Registration
• Tissue Retrieval
• Tissue Processing
• Tissue Evaluation
• Serological Testing
• Tissue Distribution

43. KERATOPLASTY
• Abnormal corneal host tissue is replaced by healthy donor
cornea.
• Corneal transplantation remains
the main method for visual
rehabilitation once disease has
affected corneal clarity.
• Corneal transplantation remains to this day one of the
most successful and most often performed human
transplants (after blood transfusions and bone grafts).

44. Replacement of diseased cornea
with donated healthy cornea.

45. HISTORY
• The first successful human corneal transplant was a
lamellar keratoplasty performed by von Hippel in 1888
using rabbit donor tissue.
• Eduard Zirm who did the first successful full thickness
penetrating keratoplasty in 1905.
• Spanish-born eye surgeon Ramon
Castroviejo successfully performed keratoplasty as early
as 1936.
• 1950, Jose Barraquer and colleagues in Colombia
applied new techniques of lamellar keratoplasty by
dissecting the corneal stroma down to two-thirds of its
thickness in both the donor and the recipient tissue.

46. INDICATIONS
OPTICAL
• Psuedophakic bullous keratopathy
• Keratoconus
• Corneal dystrophies and degenerations
• Corneal scarring
TECTONIC
• Stromal thinning
• Descemetocele
• Perforated cornea
THERAPEUTIC
• Inflammations not responding to medical therapy.
COSMETIC

47. TECHNIQUE
• PREOPRATIVE EVALUATION
• PREPARATION OF RECIPIENT
• DONOR PREPARATION
• HOST TREPHINATION
• SUTURING

48. PREOPERATIVE EVALUATION
• Comprehensive ophthalmic evaluation- B- scan, and OCT or
ultrasound biomicroscopy to asses visual potential.
• Ocular surface abnormalities must be recognized and treated
prior to penetrating keratoplasty. These include rosacea, dry
eyes, blepharitis, trichiasis, exposure keratopathy, ectropion,
and entropion.
• Intraocular pressure (IOP) must be controlled prior to
surgery.

49. • Ocular inflammation – must be recognized and treated,
• Prior corneal diseases and vascularization – History of
herpetic keratitis significantly reduces the chance of
graft success.
• Corneal thinning and melting, such as that associated
with rheumatoid arthritis, may significantly affect the
surgical outcome of penetrating keratoplasty and thus
must be treated adequately prior to the surgery.

50. PREPARATION OF RECIPIENT
• Scleral support rings applied to
fix the globe
• The recipient cornea measured
with a caliper.
• Radial marks to guide suture
placement may be made using
a gentian-violet stained 8-blade
radial marker
• Trephination

51. DONOR PREPARATION
• Rinsing the globe in a dilute povidine-iodine
solution (10% solution diluted 1:10 with balanced
saline solution) for 1-2 minutes.
• Followed by a thorough rinse with a balanced
saline solution.

52. CORNEO-SCLERAL BUTTON REMOVAL

53. DONOR TISSUE EVALUATION
• Gross in situ evaluation
• Slit lamp evaluation
• Specular microscopy

54. Gross examination
• The corneal-scleral segment shall be initially
examined grossly for clarity, epithelial defects,
foreign objects and contamination and scleral
color. e.g., jaundice.
• Enucleated globes shall be examined in the
laboratory prior to distribution and/or corneal
excision.

55. Slit-lamp examination
• Examined for epithelia and stromal pathology and
in particular endothelial disease.
• After corneal excision, the corneal-scleral rim
shall be evaluated by slit lamp biomicroscopy,
even if the donor eye has been examined with the
slit lamp prior to excision of the cornealscleral
rim, to ensure that damage to the corneal
endothelium or surgical detachment of
Descemet’s membrane did not occur.

56. SPECULAR MICROSCOPY
 For transplantation cell count should be at least
1500 cells/sq mm.

57. SEROLOGY
• The 5cc of blood collected from the donor is
tested for
• Human Immuno Deficiency virus (AIDS)
• Hepatits B and C
Syphilis etc .

58. SUTURING
• The graft is secured onto the
recipient bed by four or height
interrupted 10-0 nylon cardinal
sutures equally spaced apart.
• The first cardinal suture is
placed at the 12 o’clock
position, The second and most
important cardinal suture is
placed 180° opposite
inferiorly.
• Remaining sutures are
applied.

59. TYPES OF CORNEAL TRANSPLANTS
• Penetrating keratoplasty (PK)
• Lamellar keratoplasty (LK) –
• Anterior lamellar keratoplasty (ALK)
• Deep anterior lamellar keratoplasty
(DALK)
• Posterior lamellar keratoplasty (PLK)/
Endothelial keratoplasty (EK)
• Descemet’s stripping endothelial
keratoplasty (DSEK)
• Descemet membrane endothelial
keratoplasty (DMEK)

60. PENETRATING KERATOPLASTY
(PK)
 Indications
1 Combined endothelial and stromal disease (Fuchs’ dystrophy
with corneal ectasia or macular stromal dystrophy).
2 Severe corneal opacification and inability to ascertain the
status of the endothelium .
3 Keratoconus after hydrops with tears in Descemet’s
membrane; successful deep anterior lamellar keratoplasty is
unlikely.
4 Other causes of corneal opacification and lack of familiarity
with selective keratoplasty techniques.

61. Contraindications
1 Epithelial dysfunction secondary to limbal stem cell deficiency
(aniridia, chemical injuries), severe neurotrophic, and dry eye
states.
2 Stromal vascularization, especially when involving more than
two quadrants.
3 Multiple (two or more) graft failures.
Advantages
1 Can be used for any indication (stromal or endothelial).
2 Relatively easy surgery as compared to other techniques.
3 No lamellar – corneal interface problem thus good visual
results.

62. Disadvantages
1 Lengthy postoperative course.
2 Incidence of allograft rejection (10% to greater than 90%,
depending on the indication.
3 Suture complications: exposure, vascularization, and infection.
4 Weak graft–host junction: risk of traumatic wound dehiscence
and globe rupture.
5 Unpredictability of corneal toricity and degree of ametropia.

63. INTRAOPERATIVE COMPLICATIONS
• Scleral perforation with fixation sutures
• Improper trephination
• Damaged donor button
• Retained Descemet's membrane
• Iris–lens damage
• Anterior chamber haemorrhage

64. POSTOPERATIVE COMPLICATIONS
• Wound leak
• Flat anterior chamber with
increased intraocular pressure
• Endophthalmitis
• Persistent epithelial defect
• Primary graft failure
• Suture related.
• Graft rejection

65. LAMELLAR KERATOPLASTY
Partial thickness graft of donor tissue is used.
LAMELLAR KERATOPLASTY
PLK/EKALK
DALK DMEKDSEKSALK

66. ANTERIOR LAMELLAR KERATOPLASTY
Indications
• Indicated for corneal pathologies
affecting the anterior 85–95% of the
cornea, sparing Descemet's membrane
and endothelium
• Superficial corneal opacities,
Previous refractive surgical procedures,
Infections, trauma or degenerations and
dystrophies.

67. DEEP ANTERIOR LAMELLAR KERATOPLASTY
• Anterior layers of the central
cornea are removed and
replaced with donor tissue.
Endothelial cells and
Descemets membrane are left
in place.
USED IN
• Anterior corneal opacifications,
• Scars
• Ectatic diseases such as
keratoconus.

68. LAMELLAR DISSECTION TECHNIQUES
• Manual dissection
• Air bubble technique
• Microkeratome
• Femtosecond laser

69. CONTRAINDICATIONS OF ALK
• Absolute:
• Endothelial dysfunction
• Posterior dystrophies (Fuchs’, posterior
polymorphous)
• Pseudophakic and aphakic bullous keratopathy
• Nonguttate endothelial dystrophy
• Iridocorneal endothelial syndrome

70. Relative:
• Epithelial dysfunction , Limbal stem cell
deficiency states (aniridia, chemical injuries,
etc.)
• Chronic surface disease (keratoconjunctivitis
sicca, neurotrophic keratitis, and others)

71. ADVANTAGES
1 Preservation of host endothelium
2 Eliminates endothelial graft failure decreases the incidence of
allograft rejection
3 Allows for the incorporation of more diseased stromal tissue
includes entire ectatic area (ideal in keratoconus) Minimize
suture/wound-induce astigmatism
4 Avoids posterior pressure and is associated with a lower
incidence of suprachoroidal haemorrhage.

72. DISADVANTAGES
1 Surgical difficulty
2 Optical effect of interface, which decreases
the more posterior the location of the
lamellar dissection

73. POSTERIOR LAMELLAR KERATOPLASTY
Indications
• Posterior corneal dystrophies (Fuchs’, nonguttate
endothelial dystrophy, posterior polymorphous)
• Aphakic and pseudophakic corneal edema and
bullous keratopathy
• Iridocorneal endothelial syndrome (ICE)
• Other causes of endothelial dysfunction (trauma,
foreign body, age, etc.)

74. Contraindications
• Corneal ectasias.
• Stromal dystrophies
• Stromal scarring or opacification (infection,
interstitial keratitis, lipid keratopathy, etc.)
• Anterior corneal dystrophies and degenerations
(Reis- Bücklers, Salzmann's, Meesmann's, etc.)

75. Advantages
• Rapid visual rehabilitation
• No suture-related complications
• Decreased incidence of allograft rejection
• Intact globe, resistant to traumatic wound
dehiscence
• Predictable corneal toricity, minimal
topographic change
• Predictable, small hyperopic refractive shift .

76. Disadvantages
• Steep learning curve for surgeons, and the placement of the donor tissue can be
difficult.
• Handling the tissue gently is imperative because excessive manipulation can
result in loss of endothelial cells, leading ultimately to loss of graft clarity, which
is the principal cause of failed DSAEK
• Positioning of the air bubble
• Postoperative hyperopic shift in their refractive error.
• Endothelial rejection can occur and should be treated promptly with high dose
steroids.

77. DESCEMET'S STRIPPING AUTOMATED
ENDOTHELIAL KERATOPLASTY (DSAEK)
Surgical steps
 Stripping the diseased endothelial surface and
removing it, which is performed through a corneal
limbal incision or scleral tunnel.
 A posterior donor button includes endothelium,
Descemet's membrane, and stroma, with a resulting
thickness of 100 microns.
 The donor tissue is folded to enter the wound and is
then positioned to match up with the recipient's
eye.
 An air bubble is then positioned to temporarily
secure the interface attachment. The pumping
action of the endothelial cells helps the donor tissue
permanently stick into place and position.

78. DESCEMET MEMBRANE ENDOTHELIAL
KERATOPLASTY (DMEK)
• This endothelial keratoplasty is similar to
DSAEK except that with DMEK the donor
tissue is comprised of Descemet's/endothelial
complex and does not have any attached
central stromal tissue.
• The result of a thinner donor profile is that it
improves the patient's visual potential and
decreases the trend towards hyperopia as
compared to DSAEK.

79. AFTERCARE
• Often performed on an outpatient basis,
although some patients need brief
hospitalization after surgery.
• Patient will wear an eye patch at least
overnight. An eye shield or glasses must be
worn to protect the eye until the surgical
wound has healed.
• Eye drops will be prescribed for the patient to use for several weeks/years
after surgery.
• Drops - antibiotics to prevent infection, corticosteroids to reduce
inflammation and prevent graft rejection.

80. CARRY HOME MESSAGE

81. Why destroy a gift ? Donate
ARE YOU READY TO
BECOME A SIGHT
AMBASSADOR….
TO SUPPORT THE EYE
DONATION
MOVEMENT?

82. "There is no lovelier way to
thank God for your sight than
by giving a helping hand to
those in the dark."
- Helen Keller

83. THANK YOU