At the end of the class, students shall be able to
? Understand the importance and need of eye banking
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? Have basic knowledge of structure and functions ofeye banks
? Understand the various surgical procedures for
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corneal transplantationHistory
? 1903: E. Zirm(Czechoslovakia) performed 1st
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successful human corneal transplantation.? 1935: V P Filatov (Russia): Father of
keratoplasty and modern eye banking.
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? 1944: Dr. R. Townley Paton established the first
eye bank in New York City.
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? 1945: The first eye bank in India was started inRegional Institute of Ophthalmology, Chennai.
? 1960 : 1st successful corneal transplantation in
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India by Dr. Dhanda (Indore).? 1974: McKarey and Kaufman developed M-
K medium which allowed the excised
corneo-scleral rim to be preserved for
up to 4 days at 4?C.
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? 1985: Kaufman et al. presented K-Sol as astorage method viable for up to 10 days.
? 1989: Eye Bank Association of India was formed.
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WhydowenedanEyeBank?Infectious keratititis
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Injuries
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? Open globe injuries? Chemical injuries
Can be devastating
Need early intervention
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What is an Eye Bank ?
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Eye Bank is a non profit organizationwhich deals with the collection, storage
and distribution of the donor cornea for
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the purpose of corneal grafting, research
and supply of eye tissues to other eye
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banks for ophthalmic purposes.Structure of Eye Bank
? Medical section : Medical Director ( A qualified
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Corneal Surgeon), Trained technicians
? Administrative Section: Eye Donation Counsellor /
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Social Worker / Health Educator / ClerkFunctions of the Administrative Section
The administrative section is responsible for
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- Public awareness programmes- Liaison with government, local voluntary and
other health care agencies
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- Fund raising
Functions of the Medical Section
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Medical section deals with the entire technicaloperation of the eye bank:
-Tissue harvesting, evaluation, preservation and
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distribution
(maintaining medical quality of highest standard).
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Functions of the Eye Bank
Networking of eye banks under the umbrella of a national
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organisation ( e.g. Eye Bank Association of India) allows-Public education programmes
- Institution of newer eye banking procedures
- Training programmes and
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development of uniform medical standardsEye Banking System
Eye Banking System
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Eye Donation Center (EDC)? affiliated to a registered eye bank
(1) public and professional awareness about eye donation
(2) co-ordinate with donor families and hospitals to motivate eye
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donation(3) to harvest corneal tissue and collect blood for serology
(4) to ensure safe transportation of tissue to the parent eye bank.
Eye Bank (EB)
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? Provide a round-the-clock public response system over the telephoneand conduct public awareness programs on eye donation.
? Co-ordinate with donor families and hospitals to motivate eye
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donation/Hospital Cornea Retrieval Programs ? (HCRP)
? To harvest corneal tissue
? To process, preserve and evaluate the col ected tissue
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? To distribute tissue in an equitable manner for Keratoplasty? To ensure safe transportation of tissue
Eye Bank Training Centre (EBTC)
? Al of the eye bank functions plus training for al levels of personnel in
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eye banking and research.Equipments
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EQUIPMENTSEBTC
EB
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EDC
Slit lamp
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RequiredRequired
Not required
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Refrigerators
Required
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RequiredPreferable
Serology
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Required
Required
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Not requiredSpecular
Required
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Required if
Not required
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microscopecol ection is
200/yr
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Instruments for
Required
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RequiredRequired
corneal excision
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Autoclave
Required
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RequiredShould have
access
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Laminar flow
Required
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RequiredRequired
hood
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How It Works ?
Recovery or
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retrievalCornea
Processing
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Distribution
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Deceased family cal s Eye Bank
Grief counselor motivates
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and obtains consentRetrieval/ Recovery of
tissue
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Tissue Retrieval? Contraindications:
Systemic:
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Ocular:
? AIDS
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? Intrinsic eye diseases? Rabies
? Retinoblastoma
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? Active viral hepatitis
? Active
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? Creutzfeldt-Jakob diseaseconjuctivitis,iritis,uveitis,
? SSPE
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vitritis,retinitis
? Reye's syndrome
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? Congenital abnormalities? Death from unknown causes
(keratoconus)
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? Congenital Rubel a
? Central
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? Active septicemiaopacities,pterygium
? Leukemia (blast form)
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? Prior refractive
? Lymphoma/lymphosarcoma
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procedures (radialkeratotomy)
Preliminary preparations
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? Obtain legal permission.
? Go through the donor's medical records for any
contraindications.
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? Wash hands and be prepared with aseptic dressing.
? Identify the donor.
? Collection of postmortem blood:10ml
? Femoral vein
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? Subclavian vein? Heart
? Jugular vein
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EnucleationCorneo-scleral button excision
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Serological testing? HIV
? HBV
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? HCV
? Syphilis
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Evaluation of donor tissue? Gross examination
? Whole globe: eyes with excessive stromal
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hydration should be discarded unless specularmicroscopy can be done for endothelial cell
count.
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? Corneoscleral button:
Colour of the tissue storage media is to be
noted to rule out contamination.
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Evaluation of donor tissue
? Slit Lamp Biomicroscopic examination
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Endothelial cell countAGE
Average
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Endothelial cell
count
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10-192,900-3,500
20-29
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2,600-3,400
Critical cell density:
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30-392,400-3,200
300-500 cells/mm2
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40-49
2,300-3,100
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Functional cell density:50-59
2,100-2,900
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1500-2200 cells/mm2
60-69
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2,000-2,80070-79
1,800-2,600
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80-89
1,500-2,300
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* Philips C, Laing R, Yee R. Specular Microscopy. In: Krachmer JH, Mannis MJ, Hol and EJ (eds). Cornea,2nd ed. Philadelphia: Elsevier Mosby, 2005:261-77.
Exclusion Criteria for penetrating keratoplasty*
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? Cell density less than 2000 cells per square millimeter.(Corneas with cell density less than 2000 cells / sq. mm
may be suitable for lamellar procedures).
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? Extreme polymegathism or pleomorphism.
? Presence of significant guttata.
? Presence of many non-hexagonal or abnormally shaped
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cells.? Presence of inflammatory cells, bacteria, or debris on
endothelial surface.
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? Numerous vacuolated cells.
*Standards of Eye banking in India 2009;NPCB;Director General of Health & Family Welfare, Govt. of India
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Storage of donor tissueStorage
Short term
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Intermediate
Long term
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2-3daysVery long term
7-10days
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30days
Moist chamber
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Organ culture1year
(24hrs)
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K-sol,
medium,
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CryopreservationM-K medium
Dexsol,Optisol,
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MEM
Optisol GS
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Preservation of cornea
? Moist chamber storage
? Storage of whole globe
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? 4C? 24 hours
? Advantage: Simple
? Disadvantage:
Corneal stromal edema.
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Preservation of cornea
? Tissue Media
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Cornea storage Storage time
o Dextran
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Media(days)
o Chondroitin sulphate
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MK
4
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o Electrolyteso pH buffer system
K-SOL
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7
o Antibiotics
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CSM7
o Essential amino acids
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o Antioxidants,ATP precursors
DEXSOL
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10o Insulin
OPTISOL
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14
o Epidermal growth factor
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PROCELL14
o Antiprotease,anticoagulants
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M-K medium:? Described by Mc-Carey & Kauffman.
? Mixture of tissue culture medium (TC-199) and Dextran
(5%,40,000 MW)
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? Buffer: HEPES (N hydroxyethyl- piperazine-N-ethane
Sulphonic acid)
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? Antibiotics:Penicillin,Gentamicin,Polymyxin? Storage period- 96hrs.
K-Sol:
? Purified chondroitin sulphate in tissue culture medium
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(TC 199).? Storage:7-10days in 40 C.
Preservation of cornea
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? Long term Organ Culture storage system
? MEM media(minimum essential media)
? Developed by Harry Eagle.
? 34 degree C
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? Incubated at room temperature in nutrient medium? Storage period : 30 days
? Advantage: Enables HLA matching
? Very long time preservation:
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? Cryopreservation? 1year
CORNEAL TRANSPLANTATION
Cornea as transplant
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? Immune privilege of cornea
? Absence of blood and lymphatic channel in the graft and
its bed
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? Absence of MHC class I APCs in the graft
? Reduced expression of MHC coded alloantigen on graft
cells
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? Immunosupressive microenvironment of aqueous humor.
? Anterior chamber associated immune deviation.
Corneal Transplantation
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? Corneal transplantation refers to surgical replacement of afull-thickness or lamellar portion of the host cornea with
that of a donor eye.
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? Allograft/autograft? Full-thickness( Penetrating)/ Partial thickness ( lamellar)
Corneal Transplantation :Schematic
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Types of Keratoplasty? Optical ? to improve vision
? Tectonic- to restore or preserve corneal integrity
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? Therapeutic- to remove infected corneal tissue
? Cosmetic- to improve appearance
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Keratoplasty : Schematic DiagramIndications of Penetrating Keratoplasty(
PK)
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? Keratoconus? Post- cataract surgery edema
? Corneal dystrophies and degenerations
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? Mechanical or chemical trauma
? Microbial/postmicrobial keratitis
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? Congenital opacityLamellar keratoplasty
? Lamellar keratoplasty refers to replacement of only a portion
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of the corneal layers of the host cornea with the graft.
? Indications:
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-Opacification of superficial corneal stroma-Marginal thinning or infiltration
-Localised thinning / descemetocele formation
Types of Lamellar Keratoplasty
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? Superficial/ Deep anterior lamellar keratoplasty
( SALK/DALK)
? Descemet stripping automated endothelial
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keratoplasty (DSAEK)? Descemet membrane endothelial keratoplasty
(DMEK)
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LEGAL ASPECTS IN INDIA
? Under the Transplantation of Human Organs Act, 1994
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(THOA)1. The qualification of doctors permitted to perform
enucleation (surgical eye removal) has been reduced
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from MS (Ophth.) to MBBS.
2. Eye donation in India is always decided by the
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donor's surviving relatives and not by the actualdonor.
3. Enucleating doctors always have to legally obtain a
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written consent from the relatives of the deceased
before they actually remove the eyes.
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