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Netra Dhanam, Eye donation, eye bank, Organ donation
- 1. ॐ नमो भगवतेवासुदेवाय धन्वन्तरये अमृतकलश हस्ताय सवाामय ववनाशनाय त्रैलोक्यनाथाय श्री महाववष्णववे नम || SRI VENKATESHWARA AYURVEDIC COLLEGE MHHNR
- 2. “ ” EYE BANK, EYEDONATION & CORNEAL TRANSPLANTATION DEPARTMENT OF SHALAKHYA TANTRA PRESENTED BY: M Hari Hara Nath Reddy FINAL YEAR, BAMS SRI VENKATESHWARA AYURVEDIC COLLEGE
- 3. CONTENTS INTRODUCTION EYEBANK EYE DONATION CORNEAL TRANSPLANTATION
- 4. INTRODUCTION सवास्य गात्रस्य वशरप्रधानं ; सवेन्द्रियाणां नयनं प्रधानम् | Head is the most important part of the body and Eyes are most important among the five sense organs.
- 5. What is an EyeBank ?? Eye bank is a non profit organization that obtains, medically evaluates and distributes donated eyes for use in corneal transplantation, research and education.
- 6. THREE TIER ORGANIZATION Eye Banking is a system of Collection (harvesting) of Corneas/Eyeballs from Cadaveric or Brain Dead persons, their storage, processing and distribution to Corneal Graft Surgeons in a timely and efficiently coordinated manner. For an efficient eye banking system, a three tier organization structure has been recommended. At the top are Eye Bank Training Centers, preferably situated in every Regional Institute of Ophthalmology, followed by Eye banks in major medical colleges and/or tertiary Eye Care Centers. These eye banks and eye bank training centers should be networked with Eye donation/retrieval centers. All large hospitals in metros with mortality rate of more than 50 per month (1-2 per day) should be set up as donation/ retrieval centers and linked to the nearest eye bank.
- 7. Eye bank training centers EyeBanks Eye Retrieval Centers (ERC) TENTATIVE MODEL 5 45 2000
- 8. Eye Retrieval Center(ERC) Eye Retrieval Center has to be affiliated to a registered eye bank, and should provide the following services: Public and professional awareness about eye donation Co-ordination with donor families and hospital patients to motivate them eye donation Harvesting corneal tissue (from the community and the hospital where they are based) along with collection of blood from the Cadaver, for serology Safe storage and transportation of tissue to the parent eye bank.
- 9. Eye Bank (EB) Provide a round-the-clock public response system regarding Eye Donation Queries over the telephone and conduct public awareness programs on eye donation. Co-ordinate with donor families and hospital patients to motivate eye donation under the Hospital Cornea Retrieval Program (HCRP) To harvest corneal tissues from Cadavers/Brain dead persons. To process, preserve and evaluate the collected tissue To distribute the corneal tissue in an equitable manner for Keratoplasty To ensure safe transportation of tissue to the Keratoplasty Center.
- 10. Eye Bank TrainingCentre (EBTC) All of the eye bank functions plus training for all levels of personnel in eye banking and research.
- 11. What is Eye Donation?? Eye donation is an act of donating one’s eyes after his/her death. Only corneal blinds can be benefitted through this process but not other Blinds. It is an act of charity, purely for the benefit of the society and is totally voluntary. It is done after death.
- 12. What is Corneal Blindness?? Any profound decrease in vision or blindness due to diseases of the cornea is termed corneal blindness. It is the 4th most common cause of blindness all over the world, accounting for over 5% of the total blind population.
- 13. Infectious •Bacterial keratitis •Fungal keratitis •Viralkeratitis •Trachoma •Onchocerciasis •Leprosy •Ophthalmia neonatorum Nutritional •Vitamin A deficiency (xerophthalmia) Inflammatory •Mooren's ulcer •Steven's Johnson Syndrome Inherited •Corneal stromal dystrophies •Fuch's endothelial dystrophy Degenerative •Keratoconus Trauma •Corneal abrasion predisposing to microbial keratitis •Penetrating trauma •Chemical injury Doctor-caused (iatrogenic) •Pseudo phakic bullous keratopathy Causes of corneal blindness
- 14. Who can Donate eyes?? • Eyes should be donated within 6-8 hours of death. • Anyone can be donor, irrespective of age, sex, blood group or religion. • Anyone with cataract or spectacles can donate eyes. • Person suffering from hypertension, diabetes can also donate eyes. • Total procedures take 15-20 minutes. There is no disfigurement of the face of the donor. • Eyes can be donated even if the deceased had not formally pledged their eyes during their lifetime. • 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. • After pledging please inform your family about your wish to donate eyes, so that they can fulfill your wish.
- 15. Contraindications of EyeDonation Systemic ➢ AIDS ➢ Rabies ➢ Active viral hepatitis ➢ Creutzfeldt-Jakob disease ➢ SSPE(Subacute sclerosing panencephalitis) ➢ Death from unknown cause ➢ Congenital Rubella ➢ Active Septicemia ➢ High Risk Behavioral features ➢ Leukemia ➢ Lymphoma/ Lymphosarcoma Ocular Intrinsic eye disease: a. Active ocular or intraocular inflammation conjunctivitis, scleritis, iritis, uveitis, vitreitis choroiditis, keratitis, and retinitis (at the time of death). b. Retinoblastoma. c. Malignant tumors of the anterior ocular segment. d. Known adenocarcinoma in the eye of primary or metastatic origin. Snake bites specific for neurotoxins. Conditions that will affect graft outcome: congenital abnormalities( Keratoconus) Central opacities, Pterygeum prior refractive procedures (Radial keratotomy scar, Lamellar inserts)
- 16. Instructions to befollowed In case of a person's death; what are the instruction that people around can follow? ➢ Close the eyelids of the donor ➢ Switch off the fan; you can switch on the air -conditioner ➢ Raise the head of the deceased slightly by placing a pillow underneath ➢ Contact the nearest eye bank at 1919 as quickly as possible
- 17. ✓Donor selection ✓Tissue retrieval ✓Cornealexamination ✓Storage of Corneal tissue ✓Distribution STEPS OF EYE DONATION
- 18. DONOR SELECTION 1. Ageof Donor: There will be no influence of age on transplant outcome. Older age : Usage rate declines Lower limit : 2 years. To prevent the myopic shift after keratoplasty. 2. Medical History Review Eye banks must have consistent policies for the examination and documentation of donor’s available medical records, Medical History, Cause of death, Medications , Laboratory reports.
- 19. TISSUE RETRIEVAL ENUCLEATION Surgicalremoval of whole eye globe A synthetic globe is placed in the place. CORNEO-SCLERAL RIM EXCISION By in-situ Corneoscleral Excision Globe is retained in the orbit.
- 20. ENUCLEATION PROCEDURE The faceis prepared and draped in sterile fashion. A limbal conjunctival peritomy is performed with Wescott scissors for 360˚. Blunt dissection in the sub- Tenon’s place is carried out in each of the oblique quadrants. Each rectus muscle is identified, and cut at the insertion of globe. The superior and inferior oblique muscles are isolated and transected. Once the globe is determined to rotate freely, the Optic nerve is identified, strummed and cut with enucleating scissors or an enucleation snare wire. A synthetic globe is placed in the intraconal space to replace the volume lost. The extra ocular muscles are attached to each other. And then the eye lid is closed.
- 21. CORNEO-SCLERAL RIM EXCISION Openthe eyelids using a sterile cotton tipped applicator and insert a wire speculum. Use tenotomy scissors to lift and cut the conjunctiva at the limbus in 360 degrees. The exposed sclera is carefully scrapped from the limbus outward with a scalpel blade (#11 or #15) to remove all remaining conjunctival tissue. Use a second scalpel with a #15 blade and small clawed forceps to make an incision through the sclera 2 mm to 4 mm from the limbus and parallel to the limbus approximately 5 mm in length. Care must be taken to cut all the way through the sclera without perforating the choroid as this would cause vitreous leakage which may cause collapse of the globe including the anterior chamber and compromise the cornea. Continue the scleral incision 360 degrees using corneal section scissors.
- 22. ➢ Complete thecorneal removal by using one pair of small forceps to hold the scleral rim stationary and a iris spatula to gently push the ciliary body-choroid downward and away from the corneal-scleral button. ➢ Remaining adhesions should be pushed gently away from the corneal-scleral button working side to side and taking great care to avoid pulling on the cornea and creating folds. ➢ Do not contaminate the cornea by allowing it to touch the eyelids or other facial skin. ➢ Continue to hold the cornea by the scleral rim with the small smooth dressing forceps and aseptically transfer it to a labeled vial of storage media. ➢ Gently palpate the iris and pupil of each remaining posterior segment with a blunt instrument to rule out aphakia or pseudophakia. ➢ Insert eye caps in front of the remaining posterior poles and gently close the eyelids.
- 23. CORNEAL EXAMINATION Gross Examination The corneal-scleral segment shall be initially examined grossly for clarity, epithelial defects, foreign objects and contamination and scleral color. Slit Lamp Examination The cornea shall be examined for epithelial and stromal pathology and in particular endothelial disease. Enucleated globes shall be examined in the laboratory prior to distribution and/or corneal excision. If in situ corneal excision is performed, examination of the donor eye anterior segment with a penlight or a portable slit lamp is required. After corneal excision, the corneal-scleral rim shall be evaluated by slit lamp bio-microscopy. Specular Examination Determination of endothelial cell density via specular microscopy shall be a standard method of corneal tissue evaluation for all Eye Banks.
- 24. TISSUE GRADING RATE CRITERIA 1. Excellent i.No epithelial defects ii. Crystal clear stroma iii. No arcus senilis iv. No folds in Descemet’s membrane v. Endothelium – no defects 2. Very good i. Slight epithelial haze/ defects ii. Clear stroma iii. Very slight arcus iv. Few folds in Descemet v. Endothelium – no defects 3. Good i. Moderate epithelial defects ii. Moderate stromal cloudiness iii. Arcus < 2.5mm iv. Numerous but shallow folds v. Few vacuolated cells in endothelium 4. Fair i. Epithelial defects > 60% ii. Moderate to heavy stromal cloudiness iii. Numerous deep Descemet’s folds iv. Arcus > 2.5 mm v. Low endothelial cell density 5. Poor i. Central epithelial defects ii. Heavy stromal cloudiness iii. Marked folds iv. Marked endothelial cellular defects
- 25. STORAGE OF CORNEALTISSUE Storage Short term Intermediate Long term Very long term ➢ 2-3 days Moist chamber ➢ 4 days – Mc Carey- Kaufman medium ➢ 7 days - K- Sol medium ➢ 10 days - Dexsol medium ➢ 14 days - Optisol medium ➢ 30 days – Organ Culture medium, Minimum Essential Medium ➢ 1 year – Cryopreservation
- 26. DISTRIBUTION OF CORNEA Distribution to only hospitals and Ophthalmologists registered under Human Organ Transplantation act. Maintenance of waiting list Distribution record Feedback from the hospital receiving cornea.
- 27. CORNEAL TRANSPLANTATION or KERATOPLASTY Keratoplasty (Corneal transplantation / Grafting) is an operation in which abnormal corneal tissue of host is replaced by healthy donor Cornea. A corneal graft may be a. Full thickness ( Penetrating) b. Partial thickness ( lamellar or Deep lamellar)
- 28. PENETRATING KERATOPLASTY INDICATIONS: OPTIC Keratoplasty isperformed to improve vision ➢ Bullous keratopathy ➢ Keratoconus ➢ Dystrophies & degenerations ➢ Scarring TECTONIC Grafting may be carried out to restore or preserve corneal integrity in eyes with severe structural changes such as ➢ Stromal thinning ➢ Descemetocele
- 29. THERAPEUTIC ➢ This typeof corneal transplantation may afford removal of infected corneal tissue in eyes unresponsive to antimicrobial therapy. COSMETIC ➢ To improve the appearance of patients with corneal scars that have given a whitish or opaque hue to the cornea.
- 30. Prognostic Factors The followingfactors may adversely affect the prognosis of corneal graft and should therefore be addressed prior to surgery Abnormalities of eye lids such as blepharitis, ectropion, entropion and trichiasis should be corrected before surgery. Tear film dysfunction Recurrent or progressive forms of conjunctival inflammation, such as atopic conjunctivitis and ocular cicatricial pemphigoid. Severe stromal vascularization, extreme thinning at the proposed host graft junction and active corneal inflammation. Anterior synechiae Uncontrolled glaucoma Uveitis
- 31. Technique DETERMINATION OF GRAFTSIZE: ➢ It is done pre-operatively with a variable slit beam and operatively, by trial placement of trephines with different diameters of measurement with a caliper. ➢ Grafts of diameter 8.5mm or more are prone to postoperative anterior synechiae formation, vascularization and increased intra ocular pressure. ➢ An ideal size is 7.5mm; graft smaller than this may give rise to high astigmatism.
- 32. EXCISION OF DONARCORNEA ➢ It should always precede that of the host. Donor tissue is prepared by trephining a previously excised corneoscleral button. ➢ Alternatively, the tissue may be trephined from the intact donor globe having first injected air or viscoelastic substance into the anterior chamber ➢ The donor button is usually about 0.25mm larger in diameter than the planned diameter of the host opening, to facilitate watertight closure, minimize postoperative flattening and reduce the possibility of postoperative glaucoma.
- 33. ➢ Excision ofdiseased host tissue is then carried out taking care, not to damage the iris and lens. Sutures are placed through the insertions of the superior and inferior rectus muscles. ➢ Partial-thickness trephination is performed. ➢ The anterior chamber is entered with a knife ➢ Excision is completed with scissors ➢ Viscoelastic substance is injected. ➢ Fixation of donor button is usually with 10-0 monofilament nylon ➢ The donor button is placed onto the cornea ➢ Four interrupted radial 'cardinal' sutures are placed; the first at 12 o'clock, the second at 6 o'clock, the third at 3o'clock and the last at 9 o'clock (The corneal 'bite' should be almost full-thickness to prevent wound gape ➢ Further interrupted sutures are inserted ➢ Closure is completed with a continuous running suture ➢ Replacement of viscoelastic substance with balanced salt solution
- 34. POST-OPERATIVE MANAGEMENT Topical steroids They are used to reduce immunological graft rejection After initial administration 2-hourly and then q.i.d. for a few weeks, the dose may be further tapered, depending on the condition of the eye Steroids are usually continued at low doses such as once daily for a year or more Mydriatics b.i.d. for 2 weeks, or longer if uveitis persists. Oral acyclovir may be used in the context of pre-existing herpes simplex keratitis to minimize the risk of recurrence Removal of sutures when the graft-host junction has healed is usually after 12-18 months, although in elderly patients it may take much longer Rigid contact lenses may be required to optimize visual acuity in eyes with astigmatism
- 35. POST-OPERATIVE COMPLICATIONS Early complications ▪Persistent epithelial defects ▪ Protruding sutures → papillary hypertrophy ▪ Wound leak ▪ Flat anterior chamber ▪ Iris prolapse ▪ Uveitis ▪ Elevation of intraocular pressure ▪ Infection. Late complications ▪ Astigmatism ▪ Recurrence of initial disease process on the graft ▪ Late wound separation ▪ Retro corneal membrane formation ▪ Glaucoma ▪ Cystoid macular oedema A rare complication ▪ Fixed dilated pupil (Urrets Zavalia syndrome)
- 36. CORNEAL ALLOGRAFT REJECTION Allograft rejection of any layer of the cornea can occur following penetrating keratoplasty and, less commonly, lamellar grafts. Endothelial rejection is the most common and most severe as it can lead to severe endothelial cell loss and decompensation. Late graft failure through decompensation can also occur in the absence of further rejection episodes Stromal rejection and epithelial rejection are less frequent and respond readily to topical steroid treatment with few long-term consequences. Elements of the different types of rejection can coexist
- 37. PATHOGENESIS The corneais immunologically privileged and a normal cornea will usually not reject. However, if there is inflammation this privilege is lost and rejection may occur. Other important predisposition for rejection includes corneal vascularization, grafts over 8mm in diameter, eccentric grafts, infection, glaucoma and previous keratoplasty. If the host becomes sensitized to the major or minor histocompatibility antigens present in the donor cornea, Type IV hypersensitivity can develop against the graft and rejection and graft failure may result. Antigen presenting cells in the donor cornea may initiate this process.
- 38. SYMPTOMS OF GRAFTREJECTION These include • Blurred vision • Photophobia • Dull periocular ache However many cases are asymptomatic until advanced rejection is established. ➢ Ciliary injection and anterior uveitis is a pre-rejection manifestation. ➢ Epithelial rejection may be accompanied by an elevated line of abnormal epithelium ➢ Stromal rejection is characterized by subepithelial infiltrates. ➢ Endothelial rejection is characterized by linear pattern of keratic precipitates (Khodadoust endothelial rejection line) associated with an area of inflammation at the graft margin. ➢ Stromal oedema is indicative of endothelial failure.
- 39. Ciliary injection Epithelialrejection Subepithelial infiltrates. Khodadoust endothelial rejection line
- 40. MANAGEMENT Early treatment isessential as this greatly improves the chances of reversing the rejection episode. Topical steroids (dexamethasone phosphate 0.1% or prednisolone acetate 1%) hourly for 24 hours are the main stay of therapy. The frequency is reduced gradually over several weeks but high risk patients should be maintained on the highest tolerated topical dose (e.g. prednisolone acetate 1% q.i.d). Systemic steroids (oral prednisolone 1mg/kg/day in divided doses, or a single intravenous dose of methylprednisolone 500 mg) may help to reverse rejection and prevent further rejection episodes but only if given within 8 days of onset of rejection. Repeated intravenous methylprednisolone may be associated with loss of bone density and osteoporosis Subconjunctival steroids (betamethasone 2 mg) may be useful
- 41. DIFFERENTIAL DIAGNOSIS ➢ Graftfailure ➢ Reactivation of Herpes Simplex Virus ➢ Uveitis ➢ Epithelial down-growth
- 42. Superficial Lamellar keratoplasty Lamellar keratoplasty involves partial thickness excision of the corneal epithelium and stroma so that the endothelium and part of deep stroma are left behind
- 43. Indications Opacification ofthe superficial one-third of the corneal stroma not caused by potentially recurrent disease. Marginal corneal thinning or infiltration as in recurrent pterygium, Terrien’s marginal degeneration and limbal dermoids or other tumors Localized thinning or descemetocele formation.
- 44. Technique This issimilar to penetrating keratoplasty except that only a partial thickness of cornea is grafted
- 45. Deep Anterior Lamellarkeratoplasty Deep lamellar keratoplasty is a relatively new technique in which all opaque corneal tissue is removed almost to the level of Descemet membrane. The theoretical advantage is the decreased risk of rejection because the endothelium, a major target for rejection, is not transplanted.
- 46. Indications Disease involvingthe anterior 95% of corneal thickness with a normal endothelium and absence of breaks or scars in Descemet membrane. Chronic inflammatory disease such as atopic kerato-conjunctivitis which carries an increased risk of graft rejection
- 47. Advantages No riskof endothelial rejection although epithelial rejection may occur. Less astigmatism and a structurally stronger globe as compared with penetrating keratoplasty. Increased availability of graft material since endothelial quality is irrelevant.
- 48. Disadvantages Difficult andtime-consuming with a high risk of perforation in older patients Interface haze may limit best final visual acuity
- 49. Post operative management This is similar to penetrating keratoplasty except that topical steroids are used less frequently and sutures can usually be removed after 6 months.
- 50. Other New Techniques DescemetStripping Automated Endothelial Keratoplasty (DSAEK) It is a partial thickness cornea transplant procedure that involves selective removal of the patient's Descemet membrane and endothelium, followed by transplantation of donor corneal endothelium in addition to donor corneal stroma. Descemet Membrane Endothelial Keratoplasty (DMEK) It is a partial-thickness cornea transplant procedure that involves selective removal of the patient's Descemet membrane and endothelium, followed by transplantation of donor corneal endothelium and Descemet membrane without additional stromal tissue from the donor. Keratoprosthesis It is a surgical procedure where a diseased cornea is replaced with an artificial cornea. usually, keratoprosthesis is recommended after a person has had a failure of one or more donor corneal transplants.
- 51. Conclusion परोपकाराय फलन्द्रन्त वृक्ा परोपकारायवहन्द्रन्त नद्य । परोपकाराय दुहन्द्रन्त गाव परोपकाराथा इदं शरीरम् ।। Trees bear fruits to satiate our hunger , Rivers flow to quench our thirst, Cows give milk to nourish us, and we humans must remember that our body is for the welfare of others.
- 52. Thank you कमलायत लोचनलोकपते ववजयीभव वेङ्कट शैलपते ॥