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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 85-90

An analysis of tissue utilization at a tertiary care institute associated eye bank to improve tissue procurement and tissue utilization


1 Head of Cornea and External Diseases Unit, DE Ankleshwaria Eye Bank, M and J West Zone Regional Institute of Ophthalmology, BJ Medical College and Civil Hospital, Affiliated to Gujarat University, Ahmedabad, Gujarat, India
2 Ex-resident, Cornea and External Diseases Unit, M and J West Zone Regional Institute of Ophthalmology, BJ MedicalCollege and Civil Hospital, Affiliated to Gujarat University, Ahmedabad, Gujarat, India

Date of Submission08-Jun-2015
Date of Acceptance28-Dec-2016
Date of Web Publication25-Apr-2017

Correspondence Address:
Jagruti Navalsingh Jadeja
F/403, ‘Satej’ Apartments, Near: AUDA Sports Complex, Gulab Tower Road, Thaltej, Ahmedabad - 380 054, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3897.205186

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  Abstract 

Background: In India, most tissues are received from voluntary donors. There is a huge potential of harvesting surgically competent tissues by the Hospital Cornea Retrieval Program which involves counselors trained in grief counseling and tissue retrieval, posted at hospitals. They approach families of all the deceased in the hospital motivate them to pledge the eyes of the deceased: Advantage being that no potential donor is missed, easy availability of medical history, and reduced time interval between death and corneal excision. Aims: The aim of this study is to examine the utilization of corneas procured and determine how maximum tissue procurement and utilization can be ensured. Setting and Design: Tissue utilization analyzed at a tertiary care eye bank (EB) postapplication of revised guidelines of standards of eye banking of India, 2009. Materials and Methods: Data between January 2010 and December 2012 were reviewed. Reasons for rejection of corneas for transplantation were noted. Statistical Analysis: Retrospective analysis. Results: Of 1908 corneas accepted at our EBs in that duration, 1239 (65%) were received from voluntary donors at their residence and from other associated EBs; 599 corneas (31%) from hospitals and 70 (4%) came from mortuary. Six hundred and twenty-three corneas (33%) were transplanted, 1007 (53%) were directed toward research or training and 91 (5%) tissues had to be incinerated. Seven hundred and thirty-four (38%) were excluded from transplantation due to a contraindication in the donor's medical history. Conclusion: Majority tissues are received from voluntary eye donation with most tissues excluded due to contraindication in donor's medical history. Ensuring thoroughly trained, well-equipped enucleation teams reaching out to all suitable donors from hospitals and voluntary donors can hugely increase the numbers of surgically competent tissues.

Keywords: Eye bank, Hospital Cornea Retrieval Program, tissue utilization


How to cite this article:
Jadeja JN, Bhatt RV. An analysis of tissue utilization at a tertiary care institute associated eye bank to improve tissue procurement and tissue utilization. J Clin Ophthalmol Res 2017;5:85-90

How to cite this URL:
Jadeja JN, Bhatt RV. An analysis of tissue utilization at a tertiary care institute associated eye bank to improve tissue procurement and tissue utilization. J Clin Ophthalmol Res [serial online] 2017 [cited 2019 Aug 24];5:85-90. Available from: http://www.jcor.in/text.asp?2017/5/2/85/205186

In India, there is a huge demand-supply gap regarding donor corneas.[1],[2],[3],[4] Cornea procurement under National Programme of Control of Blindness (NPCB) shows a deficit of donor corneas; yearly target being 60,000 and collection only being 44,926 for 2010–2011, 49,410 for 2011–2012 and 53,543 for 2012–2013.

A significant proportion of corneas harvested is found unsuitable for transplantation. If we analyze tissue utilization at an eye bank (EB), it can reflect various causes of tissue exclusion and can inform us of lacunae in existing system.

The aim of this study was to study the utilization of cornea procured at our EB and determine reasons why corneas could not be used and also understand the measures needed to increase procurement of surgically competent tissues and its utilization. No such analytic study has been reported so far from the subcontinent. This analysis can prove to be a major step toward refining existing EB system.


  Materials and Methods Top


EB at our institute receives donor tissues from homes and hospitals in city and adjacent areas through voluntary donors, mortuary in our hospital and other EBs. All tissues are accepted by EB irrespective of medical or ocular history. Relatives are counseled if tissue has a contraindication for transplantation and are asked for willingness to donate for research/training. If denied use for such purpose, enucleation is not performed. Otherwise, the tissue is accepted. If serological status or medical condition of donor endangers health of medical personnel, relatives are counseled likewise, and universal precautions are taken.

All tissues are stored initially as whole eyeballs in a moist chamber and evaluated as follows. Donor age, death to enucleation time, cause of death (COD) and medical/ocular history is noted. A thorough slit lamp evaluation of tissue is performed for epithelial defects, exposure keratitis, arcus senilis, corneal scars, epithelial edema, stromal edema, stromal opacification, Descemet's membrane folds, quality of endothelium, condition of anterior chamber, iris, pupil and lens status and examined for any iatrogenic perforation. A clinical grade ranging from excellent to poor is assigned [Table 1].[5]
Table 1: Slit lamp grading of tissue

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Serological examination of blood is performed for human immunodeficiency virus (HIV), hepatitis B virus (hepatitis B surface antigen [HBsAg]), hepatitis C virus (HCV), and syphilis (venereal disease research laboratory [VDRL]). If reactive for any, tissue is incinerated and personnel involved with enucleation are intimated.

If no reason for rejection is found as per above, corneoscleral rim is excised, preserved in McKarey Kauffmann (MK) media and death to preservation time noted. Tissue is re-evaluated on slit lamp and subjected to EB specular microscopy. An endothelial cell count is obtained if possible and evaluated for any abnormalities like guttata. As published earlier by one of our teams,[6] EBSM can drastically change final grade of tissue and hence its utility. On adjusting the final grade, tissue is made available for transplantation or for research/training. Few tissues were incinerated due to their unsuitability even for research/training. Some tissues had to be sent to other EBs during temporary shifting of operation theater (OT) premises due to reconstruction of the EB and other constraints such as positive OT swabs and unavailability of suitable patients within the specified time frame of tissue storage.

From January 2010 to December 2012, all donor eyes received and processed at our EB were analyzed retrospectively. Number of corneas transplanted, made available for research, incinerated and those sent to other EBs were recorded. Reasons for exclusion of tissues from transplantation were noted.


  Results Top


Of 1908 corneas accepted at our EB from January 2010 to December 2012, 599 corneas (31%) were received from hospitals and seventy tissues (4%) came from mortuary. A major portion 1239 tissues (65%) were received from voluntary donors at their residence or other associated EBs [Table 2].
Table 2: Tissue utilization according to the source of tissues

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Of these 1908 corneas, 623 (33%) were transplanted and 1007 (53%) were made available for research/training. Ninety-one (5%) were incinerated and 187 (9%) sent to other EBs [Table 2].

Age group of 71–80 years contributed maximally to transplanted corneas. Out of total transplanted corneas, 135 (22%) corneas were from 71 to 80 years group followed by 122 (19%) corneas from 61 to 70 years group and 86 (14%) corneas from 51 to 60 years group. Out of all groups, age group of 21–30 had the highest transplantation rate [Chart 1[Additional file 1] ].

Among the corneas transplanted, 396 (64%) corneas were obtained from donors having cardio-respiratory arrest, followed by 78 (12%) tissues harvested from donors having died a natural death followed by 66 (11%) corneas retrieved from donors involved in road traffic accidents (RTA) [Chart 2 [Additional file 2]].

Most common cause for exclusion was a contraindication in “medical history” of donor with 734 corneas out of 1007, excluded for the same [Table 3]. In this group, 426 and 154 tissues were excluded, respectively, due to a history of septicemia and malignancy preceding donor death. The second common cause was improper serology for which 192 were excluded out of which 92 tissues did not have a suitable blood sample along with it. Out of 192 tissues, 108 tissues were received from other EBs and 84 were received from our institute. Third leading cause was suboptimal quality of tissues leading to rejection of 79 tissues.
Table 3: Reasons for exclusion of tissues from transplantation

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Out of incinerated tissues, 46 tissues were positive for transmissible diseases like Hepatitis B virus, HCV, (or both), HIV or syphilis. Sixteen were collapsed eyes due to perforation during enucleation. Thirteen tissues had profuse discharge noticed during enucleation or had corneal infiltration on slit-lamp examination [Table 4].
Table 4: Causes leading to incineration of tissues

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  Discussion Top


Nearly 31% tissues received at our institute were from hospitals and only 22% of tissues received from hospital were utilized as compared to 38% of tissues received from donor homes [Table 2]. While in a study by Patel et al.,[7] cornea utilization rate was as high as 79% with 68% of tissues received from coroner's service and Oliva et al.,[8] found tissue utilization as high as 72% within a Hospital Cornea Retrieval Program (HCRP) model. However, in our analysis, majority of donors from hospitals had some contraindication to utilization of tissue owing to their illness.

Proper implementation of HCRP and proper screening of potential donors by either EB counselors (EBC) or hospital staff can increase tissues received from hospitals and donations from deceased with no known contraindications. Where HCRP was successfully implemented, an effective EBC proved to be the most critical factor. Under the 11th 5-year plan, the state was granted funds to appoint 150 EBC on a contractual basis (1 year) with a fixed remuneration of 10,000 Rupees [9] which was increased to 220 counselors under the 12th 5-year plan.[10] Current eligibility requirements for EBCs include: Age limit of 35 years, graduation in sociology/social work/arts/science, computer skills, and experience in health communication. Hence, the counselors were young graduates from various fields and lacked basic medical knowledge. Furthermore, the few counselors appointed – who were all trained at our EB, were posted at district hospitals after training and none at the training center itself. They were allocated multiple tasks as per their center's requirement, not contributing to increase in surgically competent donor tissues.

Recruiting appropriately skilled candidates with social motivation and allocation of well-defined duties is essential. Internal scrutiny of EBCs' performance regularly and also by external authorities at every inspection of EB as a part of accreditation requirement can keep a check on their activities. Performance-based incentives may be offered for motivation and noncompliance to guidelines be strictly dealt with. Guidelines of standards of eye banking in India, 2009 mandate review and training for counselors once every 4 months.[9] While it need not be conducted every 4 months, it still needs to be frequent since the eye donation center constantly deals with morbidity. This training should emphasize on surgical utility of tissue and not just on numbers.

Farge et al.[11] and Moyes et al.[12] found donor age above 75 years to be the major reason for exclusion. In this study, maximum numbers of tissues transplanted belonged to age group of 71–80 years. Thus, an upper age limit is not guiding criteria for excluding a tissue. A lower age limit of 1 year could be set as threshold as out of 6 tissues received from age group <1 year; none were fit for transplant.

Tissues from donor deaths in RTA have a high transplantation rate [Chart 2]. Furthermore, more young tissues are available. Kumar et al.[13] found that a number of potential donors from trauma deaths were missed as the staff failed to approach them for eye donation. Even though the sentiment to donate exists in these families, it does not materialize in that moment of grief. In such circumstances, a trained counselor can appropriately approach the families at the right time and also help complete legal formalities to hasten tissue collection.

The majority of tissues were excluded from transplantation due to medical history of septicemia [Table 3]. Thorough scrutiny by counselor/medical practitioner can avoid rejection of usable tissue. Most of the times, diagnosis of septicemia is arbitrary and not based on blood cultures. If private hospitals are instructed legally to make a detailed discharge card and death certificate available, stating primary and secondary COD, it can clearly rule out contraindications to tissue transplantation. In cases of poisoning, the exact substance should be investigated for. Furthermore, as quoted in Saini et al.,[14] aqueous and vitreous cultures have been negative in cases of septicemia. Studies should be undertaken for safety of such corneal transplants.

To counter these issues, a unique approach would be to train the nursing staff. Nurses are aware of the medical history of patients and all deaths occurring in hospital wards and are well trained in grief counseling. It would leave counselors with more time to coordinate with outside sources of tissues and assess their suitability.

A significant number of tissues could not be used as exact COD was not known at the time of death. While postmortem (PM) report is usually available within a week, the media widely used (MK) for tissue preservation allows preservation only up to 4 days.[15] Although NPCB guidelines allow use of intermediate storage media like optisol GS and Eusol, cost and availability are major limitations to their widespread use. If such media are made easily available by the government, such tissues can be preserved which can be subsequently used after PM report.

A nonreactive serological testing for HIV, HBsAg, VDRL and HCV is mandatory before tissue transplantation. In this study, 19% of tissues could not be utilized as blood sample was either unavailable, insufficient, hemolyzed or was stored inappropriately showing unavailability of basic materials at all centers. In spite of detailed guidelines, an appropriate blood sample was not available in 42 donors even though it was received from enucleation team of a tertiary care center. Tissues received from peripheral eye collection centers had a still higher rate. Among incinerated tissues, 16 tissues were collapsed tissues due to inadvertent perforation during procedure [Table 4].

The above data suggest a lack of a constant well-trained team for enucleation. Currently, at our center, on-duty resident doctor performs enucleation. Resident doctors change every year and perform enucleation in rotation. As per amendments under transplantation of human organs act in 2011,[16] it permits trained technician to perform enucleation. Benefits of tissue retrieval by competent technician posted round the clock include consistency, more tissues from peripheral EBs and better work distribution between doctors and technician. However in spite of the amendment, employment of such technicians is yet to be.

Thus, many tissues are lost due to lack of clear guidelines and training. Also, donors from hospital deaths are missed due to lack of timely and systematic approach. Ensuring thoroughly trained and well-equipped enucleation teams, reaching out to all suitable donors from both hospitals and voluntary donors, can hugely increase the numbers of surgically competent tissues. In conclusion, effective implementation of existing laws and guidelines by all EBs and hospitals and proper implementation of HCRP can increase procurement of surgically competent tissues and its utilization.

Acknowledgment

Dr. Swapna Shanbhag (MS), Ex-resident M and J Institute of Ophthalmology, Currently Fellow of Cornea at L V Prasad Eye Institute, Hyderabad.

The team at DE Ankleshwaria Eye Bank, M and J Institute of Ophthalmology, Ahmedabad, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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