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More systematic, active eye banks needed in Asia-Pacific region
According to the World Health Organization, corneal opacities account for 5.1% of blindness worldwide and are the fourth major leading cause of blindness. With innovations in surgical techniques, there is a good chance of making a major breakthrough in combating corneal blindness in the near future. Despite potential surgical breakthroughs, insufficient donor tissue remains a challenge to tackle.
The Association of Eye Banks of Asia has made an admirable attempt to develop a continent-wide intervention program to improve the availability, efficacy and quality standard of eye banking in Asia. However, the pressing shortage of corneal tissue has rendered preventable corneal blindness almost unavoidable in areas where the supply has fallen short of the demand. The issue can be addressed with a four-pronged approach, focusing on proactive legislation, public education, publicity campaigns and a shift from passive active banking to active eye banking.
In the United States, there was a shortage of 3,500 to 5,000 corneas in 1985. There were 350 patients in New York City waiting an average of 3 months for a corneal transplant. Progressive legislation favoring cornea donation enacted from the late 1960s to the 1980s had prevented a far more serious shortage while enforcement of the Uniform Anatomical Gift Act (UAGA) further alleviated and ultimately eliminated the shortage of corneal tissue. Although the UAGA varies from state to state, it basically created the legally binding right of all competent people to direct the disposition of their bodies after death, limited only by concerns of public health and welfare. A person is given the right to create a legally enforceable gift of his or her corneas before death. Although in no jurisdiction may a validly made gift be abrogated by the next of kin, the will of the next of kin is respected most of the time. There was only one reported case in Utah in 1978 in which a person’s ability to so control the disposition of his body after death was challenged. The Supreme Court found that such control was “in the public interest” as long as it was not “absurd” or “preposterous,” further favoring corneal donation. The UAGA has tremendously increased the pool of donors and corneas available for transplantations in the United States in the past few decades. According to recent data published by the Eye Bank Association of America, 110,600 donations were reported in 2010, enabling the supply of 59,271 cornea grafts and the performance of 42,642 corneal transplants.
In the context of Asia, where legislation is not yet available, publicity and public education play an integral part by creating an environment conducive to cornea collection. In most of the Asia-Pacific region, where religious and cultural concerns have been reported to be a major barrier to corneal donation, public education programs and publicity campaigns in collaboration with leaders in societies, celebrities and/or various religious groups have proven to be effective.
A change from passive eye banking to active eye banking can also help. Instead of waiting for corneas, staff members in an active eye bank are trained to approach relatives of the deceased to procure corneas. Being the director of the first active eye bank in Hong Kong, Prof. Dennis Lam has firsthand experience in connection with cornea procurement. According to Prof. Lam, the corneal donation rate in Hong Kong was low at the time the first eye bank was founded. With a population of around 6 million in the 1990s, only one decedent would opt for corneal donation throughout the entire year, warranting a shift from passive to active eye banking. Training was provided to staff who would skillfully approach the next of kin at this time of grief. Coupled with a concerted effort in public education and publicity campaigns in collaboration with leaders in societies and celebrities that ran for more than 2 years, the rate of corneal donation has increased 100-fold, with 100 decedents opting for corneal donation per year.
The way forward would be to establish an organized and systematic eye banking system to maximize the utilization of all collected corneal tissue. With the advent of corneal lamellar surgery such as Descemet’s stripping automated endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty and deep anterior lamellar keratoplasty, corneal tissue can be used more effectively, saving the sight of 15% more patients with more or less the same amount of donated corneas available over the years. Such procedures have also improved surgical outcomes and reduced the risks of graft rejection and complications. While we are now at the turn of a new era in which combating corneal blindness is no longer a grand vision, stepped-up efforts are needed to get the message of corneal donation across. More organized, systematic, functional, active eye banks are the key if corneal surgery is to progress further.
References:
Bohigian GM, et al. JAMA. 1988;doi:10.1001/jama.1988.03720050055023.
Causes of blindness and visual impairment. World Health Organization website. http://www.who.int/blindness/causes/en/. Accessed Nov. 11, 2012.
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Lee PP, et al. Arch Ophthalmol. 1989;doi:10.1001/archopht.1989.01070020663024.
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Uniform Anatomical Gift Act. 8A ULA. 1989;16(suppl).
For more information:
Dennis S.C. Lam, MD, FRCOphth, can be reached at State Key Laboratory in Ophthalmology, Sun Yat-Yen University, 54 South Xianlie Road, Guangzhou 510060, People’s Republic of China; +852-3997-3266; fax: +852-3996-8212; email: dennislam.gm@gmail.com.