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Introduction: Current and New Technologies in Corneal Donor Tissue Evaluation Comparative Image Atlas

Gray, Kayla E., CCRP; Benetz, Beth Ann, CRA, FOPS; Stoeger, Christopher G., MBA, CEBT; Lass, Jonathan H., MD

doi: 10.1097/ICO.0000000000001609
Supplement Articles

Correspondence: Jonathan H. Lass, MD, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106 (e-mail:

Received February 28, 2018

Received in revised form March 06, 2018

Accepted March 06, 2018


Kayla E. Gray, CCRP

Innovations Operations Supervisor, Biorepository, Eversight

Beth Ann Benetz, CRA, FOPS

Professor, Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Scientific Director, CIARC and REDIARC

Christopher G. Stoeger, MBA, CEBT

Chief Executive Officer, Lions VisionGift

Jonathan H. Lass, MD

Charles I Thomas Professor, Case Western Reserve University, Department of Ophthalmology and Visual Sciences, Medical Director, Eversight Medical Director, CIARC and REDIARC


Participating Eye Banks and Individuals




Eye banks are entrusted with a precious benevolent gift—the gift of donated human ocular tissues. Not only has the donor and donor family placed their trust in eye banks, trust runs deep in the corneal transplant community that eye banks will provide only the highest quality tissue for surgery. The donated tissue must be disease-free and have the capacity to function in the recipient for many years, while tissue screening must be completed in a precise and timely manner. Tissue screening is a delicate balance that, by design, requires eye banks to determine tissue suitability in situations that at times can be somewhat ambiguous. Ambiguity, by necessity, leads to erring on the side of safety and ruling tissue ineligible for transplantation, which in turns leads to the potential of waste of a donor's gift.

Modern technology has brought additional resources to the evaluation process to aid in tissue screening of the hypothermically stored donor cornea (Fig. 1). Slit-lamp examination has been the mainstay for tissue evaluation over the course of corneal transplantation since its advent in the 20th century. Specular microscopy was subsequently applied to eye banking tissue evaluation by Bourne and others in the 1970s1 but did not become a requirement of the Eye Bank Association of America in Medical Standards until 2001.2 Since that time, slit-lamp examination and specular microscopy have complemented each other in tissue assessment for suitability with slit-lamp examination ideal for assessment of the epithelium, stroma, folds, and lower power view of the endothelium, whereas specular microscopy provides a high power view of the endothelial mosaic enabling determination of density and abnormalities (eg, guttae). Since its introduction, optical coherence tomography has been used for its noncontact measuring capabilities related to endothelial keratoplasty (EK) graft thickness.3–5 Ancillary screening benefits from this technology now aid those eye banks that use this technology for evaluation of disease processes of the epithelium and stroma (eg, infiltrate).6,7 Finally, a fourth imaging tool is now available to aid tissue screening with the ex vivo wide-field dual imaging noncontact specular microscope (CellChek® D+®, Konan Medical, Irvine, CA) with its Enhanced mode and Finder mode views.



To our knowledge, this atlas provides for the first time reference images combining the use of all 4 technologies to provide a comprehensive approach to current donor cornea tissue evaluation with the hypothermically stored donor cornea. Because organ culture is not used in the United States, the coeditors elected to restrict this atlas to the hypothermically stored donor cornea but would welcome our organ culture colleagues to develop a similar atlas. Normal and diseased states of tissue are presented in a manner which will provide detailed resources for training of both new and experienced eye bank technicians. As our understanding of imaging technology advances, surgeons can have a greater assurance that only tissue appropriate for use has been released while at the same time stewardship over the donated gift is honored. Ultimately, surgeons are the final arbiter of suitability for their individual patients. This advancement will help provide the most accurate information possible regarding tissue suitability determinations among surgeons and eye bankers.

This atlas is a collaboration among 10 eye banks. More than 300 images of corneas were submitted over the course of 2 years. It is organized such that each layer of the cornea is given its own section. In addition, a separate section on tissue processed for EK has been established. And finally, a section devoted to findings that do not fit neatly into an anatomic category rounds out the atlas. This atlas been created for the field of eye banking to share information as a community committed to providing the highest quality tissue possible for sight restoration.

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1. Bourne WM. Examination and Photography of donor corneal endothelium. Arch Ophthalmol. 1976;94:1799–1800.
2. Eye Bank Association of America. Medical Standards. Washington, DC: Eye Bank Association of America; 2017.
3. Tang M, Stoeger C, Galloway J, et al. Evaluating DSAEK graft deturgescence in preservation medium after microkeratome cut with optical coherence tomography. Cornea. 2013;32:847–850.
4. Brown JS, Wang D, Li X, et al. In situ ultrahigh-resolution optical coherence tomography characterization of eye bank corneal tissue processed for lamellar keratoplasty. Cornea. 2008;27:802–810.
5. Woodward MA, Titus MS, Shtein RM. Effect of microkeratome pass on tissue processing for Descemet stripping automated endothelial keratoplasty. Cornea. 2014;33:507–509.
6. Bald MR, Stoeger C, Galloway J, et al. Use of fourier-domain optical coherence tomography to evaluate anterior stromal opacities in donor corneas. J Ophthalmol. 2013;2013:397680.
7. Lin RC, Li Y, Tang M, et al. Screening for previous refractive surgery in eye bank corneas by using optical coherence tomography. Cornea. 2007;26:594–599.
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