In the March 1996 issue of this journal, I wrote an editorial entitled “What is Eye Banking?” giving expression to some of my views and my understanding of this important aspect of combating a serious blindness problem. That year (1995 - 1996), we had performed 283 corneal transplant procedures at L.V. Prasad Eye Institute; this number has since escalated to 1031 in the past year (2003 - 2004) - an almost four-fold increase. In the process, we have established the credibility of high quality eye banking in India, the success of the concept of Hospital Corneal Retrieval in India, and an assured supply of corneal preservation medium to all eye banks across the country. In addition, we have trained scores of corneal “specialists” (not just corneal “surgeons”) and eye banking personnel from around the world and have eliminated the waiting list for corneal transplantation in our Institute. The number-1031-also represented a milestone in the history of corneal transplantation since this is the first instance of over 1000 corneal transplants being performed at a single centre anywhere in the world. This achievement becomes particularly significant as organ transplantation has so far been considered an insurmountable problem in India. However, unfortunately such an increase in numbers of corneal transplants has not become a national trend; it remains an isolated instance of a single institution, thus begging the question, “why not?”
An analysis of the situation is quite revealing. In India, there is no dearth of knowledge, skills and resources to create a world class eye banking and corneal transplantation network. What seems to be missing, however, is a “Proactive National Movement” to translate concepts and plans into time-bound action. Needless to say, promotion of Eye Donation and creation of a National Eye Banking System lends itself only to the strategy of a “movement”.
If Government, Eye Banking organisations and corneal surgeons work together, development of eye banking and corneal transplantation services are the easiest of tasks. While some measures such as favourable legislative action governing eye banking may involve a long process, significant strides can be made in other areas such as setting up Hospital Cornea Retrieval Programmes, creating public awareness campaigns, instituting accreditation systems, training more eye banking personnel and curbing the harmful proliferation of mediocre eye banking practices.
From all the evidence available, direct and indirect, an annual performance of around 100,000 corneal transplants would have a salutary effect on the problem of reversible corneal blindness in India. Going by the experience of the eye banking systems worldwide, meeting this demand would require double that number of corneas to be harvested, i.e., 200,000 annually. Each eye bank with adequate infrastructure and trained manpower can comfortably process 4000 corneas per year, which translates to 50 eye banks for the entire country. In a country like India, where the basic infrastructure and manpower exist, this should not be a problem-theoretically.
Each of these eye banks should be an autonomous organisation, ideally with its own Board and governance structure representing all the stakeholders in the community. All the major functions of an eye bank should be carried out, including public awareness, tissue harvesting, tissue evaluation (including serology and microbiology), tissue preservation and tissue distribution. Equitable distribution is key to longterm success, since this builds credibility in the community with all its subsequent benefits. The goal is to make safe and high quality corneal tissue accessible to everyone who needs corneal transplantation in the community in an equitable manner. Essentially, this means that all those who are in need of a corneal transplant for visual rehabilitation, irrespective of socio-economic status, gender, religion, or choice of surgeon and institution, should have equal access to the eyes donated to eye banks on a first-come first-served basis.
This plan then envisages the establishment of one eye bank for every 20 million people, each of which is to be linked to 40 Eye Donation Centres (EDC) - eye banking units that are involved only in harvesting corneas. To meet the demand for training of eye banking personnel, 5 of the eye banks will be identified as training centres. In addition, each eye bank will develop a Hospital Cornea Retrieval Programme (HCRP) in 10 major hospitals in the immediate community. Half (2000) the harvesting is achieved by the Eye Bank directly through the HCRP and the other half (2000) will be through the contribution of eye donation centers, with 50 eyes (25 donors) from each EDC.
The overall financial outlay for this plan is surprisingly small. Each eye banking training centre costs around Rs.5.0 million, Rs.3.0 million for an eye bank and Rs. 50,000 for an eye donation centre. Together the entire eye banking infrastructure for the country can be created at a cost of Rs.260 million. This funding can be mobilised from Government, International Non-Governmental Organisations and local sources. The operating expenses of eye banks will be covered by processing fees (those belonging to upper socio-economic groups pay this as part of fees and for the lower socio-economic groups a subsidy may be provided by Government and INGDOs) and donations.
Another aspect that merits attention is the number of well-trained corneal specialists. If an annual target of 100 transplants per surgeon is reasonable, India needs 1000 trained specialists. Against this, the current number is less than 100. There is a need to create more corneal training centres as the existing 4 or 5 centres cannot meet the entire demand.
In summary, India needs 50 eye banks, five of which will also be eye banking training centre, 2000 eye donation centres, Cornea Retrieval Programmes in 500 hospitals and 1000 corneal specialists to make a real impact on the problem of this reversible form of corneal blindness. What are the possible next steps to get there ? A clear concept and detailed plan must be developed, followed by rigorous implementation of the plan by all concerned in a time-bound fashion. As ophthalmologists, we are obliged to play a leading role in this endevour and have to play only that role that is appropriate for us. Let all of us involved in the fight against corneal blindness work together for a national goal. If we can make that commitment, we can prove that India is definitely up to the task of serious “Eye Banking” and be a role model for other developing countries.
Source of Support:
Conflict of Interest:
1. Rao GN. What is Eye Banking? Indian J Ophthalmol. 1996;44:1–2