New Norms of Eye Banking in the COVID Era

Corneal blindness is one of the leading causes of vision loss in India, with keratoplasty offering the only definitive cure. The first successful human corneal transplantation in the world was performed in 1905. In India, the very first eye bank was established by Late Dr. Muttiah who also performed the first successful corneal transplant in 1948. Since then, the efforts by Government of India, non-governmental organizations (NGOs) and other Associations have led to innumerable advances and developments which have transformed the face of eye banking in our country. Despite all this there is a huge backlog of patients awaiting corneal transplantation owing to the mismatch between demand and supply of corneal donor tissues. Today, there are only a few eye banks in our country which have an annual collection of over 1000 corneal tissues. It is therefore imperative for eye banks to augment the tissue collection as well as utilization in order to achieve the target of more than 100,000 corneal transplants per year, required to alleviate the alarming situation of treatable corneal blindness in India. Unfortunately the COVID-19 pandemic has adversely affected all aspects of eye banking resulting in a further increase in the backlog of patients awaiting corneal transplantation.

The Challenges

As we adjust to a new normal, the entire healthcare system has required restructuring in order to cope up with the devastation wreaked by the pandemic. Eye banking and keratoplasty face unique challenges, encompassing various aspects such as the potential viral transmission via donor corneas, the evolving guidelines for donor cornea retrieval, donor counselling and retrieval process in the COVID era, routine RTPCR testing of donor as well as the recipient, handling of tissues from COVID positive donors and the formulation of guidelines for tissue retrieval from vaccinated donors.

Grief counsellors and eye donation counsellors are often the point of first contact for next of kin willing to donate the corneal tissue of their deceased family member. The initial peak of the pandemic was accompanied by a temporary cessation of donor retrieval in the absence of adequate knowledge regarding the possible transmission of virus via the corneal tissue and safety concerns. The eye-banking staff had to counsel potential donor families regarding their inability to retrieve donor tissues pending adequate guidelines.

As our understanding of this novel disease evolved, the Government of India and Eye Bank Association of India have formulated screening guidelines to exclude COVID positive individuals and high-risk contacts as potential donors. Counsellors are now faced with the additional task of determining suitability of potential donors with respect to COVID, while maintaining adequate precautions and COVID appropriate behaviour, as well as maintaining sensitivity towards the next of kin who are under additional mental stress. Thus the eye banks now have the added responsibility of training the eye donation counsellors to make them adept at functioning in these changed circumstances.

The ocular surface, conjunctiva and tears may potentially act as a reservoir for the SARS-CoV-2 virus, with viral RNA fragments being detected in various ocular tissues. Though routine donor testing remains a matter of debate, nasopharyngeal swabs for RTPCR are obtained from the donor posthumously during corneal retrieval by many eye banks, and the corneal tissue is quarantined till a confirmed COVID negative report is obtained.

While guidelines framed by various eye bank associations do not prescribe mandatory RTPCR testing before donor cornea retrieval, we strongly believe that donor testing should be mandatory till an absence of viral transmission via donor corneas can be conclusively demonstrated. Mandatory donor testing assumes even more significance in the setting of increased asymptomatic infections and re-infections, which may not be effectively screened by the existing donor selection criteria.

Ensuring safety of the healthcare workers and eye-banking personnel is of paramount importance in these trying times. The counsellors should observe social distancing and use of N-95 masks during all interactions with potential donor families, and carefully elicit the pertinent history. Technicians and doctors performing tissue retrieval should don adequate personal protective equipment with face shield and double gloves. Double betadine cleaning of the ocular surface prior to donor retrieval has reported to decrease viral transmission. In addition, the tissue should be quarantined for 48 hours before use in keratoplasty procedures. Specialized training programs for eye bank technicians is required to facilitate tissue retrieval in a safe manner in accord with the established guidelines. At present, tissues from COVID-19 positive donors are not being used for corneal transplantation, which brings forth the question of appropriate handling and disposal of such tissues. While some centres have used these tissues for research purposes, their disposal in a safe manner is imperative to avert the potential risk of viral transmission. Adjustments have also been made to the functioning of the transplant centres. Tissue recipients are now required to undergo RTPCR testing to exclude active infection at the time of surgery. Working protocols in operation theatres and wards have been modified to incorporate COVID-appropriate behaviour and maintain social distancing.

In order to successfully overcome these challenges the eye banking system of our country relies on the support of two main stakeholders, the Government agencies and the non-governmental organizations. As the initiatives from the Government of India to boost eye banking activities during the pandemic have been limited, the burden of reviving Indian eye banking now lies largely on the NGOs. Moreover, the NGOs are aptly positioned to promote public awareness about eye donation and dispelling the myths pertaining to it, owing their wide reach amongst the various educational institutions, resident welfare associations and other civil societies. In addition to promotion of public awareness, the NGOs can also provide support in the form of finances, manpower and public-private partnerships in order to sustain and augment eye banking amidst these testing times. There is a pressing need for all stakeholders to collaborate and cooperate so that we can achieve the requisite tissue collection targets, utilization rates and training of manpower, in order to eliminate the waiting list for corneal transplantation in the coming years.