Rahul M. Jindal lead surgons team to establish a sustainable eye bank in a developing nation

Corneas are among the most commonly and successfully transplanted tissues worldwide.^1,2 However, transplantation is dependent on the availability of donor tissue—a limiting factor in most developing countries. Because eye banks in developed nations cannot match the demand worldwide, it is important that developing countries create their own sustainable local corneal tissue and transplant systems.

In the May 2015 issue of the Bulletin, the authors reported on the inception of a successful corneal transplant program in the South American nation of Guyana.³ That public-private partnership (PPP) corneal transplant mission began in 2014, first with an educational visit that included talks with the host nation’s Ministry of Health, hospital leaders, and a city-wide lecture to the ophthalmologists on corneal transplantation.

Since that article was published, we have carried out additional missions aimed at creating independently sustainable eye bank and corneal transplantation services. To date, the program has supervised 34 successful corneal transplants, including the procurement of donor tissue, in Guyana.

Our work occurred in five stages and shows that specialized surgical services can be sustained through training of the local surgeon, establishing infrastructure to support the program, and following up with program participants to address any unforeseen challenges.

This article also provides insight into the global burden of eye disease and the wider ramifications of building a successful corneal transplant program in underdeveloped countries.

Five stages of the program

The corneal transplant program in Guyana used a PPP model with funding from the Subraj Foundation, New York, NY, founded by Guyanese-American philanthropist George Subraj. U.S. eye banks donated corneal tissue, U.S. surgeons donated their time and talents, and the Guyanese government supplied operating room (OR) facilities and postoperative medications. Media outlets in Guyana promoted the corneal transplant program’s mission and goals, which resulted in additional support from the community. Using the PPP model, we were able to bring the best available medical expertise from the U.S to a developing country, at no cost to patients, without relying on direct funding from any U.S. governmental agency.

Our mission was completed in five stages: an exploratory visit, initial performance of corneal transplant operations, heightened local involvement, refinement, and gaining of independence.

Exploratory visit

The purpose of the exploratory stage was to become familiar with Guyana’s health care infrastructure and licensing requirements, as well as to become acquainted with the level of education and motivation of the typical local surgeon who we would train to establish the corneal transplant service at a private hospital in Georgetown. During this stage, Stephen G. Waller, MD, a co-author of this article, joined an existing program in renal transplantation in Guyana, founded by co-author Rahul M. Jindal, MD, PhD, MBA, FACS, and Mr. Subraj. This visionary program, described in the June 2013 issue of the Bulletin, was implemented over the course of more than 20 visits to Guyana and resulted in the successful transplant of 26 living-related donor kidneys and other associated procedures.^4,5

Building on the credibility that the U.S. kidney transplant team established, Dr. Waller traveled to Guyana in 2014 to meet with local ophthalmologists and government officials. He established his own credentials for local medical privileges, investigated the clinical and surgical capacity of the region, and delivered lectures on corneal transplantation and eye banking to approximately 50 local eye care providers, including George Norton, MD, now Minister of Public Health in Guyana. Both Guyanese and U.S. stakeholders agreed that this first stage was a success.

Initial corneal transplant operations

On the second mission in August 2014, we performed six successful corneal transplants in a private hospital with donor tissue given ex-gratis by U.S. eye banks. However, we soon realized that sustainability was only possible in a public system, free of cost to the patient. For example, the private hospital charged $3,000 (U.S.) for each corneal transplant even though the corneas, instruments, sutures, and services of the U.S.-based surgeons were provided free of charge.

 

 

 

 

 

 

These successful corneal transplants drew substantial positive publicity, building momentum for the establishment of an eye bank in Georgetown. Georgetown is the headquarters city for a regional group of governments, the Caribbean Community (or CARICOM), which comprises 15 members—mostly small island nations with little hope of establishing a local eye bank. Thus, a regional eye bank in Georgetown seemed like a natural fit for the Caribbean Community.

Heightened local involvement

A total of 11 corneas were transplanted during the third mission in July 2015, this time at the Georgetown Public Hospital, which provides specialized services to the entire country. The local surgeon, Shailendra Sugrim, MD, a co-author of this article, was heavily involved in patient selection and the actual operations, and a second U.S. surgeon, co-author Joseph Pasternak, MD, led the surgical work. All of these efforts were conducted with the support of the local government and The Subraj Foundation, and the U.S. surgery team continued to assist with follow-up via e-mail after returning to the U.S.

Refinement

The fourth mission in October 2015 was designed to enhance the skills of the local surgeon by allowing him to be the primary surgeon for all steps of the operation, with U.S. surgeons assisting. In this stage, 12 corneas from multiple U.S. eye banks were transplanted. The successful procedures were again monitored postoperatively via e-mail communications.

Independence

The U.S. team left behind nine donor corneas that had not reached their expiration dates. These corneas were available for use by the local surgeon without supervision. He successfully matched five of them with appropriate recipients, experienced excellent outcomes, and garnered positive publicity. The following month, in December 2015, Dr. Norton, as the new Minister of Health, announced a legislative program to promote corneal transplantation in Guyana—the first step toward establishing an eye bank in Georgetown.

Global burden of corneal disease

The authors believe that their work in Guyana has widespread implications for easing the global burden of corneal disease. The World Health Organization (WHO) reports that 39 million people worldwide were blind as of 2010.^6,7 Corneal disease is the second most common cause of blindness in the world after cataracts. The specific pathology and epidemiology of corneal disease varies from country to country and even from one population to another and correlates with socioeconomic and other factors. For example, in some parts of Africa, up to 90 percent of all blindness is related to corneal disease.

The major causes of corneal blindness are trachoma, ocular trauma, xerophthalmia, and onchocerciasis. Globally, 500,000 new cases of childhood blindness occur each year, 70 percent of which are attributable to Vitamin A deficiency leading to xerophthalmia. The impact of vitamin A deficiency on childhood blindness and mortality was described in England in 1932, and American ophthalmologist Alfred Sommer, MD, rediscovered its impact in his work in Southeast Asia in the 1970s.^8,9This situation is heartbreaking in an era when vitamin A supplementation can be offered for pennies per person per year.

In developing countries such as Guyana, most corneal blindness occurs in the working age group, unlike cataracts, which largely affect an older patient population. Trachoma and xerophthalmia are rare. Onchocerciasis is limited to a small endemic area along the border with Brazil, where the local indigent population is hostile to outside intervention, including ivermectin treatment. Trauma from road traffic accidents or industrial and agricultural injury is common and mainly affects young adult males. Herpes simplex keratitis is another common cause of corneal blindness, and, like trauma, is usually monocular. Keratoconus, a disorder of the corneal collagen, typically blinds adolescents and young adults, but is bilateral. As cataract surgery becomes more common, corneal failure from pre-existing conditions or intraoperative surgical trauma becomes the most common diagnosis for transplant patients we have seen, both in U.S. institutions and in the Guyana cohort (see Tables 1–4).

 

Table 1. First mission cases

First Visit: 6 Cases
Recipient	Age (years) and sex	Diagnosis	Procedure	Previous visual acuity	Postoperative corrected visual acuity	Complications/ remarks
1	22F (female)	Keratoconus with apical scar	Penetrating keratoplasty	6/24	6/9 tested with pinhole (PH)	N/A
2	20M (male)	Keratoconus with apical scar	Penetrating keratoplasty	1/60	6/9	N/A
3	48M	Pseudophakic bullous keratopathy	Penetrating keratoplasty	Hand motions close to face (HM)	6/9	N/A
4	36M	Leucomatous corneal opacity	Penetrating keratoplasty	HM	6/6	N/A
5	72M	Post-bee sting corneal decompensation	Penetrating keratoplasty with cataract extraction with intraocular lens implant (IOL)	HM	6/36	Mild sub-epithelial haze with high astigmatism
6	36M	Keratoconus with apical scar	Penetrating keratoplasty	4/60	6/9	N/A

 

Table 2. Second mission cases

Second Visit: 11 Cases
Recipient	Age (years) and sex	Diagnosis	Procedure	Previous visual acuity	Postoperative corrected visual acuity	Complications/ remarks
1	56F	Painful pseudophakic bullous keratopathy	Therapeutic penetrating keratoplasty	Light perception (painful eye)	No light perception (pain-free)	Uncontrolled diabetes
2	29F	Keratoconus and hydrops	Penetrating keratoplasty	Counting fingers (CF) 1′	20/70; 20/70 PH	N/A
3	21M	Keratoconus	Penetrating keratoplasty	CF 4′	20/100; 20/100 PH	N/A
4	58M	Painful pseudophakic bullous keratopathy (anterior chamber [AC] IOL)	Penetrating keratoplasty	HM	HM; no improvement with PH	Raised intracocular pressure (IOP) after 2 months, now controlled
5	74M	Keratoconus and pseudophakic bullous keratopathy	Penetrating keratoplasty	CF 1′	CF 6′; CF 6′ PH	N/A
6	52F	Corneal opacity and cataract	Penetrating keratoplasty and IOL	HM	CF 1’; CF 1′ PH	Opposing eye blindness
7	58M	Painful pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty	CF 1′	CF 2′; CF 2′ PH	Opposing eye blindness
8	12M	Corneal opacity secondary to laser	Penetrating keratoplasty and iridoplasty	CF 6′	20/200; 20/70 PH	N/A
9	14F	Corneal opacity and traumatic cataract	Penetrating keratoplasty and IOL	HM	20/200; 20/100 PH	N/A
10	22F	Keratoconus	Penetrating keratoplasty	CF 2′	20/70; 20/50 PH	N/A
11	18M	Keratoconus and Intacs inserts	Penetrating keratoplasty	20/100	20/70; 20/50 PH	N/A

 

Table 3. Third mission cases

Third visit: 12 Cases
Recipient	Age (years) and sex	Diagnosis	Procedure	Previous visual acuity	Postoperative corrected visual acuity	Complications/ remarks
1	70M	Pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty	CF 1′	HM	Opposing eye keratoconus and patient had trauma with wound dehiscence after 1 month
2	60M	Pseudophakic bullous keratopathy	Penetrating keratoplasty	CF 1′	CF 3′	Opposing eye pseudophakic bullous keratopathy
3	76F	Pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty and AC IOL exchange	HM	CF 4′	Opposing eye keratoconus and adherent leukoma
4	12M	Keratoconus with apical scar	Penetrating keratoplasty	CF 6′	20/70; 20/50 PH	N/A
5	59F	Aphakic bullous keratopathy (childhood cataract)	Penetrating keratoplasty	CF 2′	CF 1′	Opposing eye aphakia
6	78M	Pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty	HM	CF 4′	Opposing eye subluxed IOL
7	52M	Adherent leukoma with cataract	Penetrating keratoplasty	CF 1′	20/200	N/A
8	84M	Pseudophakic bullous keratopathy	Penetrating keratoplasty			N/A
9	74F	Pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty	CF 1′	CF 6′	N/A
10	68F	Pseudophakic bullous keratopathy	Penetrating keratoplasty	HM	CF 1′	Diabetes, hypertension
11	82F	Pseudophakic bullous keratopathy	Penetrating keratoplasty	CF 4′	CF 4′	N/A
12	30F	Keratoglobus	Penetrating keratoplasty	CF 4′	CF 4′	Opposing eye subluxed keratoplasty last visit

 

Table 4. Cases performed by Dr. Sugrim

Post-Visit: 5 Cases
Recipient	Age (years) and sex	Diagnosis	Procedure	Previous visual acuity	Postoperative corrected visual acuity	Complications/ remarks
1	21M	Keratoconus with apical scar	Penetrating keratoplasty	CF 1′	CF 2′	N/A
2	55F	Aphakic bullous keratopathy	Penetrating keratoplasty and IOL	HM	CF 1′	N/A
3	46M	Post-traumatic central corneal scar	Penetrating keratoplasty	CF 4′	CF 4′	N/A
4	70F	Painful pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty and AC IOL replacement	HM	20/200	Raised IOP after 1 month
5	64F	Pseudophakic bullous keratopathy (AC IOL)	Penetrating keratoplasty and AC IOL replacement	LP	CF 4′	N/A

 

Applying lessons learned

Through our experience with these missions in Guyana, we learned several lessons that we believe can translate to similar efforts in other underdeveloped and developing nations.

A key issue in establishing a sustainable corneal transplant capacity in a new location is the local surgical infrastructure. Having a well-educated and experienced local surgeon is essential. Our Guyanese partner, Dr. Sugrim, had the right set of skills and credentials. He was familiar with corneal transplantation surgery from his residency and only needed some updated training and supervision before feeling confident enough to perform autonomously.

Another key to success is access to proper hospital and OR equipment and personnel. The OR staff at Georgetown Public Hospital are energetic and a great example of collaborative teamwork in action. The operating microscope has teaching eyepieces that allow simultaneous viewing for the surgeon and a teacher or student and are essential for training local surgeons.

Eye bank requirements and procedures

Whereas eye banks in the U.S. must be certified by the Eye Bank Association of America (EBAA) and the Food and Drug Administration, eye banks in Latin America and the Caribbean basin should be certified by the Pan American Association of Eye Banks, also known as Associação Pan-Americana de Bancos de Olhos (APABO). APABO certification requirements include adequate space and equipment, 24-hour telephone service, certified technicians, a medical director (an ophthalmologist with expertise in cornea transplantation), and acceptance by the Ministry of Health in the host country. The medical director is responsible for ensuring application of medical standards, education of health care personnel, release and distribution of corneal tissue for transplant, and oversight of the waiting list. An administrative director is responsible for public awareness and quality control, as well as interaction with accreditation agencies, including the APABO, the Ministry of Health, and the national association of ophthalmology.

An approved eye bank also must have at least one certified technician. The role of the eye bank technician includes obtaining informed consent, reviewing medical history, performing a physical examination of the donor, evaluating the eye and determining appropriateness of tissue for transplantation, retrieving tissue by following standard operating procedures of the eye bank, and obtaining serologic testing of the donor. The technician must ensure that the donor has no contraindications, such as testing positive for the human immunodeficiency virus or hepatitis, an injectable drug abuse profile, or active infection of the eye. The medical director oversees the technician’s performance of these tasks and ensures an equitable system for the transplant waiting list, with priority to younger patients and those patients with aggressive disease or bilateral blindness. In most U.S. metropolitan areas, cornea tissue is accessible to such a degree that surgeons can schedule transplants as routine cases on their normal OR day and expect suitable donor tissue to be available.

An independent eye bank must establish medical standards to protect the recipient and the technician, uniform evaluation procedures, systems for recipient and donor data collection, quality assurance procedures, and processes for outcome analysis and ensuring accountability. Thanks to the efficient framework established by the EBAA and high rates of eye donation, the number of cornea donations in the U.S. is on the rise, and often high-quality corneas are available gratis for humanitarian use. Dr. Waller has used this resource in more than a dozen countries, never paying for the donor corneas or charging the host nation recipients. A similar program in the developing world is at the National Eye Bank of Sri Lanka, which is an exemplar of corneal donation and international export of corneas in Asia and serves as a role model for both developed and developing countries.¹⁰

Future visits to sustain the progress to date will focus on improving the pre- and postoperative care of patients, as well as intraoperative teaching and support. Additionally, establishing a local source of donor corneas, potentially a regional eye bank for the entire group of 15 Caribbean Community nations, will take continued medical credibility and persistent political efforts.

The cohort of patients for whom we have performed transplants have a range of diagnoses. The outcomes match those expected of the same cohort in the developed world, and should be the foundation of a sustainable eye banking effort in Guyana. Reporting the rehabilitation of exemplary cases can give visibility and credibility to all the eye bank establishment efforts. Engaging surgeons and potential patients from other Caribbean Community countries may accelerate the momentum we have already achieved in a short time span.

Conclusion

Our team has shown that the PPP model can be used successfully to sustain both kidney transplantation and corneal transplantation in a developing nation. Our five-step approach has shown that specialized surgical services can be sustained with focused training of the local surgeon and close follow-up.

Although no firm timeline has been set for establishing the eye bank in Guyana, each visit by the PPP team improves local capacity, and all parties are focused on creating a program that the host nation can sustain independently. In December 2015, Dr. Norton announced a plan to create legislation for eye donation, which is the first step in the process.¹¹

Acknowledgements

The authors would like to recognize the Subraj Foundation, New York, NY, for funding the missions and the Georgetown Public Hospital Corporation for providing the use of ORs, clinics, and paramedic staff.

Disclaimer

The views expressed in this article are those of the authors and do not reflect the official policy of the Uniformed Services University of the Health Sciences (USUHS), the U.S. Department of the Army, the U.S. Department of Defense, or the U.S. government. No financial conflict of interest exists.

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References

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3. Waller SG, Altieri MS, Jindal RM. Surgeons develop visionary plan to bring corneal transplants to developing countries. Bull Am Coll Surg. 2015;100(5):22-28. Available at: bulletin.facs.org/2015/05/surgeons-develop-visionary-plan-to-bring-corneal-transplants-to-developing-countries/. Accessed April 12, 2016.
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7. World Health Organization. Visual impairment and blindness. Fact sheet No. 282. Updated August 2014. Available at:www.who.int/mediacentre/factsheets/fs282/en/. Accessed March 7, 2016.
8. Ellison JB. Intensive vitamin therapy in measles. Br Med J. 1932;2(3745):708-711.
9. Sommer A, Tarwotjo I, Djunaedi E, et al. Impact of vitamin A supplementation on childhood mortality. A randomised controlled community trial. Lancet. 1986;1(8491):1169-1173.
10. Gain P, Jullienne R, He Z, et al. Global survey of corneal transplantation and eye banking. JAMA Ophthalmol.2016;134(2):167-173.
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Source: Bulletin