"Even among what little was collected, only half have been successfully transplanted due to hurdles created by the pandemic. "
Dr Mahipal Sachdev, professor and the president of the All India Ophthalmological Society (AIOS), during a procedure
THE pandemic has seen a massive drop in cornea collection and transplant in the country, majorly because of the Union Ministry of Health's directive against home visits for retrieval from the non-COVID-19 deceased. The city activists now demand that eye banks are allowed to resume home collection of corneas with adequate safety against the virus. >> P08
CITY activist B N Kumar said when people go for cremations, they are asked for no-COVID-19 certificate as a precautionary measure. Similarly, eye banks should be able to collect cornea with a certificate declaring the deceased did not have COVID-19.
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The drastic fall in cornea collection is severely impacting eye surgeries, which is sad, he added.
Dr Suvira Jain of K G Bachooali Eye hospital, Parel, suggested encouraging all eye banks to start functioning, and requested government to consider resuming home collection setting appropriate screening guidelines for donors
The awareness about organ donation, particularly of eyes, must be spread far and wide. Kumar pointed out that studies show half of the eyes donated are unfit for transplant. This calls for improved efficiency of eye banks, he said.
The All India Ophthalmological Society (AIOS) is in the process of collecting data on cornea collection and transplants since the outbreak of the novel Coronavirus in the country.
Preliminary data from March and May 2020 shows only 1,900 corneas were collected across the country, whereas during the same period in 2019, eye banks collected 8,747 corneas -- a drop of almost 78 per cent. In June 2020, the number came down to 192 from 2,997 in June 2019 -- a drop of almost 82 per cent.
Dr Meghali Bhattacharje from Shanmukhananda Eye Care, Matunga, examines a patient
In terms of transplants, 880 were done between March and May 2020, against 4,129 during the same period in 2019. A total of 1,078 transplants were done in June 2019, whereas only 196 were done in June this year.
Dr Mahipal Sachdev, professor and AIOS president, said, “We have procured the all-India cornea retrieval and transplant data till June 2020, and we are still in the process of collecting the same in the following months. As per the Ministry of Health and Family Welfare (MoHFW) directive, all home collection of cornea has been put on hold since the virus outbreak. Almost nil donation has come in from home collection. Those collected so far are from the non-COVID-19 hospital.”
He added that drop has also been seen in transplants, "which is usually nearly 50 per cent of the collected corneas, as nearly half of them cannot be transplanted due to various factors.”
“All medical activities deemed required by the hospital can be carried out by all hospitals, except in containment zones. COVID testing for pre-operative patients is not mandatory but can be done as per the hospital policy and at the discretion of an anaesthetist or doctor even if the patient is asymptomatic. Prioritise surgeries as per medical emergency for corneal transplants: Tectonic and therapeutic corneal transplants to be done on priority over optical and lamellar corneal transplants. Special consents can be added to the preoperative protocol for COVID time” said Dr Sachdev.
"The AIOS has come up with a 100-page directives for all its 23,000 members nationwide, wherein preventive steps are being given for various ophthalmological treatments, including surgery and eye care,” said Dr Sachdev.
"The number of corneal blind patients is 1.1 million and every year approx 35,000 patients are added to the list. The number of transplants performed in 2019-2020 is over 26,500," he said. As per the latest National Blindness and Visual Impairment Survey 2019, Corneal opacity is the second largest cause of blindness in the population aged above 50, he added.
Dr Meghali Bhattacharjee, alumna of Shankar Netralaya in Chennai and the centre head at Shanmukhananda Eye Care, Matunga, said, “Earlier, we would get major cornea donation from deceased via home collection, which has become almost nil during the pandemic, as it is not possible to test the deceased for COVID-19 within six hours, the time within which the eyes need to be harvested in the eye bank.”
She added, “The cornea transplant is also called Keratoplasty, where in the recipients' damaged cornea, which had caused temporary blindness, is rectified through the donor’s cornea, which at present has drastically reduced at this moment of time due to the pandemic, as the number of collection of corneas are only restricted through non-COVID hospital donations.”
"Corneal blindness is the second common form of blindness that we have been seeing for the past couple of decades in the country. The COVID-19 pandemic has adversely impacted the number of cornea transplants not only in India, but world over," Dr Meghali added.
The Mumbai chapter
Dr Suvira Jain, clinical head of department (general ophthalmology /cataract/ cornea and phaco development) at K G Haji Bachooali Eye hospital, Parel, said, “Eye banking came to a grand halt because we were hit with an immediate lockdown from March 20. As the city's lifeline shut down, transportation of technicians to eye banks stopped and lack of knowledge about the virus resulted in fear among the technicians about home visits."
Eye Bank Association of India (EBAI) came up with its guidelines in April, suggesting no voluntary calls for home collection as deaths due to COVID-19 could not be ruled out, as there was a risk of technicians contracting the virus. EBAI stated calls for collection should only be taken from non-COVID-19 hospitals.
Potential donors were ruled out if there was a history of travel within 28 days, or had fever or respiratory symptoms before death.
Once the eye banks have confirmed they have excluded the history required to retrieve eyeballs, they go ahead with two different protocols. Certain eye banks wait for last COVID-19 report provided negative while patient was alive, will collect eyeball process it in addition to the other eye banks would do a RAT test on site and wait for ten minutes if negative will go ahead with retrieval with proper protection according to covid guidelines get the RT PCR (performed by resident doctors from supportive hospitals) with necessary blood tests.
The EBAI guidelines also stated that the tissue be quarantined for 48 hours before giving it away. “Eyeball retrieval was done by trained technicians after following strict guidelines. Tissue was collected with corneal scleral rims (donated part of the eyeball) retrieved after double contact of povidone iodine + disposal of waste and kits in double layered bags to avoid risk of infection to others"
All donor forms and documents were sanitised with UV light exposure in laminar flow hood for one hour.
Over a period of time, certain eye banks started collecting tissue from non-COVID-19 patients admitted in COVID-19 dedicated hospitals, because of very strict protocol of admission, isolation and testing for COVID and they were also kept segregated."
Tissue distribution
Tissue is distributed according to the CDSM (cornea distribution system of Maharashtra), as it is clearly obvious the number of tissues collected for eye donation significantly thereby increasing the waiting list significantly.
As a priority, tissue is being provided to the Mumbai-Thane area and cases with therapeutic/corneal infections/children/ one-eyed patients are given priority requiring keratoplasty as opposed to routine optical keratoplasty (keratoplasty for corneal opacity/ decompensation), explained Dr Jain.
Lamellar Keratoplasty?
One of the other reasons for lamellar keratoplasty is non-COVID-19 admissions in hospitals during the pandemic have reduced significantly. Certain eye banks have risen to the occasion and provided cryo-preserved/Glycerol preserved tissue for highly infected eyes (therapeutic keratoplasty) with the aim of salvaging eyes.
According to our survey, the overall drop in eyeball retrieval between March 17 to October 14 this year, in comparison to the same period in 2019, was 92-95 per cent whereas the utilisation rates also significantly dropped between 89-95 per cent, said Dr Jain.
The way forward
Dr Jain suggests encouraging all eye banks to start functioning, requesting the government to consider resuming home collection of tissue after setting appropriate screening guidelines for these patients. Encouraging collection of tissue from non-COVID-19 deceased individuals from hospitals.
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Precautions while seeking ophthalmic care
Dr Suvira Jain and Dr Neha Vyas Joshi, Cornea Fellow, have listed a few advise for patients seeking ophthalmic care during the pandemic
1. Patients are advised to seek ophthalmic medical care only when essential.
2. If issues, like red eye/swollen eye, can be solved by teleconsultation you can book an appointment for the same. However, it is preferable to be seen by the treating ophthalmic clinician.
3. Sanitisation of the clinic and optimal cleansing of the clinic equipment is done at a regular basis to ensure patient safety.
4. There seems to be a general trend of patients to consult doctors at non-COVID-19 centres rather than centres which usually treat COVID patients. It's completely ok to do so as it’s a personal choice of the patient.
6. There is no evidence to prove an increased risk of COVID-19 infection because of your visit to an ophthalmic consultant, however, all precautions must be strictly adhered to.
7. Wearing a clean mask that covers the nose and mouth adequately is mandatory at all times. Often clinics do provide a disposable mask if the patient does not have a mask or has an inappropriate one.
8. Please ensure you sanitise your hands after wearing/adjusting the mask.
9. Refrain from touching any other surface after wearing the mask.
10. Carry your personal Hand sanitiser to the clinic.
11. Please keep your appointment timing to avoid crowding due to overlapping of patients
12. If given an option, it is preferable to wait outside in an open area until called inside for your appointment.
13. If waiting in a clinic, preferably wait in a well ventilated area and maintain adequate distance between the patients around.
14. It is advisable to Restrict your accompanying attendants to bare minimum.
15. Minimise the consultation time to what's essential. Perhaps extensive queries can be answered on telephone or via email.
16. At the end of the consultation, dispose of your mask, bathe immediately after reaching home and change your clothes.
17. As responsible citizens, please refrain from visiting any clinic if you have any symptoms suggestive of COVID-19 or have come in contact with any COVID-19-positive patient within the last 14 days.
- Dr Meghali Bhattacharje, centre head, Shanmukhananda Eye Care, Matunga
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