Changing inclinations of eye banking

Sight is the noblest sense of man.

- Albrecht Durer

The role of eye banking practices remains crucial in the eradication of corneal blindness. Eye banks are constantly challenged by the limitation of unsteady donor corneal tissue availability and donor tissue-related infection concerns. Decreasing donor corneal tissue demand, optimal tissue sharing practices, improved eye banking personnel training, better access of remote populations to trained corneal surgeons, improving donor storage media, and provision of precut-preloaded donor tissues for endothelial transplants are some of the concerns in the expanding scope of eye banking practices. Eye banks are also facing the challenge of distribution of high-quality donor tissues, given the medical advancements in communicable disease management that enable viral load reduction and disease cure.[1] Whether the donor corneal tissue of such voluntary donors will be suitable for eye banking practices is a matter that will become a reality soon. This brings to the forefront the question of revisiting the donor deferral criteria for eye banks, transplantation regulators, and standard setting organizations, especially in societies with a higher prevalence of communicable infectious diseases. Estimation of SARS-CoV-2 colonization in ocular tissues, long-term corneal preservation, new disinfection strategies, alternatives to donor corneal tissues, custom corneal transplants, and cell-based therapies for the treatment of corneal disease were some of the avenues that were widely explored during the recent COVID pandemic’.[2,3,4]

Although long-term follow-up data are lacking, preloaded Descemet membrane endothelial keratoplasty (pDMEK) has been recommended to be more cost-effective in comparison to that of non-preloaded DMEK (n-pDMEK).[5] Eye banks need to work toward optimal provision of preloaded tissues to enable surgeons adopt DMEK more effectually into their practices. A recent report on the effective storage of human corneas for 3 months in the Active Storage Machine (ASM) that establishes intra-ocular pressure and medium renewal shows optimism on extending eye banking perspectives to experimental research.[6]

The constant challenge of meeting the increasing demand for transplantable donor corneal tissues, which is faced by eye banks world over, has fueled research to explore alternate avenues. The concept of clinical application of corneal stromal replacement therefore has been widely researched in recent times. Research on biosynthetic corneal substitutes such as synthetic inert keratoprostheses, acellular scaffolds with and without enhancement of endogenous regeneration, and cell-based replacements[7] has come to the center stage in recent times. Corneal tissue bioengineering research is encountered with concerns in isolation and stable expansion of the various cell types required for effective corneal regeneration. Current trends in experimental and preclinical research in this area hover around a combined approach of integration of stem cell expansion and a biological or synthetic scaffold.[8] With promising research work going into artificial biosynthetic cornea modeling with 3D printing, it remains to be seen if it will be able to attain suitable optical clarity, tectonic integrity, and biocompatibility.[9] Future prospects of eye bank functioning look at the integration of donor tissue logistics with that of research related to human pluripotent stem cell lines for use in cell therapy manufacturing.[10]

Besides providing support to the training of eye banking personnel and corneal transplant surgeons in remote areas, functioning eye banking model establishments in various nations are moving toward innovative research pertaining to pluripotent stem cell, corneal epithelial, stromal, and endothelial stem cell bioengineering. A paradigm shift in healthcare related to eye banking is now witnessing a rise in “venture philanthropy” practices of not-for-profit eye banking models, which coexist with regional eye banks and are working toward spearheading innovative research related to donor corneal tissues through their profit-based subsidiary establishments.[11] Several ethical questions remain in the face of such functioning eye banking model establishments, which claim to integrate patient, surgeon, donor, and practice logistics related to eye banking and research.

Among all these rising concerns, on the occasion of 38^th National Eye Donation Fortnight (August 25 to September 8), we raise an oath to honor the memory of all those donors for their act of supreme kindness to humanity.