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March 2013 Issue

Post-ARVO Eye Banking Workshop Registration is Now Open!

SightLife will sponsor a surgeon training immediately following the Association for Research in Vision and Ophthalmology (ARVO) conference in Seattle, WA. Interested surgeons from around the world are invited to attend this 1.5 day workshop (9-10 May) that will include best practices from SightLife and other leading eye banks as well as a deep dive into practical applications for building successful eye banks in developing countries. If you are interested in learning more, or to register, contact Brian Washburn at .(JavaScript must be enabled to view this email address).

 
photo of SightLife trainers and EDCs
SightLife trainers and EDCs at the end of a training session at the SightLife office in New Delhi

The Power of Partnerships

In the six months since it was established, the Delhi Centralized Hospital Cornea Recovery Project (DCHCRP) already has many “firsts” to its credit. Among them, nine corneal transplants in a single day, telephonic consent, and a record three donor assents in just one hour.

The project is itself a first-of-its-kind initiative in India to collectively address the challenges in collection and utilization of transplantable tissues. Four organizations — the National Eye Bank at AIIMS, GNEC, Dr Shroff’s Charity Eye Hospital and SightLife — have joined hands to make DCHCRP a story of successful public-private initiative.

“DCHCRP has shown encouraging results in a short time,” says Dr. Radhika Tandon, Medical Director, NEB. In the 6-months since its launch, NEB, GNEC and SCEH have reported an average 107% growth in number of transplants done in 2012, compared to their performance in 2011. More importantly, 72% of the total transplants done in the latter half of 2012 were from tissues generated through DCHCRP.  “We are excited about the project and are enjoying the outcomes so far,” adds Dr. Tandon.

To ensure smooth functioning of the project, two committees have been formed for continuous guidance, support and review. Overall direction-setting is provided by the Steering Committee, which has top-level representation from all partners. The Working Committee, meanwhile, comprises key persons from each eye bank and ensures implementation of the project. A dedicated manager is responsible for managing the project on a day-to-day basis.

“Because of DCHCRP I have been able to operate on young and bilateral blind patients who had been waiting for tissues for a long time,” says GNEC’s Medical Director Dr. Ritu Arora, showing her recipient records. “The waiting list is decreasing day by day.”

A distinguishing feature of the DCHCRP is sharing of tissues generated through the project. Each eye bank has a reserved quota per month. Once that is met, the tissues are shared between themselves at a no-cost basis.

“When the intention is clear, the mechanism will appear. DCHCRP is proof of this saying,” says Dr. Umang Mathur, Medical Director of SCEH. “The intent was clear and there was motivation to contribute towards efforts in treatment of corneal blindness. SightLife provided the direction and technical support that allowed us to share our talents and strengths with each other.”

EDCs: The Backbone of the Project

EDCs are integral to the success of hospital cornea retrieval programs. A two-pronged approach was adopted to ensure that the project was supported by a group of dedicated, motivated and trained personnel. Of the total 15 EDCs in the project, seven have been pooled in by SightLife, six by SCEH (two of them senior EDCs) and two by AIIMS.

The SightLife-led hiring process included three rounds of selection, including field visits by the applicants. The Selection Committee itself comprises representatives from all partners. In the first phase of hiring, five EDCs were appointed and, along with their peers from AIIMS and SCEH, they underwent 15 days of extensive training and onboarding programs. Two more EDCs were hired in October. Of the 15 EDCs, four EDCs are posted at AIIMS and the hospital’s Trauma Center, three at LNJP Hospital, two at R.M.L. Hospital, one each at GB Pant and DDU Hospitals, and four EDCs in smaller hospitals.

Within the first month, the program’s EDCs were posting significant results:

  • 65 corneas transplanted during the first month
  • 343 corneas transplanted in 6 months
  • average per EDC was 5.4 transplants a month

EDCs Deepak and Pooja reported the highest productivity with an average of 10 transplants a month. The fact that all EDCs have reported a 100% attendance is proof of their dedication to the project. “I feel very special and proud to be chosen for this job as I am able to help people see this beautiful world,” says Pooja. “This job made me a responsible person.”

To ensure EDCs continue to be motivated and are armed with adequate training, team-building sessions and coaching programs are conducted on a monthly basis. The DCHCRP Manager also tailors training programs according to individual needs, and carries out field visits to provide hands-on real-time guidance in the hospital environment.

Pooling of resources is not limited to EDCs. The medical directors — Dr. Mathur, Dr. Tandon, and Dr. Arora — work in close collaboration on standardization of processes, including adopting a common contraindications protocol.

Looking Ahead

The DCHCRP team delivered 9% above-target performance in 2012. The goal for 2013 is to achieve 1,100 transplants by:

  • hiring more EDCs
  • adding new hospitals to the partnership
  • focusing on hospital services
  • creating professional development plans for all eye donation counselors (EDCs)
  • standardizing recovery and evaluation processes, including a refresher training program for technicians.

The dedicated DCHCRP team that is learning from each other and is open to sharing has the potential to make the project a model that can be scaled and sustained in other cities in India and developing countries where tissue availability is a challenge. “We are optimistic that DCHCRP will develop into a successful model that can be replicated elsewhere,” says Dr. Tandon.

 
photo of EDCs Jagat and Roshan Singh
Father and son EDC team Jagat and Roshan Singh

Jagat and Roshan Singh

Roshni. “Ray of Light.” In the world of Eye Donation Counselors in India, roshni is a powerful word. Their conversations with the deceased’s families are peppered with this magic word that evokes powerful imagery—of a veil dark as night being lifted to allow the first rays of light to enter the innermost recesses, brightening an existence so far deprived of the sense of sight. And when this word is used in the context of providing sight to children it has the power to work wonders.

Jagat Singh, 54, knows the worth of the word in sight restoration. He’s been an EDC for eight years with the eye bank at Dr Shroff Charity Eye Hospital, Delhi. Thus far, he has motivated 575 families.

A typical working day for Jagat begins at the hospital where he is posted. His job of tracking deaths is easier if the hospital has a centralized death notification center. Otherwise, a prudently cultivated network of nurses, ward boys, and other hospital staff alerts him to a death.

He begins with checking the medical history of the deceased to rule out contraindications. The next step is crucial to get consent — observing family members to zero in on one person whom appears influential. Meanwhile, he also engages himself with the family, offering any kind of assistance they may require. He then approaches the decision-maker. How he conveys the message — his demeanor, language, and the subject — is critical to getting consent.

When he talks about being an EDC, Jagat slips into his role instinctively. His voice is not inappropriately loud, nor too soft that the request is mistaken as “begging”. His body language expresses genuine empathy. He commiserates, then requests for donation. He then braces himself for the questions that will follow (in some cases, an outright “no,” a hard stare, a tell-off). The questions — interrogative and probing — could come from many quarters, even simultaneously.

For an EDC, confidence in getting consent comes through formal training followed by hands-on experiences. “But you also have to have an unquestionable belief that you are working towards a virtuous cause,” says Jagat. Experience has taught him how to detach himself emotionally from bereavements he is exposed to. He has also learned to accept “no” for an answer as long as he knows he’s done his job to the best of his abilities.

All in the Family

Jagat was literally to the hospital born, in the staff quarters of the SCEH — one of the first eye care centers in Delhi, it celebrates its centenary in 2014 — where his father was employed. He was married at 14 to a girl who was nine. At 17, he was a father. In 1977, Jagat was given his father’s job after his demise. He worked in various departments of the hospital till 2004 when he was among the first to join the newly launched eye bank.

Shroff’s quarters are also where his children were born. Incidentally all his children have names that are synonymous with light — Roshni, Jyoti, Roshan and Sandeep. Following in the footsteps of his father is Roshan, 29.

As an EDC with the Delhi Centralized Hospital Cornea Retrieval Project, Roshan is creating new records — highest number of consents in a month by an EDC (10) and three consents within an hour — within six months of recruitment.

That the young Roshan has learned well from his father is evident in the way he talks about his role and commitment. Jagat had introduced his grieving son to his world of death to help him cope with his own loss. Married just four years, Roshan was still mourning the loss of his wife, who had left behind twin daughters and a 2-month-old following pregnancy-induced jaundice from which she could not recover.

As if by Divine Providence, Roshan’s second consent came from a family who had just lost their two year-old named Roshni. When the retrieval was done, Roshni’s uncle came to Roshan and said something that reminded the young EDC that he was living up to his name. “Ek Roshan ne ek Roshni ko roshni dee aur wo Roshni phir se duniya mein dusron ko roshni degi.” Loosely translated, it means a light lighting up the life of someone without light. This isn’t clichéd wordplay. Neither to the donor and recipient, nor to Jagat and Roshan.

 
photo of 16-year-old Nepal Eye Bank cornea recipient with her family
16-year-old Jasima, center, received her cornea transplant from the Nepal Eye Bank

Nepal Establishes Corneal Retrieval Program

In an effort to address the urgent backlog of patients awaiting cornea transplants, the Tilaganga Eye Institute’s Nepal Eye Bank in December launched its community-based hospital cornea retrieval program (HCRP). The objective is to make at least 500 transplantable tissues available to corneal surgeons in 2013.

Five counselors were handpicked from a pool of over 160 candidates. An extensive six-step hiring process was followed rigorously to ensure the chosen EDCs were deeply motivated, dedicated and hard-working. Rakhi Nathawat, Mridula Chettri Singh, and Manoj Gulati from SightLife spent time in the selection and onboarding process for EDCs. Meanwhile, Dr. Leena Bajracharya, Bhagirath Baniya and Shankha Twyana continue to play an active role in integrating the EDCs into the project.

Two large-mortality hospitals in Kathmandu — Tribhuwan University Teaching Hospital and Bir Hospital — collaborated with Nepal Eye Bank for the project. In the first month, 28 HCRP corneas were transplanted. Each of the EDCs has reported a minimum of one successful case.

Ultimately, the goal is to collect sufficient corneas for distribution to surgeons throughout Nepal via a system similar to the one in India. SightLife recently conducted a survey to understand the practice of corneal surgery in Nepal including demand for tissue and surgeon potential.

 
photo of DSEK corneal tissue preparation
An eye bank technician performs DSEK on a donor cornea

First Pre-Cut Tissue Centre Opens in South Asia

The SightLife Pre-Cut Centre at the L. V. Prasad Eye Institute in Hyderabad has created a buzz among corneal surgeons in India since its inauguration in October 2012.

The center opens the doors for corneal surgeons in India to access quality tissues for DSEK (Descemet’s Stripping Endothelial Keratoplasty). DSEK has increasingly gained popularity among surgeons as a technique of choice for treating various diseases of the cornea.

Since 2006, eye banks in the U.S. and Europe have been developing protocols to safely and effectively prepare donor tissue for surgeons pre-operatively at eye banks.

Benefits of DSEK:

  • saves time and money
  • eliminates the stress of performing donor corneal dissection in the operating room
  • does away with the cost of investing in specialized corneal dissection instruments
  • eliminates the potential complications associated with intraoperative cutting of donor tissue

Preparing the posterior lamellar tissue for DSEK requires special tools and trained professionals. The new center at LVPEI is outfitted with the required expertise and equipment, including a new microkeratome. Every tissue is re-evaluated for cell count prior to and after dissection. All pre-cut tissues are stored in a viewing chamber with a long-term storage media.

The SightLife Pre-Cut Centre will soon be available to surgeons across the country.

 
photo of 22-year-old cornea recipient Jobin Thomas
22-year-old cornea recipient Jobin Thomas

Jobin Thomas

Age: 22
Location: Idukki, Kerala (India)
Pre-surgical Diagnosis: Keratoconous
Surgery Type: DALK
Surgeon: Dr. Aneeta Jabbar
Eye Bank: Eye Bank Association of Kerala

At 22, Jobin Thomas is like any other young adult — ambitious and raring to go. But just six months ago it was a different story. For four years, he had been running between eye care centers seeking treatment for his blurring vision. He discontinued studies, scouted for work, and tried to hold on to whatever he could find. Finally, he arrived at the Little Flower Hospital in Angamaly.

Thomas was diagnosed with keratoconous in both eyes along with a scar in the left cornea. Soft lenses were not an option because he was allergic, RGP lenses were ruled out because he had developed intolerance due to long-term use, and implantable contact lenses (Intacs) were unaffordable. Finally, Dr Aneeta Jabbar decided to do a DALK on his left eye. The surgery was done in August 2012 with tissue provided by the Eye Bank Association of Kerala.

Today, Jobin sees 6/24 with his left eye. He’s awaiting surgery on the second but he’s already seeing a world of hope, where he is studying, working and living a “normal” life.

 

Diskshu

Age: 7
Location: Jaipur, Rajasthan (India)
Eye Donation Counselors: Priyanka Swami and Ram Chandra Gurjar
Recovery Technician: Nav Ratan Gurjar
Eye Bank: Eye Bank Association of Rajasthan

The kite-flying season in Jaipur is a magical time for children. As seven year old Diskshu tried to catch one of the colorful kites fluttering in the winter sky, he was unaware of the danger of doing so on the terrace of a house. His fall to the ground proved fatal.

Eye donation counselors Priyanka Swami and Ram Chandra Gurjar were doing the rounds at SMS hospital when Diskshu’s body was wheeled in. As they waited for the police to arrive, they screened the attending family members to determine who best to approach for permission to donate Diskshu’s corneas. Priyanka was particularly anxious since this was her first case as an EDC. With the support of the police and the mortuary staff, she and Ram Chandra approached the uncle of the child, explaining that the donation of corneas could possibly give sight to two blind children.

The uncle heard them out and then called on Diskshu’s father, who wanted to consult the elders. Diskshu’s family eventually consented to the cornea donation with the condition that the recovery was done within 20 minutes. Says Priyanka, “For me, this was one instance where the eye bank, mortuary staff and police personnel came together to support the cause of blindness.”

 

Dr. Vikas Mittal

Age: 36
Centre: Sanjeevini Eye Care, Ambala, Haryana
Training in Cornea: L.V. Prasad Eye Institute, Hyderabad (2005-2006)
Surgical Expertise: PK, DALK, DSEK, DMEK
Annual Number of Corneal Surgeries in 2012: 305

Why Cornea: Just a few months after my PG, at a conference in 2004 in Chennai, I watched Dr Mark Terry present on endothelial keratoplasty. He opened up the possibility of what I used to dream of: what if we could just replace the endothelium? There and then I decided “cornea” was my calling. Terry’s face and presentation are still vivid in my mind. I decided on doing a fellowship from LVPEI. It took me three attempts and one year to get into a training of my choice. There has been no turning back since then.

Return to Home City: Post-fellowship, my wife, Ruchi (who did a vitreo-retina fellowship from Sankara
Nethralaya) and I had lots of opportunities in cities in southern India. We were surely tempted. But since Ambala is my native place and I am emotionally attached to this town, we decided to return home in November 2006 on one-year trial period. We would relocate if we could not sustain ourselves. I met other private practitioners and started work. When I told my peers and seniors that I wanted to practice cornea in a small city like Ambala, many of them cautioned me about scope of work. I was reminded of legal issues involved in cornea transplant surgery, lack of tissues and challenges involved in dealing with post-op patients. But I was convinced I wanted to work in Ambala. God was kind to us, and one year was enough for me to see the need and the potential, and also know I had acceptance among my people. In August 2008, I started my own practice. Today, I am happy I am making a difference, though small so far, in the region where I was brought up.

Success Mantra: Follow your passion. I am fortunate I have a profession I love. Get good training. LVPEI made a better human being out of me. Apart from giving me academic expertise, it taught me how to approach life and the patients.

Daily Drive: I draw a lot of satisfaction from every day work and the fact that I am in tune with the best techniques and technology available in the world. I try to involve myself in academics too, which is another significant drive for me. And yes, I have strong faith in God.

High Point in Life: Birth of my first son Aarav in Oct 2006 and my first EK in 2007.

Biggest Challenge: Time management. There is so much I want to do.

Outside Ophthalmology: Adventure sports, traveling, reading.

 

Ethiopia’s First Hospital-Based Donor

The Eye Bank of Ethiopia recently reached a milestone, recovering its first corneas from a hospital-based donor. Since its founding, EBE has relied solely on legislative/presumed consent from donors in the police morgue.  While technically this first donation was a first-person consent (donor card/ pledge form) and the approach was family-initiated (voluntary), this case marks a critical change to active interaction with donor families and tissue recovery being performed in a hospital environment. “This donor has made history,” said Wondu Alemayhu, who was involved with establishing the eye bank.

As EBE continues to increase its eye donation counselor staff and training, build hospital relationships and conduct awareness activities, this is a significant step in its progress towards acceptance and adoption of active family-approach processes in the hospitals (HCRP).

 
pie chart

Cornea Distribution System

The SightLife-EBAI Cornea Distribution System (CDS) pilot project, established to distribute cornea tissue in excess of local community demand at a national level, distributed 211 donor corneas to 18 surgeons in India during its first six months of existence.

Two eye banks—the Drushti Daan Eye Bank, Bhubaneswar, and Eye Bank Association of Kerala, Angamaly—participated in the pilot project that was launched on July 15, 2013.

Of the 211 tissues, 203 were optical and eight were therapeutic. The average age of the donor tissue distributed through CDS was 53, while the average cell count was 2,776.

The tissues were prioritized and matched according to the medical prioritization policy laid down by the Surgeon Advisory Committee of the CDS. Usage included seven cases of emergency and bilateral blind, 35 emergencies, four bilateral blind children, nine children with routine pre-surgical diagnosis, 38 routine bilateral blind and the remaining for routine surgeries.

Dr. Shroff’s Charity Eye Hospital, Delhi, joined the CDS in January 2013.

 

MEB and EBSR

With two managers leaving the eye bank in succession, Mohsin Eye Bank (Vishakhapatnam) and Eye Bank Society of Rajasthan (Jaipur) were both facing the challenge of running an eye bank without an operational leader.

The counter-effects of operational leaders leaving in succession were evident. At Mohsin, the average number of transplants fell from 24 during the first quarter of 2011 to 11 during the second quarter. The story was no different in Jaipur, with two managers leaving the eye bank within a span of three months, causing a drop in productivity during second and third quarters of 2012.

Thankfully, for MEB, G. Radhakrishna joined the eye bank in January 2012 and for EBSR, Priyanka Swami joined in October 2012.  Different locations, different environments, different sets of challenges, yet these two eye bank managers have managed to turn around the eye banks.

Read more about MEB and EBSR’s EBM-driven success stories in the next issue.

 
photo of corneal surgeon Anthony Aldave and medical students
Dr. Anthony Aldave shares corneal surgery skills with students in Vietnam

Building Surgeon Capacity Around the World

In developing countries, there are 10 million people in need of corneal transplants. Yet less than 50,000 transplants are performed annually by about 1,000 surgeons.

The challenges to filling the global need for corneal transplants  in developing countries are:

  • lack of transplantable tissues
  • insufficient number of surgeons
  • lack of understanding of patient selection criteria and follow-up
  • lack of access to new surgical techniques that increase post-op success rate and utilization of tissues

India, for instance, has set a goal of performing 100,000 cornea transplants by 2020. Just seven years short of the milestone year, however, the country’s estimated 350 corneal surgeons only perform 20,000 surgeries annually — far short of the goal.

To address the gap, SightLife established the Corneal Surgeon Capacity Taskforce (CSCT) — comprised of a global team of corneal surgeons and INGOs committed to eliminate corneal blindness — to work towards training more corneal surgeons and highlighting the importance of both appropriate patient selection and rigorous post-op follow up.

Read more about CSCT’s work on boosting surgeon capacity in future issues of Viewpoints.