Friday, July 29, 2022

The Need For Separating Corneas From Other Organs In Transplantation of Human Organs and Tissues Act

By Jashwant Mehta, Founder Member & Ex President, Eye Bank Association of India (EBAI) & Chairman (Board of Advisor) & Managing Trustee, EBCRC

Eye Donation:

When we talk about eye donation it is mainly the retrieval of corneas from the human body after death. Cornea is a transparent outermost layer of the eye and it can be compared to the lens of the camera. Light goes in the eyes through cornea like lenses in the camera. In case of any injury to the eye due to any accident or any infection to the eye, the cornea gets damaged and the light cannot enter the eye. This condition is called corneal opacity. Thus even if the other organs of the eye like retina etc. are intact, there will be no vision. Unlike other organs such as kidney, liver, heart etc. which have to be retrieved before the actual death takes place; the endothelium cells in cornea remain alive up to 6 hrs after death and if retrieved within this period it is viable for transplantation.

Present status of corneal opacity & eye donation:

While there are several causes of blindness such as Cataract, Glaucoma or Retina detachment, the no. of people who suffer from corneal opacity are estimated about 8 to 10% of the total blind which works to about the 3/4 (three quarter) of the million people who can be benefited from the corneal transplant 

Prior to the pandemic which has badly affected eye donation activity, we had around 25000 corneal transplants per annum taking place in our country. To eradicate corneal blindness in a reasonable time frame of say 10 years of time, we need to perform at least 100000 transplants per year. To give some idea about the USA which is having 30% of our population, on an average they perform 50000 transplants every year.

It is very obvious that we need to separate cornea from the other organs and have favourable legislation. In fact, when HOTA was being enacted in 1994, we had prepared a model corneal Grafting Act & submitted to the parliament. Unfortunately, our law makers have never taken a note of this & this has seriously retarded our progress.

We started eye donation activity way back in the mid fifties. But in 65 years our progress is very slow. Several countries including the USA have separated cornea from other organs & have proactive legislation & their progress has been much better than ours. To give you some idea during the 10 years period between 1961 & 1971 they had a total of 20000 transplants performed. After a proactive & favourable legislation was enacted in various states in mid 70s and 80s, the number of eye donations which was a mere 6000 in 1967, touched a huge figure of 36000 in 1988. Presently in the USA, apart from performing 50000 transplants, they have surplus corneas which are sent to other countries where there is an acute need, number being 20000 to 25000 per annum.

By having cornea clubbed with other organs, all-along it has hampered the eye donation activities. Till 2012 it was mandatory to have a registered medical practitioner to enucleate the eyes. There were several obstacles created in HOTA including the requirement of a registered medical practitioner for retrieval of cornea. In large numbers of eye donations the retrieval of eyes has to be done at the home of the deceased and it was difficult to have registered medical practitioners who could spare the time of atleast 2 hrs required for this process. It was only in 2012, when HOTA was replaced with THOTA, we could manage to set this amendment. However, except for this cornea is still clubbed with other organs & we have no provision for Required Request & Presumed Consent which has helped the other countries to achieve much faster progress in eye donation & corneal transplant. In Required Request provision, the request for consent for eye donation is mandatory to be made to the next of kin when the death takes place & it has been found that if request is made even with little motivation so atleast 10% families are agreeable for consent for eye donation. In Mumbai alone nearly 80000 to 90000 deaths take place every year & we are able to retrieve 10% cornea, the number would be 8000 to 9000 eye donation. This is much larger than the present 1500 to 2000 eye donations received every year. In Presume Consent, unless there is a pre recorded refusal, the cornea is allowed to be retrieved in all medico legal cases where post-mortem has to be performed. In Mumbai alone we have 7000 medico legal cases where post-mortem is required to be performed & even if we are able to retrieve 30 to 40% of cases, this also would go a long way & Bombay itself can become the hub for corneal transplant in Maharashtra.

In the USA, the Required Request Law is strictly enforced in every case of death and hospital authorities have to request and if the request is not made, there is a punitive punishment. Similarly, under Presumed Consent, the eyes are allowed to be retrieved in all post-mortem cases. It must be mentioned that removal of eyes doesn’t affect post-mortem findings & also doesn’t disfigure the face. Both these are not possible for obvious reasons in other organs.

After our continuous representation & follow-up with good offices of Mr. Desiraju who was the then Health Secretary, we could manage to overcome this hurdle & have trained technicians permitted to enucleate the eyes and from 2013 till now HOTA has amended and now it is THOTA. However, except for this amendment cornea is not clubbed with other organs & there are no provision of Required Request & Presumed Consent for eye donation.

Having a proactive & favourable legislation would not only eradicate corneal blindness in our country but will also enable us to send corneas in several countries such as our neighbouring countries Bangladesh, Malaysia & several countries in Africa etc. where there is an acute shortage and will make India a leader in eye donation & corneal transplant in the world. 

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