Eye Donation

Eye donation is the voluntary donation of the eyes after death, for corneal transplantation, for research, or for training. Only the cornea is transplanted — the whole eye cannot be transplanted, because the optic nerve cannot be reconnected.

Corneal blindness is a leading cause of avoidable blindness in India, with a large accumulated backlog and a substantial annual incidence. Demand for donor tissue far exceeds supply, and the utilisation rate of collected corneas is only about 50%.

Corneal blindness is important in geriatrics because pseudophakic and aphakic bullous keratopathy, Fuchs endothelial dystrophy, corneal degeneration and infective keratitis are the typical indications in older Indian patients — and because most donors are older adults.

Eye banking is governed by the Transplantation of Human Organs Act 1994, amended in 2011 (THOTA), with Rules 2014. Eye banks and eye donation centres must be registered under the Act, and commercial dealing in tissue is a punishable offence.

The National Programme for Control of Blindness and Visual Impairment (NPCB&VI;) provides grants-in-aid for eye collection and infrastructure; the Eye Bank Association of India (EBAI) sets professional standards; and the National Eye Bank at AIIMS, New Delhi is the apex institution.

The service structure is a three-tier one — eye donation centres (motivate and collect), eye retrieval centres (retrieve tissue) and eye banks (retrieve, evaluate, preserve and distribute). Only a registered eye bank may distribute tissue.

Service fees may be charged only to recover the cost of retrieval, processing, storage and distribution; there must be no profiteering, and the charging policy must be approved by the competent authority.

Anyone can donate — any age, any sex, any blood group. Spectacle wearers, people who have had cataract surgery, and those with diabetes or hypertension can all donate. Pledging during life is encouraged but is not legally binding.

Absolute systemic contraindications: death of unknown cause; HIV; hepatitis B; hepatitis C; active syphilis; rabies; septicaemia; leukaemia and lymphoma; disseminated malignancy; Creutzfeldt–Jakob disease and other prion disease; active viral encephalitis; subacute sclerosing panencephalitis; congenital rubella; Reye syndrome; and tetanus.

Ocular contraindications: retinoblastoma and other ocular malignancy, active ocular or intraocular inflammation, and previous anterior segment surgery of unknown nature. Prior refractive surgery is a relative contraindication for optical grafts.

Even where an absolute contraindication exists, the family must be told clearly, and the eyes are not retrieved unless the family is fully informed and still wishes to donate. Tissue unsuitable for transplantation may be used for research and training.

Inform the nearest eye bank immediately. Eyes should be retrieved within 6 hours of death (this may be extended when the body is refrigerated).

Simple measures while awaiting the team: close the eyelids; switch off the fan; raise the head of the body by about six inches; place moist cotton or a cold pack over the closed lids; instil antibiotic drops if available; and keep a copy of the death certificate ready.

Written consent must be obtained on the prescribed form from the legal custodian or next of kin, even if the deceased had pledged. Death must be certified by a registered medical practitioner, or the retrieval team must satisfy itself that life is extinct.

Retrieval is by either enucleation (removal of the whole globe) or in-situ corneoscleral rim excision. Corneoscleral excision is preferred in hospital programmes — it is quicker, uses less tissue and gives better cosmesis. It is performed by trained personnel using sterile technique, in a laminar flow hood or operating room where done in a laboratory.

A donor blood sample is mandatory and is tested for HIV 1 and 2, HBsAg, anti-HCV and syphilis (VDRL/TPHA). The tissue is graded on slit-lamp and specular microscopy; endothelial cell density (generally above 2000–2500 cells/mm²) determines whether tissue is optical grade or usable only for tectonic or therapeutic purposes.

Preservation options: moist chamber (up to 24–48 hours), McCarey–Kaufman medium (2–4 days), Optisol-GS at 2–8°C (up to 14 days) and organ culture at 31–37°C (up to 4 weeks).

Uses: optical keratoplasty (penetrating keratoplasty, DALK, DSAEK, DMEK), therapeutic and tectonic grafts, patch grafts for glaucoma drainage devices, limbal stem cell transplantation, and research and surgical training.

One donor traditionally gives sight to two people. With modern component (lamellar) surgery, a single cornea can be split so that one donor may benefit more than two recipients.

Voluntary (home-death) donation gives lower yield and poorer tissue quality because of delay. The Hospital Cornea Retrieval Programme (HCRP), launched by EBAI in 1991, is the main source of good-quality tissue — trained grief counsellors approach the families of all patients dying in hospital.

HCRP advantages: no potential donor is missed; a detailed medical history is available to assess eligibility; younger donors are accessed; the death-to-retrieval interval is short; and it is cost-effective. Structured grief counselling is the single most effective intervention for raising consent conversion.

Barriers: lack of public awareness; family refusal at a time of grief; myths about disfigurement, religious objection and beliefs about rebirth; failure of hospital staff to intimate the eye bank; shortage of trained counsellors; non-uniform standards between eye banks; and inadequate accreditation.

Promotion: National Eye Donation Fortnight is observed from 25 August to 8 September every year. Other measures are pledge registration, mass media and community campaigns, involvement of religious and community leaders, and sensitisation of ICU, casualty and ward staff to identify and refer every eligible death.

Donor age is not a bar. The Cornea Donor Study showed that graft survival at five and ten years is comparable across donor ages from 12 to 75 years — so older donors are entirely acceptable and are in fact the main donor pool.

The geriatrician's role is practical: raise eye donation during advance care planning, include it in advance directive discussions alongside organ and tissue donation, counsel families sensitively, and ensure timely intimation to the eye bank after an expected death.

Ethical principles: voluntary and informed consent; no reward, inducement or coercion; dignity and respect for the body; confidentiality between donor and recipient families; equitable allocation on clinical need; and complete documentation, traceability and recall systems.

Standards of Eye Banking in India (2020, NPCB&VI; with EBAI) — an updated national standard replacing the 2009 DGHS document. It sets accreditation criteria (an eye bank must collect at least 25 surgical-grade tissues a year to be accredited, otherwise it is re-designated as an eye retrieval centre), mandates periodic re-inspection, restates that service fees may only recover cost with no profiteering, and requires documented tissue tracking and recall.

AIOS–EBAI consensus statement on cornea and eye banking during the COVID-19 era (Indian Journal of Ophthalmology 2020) — added respiratory-infection screening of donors, deferral criteria, PPE requirements and safe restart protocols. It remains the template for pandemic preparedness in eye banking.

Shift from penetrating keratoplasty to endothelial and lamellar keratoplasty: DSAEK and DMEK for endothelial disease and DALK for stromal disease now dominate practice. Because these use only part of the cornea, a single donor cornea can be split between recipients, effectively multiplying the impact of each donation.

Pre-cut and pre-loaded tissue prepared by the eye bank (eye-bank-prepared DMEK/DSAEK grafts) reduces intra-operative tissue loss and surgeon preparation time, and is being adopted by larger Indian eye banks.

Cell-based therapy: cultivated human corneal endothelial cell injection (pioneered in Japan) has shown durable restoration of corneal clarity in bullous keratopathy, and further trials are ongoing. If successful at scale, a single donor cornea could treat dozens of recipients.

Bioengineered corneal implants from medical-grade porcine collagen (reported in Nature Biotechnology, 2022, with two-year outcomes in India and Iran) restored vision in advanced keratoconus with a minimally invasive, suture-free technique — a potential low-cost alternative to donor tissue in resource-limited settings.

National Organ Transplant Programme policy changes (2023–2024) — the Union Health Ministry directed states to remove the upper age limit of 65 years for registration for deceased-donor organs, to remove the domicile requirement so that a patient may register in any state, and to abolish registration fees. These reduce structural barriers for older patients across transplantation.

2025 prospective Indian studies (including from Gandhi Medical College, Bhopal) confirm that dedicated grief counselling within the HCRP significantly increases both willingness to donate and actual conversion to donation — supporting investment in counsellor posts rather than in mass publicity alone.

Persisting gap: India procures a substantial number of corneas each year but the utilisation rate remains around 50%. Current policy emphasis has therefore shifted from raising collection numbers to improving tissue quality, shortening death-to-preservation time, standardising medical criteria and strengthening HCRP.

Regenerative and alternative approaches — simple limbal epithelial transplantation (SLET), cultivated limbal epithelial transplantation (CLET) and keratoprosthesis (Boston KPro, LVP-KPro) — reduce dependence on donor tissue in bilateral limbal stem cell deficiency and repeated graft failure.