THE SKILL OF SURGEONS and the whole therapeutic arsenal still depends on a supply of corneas. And these still have only one source: the eyes of the recently deceased.
For transplantation, corneas must be harvested from donors within 20 hours (but preferably, within eight hours) of death, and must be transplanted within a few hours more. This requires a miracle of organization and coordination, a miracle that takes place every day at the Doheny Eye and Tissue Transplant Bank.
When the Doheny Eye Bank was chartered in 1947, it was one of the very first of its kind. Today, more than 100 banks supply the country with 40,000 corneas per year.
Doheny Eye Bank executive director Donald E. Ward relates what must take place with the clock ticking: The cornea is recovered from a donor and replaced with a clear cosmetic eye-cap. The donated cornea is then transported to the eye bank to be evaluated for transparency. Tech-nicians review the tissues medical history, then test it for all types of hepatitis, HIV, HTLV1 and syphilis. If it passes, the cornea is placed in a special refrigerated container that can maintain a temperature between 2 and 6 degrees centigrade while it is dispatched to an operating room anywhere in the United States. Doctors try to match tissue to specific requirements. For example, if the transplant will go to a child, they look for a young cornea.
But the top priority is assuring the ongoing availability of healthy corneas. While heart, liver and other transplant candidates must wait on lists for organs to become available, tissue banking now assures that a surgeon can schedule corneal replacement surgery for any desired date with a reasonable expectation that a transplantable cornea will be there.
In addition, during the past 10 years, the Doheny Eye Bank has provided an estimated $1 million worth of free service to indigent patients in Southern California. The eye bank provides the tissue to Los Angeles County-operated hospitals and physicians who waive their fees in order to make corneal transplants available to anyone, regardless of income.
Availability used to be even greater. Formerly, a government code in effect in 23 states permitted corneas to be taken whenever a coroners autopsy was to be performed, so long as family members of the deceased had not filed a statement explicitly forbidding the removal. The law ensured a continuing supply of good, transplantable corneas, with a complete medical history from the accompanying autopsy, says Ward.
Three years ago, the California state legislature reviewed the law and decided that too much latitude was being given to the coroners office and eye banks. In November 1997, the legislature repealed the section of the code allowing corneal removal during coroners autopsies without additional, explicitly obtained consent from the family of the deceased. This change could have created a severe shortage of corneas and other tissues in California, says Ward. It had the immediate effect of cutting the volume of usable corneas in half.
Fortunately, a federal rule was introduced that allows California eye banks an alternative route to get the required tissue. Under the new rule, for a hospital to qualify for Medicare reimbursements, it must report deaths immediately to a facility that can organize transplant activity. With deaths reported promptly, administrators can approach relatives on the spot to request organ donations. Sometimes hospital officials do this; more often, the consent is sought by a specialist like Dohenys Diane Martinez, who has been asking bereaved families to consider donating tissue for seven years.
Making the approach, she acknowledges, is the most uncomfortable part of the job. But I consider it my job to give a family the opportunity to make a decision, Martinez says. Yes, its difficult, but if I dont call, Ive taken away their opportunity.
Her approach is quiet. She answers questions two common ones are whether the operation will affect the appearance of the deceased (it wont), and if they can contact the recipient (yes, with the recipients consent). I emphasize that it is a choice, but there is no right or wrong choice, says Martinez.
The job can be unexpectedly rewarding. Sometimes, Martinez says, you establish a bond. And you are able to give a grieving family something that is important a feeling that at least one good thing has come out of bereavement, the opportunity to provide second sight for someone else.
Science writer Eric Mankin wrote the cover story A Gift for the Future in the Winter 1999 issue. For information about corneal transplantation or donation, call 800-USC-CARE.