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BritishlowunalofOphthalmology, 1990,74,685-687 685 MINI REVIEW Br J Ophthalmol: first published as 10.1136/bjo.74.11.685 on 1 November 1990. Downloaded from Supply of corneal tissue in the United Kingdom Within the last seven years in the UK there have been A course, organised by the Department ofOphthalmology in significant changes in the supply of corneal tissue for Bristol, is run specifically as a result of this Act to provide transplantation. Most ophthalmic surgeons here previously training in enucleation and storage techniques. The Corneal relied on local donors as their only source oftissue for corneal Tissue Act 1986 has thus reduced the likelihood of eyes not grafts. This meant that the grafts often had to be performed being retrieved and has brought the UK into line with other as emergency operations, and that excess tissue was wasted European countries and the USA. Indeed, hospitals, such as because of limited storage times and the lack of a simple in Norwich, that have specifically employed someone to routine mechanism for transferring the tissue to other retrieve eyes have been able markedly to increase the amount hospitals. The likelihood of tissue matching for patients at oftissue collected. high risk of immunological rejection was also severely limited. Some hospitals, notably Moorfields Eye Hospital in London and the Queen Victoria Hospital in East Grinstead, Corneal Transplant Service Eye Bank were able to schedule grafts by ensuring an adequate supply The next major advance in the supply ofcorneal tissue in the of tissue through well organised donor retrieval programmes UK also came in 1986 when the Corneal Transplant Service and through the establishment of eye banks, but they were Eye Bank was set up in Bristol.2 This was a joint initiative by very much in the minority. The eye banks at East Grinstead Bristol University Department of Ophthalmology, the and Moorfields were set up in 1959 and 1965, respectively. UKTS, and the Iris Fund. This eye bank, which is situated in the theatre suite of the Bristol Eye Hospital, was the first in the UK to apply organ culture techniques for the storage of Corneal Transplant Service human corneas for transplantation.' Instead of storing whole In 1983 the Corneal Transplant Service was inaugurated by eyes in moist chambers at 4VC or corneoscleral discs in tissue the UK Transplant Service (UKTS) and the Iris Fund for the culture medium at 40C, corneas are excised with a 2-4 mm Prevention of Blindness with the aims of improving the scleral rim and suspended in tissue culture medium at 34WC, availability of corneal tissue for transplantation and of which extends the permissible storage time from a few hours reducing tissue wastage.' The functions of UKTS are to or days to 30 days." match and distribute organs and tissues for transplantation, When coupled with the national distribution service to hold lists of patients awaiting transplants throughout the provided by the UKTS this capacity for extended corneal UK, to provide laboratory services for tissue typing includ- storage has a number of advantages. Perhaps the most ing the supply of tissue typing reagents to all tissue typing important is that the timing of a routine graft need no longer http://bjo.bmj.com/ laboratories in the UK, and to collect and analyse statistical be determined by the immediate availability of a suitable data on transplantation in the UK. The Corneal Transplant local donor, allowing grafts to be performed electively. Subcommittee of the UKTS Management Committee was Surgeons are now able to plan grafts well in advance simply established by the Department of Health to advise on the by requesting corneas through the UKTS for the dates when functioning ofthis new service to ophthalmologists. they wish to graft their patients. Over 50% of grafts are The Corneal Transplant Service enables corneas that scheduled with seven or more days' notice and 25% are cannot be used locally to be offered through the UKTS for planned more than two weeks in advance. Only 10% ofgrafts on September 30, 2021 by guest. Protected copyright. use in patients at other hospitals, ensuring a wide and fair are performed within two days of requests being placed with distribution of tissue and greatly reducing wastage. The the UKTS, and these are mainly emergencies. The average UKTS makes all of the necessary arrangements, including time between a request and the graft is 11 days, which is transportation, and relieves surgeons of the administrative ample time both for the surgeons and the patients to make all burden involved in sharing tissue. In addition patients who necessary arrangements. Moreover only 13% of organ cul- are likely to suffer graft failure through immunological tured corneas are grafted in evenings after 6 pm. Another rejection have a far greater chance ofreceiving a well matched major advantage is that corneas are always available for emer- cornea, because links with other transplant teams through gencies. The longer storage time also means that essential UKTS and Transplant Co-ordinators have increased the tasks such as donor screening for HIV and hepatitis B do not numbers of corneas retrieved from tissue typed multiorgan need to be done with such urgency but can be carried out at donors. Corneas from tissue typed donors are offered for the convenience of the testing laboratory. patients on the national waiting list with the best tissue During organ culture, corneas are screened for bacterial match. and fungal contamination. At least 40% ofthe eyes sent to the eye bank are contaminated by bacteria (mainlyStaphylococcus spp). Cleaning of the external ocular surface with polyvinyl- Corneal Tissue Act 1986 pyrrolidone iodine before corneoscleral disc excision and the Under the Human Tissues Act 1961 organs and tissues for antibiotics in the culture medium reduce the incidence of transplantation could be removed from a donor only by a contamination during organ culture to only 7%. Contamina- fully registered medical practitioner. There was always a tion is revealed either through clouding of the culture chance, therefore, that eyes would not be retrieved from a medium or by routine screening of the medium during donor by an ophthalmologist because ofother more pressing culture. All contaminated organ cultures are discarded. Thus clinical demands. In 1986 this law was amended to allow suit- surgeons receive tissue that should be free of bacterial and ably trained persons who were not medically qualified to fungal contaminants, which is not the case with corneas or remove eyesfor therapeutic, research, and teaching purposes. whole eyes stored at 4VC. 686 Armitage, Moss, Bradley, Easty Figure I The influence of 3,000 Figure 3 Corneas stored donor age on the proportion in the CTS Eye Bank in Br J Ophthalmol: first published as 10.1136/bjo.74.11.685 on 1 November 1990. Downloaded from oforgan cultured corneas Bristol and suppliedfor discarded because of transplantation between I endothelial defects between 2,500 January 1989 and307une IJanuary 1989 and 30 1990. The datafor 1990 June 1990. The total are extrapolatedfrom the numbers oforgan cultured figuresfor thefirst six corneas in each age range 2,000 months ofthatyear. were: 0-19yr, 380; 20-39 a) yr, 530; 40-59yr, 810; . 60-79yr, 1365; 80-99yr, c 1,500 z 341. 8 1,000 500 0 1986 1987 1966 1989 1990 01 A Years 0-19 20-39 40-59 6 Age (years) The corneal endothelium is carefully examined prior to techniques, since excess tissue collected in the areas served transplantation to ensure an intact endothelial mosaic with by those banks can be channelled through Bristol for an adequate density of viable cells. This allows corneas from redistribution to other hospitals in the UK. This can be done older donors to be used with confidence and damaged corneas without undue haste owing to the greater amount oftime that from younger donors that might otherwise have been used the tissue can be stored in a viable state in organ culture. can be identified and discarded. As might be expected, the There has also been a tremendous willingness of surgeons in discard rate owing to endothelial defects increases with donor other hospitals to retrieve eyes not required for their own age, rising from approximately 10% in donors under 20 years immediate needs. to almost 30% in donors over 80 years (Fig 1). Overall, approximately 30% of corneas stored in organ culture are eventually discarded for a variety of reasons including Corneal transplant service eye bank network inadequate endothelium, cause of donor's death, microbial In 1988 the David Lucas Eye Bank was opened in Man- contamination, and lack of HIV or hepatitis B tests (Fig 2). chester. This facility also stores corneas by organ culture and In 1986 a total of 59 organ cultured corneas were supplied is fully integrated within the Corneal Transplant Service. through the Bristol eye bank to 11 hospitals. Since then there The pattern in the UK has thus shifted from corneas being has been a substantial rise both in the numbers of corneas procured and used locally to the majority of corneal tissue http://bjo.bmj.com/ stored and distributed and in the number of participating being supplied through a loose network of four eye banks hospitals. Within three years over 1500 corneas a year were situated at Bristol, East Grinstead, Manchester, and Moor- being supplied through the Bristol eye bank to over 100 fields. In 1989 alone, over 2000 corneas were supplied for hospitals throughout the UK and Eire (Fig 3). The average grafts through these four eye banks. This system has the donor age between 1 January 1989 and 30 June 1990 was 53 advantage that just a few eye banks serve a wide geographical years (SD 22-9, n= 1802) and that of tissue typed donors was area in an efficient and cost effective manner.

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