specular evaluation of endothelium in pseudophakic …

SPECULAR EVALUATION OF

ENDOTHELIUM IN PSEUDOPHAKIC

DONOR CORNEA

DISSERTATION SUBMITTED FOR

MS (Branch III) Ophthalmology

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY, CHENNAI

APRIL - 2015

CERTIFICATE

This is to certify that the thesis entitled “SPECULAR EVALUATION OF

ENDOTHELIUM IN PSEUDOPHAKIC DONOR CORNEA” is the

original work of Dr. Betsy Clement and was conducted under our direct

supervision and guidance at Aravind Eye Hospitals and Postgraduate

Institute of Ophthalmology, Madurai

Dr.Mano Ranjan Das Dr. N.Venkatesh Prajna Guide, Medical Officer & Senior Consultant, Head of Department Cornea Services Cornea Services Aravind Eye Hospital, Aravind Eye Hospital, Madurai. Madurai.

Dr.M.Srinivasan Director Emeritus,

Aravind Eye Hospital, Madurai.

DECLARATION

I, Dr. Betsy Clement hereby declare that this dissertation entitled, entitled

“SPECULAR EVALUATION OF ENDOTHELIUM IN

PSEUDOPHAKIC DONOR CORNEA” is being submitted in partial

fulfillment for the award of MS degree in Ophthalmology by The

TamilNadu Dr.MGR Medical University in the examination to be held in

April 2015.

I declare that this dissertation is my original work and has not formed the

basis for the award of any other degree or diploma award to me previously.

Dr. Betsy Clement

Aravind Eye Hospital &

PG Institute of Ophthalmology,

Madurai, TamilNadu.

ACKNOWLEDGEMENT

I take this opportunity to pay my respect and homage to

Dr.G.Venkatasamy, our founder and visionary, whose dynamism had led

Aravind Eye Care System against all odds to its epitope.

It is a proud privilege and pleasure to express my thanks and

indebtedness towards my revered mentor and guide Dr. Mano Ranjan Das,

Senior Consultant, Cornea services, Aravind Eye Hospital Madurai, for

being a constant source of motivation and encouragement, which ultimately

structured my thesis .

I am grateful to Dr. N.V.Prajna, Director of Academics, Aravind Eye

Care System, who offered his excellent guidance and support throughout my

residency programme.

I am very grateful to Dr.R.D.Ravindran, Chairman of Aravind Eye

Care System for having created an environment enriched with all the

facilities for learning and gaining knowledge. I am privileged to have on my

side Dr. P. Namperumalsamy, Chairman Emeritus & Director of Research,

Dr.G.Natchiar, Director Emeritus (Human Resource Department),

Dr.M.Srinivasan, Director Emeritus and other scholars of ophthalmology at

Aravind Eye Care System .

My sincere thanks to Dr.Arun Kumar Panigrahi, Cornea Medical

Officer, and all the paramedical staffs for their excellent co- operation

during the study.

My special thanks to the staff of Rotary Aravind International Eye

Bank, for their services and constant support. I am grateful to all the families

who came forward to donate the eyes of their loved ones.

I also extend my thanks to the Biostatistician, Mr. Vijayakumar; the

Photography Department and Media Nett Computers.

Last but not the least, I would like to thank my friends and family

members who have always stood by me throughout.

Dr. Betsy

CONTENTS

S.No. Part I Page. No.

1. Introduction 1

2. Literature Review 5

3. Cornea & Blindness due to Corneal Diseases 19

4. Corneal Transplantation 27

5. Donor Corneal Tissue and Eye Donation 45

6. Eye Banking 48

7. Corneal Preservation 52

8. Corneal Evaluation 59

9. Cataract and Pseudophakia 67

10. Future 72

Part II

1. Aims and Objectives 74

2. Materials and Methods 75

3. Results 84

4. Demographics 86

5. Discussion 102

6. Summary and Conclusion 107

INTRODUCTION

Corneal blindness is an important cause of preventable blindness.

Corneal blindness is the third leading cause of blindness globally after

cataract and glaucoma36.

According to the World Health Organization, “corneal diseases are

among the major causes of vision loss and blindness in the world today, after

cataract and glaucoma.” In India, it is estimated that there are approximately

6.8 million people who have vision less than 6/60 in at least one eye due to

corneal diseases; of these, about a million have bilateral involvement. It is

expected that the number of individuals with unilateral corneal blindness in

India will increase to 10.6 million by 202033.

According to the National Programme for Control of Blindness

(NPCB) estimates, there are currently 120,000 corneal blind persons in the

country. According to this estimate there is addition of 25,000-30,000

corneal blindness cases every year in the country. The burden of corneal

disease in our country is reflected by the fact that 90% of the global cases of

ocular trauma and corneal ulceration leading to corneal blindness occur in

developing countries.

Most common corneal disorders are corneal scars and dystrophies.

The successful medical and surgical management decreases the ocular

morbidity. Corneal transplant is one of the most common and successful

transplant procedures.

Each year nearly 100,000 corneal transplants are being performed,

the world over, yet the people affected by various disorders, who would

benefit from corneal transplantation in reality are around 10,000,000 36.

One third of the world’s 4 crore blind population, resides in India

alone. Corneal blindness is approximately 25% of total 1.5 crore blind

people in our country33. Infections, injuries, malnutrition, degenerations and

dystrophies are important causes of corneal blindness. Whatever may be the

cause, but the remedy is the same, that is corneal transplantation.

The demand for corneal tissue for transplantation is huge. India needs

2 lakh donor eyes per year to take care of the demands of the corneal blinds

in our country. We are able to collect approximately 25,000 donor eyes per

year33.

Eye banks play an important role in the supply of good quality corneal

donor tissue. In the past, age was a criterion when eyes of donors more than

75 years of age were not considered for transplantation. But after many

studies it has been proved that age alone is not a criteria 24, 27.

Similarly with the number of pseudophakic eyes on the increase, more

so with ever improving cataract surgical techniques and machines, the myth

of rejecting pseudophakic eyes for transplantation is being changed 25, 28, 29.

This study aims to evaluate pseudophakic donor corneas in the Rotary

Aravind International Eye Bank over a study period of one year (August

2013 to July 2014). The donor tissues, after evaluation by slit lamp and

specular microscopy, and deemed suitable, are used either for therapeutic or

optical grafts. The outcome of this study is to evaluate the percentage of

pseudophakic donor corneas being used for corneal transplantation.

LITERATURE REVIEW “Donor age and factors related to endothelial cell loss 10 years after

penetrating keratoplasty: Specular Microscopy Ancillary Study.”

Ophthalmology . 2013;

Lass and Benetz et al., concluded that in eyes with a clear graft 10 years

after penetrating keratoplasty, substantial endothelial cell loss is seen. The

rate of cell loss is slightly greater with older donor age. ‘Greater

preoperative ECD and larger donor tissue size are associated with high

endothelial cell densities at ten years’.

A comparative assessment of endothelium from pseudophakic and

phakic donor corneas stored in organ culture

British Journal of Ophthalmology. April, 2002.

F M Meier et al., in their study concluded that after one to two weeks in

organ culture the corneal endothelium from pseudophakic eyes appeared to

be similar to that of phakic eyes. Their finding suggested that the routine

disqualification of pseudophakic corneal donor tissue should not be done.

They stated that the utilization of at least some pseudophakic donor corneas

might substantially increase the potential donor pool for corneal

transplantation.

Evaluation and transplantation of corneas from pseudophakic donor

eyes. Cornea. 1999, November.

Mindrup et al., did a study on 45 pairs of donor eyes to evaluate the quality

of donor corneal tissues from pseudophakic eyes for corneal grafting. Their

results showed that 68 of the 90 corneas did not satisfy the transplantation

requirement criteria. Nine donor corneal tissues from pseudophakic donors

were transplanted and resulted in one primary graft failure. They concluded

that corneal donor tissues from pseudophakic donor eyes may need a more

extensive evaluation to certify the endothelial viability than is presently

required by the eye bank standards for corneal transplantation.

Corneal harvesting from donors over 85 years of age: cornea outcome

after banking and grafting.

French Journal of Ophthalmology. 2002, March. Gain and Rizzi et

al., studied the donor corneal tissues from very old donors after organ

culture and documented their results as clinical and endothelial outcomes in

the recipients after PKP. They concluded that in countries with high

standards of living and their aging population, the increasing need for donor

corneal tissues, the availability of techniques for the selection of donor

corneal tissues based on endothelial quality, the very old should not be

labeled unsuitable for donor corneal tissue harvesting.

Quality of corneal donor tissue in the greater-than-75-year age group.

Cornea. 1997, September.

Probst et al., Stated that their Laboratory study results suggested that

pseudophakic eyes from many older corneal donors might be suitable for

corneal grafting.

Endothelial evaluation in the cornea bank.

Dev Ophthalmol. 2009.

Schroeter et al., stated that for the evaluation of organ cultured donor

corneas the light microscope was the first-choice technique. For the

microscopic evaluation of the endothelial cells the corneas needed to be

immersed in a hypotonic solution and the number of cells and their

morphology analysed. The cell density could be estimated by the fixed

frame / L method and the usage of the image analysis system by computer

processing and counting of digitalized endothelial cell images. They insisted

that the evaluation of the endothelium was a must at the end of the organ

culture. They stated that a high endothelial cell density at the end of the

culture period was a decisive criterion before releasing a donor corneal

tissue for grafting, an ECD of 2000-2200 cells/mm square being the lower

limit for the longest possible graft survival.

Morphology assessment of the endothelial cells would involve the

routine estimation of pleomorphism, polymegathism and vacuolization of

the cells.

Cornea Donor Study (CDS): Ophthalmology. 2013.

Lass and Benetz et al., The Cornea Donor Study (CDS) was designed as a

prospective cohort study

Ø To determine whether the graft-failure rate over a 5-year follow-up

period is equivalent with corneal tissue from donors older than 65

years of age compared with that from younger donors;

Ø To assess the relationship between donor: recipient ABO

compatibility and graft failure due to rejection; and

Ø To assess corneal endothelial cell density as an indicator of the health

of the cornea and as a surrogate outcome measure (in an optional

specular microscopy ancillary study). Eligible subjects were 40 to 80

years of age, with corneal disease characterized by the presence of a

condition associated with endothelial dysfunction, including

pseudophakic corneal edema, Fuchs’ dystrophy, posterior

polymorphous dystrophy, endothelial failure from another cause,

interstitial keratitis (nonherpetic), or perforating corneal

injury. Subjects were followed for five years

The Cornea Donor Study is an ongoing study and it is documenting the

long term effects of using donor corneal tissues from older age group and

pseudophakes. The results have been encouraging and these tissues have

been reported to be comparable to younger and phakic eyes.

Tissue utilization at the Minnesota Lions' Eye Bank

Cornea. 1995, November.

Moyes et al., examined the utilization of donor corneal tissues

collected in the eye bank. They wanted to analyze why the donor corneal

tissues were being rejected and how the number of donor corneal tissues

could be made available in more numbers. A retrospective review of 2,382

corneas procured between December 1, 1992 and November 30, 1993 were

evaluated by the Minnesota Lions’ Eye Bank. Of the 2,382 eyes only 748

corneas amounting to 31 % were utilized for corneal transplantation.

They had an exclusion criteria of donors above the age of 75 years

and pseudophakic eyes.

The analysis showed that the most common reason for exclusion of

poor quality tissues was the specular microscopic abnormalities such as

epithelial defects , arcus senilis etc. Only 14 corneas were excluded because

of decreased endothelial cell density.

They suggested that the validity of exclusion criteria using

abnormalities detected by specular microscopic examination, needed further

analysis. Also the exclusion criterias of age above 75 years and

pseudophacia needed further evaluation.

Preservation of Human Cornea, Transfus Med Hemother.2011.

W. John Armitage stated that for a corneal transplant to be successful

the endothelium should be viable.

The primary function of this single layer of cells is to maintain corneal

transparency by the control of hydration of the stromal collagenous layer. As

the endothelial cells of the human corneal tissue do not proliferate readily,

the primary aim of the methods of corneal storage is to preserve the corneal

endothelium.

The method of cryopreservation is complicated and there are chances

of the endothelial cells being damaged, which has limited its utility. Organ

culture at 28-37 degrees centigrade has extended the storage time for four

weeks and is used widely in Europe. Hypothermia at 2-8 degrees centigrade

is the most commonly used method of storage of donor corneal tissues and it

allows the storage for 7-14 days. Corneal transplantation results from donor

corneal tissues stored by these two techniques appear similar.

The Use of Glycerol-Preserved Corneas in the Developing World,

Middle East Afr J Ophthalmol. 2010 Jan-Mar.

Michael et al., have discussed the use of glycerol preserved corneal

donor tissues and its applications throughout the developing world.

Corneal Blindness being the third leading cause of blindness in the

developing world includes various infections, inflammatory and

degenerative diseases of the eye. If enough donor corneal tissues and the

necessary surgical skill is available, most of these conditions can be rectified

with partial or full thickness corneal transplantations.

Various factors are seen which hinder the availability of Fresh

Corneal Tissues for transplantation as compared to the western world.

Glycerol- preserved corneal donor tissues overcome many of the

limitations such as lack of good eye banking networks, tissue shortage,

unreliable storage and transportation facilities, unorganized tissue

distribution networks etc. With the development of lamellar keratoplasties

the potential use of acellular corneal tissue is increasing and the long term

preservation techniques are being revisited to increase the donor corneal

tissue availability in the developing world.

“Comparison of corneal endothelial cell loss during phacoemulsification

using continuous anterior chamber infusion versus those using

ophthalmic viscosurgical device: Randomized controlled trial”

Year: 2009 | Volume : 57 | Issue: 2 | Page: 99 –103.

BK Nayak, et al., of P.D. Hinduja National Hospital and MRC,

Mumbai, India., concluded that there was not significant difference in the

immediate post-operative corneal edema or corneal endothelial cell loss upto

a period of one month, when either continuous anterior chamber (infusion)

maintainer or ophthalmic viscosurgical devices were used .

“Comparison of morphological and functional endothelial cell changes

after cataract surgery: Phacoemulsification versus manual small-

incision cataract surgery”

Year:2014 | Volume:21 | Issue:1 | Page: 56-60

Sunil Ganekal et al.,Nayana Superspecialty Eye Hospital and

Research Center; Karnataka, India., concluded that manual small incision

cataract surgery was still a safe surgery in the developing world. Inspite of

the initial decrease in the endothelial cell count in MSICS the other

parameters such as co-efficient of variation, the standard deviation and the

central corneal thickness were maintained in both the groups. This finding

indicates that the function and morphology of the endothelial cells in the

corneas were not affected.

Effect of cataract surgery on the corneal endothelium: modern

phacoemulsification compared with extracapsular cataract surgery.

Ophthalmology. 2004, April.

Bourne et al., stated that there was no significant difference between

the two operative techniques. The total corneal endothelial cell loss was

similar. Patients with hard cataracts who had a increased risk of corneal

endothelial tissue loss with phacoemulsification, extra capsular cataract

extraction was a better option.

Central corneal volume and endothelial cell count following

femtosecond laser-assisted refractive cataract surgery compared to

conventional phacoemulsification.

Journal of Refractive Surgery. 2012, June.

Takács et al., concluded that in the early post operative period,

femtosecond laser-assisted cataract surgery causes lesser corneal edema and

might cause less injury to the corneal endothelium than phacoemulsification.

Donor corneal tissue evaluation:

Year : 1996 | Volume : 44 | Issue : 1 | Page : 3-13

Jagjit et al., Postgraduate Institute of Medical Education and

Research, Chandigarh, India, gave a comprehensive review of current trends

in donor corneal tissue evaluation, worldwide.

They stated that for the success of corneal grafting a proper evaluation

of the donor corneal tissue is essential. The cause of death and the condition

of the eye should be carefully noted to rule out any contraindications for

donor corneal tissue utilization. The death to enucleation time should be

meticulously recorded.

Gross examination of the eye, slit lamp biomicroscopy are essential

and the specular microscopic evaluation gives a critical picture of the

endothelium of the donor corneal tissue.

Burden of Corneal Blindness in India, Indian Journal of Community

Medicine, 2013.

Noopur Gupta ,and Radhika Tandon,et al., stated that to eradicate

corneal blindness a multipronged strategy must be developed. The various

issues fall under the realm of Public Health. The control of the preventable

causes needs extensive community participation and community support.

Curable causes of blindness need a spectrum of care, medical and

surgical intervention (corneal grafting) and optical rehabilitation.

Continued assessment of the Burden of Corneal Blindness and

periodic review of the trends is needed to effectively plan preventive,

promotive and rehabilitative blindness control strategies.

Specular microscopic evaluation of donor corneal endothelium.

Archives of Ophthalmology, Feb 1986.

Matsuda et al., performed wide-field specular microscopy and

pachymetry on 92 donor corneal tissues to evaluate the changes occurring in

the corneal endothelium during moist chamber storage of upto 48 hours. The

sample was divided into two groups: group I (younger) with a mean age of

34 years, and group II (older) with a mean age of 72 years.

They stated that there were no significant differences when storage

intervals were similar. Beyond 12 hours there were increase in the

polymegathism (co-efficient of variation in cell area) and pleomorphism

(percentage of hexagonal cells) and corneal thickness.

They also suggested that specular microscopy was a more reliable

method of screening donor corneal tissues than donor age or corneal

thickness.

CORNEA AND BLINDNESS DUE TO CORNEAL

DISORDERS

Cornea:

Cornea is the transparent, dome-shaped window that covers the iris,

the pupil and the anterior chamber of the eye. The transparent cornea is a

complex structure and forms one sixth of the anterior wall of the globe. A

healthy cornea with the overlying tear film is responsible for about three

quarters of the optical refractive power of the eye (40-44D) and protects the

eye against infection, structural damage and also contains the intraocular

pressure.

While the cornea contributes most of the eye's focusing power, its

focus is fixed. The curvature of the lens, on the other hand, can be adjusted

to "tune" the focus depending upon the object's distance.

Medical terms related to the cornea often start with the prefix "kerat-"

from the Greek word horn.

Embryology:

The corneal epithelium is formed from the surface ectoderm at around

six weeks of gestation. In the seventh week, three waves of mesenchymal

cells (from the neural crest) migrate forward from around the lens vesicle to

form the corneal and trabecular endothelium, corneal stroma and iris stroma.

The final adult corneal epithelium is attained by thirty seven weeks of

gestation.

The corneal diameter enlarges from 4.2 mm at sixteen weeks, to 10

mm at birth to 12 mm horizontal and 11.5 mm vertically in adulthood. At

birth the central endothelial cell density is around 5000 cells/mm2. The

endothelium has a very limited regenerative capacity and progressive

cellular senescence occurs in two phases. The rapid phase in infancy -

reaches 3500 cells/mm square, by five years of age. Thereafter the decrease

occurs at a linear rate of 0.3 - 0.6 % per year 7.

The shape of the cornea is prolate being flatter in the periphery and

steeper centrally which creates an aspheric optical system. It is

approximately 540 µm thick centrally on average and thicker towards the

periphery. The normal cornea is free of blood vessels (avascular), nutrients

are supplied and metabolic products removed mainly via aqueous humour,

posteriorly and tear film anteriorly and also from neurotrophins supplied by

nerve fibres that innervate it. The cornea is the most densely innervated

tissue in the body with a sub-epithelial and a deeper stromal plexus, both

supplied by the first division of the trigeminal nerve. The unmyelinated

nerve endings are sensitive to touch, temperature and chemicals. A touch of

the cornea causes an involuntary reflex to close the eyelid. Transparency,

avascularity, the presence of immature resident immune cells, and

immunologic privilege makes the cornea a very special tissue.

Layers of the Cornea:

The human cornea has five layers. From the anterior to posterior the

layers of the human cornea are:

1. Corneal epithelium: It is a thin layer of non-keratinized stratified

squamous epithelium, kept moist with tears. It is continuous with the

conjunctival epithelium, and is composed of about 6 layers of cells

which are shed constantly on the exposed layer and are regenerated by

multiplication in the basal layer.

2. Bowman's layer: (the anterior limiting membrane): It is a tough,

acellular layer composed of collagen (mainly type I collagen fibrils)

which protects the corneal stroma. This layer is 8 to 14 (μm) thick.

3. Corneal stroma : (substantia propria): It is a thick, transparent

middle layer, consisting of regularly arranged collagen fibers along

with sparsely distributed (interconnected) keratocytes, which are the

cells for general repair and maintenance. It constitutes 90% of corneal

thickness.

4. Descemet's membrane: (posterior limiting membrane): It is a thin

acellular layer that serves as the modified basement membrane of the

corneal endothelium. This layer is composed mainly of collagen type

IV fibrils, less rigid than collagen type I fibrils, and is around 5-20 μm

thick, depending on the subject's age.

Just anterior to Descemet's membrane, very thin and strong

layer, the Dua's Layer, 15 microns thick and able to withstand 1.5 to 2

bars of pressure, may exist according to one study, (possibly six

layers40.)

5. Corneal endothelium: It is a single layer of simple squamous or low

cuboidal , of mitochondria-rich cells, around 15 microns thick. These

cells are responsible for regulating fluid and solute transport between

the aqueous and corneal stromal compartments. The cells of the

endothelium do not regenerate. They instead stretch to compensate for

dead cells which reduce the overall cell density of the endothelium. If

the endothelium can no longer maintain a proper fluid balance,

stromal swelling due to excess fluids and subsequent loss of

transparency7.

Corneal Blindness:

Corneal Blindness is a visual impairment that occurs from the cornea

becoming clouded or scarred by a range of eye diseases, injuries or

infections which damage the corneal tissues and affects its transparency

leading to permanent blindness.

Blindness is defined36 (World Health Organization, 2008) as

“presenting visual acuity less than 3 / 60 in the better eye.” In keeping with

the recommendation of the World Health Organization the National

Programme for the Control of Blindness in India has categorized presenting

distance visual acuity less than 3/ 60 in the better eye as Social Blindness.

Visual acuity between 3/60 and 6/60 is called Economic Blindness.

Preventable blindness includes corneal scarring due to trauma and

infection which are preventable. In India various measures are being taken to

address the problem of Corneal Blindness to achieve the goals of Vision

2020.

Causes of Corneal Blindness:

The causes26 of corneal blindness are:

1) Infectious:

a. Bacterial keratitis

b. Fungal keratitis

c. Viral keratitis

d. Trachoma

e. Onchocerciasis

f. Leprosy

g. Ophthalmia neonatorum

2) Nutritional

a. Vitamin A deficiency ( xerophthalmia )

3) Inflammatory

a. Mooren’s ulcer

b. Stevens Johnson Syndrome

4) Degenerative

a. Keratoconus

5) Trauma

a. Corneal abrasion

b. Penetrating trauma

c. Chemical injury

6) Iatrogenic

a. Pseudophakic Bullous Keratopathy.

In the developed world43 the main causes of corneal blindness8 are:

1. Pseudophakic Bullous Keratopathy

2. Keratoconus

3. Fuch Corneal Dystrophy

In the developing world the main causes43 of corneal blindness are :

1. Corneal Scarring

2. Adherent Leucoma

3. Active Infectious Keratitis

4. Corneal Perforation


6. Keratoconus and other ectatic disorders

7. Fuch’s endothelial Corneal Dystrophy

8. Corneal Stromal Dystrophies

9. Corneal Injuries : open globe/ chemical / thermal

10. Trachoma

11. Vitamin A Deficiency

12. Ocular Surface Disorders.

CORNEAL TRANSPLANTATIONS

Corneal Transplant is the procedure of choice to combat Corneal

Blindness. The idea to replace diseased cornea originated in the eighteenth

century in the mind of a Frenchman named G.P. De Quengsy (who outlined

the details of the procedure). Reisinger coined the term Keratoplasty in the

nineteenth century and the first successful human penetrating corneal

transplantation was performed by Zirm in 1905.

Corneal transplantation, also known as corneal grafting / keratoplasty,

is a surgical procedure where a damaged or diseased cornea is replaced by

donated corneal tissue (the graft) in its entirety (penetrating keratoplasty) or

in part (lamellar keratoplasty). The graft is taken from a recently deceased

individual with no known diseases or other factors that may affect the

viability of the donated tissue or the health of the recipient.

The Indications of Keratoplasty are :

1) Optical – to clear the visual axis for visual rehabilitation

2) Therapeutic – to eliminate the corneal infection / load in refractory

cases

3) Tectonic – to preserve the structural integrity of the globe

4) Cosmetic – to improve appearance of the eye.

The clinical indications of OPTICAL penetrating keratoplasty are:

1. Pseudophakic / aphakic corneal decompensaion

2. Stromal Corneal Dystrophies – e.g. Macular, Lattice etc.

3. Primary Corneal Endotheliopathies – e.g. Fuch’s , PPMD etc.

4. Corneal Ectasias and thinning – e.g. Keratoconus

5. Congenital corneal opacity – e.g. Peter’s anomaly

6. Acquired corneal scars – post trauma / infectious / viral

7. Non-infectious Ulcerative keratitis – e.g. Mooren’s ulcer

8. Corneal Degenerations

9. Failed corneal grafts

10. Secondary optical grafts

The clinical indications for THERAPEUTIC Keratoplasty are:

1) Non-healing Infectious Keratitis

2) Infectious Keratitis with impending perforation

3) Infectious Keratitis with perforation

4) Post chemical injury with corneal melt.

Clinical indications for TECTONIC grafts are:

1) To reconstruct the ocular surface- in perforations etc

2) To strengthen the cornea – in peripheral thinning disorder with

perforation etc

Clinical indications for COSMETIC grafts are:

1) To improve appearance of eyes – with whitish corneal scar etc.

There have been changing trends in the indications6 for penetrating

keratoplasty over the last twenty five years17, 18, 19 or so, especially in the

developed world. Earlier viral keratitis, keratoconus and regrafts were the

common indications, pseudophakic bullous keratopathy being unheard of.

With the increase in the number of cataract surgeries etc, pseudophakic and

aphakic bullous keratopathy has become more common. Whereas in the

developing countries corneal scars due to infections and trauma are the most

common indications. So currently the scenario in the developed and

developing countries are as follows:

In the developed world the main indications of penetrating

keratoplasty are:

1) Pseudophakic Bullous Keratopathy

2) Keratoconus

3) Fuch Corneal Dystrophy

In the developing world the main indications of penetrating

keratoplasty are:

1. Corneal Scarring

2. Adherent Leucoma

3. Active Infectious Keratitis

4. Corneal Perforation


6. Keratoconus

7. Fuch’s Corneal Dystrophy

8. Corneal Dystrophies

Techniques of Keratoplasty:

Keratoplasty can be 16-

1) Penetrating Keratoplasty

2) Lamellar Keratoplasty

Penetrating Keratoplasty:

Penetrating Keratoplasty comprises of replacement of the full thickness

host corneal tissue with full thickness donor corneal tissue.

Prognosis for graft clarity in penetrating keratoplasty depends on

Ø Initial pathological condition of host cornea

§ Quality of donor tissue

§ Surgical technique

Ø Timing of surgery

Ø Postoperative care etc;

Description of outcomes after Corneal Grafting surgery has been

given as four major catergories by Buxton et.al15.

1) Group 1-Excellent Prognosis (Success Rate > 90%)

a. Keratoconus

b. Central / paracentral corneal scars

c. Stromal Dystrophy – granular, lattice

d. Early central Fuch’s endothelial dystrophy

2) Group 2- Very Good Prognosis (Success Rate 80-90%)

a. Advanced Fuch’s endothelial dystrophy

b. Aphakic / pseudophakic bullous keratopathy

c. Inactive herpetic keratitis

d. Macular stromal dystrophy

3) Group 3- Fair Prognosis (Success Rate 50 – 80%)

a. Active microbial keratitis

b. Active herpetic keratitis

c. Congenital hereditary endothelial dystrophy

d. Corneal grafts in young children

e. Mild chemical injury

f. Moderate keratoconjunctivitis sicca

4) Group 4- Poor Prognosis (Success Rate < 50 %)

a. Severe chemical injury

b. Radiation injury

c. Ocular cicatricial pemphigoid

d. Stevens-Johnson’s Syndrome

e. Neuroparalytic disease

f. Congenital glaucoma

g. Epithelial downgrowth

h. Anterior segment mesodermal dysgenesis

i. Multiple failed grafts

Anatomical success is by achieving a clear and thin graft while

functional success means significant visual improvement ( two or more lines

of Snellens Visual Acuity Chart) post operatively.

Lamellar Keratoplasty:

Lamellar Keratoplasty targets to remove partial thickness of

pathological host tissue and is replaced with donor tissue of similar size and

thickness thus retaining normal host tissue1,2.

Lamellar keratoplasty is of the following types:

1) Anterior Lamellar Keratoplasty-replaces the anterior stroma:

ALK - Anterior Lamellar Keratoplasty ,

DALK -Deep Anterior lamellar Keratoplasty

FALK – Femtosecond laser assisted Anterior Lamellar Keratoplasty

2) Posterior Lamellar Keratoplasty- deep stromal and endothelial layers

replaced:

DLEK-Deep Lamellar Endothelial Keratoplasty

DSEK-Descemets Stripping Endothelial Keratoplasty

DSAEK- Descemets Stripping Automated Endothelial Keratoplasty

DMEK – Descemets Membrane Endothelial Keratoplasty

FLEK – Femtosecond laser assisted Endothelial Lamellar

Keratoplasty

Advantages of Lamellar Keratoplasty over conventional Penetrating

Keratoplasty4 are :

v It’s an extra-ocular procedure

v Reduced risk of intra-ocular complications such as Glaucoma,

Cataract formation, Cystoid macular edema, Retinal Detachment,

Endophthalmitis, Expulsive Hemorrhage etc.

v No risk of endothelial graft rejection

v Does not require optical grade donor tissue

v Stronger Corneal Wound- and less chance of traumatic Graft-Host-

Junction wound dehiscence

v Larger graft can be performed

v Penetrating Keratoplasty can be done at a later date if needed.

COMPLICATIONS OF PENETRATING KERATOPLASTY:

Penetrating Keratoplasty is an intricate procedure, and its success rate

depends on good quality donor corneal tissue and good surgical technique.

Complications of Penetrating Keratoplasty can be divided into:

1) Intra-operative complications

2) Post-operative complications

Intra-operative complications :

1) Related to surgical technique:

a. Scleral perforation.

b. Improper trephination.

c. Retained Descemet’s Membrane.

d. Endothelial damage.

e. Intraocular Hemorrhage.

f. Vitreous loss.

2) Unrelated to surgical technique:

a. Expulsive choroidal hemorrhage

Postoperative Complications:

1) Immediate Postoperative:

a. Wound leak

b. Persistent epithelial defect

c. Post-operative inflammation

d. Suture related infiltrates

e. Raised intra-ocular pressure

f. Pupillary block

g. Anterior synechiae formation

h. Choroidal detachment / hemorrhage

i. Graft failure

2) Late postoperative :

a. Post –PK astigmatism

b. Graft infection

c. Graft rejection

d. Post-Penetrating Keratoplasty glaucoma

GRAFT FAILURE AND GRAFT REJECTION:

Graft Failure:

Graft failure is an irreversible loss of graft corneal transparency . It

can be primary failure or late donor failure or end result of multiple rejection

episodes47.

Primary graft failure :

The graft is irreversibly edematous, right from the immediate post-

operative period. The causes are:

1) Poor quality donor tissue

2) Traumatic surgery destroying the viable endothelium

Of all the post-operative complications the quality of the donor tissue

affects the Primary graft failure. If the donor corneal tissue is of poor

quality with a low endothelial reserve or inadequate endothelial cell count,

the graft is prone to go for primary graft failure.

Secondary Graft Failure:

Secondary graft failure depends on other factors (host factors,

secondary infections etc) and occurs later. The causes are:

1) Irreversible rejection

2) Infection

3) trauma

The treatment for graft failure is : REGRAFT.

Graft Rejection:

Graft rejection is an immunologically mediated reversible loss of graft

transparency in a graft which remained clear for at least 10 – 14 days

following penetrating keratoplasty47.

Corneal graft rejection can be classified as (in decreasing order of

frequency):

• Endothelial rejection

• Subepithelial rejection

• Epithelial rejection

• Stromal rejection

The risk factors for rejection are:

Host factors:

1. Corneal stromal vascularisation

2. Regrafts : two or more – high chances

3. Co-existing conditions – like uveitis, herpes simplex keratitis, atopy etc.

4. Active ocular inflammation -at the time of surgery

5. Age – young patient

Technical factors:

1) Larger graft

2) Eccentric graft

3) Therapeutic keratoplasty

4) Suture removal

5) Loose sutures

Donor factors which influence graft rejection are mainly:

• Method of storage.

• Duration of storage

• Pretreatment of donor tissue with ultra-violet rays may reduce chances

of rejection.

• Nature of donor button cutting (strength of Antigen Presenting Cells).

• Antigenic load of HLA and ABO antigens.

The Colloborative Corneal Transplant Studies (CCTS) concluded that

donor-recipient tissue HLA typing has no significant long term effect on

success of transplantation, while ABO compatability is more useful. The

CCTS study20 also states that donor corneal preservation characteristics were

not reported to have significant influence on graft outcome.

SYMPTOMS AND SIGNS OF GRAFT REJECTION:

Symptoms precede the signs. The patient needs to be counseled

adequately so that he/she present to the clinic as soon as the symptoms

begin. This will help in starting treatment immediately and reversing the

rejection episode.

Symptoms:

• Decreased vision

• Photophobia and glare

Signs:

• Circumcorneal congestion

• Keratic Precipitates

• Localized corneal edema

• Generalized corneal edema

• Khodadoust Line (endothelial rejection)

Treatment of endothelial rejection:

1. Topical 1% Prednisolone Acetate eyedrops suspension. Titrate

according to the response.

2. Subconjunctival injection of 0.5 mg Dexamethasone.

3. Oral Prednisolone acetate 1 mg/kg body weight.

4. Intravenous methyl Prednisolone Acetate.

5. If it is still irreversible, then plan for a Regraft.

PENETRATING KERATOPLASTY AND CATARACT SURGERY:

The assessment of lens status is essential in every case of

Keratoplasty. A cataractous lens needs to be removed simultaneously when

an Optical Keratoplasty is planned (Triple Procedure). The advantages of a

simultaneous procedure are performance of a single procedure and lesser

risk of endothelial damage of the graft from a subsequent cataract surgery.

The disadvantage lies in the difficulty in calculating the intraocular lens

power9.

When planning a two stage procedure, cataract surgery is to be done

in an eye with corneal transplantation, after at least three months of

keratoplasty. Refractive power stabilization of the cornea occurs after

complete suture removal of the graft.

When a combined procedure is planned, cataract surgery and corneal

grafting can be performed either as Phacoemulsification with intraocular

lens implantation first, followed by keratoplasty; or as keratoplasty with

open sky, extra-capsular extraction of the cataract and intraocular lens

implantation, depending on density of the corneal opacity.

PEDIATRIC KERATOPLASTY:

Grafts in infants and children can often be difficult as the cornea and

sclera are more elastic and are difficult to handle, the iris more adhesive,

vitreous more tenacious and the eyes mount a more severe inflammatory

response11.

Follow up care is difficult in children. They are also not able to

complain or report about the early symptoms of rejection and hence the

prompt treatment to reverse it not initiated.

The indications for keratoplasty in children in the order of frequency

are:

1) Trauma- poor prognosis

2) Congenital corneal opacities-poor prognosis due to amblyopia

3) Acquired non-traumatic conditions :

a. Infection

b. Stevens –Johnson Syndrome

c. Keratoconus.

The probability of obtaining a clear graft at the age of one year has

been shown to be maximum in cases of acquired not traumatic opacities,

followed by cases of trauma and least in cases of congenital anomalies.

CORNEAL DONATION

Donor Cornea:

To address the problem of corneal blindness by doing Keratoplasty

(removing diseased corneal tissue and replacing it with healthy donor

tissue), the supply of good quality donor corneal tissue is needed. This is

taken care of by Eye Banks which harvest, preserve, evaluate and distribute

good quality donor corneal tissues.

Keeping the donor cornea transparent:

The cornea upon death or removal of an eye from the donor, absorbs

the aqueous humor, thickens, and becomes hazy. Transparency of the

corneal tissue can be restored by putting it in a warm, well-ventilated

chamber at 31 °C (88 °F, i.e. normal temperature), allowing the fluid to

leave the cornea and become transparent. The cornea takes in fluid from the

aqueous humor and the small blood vessels of the limbus, but a pump ejects

the fluid immediately upon entry. When energy is deficient the pump may

fail, which occurs at death. But the cadaver eye can be placed in a warm

chamber and the reservoirs of sugar and glycogen can keep the cornea

transparent for at least 24 hours. The best way to keep the corneal tissue for

corneal transplantation is to remove it from the eyeball, thus preventing it

from absorbing aqueous5.

Eye Donation :

The process of corneal transplantation begins with availability of

donor corneas. Potential donors can be recruited from Community Corneal

Retrieval Programmes and Hospital Corneal Retrieval Programmes. The

selection of donor corneal tissue is influenced by the potential for

transmission of disease to the recipient, and also by the quality or potential

efficacy of the tissue. There are guidelines for Eye Banks for donor

selection.

There are a few contraindications for donor selection which may be

absolute or relative. They are:

v Death due to an unknown cause

v Septicaemia

v HIV

v Rabies

v CNS infectious diseases

v Systemic infections such as syphilis, hepatitis B and C

v Leukemia and disseminated lymphoma

v Intraocular tumours.

In India Eye Donation is always decided by the donor’s surviving

relatives and not by the actual donor. The enucleating doctors have to legally

obtain a written consent from the relatives of the deceased before they

actually remove the eyes. When a consented donor meets medical and social

screening criteria, and the physical assessment reveals no contraindication to

donation, the collection of the donor tissue is carried out.

"Recovery" refers to the retrieval of organs or tissues from a deceased

organ donor. Recovery is currently the preferred term, although "harvesting"

and "procurement" have been used in the past, they are considered

inappropriate, harsh, and potentially inaccurate.

It can be either by whole globe enucleation or by in-situ corneo-

scleral excision. During enucleation the aim is to minimize manipulation of

tissues surrounding the eye in order to preserve the donor’s appearance, to

prevent touching or distortion of the corneal tissue and thus minimize any

cell loss (epithelial or endothelial) and to reduce bacterial contamination 21.

Along with the donor tissue collection, blood from the donor is also

withdrawn in order to perform few serological tests to rule out any systemic

contraindications for the use of the donor tissue (i.e infectious diseases such

as Human Immunodeficiency Virus, Hepatitis B virus, Hepatitis C virus,

Syphilis etc.)

In our institute we perform whole globe removal and preserve it in a

Moist Chamber. The certified medical practioners enucleate the whole globe

after obtaining the consent of the next of kin of the deceased. The whole

globe in the moist chamber is preserved in the refrigerator at 2-8 degrees

centigrade till the corneo-scleral rim excision is done. The trained eye bank

technicians take the whole globe from refrigeration, decontaminate it and

then excise the corneo-scleral rim and preserve it in tissue culture medium

such as Cornisol. This storage medium allows preservation of the donor

corneal tissue upto fourteen days, till its utilization for corneal

transplantation.

EYE BANKING

Eye Bank:

“An eye bank is a non-profit organization with an aim to acquire and

provide donated human eye tissue for corneal transplantation procedures in

addition to providing vital tissue for research and education. It also stores

and preserves human corneal tissue for future use.”

In 1944, the first eye bank was founded in New York City by two

physicians, Dr. Townley Paton and Dr. John MacLean. In India, the first eye

bank was established in 1945 at Madras [Chennai] and the first successful

corneal transplantation was carried by Dr. Dhanda of Indore in 1960.

Eye Bank Association of India (EBAI) established in 1989, co-

ordinates all eye banks and provides training for eye bank technicians to

improve quality and quantity of corneal tissues32. EBAI stresses on the

importance of registration, networking, availability of resources and

information, education and communication22, 23. It has also clearly laid down

the code of ethics for Eye Banks. The medical standards have been

prescribed by the Government of India. Eye Banks are expected to maintain

stringent conditions needed for processing the collected tissue. These

guidelines have brought about uniformity in the approach to eye banking.

Transplantation of Human Organs Act (THOA) provides for the

regulation of removal, storage and transplantation of human organs for the

therapeutic purposes and prevention of commercial dealings in human

organs. THOA in section 3 currently postulates that organs shall be removed

by a Registered Medical Practioner only. Under Subsection (4) – Section 4A

shall be inserted to provide that a technician possessing such qualifications

and experience may be allowed to perform enucleation 38.

Rotary Aravind International Eye Bank

EYE Bank Work Process - Flow Chart

CCRP HCRP

Ensure Safe

Transportation

Evaluation

Serology

Excision

Preservation

Specular Microscopy

Distribution

RAIEB/ CC

Slit Lamp

Medical Director

HIV,HCV HBSAg. syphillis

Trained technician

C- MK Scl- Glecerin

AMG- Dulbecco

Trained technician

Trained technician

Trained technician

Research & Training

Not Fit

+ve

Transplantation

Trained technician

Discarded

CORNEAL PRESERVATION

The objective of corneal preservation is to store the corneal tissue

while maintaining its function and cellular integrity after retrieval of the

tissue from the donor until its use for grafting.

Over the years, various methods have been developed and introduced,

on the one hand to increase the duration of storage with the aim of a more

efficient use of the donor tissue and the possibility of safe transport to

transplantation sites and on the other hand to increase tissue quality by

microbiological testing and tissue evaluation procedures14 .

The quality of the Corneal Endothelium in enucleated eyes

deteriorates in 24 to 36 hours. Enucleated eyes are kept in Moist Chambers

and stored at 4º centigrade. The viability of the corneo-scleral buttons can be

prolonged by preservation in tissue culture medium. There are short term or

intermediate methods and long term storage methods.

Ø Moist Chamber Storage is the time-honored corneal preservation

method; it consists of keeping enucleated eyes at 0–4 °C in a sealed

jar containing a pad of cotton gauze soaked in saline to provide a

humid environment. The time limit placed upon this method of

storage is 24–48 hr after which the viability of the endothelium

deteriorates rapidly.

The major advantage of this method is its simplicity, since is requires

little expertise and a minimum of manipulation.

The major disadvantage is the very limited storage time.

Ø Storage in M-K (McCarey-Kaufman) Medium has been replaced by

Optisol GS or Cornisol Medium. It involves excision of the

corneoscleral segment from the donor eye and immersing it,

endothelial side uppermost, in a medium consisting of tissue culture

medium, 5% Dextran 40, and antibiotics37. Laboratory and clinical

studies indicate that storage in M-K medium at 4 °C preserves human

endothelial cells for up to 4 days when the eye has been removed from

the cadaver in less than 10 hr postmortem3. Now with Optisol and

Cornisol medium the cadaver eyes recovered within 6 hours

postmortem can be preserved for 14 days10, 13.

v Optisol :

Optisol was described in 1991 by Kaufman and his associates. It

contains in addition both dextran and chondroitin sulfate to enhance corneal

dehydration during storage. Its constituents are:

• TC 199 + minimum essential medium

• 2.5 % chondroitin sulfate

• 1% Dextran, Mol. Wt. 40,000.

• HEPES buffer

• Gentamicin sulfate 100 µg/ml

• Nonessential amino acids 0.1 mmol/l

• Sodium bicarbonate

• Sodium pyruvate 1mmol/l

• Additional antioxidants.

v Cornisol:

Cornisol is a sterile, buffered corneal preservation medium, produced

by Aurolab, Madurai, India. It is supplemented with chondroitin sulfate

(acts as membrane stabilizer), recombinant human insulin (metabolism

enhancer), Dextran (osmotic agent), stabilized L-glutamine, ATP

precursors, vitamins, trace elements, Mucopolysaccharides with

Gentamicin Sulphate (100µgm/ml), Streptomycin Sulphate (200 µgm/ml)

and pH indicator. It is packaged in 20 ml vials, with clear optical bottoms

for easy microscopic evaluation.

Ø Glycerol storage :

Glycerol (glycerin) is a colorless, odorless, and viscous liquid whose

three hydrophilic hydroxyl groups impart both solubility in water and

hygroscopicity (water-absorption). Glycerol has excellent anti-bacterial,

anti-fungal, and anti-viral properties, well documented by literature on

skin and bone banking and scleral patches for ophthalmic surgery .

Glycerol acts as a cryo-protectant for frozen tissue storage, because it

binds strongly to water and forestalls the formation of damaging ice

crystals35.

Ø Organ Culture Preservation:

In organ culture preservation corneas are incubated in tissue culture

medium supplemented with fetal calf serum, anti-biotics, and

antimycotics at 30–37°C. The swelling of the cornea, due to the absence

of dehydrating agents in the medium, is reversed shortly before

transplantation by placing the cornea (earlier) in M-K medium at 4°C 12.

Currently the swelling is reversed by transferring the corneas to a culture

medium supplemented with dextran (4–8%) at room temperature to 37°C.

The organ culture medium consists of :

• Engle’s minimum essential medium

• Earle’s salts without L-glutamine

• L-glutamine

• Decompensated calf serum

• 1.5% chondroitin sulfate (mol.wt. 50,000).

Because the integrity of the endothelium is better maintained during

organ culture the storage time of 4 to 5 weeks allowed by organ culture is

long compared with the generally accepted period of 3 to 5 days for

hypothermic storage.

Ø Cryopreservation :

It can be regarded as the only true long -term storage method that can

preserve the corneas for an indefinite period of time. Capella and

Kaufman developed the basic method of Cryopreservation. Here, the

corneo-scleral rim is passed through a series of solutions containing

increasing concentrations of Dimethyl Sulfoxide (DMSO) upto 7.5%, for

10 minutes in each solution. The tissue is then frozen at a controlled rate

upto -80 degrees centigrade and then stored at -160 degrees centigrade

indefinitely.

Cryopreservation needs expensive equipment and highly trained

personnel. A slight error in the procedure can lead to tissue damage

rendering it unsuitable for corneal transplantation. The mechanisms of

damage to tissue during freezing and de-freezing include increased solute

concentration, intracellular micro-ice crystal formation, changes in pH and

osmolarity etc.

In developing countries long term storage procedures of Organ

Culture and Cryopreservation are not in practice

CORNEAL TISSUE EVALUATION

The corneas are visually examined and evaluated underneath a slit-

lamp, and the number of endothelial cells are counted underneath a specular

microscope. The corneas are rated, usually on a scale of 0-4, for donor

suitability based on the specular and slit-lamp evaluations.

Corneal evaluation begins with a gross examination of the corneas in

situ. Torchlight or penlight examination reveals epithelial dryness / exposure

/erosions, abnormal corneal shape, blood or cloudiness in anterior chamber,

corneal scars or infiltrates, arcus senilis, signs of conjunctivitis and

discharge.

Ø Slit Lamp Examination:

Slit Lamp Examination gives a more accurate description of the

cornea. It reveals earlier stage of pathology which are grossly visible. Under

low and high magnification major defects are looked for, and their nature

and extent studied. The slit lamp characteristics of the donor corneas are

summarized in the “ donor evaluation chart”. Epithelial defects, exposure

and epithelial haze are looked for. Stroma is examined for overall clarity,

arcus, edema and stromal folds. Descemet’s folds and endothelial stress lines

are looked for.

The corneal tissue is graded and labeled as excellent, very good , fair

and poor or not suitable for surgery. The final corneal evaluation criteria is:

Excellent:

ü no epithelial defects

ü Crystal clear stroma

ü No arcus senilis

ü Excellent endothelium-no defects

Very Good:

ü Slight epithelial haze or defects

ü Clear stroma

ü Very slight arcus

ü Few light folds

ü Very good to excellent endothelium-no defects

Good:

ü Obvious moderate epithelial defects

ü Light –to-moderate cloudiness

ü Moderate arcus senilis <2.5 mm

ü Obvious folds (numerous but shallow)

ü Few vacuolated cells

Fair:

ü Obvious epithelial defects (>60%)

ü Moderate to heavy stromal cloudiness

ü Heavy folds (numerous, deep, central)

ü Heavy arcus senilis >2.5 mm

ü Fair to good endothelium- moderate endothelial defects,

vacuolated cells, low cell density

Poor:

ü Moderate vacuolated cells (some central)

ü Severe stromal cloudiness

ü Marked folds (heavy, numerous, central)

ü Fair endothelium – marked defects, low cell density, numerous

central vacuolated cells

ü Technical problems in removal

Ø Specular Examination-

A specular reflection of the endothelial layer can be observed in a

small area of the endothelial reflex. The corneal endothelial condition is

central to evaluating the suitability of corneal tissue for penetrating

keratoplasty, as it is mainly responsible for the maintenance of corneal

turgor and transparency.

Specular Microscopy determines endothelial cell density, cell

pleomorphism and polymegathism and identification of corneal guttata.

Specular microscope is used by the eye bank using hypothermic storage of

corneo -scleral buttons.

Specular microscopy by fixed frame analysis is a technique that uses a

standard size frame to count the cells. The frame acts as an overlay and all

the cells within the area are counted, those touching two sides are included

and those touching other two sides are excluded.

The following features of endothelial cells are noted:

• Cell density

• Cell shape, size, uniformity, pleomorphism and polymegathism

• Presence of corneal guttata

• Evidence of any old intraocular inflammation and endothelial

insult.

The higher the cell density, greater would be the success of

transplantation. Donor corneal tissues with considerable polymegathism or

pleomorphism have a high incidence of postsurgical decompensation and

have a reduced functional reserve. Presence of corneal guttata also leads to

reduced endothelial functional reserve.

The criteria to consider a cornea unsatisfactory are :

• Very low endothelial cell count (<1500 cells/mm2)

• Extreme polymegathism or pleomorphism

• Presence of significant corneal guttata

• Presence of extensive areas with severe edema

• Presence of inflammatory cells on the endothelium.

Organ Culture Storage Methods prefer other methods of Endothelial

evaluation such as Phase contrast Microscopy, transmitted light microscopy

accompanied by trypan blue intravital staining of the endothelial layer. The

various methods of assessing corneal endothelial viability include:

1. Staining Method: It uses dyes to stain the devitalized or viable

endothelial cells which can then be counted. Dyes such as

Trypan Blue, Nitro Blue Tetrazolium, Acridine Orange, Rose

Bengal, Evans Blue and Alizarine Red are used.

2. Temperature Reversal: It gives a direct demonstration on

corneal endothelial function by showing the reversal of corneal

thickening after warming the cooled cornea.

3. Bicarbonate flux: It monitors the maintenance of endothelial

bicarbonate flux as a measure of endothelial viability.

4. Electron Microscopy: It allows the examination of morphology

of cells and the structural damage.

5. Enzyme Release: It monitors the release of cytoplasmic or

lysosomal enzymes into the aqueous humour which is related to

organelle and plasma membrane disruption and thus tissue

viability.

6. Magnetic Resonance Imaging: It non-invasively measures the

intracorneal pH and determines the levels of adenosine

triphosphate, inorganic phosphate,etc.

7. Redox Fluorometry: It non-invasively determines the

metabolic status of the corneal tissue by measuring the relative

concentration of reduced pyridine nucleotides and oxidized

flavoproteins.

8. Intracellular Glutathione: It takes the intracellular glutathione

oxidation- reduction profile as a method of assessing the

capability of fluid transport by the corneal endothelium.

9. Radioactive Isotopes Studies: It takes the ability of corneal

endothelial cells to incorporate tritiated uridine into RNA as a

measure of their viability.

10. Oxygen Consumption: It takes oxygen consumption as a

measure of endothelial cell viability.

11. Endothelial Tissue Culture: It takes into account, the

availability of endothelial cells to proliferate in tissue culture as

a measure of endothelial cell viability.

CATARACT AND PSEUDOPHAKIA

Cataract :

Cataract is defined as any type of clouding or opacity of the lens

which prevents clear vision. Age –related / senile cataract is the most

common cause of blindness in the world. Occasionally children can be born

with the condition (congenital cataract), or a cataract may develop after eye

injuries (traumatic cataract), inflammation (complicated cataract) and some

other eye conditions.

Cataract is the leading cause of blindness globally. As people in the

world live longer, the number of people with cataract is anticipated to grow.

Cataract is also an important cause of low vision in both developed and

developing countries.

The development of cataract may be delayed by reduction of

ultraviolet light exposure and cigarette smoking. Additional risk factors like

diabetes mellitus and high body mass index have been identified.

The American Cooperative Cataract Research Group (CCRG) has

proposed a classification based on the stereoscopic color photographs of

excised human lenses. The cataracts are classified as:

1) Hypermature cataracts

2) Mature cataracts

3) Immature cataracts

a. Anterior subcapsular cataract

b. Posterior subcapsular cataract

c. Anterior cortical cataract

d. Equatorial cortical cataract

e. Posterior cortical cataract

f. Supranuclear cataract

g. Nuclear cataract.

The classification of cataracts is significant because the immature

cataracts are easier to extract and the surgical techniques cause least damage

to the corneal endothelium. The mature and hypermature cataracts are more

difficult to remove and the surgical techniques that need to be used may

cause comparatively more damage to the corneal endothelium.

The treatment of cataract is surgical and very successful in restoring

vision. The opaque lens is removed and replaced by an artificial intraocular

lens.

CATARACT EXTRACTION

Advancements in Surgical Techniques:

In the twenty-first century modern cataract-intraocular surgery has

become one of the safest, most successful and most frequently performed

outpatient surgeries world over. A significant evolution of surgical

techniques has taken place.

The most remarkable advance is the considerable decrease in the size

of the wound incision. Small incision cataract surgery using

phacoemulsification through clear corneal self-sealing incisions avoids

cauterization and suturing.

Phacoemulsification was invented and pioneered by Dr. Charles D

Kelman, who used a 2-3 mm incision and vibrational energy to fragment the

lens inside the eye. Bimanual Phacoemulsification can now be performed

through an Ultra-small (0.9 mm) incision using Phakonit technique. Phako –

phacoemulsification performed with Needle opening (N) via an Ultra-small

Incision (I) and with the sleeveless ultrasound Tip (T).

Femtosecond Laser assisted cataract surgery has taken the surgery to a

new level of precision and surgical outcomes. Femtosecond laser is used to

make partial cuts on the anterior lens capsule, cornea and also to partially

emulsify the lens.This makes the corneal entry, capsulorhexis and

phacoemulsification precise and less traumatic to the corneal

endothelium39, 42.

Anaesthetic techniques have advanced from Retro Bulbar Injections,

Peribulbar Injections to topical or phaco anaesthesia which include

anaesthetic eye drops application, sponge anaesthesia, intra-cameral

injection and gel application.

A variety of foldable and rollable Intra Ocular Lenses manufactured

from hydrophobic or hydrophilic acrylics and silicone biomaterials are

available today. These foldable lenses with truncated optics are preferred by

many surgeons because of reduced incidence of Posterior Capsular

Opacification.

Viscosurgery using the viscoelastic substances( which are solutions

with dual properties acting as viscous liquids and elastic solids or gels) has

helped the surgeons in many steps of the cataract surgery. The viscoelastics

act as a soft surgical instrument,- OVD (Ophthalmic Viscosurgical Devices).

They are used during cataract surgery and intraocular lens implantation to

maintain the anterior chamber depth and capsular bag distention, so creating

and preserving working space for the ophthalmic surgeon. Cohesive ,

Dispersive and Viscoadaptive types of viscoelastics are used in various

situations.

The new intraocular lens designs, improved manufacturing techniques

and quality controls coupled with improved microsurgical techniques and

viscosurgery have contributed to this level of acceptance and

advancement30, 31.

FUTURE

The future holds further promise of advancements such as

Femtosecond laser assisted endothelial keratoplasty (FLEK), Femtosecond

laser assisted anterior lamellar Keratoplasty (FALK) and culture of

endothelial cells from donor corneas and used in various endothelial

dystrophies and deficiencies etc.

Hence with all these newer advancements, cataract surgery has

become more common, of shorter duration, sutureless and less traumatizing

to ocular tissues especially the corneal endothelium. People are seen to opt

for this surgery at an earlier age as compared to the past.

So we see the following changes:

1. Younger people undergoing cataract surgery

2. Better methods (least traumatic to endothelium) of cataract surgery

3. Advances in assisting techniques- Viscoelastics, Machines, Femto etc

4. Longer preservation of Corneal Buttons in newer media ( Cornisol etc)

5. Hospital and Community based Corneal Retrieval Programmes

6. Corneal transplantation techniques - improved

With this trend maintaining we are sure to see an increase in the

percentage of pseudophakic donor corneal tissues in the eye banks in the

future. In keeping with the advancement in surgical techniques the damage

to the corneal endothelial cells is going to be low. So all tissues must be

evaluated by critical methods and if the corneal endothelial cell density is

good, the donor tissue can be used for optical and therapeutic grafts.

Further follow up and continued study is needed to document the

outcome of these pseudophakic donor corneal tissues in the recipients.

AIMS AND OBJECTIVES

1. To evaluate the Pseudophakic donor corneas by Slit Lamp

Examination and Specular Microscopy.

2. To assess the quality of donor corneas and use for grafting (corneal

transplantation).

MATERIALS AND METHODS

A Prospective study done to evaluate the endothelium in the whole

globe pseudophakic donor.

DATA COLLECTION:

All pseudophakic donor eyes received during the Study period of

One year, from 1st August 2013 to 31st July 2014 at Rotary Aravind

International Eye Bank, Madurai have been enrolled in the study.

A total of 1666 number of corneal donor tissue received by the eye

bank during the one year study period , of which 601 were pseudophakic.

METHODS:

The evaluation of donor cornea was done by the trained eye bank

technicians in accordance to the Eye Bank Protocol guidelines set by the

NPCB (National Programme for Control of Blindness ).

Inclusion criteria:

� All Pseudophakic Donor corneas from intact globe suitable for

transplantation.

Exclusion criteria:

� Phakic donors

� Aphakic donors

� Anterior chamber IOL

� Vitreous in AC touching endothelium

� Irregular pupil with PAS / PS

� Infected eyes / infiltrate in cornea

� Collapsed globe

The donor cornea retrieval was done by ophthalmologists (as per NPCB

guidelines) by whole globe enucleation and brought to the eye bank in the

Moist Chamber and stored at 4 degree centigrade till the corneo-scleral

button excision. The moist chamber allows storage upto 24 hours and

maximally upto 48 hours.

The whole globe was then examined under Topcon slit lamp by the

trained eye bank technicians and graded as excellent / very good / good / fair

/ NSFS (not suitable for surgery). The criteria are epithelial compactness,

epithelial defects, exposure, stromal cloudiness, arcus, descemets membrane

folds, endothelium etc.

The corneo-scleral button excision was done in a laminar flow

chamber under aseptic conditions after decontamination of the whole globe

in 5% povidone iodine for 3 minutes and then in saline mixed with amikacin

[20ml saline +2cc (or 100mg) amikacin] for 3 minutes. The whole globe was

then dipped in saline to wash off the povidone iodine and amikacin and then

placed on sterile surface to excise the corneo-scleral button.

The excised corneo-scleral button was stored in Cornisol at 4-5

degrees centigrade. The specular microscopic evaluation using Konan Non

Contact Specular Microscope, was done after removing the corneal donor

tissue from refrigeration and keeping at room temperature for two hours.

After evaluation the tissue would be stored at 4-5 degrees centigrade till

utilization. The stored corneal donor tissue would be allotted as per the

surgeons requirement. The tissue would be transferred to the operation

theatre in ice buckets and refrigerated again at 4-5 degrees centigrade till the

actual utilization on table.

Earlier the M-K medium (McCarey- Kaufman medium) was used

which allowed storage for only 3-4 days. But with the availability of

Cornisol and Optisol the storage time has increased upto 14 – 15 days. The

average storage time in our study was 130.70 (103.08) hours and the range is

4 to 386 hours.

The donor corneo-scleral button stored in the Cornisol medium was

examined using Konan’s Non-Contact Specular Microscope. The corneal

tissue placed endothelium facing down inside the cornisol vial, was placed

inside the beaker with water, and positioned on the specular microscope.

The central cornea was evaluated by the center method i.e. where the

center of each contiguous cell was marked (a built-in high resolution camera

gives high quality images of the donor corneal tissue). The built –in cell

analysis system allows an accurate and rapid endothelial cell count. The

donor endothelial morphology was evaluated by measuring the endothelial

cell density, co-efficient of variation of cell area and percentage

hexagonality.

Based on the Slit Lamp Examination Grade and the Specular

Microscopic parameters the pseudophakic corneal endothelial tissues were

used for:

1. Optical use-slit lamp examination – good and better grades, specular

microscopic examination – ECD-- > 2100 cells /cubic mm, CV – 30 -

50%, 6A- 40-60%

2. Young TPK- optical grade tissue.

3. DALK- therapeutic grade tissue.

4. Therapeutic Keratoplasty grade tissue-( S/L/E- Fair , ECD -1200-1800 )

5. Discarded Tissues- S/L/E- NSFS, Serology positive, Culture Positive,

tissue Damage.

Slit Lamp Examination :-

• Donor Evaluation Chart:

� A thorough slit lamp examination of the donor eyeball to record the

status of the epithelium, stroma, lens, descemet's membrane and

endothelium and grade the pseudophakic donor cornea as :

� Excellent

� Very Good

� Good

� Fair

� NSFS (Not Suitable For Surgery).

Specular microscopy parameters considered: –

� Number of cells

� Cell density

� Coefficient of variation

� Hexagonality

RESULTS

A prospective study was done with a sample size of 601 pseudophakic

donor eyeballs. The total number of donor eyeballs received during the study

period of twelve months was 1666, the percentage of pseudophakic eyes

being 36.07%.

The 345 donors in the study ranged in age from 31-104 years with a

mean age of 77.85 years. There were 155 female donors (44.9%) and 190

males (55.1%). There were 89 donors with unilateral pseudophakia (25.8%)

and 256 donors bilaterally pseudophakic (74.2%).

The mean enucleation time was 3 hours 12 minutes, ranging from 15

minutes to 9 hours 30 minutes.

The mean preservation time was 14 hours 25 minutes, ranging from

45 minutes to 39 hours.

The mean storage time was 130 hours 42 minutes, ranging from 4 to

386 hours. The storage time in our study is prolonged due to use of cornisol

as storage medium.

The most common cause of death was cardiovascular disease

(84.4 % ), followed by chronic obstructive pulmonary disease (11 %), , road

traffic accidents ( 1.7 %), multisystem failure (1.5 %) and others (1.5 %).

Of the 601 pseudophakic eyes, 405 eyes were rejected based on slit

lamp evaluation grade (used for research and training), serology positivity or

growth in culture (discarded). 196 corneal donor tissues were utilized, 23

for optical purpose and 173 for tectonic/ therapeutic purpose. Among the

optical surgeries 12 were Penetrating Keratoplasties and 11 were Deep

Anterior Lamellar Keratoplasties. Of the 173 tectonic grafts 14 were young

Therapeutic Penetrating Keratoplasties and the rest tectonic grafts.

The corneal donor tissues which were evaluated had a mean

endothelial cell density of 1924.64, a mean Co-efficient of Variation of

46.36 and a mean hexagonality of 47.67.

DEMOGRAPHICS

Age:

Mean (SD) of the age is 77.85 (9.7) and the range is 31 -104 yrs.

Age Category

Age category n %

< 65 40 11.6

66 – 75 99 28.7

76 – 85 134 38.8

86 – 95 67 19.4

>95 5 1.5

Total 345 100.0

Age category Use

Total P-value Yes No

< 65 27(42.2) 37(57.8) 64

<0.001

66 – 75 72(43.1) 95(56.9) 167

76 – 85 76(32.1) 161(67.9) 237

86 – 95 21(17.1) 102(82.9) 123

>95 - 10(100.0) 10

Total 196(32.6) 405(67.4) 601

38.8%

19.4%

<=65

42.2% 43.1%

57.8% 56.9%

0%

20%

40%

60%

80%

100%

<=65 66

11.6%

28.7%

1.5%

Age

66 - 75 76 - 85 86 - 95 >95

43.1%32.1%

17.1%0.0%

56.9%67.9%

82.9%100.0%

66 - 75 76 - 85 86 - 95 >95

Age

Yes No

28.7%

100.0%

Sex:

Total number of patients are 345, females

190 (55.1%).

Sex

Sex

Female

Male

Total

Female, 55.1%

Total number of patients are 345, females – 155 (44.9%) and males

No.of patients %

155 44.9

190 55.1

345 100

Male, 44.9%

Sex

155 (44.9%) and males –

Male, 44.9%

Laterality:

Of 345 patients, 89 were unilateral ( 25.8%) and 256 were bilaterally

pseudophakic (74.1%).

Laterality

Laterality

Unilateral

Bilateral

Bilateral, 74.2%


No.of patients %

89 25.8

256 74.2

Unilateral, 25.8%

Laterality


Unilateral, 25.8%

Enucleation time:

Mean (SD) of enucleation time is 3.20 (1.56) hours and the range is 15

mins to 9.5 hours.

Enucleation time category N %

< 2hours 170 28.3

2 – 4 hours 293 48.8

4 – 6 hours 113 18.8

>6 hours 25 4.2

Total 601 100.0

Enucleation time category Use Total Optical Tectonic No

< 2hours 4 50 116 170

2 – 4 hours 14 97 182 293

4 – 6 hours 4 23 86 113

>6 hours 1 3 21 25

Enucleation time category Use

Total P-value Yes No

< 2hours 54(31.8) 116(68.2) 170

<0.001

2 – 4 hours 111(37.9) 182(62.1) 293

4 – 6 hours 27(23.9) 86(76.1) 113

>6 hours 4(16.0) 21(84.0) 25

Total 196(32.6) 405(67.4) 601

48.8%

Enucleation time cateogry

<=2 hours

31.8%

68.2%

0%

20%

40%

60%

80%

100%

<=2 hours

28.3%

18.8%

4.2%

Enucleation time cateogry

2 - 4 hours 4 - 6 hours >6 hours

37.9%23.9%

16.0%

62.1%76.1% 84.0%


Enucleation time

Yes No

Preservation time:

Mean (SD) of preservation time is 14.42 (6.92) hours and the range is 45

mins to 39 hours.

Preservation time n %

< 6 hours 19 9.2

6 – 12 hours 62 30.0

12 – 24 hours 112 54.1

>24 hours 14 6.8

Total 207 100.0

Preservation time Use Total Optical Tectonic No

< 6 hours 1 14 4 19

6 – 12 hours 12 44 6 62

12 – 24 hours 8 98 6 112

>24 hours 2 10 2 14

Total 23 166 18 207

Preservation time Use

Total P-value

Yes No

< 6 hours 15(79.0) 4(21.0) 19

0.119 6 – 12 hours 56(90.3) 6(9.7) 62

12 – 24 hours 106(94.6) 6(5.4) 112

>24 hours 12(85.7) 2(14.3) 14

Total 189(91.3) 18(8.7) 207

54.1%

<=6 hours

79.0%

21.0%

0%

20%

40%

60%

80%

100%

<=6 hours

Preservation time

9.2%

30.0%

6.8%

Preservation time


90.3% 94.6%85.7%

9.7% 5.4%14.3%


Preservation time-Use

Yes No

>24 hours

Storage time:

Mean (SD) of storage time is130.70 (103.08) hours and the range is 4 to

386 hours.

Storage time n %

< 1 day 21 10.7

1-2 day 45 23.0

2 – 7 days 89 45.4

7 – 14 days 35 17.9

>14 days 6 3.1

Total 196 100.0

Storage time

category

Use Total

Optical Tectonic

< 1 day 5 16 21

1-2 day 4 41 45

2 – 7 days 12 77 89

7 – 14 days 2 33 35

>14 days 0 6 6

Total 23 173 196

45.0%

<=1 day 1 - 2 days

11.0%

23.0%

18.0%

3.0%

Storage time

2 days 2 - 7 days 7 - 14 days >14 days

11.0%

>14 days

Use:

Use

DALK

PKP

Tectonic*

TPK

Young TPK

Total

*K-pro – 1, Patch graft – 17, Scl graft

57.1%

DALK PKP

N %

11 5.6

12 6.1

Tectonic* 47 24.0

112 57.1

Young TPK 14 7.1

196 100

17, Scl graft – 29

5.6%

6.1%

24.0%

7.1%

Use

PKP Tectonic TPK Young TPK

6.1%

Young TPK

Specular Parameters Data:

Measurement

Variable n Mean(SD) Min-max

Cell density 69 1924.64(490.5) 886 – 3048

CV 69 46.36(7.8) 31 – 67

Num 69 70.54(25.7) 12 – 133

6 A 69 47.67(8.9) 25 – 65

Cause of death:

Cause of death n %

Cardiac 289 83.5

RTA 6 1.7

Respiratory 38 11.0

Other 13 3.8

Total 346 100.0

Cause of death Use

Total Optical Tectonic No

Cardiac 11 92 186 289

RTA - 3 3 6

Respiratory 1 7 30 38

Other 1 4 8 13

Total 13 106 227 346

Cause of death Use

Total P-value

Yes No

Cardiac 103(35.6) 186(64.4) 289

0.242 RTA 3(50.0) 3(50.0) 6

Respiratory 8(21.0) 30(79.0) 38

Other 5(38.5) 8(61.5) 13

Total 119(34.4) 227(65.6) 346

84.4%

Cardio vascular RTA

35.7%50%

64.3%

0%

20%

40%

60%

80%

100%

Cardio vascular

1.7%

11.0%

1.5%1.5%

Cause of Death

RTA Respiratory Multi system failure Other

50%

21.0%

80.0%

20.0%

50%

79.0%

20.0%

80.0%

RTA Respiratory Multi system failure

Other

Cause of Death-Use

Yes No

Other

20.0%

80.0%

Other

DISCUSSION

Corneal blindness still is one among the leading causes of blindness.

The principal solution for corneal blindness is corneal transplantation. The

limiting factor for this therapeutic and optical procedure is the availability of

suitable donor corneal tissue.

The leading causes of corneal blindness in India are Corneal scarring ,

adherent leucoma, infectious keratitis and corneal perforation followed by

Pseudophakic Bullous Keratopathy and Fuch’s and other Corneal

Dystrophies. So we see that therapeutic and tectonic keratoplasties

predominating the corneal transplantation scenario. This arises due to the

manual mode of labour and stone, stick, thermal and chemical injuries being

more common. The agricultural population being more and the level of

awareness and education being less among the rural masses in developing

countries, this infectious etiology of corneal diseases predominates.

Pseudophakic Bullous Keratopathy is also on the rise due to the increasing

number of Cataract surgeries being performed.

So we see an overall increase in the demand for corneal tissues both

for primary therapeutic and optical corneal transplantations and secondary

optical corneal transplantation. This demand can be aimed to be met by

increasing education and awareness about eye safety, eye donation and

corneal transplantations, and also by evaluating all potential donor

pseudophakic corneal tissues too.

Public awareness of eye donation and corneal transplantation is quite

high which has led to an increase in the collection of donor eyes. The rise in

community participation by volunteers, Lions Club, Rotary Groups etc has

boosted the Community Cornea Retrieval Programme. The role of grief

counselors in the Hospital Retrieval Programme has also increased the

turnover of potential donors amidst untimely deaths too.

Cataract surgeries in the younger age group and in early cataracts

using good anaesthetical and surgical techniques, instruments and

viscoelastics, foldable intraocular lenses and phacoemulsification and

femtosecond laser machines has proved useful in protecting the corneal

endothelium in the pseudophakic donor eyes. Hence we consider these

corneal pseudophakic donor tissues to also have a good endothelial cell

density count, and be a potential pool of suitable donor corneas and be

considered for corneal grafting.

The Cornea Donor Study group concluded that there was little change

in the mean of the endothelial cell density when the donor age was beyond

60.

Our study of 601 pseudophakic donor corneas received over a period

of twelve months shows the percentage of usage of these tissues after careful

examination, preservation and evaluation, for optical and therapeutic

purposes.

The study involved 345 patients, 89 of whom were unilaterally

pseudophakic and 256 of them bilaterally pseudophakic. The criteria of

Corneal donor tissues having an endothelial cell density more than 2000

cells/cmm, corneal overall grading of good and above, and with no

serological contraindications, ruled out 589 eyes from being used for optical

grade corneal transplantation. Only Twelve pseudophakic donor corneal

tissues from this study were used for optical purpose penetrating

keratoplasty (PKP). From the remaining pool Fourteen pseudophakic donor

corneal tissues were used for young therapeutic keratoplasties (TPK), Eleven

pseudophakic donor corneal tissues were used for deep anterior lamellar

keratoplasty (DALK), and 159 pseudophakic donor corneal tissues were

used for tectonic and therapeutic grafts.

Best and Reinard et al., reported that their study “reveal no reason to

regard pseudophacia as a principal contraindication for corneal donation,

provided a critical endothelial evaluation is carried out”. Our study has also

shown that there is a potential pool of suitable corneal donor tissue among

pseudophakic donor corneas, which need to be meticulously excised and

stored, and critically evaluated and carefully dispatched for the benefit of the

corneally blind.

Mindrup et al., reported that “corneas from pseudophakic donor eyes

may need more extensive evaluation.” We agree that more extensive

evaluation is needed than endothelial cell density and morphological

assessment to ensure good optical grade corneal transplantations.

LIMITATIONS

1. There needs to be a long term follow up of the cases of Penetrating

Keratoplasty to calculate the endothelial cell count after 1, 5, 10 years

etc.

2. The cases of Young Therapeutic Keratoplasty also need to be

followed up to check the endothelial cell density in the post operative

period.

3. We need to stress the importance of enucleation within 6 hours, post

mortem in the community, the beating heart organ donation in

hospitals, care of the eyes in the cadaver by educating the masses and

increasing the awareness in the community and the network of

voluntary organizations. This will increase the quality of enucleated

corneal tissues.

SUMMARY AND CONCLUSION

A prospective study done at Rotary Aravind International Eye Bank,

Aravind eye hospital and Post Graduate Institute of Ophthalmology,

Madurai, during a study period of one year, to evaluate the pseudophakic

donor corneal endothelium by Slit Lamp Examination using a 3D PS-11,

Topcon Slit Lamp, and Specular Microscopic Examination using the EKA -

98, Eye Bank Konan Specular Microscope, yielded a sample size of 601

eyes . The total number of eyes collected by the eye bank during the twelve

months was 1666. The following conclusions were reached.

Important observations made from this study:

1. 36.07 % of donor eyes received were pseudophakic.

2. 32.61 % of pseudophakic donor eyes were utilized for corneal

transplantation .

3. 18.88 % of the utilized pseudophakic donor eyes were used for optical

purposes

OUTCOME OF STUDY

Ø Endothelial cell count and specular parameters give an idea of

percentage of pseudophakic donor corneas, suitable for optical use.

Ø In the one year of study period 36.07% of eyes received at the eye

bank were pseudophakic and of the utilized pseudophakic donor

corneas, twelve were used for Penetrating Keratoplasties (6.12%),

eleven were used for Deep Anterior Lamellar Keratoplasty (5.61%)

and fourteen for Young Therapeutic Keratoplasties (7.14 %).

POLYMEGATHISM

PLEOMORPHISM

FIXED FRAME ANALYSIS

POLYMEGATHISM

PLEOMORPHISM

FIXED FRAME ANALYSIS

CORNEA

BIBLIOGRAPHY

1. Malbran E, Stefani C. Lamellar keratoplasty in corneal ectasias.

Ophthalmologica. 1972;164(1):59–70.

2. Barraquer JI. Lamellar keratoplasty. (Special techniques). Ann

Ophthalmol. 1972 Jun;4(6):437–69.

3. McCarey BE, Kaufman HE. Improved corneal storage. Invest

Ophthalmol. 1974 Mar;13(3):165–73.

4. Richard JM, Paton D, Gasset AR. A comparison of penetrating

keratoplasty and lamellar keratoplasty in the surgical management of

keratoconus. Am J Ophthalmol. 1978 Dec;86(6):807–11.

5. Rao GN, Shaw EL, Arthur EJ, Aquavella JV. Endothelial cell

morphology and corneal deturgescence. Ann Ophthalmol. 1979

Jun;11(6):885–99.

6. Smith RE, McDonald HR, Nesburn AB, Minckler DS. Penetrating

keratoplasty: changing indications, 1947 to 1978. Arch Ophthalmol. 1980

Jul;98(7):1226–9.

7. Hoffer KJ, Kraff MC. Normal endothelial cell count range.

Ophthalmology. 1980 Sep;87(9):861–6.

8. Meyer RF, Sugar A. Penetrating keratoplasty in pseudophakic bullous

keratopathy. Am J Ophthalmol. 1980 Nov;90(5):677–81.

9. Charlton KH, Binder PS, Perl T. Visual prognosis in pseudophakic

corneal transplants. Ophthalmic Surg. 1981 Jun;12(6):411–9.

10. Kaufman HE, Varnell ED, Kaufman S. Chondroitin sulfate in a new

cornea preservation medium. Am J Ophthalmol. 1984 Jul 15;98(1):112–

4.

11. Stulting RD, Sumers KD, Cavanagh HD, Waring GO, Gammon JA.

Penetrating keratoplasty in children. Ophthalmology. 1984

Oct;91(10):1222–30.

12. Doughman DJ, Lindstorm RL and. Long-term organ culture for corneal

storage: Minnesota system. In Brightbill FS (Ed): Corneal Surgery:

Theory, Technique and Tissue. CV Mosby Co, 1986;84-93.

13. Bourne WM. Endothelial cell survival on transplanted human corneas

preserved at 4 C in 2.5% chondroitin sulfate for one to 13 days. Am J

Ophthalmol. 1986 Sep 15;102(3):382–6.

14. Lindstrom RL, Doughman DJ, Skelnik DL, Mindrup EA. Corneal

preservation at 4 degrees C with chondroitin sulfate containing medium.

Trans Am Ophthalmol Soc. 1987;85:332–49

15. Buxton JN, Seedor JA, Perry HD, Eagle RC, Pecego JA. Donor failure

after corneal transplantation surgery. Cornea. 1988;7(2):89–95.

16. Brady SE, Rapuano CJ, Arentsen JJ, Cohen EJ, Laibson PR. Clinical

indications for and procedures associated with penetrating keratoplasty,

1983-1988. Am J Ophthalmol. 1989 Aug 15;108(2):118–22.

17. Doren GS, Cohen EJ, Brady SE, Arentsen JJ, Laibson PR. Penetrating

keratoplasty after ocular trauma. Am J Ophthalmol. 1990 Oct

15;110(4):408–11.

18. Al Faran MF, Tabbara KF. Corneal dystrophies among patients

undergoing keratoplasty in Saudi Arabia. Cornea. 1991 Jan;10(1):13–6.

19. Lindquist TD, McGlothan JS, Rotkis WM, Chandler JW. Indications for

penetrating keratoplasty: 1980-1988. Cornea. 1991 May;10(3):210–6.

20. The collaborative corneal transplantation studies (CCTS). Effectiveness

of histocompatibility matching in high-risk corneal transplantation. The

Collaborative Corneal Transplantation Studies Research Group. Arch

Ophthalmol. 1992 Oct;110(10):1392–403.

21. Lane SS, Mizener MW, Dubbel PA, Mindrup EA, Wick AA, Doughman

DJ, et al. Whole globe enucleation versus in situ corneal excision: a study

of tissue trauma and contamination. Cornea. 1994 Jul;13(4):305–9.

22. Moyes AL, Holland EJ, Palmon FE, Dvorak JA, Doughman DJ. Tissue

utilization at the Minnesota Lions’ Eye Bank. Cornea. 1995

Nov;14(6):571–7.

23. Saini JS, Reddy MK, Jain AK, Ravindra MS, Jhaveria S, Raghuram L.

Perspectives in eye banking. Indian J Ophthalmol. 1996 Mar;44(1):47–

55.

24. Probst LE, Halfaker BA, Holland EJ. Quality of corneal donor tissue in

the greater-than-75-year age group. Cornea. 1997 Sep;16(5):507–11.

25. Mindrup EA, Dubbel PA, Doughman DJ. Evaluation and transplantation

of corneas from pseudophakic donor eyes. Cornea. 1999 Nov;18(6):652–

7.

26. Whitcher JP, Srinivasan M, Upadhyay MP. Corneal blindness: a global

perspective. Bulletin of the World Health Organization. 2001

Jan;79(3):214–21.

27. Gain P, Rizzi P, Thuret G, Chiquet C, Michel-Valanconny C, Pugniet JL,

et al. [Corneal harvesting from donors over 85 years of age: cornea

outcome after banking and grafting]. J Fr Ophtalmol. 2002

Mar;25(3):274–89.

28. Meier FM, Tschanz SA, Ganzfried R, Epstein D. A comparative

assessment of endothelium from pseudophakic and phakic donor corneas

stored in organ culture. Br J Ophthalmol. 2002 Apr;86(4):400–3.

29. Best J, Reinhard T, Böhringer D, Spelsberg H, Sundmacher R.

[Perforating keratoplasty with transplants from pseudophakic donors].

Ophthalmologe. 2002 Jun;99(6):444–7.

30. Bourne RRA, Minassian DC, Dart JKG, Rosen P, Kaushal S, Wingate N.

Effect of cataract surgery on the corneal endothelium: modern

phacoemulsification compared with extracapsular cataract surgery.

Ophthalmology. 2004 Apr;111(4):679–85.

31. Nayak BK, Jain EK. Comparison of corneal endothelial cell loss during

phacoemulsification using continuous anterior chamber infusion versus

those using ophthalmic viscosurgical device: randomized controlled trial.

Indian J Ophthalmol. 2009 Apr;57(2):99–103.

32. Burton MJ. Prevention, treatment and rehabilitation. Community Eye

Health. 2009 Dec;22(71):33–5.

33. Eye Bank Association of India Medical standards, Directorate General of

Health Services Ministry of Health & Family Welfare Government of

India.http://www.google.co.in/url?sa=t&rct=j&q=&esrc=s&source=web

&cd=1&ved=0CBwQFjAA&url=http%3A%2F%2Fnpcb.nic.in%2Fwrite

readdata%2Fmainlinkfile%2Ffile176.pdf&ei=1YgyVPTdGIv8ugSx5ILo

CA&usg=AFQjCNE_98HKPFt6F_zk3sTG1WAChzI8wQ.

34. Schroeter J, Rieck P. Endothelial evaluation in the cornea bank. Dev

Ophthalmol. 2009;43:47–62.

35. Feilmeier MR, Tabin GC, Williams L, Oliva M. The use of glycerol-

preserved corneas in the developing world. Middle East Afr J

Ophthalmol. 2010 Jan;17(1):38–43.

36. Prevention of Blindness and Visual Impairment : Universal eye health: a

global action plan 2014–2019 WHO. http://www.who.int/research/en/

37. Armitage WJ. Preservation of Human Cornea. Transfus Med Hemother.

2011;38(2):143–7.

38. The Transplantation of Human Organs Act. 2011,Government of

India. http://pib.nic.in/newsite/erelease.aspx?relid=101217

39. Takács AI, Kovács I, Miháltz K, Filkorn T, Knorz MC, Nagy ZZ. Central

corneal volume and endothelial cell count following femtosecond laser-

http://www.google.co.in/url?sa=t&rct=j&q=&esrc=s&source=web

http://www.who.int/research/en/

http://pib.nic.in/newsite/erelease.aspx?relid=101217

assisted refractive cataract surgery compared to conventional

phacoemulsification. J Refract Surg. 2012 Jun;28(6):387–91.

40. Dua HS, Faraj LA, Said DG, Gray T, Lowe J. Human corneal anatomy

redefined: a novel pre-Descemet’s layer (Dua’s layer). Ophthalmology.

2013 Sep;120(9):1778–85.

41. Writing Committee for the Cornea Donor Study Research Group, Lass

JH, Benetz BA, Gal RL, Kollman C, Raghinaru D, et al. Donor age and

factors related to endothelial cell loss 10 years after penetrating

keratoplasty: Specular Microscopy Ancillary Study. Ophthalmology.

2013 Dec;120(12):2428–35.

42. Ganekal S, Nagarajappa A. Comparison of morphological and functional

endothelial cell changes after cataract surgery: phacoemulsification

versus manual small-incision cataract surgery. Middle East Afr J

Ophthalmol. 2014 Mar;21(1):56–60.

43. AAO/ Basic and Clinical Science Course / Vol: 8 - External Disease and

Cornea: 2011-2012, San Francisco: AAO, 2011. xiv, 324

44. Krachmer, Jay H Cornea / Vol: 1 - Fundamentals of cornea and

External Disease , St. Louis: Mosby, 1997. 3v., xxx, 558p.

45. Zia Chaudhuri. Postgraduate Ophthalmology / Vol: 1 - , New Delhi:

Jaypee-Highlights, 2011. 1113

46. Dutta, L C Modern Ophthalmology Ed. 3, New Delhi: Jaypee Brothers,

2005. 2v., xvii, 555p.

47. Prajna, N V. Aravind FAQs in Ophthalmology, New Delhi: Jaypee-

Highlights, 2013. p.701

PROFORMA

Study Number :

Eye Bank Number:

Age of Donor :

Sex: Male : Female :

Date of Death : Time of Death:

Date and Time of Enucleation:

Cause of Death :

Death to preservation time:

Method of preservation:

Storage time:

Medical History :

Diabetes

Hypertension

Coronary Heart disease

Others

Specular Microscopy - Parameters

Number of Cells

Cell density

Standard deviation

Coefficient of variation

Average

Maximum cell size

Minimum cell size

Hexagonality

Slit Lamp Examination :-

• Donor Evaluation Chart:

S.N

O

Stud

y ID

Mon

th

Eye

Age

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SD CV NU

M

6A USE

REM

ARKS

1 473 8 R 70 M HT CRA 2hrs30min 6hrs FAIR 23hrs TPK2 473 8 L FAIR 25hrs TPK3 476 8 R 55 F CVA 3hrs40min 7hrs30min FAIR 26hrs TPK4 476 8 L FAIR 28hrs TPK5 480 8 R 64 M MI 3hrs NSFS6 480 8 L NSFS7 481 8 R 89 M RESP.DIST 2hrs30min 12hrs30min FAIR 123hrs SCL.GFT8 481 8 L NSFS9 482 8 L 69 M IHD CRA 3hrs.45min 17hrs45min FAIR 19hrs TPK

10 483 8 L 48 M 3hrs 14hrs GOOD 14hrs.51min 14hrs 420 2380 1236 93 205 48 105 49 PKP11 485 8 R 84 M DM CRA 2hrs15min 19hrs FAIR 46hrs TPK12 485 8 L FAIR 44hrs TPK13 486 8 R 69 M MI 3hrs30min 21hrs FAIR 166hrs TPK14 486 8 L FAIR 115hrs SCL.GFT.15 488 8 R 77 M MI 4hrs 4hrs FAIR 48hrs TPK16 488 8 L FAIR 145hrs TPK17 489 8 R 75 M HT.IHD.CKD CRA 4hrs 16hrs FAIR 19hrs TPK18 489 8 L FAIR 44hrs TPK19 491 8 R 90 F RESP.DIST. 3hrs15min NSFS20 491 8 L NSFS21 492 8 L 74 F MI 2hrs45min NSFS22 493 8 L 74 F AGE CRA 1hr10min 8hrs30min GOOD 10hrs.45min 22hrs 370 2702 832 96 140 37 123 41 PKP23 494 8 L 70 F CRA 1hrs30min 11hrs.30min GOOD 13hrs.31min 38hrs 426 2347 1358 59 204 47 64 45 TPK YNG 24 497 8 R 80 M CRA 3hrs FAIR GROWTH25 497 8 L FAIR GROWTH26 500 8 R 70 M IHD CRA 2hrs40min 8hrs10min FAIR 9hrs.31min 8hrs 354 2824 959 56 143 40 133 53 PKP27 500 8 L FAIR 9hrs.36min 11hrs 359 2785 793 119 123 34 127 54 TPK YNG28 501 8 R 85 M HIP# CRA 2hrs 13hrs.35min FAIR 64hrs TPK29 501 8 L FAIR 111hrs TPK30 503 8 L 73 F HT.IHD CRA 3hrs20min 5hrs.30min FAIR 48hrs TPK31 505 8 R 75 F ICranHge CRA 3hrs45min 45min FAIR 27hrs SCL.GFT.

MASTER CHART

32 505 8 L FAIR 54hrs TPK33 513 8 R 80 M MI 3hrs NSFS34 513 8 L NSFS35 514 8 R 96 M MI 3hrs40min NSFS36 514 8 L NSFS37 520 8 R 90 M MI 2hrs.20min NSFS SYPH+38 521 8 R 75 F RTA Hd.Injury 8hrs55min NSFS39 521 8 L NSFS40 522 8 L 70 F CRA 3hrs NSFS41 525 8 R 73 F CRA 5hrs25min 12hrs55min NSFS42 525 8 L FAIR 27hrs DALK43 534 9 R 90 M MI 5hrs 18hrs FAIR 64hrs TPK44 534 9 L FAIR 66hrs TPK45 535 9 R 69 M DM.Dep.Park. CRA 3hrs30min 6hrs.30min FAIR 49hrs PATCH.GFT46 535 9 L FAIR 70hrs DALK47 537 9 R 82 M RESP.DIST. 3hrs NSFS48 537 9 L NSFS49 538 9 R 90 F MI 2hrs15min 8hrs30min FAIR 75hrs TPK50 538 9 L FAIR 125hrs TPK51 539 9 L 65 M CRA 3hrs45min 8hrs30min GOOD 9hrs.14min 7hrs 456 2192 865 183 160 35 98 60 PKP52 541 9 L 83 M HT.Psorias. CRA 4hrs10min 10hrs FAIR 74hrs TPK53 546 9 R 77 F DM CRA 2hrs30min 15hrs FAIR 16hrs TPK54 546 9 L GOOD TISS.DMG55 547 9 R 75 F MI 2hrs 39hrs NSFS56 548 9 R 70 F DM.HT.IHD.CKD. CRA 4hrs15min 5hrs.30min NSFS57 548 9 L FAIR 9hrs TPK58 552 9 L 60 F CRA 2hrs55min 5hrs55min FAIR 21hrs.66min 21hrs 661 1512 1488 82 289 43 45 60 DALK59 553 9 R 97 M RESP.DIST. 1hr30min NSFS60 553 9 L NSFS61 560 9 R 73 F RENAL FLR. 1hr.15min 17hrs FAIR 18hrs04min 19hrs 665 1503 663 79 929 39 45 51 TPK62 560 9 L FAIR 18hrs.52min 21hrs 459 2178 821 227 181 39 12 58 TPK YNG63 563 9 L 84 M RTA MULTI.INJ. 4hrs 7hrs FAIR 9hrs 4hrs 647 1545 2072 130 362 55 58 29 TPK YNG64 564 9 R 85 F CRA 4hrs NSFS65 564 9 L NSFS66 565 9 R 79 M MI 5hrs NSFS67 565 9 L NSFS68 570 9 L 90 M MI 1hr30min NSFS69 572 9 R 86 F HT.IHD MI 3hrs25min 10hrs FAIR 13hrs.26min 35hrs 497 2012 1272 186 234 47 45 42 TPK YNG70 572 9 L FAIR 15hrs.20min 204hrs 617 1620 1424 203 276 44 57 39 TPK71 574 9 R 75 M CRA 3hrs 10hrs FAIR 26hrs59min 197hrs 477 2096 1056 94 200 41 91 55 TPK YNG

72 574 9 L FAIR 27hrs.07min 243hrs 546 1831 2576 121 315 57 81 63 DALK73 576 9 R 80 F CRA NSFS74 576 9 L NSFS75 580 9 R 64 F MI 2hrs 19hrs30min FAIR 23hrs04min 119hrs 503 1988 1772 64 279 55 82 40 PKP76 580 9 L FAIR 23hrs23min 92hrs 663 1508 1662 91 394 59 50 38 TPK77 583 9 R 77 F MI 2hrs NSFS78 583 9 L NSFS79 584 9 R 78 M DM CRA 3hrs20min NSFS80 584 9 L NSFS81 585 9 R 92 F CRA 2hrs30min NSFS82 585 9 L NSFS83 588 9 R 65 F DM.HT CRA 5hrs 7hrs50min GOOD 12hrs 294hrs 520 1923 1038 118 210 40 82 48 TPK YNG84 588 9 L GOOD 12hrs.06min 247hrs 457 2188 1178 127 207 45 102 48 TPK YNG85 591 10 R 69 F HT MI 45min 14hrs20min FAIR 21hrs06min 353hrs 545 1834 1230 192 268 49 54 39 TPK YNG86 591 10 L FAIR 329hrs TPK87 592 10 R 51 M CVA MI 8hrs35min NSFS88 592 10 L NSFS89 597 10 R 75 F CRA 3hrs45min NSFS90 597 10 L NSFS91 598 10 R 83 M CRA 2hrs15min NSFS92 598 10 L NSFS93 599 10 R 90 M MI 3hrs NSFS94 599 10 L NSFS95 600 10 R 56 M DM.HT MI 5hrs20min 7hrs30min GOOD 32hrs.38min 51hrs 419 2386 1011 127 176 42 107 49 PATCH GFT.96 600 10 L GOOD 32hrs.35min 52hrs 397 2518 834 93 158 39 107 41 PKP97 601 10 R 76 M MI 3hrs NSFS98 601 10 L NSFS99 603 10 R 86 M MI 6hrs20min NSFS

100 603 10 L NSFS101 604 10 R 64 F MI 4hrs45min NSFS102 604 10 L NSFS103 606 10 R 65 F MI 3hrs NSFS104 606 10 L NSFS105 608 10 R 74 F MI 4hrs30min NSFS106 608 10 L NSFS107 609 10 R 80 F MI 6hrs NSFS108 609 10 L NSFS109 611 10 L 71 F CRA 2hrs NSFS110 613 10 R 80 F MI 1hr25min NSFS111 613 10 L NSFS

112 614 10 R 66 F CRA 2hrs30min NSFS113 615 10 R 72 F MI 2hrs50min 35hrs.30min FAIR 61hrs.44min 135hrs 569 1757 1575 138 282 49 65 43 TPK114 615 10 L FAIR 62hrs.35min 208hrs 572 1748 2029 140 350 61 60 37 TPK115 624 10 L 81 F CRA 1hr45min 5hrs.30min GOOD 8hrs.10min 123hrs 421 2375 1187 84 212 50 85 47 TPK116 627 10 R 93 M CRA 3hrs NSFS117 629 10 R 82 F DM.HT CVA 3hrs45min NSFS118 629 10 L NSFS119 631 10 L 75 M RESP.DST. 3hrs 14hrs.30min GOOD 18hrs55min 111hrs 480 2083 1135 191 224 46 53 47 TPK120 633 10 R 68 M An.CVA Card.Shk. 3hrs25min 6hrs15min GOOD 7hrs56min 47hrs 424 2358 1316 148 238 56 58 40 PKP121 633 10 L GOOD 7hrs.52min 49hrs 430 2325 1354 85 227 52 78 50 PKP122 634 10 R 66 F CerebellarHge. 2hrs NSFS123 634 10 L NSFS124 641 10 R 90 M CRA 1hr15min 3hrs FAIR TISS.DMG.125 641 10 L FAIR 91hrs SCL.GFT126 645 10 R 85 M DM.Psych. CRA 1hrs45min 20hrs FAIR 37hrs.11min 39hrs 1032 968 2291 383 485 46 51 61 TPK127 645 10 L FAIR 37hrs.18min 40hrs 1128 886 2378 422 464 41 42 33 TPK128 646 10 R 79 M HT,CVA CRA 1hrs30min 12hrs40min FAIR 84hrs PATCH.GFT129 646 10 L FAIR 87hrs TPK130 650 10 R 84 F CRA 3hrs 14hrs FAIR 30hrs.37min 32hrs 655 1526 1674 189 309 47 52 44 TPK131 650 10 L FAIR 30hrs.42min 55hrs 786 1272 1892 178 401 51 53 34 TPK132 653 10 L 77 M MI 2hrs15min 12hrs.30min FAIR 13hrs.34min 38hrs 823 1215 2486 247 492 59 36 56 TPK133 655 10 R 65 M DM.BA.CRF CRA 4hrs 6hrs.30min FAIR 124hrs TPK134 658 11 R 101 M CRA 2hrs15min NSFS135 658 11 L NSFS136 659 11 R 66 M MI 1hrs10min NSFS137 659 11 L NSFS138 660 11 R 92 F DM.HT.CVA.Ca.BreastCRA 2hrs NSFS HCV+139 660 11 L NSFS HCV+140 661 11 R 91 M PULM.ED. 2hrs NSFS141 661 11 L NSFS142 662 11 R 67 M CVA CRA 3hrs45min 26hrs15min FAIR 126hrs TPK143 665 11 R 78 M HT.HRF CRA 4hrs NSFS144 665 11 L NSFS145 666 11 R 60 M RTA MULTI.INJ. 4hrs 19hrs FAIR 20hrs07min 161hrs 328 3048 841 55 142 43 91 53 TPK YNG146 666 11 L FAIR 20hrs.20min 114hrs 414 2415 1016 109 172 41 103 46 TPK YNG147 668 11 R 79 F MI 3hrs 20hrs FAIR 186hrs TPK148 668 11 L FAIR 164hrs TPK149 672 11 R 91 M DM.Glau. CRA 3hrs10min NSFS150 672 11 L NSFS151 674 11 R 72 M CKD CRA 3hrs45min NSFS

152 674 11 L NSFS153 681 11 R 85 M CRA 1hrs50min 16hrs FAIR 139hrs TPK154 681 11 L NSFS155 684 11 L 80 M DM.HT.CVA CRA 1hrs30min 12hrs FAIR 154hrs SCL.GFT156 687 11 R 65 F CVA CRA 3hrs40min 7hrs FAIR 25hrs.25min 264hrs 611 1636 1169 227 215 35 66 56 TPK157 687 11 L FAIR 25hrs.30min 265hrs 503 1988 1323 180 194 38 88 47 TPK158 689 11 R 90 F MI 2hrs NSFS159 689 11 L NSFS160 693 11 L 76 M DM.HT MI 3hrs 23hrs FAIR 27hrs31min 360hrs 488 2049 1350 249 94 51 53 36 TPK ?161 694 11 R 81 M CRA 3hrs15min NSFS162 694 11 L NSFS163 696 11 R 73 F Cerebral Hge 3hrs50min NSFS164 696 11 L NSFS165 697 11 R 65 F MI 4hrs FAIR GROWTH166 699 11 R 93 M CRA 1hrs30min NSFS167 699 11 L NSFS168 701 11 L 76 M CRA 2hrs10min 9hrs55min FAIR 299hrs TPK169 702 11 R 104 F CRA 3hrs30min NSFS170 702 11 L NSFS171 703 11 R 85 M CVA 0.30min NSFS172 703 11 L NSFS173 704 11 R CVA 2hrs25min NSFS174 704 11 L 79 M CVA 2hrs25min NSFS175 706 11 R 85 M MI 5hrs NSFS176 706 11 L NSFS177 707 11 R 73 F CRA 4hrs NSFS178 707 11 L NSFS179 711 11 R 80 F CRA 2hrs40min NSFS180 711 11 L NSFS181 712 11 R 73 F CRA 1hrs10min NSFS182 712 11 L NSFS183 715 11 R 61 M DM MI 4hrs45min NSFS184 716 11 R 83 M MI 4hrs15min 16hrs.15min FAIR185 718 11 R 90 F RESP.DST. 3hrs NSFS186 718 11 L NSFS187 719 11 R 65 M MI 3hrs50min NSFS188 719 11 L NSFS189 722 11 L 63 F DM.HT MI 4hrs45min NSFS190 728 11 R 73 F HT CVA 6hrs30min NSFS191 728 11 L NSFS

192 732 12 R 93 M MI 1hr NSFS193 732 12 L NSFS194 731 12 R 88 F Br.Ca. PL.EFF. 4hrs NSFS195 731 12 L NSFS196 738 12 R 67 M MI 4hrs NSFS197 742 12 R 80 F CRA 3hrs 18hrs.30min FAIR 211hrs TPK198 742 12 L FAIR 234hrs TPK199 746 12 R 71 M MI 3hrs NSFS200 746 12 L NSFS201 744 12 R 85 F BA CVA 2hrs10min 6hrs.30min FAIR 197hrs SCL.GFT202 744 12 L FAIR 245hrs SCL.GFT203 747 12 R 85 M CRA 5hrs 9hrs.30min FAIR 281hrs SCL.GFT204 747 12 L FAIR 290hrs TPK205 749 12 R 76 M DM CRA 1hr15min 17hrs GOOD 21hrs.55min 235hrs 529 1890 1465 72 262 49 57 49 TPK206 749 12 L GOOD 22hrs.03min 236hrs 694 1440 1607 251 312 44 43 30 TPK207 750 12 R 81 F RE.Trab+ CRA 3hrs25min NSFS208 750 12 L 13hrs.15min GOOD 18hrs.52min 60hrs 370 2702 668 183 117 31 56 52 PKP209 753 12 R 89 F COPD RESP.DIST. 2hrs15min NSFS SYPH.+210 753 12 L NSFS SYPH.+211 754 12 R 75 F RESP.DIST. 1hr FAIR212 754 12 L FAIR SYPH.+213 760 12 R 87 M RESP.DIST. 2hrs4min NSFS SYPH.+214 760 12 L NSFS215 762 12 R 87 F DM.HT. RESP.DIST. 3hrs15min NSFS216 762 12 L NSFS217 767 12 R 90 M CRA 2hrs NSFS218 767 12 L NSFS219 770 12 R 65 F BA RESP.DIST. 4hrs 15hrs.30min FAIR 351hrs TPK220 770 12 L FAIR 372hrs SCL.GFT221 772 12 R 83 M MI 2hrs40min NSFS222 772 12 L NSFS223 773 12 R 75 F CRA 1hrs30min NSFS224 773 12 L NSFS225 777 12 R 72 M DM CRA 5hrs 10hrs.30min FAIR 14hrs.21min 295hrs 710 1408 1371 247 253 35 54 59 TPK226 777 12 L FAIR 14hrs.25min 319hrs 825 1212 1767 373 311 37 47 62 TPK227 778 12 L 82 M CRF 1hrs30min 14hrs.30min FAIR 181hrs SCL.GFT228 781 12 R 77 M BA CRA 5hrs NSFS229 781 12 L NSFS230 782 12 R 75 F CRA 4hrs50min NSFS231 782 12 L NSFS

232 783 12 R 77 M CRA 3hrs55min NSFS233 783 12 L NSFS234 786 12 R 78 F CRA 4hrs 16hrs FAIR SCL.GFT 6months235 786 12 L FAIR SCL.GFT 6months236 788 12 R 80 F MI 1hr30min NSFS237 788 12 L NSFS238 790 12 R 80 F DM.HT CRA 2hrs15min NSFS239 790 12 L NSFS240 792 12 R M HRF 6hrs15min NSFS241 792 12 L 77 M HRF CRA NSFS242 793 12 L 85 M COPD RESP.DIST. 1hr NSFS243 794 12 R 93 M CRA 2hrs15min NSFS244 794 12 L NSFS245 799 12 L 74 M RESP.DIST. 4hrs NSFS246 802 12 R 73 M MI 2hrs15min NSFS247 802 12 L NSFS248 805 12 R 87 F RESP.DIST. 6hrs35min NSFS249 805 12 L NSFS250 808 12 R 78 M CRA 5hrs NSFS251 808 12 L NSFS252 809 12 R 78 M Ca. Prostr. CRA 1hr NSFS253 809 12 L NSFS254 810 12 R 75 M RTA Head Inj. 5hrs20min NSFS255 810 12 L NSFS256 812 12 R 64 F MI 2hrs30min NSFS257 812 12 L NSFS258 813 12 R 87 M CRA 2hrs15min NSFS259 1 12 L 80 M MI 2hrs40min NSFS260 2 1 R 88 F HT MI 2hrs25min NSFS261 2 1 L NSFS262 4 1 R 78 M DM,IHD MI 2hrs35min NSFS263 5 1 R 85 M CRA 1hr15min NSFS264 5 1 L NSFS265 3 1 R 78 F DM CRA 3hrs15min 5hrs FAIR 10hrs.41min 338hrs 693 1443 2405 180 358 51 61 51 SCL.GFT266 3 1 L FAIR 10hrs.45min 386hrs 507 1972 1793 116 268 52 87 56 SCL.GFT267 9 1 R 60 F Cancer CRA 2hrs50min 17hrs30min FAIR 22hrs.43min 329hrs 700 1428 2018 216 401 57 63 25 SCL.GFT268 14 1 L 82 F CRA 2hrs10min NSFS269 15 1 L 79 M PULM.ED. 2hrs NSFS270 17 1 L 80 M IHD CRA 5hrs 6hrs.30min GOOD 23hrs 71hrs 454 2202 1315 73 214 47 101 52 TPK271 18 1 L 90 F MI 2hrs30min NSFS

272 22 1 R 91 F MI 1hr30min NSFS273 22 1 L NSFS274 34 1 R 90 F RESP.DIST. 1hr30min NSFS275 34 1 L NSFS276 35 1 R 78 M ?SEPTIC. CRA 4hrs30min NSFS277 35 1 L NSFS278 36 1 R 63 M HT.IHD MI 1hr55min NSFS279 36 1 L NSFS280 39 1 R 84 M DM.HT CRA 1hr30min NSFS281 39 1 L NSFS282 41 1 R 96 M MI 2hrs55min NSFS283 41 1 L NSFS284 47 1 L 74 M HT.IHD MI 2hrs NSFS285 52 1 R 92 F MI 2hrs NSFS286 52 1 L NSFS287 54 1 R 88 F CRA 4hrs30min NSFS288 54 1 L NSFS289 55 1 R 85 M CRA 4hrs NSFS290 55 1 L NSFS291 59 1 R 40 F MI 3hrs NSFS292 59 1 L NSFS293 62 1 R 80 M CRA 2hrs NSFS294 62 1 L NSFS295 63 1 R 85 F CVA CRA 3hrs20min NSFS296 63 1 L NSFS297 64 1 R 75 F RESP.DIST. 2hrs30min NSFS298 64 1 L NSFS299 70 1 R 87 M MI 5hrs15min NSFS300 70 1 L NSFS301 72 1 R 86 M CRA 2hrs30min NSFS302 73 1 R 83 F MI 6hrs NSFS303 73 1 L NSFS304 76 1 R 72 F SCC CRA 0.15min 18hrs40min FAIR 144hrs TPK305 76 1 L FAIR 119hrs TPK306 77 2 R 73 F CRA 4hrs30min NSFS307 77 2 L NSFS308 89 2 R 80 F CRA 1hr50min NSFS309 89 2 L NSFS310 92 2 R 85 F RESP.DIST. 2hrs NSFS311 95 2 R 70 F CRA 5hrs 23hrs GOOD 156hrs SCL.GFT.

312 100 2 R 87 F MI 5hrs15min NSFS313 100 2 L NSFS314 101 2 R 60 M MI 4hrs NSFS315 101 2 L NSFS316 102 2 R 75 M IHD CRA 4hrs15min NSFS317 103 2 R 82 M MI 4hrs NSFS318 103 2 L NSFS319 107 2 R 90 M DM,IHD CRA 2hrs NSFS320 107 2 L NSFS321 108 2 R 93 M MI 5hrs40min NSFS322 108 2 L NSFS323 110 2 R 81 F CRA 3hrs NSFS324 110 2 L NSFS325 114 2 R 72 M DM.HT CRA 1hr45min NSFS SYPH+326 114 2 L NSFS SYPH+327 115 2 R 79 F MI 2hrs40min NSFS328 115 2 L NSFS329 116 2 R 80 F CRA 1hr05min 18hrs FAIR 46hrs TPK330 116 2 L FAIR 67hrs SCL.GFT331 118 2 R 83 F CRA 2hrs45min NSFS332 118 2 L NSFS333 120 2 R 85 F MI 2hrs40min NSFS334 120 2 L NSFS335 122 2 R 74 M HT.COPD CRA 6hrs30min 17hrs FAIR 62hrs TPK336 122 2 L FAIR 83hrs DALK337 121 2 R 76 M MI 4hrs45min NSFS338 121 2 L NSFS339 124 2 R 65 M IHD CRA 4hrs20min 19hrs30min FAIR 139hrs TPK340 126 2 R 80 F MI 6hrs05min NSFS341 128 2 L 87 M MI 1hr 23hrs30min FAIR 26hrs TPK342 130 2 R 85 M CRA 3hrs40min 12hrs FAIR 80hrs DALK343 130 2 L FAIR TISS.DMG344 133 2 R 65 M RESP.DIST. 2hrs30min NSFS345 133 2 L NSFS346 135 2 R 64 F CRA 5hrs15min NSFS HCV+347 135 2 L NSFS HCV+348 136 2 R 79 F MI 4hrs NSFS349 137 2 R 78 M DM.HT CRA 3hrs35min 20hrs30min FAIR 44hrs TPK350 137 2 L FAIR 42hrs SCL.GFT351 138 2 L 64 F HT.An.HCC CRA 5hrs45min 16hrs GOOD 18hrs47min 86hrs 854 1170 1765 188 339 39 38 63 TPK

352 139 2 R 70 M DM MI 7hrs 9hrs FAIR 23hrs TPK353 139 2 L FAIR 72hrs TPK354 143 2 L 79 M MI 1hr55min NSFS355 144 2 R 87 M MI 2hrs 14hrs FAIR 182hrs TPK356 144 2 L FAIR 184hrs PATCH.GFT357 145 2 R 88 M MI 2hrs NSFS358 145 2 L NSFS359 146 3 R 87 M MI 4hrs NSFS360 146 3 L NSFS361 148 3 R 85 F CRA 2hrs NSFS362 148 3 L NSFS363 149 3 R 80 F CRA 2hrs45min NSFS364 149 3 L NSFS365 150 3 R 70 F MI 3hrs NSFS366 150 3 L NSFS367 151 3 R 88 M CRA 2hrs40min NSFS368 152 3 L 77 M DM CRA 3hrs 11hrs FAIR 16hrs.33min 132hrs 517 1934 1710 127 274 52 88 51 TPK369 154 3 R 84 F MI 5hrs NSFS370 154 3 L NSFS371 157 3 R 73 F CRA 1hr30min 4hrs FAIR 91hrs SCL.GFT372 157 3 L FAIR 140hrs SCL.GFT373 161 3 R 73 M CRA 3hrs 11hrs FAIR 31hrs.11min 151hrs 621 1610 2044 117 334 53 73 45374 161 3 L FAIR 31hrs.13min 128hrs 513 1949 1179 156 216 42 83 52375 168 3 R 85 F RESP.DIST. 2hrs NSFS376 168 3 L NSFS377 169 3 R 73 M CRA 1hr30min NSFS378 170 3 L 85 M MI 3hrs NSFS379 172 3 R 70 M CRA 2hrs 27hrs FAIR 32hrs.32min 122hrs 662 1510 1462 185 304 45 34 53 SCL.GFT380 173 3 R 85 F CRA 5hrs30min NSFS381 173 3 L NSFS382 175 3 R M MI 1hr30min NSFS383 175 3 L NSFS384 178 3 R 86 F MI 1hr40min NSFS385 178 3 L NSFS386 180 3 R 74 M CRA 5hrs05min NSFS387 184 3 R 83 M MI 3hrs NSFS388 184 3 L NSFS389 186 3 R 74 M CRA 1hr45min NSFS390 186 3 L NSFS391 188 3 L 85 F MI 0.45min 20hrs30min FAIR 46hrs PATCH GFT.

392 190 3 R 83 M MI 3hrs20min 14hrs FAIR 86hrs TPK393 190 3 L FAIR 64hrs TPK394 192 3 R 84 F CRA 2hrs15mins 14hrs FAIR 38hrs SCL.GFT395 192 3 L FAIR 39hrs SCL.GFT396 193 3 L 65 F CRA 5hrs10min NSFS397 194 3 R 76 M MI 4hrs20min NSFS398 194 3 L NSFS399 196 3 R 64 F RTA MULTI.INJ. 3hrs45min 6hrs.30min FAIR 23hrs55min 48hrs 840 1190 2135 395 411 48 38 37 TPK400 196 3 L FAIR 23hrs58min 120hrs 845 1183 3372 163 573 67 47 45 TPK401 197 3 R 78 M CRA 4hrs50min NSFS402 197 3 L NSFS403 198 3 R 75 F RESP.DIST. 2hrs30min 9hrs FAIR 129hrs TPK404 198 3 L NSFS405 202 3 R 80 F RESP.DIST. 1hr30min NSFS406 202 3 L NSFS407 207 3 R 64 M Ca.Urethra LIVER SEC. 4hrs15min NSFS408 208 3 R 88 M DM.IHD.CKD CRA NSFS409 210 3 R 72 M MI 8hrs45min NSFS410 210 3 L NSFS411 211 3 R 68 M MI 5hrs15min NSFS412 211 3 L NSFS413 213 3 R 82 F MI 4hrs 27hrs.30min FAIR 51hrs TPK414 213 3 L FAIR 24hrs DALK415 218 4 L 61 F DM.IHD CRA 4hrs 28hrs GOOD 27hrs PATCH GFT.416 219 4 R 86 M RESP.DIST. 2hrs30min NSFS417 225 4 R 70 F MI 1hr45min 9hrs.30min FAIR 27hrs TPK418 233 4 R 88 M MI 3hrs 10hrs30min GOOD 12hrs 36hrs 635 1574 1652 55 323 50 43 37 TPK419 234 4 L 73 M DM.HT. MI 2hrs 7hrs FAIR 22hrs37min 167hrs 657 1522 1562 166 276 42 67 52 SCL.GFT.420 236 4 R 70 F MI 1hr30min NSFS421 236 4 L NSFS422 241 4 R 62 M DM.IHD MI 3hrs30min NSFS423 241 4 L NSFS424 243 4 R 80 M MI 4hrs30min 23hrs.30min FAIR 185hrs PATCH.GFT425 243 4 L FAIR 139hrs TPK426 245 4 R 66 M DM.CRF CRA 1hr NSFS427 246 4 R 91 M DM.HT.?SEPT. CRA NSFS428 246 4 L NSFS429 248 4 R 70 M MI 3hrs55min NSFS430 248 4 L NSFS431 253 4 L 84 M MI 3hrs 12hrs GOOD 38hrs TPK

432 254 4 R 74 M RENAL FAILURE 3hrs30min 17hrs.30min FAIR 18hrs TPK433 254 4 L FAIR 41hrs TPK434 255 4 R 92 F MI 3hrs45min NSFS435 255 4 L NSFS436 257 4 R 63 F CVA 2hrs NSFS437 257 4 L NSFS438 258 4 R 81 F RESP.DIST. 0.45min NSFS Scar+439 258 4 L 12hrs FAIR 40hrs TPK440 259 4 L 80 F CVA MI 7hrs30min NSFS441 263 4 R 83 F CRA 0.50min NSFS442 263 4 L NSFS443 266 4 R 93 M MI 1hr40min 13hrs FAIR 86hrs TPK444 266 4 L FAIR 88hrs TPK445 272 4 R 90 M MI 1hr20min NSFS446 272 4 L NSFS447 274 4 R 77 F STR.HRNA 4hr 17hrs GOOD 21hrs.45min 111hrs 446 2242 1493 105 211 47 100 51 PKP448 274 4 L GOOD 21hrs.51min 88hrs 413 2421 1046 87 209 50 100 48 TPK YNG449 276 4 R 77 M MI 1hr30min NSFS450 276 4 L NSFS451 278 4 R 84 F DM.IHD MI 4hrs45min 10hrs30min FAIR 26hrs TPK452 278 4 L FAIR 48hrs SCL.GFT453 281 4 R 93 F MI 3hrs30min 18hrs FAIR 41hrs SCL.GFT454 281 4 L FAIR 91hrs TPK455 282 4 L 60 M PARKIN. CRA 5hrs25min 21hrs FAIR 235hrs TPK456 284 4 R 80 M MI 5hrs NSFS457 284 4 L NSFS458 290 5 L 80 F CRA 2hrs30min NSFS459 292 5 R 75 M CRA 2hrs15min NSFS460 292 5 L NSFS461 299 5 R 93 M MI 0.15min 18hrs FAIR 85hrs PATCH GFT.462 299 5 L FAIR 86hrs SCL.GFT.463 301 5 R 83 M RESP.DIST. 3hrs30min 4hrs30min GOOD 29hrs.18min 120hrs 436 2293 1401 113 199 45 95 58 PATCH GFT.464 301 5 L GOOD 29hrs.34min 100hrs 471 2123 1309 70 264 56 72 31 TPK465 302 5 L 73 F CRA 2hrs 17hrs FAIR 21hrs.53min 138hrs 505 1980 1189 135 226 44 57 49 TPK466 308 5 L 83 M MI 1hrs30min 22hrs FAIR 21hrs.58min 192hrs 640 1562 1872 119 338 52 62 52 TPK467 311 5 R 77 F CRA 3hrs 12hrs30min FAIR 36hrs TPK468 311 5 L FAIR 58hrs SCL.GFT.469 313 5 R 87 M CRA 2hrs10min NSFS470 313 5 L NSFS471 314 5 R 87 M CRA 3hrs NSFS

472 314 5 L NSFS473 318 5 R 76 F DM CRA 6hrs NSFS474 318 5 L NSFS475 321 5 R 75 F CRA 3hrs 24hrs FAIR 48hrs TPK476 321 5 L FAIR 72hrs TPK477 323 5 R 95 M MI 5hrs NSFS478 323 5 L NSFS479 325 5 R 85 M RESP.DIST 5hrs40min NSFS480 325 5 L NSFS481 328 5 R 75 F RESP.DIST 4hrs NSFS482 328 5 L NSFS483 329 5 R 70 F CRA 1hr50min FAIR 52hrs TPK484 329 5 L FAIR 96hrs K-PRO485 331 5 R 75 F MI 6hrs10min NSFS486 331 5 L NSFS487 332 5 R 90 F RESP.DIST 2hrs NSFS488 332 5 L NSFS489 333 5 L 66 F MI 1hr45min 13hrs45min GOOD 17hrs51min 37hrs 452 2346 1592 126 212 46 102 52 PKP490 336 5 R 80 F DM DM.COMA 2hrs50min NSFS491 336 5 L NSFS492 337 5 L 78 M CKD 4hrs20min NSFS493 338 5 R 72 M MI 3hrs 8hrs30min FAIR 72hrs PATCH GFT.494 339 5 R 70 M MULT.MYELOMA2hrs10min NSFS MM495 339 5 L NSFS MM496 343 5 R 80 F MI 1hr 28hrs30min FAIR 24hrs PATCH GFT.497 343 5 L FAIR 70hrs SCL.GFT.498 346 6 R 72 F RESP.DIST 2hrs FAIR GROWTH499 346 6 L FAIR GROWTH500 350 6 R 54 F CRA 4hrs30min 7hrs30min FAIR 23hrs44min 48hrs 551 1814 1388 92 441 51 42 46 DALK501 350 6 L FAIR 23hrs48min 72hrs 685 1459 1915 94 286 64 46 41 DALK502 351 6 R 75 F MI 3hrs40min 12hrs.30min FAIR 36hrs TPK503 351 6 L FAIR 38hrs TPK504 354 6 R 67 M HEP.FAILR. 1hr30min 14hrs FAIR 40hrs TPK505 354 6 L FAIR 89hrs TPK506 355 6 R 82 M COPD RESP.DIST. 1hr30min NSFS507 355 6 L NSFS508 359 6 R 76 M COPD RESP.DIST. 3hrs NSFS509 359 6 L NSFS510 363 6 R 65 F OV.TR CRA 8hrs15min NSFS511 364 6 R 75 F Ca.Oesoph. CRA 3hrs NSFS

512 364 6 L NSFS513 366 6 R 80 M MI 3hrs25min NSFS514 366 6 L NSFS515 367 6 R 76 M MI 5hrs NSFS516 367 6 L NSFS517 368 6 R 76 M MI 1hr35min NSFS518 368 6 L NSFS519 370 6 R 80 F RTA MULTI.INJ. 4hrs35min NSFS520 370 6 L NSFS521 371 6 R 78 F MI 2hrs30min FAIR GROWTH522 371 6 L FAIR GROWTH523 372 6 R 90 M MI 2hrs 17hrs FAIR 42hrs TPK524 372 6 L FAIR 67hrs TPK525 373 6 R 83 F MI 4hrs15min 21hrs FAIR 43hrs TPK526 373 6 L FAIR 45hrs TPK527 374 6 R 85 M CRA 5hrs30min NSFS528 374 6 L NSFS529 378 6 R 78 M MI 2hrs45min 20hrs FAIR 44hrs TPK530 378 6 L FAIR 69hrs TPK531 379 6 R 89 M MI 2hrs NSFS532 379 6 L NSFS533 383 6 R 84 M CRA 3hrs50min 6hrs30min FAIR 78hrs TPK534 383 6 L FAIR 7hrs TPK535 384 6 R 90 F CRA 1hr30min NSFS536 384 6 L NSFS537 385 6 R 88 M CRA 5hrs30min NSFS538 385 6 L NSFS539 388 6 L 74 M MI 4hrs05min 26hrs.30min FAIR 50hrs TPK540 390 6 R 72 F DM.HT CRA 2hrs40min 22hrs30min FAIR 23hrs TPK541 390 6 L FAIR 24hrs TPK542 392 6 R 84 F CRA 3hrs15min 14hrs45min FAIR 86hrs PATCH GFT.543 393 6 R 72 M CRA 3hrs NSFS544 393 6 L NSFS545 397 6 R 87 M CVA 2hrs NSFS546 397 6 L 25hrs FAIR 144hrs PATCH GFT.547 398 6 R 84 F CVA 2hrs45min 23hrs FAIR 72hrs TPK548 398 6 L FAIR 96hrs TPK549 399 6 R 73 M MI 2hrs50min 38hrs FAIR 43hrs.34min. 85hrs 375 2666 1399 82 205 54 101 46 PKP550 402 7 R 91 M MI 1hr40min NSFS551 402 7 L NSFS

552 406 7 R 74 M CRA 5hrs45min NSFS553 406 7 L NSFS554 409 7 R 72 M CRA 2hrs10min 17hrs FAIR 38hrs.17min 208hrs 392 2551 967 112 178 45 68 56 TPK YNG555 409 7 L FAIR 38hrs.01min 209hrs 411 2433 998 84 170 41 85 46 PATCH GFT. YNG556 413 7 R 86 F CRA 2hrs NSFS557 413 7 L NSFS558 415 7 R 69 M BA RESP.DIST. 1hr20min 19hrs FAIR 190hrs TPK559 416 7 R 74 F CVA 1hr 20hrs GOOD 34hrs.11min 84hrs 396 2525 997 106 173 43 118 49 DALK560 428 7 R 79 F CRA 1hr30min NSFS561 429 7 R 73 M CVA 1hr30min NSFS562 429 7 L NSFS563 431 7 R 72 M CRA 3hrs30min NSFS564 431 7 L NSFS565 435 7 R 85 F MI 2hrs NSFS566 435 7 L NSFS567 437 7 R 81 F CRA 4hrs25min NSFS568 445 7 R 66 M MI 2hrs15min 22hrs FAIR 144hrs PATCH GFT.569 445 7 L FAIR 120hrs PATCH GFT.570 446 7 R 67 M DM.HT. MI 1hr30min 10hrs FAIR 148hrs PATCH GFT.571 446 7 L FAIR 245hrs TPK572 449 7 R 78 F CRA 4hrs15min NSFS573 449 7 L NSFS574 450 7 R 75 M MI 2hrs10min NSFS575 450 7 L NSFS576 451 7 L 77 M CRA 1hr30min NSFS577 455 7 L 63 F DM PULM.ED. 2hrs20min 19hrs FAIR 26hrs16min 332hrs 575 1739 1240 150 197 34 81 65 TPK578 457 7 R 84 M CRA 2hrs NSFS579 457 7 L NSFS580 460 7 R 76 M MI 2hrs.30min NSFS581 460 7 L NSFS582 461 7 R 70 M DM MI 2hrs.30min NSFS583 461 7 L NSFS584 467 7 R 66 F CKD PULM.ED. 4hrs40min NSFS585 467 7 L NSFS586 470 7 R 67 F DM.HT PULM.ED. 3hrs30min 7hrs10min GOOD 11hrs31min 171hrs 469 2132 844 194 149 31 58 48 DALK587 471 7 R 71 M DM.HT CRA 5hrs.50min NSFS588 471 7 L NSFS589 472 7 R 87 M RESP.DIST. 2hrs.30min NSFS590 472 7 L NSFS591 473 7 R 31 M HANGING 2hrs.05min NSFS

592 473 7 L NSFS593 476 7 R 76 F DM.,HEP.FLR. MI 2hrs.30min NSFS594 476 7 L NSFS595 480 7 R 85 F MI 2hrs.20min NSFS596 480 7 L NSFS597 487 7 R 94 M MI 9hr.30mins NSFS598 487 7 L NSFS599 488 7 R 95 F CRA 3hrs.45min NSFS600 488 7 L NSFS601 490 7 L 67 M DM.HT CRA 3hrs.35min 18hrs FAIR 186hrs TPK

ABBREVIATIONS

PKP - Penetrating Keratoplasty

TPK - Therapeutic Keratoplasty

DALK - Deep Anterior Lamellar Keratoplasty

YNG TPK - Young Therapeutic Keratoplasty

NSFS - Not Suitable For Surgery

CD/ECD - Endothelial Cell Density

CV - Coefficient of Variation

SD - Standard Deviation

6A - Hexagonality

WHO - World Health Organisation

NPCB - National Programme for the Control of Blindness

specular evaluation of endothelium in pseudophakic …

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