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Revista Brasileira de Oftalmologia

versão impressa ISSN 0034-7280

Rev. bras.oftalmol. vol.73 no.6 Rio de Janeiro nov./dez. 2014

https://doi.org/10.5935/0034-7280.20140077 

Update Article

A comparative review between the updated models of Brazilian, United Kingdom and American eye banks and lamellar transplants

Uma revisão comparativa entre os modelos atuais de bancos de olhos e transplantes lamelares do Brasil, Reino Unido e Estados Unidos

Gustavo Victor1 

Sidney Júlio de Faria e Sousa2 

Marcos Alonso Garcia1 

Mário Henrique Camargos de Lima1 

Milton Ruiz Alves1 

1Faculdade de Medicina da Universidade de São Paulo (SP), Brazil

2Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo – Ribeirão Preto (SP), Brazil


ABSTRACT

The corneal transplantation (CT) is the most commonly performed type of transplant in the world and the Eye Banks are organizations whose capture, evaluate, preserve, store and distribute ocular tissues. With the evolution of surgical techniques and equipment for CT, the BOs had to evolve to keep up with these requirements. This evolution goes from tissues capture techniques, donating money and clarification to the patient (e.g. internet-based), use of current equipment for more adequate tissues supply for the most current surgical techniques, integration of BOs of certain country and real-time management of stocks of ocular tissues, and adequacy of laws that manage the entire process. This review aims to make a comparative review between the updated models of Brazilian, United Kingdon and American Eye Banks. Like, check what the trend towards lamellar transplants in these three countries.

Key words: Cornea; Corneal transplantation; Laser; Health services administration; Benchmarking; Brazil; United States

RESUMO

O transplante de córnea (CT) é o tipo de transplante mais realizado no mundo e os Bancos de Olhos (BO) são organizações que capturam, evoluem, preservam, guardam e distribuem tecidos oculares. Com a evolução das técnicas cirúrgicas e equipamentos para o CT, os BOs precisaram evoluir para acompanhar estas necessidades. Esta evolução vai desde técnicas de captura de tecidos; doação de dinheiro e esclarecimento ao paciente (baseadas na internet, por exemplo); utilização de equipamentos modernos, para fornecimento mais adequado de tecidos para técnicas cirúrgicas mais atualizadas; integração dos BOs de determinado país e gerenciamento em tempo real dos estoques de tecidos oculares, e adequação das leis que gerem todo este processo. Esta revisão tem como objetivo fazer uma comparação dos modelos atualizados de BOs brasileiro, inglês e americano, além de avaliar a tendência dos tipos de CT nestes países e sugerir melhorias ao modelo de BO brasileiro.

Palavras-Chave: Córnea; Transplante de córnea; Laser; Administração de serviços de saúde; Benchmarking; Brasil; Estados Unidos

INTRODUCTION

Eye Banks

The Eye Banks are nonprofit organizations whose capture, evaluate, preserve, store and distribute ocular tissues. Anywhere in the world through local legislation, these organizations were created, are regulated and inspected.

Lamellar Transplants

The lamellar transplantation (LT) was first performed by Von Hippel in 1888(1). This technique is more difficult to do and used to provide less visual acuity than the penetrant keratoplasty (PK). For these reasons, especially, the LT until about a decade ago, was done mostly for tectonic and/or cosmetics purposes, and the PK used for optical purposes, where wanted best final visual acuity, even if the patient needed to replace only part of the cornea, anterior or posterior(2). With the development of Eye Banks, surgical techniques and equipment as the artificial anterior chamber, microkeratome and femtosecond lasers, LT was more refined and technically reproducible, thus getting significant improvement in final visual acuity(2-10). Thus, LT (anterior or posterior) is becoming the technique of choice in conditions in which it is only necessary to exchange a part of the cornea (anterior or posterior)(2,3,9,10), as keratoconus and endothelial dysfunction. These two diseases remain among the top three causes of transplants in world(9,10).

This review aims to make a comparative review between the updated models of Brazilian, United Kingdon and American Eye Banks. Like, check what the trend towards lamellar transplants in these three countries.

In Brazil Transplants

Brazil ranks second in the absolute number of transplants performed annually worldwide. If we consider the relative number of transplants and GDP (gross national product), Brazil ranks third, favored by investments made in this area and the stimulus given to its increase(11). Table 1 shows the evolution of the types of transplants in Brazil between 2001 and 2011.

Table 1 Evolution of the types of transplants in Brazil between 2001 and 2011 

Ano Órgãos sólidos Tecido ocular Células Total
Coração Fígado Pulmão Rim Pâncreas Rim/Pâncreas Fígado/Rim Córnea TMO
2001 143 542 25 2672 39 105 6 6.193 703 10.428
2002 149 654 36 2.714 57 161 5 6.556 871 11.203
2003 181 794 43 2.911 53 203 9 7.556 972 12.722
2004 200 914 39 3.126 94 201 10 8.394 1.197 14.175
2005 181 939 42 2.903 112 108 8 9.970 1.307 15.570
2006 155 978 55 2.961 88 125 12 10.382 1.032 15.788
2007 159 971 50 3.040 78 116 33 11.419 1.439 17.305
2008 205 1.110 53 3.154 43 127 26 12.825 1.446 18.989
2009 201 1.322 59 4.259 39 119   12.723 1.531 20.253
2010 167 1.404 60 4.660 44 87   12.923 1.695 21.040
2011 159 1.496 49 4.939 54 130   14.838 1.732 23.397

Source: http://aplicacao.saude.gov.br/portal/public/transplantes/destaque/dest5. Accessed on 04/21/2012

The importance of corneal transplantation (CT) for Brazil can be observed, both by popular demand as the state investment, as represented 63.42% of all transplants performed in Brazil in 2011. In 2009, the MS invested about R$ 900 million in transplants(12). Despite the increase in the number of corneal transplants in Brazil, can be seen in Table 2 the great difference in numbers of transplants in several Brazilian States over the years, which reflects the inefficiency in generating a model of Eye Banks efficient nationwide.

Table 2 Annual change in the number of corneal transplants by Brazilian State (2001-2011) 

UF 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Acre 0 0 0 0 0 0 0 0 0 19 18
Alagoas 8 8 10 10 26 18 7 51 82 63 117
Amazonas 0 0 6 19 35 68 88 118 95 119 139
Bahia 40 41 43 57 87 98 168 258 209 198 228
Ceará 113 181 240 325 310 227 400 473 420 475 788
Distrito Federal 124 105 158 185 298 276 289 299 390 369 327
Espirito Santo 57 108 117 100 120 91 69 122 131 159 323
Goiás 542 584 585 757 862 795 443 403 404 403 796
Maranhão 6 8 1 4 11 58 60 79 129 128 119
Mato Grosso 24 43 30 31 42 39 147 162 117 41 285
Mato Grosso do Sul 74 56 118 165 13 90 183 173 180 177 180
Minas Gerais 840 541 948 1226 956 632 1033 1478 1446 1328 1437
Pará 98 151 80 69 82 79 97 104 135 135 160
Paraíba 66 186 132 184 154 143 123 135 202 171 154
Paraná 448 443 483 606 461 615 885 1000 947 752 1298
Pernambuco 215 217 311 336 391 522 494 632 671 502 661
Piauí 25 46 39 44 61 39 46 37 126 160 170
Rio de Janeiro 114 205 257 157 141 77 54 78 88 145 294
Rio Grande do Norte 0 102 97 138 128 125 128 89 171 194 278
Rio Grande do Sul 508 604 527 352 632 805 605 595 607 759 918
Rondonia 0 0 0 0 0 0 2 30 0 3 0
Santa Catarina 210 171 207 210 240 285 281 241 414 496 462
São Paulo 2623 2714 3100 3331 4888 5255 5762 6209 5655 6037 5547
Sergipe 58 42 67 88 32 45 55 59 104 90 139
Brasil 6193 6556 7556 8394 9970 10382 11419 12825 12723 12923 14838

Source: http://aplicacao.saude.gov.br/portal/public/transplantes/destaque/dest5; accessed on 04/21/2012

Can be observed that there are states that do not perform any CT in 2011, another did not perform CT between 2001-2009, and that there are more developed states having fewer transplants than other less developed. On the other hand, only the State of São Paulo was responsible for 37.39% of corneal transplants performed in Brazil in 2011.

Lamellar Transplants

Of these nearly 15,000 CT held in Brazil in 2011, do not know for sure how many were LT and how many were PK, because there isn't this kind of statistical control in Brazil.

In United Kingdon

Like in Brazil, if no wish has been expressed in life then specially trained healthcare professionals should approach the family for their authorization to proceed, based on their knowledge of the potential donor (opt-in)(13). Currently there are 14 European nations operating under a system of opt-out or 'presumed consent': Austria, Belgium, Czech Republic, Finland, France, Greece, Hungary, Italy, Luxembourg, Poland, Portugal, Slovak Republic, Spain, Sweden(13). In UK, 16.124.871 people (The total at 31 March 2009) registered on the NHS Organ Donor Register(13) (a web based database).

Transplants

Figure 1 shows the evolution of the number of corneas donated and the number of corneas grafted in the UK between 2002 and 2012(14).

Source: http://www.organdonation.nhs.uk/statistics/transplant_activity_report/archive_activity_reports/

Figure 1 Evolution of the number of corneas donated and the number of corneas grafted in the UK between 2002 and 2012(14) 

Figure 2 shows the evolution, in a decade, of the numbers of LT for keratoconus, preserving the patient's healthy endothelium and changing only the corneal stroma(9).

Source: Trends in the Indications for Corneal Graft Surgery in the United Kingdom: 1999 Through 2009. Arch Ophthalmol. 2012;130(5):621-628

Figure 2 Evolution, in a decade, of the numbers of LT for keratoconus. PK: Penetrant keratoplasty, DALK: Deep anterior lamellar keratoplasty(9) 

Figure 3 shows the evolution, in a decade, of the numbers of LT for endothelial failure, preserving the patient's healthy stroma and changing only the corneal endothelium(9).

Source: Trends in the Indications for Corneal Graft Surgery in the United Kingdom: 1999 Through 2009. Arch Ophthalmol. 2012;130(5):621-628

Figure 3 Evolution, in a decade, of the numbers of LT for endothelial failure, preserving the patient’s healthy stroma and changing only the corneal endothelium(9); PK: Penetrant keratoplasty; EK: Endothelium keratoplasty 

In the UK it is possible to request and receive from Eye Bank a corneal donor lamella with specific thickness and diameter to the realization of LT. As in Brazil, the patient dosen't pay to the donnor cornea.

In United States

Currently, there are 84 Eye Banks in the U.S. In 2013, the Eye Bank Association of America (EBAA) published the statistical report for 2012(10). Since 2011, the EBAA began a new monthly collection methodology for the Statistical Report using EBAA CONNECT, a real-time, web-based statistical reporting and analytics engine designed specifically for the EBAA by Transplant Connect©(10). In this study, the data reported were from 80 Eye Banks. Prior to 2008, all keratoplasties were counted as "penetrating keratoplasty". From 2008, pre-cut and uncut tissue utilization was stratified into penetrating grafts (PK), endothelial keratoplasty (EK), anterior lamellar keratoplasty (ALK), keratolimbal allografts (KLA), and tectonic grafts (TK). Keratoprosthesis (K-Pro) as a specific utilization was added in 2009. Before 2009, domestic and international data from U.S eye banks were combined. In 2009 and 2010, stratified data was only collected for tissue distributed and used within the U.S. For 2011 and beyond, tissue provided by U.S. eye banks was stratified and separated into domestic and international use. International use of tissue sent from U.S. eye banks was generally not included in statistical analysis before 201(10). Beginning in 2012, eight international banks began using the EBAA Connect data system(10).

Transplants

In the U.S., tissue supplied by U.S. Eye Banks for all keratoplasty procedures types in 2012 was 68,681. Of these tissues, 46.684 were used to transplants in US and 19,546 corneas were exported internationally(10). The Figure 4 shows the annual number of corneal transplants supplied by U.S. Eye Banks (US and exported)(10).

Source: Eye Bank Association of America. 2012 Banking Statistical Report

Figure 4 Shows the annual number of corneal transplants supplied by U.S. Eye Banks (US and exported)(10) 

Figure 5 shows annually, the number of corneas available and how these have been used for transplants in the USA between 1991-2012(10).

Figure 5 Number of corneas available and how these have been used for transplants in the USA between 1991-2012; in 2011 and progressing, long-term preserved corneal tissue is included in the total(10). (3)Until 2010, corneal grafts total did not include long-term preserved corneal tissue 

Year Total provided by U.S. Performed in U.S.
1991 39,515 35,831
1992 39,973 35,525
1993 40,215 35,173
1994 41,539 35,022
1995 42,740 35,300
1996 43,711 34,668
1997 43,492 35,209
1998 45,579 35,861
1999 45,765 33,020
2000 46,949 33,260
2001 46,532 33,035
2002 46,440 32,559
2003 46,436 32,240
2004 46,841 32,106
2005 44,329 31,952
2006 45,035 33,962
2007 50,122 39,391
2008 52,487 41,652
2009 59,784 42,606
2010 59,271 42,642
2011 67,5903 46,196
2012 68,682 46,684

Source: Eye Bank Association of America. 2012 Banking statistical report

Lamellar Transplants

Figure 6 shows the annual number of surgeries by type of cornea transplant between 2005-2012(10).

Figure 6 The annual number of surgeries by type of cornea transplant between 2005-2012(10)

Domestic surgery use 2012 2011 2010 2009 2008 2007 2006 2005
Penetrating Keratoplasty 21,422 21,620 21,970 23,269 32,524 34,806 37,776 42,063
Endothelial Keratoplasty 23,049 21,555 19,159 18,221 17,468 14,159 6,027 1,398
Anterior Lamellar Keratoplasty 883 932 1,041 774 1,072 950 806 641
Keratolimbal Allograft 80 69 130 120 173 207 138 175

It can be seen that since 2011 the number of LT (anterior and posterior) is greater than the number of PK, and that in 2012 the number of posterior LT alone was greater than the number of PK.

In the United States all Eye Banks provide donor corneal lamellae. The current cost of a corneal donor (lamella or not) varies on average between US$ 1,949.00 to US$ 2,449.00(15).

Comments and suggestions

Although the penetrating keratoplasty indications were similar in the world(9,10,16-20), management of eye banks model have improved in Brazil(21) and the Brazilian corneal surgeons perform the most updated techniques of CT, it can be seen that there is an inefficiency of the Brazilian system at the national level by the huge discrepancy in the number of transplants in several Brazilian states. In 2010, only São Paulo made 1.7 times more CT than all UK did in 2012. In 2011, Brazil made 4.2 times more CT than all UK did in 2012. In the other hand, in 2011, the EUA performed 3.11 times more CT than Brazil in the same year. In this same period, the US exported more corneas than the number of CT across Brazil. Thus it is important to consider whether the Brazilians Eye Bank are following trends and best practices of other major Eye Banks in the First World. The three countries use the opt-in system for cornea donation.

Clearly, it is observed that in the United States (since 2011) and the UK (since 2009) are performed more posterior LT (endothelial) than PK. There is also a significant number of anterior LT in these countries. In this issue specifically, in Brazil the vast majority of Eye Banks as corneal surgeons do not have equipment (microkeratome, artificial anterior chambers, femtosecond lasers) for manufacturing their own donor corneal lamellar (anterior or posterior) from the donor corneal-scleral button. Thus, the number of LT performed in Brazil is a tiny fraction of the total CT. So, despite being a global trend, the LT is not encouraged by the Brazilian Eye Bank System, where there is practically no supply of donor corneal lamellae by Eye Banks, as in England or the United States have.

Suggestions

1. Investment in national awareness campaigns, guidance and fundraising (donations, web-donations with CBO help);

2. Specific guidance program to improve patient's knowledge about the main causes of CT and its treatments(22);

3. Developing a specific guidance program on protocols related to the importance, capture and donation of organs and tissues for TC, intended for all physicians and key stakeholders such as: CNCDOs, Intra-Hospital commissions, State and Municipal Health;

4. Investment for the 24 hours system of communication, transportation and collection nationwide;

5. Allow Eye Banks operate outside hospitals;

6. Partnership between the MS and the Brazilian Council of Ophthalmology (CBO) to develop and implement, in all national Eye Banks, software for on-line management, supervision and control of donated tissues and all types of cornea transplants;

7. Investment in equipment, material and human resources in Eye Banks for the possibility of making donor corneal lamellae;

8. Possibility to enrollment lamellar transplant (anterior and posterior) on Eye Banks;

9. Creating a web based database for the population could enroll as organ donors and tissues, as well as be able to make financial donations.

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Received: February 01, 2014; Accepted: March 17, 2014

Corresponding author: Gustavo Victor, Republica do Líbano Avenue, nº 1034, Zip code: 04002-001 – São Paulo (SP), Brazil, Phone: +55 (11) 3884-2020 – Fax: +55 (11) 3884-7680. E-mail: gustavo.victor@eyeclinic.com.br

The authors declare no conflicts of interest

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