"At any time you go to the SLIEB, there are about 60 patients waiting. The waiting time is about one to one-and-a-half months. But this is not bad based on international standards. Other countries have a longer waiting time. But then again if we had more corneas, waiting time would be shorter." -Dr. Padilla

    Dr. Padilla explains that as a member of the IFETB, the SLIEB is obliged to share 30 percent of surgically viable corneas it harvests internationally. In return, the SLIEB receives from the IFETB reagents for serologic processing of the corneas and solutions to preserve them. Aside from this, the SLIEB is included in the IFETB's network that provides new information and research data regarding various eye diseases, particularly corneal disease.

    Through the sharing arrangement, corneas reach areas where they are needed most-where the incidence of corneal blindness is high-like Saudi Arabia, Oman, Israel, Jordan, Syria, Lebanon, Kenya, and Zimbabwe. In these countries, corneal blindness is prevalent due to infectious etiologies, the most common of which is trachoma. Caused by the protozoan Chlamydia trachomatis, trachoma can be highly contagious and thrives well in dry equatorial weather and arid regions where water scarcity hampers sanitation. Other countries reached by corneas from the SLIEB are Guam, Thailand, Japan, Taiwan, Greece, Switzerland, Germany, France, Spain, Portugal, Lebanon, the United Kingdom, and the United States.

    Although 70 percent of surgically viable corneas remain in the country, they are not enough to meet local demand. In fact, Dr. Padilla says: "At any one time you go to the SLIEB, there are about 60 patients waiting. The waiting time is about one to one-and-a-half months. But this is not bad based on international standards. Other countries have a longer waiting time. But then again if we had more corneas, waiting time will be shorter."

    Dr. Padilla recalls that waiting time was shorter when the SLIEB started because not too many ophthalmologists were doing corneal transplantation at the time. "Now more and more specialists are doing corneal transplantation throughout the country, so the demand for corneal tissue has gone up exponentially. This can also be due to the fact that doctors know there is an eye bank and that they can avail themselves of corneal tissue when they need it. However, the supply and procurement of corneas have not kept up with this demand."

Keeping Up

    Dr. Padilla says most donor corneas are obtained from unclaimed or unidentified bodies that end up in various police-accredited morgues in Metro Manila. The majority come from trauma victims; a handful from donations or exenterations. Since 1996, though, the SLIEB has been making progress with donations. Dr. Padilla notes, however, that transplant coordinators in many hospitals focus more on the major solid organs like the heart, liver, and kidneys and fail to ask families if they are willing to donate tissues like corneas.

    To disseminate information and encourage more people to donate corneas, the SLIEB regularly holds seminars both for transplant coordinators and the public. It also established a hospital retrieval program in 1998 where transplant coordinators were tapped to discuss corneal donation with families of the recently departed.

    Says Dr. Padilla: "We found out that the best time to talk to relatives of a potential dead donor is when the body is already in the morgue. Not in the room, or when the patient had just died. It is during this time when they are still very emotional, sometimes trying to get over the death of the relative. But once the body is in the morgue, the family is already open to arrangements including organ and tissue donation."

    Under international standards, the first 12 hours from death present the golden period for retrieval of corneas. The Eye Bank Association of America (EBAA) sets the optimum time of retrieval at 18 to 20 hours.

    But a study conducted by Dr. Padilla and Drs. Teresa Almeda and Alfonso Bengzon established that in the Philippines, corneas must be retrieved within nine hours post-mortem to have a 70 percent (or higher) chance of being rated "very good." The research pointed out that delay in harvesting and the country's tropical climate affect the quality of donor corneas.

    Studies in North America and Japan corroborate their findings. These studies noted that colder climate and the immediate refrigeration of cadavers were crucial in the retrieval of high quality corneas and in stretching the retrieval time to 20 hours.

    The SLIEB has also started tapping funeral homes, a move that Dr. Padilla considers "innovative." "Even the United States hasn't done that. In fact, they are trying to copy what we have done."

    Under the setup, funeral homes personnel also ask relatives of the dead if they would wish to have their loved one's corneas donated "so that someone who is blind may see."

    "It is as simple as that; a very simple SOP," says Dr. Padilla. "If the family decides to donate, the transplant coordinator or staff member at the funeral home talks to them and an Eye Bank technician is called to perform the corneal retrieval."

Meeting the Standards

    Dr. Padilla notes that about a quarter of corneas donated to the SLIEB are turned down for being serologically positive or unfit for transplantation. The majority of these cases are attributable to active hepatitis B. Hepatitis C and HIV/AIDS are a far second and third in the list of causes for turning down donations. Donations are also rejected if the donor has syphilis, rabies, active TB, sepsis, leukemia, and primary diseases of the eye. Also rejected are corneas that have amassed substantial damage from direct trauma. A donor who has been imprisoned for more than 72 hours within six months from death is also disqualified.

    Aside from serologic testing, the SLIEB boasts of a specular microscope donated by Rotary International. "Without the specular microscope," Dr. Padilla quips, "it is very difficult to assess the quality of the cornea. With this we can be very exact. We can tell if a tissue is good. And not all eye banks have this."

    With the specular microscope Dr. Padilla says they are able to measure the density of corneal endothelial cells, coefficient of variation, and the standard deviation. Cell count greater than 2500/mm3, values less than 40 and less than 100 respectively mean the tissue is in good shape.

    Dr. Padilla says the corneal rejection rate is only about five percent and can be dealt with using steroids. Cyclosporin is reserved for the more extensive cases.

    Since the majority of cases the SLIEB services are charity and indigent patients, a "Surgical Fund for Indigent Patients" was put up in 1999 with the help of ABS-CBN, Aboitiz Foundation, and TBI. Patients are evaluated by a social worker and if they qualify, the Fund finances the cost of surgery up to PhP15,000. Doctor's fees and the cost of the cornea (valued at about US$1,300 in the international market) are waived. The Surgical Fund benefits five patients a month. For the better-off patients, they are charged the serologic processing fee of PhP8,500 and the cost of surgery. But the corneas are free.

    The SLIEB has contributed much to lowering the cost of corneal transplantation that traditionally cost about PhP100,000. It can not be performed for as low as PhP6,000 in cases where the recipient is a beneficiary of the Surgical Fund.

    "In the past, corneas were shipped to the country from the US every week just so that ophthalmologists would be able to perform corneal transplants," says neuro-ophthalmologist Dr. Jesus Tamesis Jr. (MEDICAL OBSERVER, November 2000). "Aside from shipping costs, testing of the donor tissue is not cheap. All these had to be shouldered by the patient."

    His father, the late Dr. Jesus Tamesis Sr. who performed the first successful corneal transplantation in the Philippines on December 29, 1949, was a visionary who lobbied for the passage of Republic Act 349. The law organized the Philippine Eye Bank for Sight Restoration (PEBSR) in 1951.

    With the creation of the PEBSR, the elder Tamesis hoped that corneal transplantation would become more affordable via local sources instead of importing them from the US. But Filipinos were still not receptive to the idea of organ or tissue donation.

    Dr. Pearl Tamesis-Villalon, one of the country's few retina surgeons recounts the difficulties her father encountered when he co-founded the PEBSR. "The idea [of an eye bank then] did not prosper because back in the 1950s and 1960s, Filipinos were indifferent to tissue and organ donation and attached some stigma to it." Also not too many ophthalmologists have been trained then to perform the procedure, and the few who were trained were not willing to perform it because of the long wait for corneas that usually discouraged patients themselves.

    Dr. Padilla recalls the elder Dr. Tamesis and his colleagues were relentless in putting up an eye bank. "When I was a resident in the 1970s and 1980s, they were still trying hard to create an eye bank. So when we finally put up the SLIEB, it was sad that Dr. Tamesis was not there to witness it, but we were happy because the SLIEB is a realization of his dream."

Keeping the Dream in Sight

    In 1996, when the executive council of the Philippine Academy of Ophthalmology (PAO) created the Tamesis Community Service Award, the Tamesis clan was asked to decide who would receive the first award. Given in November 2000 during the annual meeting of the PAO, the Award decidedly went to the SLIEB.

    The Tamesis children, Pearl and Jesus Jr., agreed that the SLIEB deserved the first award which according to Jesus, Jr. embodies his father's efforts to improve health care in the country. The whole family thinks "it is a very good achievement for the Philippines to have an eye bank that can give corneas to people in dire need."

    The PAO-Tamesis Community Service Award is not the first the SLIEB has received. It received an award from the TBI in 1998 "for its exemplary work in sight restoration for the corneally blind." The SLIEB was also featured in the American television series The Visionaries in its episode "Adventures of the Heart" in July 1999. The program, which "seeks to discover the magic that occurs when one human helps another," provides insights into philanthropic work by profiling and featuring organizations that make a difference and people who dedicate their lives and careers to serve others. The series which has been airing in US national TV since 1995 has also featured the American Liver Foundation, Refugees International, Salesian Fathers, Maryknoll Sisters, Habitat for Humanity, Zonta International, Salvation Army, and Group B Strep Association to name a few.

 

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