As corneal specialists, the technique and art of corneal transplantation is what our fellowship is designed to teach. However, through the years, corneal transplantation has evolved to mean something entirely different than it did 20 years ago, and the eye banks that provide the precious tissue needed for transplantation have seen significant changes.

Yesterday’s Eye Banks

When I started my residency at Bascom Palmer in 2000, the eye bank did not charge a processing fee for tissue and relied on residents to handle these “after-hours” calls (often at 2 o’clock in the morning). Back then, the only transplant option was a penetrating keratoplasty, and wait lists for tissue were typically up to 3 months long. Even then, tissue was never guaranteed to be available, forcing surgeons to occasionally cancel surgery.

Today’s Eye Banks

Twenty years later, eye banks, like corneal transplants, have evolved dramatically. In 2020, all U.S. eye banks charge a processing fee, eye banks operate 24/7, and many have developed sophisticated processing programs that allow for the preparation of tissue for partial-thickness transplants tailored specifically for our patient’s needs. Additionally, waitlists for corneal tissue are a thing of the past and surgery is almost never cancelled, as eye banks across the U.S. work together to cover scheduled surgeries.

This dramatic change in eye banking has resulted in an excess of tissue in the U.S. and has increased competition among eye banks, driving them to improve customer service and increase available tissue offerings, leading to unprecedented innovations, including ultra-thin Descemet Stripping Automated Endothelial Keratoplasty (DSAEK), pre-cut Descemet’s membrane endothelial keratoplasty (DMEK), and preloaded tissue. This dramatic change has also led to changing the eye bank model. Years ago most eye banks were relatively small and functioned to serve their local community, whereas today there are eye banks of varying sizes, some of which are very large and focus on serving surgeons across the United States and even internationally. While for decades all eye banks operated under a non-profit eye banking model, one eye bank now operates as a for-profit.

EYE BANK ASSOCIATION OF AMERICA STATS

85,411
NUMBER OF CORNEAS PROVIDED FOR TRANSPLANT IN 2018

68,102
NUMBER OF U.S. DONORS OF OCULAR TISSUE IN 2018

+95%
SUCCESS RATE OF CORNEAL TRANSPLANTATIONS

$6.0B
LIFETIME ECONOMIC BENEFIT OF CORNEA TRANSPLANTS PERFORMED IN 2018

Statistics courtesy Eye Bank Association of America

A New Model

In 2016, SightLife, the largest eye bank in the United States, created CorneaGen, a for-profit entity, to further the company’s mission to eradicate corneal blindness by 2040. This noble goal is shared by eye banks and corneal surgeons worldwide, but the for-profit model has introduced capitalism and further increased competition in the eye banking world. It has also fueled controversy and potential ethical considerations, as the gift of human tissue made by donor families is now viewed as a commodity that benefits investors. That said, having seen the benefit that competition has had on eye banking operations, it is difficult not to explore the possibility that capitalism, choice, and the potential for negotiations and consolidation may have potential benefits for patients, surgeons and, perhaps, even the field of eye banking.

Economy of scale and increased financial resources make it difficult for the small, local eye bank to compete with larger entities, like CorneaGen. The local eye bank may not be able to offer the same breadth of tissue choices in the same timely manner, and although many of us feel a loyalty to our local eye bank, we also want the best tissue for our patients, which is sometimes easier to obtain from a larger, more geographically diversified source. Small, local eye banks are confronted by surgeons performing fewer penetrating keratoplasty, and those who do little or no processing have had to deal with local surgeons choosing to acquire their tissue from a larger organization outside their local area.

Through the years, some of these smaller eye banks have chosen to participate in a model that combines efforts to ensure the future and viability of all entities. In some areas, for example, eye banks have partnered with CorneaGen, allowing the local eye bank to continue to recover corneal tissue, while CorneaGen manages processing and distribution. In other areas, nonprofit eye banks have chosen to avoid working under a for-profit model and have joined forces through consortiums and consolidations to pool resources and compete. As we sit on the cusp of offering cultured endothelial cells and consider the future of corneal transplantation, it is evident that processing techniques will continue to increase in sophistication and scope. Because of this, larger nonprofit eye banks and entities like CorneaGen, with increased resources, may be in the best position to move us into the future. It can “feel” ethically ambiguous and potentially inhumane to discuss the use of human tissue and transplantation in the context of competition and capitalism, but it is a reality and ultimately, may be in the best interest of our patients and in the interest of progress.

Meeting in the Middle

After discussing this topic with both nonprofit and for-profit entities, I believe that the best solution for cornea acquisition and distribution (and ultimately, what’s best for the eradication of corneal blindness) may lie somewhere in the middle and may require us to set aside emotional considerations and accept the realities of the advantage that economies of scale may offer. Ultimately, we all want the best tissue for our patients in a timely, dependable manner at a reasonable cost. And both nonprofit eye banks and for-profit entities, such as CorneaGen, are designed with the same mission of curing corneal blindness. Working together to ensure the survival of the local eye bank, possibly with cooperation with larger corporate entities that would provide support to those to whom we’ve developed loyalty, may be part of the compromise. Whether this can be accomplished within a nonprofit model or be better managed by a for-profit entity remains to be seen. CP

DR. DONALDSON is a professor of clinical ophthalmology at Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, and medical director at Bascom Palmer Eye Institute of Plantation in Florida. Reach her at KDonaldson@med.miami.edu.