“This one,” explained Dr. Shafer, “was specifically for keratoplasty.”
Trillium Vision’s Vision
The outreach was conducted by Trillium Vision Foundation, a group cofounded by optometrist Eris Jordan, who also worked with CorneaGen. During her work with the company in El Salvador for preclinical trials for injected endothelial cell therapy for Fuch’s dystrophy and pseudophakic bullous keratopathy, she noticed two problems:
A lot of patients did not meet inclusion criteria because they had full-thickness disease. Because the ophthalmic community in El Salvador “doesn’t have the robust eye banking system found in the United States, there was no way for them to receive the transplant they needed,” said Dr. Shafer.
That lack of access to corneal tissue meant that local ocular surgeons had no access to keratoplasty technique. “You can’t access the tissue to do it,” Dr. Shafer explained.
To address these problems, Dr. Jordan reached out to CorneaGen colleagues Jared Young and JD Osborne. Together they founded Trillium Vision Foundation with the goal of bringing keratoplasty to El Salvador. Dr. Shafer’s trip was only the second outreach the foundation sponsored.
Dr. Shafer became friendly with JD Osborne during his time as a cornea fellow at Vance Thompson Vision, and they remained in close communication as Dr. Shafer progressed in his career. JD made the introduction to Jared Young and Eris Jordan, and they all had natural chemistry and synergy. When they asked him to take part in the global ophthalmology trip, it was a no brainer.
The Hunt for 16 Corneas
Working with a local clinic—Clinica Quesada in San Salvador Trillium identified 16 patients who were eligible for full-thickness transplantation and arranged to have all 16 undergo surgery on one day so the surgical volunteers could get them all done in one trip.
“Back home in the states, we had to figure out how to actually get 16 corneas,” Dr. Shafer said. “We all reached out to our local eye banks and various places with the goal of persuading them to donate tissue.”
Dr. Shafer contacted a local Philadelphia eye bank, AltruVision. “They donated I think 6 to 8 or so corneas and other eye banks around the country also contributed,” enabling Trillium to meet its goal.
Then all the corneas were sent to Dr. Shafer’s residence for him to bring with him on the plane to El Salvador.
“I'll never forget it. I opened the package because I had to repackage them for the airport. They were all on ice. I laid out all 16 corneas on my dining room table and my then 4-year-old sat there stacking and counting them.”
The next morning, Dr. Shafer headed to the airport with a cooler full of corneas and a notice on the side of it that read, “Human tissue for transplantation.”
“I walked into the airport holding this and one of the TSA agents, said, ‘You’re not going to be allowed to bring that.’ And I was like, ‘Oh, I'm bringing this!’”
Sure enough, when Dr. Shafer was going through security, he was asked about the contents of the box. “I said, ‘This is human tissue for transplantation. It’s not allowed to go through the X-ray scanner because it’s tissue and we want to make sure it stays alive. We don’t want the X-rays to damage it.’”
So instead, the agents opened the box to inspect its contents. As one of the TSA agents was doing so, Dr. Shafer told him it was corneas for corneal transplants.
“And the guy said, ‘Let me get one of those,’ just kind of joking, I thought. But he said, ‘No, I'm serious. I need one of those.’ I looked at him, and saw he was wearing a scleral lens, the lens that patients who have keratoconus wear.
“I said, ‘You have keratoconus, don't you?’ He said, ‘I do. And I need a corneal transplant.’ And I thought, oh, my God, this is a sort of synchrony in the universe! That guy went on to become my patient because he was local in Philly.”
With one adventure under his belt, Dr. Shafer then boarded the plane to San Salvador. Upon arrival, he went immediately to Clinica Quesada to put the corneal tissue in a refrigerator. He said work began that very day.
The team started by going throu gh the charts of the 16 patients who were to receive transplants. “We went through each of them, and we matched each to the tissue because when you get corneal tissue, it comes with the whole vignette of that person, the donor.”
For that reason, he says, a thorough medical history is crucial. Matches were made based on the age of graft, age of donor, age of patient, and endothelial cell counts, with surgeons trying to reserve the most robust tissue for the youngest patients.
Next, the team laid out their surgical day. Cases that appeared to be routine were scheduled first to help the local surgeons gain proficiency and confidence, with the more complex case cases scheduled later in the day.
"From 0 to 60" in 12 Hours
The next morning, the surgical team went to Clinica Quesada “bright and early,” he said. For approximately 12 consecutive hours, they performed transplants as he and Dr. Sila Bal, a corneal specialist in Hawaii, coached the local ophthalmologists on the different techniques for keratoplasty.
“This was all penetrating keratoplasty, all full-thickness transplants. There were some really sick eyes, but we made it through every single one of them. It was so rewarding watching the surgeons start with their first graft ever and go on to their fourth graft by the end of the day and get faster, more efficient and safer with each surgery. You could see them feeling good about themselves by the time we finished.”
The next morning was devoted to postop evaluations. Patients’ eyes “looked absolutely wonderful,” Dr. Shafer said, with no serious complications. Many patients were seeing for the first time after suffering for a long period with corneal blindness. “There were tears in people's eyes. It was extremely rewarding.”
The few issues the team did encounter, he noted, were mostly patient-pathology related.
Next on the agenda was coaching the local surgeons on how to perform the later follow-up visits. Because keratoplasty requires more post-treatment care than cataract surgery, Dr. Shafer and the rest of the team focused on issues such as the postop drop regimen these patients require and the signs that indicate it’s time to call for help from a more experienced surgeon.
Even after he and the other team members had returned home, Dr. Shafer noted they are still available to advise the Salvadoran surgeons they’d worked with.
“We’re still connected on a WhatsApp group and if issues arise with these patients, the surgeons reach out and kind of run their plan through us and we confirm or deny and modify as needed,” Dr. Shafer said.
He's Got the Bug
The trip to El Salvador was Dr. Shafer’s first exposure to global ophthalmology, but he feels certain it will not be his last. “It was extraordinarily rewarding, and it kind of gave me the bug. I really am looking forward to my next opportunity to participate.” OASC