Eye banking in India: Present status, goals, and prospects for a future-ready ecosystem

The evolution of eye banking

Eye banking constitutes a critical component for the success of transplantation. Adopting medical standards of high quality including appropriate infrastructure and well-trained eye banking personnel of all cadres, operating systems of highest order including evaluation, preservation, and distribution of donor corneas are important.

Historically, eye banks were conceptualised as organisations retrieving whole eyeballs and preserving donor corneas in storage solutions for corneal transplantation. Over the years, the scope of eye banking has expanded beyond tissue retrieval, to longer-term tissue preservation, microbiological diagnostics for donor screening, tissue processing, surgical allocation, digital documentation, data archival, advocacy, awareness and new research initiatives for novel therapies.^4-7

Eye banking in India has a long history but did not keep with the adoption of international standards until about thirty years ago.^8-11 Global surveys on eye banking and corneal transplantation place India’s success in cornea collection and transplantation next only to the US.^12,13 Government-led early initiatives through the National Program for Control of Blindness (and now vision impairment), community eye donation awareness campaigns, support from voluntary organisations, and high-quality corneal specialist training programmes have all contributed to this robust system.^8,14

Current status and challenges

The advent of modern eye banking began in southern India from the early 1990s, with the adoption of international standards and best practices from high-volume, high-quality eye bank systems in the USA.^8,14,15 Today, India is home to one of the largest eye banks in the Asia-pacific region. In fact, corneal transplants are now offered to patients without any wait lists in many parts of the country.

However, this level of success is limited to some non-profit networks, and is unevenly distributed across the country.^8,14 Approximately 396 registered eye banks are under the Eye Bank Association of India (EBAI), however, only a fraction of them (20 to 25) meet the required standards and harvest over 100 corneas a yr.⁴ There remain several challenges to sustainability and for exploring the future potential, including favourable legislation for sharing tissues. Because of this, the number of corneas available lags the estimated demand to eliminate corneal blindness.

Eye Bank Association of India (EBAI) data from 2023 revealed that only 47,676 corneas were retrieved and 29,057 were utilised, resulting in a national utilisation rate of approximately 60%. This is far short of the estimated need of 100,000 transplants per yr to clear the existing backlog.^5,14 Gross cornea collection figures alone are poor markers of performance. If large proportions of tissue remain unusable, or if transplantation access is disparate and concentrated in a few regions or States, millions may be denied vision for structural reasons.^5,11,15

The challenge is not only to increase the number of donor corneas retrieved, but to also ensure that the retrieved corneas are suitable, safely processed, equitably distributed, and effectively utilised in a transplant facility available at a convenient location to the patients throughout the country.^8,11,15 In addition, sustainability of eye banking activities requires continued support and trust from the communities, hospital partners for retrieval programmes, and importantly conducive transplantation laws. It is essential to design a ‘resilient, self-maintained eye banking system’ at the national, State and regional levels.

New roles, broader vistas

The prospects and relevance of eye banking extend far beyond providing donor corneas for cornea care. Advances in technology, research and translational aspects of eye banking continue to evolve. Eye banks have also kept pace with evolving surgical techniques and novel therapies.^6-8 A great example is the evolution of corneal transplantation; it is no longer synonymous with a full-thickness graft of the donor tissue.^14-18 Modern lamellar (or partial thickness) surgeries, such as anterior lamellar keratoplasty (ALK), Descemet stripping endothelial keratoplasty (DSEK), and Descemet membrane endothelial keratoplasty (DMEK) have brought nuance and versatility to eye bank processes.^3,5

The partial layers of the cornea that were once prepared by corneal surgeons in operating rooms are now separated by well-trained technicians in eye banks, thereby reducing surgical time, delays and postponement of surgeries due to inadvertent tissue preparation failures. The recognition of the utility of placental amnion (the inner membrane of the placental sac) in healing an injured ocular surface has led eye banks to incorporate amniotic membrane processing into their practice.^5,13 Likewise, scleral tissue (the tough, outer white layer of the eye) preservation and provision began for managing the eyes with glaucoma that require drainage surgeries for controlling the disease.^5,13

The eye bank of tomorrow

The future of ophthalmic transplantation is evolving far beyond conventional retrieval and storage of donor corneas. Advances in regenerative medicine, cell therapy, tissue engineering, and biofabrication are redefining the role of the modern eye bank.^19-22 At the fore front of this transition is an integrated Cell, Tissue, & Eye Bank, envisioned as a comprehensive translational platform that bridges eye banking, regenerative medicine, and advanced therapeutics.²³ Apart from donor corneal tissue, emerging therapies increasingly rely on selective tissue processing, cellular harvesting, cultivated stem cells, bioengineered scaffolds, and advanced therapeutic medicinal products (ATMPs). These developments necessitate a parallel evolution in eye banking infrastructure and philosophy.

An integrated model could expand the scope of eye banking from a tissue retrieval service into a biologics and regenerative therapeutics hub. This includes procurement, processing, manufacturing, quality assurance, storage, and distribution of a wide spectrum of ocular and non-ocular biologic products under cGMP and cGLP-compliant conditions.

This is a new vision for an eye bank that will transform eye banking from a passive support service to an active engine for regenerative ophthalmology. The eye bank of the future will be a comprehensive, ophthalmic biologics platform capable of supporting the next generation of ocular therapies. These transformed eye banks, especially in the Indian context, should explore a more cohesive and collaborative partnership model²⁴ to meet the goal of eliminating of corneal blindness.