Download Study of Enucleated Eyeballs Rejected Due to Sepsis and

73rd AIOC 2015, New Delhi
This paper was judged the BEST PAPER of
COMMUNITY/ SOCIAL OPHTHALMLOGY-I Session.
Study of Enucleated Eyeballs Rejected Due
to Sepsis and Malignancy, for Culture and
Histopathology.
Dr. Sameer G Datar, Dr. Mayur Moreker
C
orneal diseases are a significant cause of visual impairment and
blindness in the developing world. The Andhra Pradesh Eye disease
study (APEDS) reported the prevalence of corneal blindness at 0.13% (95%
CI: 0.06-0.24), constituting 9% of all blindness.1 Approximately 18.7 million
people are blind in India.2 Every year another 20,000 join the list.3 The
National Programme for Control of Blindness (NPCB) estimates, there are
currently 120,000 corneal blind persons in the country. According to this
estimate there is addition of 25,000-30,000 corneal blindness cases every year
in the country.4 The burden of corneal disease in our country is reflected by
the fact that 90% of the global cases of ocular trauma and corneal ulceration
leading to corneal blindness occur in developing countries.5
Corneal transplantation remains a major treatment option for restoring
sight among those suffering from corneal blindness. The current cornea
procurement rate in India is 22,000 per year. It is estimated that a significant
proportion of donor corneas are unsuitable for corneal transplantation.6
Enucleated eyeballs in the eye bank are used for corneal transplantation
for corneal diseases. These enucleations were done on the deceased when
the relatives consent for eye donation. As this comes under human organ
transplant act, there are stringent criteria for their use.7,8 The deceased
has to be free of any infection (threatening its spread to the recipient) or
malignancy. It is therefore followed that eyeballs from deceased due to
terminally malignant, and metastatic disease, cannot be used as there are
chances of its spread to the recipient, similar to those of infection. There is
no strong evidence to estimate such a risk though.
Malignancies are known to spread through blood and lymphatics and
metastasize to distant organs. In the eye, barring cornea, lens and vitreous
all other tissues are vascular, choroid being characteristically the most
vascular of all. Therefore metastasis of malignancies can occur in the eye.
Of all the choroidal tumours, metastatic or “secondaries” is very common.
The choroid is the most common site for uveal metastases, and the tumors
occur most often in the posterior pole of the eye with an average of two
tumors per eye.9 Cornea being avascular, has the least chance of showing
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any metastatic lesion, therefore, though cornea from malignant donors can
be used for transplant purposes, it has to be documented by some concrete
evidence. This study is therefore designed to utilize the donated tissue for
research purpose and actually process it for histopathology to rule in or
rule out any evidence of malignancy in various tissues of the eye, cornea
being the main concern.
Deaths due to septicaemia occur in hospital or home. There are no criteria
to define septicaemia, other than blood culture positivity. On most of the
occasions when the death is declared and “septicaemia” is mentioned as
the cause of death, there are not enough reports available to support the
diagnosis of septicaemia. It is more difficult in home deaths to attain the
detailed history and reports of the deceased. Commonly available report,
and which is one of the criteria to establish a diagnosis of septicaemia is
Total Leucocyte Count (TLC). This study was also designed to look into
these donated tissues (from deaths due to septicaemia) for evidence or trace
of any infection in the ocular tissues. Spread of infection throughout the
blood stream is pathologically evident in septicaemia. Spread to ocular
tissue is therefore expected. Positive culture report showing growth of any
organism in any of the ocular tissue was the basis of this study design. This
was to be correlated with the available reports if any (blood culture, TLC
etc).
Here we study 98 enucleated eyes (from eye donations), 66 septicaemic (11
had to be refused for technical purposes, therefore study eyes were 55) and
32 malignant, to estimate whether there is any trace of either infection or
malignancy in any part of the eyeball.
Procedure
Enucleation for eye donation call is done under aseptic precautions. It is
done at the bedside wherever death has occurred, either hospital or home.
With all aseptic measures, the eyes are painted with betadine and draped
with a sterile whole towel. All autoclaved sterile instruments are used
for the procedure. Eye speculum is used to open the lids, and peritomy is
performed. The four rectii muscles are identified and cut with scissors. Then
with the enucleation scissors the optic nerve is cut and the whole eyeball is
taken out of the socket. It is then washed with gentamicin and placed in a
glass bottle on a specialized stand, nicely packed from all sides with cotton,
avoiding any injury to the cornea. The bottle is then carried in a cold chain
to the eye bank and placed in the refrigerator at 4º Celsius.
MaterialS and MethodS
Enucleated eye balls which were rejected (for corneal transplantation) due
to septicemia or malignancy, irrespective of age and gender were included
73rd AIOC 2015, New Delhi
in this study. These eye balls were examined during period September 2011
to October 2013. Enucleation was done on the deceased after consent from
relatives of donor for eye donation. The tissue was sent to the laboratory
in formalin for histopathological examination and in normal saline for
microbiological examination (culture and examination).
The Eye balls of donors who had known history of any type of malignancy
were examined for histopathology examination to look for inflammatory
deposits / malignancy / metastatic cells in eye,. Each part of eye such
as cornea, conjunctiva, sclera, choroid, vitreous and lens was separately
examined.
The eye balls of donors whose death was due to septicemia and multi organ
failure were cultured for aerobic and anaerobic growth to look for traces of
infection in any tissue. Each part of eye such as cornea, conjunctiva, sclera,
choroid, vitreous and lens was separately cultured and examined.
Results
Total 282 donors donated their eyes to our eye bank during the period
September 2011 to October 2013. Out of that, 105 donor’s eyes (210 eye balls)
were rejected for corneal transplantation due to the donor having history of
malignancy or septicemia. 98 eye balls were considered for present study;
where as 7 donor’s eyeballs were not considered due to unavailability of
past records (history).
Out of these 98 eye balls, 66 (67%) eyes were from donors whose death due
to septicemia and 32 (33%) were
from donors whose death due to any
malignancy. (Figure 1)
32 eye balls of donors whose death
was due to any malignancy were
examined for histopathology. 22
(68.8%) were male and 10 (31.3%)
were female donor with known
history of Malignancy. Average age
at death of donor was 71.0 ± 11.65 yrs, age ranges from 43 to 88 yrs. (Table
1). All 32 eye balls (100 %) did not showed any type of inflammatory and
or neoplasmic pathology. Also we had not observed any involvement by
malignant lymphoma and metastatic deposits of carcinoma in the 32 (100
%) eye balls (Table 2).
66 eye balls of donors were those whose death was due to septicemia,
but only 55 were examined for microbiology examination as 11 had to be
refused for technical purposes. Out of these 66 donors, 37 (56.1%) were male
and 29 (43.9%) were female. Average age at death of donor was 73.24 ± 19.41
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Table 1: Donors history (Death was due to Malignancy)
No. of patients
%
GenderMale
22 68.8
Female
1031.3
Death at
Hospital
16
1650
50
Home
Cause of death
t cell lymphoma
1
3.1
ca lung
2
6.3
12.5
ca breast
4
ca prostate
3
9.4
ca colon
2
6.3
ca hepato cellular
3
9.4
ca larynx
1
3.1
ca ovary
1
3.1
ca tong
2
6.3
ca oesophagus
4
12.5
ca uterus
1
3.1
3.1
ca renal
1
Leukemia
26.3
Ca head and neck
1
Ca thyroid
2
3.1
Ca gastric
1
6.3
6.3
Table 2: Eye ball status of 32 eyes of donors with known history of
malignancy
No. of patients
%
No e/o inflammatory pathology and no neoplastic pathology
2
6.3
No e/o involvement by malignant lymphoma and metastatic deposits of carcinoma
30
93.8
Table 3: Donors history (death due to Septicemia and other
infections)
Gender Male
No. of patients
%
3756.1
Female
2943.9
Death at
Hospital
45
Home
2131.8
Cause of death
Sepsis
56
84.8
other infection
10
15.2
68.2
73rd AIOC 2015, New Delhi
yrs, age ranges from 02 to 98 yrs. (Table 3). 11 had to be refused for technical
purposes, therefore study eyes were 55. In that, 30 (54.5 %) eye balls showed
no growth in aerobic culture and 25 (45.5 %) had shown growth in aerobic
culture (Table 4).
Table 4: Eye ball status of (55) eyes of donors whose death due to
septicemia
No. of patients
%
No growth in aerobic culture
30
54.5
Growth in culture
25
45.5
Out of total 55 eye examined, only 26 had Total Leukocyte count (TLC)
reports available. From those 26 available reports 13 (50.0%) had micro
organism growth in one of the tissues barring conjunctiva and cornea
and 13 (50.0 %) had no micro organism growth in any of the ocular tissue.
From the 13 eyes with growth in one of the tissues 11 (84.6%) had raised
TLC’s, which is supposed to be a marker for septicaemia, whereas 2 (15.4%)
had normal TLC levels (can be due to general debility also). We observed
significant difference (p=0.039) in micro organism growth between donors
with high TLC levels and donors with normal TLC levels. This may suggest
that donor with high TLC (n=17) levels maximum, i.e. 64.7 % have micro
organism growth in ocular tissues, whereas among those 9 who had normal
TLC, 77 .7 % had no growth in any of the ocular tissues (p=0.039) (Table 5).
Table 5: TLC interpretation of 26 eyes
TLC
Normal TLC
Count
interpretation
4000-11000
% Eyeball status
High TLC >11000
No growth Growth
(n=13)
(n= 13)
7
2
53.8%
15.4%
Count
% Eyeball status
TotalCount
13
6
11
46.2%
84.6%
13
p =0.039
Table 6: Micro organism growth in various orbital tissues. (N=55)
Eye Tissue
Micro Organism Growth Present Micro Organism Growth Absent
No of Eye
%
No of Eye
%
Choroid16
29.1
39
70.9
Cornea18
32.7
37
67.3
Lens13
23.6
42
76.4
Vitreous12
21.8
43
78.2
Sclera18
32.7
37
67.3
Conjunctiva18
32.7
37
67.3
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Discussion
There was no attempt in the past to correlate the corneal contamination
with the systemic infection directly, in case of tissues collected from
septicaemic donors. Clark and associates10 questioned the relationship of
bacteremia and corneal contamination. They cultured the aqueous humor
in 50 patients who died with infectious or chronic debilitating disease.
The aqueous humor was found to remain consistently sterile despite a
45% incidence of postmortem bacteremia. They concluded that the lack of
aqueous contamination negated a direct or causal relationship between
bacteremia and corneal contamination.
Several studies have cited positive conjunctival cultures in cadavers to range
from 12% to 100%, depending on the method used for donor preparation.11
These results most likely represent surface contamination only and do not
appear to be a frequent cause of postoperative endophthalmitis. Rollins
and Stocker12 showed that while 61% of their donor eyes were associated
with positive conjunctival cultures, there were no cases of post operative
infection. A similar study by Pardos and Gallagher13 of 4,167 donor eyes
yielded a 12.4% incidence of positive cultures, and only two occurrences
of post keratoplasty endophthalmitis in 1,880 transplants. In both cases of
infection, donor corneal cultures were negative. Chittum et. al.11 have found
a correlation that patients with documented or suspected sepsis at the time
of death have a significantly higher incidence of corneal contamination
than control donors.
Spelsberg H et. al.14, in their data revealed no contraindication against
the use of corneal grafts derived from septic donors, provided, critical
graft assessment in organ culture is done. No patient who had received a
graft from a septic donor had experienced endophthalmitis. The question
if endophthalmitis can be transmitted via donor corneas in properly
performed organ culture has not yet been answered, and that study seems
to be the first to report on the clinical course of transplanted corneas from
septic donors stored in long-term organ culture medium. Long term organ
culture at 30–37°C not only allows the growth of pathogens but also a
maximal antibiotic effect.
Use of organ culture for every corneal tissue can be economically burdening,
and not using a tissue from a septicaemic donor for fear of transmitting the
infection, will be like wasting a few good tissues. Therefore it is the need of
time we come to some conclusive method whereby we can decide whether
the tissue from a septic donor is viable for surgical transplantation or not.
Here we studied 55 eyes from septic deaths for microbiology examination
where 45.5 % eyes showed growth in aerobic culture. We went on to look for
73rd AIOC 2015, New Delhi
total leucocyte count, which is one of the markers for septicemia and which
can be easily available with the relatives or hospital reports and found that
only 26 patients had Total Leukocyte count (TLC) reports available. From
those 26 available reports 50.0% had micro organism growth in one of the
tissues barring conjunctiva and cornea. Exclusion of cornea and conjunctiva
was a criteria as it can be due to contamination. Of those 13 eyes with
growth in one of the tissues, 11 (84.6%) had raised TLC’s, whereas 2 (15.4%)
had normal TLC levels (can be due to general debility also). This significant
difference (p=0.039) in micro organism growth between donors with high
TLC levels and donors with normal TLC levels suggests that donor with
high TLC levels may show micro organism growth in ocular tissues, and
those with normal TLC level can have sepsis free ocular tissues, thereby
making TLC a criterion for judging the suitability of the septicaemic tissue
for surgical use, (p=0.039)
The incidence of ocular metastases in corneal donors with active
malignancy is very low. Donor-recipient tumor transmission through
corneal transplantation is highly improbable when the eyes are free of
cancer.15
Where all the 32 eye balls of donors whose death was due to any malignancy
were examined for histopathology, all 32 eye balls (100%) did not show
any type of inflammatory and or neoplasmic pathology. Also we had not
observed any involvement by malignant lymphoma and metastatic deposits
of carcinoma in the 32 (100 %) eye balls, thereby making them viable for use
in patient care.
Limitations
A bigger sample size needs to be studied, for stronger evidence, and
cases with detailed reports of malignancy and sepsis e.g. type and grade
of malignancy, type and source of infection will help in establishing a
stronger association. Other septicaemia markers and detailed reports of
cause of death and pre mortal conditions, though difficult to obtain in such
situations would help in a better way to make a conclusion.
References
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