MIRACLE by DREAM: Mega Initiative for eRAdication of Corneal bLindness by Digitization Re-energizing, Education, Advocacy, and Multitasking.

The wonders of nature never fail to remind us of the marvels of life on earth, the only livable planet as far as we are aware. The intricacies of design and function of the human eye miraculously bestow upon us the profound gift of perceiving the world’s wonders. The cornea, which is a beautifully transparent and naturally colorless tissue, serves as a window of the eye and visual system and together with the precorneal tear film, it works as a functional unit playing a significant role in providing clear eye sight. In addition to its transparency, the corneal shape, contour, and regular curvature are important facets of its physical properties that facilitate undisturbed light transmission and the focusing mechanism of the eye. Regrettably, not all are blessed with the radiance of pristine vision. Disorders of the cornea that disrupt its biological properties and physical characteristics compromise its function, leading to various degrees of visual impairment and even blindness. Once the damage to this delicate tissue becomes irreversible, surgical replacement is used as the standard surgical approach. For those shackled by the darkness of corneal blindness, the advent of corneal transplants in the beginning of the 20th century emerged as a beacon of hope. The progressive evolution of eye banking over the past century, bolstered by astute legal provisions, has indisputably revolutionized modern health care, making the restoration of sight an attainable reality for countless individuals. As with almost all advancements in the field of medicine, the initiation of innovation in this field was need driven, led by the indomitable spirit of clinicians who sought to provide the best for their patients in their hour of need. Corneal transplantation and eye banking are shining examples of such feats and endeavors accomplished by the pioneering ophthalmologists of yesteryears. Attempts started way back, as far back as the early 1800s, and the crucible for these early efforts was Europe.[1,2] Historically, in the journey of evolution of keratoplasty, this period spanning the years 1789–1824 is labeled as “Inspiration.”[3] These early attempts may have been unsuccessful in the short term, but they did ignite a spark which played a pivotal role in transforming an idea into a reality over time. The journey was indeed long and arduous and the subsequent period from 1825 to 1872 is aptly categorized as that of “trials and frustration,”[3] These pioneering efforts finally did lead to a major milestone in December 1905, when the first human corneal transplantation was performed in Europe in Moravia (which is now the Czech Republic) by Dr. Eduard Zirm[4] from Olmutz in Slovakia, wherein the cornea from an 11-year-old living boy undergoing enucleation for an eye that was blind after an intraocular metallic foreign body injury was used to save both eyes of a 45-year-old farm worker who had suffered lime burns and consequently had severe central scarring with a vision of hand movements in both eyes. Zirm undertook enucleation of the blind eye of the donor, kept it in warm physiological saline solution, and commenced the transplantation without delay. He used the clear cornea taken from the enucleated eye to fashion two corneal buttons of 5.0 mm diameter each from the single cornea, using a trephine previously developed by von Hippel in 1888, kept the harvested grafts between two pieces of gauze moistened with saline over steam emanating from a container of hot, sterilized water, and transplanted one each in both eyes of the recipient using a bridge of conjunctiva sutured over the corneas to hold the transplants in place. One of the grafts failed, while the other cleared and the patient could be sent home 15 weeks after the surgery. It was reported that the patient had a recorded visual acuity of 6/36 with a stenopeic slit and lived for 3 years after surgery. Zirm himself died in 1944 with 45 publications to his credit, but no other recorded corneal transplant after the first one reported by him.[5] Truly, his work was the fitting conclusion to the period from 1873 to 1905 acknowledged as “Conviction.”[3] Zirm’s heroic surgery ushered in the new era from 1906 to mid-1970s recognized as “Achievement,”[3] which was followed by the fifth stage of “Refinement” from mid-1970s to late 1990s,[3] and subsequently, the reinvigoration of lamellar surgeries in the modern era “Revival of lamellar grafting” from late 1990s to today.[6] The unfolding of the journey of evolution of corneal transplantation is incomplete without unraveling the simultaneous remarkable strides in eye banking from a primitive beginning to a complete transformation into a finely tuned technologically advanced field that plays a seminal role in present-day health care. Starting with the period when living donor tissue was used (1905–1935), it transitioned to the period when postmortem deceased donor tissue was used (1935–today) to the period of experimental storage methods for corneoscleral discs (1960s–today) and culminated in the period of storage of corneoscleral discs in tissue culture medium (1973–today), which includes both organ culture at a physiological temperature (30°C–37°C) and hypothermic storage in corneal preservation media (2°C–8°C). An acknowledgment of current-day trends with incorporation of cutting-edge technologies to provide precut tissues with specifically tailored dimensions, customized delivery protocols, and capabilities for bioengineered or 3D-printed tissues merits a separate recognition of the period from 2006 to today as an elevation of eye banking to its zenith. While the advancements in corneal transplantation surgery and the surging momentum of eye banking have significantly improved the availability and success rates of corneal transplants, legal provisions have also been instrumental in facilitating and regulating the entire process. To ensure the ethical and safe distribution of ocular tissues, countries worldwide have implemented various legal frameworks fostered by synergistic global collaborations. Broadly speaking, the concomitant founding of cogent legal provisions emphatically devised to safeguard ethical, equitable, and efficacious eye banking practices has played a pivotal role in every facet of the corneal transplantation ecosystem. The sanctity of informed consent, importance of centralized donor registries, the shroud of anonymity and fortification of confidentiality, conscientiously safeguarding the sacrosanctity of both donors and recipients shielding them from unwarranted intrusion, stringent regulations in tissue handling and processing with scrupulous adherence to regulations, embodiment of ethical and equitable distribution paving the way for universal accessibility irrespective of socioeconomic strata, nurturing research and development, harmonizing medical science with best practices, and galvanizing the metamorphosis of new knowledge have all helped catapult the field of eye banking and corneal transplantation to greater heights of success. In the annals of human progress, India has kept its position of leadership with the indomitable spirit of all stakeholders and its own astute legal provisions that form the bedrock of this compassionate enterprise developed over the years and revised from time to time. First person consent, mandatory notification of death, mandatory request, facilitation of permissions in medico-legal cases, recognition of corneas as a national resource with elimination of state-bound restrictions with a harmonious interplay of eye banking and compassionate legal facilitation by evoking a separate chapter for corneas in the Rules under the Transplantation of Organs and Tissues Act (THOTA) in our country are some of the measures that can be undertaken in mission mode under the MIRACLE by DREAM in India initiative if we so wish. May the radiance of renewed vision and the symphony of sight restoration play on eternally! Dr. Radhika Tandon, MD, DNB, FRCOphth, FRCSEd, FNASI, FNAMS Professor of Ophthalmology, Cornea, Cataract and Refractive Surgery, Ocular Oncology and Low Vision Services, Chairperson National Eye Bank, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi. Past President Eye Bank Association of India About the AuthorRadhika Tandon The author is Professor of Ophthalmology at AIIMS with over 30 years of experience in Ophthalmology and over 300 publications to her credit. Currently head of Unit 6 : Cornea, Cataract and Refractive Surgery, Ocular Oncology and Low Vision Services at Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS she is also Chairperson of the National Eye Bank and Past President of the Eye Bank Association of India