Retrieval and preservation of the eyeball from a post-mortem donor

CLINICAL PROTOCOL FOR MEDICAL INTERVENTION

4) Users of the clinical protocol:

pathologists, transplantologists, ophthalmologists.

5) Patient category: adults.

6) Evidence level scale:

A High-quality meta-analysis, systematic review of RCTs or large RCT with very low probability (++) of systematic error, the results of which can be applied to the relevant population

B High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of systematic error or RCT with low (+) risk of systematic error, the results of which can be applied to the relevant population

C Cohort or case-control study or controlled study without randomization with low risk of systematic error (+). Results that can be applied to the relevant population or RCT with very low or low risk of systematic error (++ or +), the results of which cannot be directly applied to the relevant population.

D Case series description or uncontrolled study, or expert opinion.

7) Definition: [1] Removal of the eyeball from a postmortem donor is a medical procedure for obtaining a functionally complete corneal transplant of the eyeball, suitable for further preservation, transportation and transplantation to a recipient.

8) Clinical classification: none. 2. Methods and approaches for conducting medical intervention: 1) Purpose of medical intervention: removal of the eyeball from a postmortem donor for transplantation ophthalmic surgery.

2) Indications for medical intervention: brain death (in the presence of an eyeball recipient); biological death (in the presence of an eyeball recipient).

3) Contraindications to medical intervention: presence of documented refusal of postmortem organ donation; age less than 18 years and more than 62 years; acute infectious and contagious diseases; uncontrolled bacterial sepsis; positive ELISA marker for HIV (anti-HIV, HIVAg, RNA-HIV); positive ELISA for hepatitis B virus markers (HBsAg, DNA-HBV) or C (anti-HCV, RNA-HCV, HCVAg); positive ELISA result for detection of Treponema pallidum; any malignant neoplasm with metastases (except isolated brain tumor, as well as treated cases and absence of

recurrence within the last two years); death from carbon monoxide poisoning with carboxyhemoglobin level more than 20%; presence of established focal and/or diffuse eye diseases; drowning; damage to organs (part of organ) and (or) tissues (part of tissue) of vision; presence of any opacities in the optical zone of the cornea; presence of post-traumatic scars; presence of keratotomy scars after radial/tangential keratotomy; presence of adhesive changes (iridocorneal adhesions).

4) Basic and additional diagnostic measures necessary for conducting medical intervention: Basic diagnostic measures: determination of hepatitis B (HBsAg) and C (anti-HCV) markers by ELISA/CLIA method; ELISA/CLIA for HIV; microreaction for syphilis; visual assessment of eyeballs.

Additional diagnostic measures: assessment of corneal condition using an ophthalmoscope and/or handheld biomicroscope.

5) Requirements and conditions for conducting medical intervention: Requirements for compliance with safety measures, sanitary and anti-epidemic regime: 1) Code of the Republic of Kazakhstan "On the health of the people and the healthcare system"; 2) Safety measures and anti-epidemic regime according to Sanitary Rules "Sanitary and epidemiological requirements for healthcare facilities", approved by order of the Minister of Health of the Republic of Kazakhstan No. ҚR DSM-96/2020 dated August 11, 2020; 3) "On approval of rules and conditions for removal, procurement, storage, preservation, transportation, transplantation of organs (part of organ) and (or) tissues (part of tissue) from donor to recipient" Order of the Minister of Health of the Republic of Kazakhstan dated November 25, 2020 No. ҚR DSM-207/2020; 4) "On approval of rules for removal and preservation of vision organs from corpses for the purpose of transplantation in organizations carrying out activities of pathological anatomy and forensic medical examination". Order of the Minister of Health of the Republic of Kazakhstan dated December 21, 2020 No. ҚR DSM-307/2020.

Equipment requirements: Technical equipment: standard autopsy equipment and instruments;

eyelid speculum;

curved scissors;

strabismus hook;

forceps;

needle holder;

blunt-tipped scissors;

ophthalmic microsurgical forceps;

ophthalmic microsurgical knives;

flushing system (for organ washing);

organ transport container;

orbital implant;

ophthalmoscope;

handheld biomicroscope.

Requirements for consumables:

antiseptic: povidone-iodine 0.5% solution;

frozen sterile physiological saline ("ice");

sterile physiological saline;

monofilament suture materials;

solutions for organ perfusion and preservation;

70% ethyl alcohol;

antimicrobial fluoroquinolone preparation for topical use in ophthalmology (broad-spectrum antibiotics) – 0.5% levofloxacin solution or 0.5% moxifloxacin, or 0.3% ciprofloxacin, or aminoglycosides for topical use in ophthalmology: 0.3% tobramycin;

0.18% adrenaline solution;

sterile container with lid 50-100 ml;

preservation medium;

medical devices.

Requirements for donor preparation:

In order to ensure sterility of donor corneal, scleral and adjacent tissue transplants at the autopsy stage, it is recommended not to isolate individual tissue fragments of the eyeball required for transplantation (cornea, sclera, etc.), but to perform autopsy of the entire eyeball from the deceased donor with subsequent tissue preparation under sterile conditions at an ophthalmology center or cornea bank.

Enucleation from a deceased donor is performed no later than 24 hours from the time of declaration of brain death and biological death of the donor.

Methodology for performing the procedure/intervention:

Stage 1 - sanitation:

In compliance with aseptic and antiseptic rules, the physician's hands must be gloved in sterile gloves, instruments clean. Sanitation of the conjunctival cavity is performed by jet irrigation with antiseptic solution and instillation of broad-spectrum antibiotic. The eyelids are mobilized with a blepharostat.

ORGANIZATIONAL ASPECTS OF THE CLINICAL PROTOCOL:

3.1 List of developers with qualification data: 1) Manekenova Kenzhekyz Boranbaevna – Doctor of Medical Sciences, Professor, Head of the Department of Pathological Anatomy, NAO "Astana Medical University". 2) Khasanov Rufat Mirshatovich – Deputy Director for Medical Affairs, CGE on REM "City Pathoanatomical Bureau" GU "Public Health Department of Almaty City". 3) Lyasova Alla Anatolyevna – Director of GCP on REM "Pathoanatomical Bureau" of Astana City Akimat, Chief External Pathologist of GU "Public Health Department of Astana City". 4) Botabekova Tursungul Kobzhasarovna – Corresponding Member of the NAS RK, Doctor of Medical Sciences, Professor, Chief External Ophthalmologist of the Ministry of Health of the Republic of Kazakhstan. 5) Zhilgeldina Nazgul Zashitovna – Candidate of Medical Sciences, Deputy Director of RSE on REM "Republican Center for Transplantation Coordination and High-Tech Medical Services" 6) Bisengalieva Gulzhan Oralovna – Republican Transplant Coordinator of RSE on REM "Republican Center for Transplantation Coordination and High-Tech Medical Services" 7) Kupenov Sungat Karataevich – Head of the Eye Microsurgery Center, GCP on REM "City Multidisciplinary Hospital No. 2" Public Health Department of Astana City. Chief External Ophthalmologist of GU "Public Health Department of Astana City"

2) Conflict of interest: none.

3) Reviewer data: 1) Shaimardanova Galiya Masugutovna – Doctor of Medical Sciences, Professor, JSC "National Scientific Medical Center", pathologist of the pathological anatomy department. 2) Daurekhanov Asatay Mametovich – Doctor of Medical Sciences, Professor, Head of the Department "General Medical Practice 2" of the International Kazakh-Turkish University named after Khoja Ahmed Yasawi, pathologist. 4) Begimbayeva Gulnara Enbekovna - Doctor of Medical Sciences, Chairman of the Expert Council on Cornea of the Republican Society of Ophthalmologists, Senior Lecturer of the Department of Ophthalmology of the Non-profit Educational Organization "Kazakh-Russian Medical University". 3) Kurmangaliyeva Madina Maratovna – Doctor of Medical Sciences, Chief Ophthalmologist of the Republican State Enterprise on the Right of Economic Management "Hospital of the Medical Center of the Office of the President of the Republic of Kazakhstan".

4) Indication of conditions for revision of the clinical protocol: revision not less than once every 5 years and not more than once every 3 years in the presence of new diagnostic and treatment methods with a level of evidence.

5) List of references used: Regulatory legal acts: 1) Code of the Republic of Kazakhstan dated July 7, 2020 No. 360-VI ZRK "On the Health of the People and the Healthcare System". 2) Order of the Acting Minister of Health of the Republic of Kazakhstan dated October 27, 2020 No. ҚR DSM-156/2020 "On approval of the rules for establishing irreversible brain death and the rules for terminating artificial measures to maintain organ functions in case of irreversible brain death". 3) Order of the Minister of Health of the Republic of Kazakhstan dated November 25, 2020 No. ҚR DSM-207/2020 "On approval of the rules and conditions for removal, procurement, storage, preservation, transportation, transplantation of organs (part of an organ) and (or) tissues (part of tissue) from donor to recipient" 4) Order of the Minister of Health of the Republic of Kazakhstan dated December 21, 2020 No. ҚR DSM-307/2020 "On approval of the rules for removal and preservation of visual organs from corpses for the purpose of transplantation in organizations carrying out pathological anatomy and forensic medical examination activities".

Main literature: 1. Posterior lamellar keratoplasty/ compiled by Anisimova N.S., Shilova N.F., Pozdeeva N.A., Malyugin B.E., Gavrilova N.A., Anisimov S.I.: Educational-methodological manual / MSMSU. - M.: RIO MSMSU, 2021. - 40 p.: ill. 2. Balatskaya N.V. Immunological status in patients with post-traumatic uveitis and its diagnostic significance: educational-methodological manual / N.V. Balatskaya, I.A. Filatova, V.O. Denisyuk / Edited by V.V. Neroev. – Moscow: FSBI "NMRC GB named after Helmholtz" of the Ministry of Health of Russia, 2020. – 25 p.

Approved by the Joint Commission on Quality

of Medical Services of the Ministry of Health

of the Republic of Kazakhstan dated September 26, 2024

Protocol No. 215

"RETRIEVAL AND PRESERVATION OF THE EYEBALL FROM A POSTMORTEM DONOR"

Introduction 1) ICD-10 Code(s):

Code Name H16.0 Corneal ulcer H17.0 Adherent leukoma H17.1 Other central corneal opacity H18.1 Bullous keratopathy H18.2 Other corneal edema H18.3 Changes in corneal membranes H18.4 Corneal degeneration H18.5 Hereditary corneal dystrophies H18.6 Keratoconus H18.7 Other corneal deformities H18.8 Other specified diseases of cornea

2) Date of protocol development/revision: 2024.

3) Abbreviations used in the protocol: IFA – immunoenzyme assay ICHLA – immunochemiluminescent assay PTR – corneal transplantability index

Stage – eyeball extraction: A lid retractor is inserted and a circular incision of the conjunctiva is made with small curved scissors at the limbus itself, preserving the conjunctiva for the future prosthesis. The conjunctival incision is performed paralimbally in a boat shape, leaving small areas of conjunctiva on the eyeball at 3 and 9 o'clock, and it is dissected. The conjunctiva is dissected from the eyeball as deeply as possible. In the presence of adhesions between the conjunctiva and sclera or scars, they are separated by blunt or sharp dissection in the intermuscular spaces and subconjunctivally. With a strabismus hook, the tendon of the superior rectus muscle is grasped and cut at the sclera. In the same manner, the tendons of the lateral and inferior rectus muscles are cut. The tendon of the medial muscle is cut last, leaving 4-5 mm of this tendon on the sclera. The tendon is grasped with strong forceps and the eyeball is rotated strongly outward using the forceps. Simultaneously, blunt-tipped enucleation scissors in closed position are introduced deep into the wound along the medial surface of the eyeball. Having felt the taut strand of the optic nerve with the scissors, the nerve is cut in one motion, slightly stepping back from the posterior surface of the eyeball (by 2 mm). After this, the eyeball is removed from the orbit (if the lid retractor creates obstacles, it is removed). With scissors, the oblique muscles and special strands that remained previously uncut are cut at the sclera itself.

Stage – eyeball preservation: The extracted eyeball is washed with sterile physiological solution, placed cornea-up in a dry sterile container and closed with a lid – for direct transplantation; for transfer to a corneal bank, it is placed in a container with preservative solution.

The container (separate for each eyeball) in which the eyeball is placed is labeled indicating donor data, age, time of death, and time of eyeball retrieval. The container is placed in a refrigerator at a temperature of +2 to +4°C until transfer to a medical organization or corneal bank. Transportation of donor material will be carried out by specialists from the medical organization engaged in keratoplasty or specialists from the corneal bank (Code of the Republic of Kazakhstan "On People's Health and Healthcare System"; Order of the Minister of Health of the Republic of Kazakhstan dated November 25, 2020 No. ҚР ДСМ-207/2020 "On approval of rules and conditions for retrieval, procurement, storage, preservation, transportation, transplantation of organs (part of organ) and (or) tissues (part of tissue) from donor to recipient"; Order of the Minister of Health of the Republic of Kazakhstan dated December 21, 2020 No. ҚР ДСМ-307/2020 "On approval of rules for retrieval and preservation of visual organs from corpses for transplantation purposes in organizations carrying out pathological anatomy and forensic medical examination activities").

Stage – orbital implant insertion: The cavity of the muscular cone is opened with lid elevators and tamponaded with gauze tampons. An orbital implant corresponding to the color of the donor's iris is placed in the cavity of the muscular cone. "U"-shaped or 2-knot sutures are placed on the donor's eyelid.

Stage – assessment of the condition of donor eyeball corneas: conducted by an ophthalmologist or corneal bank staff member upon receipt of donor material, for the presence of deep intrastromal opacities, pronounced Arcus senilis (Senile Arc). Examination is performed using an ophthalmoscope and/or handheld biomicroscope in two stages:

Morphological assessment (which evaluates the integrity and suitability of the cornea, excluding morphological defects, congenital anomalies, traces of previous injuries, eye surgeries, postmortem structural changes); Morphological screening is evaluated on a three-point scale; material corresponding to 2 and 3 points is considered suitable.

Physiological tissue screening – conducting an adrenaline test to investigate viability and transplantability.

Adrenaline test assessment Grade A – onset of pupillary reaction after 5 min, the test is considered sharply positive according to the viability criterion of donor material (postmortem ATP loss in corneal cells, according to 31P-NMR-spectrometry data, is 0–55% of the initial value – conditional norm). Grade B – onset of pupillary reaction after 10 min, the test is considered positive according to the bioenergetic viability criterion of donor material (postmortem ATP loss in corneal cells, according to 31P-NMR-spectrometry data, is 56–69% of the initial value). Grade C – onset of pupillary reaction to adrenaline noted after 15 min, the test is considered doubtful (conditionally positive) and corresponds to grade "C" according to the energetic viability criterion of donor material (postmortem ATP loss in corneal cells, according to 31P-NMR-spectrometry data, is 70–100% of the initial value). In the absence of reaction after 15 min, the test is considered negative and corresponds to grade "0" ("zero"), and the donor material is assessed as energetically incompetent and nonviable (residual ATP quota in corneal cells is practically equal to 0%).

For successful corneal transplantation (keratoplasty), donor material corresponding to grades "A" and "B", "C" is considered physiologically suitable.

Upon completion of morphological and physiological testing of cadaveric donor corneas, the corneal transplantability index (CTI) is determined and human cadaveric corneas are selected for penetrating and lamellar keratoplasty based on the working classification. For example: Donor material CTI 3-A or 3-B.

Accordingly, the selected cadaveric tissue material undergoes several technological stages of procurement for subsequent transplantation in the clinic. Or it is subject to disposal.

stage – disposal act: conducted after the ophthalmologist's conclusion regarding non-compliance of donor material quality. The pathologist completes the disposal act and signs it jointly with the ophthalmologist.

6) Indicators of medical intervention effectiveness: anatomical integrity of the retrieved eyeball.

Mineeva L.A. Ophthalmology for the general practitioner: educational-methodological manual/Mineeva L.I. et al. – Moscow: GEOTAR-Media, 2018 – 200 p. 4. Egorova, E. A. Ophthalmology: textbook / ed. by E. A. Egorova. - 2nd ed., revised and supplemented - Moscow: GEOTAR-Media, 2021. - 272 p.: ill. - 272 p. 5. Sidorenko, E. I. Ophthalmology: textbook / ed. by Sidorenko E. I. - Moscow: GEOTAR-Media, 2018. - 656 p. 6. Takhchidi, Kh. P. Ophthalmology: textbook / Takhchidi Kh. P., Yartseva N. S., Gavrilova N. A., Deev L. A. - Moscow: GEOTAR-Media, 2011. 7. Research methods in ophthalmology: educational manual / A. E. Aprelev, I. V. Astafiev, A. M. Iserkepova [et al.]. — Orenburg: OrSMU, 2020. — 172 p. 8. Avetisov, S. E. Ophthalmology: national guidelines / ed. by S. E. Avetisov, E. A. Egorov, L. K. Moshetova, V. V. Neroev, Kh. P. Takhchidi. - 2nd ed., revised and supplemented - Moscow: GEOTAR-Media, 2022. - (Series "National Guidelines"). - 904 p. 9. Sidorenko, E. I. Ophthalmology. Guide to practical classes: educational manual / ed. by E. I. Sidorenko - Moscow: GEOTAR-Media, 2019. - 304 p. 10. Aznuryan I.E., Balasanyan V.O., Markova E.Yu. Diagnosis and treatment of concomitant convergent strabismus/ I.E. Aznuryan, V.O. Balasanyan, E.Yu. Markova Moscow: GEOTAR-Media, 2020

Additional literature: 11. Bikbov M.M., Usubov E.L., Zainetdinov A.F. Keratoplasty in keratoconus: advantages and disadvantages. Russian Ophthalmological Journal. 2021;14(4):130-136. 12. Nosirov P. O. Modern technologies of refractive lenticule extraction in myopia correction / Mushkova I.A., Kostenev S.V., Maychuk N.V., Obraztsova M.R., Nosirov P.O., Malyshev I.S. // Russian Ophthalmological Journal. – 2022. – Vol. 15. – No. S2. – P. 98-103. 13. Intrastromal transplantation of Descemet's membrane in advanced keratoconus / O.G. Oganesyan, V.R. Getadaryan, P.M. Ashikova [et al.] // Ophthalmology Reports. - 2020. – Vol. 13, No. 2. – P. 43-48. 14. Bowman layer transplantation in progressive keratoconus / O.G. Oganesyan, V.R. Getadaryan, P.V. Makarov, A.A. Grdikanyan // Russian Ophthalmological Journal. – 2019. Volume 12, No. 4. – P. 43-50 15. Filippova E.O., Chernyakov A.S., Ivanova N.M. Application of polymeric materials in the treatment of corneal diseases // Avicenna Bulletin. 2019. Vol. 21, No. 3. P. 496–501. DOI: 10.25005/2074-0581-2019-21-3-496-501 16. Kazaykin V.N., Ponomarev V.O. Software for automatic calculation of individual antibiotic doses for intravitreal administration in the treatment of bacterial endophthalmitis based on mathematical modeling of the vitreous cavity of the eyeball // Ophthalmology. – 2019 17. Azevedo, M.O. Literature review and suggested protocol for prevention and treatment of corneal graft rejection / M.O.Azevedo, B.A.Shalaby, M.Zarei-Ghanavati, C.Liu // Eye (Lond). - 2020. - Vol.34. - 3. -P.442-450.

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