Canadian corneal transplant track record "dismal"

COS 2012, July 3 - The Canadian corneal transplant track record is dismal when compared with other parts of the world, and experts are calling for Canada to mend its ways.

"In many ways, we are worse off than some areas in the developing world," said Dr. Paul Dubord, clinical professor in the Department of Ophthalmology and Visual Sciences at the University of British Columbia in Vancouver. For example, in Hyderabad, the capital of Andhra Pradesh, a state in India with a population of 84.6 million, "people there have better access to corneal transplantation than the citizens of Canada," he added.

Canadian surgeons perform fewer than 2,500 corneal transplants a year - about half the number performed by surgeons in the United States, where the need for corneal transplantation is roughly the same as here. Wait times for a corneal transplant in Canada average 6-36 months, whereas there are no elective waiting lists in the United States. Dubord also noted that a larger proportion of Canadian surgeries are performed on an emergency basis compared with U.S. surgeries.

Only 20% of corneal tissue in Canada is pre-cut; in the United States, the proportion is 40% to 50%. "If you pre-cut tissue in the eye bank, the tissue is better quality, you know exactly what you are transplanting because you do endothelial cell counts after your cut, and it's better for hospitals because it takes less time in the operating room to do the procedure," Dubord said.

Dubord is also the board chair at SightLife, one of the world's leading eye banks, and he added that Canadian eye banks lack accountability. "Whether an eye bank does zero corneal transplants or 3,000, they get exactly the same amount of funding. There is no accountability to increase performance and delivery of care to patients," he said. There is also a "massive misalignment" between the Canadian supply of donated corneas and the demand, even though it has been his experience that people here, as much as anywhere, want to donate.

Corneal transplantation is also highly cost-effective. A 2011 report by Canadian Blood Services listed the total cost of a corneal transplant in Canada in 2010 dollars at $5,117. Dubord noted that Canada considers any health intervention to be cost-effective if it is less than $40,000-$50,000 per quality-adjusted life-year (QALY). One study showed a cost-utility of $11,557 10 years after penetrating keratoplasty (PK) surgery, which suggests that corneal transplantation is cost-effective.

Solutions to improve corneal transplantation in Canada include the creation of a more successful model that may mean duplicating what has been done elsewhere in the world. A key element is better management of the eye-banking system, Dubord said. "Most surgeons are not familiar with having access to good quality corneas," he added. Plus, training surgeons and fellows to expedite PK surgery needs to be addressed.

Inadequacies of distribution systems also need to be corrected to facilitate transfer of excess corneal tissue from one community or province to another to meet demands.

"The legislation is in place in Canada to make things work, and most eye banks are accredited by the Eye Bank Association of America; it's just that the systems and processes we have in place are not good and neither is our training. There are going to be challenges, but we have to put together a comprehensive corneal transplant eye-banking program in Canada for the common good, namely to better service our patients," Dubord concluded.