The burden of medical contraindications to corneal donation: Time for review

Corneal graft (keratoplasty) is the most common allograft in the world, but the imbalance between the number of donors and the number of patients waiting for transplants is abysmal on a global scale and varies enormously from one country to another. The risk of transmission of systemic diseases from donor to recipient is demonstrably low. In over 50 years and an estimated 2.5 million transplants, only 8 cases of rabies, 2 cases of hepatitis B and 2 cases of Creutzfeldt-Jakob disease (CJD) have been documented. Conversely, other cases of rabies, HIV, hep C, hep B and CJD have not been transmitted via keratoplasty. The list of medical contraindications (CI) to corneal donation also includes diseases for which no actual, only theoretical, risk has been identified, in particular, neurodegenerative diseases, hematological malignancies, melanomas, tumors of the central nervous system, neoplastic meningitis and lymphangitic carcinomatosis. Their contribution to the reduction in the potential donor pool has not previously been investigated. We analyzed 45 months of exhaustive data from the hospital coordination for organ and tissue procurement at St-Etienne University Hospital (01/01/2020 to 06/09/2023). Out of the 2349 consecutive potential donors' files analyzed by the coordination team,1346 (57%) had an CI to donation. The identification of a neurodegenerative disease was the most frequent, accounting for 16% of the files examined and 29% of CIs. Of these, 75% were related to cognitive disorders. The 5 diseases or families of diseases for which there is only theoretical risk of transmission equated to a loss of 712 potential donors, corresponding to 30% of the files examined and 53% of all CIs. Of the 1003 deceased without CI, 738 families (74%) were contacted. No objection to donation was received in 52% of cases, enabling 385 procurements to be carried out. Removing these 5 CIs would have increased the number of donors by 71% (658 instead of 385). The potential pool of corneal donors is significantly restricted by a group of CIs introduced decades ago in response to a theoretical transmission of disease. A substantive amount of evidence now suggests that many CIs now need to be reviewed, modified or discarded altogether. This approach will result in a highly significant worldwide increase in the availability of corneas for transplant and have an immediate and major impact in reducing corneal blindness across the globe. We propose that this reduction in CIs be accompanied by a prospective evaluation process, by allocating the corneas of these donors to patients aged 75 years and over, and by monitoring them for a minimum of 5 years.