An eye for two eyes

Sabin Bogati was born completely blind and spent his childhood at home in Syangja, cared for by his parents, and unable to attend school.

Finally, at the age of 11 he could see for the first time after an operation to insert a transplanted cornea from a donor. Today Bogati, now 27, has completed his Bachelor’s and runs a shop in Kathmandu.

He remembers being able to see the world around him for the first time: “For months after surgery, I used to stay outside for hours, admiring flowers, clouds, and birds chirping on tree tops. The world was more beautiful than I had ever imagined.” 

Bogati got cornea transplants in both of his eyes at the Tilganga Institute of Ophthalmology, in Kathmandu and is one of thousands of Nepalis who have been given the gift of sight in a unique program to encourage people to donate their eyes after death. 

“If you want to see how cornea transplants can change lives, look no further than Sabin Bogati,” says Shankha Narayan Twyana, Eye Bank manager at Tilganga Institute of Ophthalmology.

The Institute started harvesting corneas on a small scale locally as an alternative to imported corneas in 1994. Since then, it has had a growing eye donation pledging program, and has been harvesting corneas for transplantation from hospitals and cremation sites. 

This has made Nepal Eye Bank increasingly self-sufficient in corneas, harvesting enough lenses from donors all over Nepal, with no need to import. Indeed, Nepal now exports corneas to countries where organ donations are not allowed for religious reasons, or where cornea transplants are not well-developed.  

Just last year, the bank harvested 880 corneas locally, more than in 2020 or 2021 when access to the crematorium and hospitals were restricted due to the pandemic. Just in the first four months of 2023, Nepal Eye Bank had already collected 507 tissues. “We have seen a very encouraging and spectacular growth,” adds Twyana.

Unlike in organ transplants, donors and recipients of corneas don’t need to be an exact match. One cornea can help restore the sight of as many as four people because the lens has layers that can be peeled off.

Many Nepalis are still reluctant to donate their eyes because of the superstition that it will make them blind in their next life. “Cornea is still one tissue that donors seem to have the most qualms about donating,” says Kiran Subba, tissue evaluation supervisor at Nepal Eye Bank. “The eyes are an external organ and a critical part of facial identity. This makes people more psychologically attached to eyes, compared to say kidneys or the liver.”

 At Tilganga, donation staff are trying to change this perception, arguing that donating corneas after death is no different from donating other organs. It also conducts public memorials to honour deceased donors and their families as a way to break the taboo.  

The latest memorial earlier this month paid respects to 1,503 cornea donors in the past three years.

Twyana says the donation program is growing. In 2013, for every 100 families the Bank approached only 33 would agree to donate the eyes of their relative. This number has now increased to 65%. 

This acceptance is also reflected in the number of living individuals who have agreed to donate their corneas to Nepal Eye Bank after they die. Today, Tilganga has a roster of 107,000 willing donors. 

“We get a call when the person who has pledged his eye dies, and our team reaches the hospital or crematorium within eight hours of the death,” explains Twyana, “After tests, we carry out the extraction.” 

From there, the cornea reaches the Tissue Evaluation Unit at the Eye Bank, where it is checked for quality. Supervisors like Kiran Subba inspect the lens, and determine which patient the cornea can be transplanted into. 

“Our main work here is cornea matchmaking,” explains Subba in his lab, showing us a small bottle with red fluid containing a cornea that was harvested for transplantation. 

Nepal Eye Bank was able to leapfrog in 2021 with advanced technology that allows a single cornea tissue to be separated into two layers which can then be used in upper and lower level surgeries to restore vision in two different individuals. 

Two corneas from each donor can now give sight to a total of four vision-impaired individuals in need of new corneas. “This doubles the number of patients we can treat with the same number of corneas,” adds Subba. 

Nepal Eye Bank has also started a procedure called DMEK tissue preparation which results in earlier and better visual outcomes after transplantation, compared to the more traditional methods of cornea preparation used previously. It also presents a lower risk of tissue rejection in patients after surgery.

“In the near future, we are also looking into starting the procurement and distribution of amniotic membranes for various forms of eye surgery,” adds Twyana. Starting the use of amniotic membranes for treating conjunctival and corneal diseases can open up an entirely new avenue for eye care in Nepal.

Such developments at Tilganga form the foundation for advanced eye care spreading all across the country. With its strong collaboration with major eye hospitals in all seven provinces, Nepal Eye Bank is working closely to decentralise corneal harvesting and transplantation services, among other eye treatments, in as many locations as possible. 

“If a patient wants to donate corneas after death, their body should not have to be brought to Kathmandu for the extraction. Similarly, if a patient like me needs a transplant they should not have to travel all the way from Syangja to Tilganga,” says Sabin Bogati. 

Bogati had a congenital eye defect, but there are many other causes for corneal blindness, including abrasion, injury, infection, cataract and other less common dystrophies that affect 0.32% of Nepalis. 

And at the current pace of progress, Bogati is optimistic that all Nepalis will soon have the same level of eye care. He adds: “I hope I can see that day with my own eyes.”

Extract from Sabin Bogati’s speech at a memorial service for cornea donors on 10 June, 2023:

All credit for the education and opportunities I have received to this day go entirely to my family, my donor, and to Tilganga Institute of Ophthalmology. I will forever remain grateful to Dr Sanduk Ruit and his entire team for completely changing my life. Without their support, I may never have been able to see. 

In the future, if there comes a time when I can donate my own eyes, I will certainly do so, along with donating all other useful organs in my body. 

 Thank you so much.