2013 EYE BANKING STATISTICAL REPORT

Transcription

1 2013 EYE BANKING STATISTICAL REPORT Eye Bank Association of America th Street, N.W. Suite 1010 Washington, DC Phone (202) EBAA. All rights reserved

2 Table of Contents Statistical Report Analysis: Surgical Use and Indications for Corneal Transplant, Statistics from United States Eye Banks Referral Trends, Transplant and Conversion Rates 8 Donor Demographics 15 Eligibility and Suitability for Tissue Intended for Surgery 19 Reasons Released Tissues Were Not Transplanted 33 Outcomes of Tissue Recovered For Transplant 36 Use of Donated Tissue 40 Annual Comparison of the Number of Corneal Transplants Supplied by U.S. Banks 41 Domestic Surgery Use of Intermediate-Term Preserved Tissue 42 Annual Comparison of the Domestic Use of U.S. Supplied Intermediate-Term 45 Preserved Tissue International Use of Intermediate-Term Preserved Tissue 47 Long-Term Preserved Tissue Preservation and Distribution 51 Tissue Processing for Transplant 55 Forwarded Tissue 59 Indications for Corneal Transplant 61 Statistics from International Eye Banks Referral Trends, Transplant and Conversion Rates 70 Donor Demographics 75 Eligibility and Suitability for Tissue Intended for Surgery 78 Reasons Released Tissues Were Not Transplanted 86 Outcomes of Tissue Recovered For Transplant 87 Use of Donated Tissue 89 Domestic Surgery Use of Intermediate-Term Preserved Tissue 90 International Use of Intermediate-Term Preserved Tissue 94 Long-Term Preserved Tissue Preservation and Distribution 97 Tissue Processing for Transplant 101 Forwarded Tissue 104 Indications for Corneal Transplant 105 Eye Banks Submitting Data for the 2012 Statistical Report 112 2

3 Surgical Use and Indications for Corneal Transplant Statistical Report Analysis 2013 Introduction: The 2013 Eye Banking Statistical Report from the Eye Bank Association of America (EBAA) includes information on all 76 U.S. and 10 international member eye banks reporting data for the calendar year 2013, and represents an essentially complete picture of eye banking activity of the eye banks in the United States. For details on the history and methodology of the reporting process and information on EBAA Connect, please refer to the Overview from the 2012 EBAA Statistical Report Analysis. Utilization of Tissue: Domestic eye banks for 2013 reported an increase in total number of donors (62,274, 5.2%) and total globes/corneas donated (123,079, 5.2%) compared to Utilization of tissue supplied by U.S. eye banks for both domestic and international use is shown in Table 1: Use of Donated Tissues. Total grafts (72,736) were up 5.9% in While penetrating keratoplasty numbers were flat (36,998, up 0.8%), more tissue was used for endothelial keratoplasty (EK) (27,298, up 12.4%) and for lamellar keratoplasty (ALK) (2,009, up 8.3%) in 2013 than in There was no significant change in the number of corneas used for KLA or keratoprosthesis. Table 1: Use of U.S. Donated Tissues Distribution Corneal Grafts Total 72,736 68,681 67,590 59,271 59,784 Penetrating Keratoplasty 36,998 36,716 36,144 21,970 23,269 Anterior Lamellar Keratoplasty 2,009 1,855 1,778 1, Endothelial Keratoplasty 27,298 24,277 23,287 19,159 18,221 Keratolimbal Allograft Keratoprosthesis (K-Pro) Glaucoma Shunt Patch or other nonkeratoplasty use Other keratoplasty (experimental surgery) Unknown or Unspecified 1,068 1,554 2, Sclera 3,693 3,497 5,507 6,746 7,634 Long-Term Preserved Corneas 4,840 5,095 4,409 3,518 2,053 Keratoplasty Glaucoma Shunt Patching 4,040 4,435 3, Other Surgical Uses Research 17,384 19,320 19,230 17,260 14,547 Training 7,451 6,850 6,940 5,726 7,113 3

4 Domestically, the number of PKs performed continued to decrease in 2013 (20,954, -2.2%). See Table 2 and Figure 1: Domestic Surgery Use of U.S. Supplied Intermediate Term Preserved Tissues below. At the same time, the number of corneas used for endothelial keratoplasty (24,987, 8.4%) and ALK (951, 7.7%) increased in Endothelial keratoplasty is now the most common keratoplasty procedure performed in the United States. Table 2: Domestic Use of Intermediate-Term Preserved Tissues Annual Comparison Domestic Surgery Use Penetrating Keratoplasty 20,954 21,422 21,620 21,970 23,269 32,524 34,806 37,776 42,063 Endothelial Keratoplasty 24,987 23,049 21,555 19,159 18,221 17,468 14,159 6,027 1,398 Anterior Lamellar Keratoplasty , , Keratolimbal Allograft Figure 1: Domestic Surgery Use of U.S. Supplied Intermediate Term Preserved Tissues The frequency of PK, EK and ALK use is shown in Figure 2: Domestic PK vs. EK vs. DALK. The number of DMEK procedures has more than doubled (1,522, up 103.5%), and figures 3 ( Domestic DSEK trend) and 4 ( Domestic DMEK Trend) suggest increased interest in DMEK as an endothelial keratoplasty procedure. 4

5 Figure 2: Domestic PK vs. EK vs. ALK Surgery Trends Figure 3: Domestic DSEK Trend Figure 4: Domestic DMEK Trend Domestic DMEK Trend - U.S. Eye Banks Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Indications for Transplant: Since 2011, the most frequent indication for transplant noted has been unknown ; the indications for transplant of all 66,305 corneas accounted for in the system are shown in Table 3: Indications for Corneal Transplant Reported by US Banks, on page 61 of the report. Table 4 below shows the data in table 3 condensed into four basic categories that now dictate the procedure performed: 1) endothelial cell failure, 2) stromal or full thickness (non-endothelial) disease, 3) regrafts and 4) unknown. Within these categories, Fuchs dystrophy was the most common indication for keratoplasty in 2013 (14,153, 21.3%). Post cataract surgery edema was second (8,244, 12.4%) and keratoconus (6,894, 10.4%) was third. Repeat transplants were fourth (6,585, 9.9%). 5

6 Table 4: Indications for Transplant Endothelial Cell Failure Surgical Diagnosis PK ALK EK TOTAL A Post-cataract surgery 3, % , % 8,244 edema C Fuch's Dystrophy 1, % , % 14,153 M Other causes of 1, % , % 4,112 endothelial dysfunction Subtotal 5, % 0 0% 20, % 26, % of PK 75.7% of EK 40.0% of total Stromal or Full Thickness (non-endothelial) Disease Surgical Diagnosis PK ALK EK TOTAL B Keratoconus 6, % % ,894 E Other Degenerations 1, % % ,911 of Dystrophies F Post-refractive % % Surgery G Microbial Changes % % H Mechanical or 1, % % ,197 Chemical Trauma I Congenital Opacities % % J Pterygium % % K Non-infectious 1, % % ,137 ulcerative keratitis or perforations L Other causes of 3, % % ,301 corneal dysfunction or distortion Subtotal 14, % 1, % 0 0% 16, % of PK 56.6% of ALK 24.3% of total D Regraft Surgical Diagnosis PK ALK EK TOTAL Repeat Corneal 4, % % 2, % 6,585 Transplant 11.5% of PK 1.9% of ALK 8.4% of EK 9.9% of Total Unknown / Unspecified Surgical Diagnosis PK ALK EK TOTAL Z. Unknown, unreported, 11, % % 4, % 17,085 or unspecified 32.2% of PK 41.4% of ALK 15.9% of EK 25.8% of Total PK ALK EK TOTAL Total for Each Procedure 36, % 2, % 27, % 66,305 6

7 Forty per cent of all keratoplasty procedures were performed for endothelial failure (Fuchs, post cataract surgery edema and other caused of edema). Of this 40%, there were 20,662 EKs (77.9%) and 5,847 PKs (22.1%). 24.3% of keratoplasty procedures were performed for stromal or full thickness disease; 92.9% were PKs and 7.1% were ALK. For keratoconus, there were 6,215 (90.2%) PKs and 679 (9.8%) DALKs performed. There were 6,585 (9.9%) regrafts performed: regraft rates were 1.9% for ALK, 8.4% for EK and 11.5% for PK. Of concern is the 25.8% unknown diagnosis submitted for all keratoplasty procedures, which could skew the data in any direction and limit the significance of conclusions drawn. The unknowns are mostly internationally distributed tissue and should have the profile of internationally used tissue. Conclusions: 1) Endothelial keratoplasty was the most common U.S. keratoplasty procedure in ) 40% of all keratoplasty procedures were for endothelial disease in ) EK increased 9.2% in 2013 while PK numbers were essentially unchanged. a) DMEK increased 103.5%, from 748 in 2012 to 1,522 in 2013 b) DSEK increased 5.2%, from 22,301 in 2012 to 23,465 in ) The number of penetrating keratoplasty procedures with tissue in intermediate-term storage medium was essentially unchanged in ) There was no significant change in KLA or keratoprosthesis numbers in ) The number of keratoplasty procedures reported as Unknown continues to be a significant surgeon induced source of error in the statistical reporting process and may be improved by implementing a recipient registry. Woodford S. Van Meter, MD Professor of Ophthalmology University of Kentucky Medical Director Lions Eye Bank of Lexington 7

8 2013 Eye Banking Statistics Reported by U.S. Banks: Death Referrals and Tissue Recoveries 76 U.S. Eye Banks Reporting Donations Number of Eye Banks Reporting Total Whole Globes and Corneas Donated 123, , , , ,289 Total Number of Donors 62,274 59,221 57,835 55,913 53,786 Death Referrals Total Death Referrals 738, ,479 Death referrals determined eligible 168, ,688 Tissue Recoveries Total Donors 62,274 59,221 Donors recovered not found on donor registry or known to have first person consent 32,628 33,016 Donors recovered found on donor registry or known to have first person consent 29,646 26,205 Eyes or Corneas Recovered with Intent for Surgical Use 110, ,774 Eyes or Corneas Recovered for Other Uses 12,714 13,216 Using the number of corneas recovered for transplant use as a measure of eye bank size, a trend of eye bank growth is evident. While the number of corneas recovered for transplant use grew by nearly 7,000 between 2012 and 2013, it is evident that the two largest eye banks were responsible for nearly half of this growth. 79 U.S. banks reported data in 2011, 80 eye banks reported data in 2012, and 76 eye banks reported data in The change in 2013 did not reflect that there were fewer eye banks, rather that a series of associated eye banks began reporting as one entity. The remaining half of the growth was distributed over the mid-tier eye banks. The average number of corneas recovered for transplant per eye bank rose by 44 between 2011 and 2012, but rose by 155 between 2012 and In the second year of reporting data using the same system as U.S. domestic eye banks, 10 international EBAA member eye banks reported data in 2013, compared to 8 in The average number of corneas recovered per eye bank decreased by 169 between 2012 and 2013, indicative of induction of smaller eye banks into the EBAA. 8

9 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Comparison of Eye Bank Cornea Recovery Rates 76 U.S. Eye Banks Reporting Recovered Corneas < , ,001-2, ,001-3, ,001-4, ,001-5, ,001-6, ,001-7, ,001-8, ,001-9, ,001-10, >10, Avg. Corneas Recovered for Transplant

10 2013 Eye Banking Statistics Reported by U.S. Banks: Referral Trends, Transplant and Conversion Rates 76 U.S. Eye Banks Reporting U.S. Eye Banks Month Transplant Rate Conversion Rate Death Referrals Transplant Eligible Referrals Transplant Intended Corneas Recovered Jan % 31.7% Feb % 30.4% Mar % 30.7% Apr % 32.5% May % 32.1% Jun % 33.9% Jul % 34.1% Aug % 34.8% Sep % 34.5% Oct % 35.2% Nov % 35.8% Dec % 31.5% Total 66.5% 30.1% Total 66.2% 31.7% Total 65.9% 33.0% Avg. N/A N/A Std. Dev. 1.0% 1.8% *Transplant rate is the number of corneas used for transplant divided by the number recovered for transplant. Conversion rate is the number of transplant donors divided by the number of transplant eligible referrals. 10

11 2013 Eye Banking Statistics Reported by U.S. Banks: Referral Trends, Transplant and Conversion Rates 76 U.S. Eye Banks Reporting 11

12 2013 Eye Banking Statistics Reported by U.S. Banks: Referral Trends, Transplant and Conversion Rates 76 U.S. Eye Banks Reporting 12

13 2013 Eye Banking Statistics Reported by U.S. Banks: Transplant and Conversion Rates 76 U.S. Eye Banks Reporting 13

14 2013 U.S. Eye Banking Statistics: Analysis of Referrals, Transplant & Conversion Rates 76 U.S. Eye Banks Reporting In the U.S., the rate of death referrals ranged between roughly 56,000 and 68,000 per month with the exception of December 2011 (80,590), December 2012 (71,399), and January 2013 (74,396). This showed a small trend of spiking death referral activity annually during cold months (perhaps related to winter season pathogens like influenza). Not surprisingly, the pattern of referrals determined eligible for transplant roughly matched the pattern of referrals received. However, in December 2011 and December 2013, the magnitude of the spike in referrals determined eligible was smaller than the magnitude of the spike of referrals received. This demonstrated that in periods of reduced surgical demand, eye banks may change medical criteria temporarily to stem the flow of transplant tissue that could expire rather than be used for transplant. Throughout 2013, the conversion rate of eligible death referrals into donors continually increased until the holiday season (December). The conversion rate trends repeatedly demonstrate how eye banks reduced supply of tissue during periods of reduced surgical activity. The conversion rate, defined as the number of transplant donors recovered from transplant eligible referrals, declined both in December 2011 and December In December 2012, the surgical demand in the U.S. did not decline as dramatically as in December 2011 and December The U.S. transplant rate decreased slightly in During this time period, no significant new eligibility criteria changes by the EBAA or FDA occurred. Eye banks recovered more tissue intended for transplant in 2013 and did so from an increased rate of upper age ranges. In mid-2011, the Ultrio test for HIV/HBV/HCV NAT, a triplex test, began to replace the HIV/HCV NAT duplex testing, introducing HBV NAT into the testing regime (at least partially). In 2013, West Nile Virus NAT testing began to appear on some eye donors shared with tissue banks. There was an increased rate of positive serological tests, dementia found by medical record, stromal infiltrates, and processing damage in A trend of donors with known donor registry documentation continued to increase, while those with no known donor registration decreased. As eye banks increase use of donor registration as consent to recover tissue, this established a trend in which donor registration may exceed next-of-kin consent by This was an expected outcome of eye banks applying donor registry as consent more actively since Donor registry accounted for 47.6% of donors in the U.S. (up from 44.2% in 2012), compared with 3.5% at international banks. Referral rate, transplant rate, and conversion rate values are not comparable between U.S. banks and international banks due to the vastly different social influences and developmental stages of eye banking, as well as significantly different sample sizes. One international bank reported referral data for only 3 months. The two new international eye banks only submitted partial data for the year, since they became EBAA members mid-year. Useful analysis of referral activity was significantly hindered by this limited reporting. Conversion rate by the reporting international eye banks found a new plateau in 2013 around 64%, while transplant rate vacillated around 65%, a value comparable to U.S. eye banks. 14

15 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Donors by Age Reported by U.S. Banks 76 U.S. Eye Banks Reporting Age <1 Age 1-10 U.S. Eye Banks - Age Profile Age Age Age Age Age Age Age Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Total Monthly Avg Std. Dev Age >80 15

16 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Donors by Age Reported by U.S. Banks 76 U.S. Eye Banks Reporting Age Under One Year % % Age % % Age , % 1, % Age , % 2, % Age , % 3, % Age , % 7, % Age , % 14, % Age , % 19, % Age , % 7, % Over 80 2, % 1, % Total Donors by Age 62,274 59,221 16

17 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Donors by Gender Reported by U.S. Banks 76 U.S. Eye Banks Reporting U.S. Eye Banks - Sex Profile Month Male Female Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Total Monthly Avg Std. Dev Donor Sex Profile - U.S. Eye Banks 39% Male 61% Female 17

18 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Cause of Death Reported by U.S. Banks 76 U.S. Eye Banks Reporting U.S. Eye Banks - Cause of Death Profile Month Heart Cancer CVA Respiratory Trauma Other Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Total Monthly Avg Std. Dev

19 2013 Eye Banking Statistics Reported by U.S. Banks: Reasons Tissue Intended for Surgery Was Not Released 76 U.S. Eye Banks Reporting There are several reasons why tissue intended for surgery may not ultimately be used for surgery. These include positive serology results, defects noted at the time of evaluation (scars, infiltrates, low cell counts, etc.) and/or medical or social history information, all of which occur subsequent to initial screening and procurement. Contraindications for Transplant Positive or Reactive Test for Communicable Disease Agent or Disease 9, % 9, % Anti-HIV-1/ % % HIV-1 Nucleic Acid Test Positive % % Anti-HCV 2, % 1, % Hepatitis C Nucleic Acid Test Positive % % Hepatitis B Surface Antigen (HBsAg) Positive % % Hepatitis B Core (HBcAb) Positive 4, % 4, % Syphilis Positive % % HTLV Antibody (HTLV I/II Ab) % % Other Positive Serology % % Other Communicable Disease Testing Issue % % Medical Record or Autopsy Findings 7, % 6, % Dementia % % Sepsis 3, % 3, % Sepsis - (determined by positive blood cultures) % % Sepsis - (determined by other indicators) 2, % 2, % Plasma Dilution % % Unknown Cause of Death % % Medical Record or Autopsy Findings: Other 1, % 1, % Medical/Social Interview 2, % 2, % Travel Questions % % Dementia / Neurological Issues % % Medical/Social Interview: Other 1, % 1, % Body Exam % % Total eyes/corneas intended for transplant but not released for transplant 32,456 30,185 1 Some tissues had multiple contraindications. 19

20 2013 Eye Banking Statistics Reported by U.S. Banks: Reasons Tissue Intended for Surgery Was Not Released 76 U.S. Eye Banks Reporting Contraindications for Transplant (continued) Tissue Suitability (e.g. slit lamp/spec eval) 12, % 12, % Epithelium % % Stroma 5, % 5, % Prior reactive surgery % % Scar 1, % 1, % Infiltrate 2, % 2, % Foreign Body % % Other 1, % 1, % Descemet s membrane % % Endothelium 5, % 6, % Quality Issue % % Storage % % Labeling % % Processing % % Supply or Reagent % % Environmental Control % % Other Reason prior to Tissue Release 2, % 2, % Total eyes/corneas intended for transplant but not released for transplant 32,456 30,185 20

21 2013 Eye Banking Statistics Reported by U.S. Banks: Reasons Tissue Intended for Surgery Was Not Released 76 U.S. Eye Banks Reporting 21

22 Analysis of the Reasons Tissue Intended for Surgery Was Not Suitable for Transplant 76 U.S. Eye Banks Reporting Month All Reasons Not Released U.S. Eye Banks: Not Released for Transplant (Overview) Serology Tests Testing Issue Medical Record/ Autopsy Finding Medical / Social History Finding Body Exam Tissue Suitability Quality Issue Other Reason Jan % 8.4% 0.3% 7.0% 2.1% 0.2% 12.1% 0.4% 2.3% Feb % 9.3% 0.4% 6.0% 2.1% 0.2% 12.1% 0.6% 1.6% Mar % 8.7% 0.6% 7.0% 1.7% 0.1% 12.2% 0.6% 1.9% Apr % 8.7% 0.3% 6.3% 2.0% 0.2% 11.3% 0.3% 2.5% May % 9.0% 0.4% 6.4% 1.9% 0.1% 9.6% 0.3% 2.7% Jun % 9.1% 0.3% 6.0% 2.1% 0.1% 10.2% 0.3% 2.3% Jul % 8.9% 0.2% 7.2% 1.7% 0.3% 11.4% 0.4% 1.6% Aug % 8.3% 0.2% 6.2% 1.8% 0.1% 10.8% 0.3% 1.7% Sep % 9.1% 0.3% 6.3% 2.0% 0.2% 11.5% 0.3% 1.8% Oct % 8.6% 0.6% 6.2% 2.1% 0.1% 10.7% 0.4% 2.1% Nov % 8.2% 0.3% 6.5% 2.1% 0.3% 11.4% 0.3% 2.3% Dec % 8.8% 0.2% 6.4% 2.2% 0.2% 11.4% 0.3% 2.2% 2011 Avg. 29.0% 8.2% 0.2% 6.7% 1.7% 0.2% 11.0% 0.5% 0.5% 2012 Avg. 29.1% 8.9% 0.3% 6.5% 2.1% 0.3% 11.9% 0.4% 2.2% 2013 Avg. 29.4% 8.7% 0.3% 6.5% 2.0% 0.2% 11.2% 0.4% 2.1% Std. Dev. 0.9% 0.3% 0.1% 0.4% 0.2% 0.1% 0.8% 0.1% 0.4% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" When reviewing information on tissue not released for transplant, percentages must be used to identify trends, since raw numbers vary too much with recovery rates. Percentages are calculated by dividing the number of corneas not released for any given reason by the number of corneas recovered for transplant use. In the U.S., tissue not released due to serologic testing decreased 0.2% (about 400 additional seropositive donors with about 6,600 more donors recovered for transplant). Between 2012 and 2013, the only category that increased appreciably was serologic testing. Tissue suitability decreased significantly (0.7%), but did not fall to the same level as in Other categories remained similar in magnitude to the rates in The most striking change in this data (in the U.S.) between 2011 and 2012 was due to "other reasons." The values for "other reasons" spiked to a new plateau in January 2012 and continued at the new level from that point forward. A change in the staff that collected data, resulting in a different interpretation and reporting, or that there was an unreported specific influence on the release of donor tissue at several banks appeared to have occurred. Whatever the inexplicable cause, the trend remained the same throughout

23 Comparing U.S. and international banks, a few notable differences are apparent. The U.S. does not release tissue for transplant due to serologic testing in 2013 at a rate of 8.7%, while international banks report the same occurrence at 6.0%. Interestingly, the U.S. and international eye banks experienced the same rate of increase in positive serologic testing as a percentage of tissue recovered for transplant use. Other comparisons include medical record or autopsy findings (6.5% in the U.S., 4.0% internationally), medical/social history findings (2.0% in the U.S., 3.6% internationally), tissue suitability (11.2% in the U.S., 10.2% internationally), quality reasons (0.4% in the U.S., 1.1% internationally), and "other reasons" (2.1% in the U.S., 6.6% internationally). Notably, as U.S. eye banks increase the rate of donor recovery using donor designation, the rate of finding tissue ineligible due to medical/social interview findings has not increased. 23

24 Analysis of the Reasons Tissue Intended for Surgery Was Not Suitable for Transplant 76 U.S. Eye Banks Reporting Month Reasons Tissue Recovered for Transplant Not Used for Transplant U.S. Eye Bank Data Subset: Serologic Testing All Serology Tests HIV Ab HIV NAT HBsAg HBcAb HCV Ab HCV NAT Syphilis HTLV Ab Other Test Jan % 0.2% 0.1% 0.7% 4.1% 2.0% 0.6% 0.4% 0.2% 0.2% Feb % 0.1% 0.1% 0.6% 4.4% 2.1% 1.0% 0.4% 0.2% 0.4% Mar % 0.2% 0.1% 0.7% 4.0% 1.8% 0.9% 0.4% 0.3% 0.3% Apr % 0.1% 0.0% 0.5% 4.5% 2.0% 0.7% 0.3% 0.2% 0.5% May % 0.1% 0.0% 0.8% 4.1% 2.2% 0.7% 0.3% 0.3% 0.5% Jun % 0.1% 0.1% 1.0% 4.4% 1.7% 0.7% 0.4% 0.2% 0.5% Jul % 0.1% 0.2% 0.8% 4.3% 1.8% 0.7% 0.4% 0.2% 0.4% Aug % 0.3% 0.1% 0.7% 3.6% 1.8% 0.7% 0.4% 0.2% 0.6% Sep % 0.1% 0.0% 0.6% 4.7% 1.9% 0.7% 0.3% 0.2% 0.6% Oct % 0.2% 0.1% 0.7% 4.5% 1.6% 0.5% 0.3% 0.2% 0.6% Nov % 0.1% 0.1% 0.9% 3.7% 1.7% 0.5% 0.4% 0.2% 0.7% Dec % 0.2% 0.1% 0.7% 4.3% 1.6% 0.6% 0.3% 0.2% 0.8% 2011 Avg. 8.2% 0.2% 0.2% 0.7% 3.5% 1.9% 0.7% 0.3% 0.3% 0.3% 2012 Avg. 8.9% 0.2% 0.1% 0.8% 4.2% 1.9% 0.6% 0.3% 0.2% 0.5% 2013 Avg. 8.7% 0.2% 0.1% 0.7% 4.2% 1.8% 0.7% 0.4% 0.2% 0.5% Std. Dev. 0.3% 0.1% 0.0% 0.1% 0.3% 0.2% 0.1% 0.1% 0.0% 0.2% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" In the U.S., positive serologic testing for hepatitis B decreased slightly between 2012 (5.0%) and 2013 (4.8%). The rate is still higher than in 2011 (4.2%). Internationally, the rate of hepatitis B positive donors increased between 2012 (3.2%) and 2013 (3.7%). HBV NAT testing as a reason for not releasing tissue for transplant was not measured in 2011 through 2013, but will be an independent measure in Trends for Hepatitis C, syphilis, and HIV tests, remained flat (within 0.1% change) in the U.S. International banks reported a drop in HCV positive donors between 2012 (1.7%) and 2013 (1.1%). U.S. banks reported an increasing trend in "other tests" as a reason for not releasing tissue for transplant. This is a result of increased use of HBV NAT and WNV NAT testing. 24

25 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Reasons Tissues Were Not Released 76 U.S. Eye Banks Reporting 25

26 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Reasons Tissues Were Not Released 76 U.S. Eye Banks Reporting Month Reasons Tissue Recovered for Transplant Not Used for Transplant U.S. Eye Bank Data Subset: Medical Record and Autopsy All Medical Record Dementia / Neuro Sepsis (Cultures) Sepsis (Other) Plasma Dilution Unknown Cause of Death Other Jan % 0.7% 1.0% 2.8% 0.4% 0.5% 1.7% Feb % 0.6% 0.8% 2.2% 0.5% 0.4% 1.6% Mar % 0.5% 0.8% 2.8% 0.6% 0.5% 1.9% Apr % 0.5% 0.9% 2.4% 0.4% 0.5% 1.6% May % 0.4% 0.7% 2.3% 0.5% 0.5% 2.0% Jun % 0.5% 0.8% 2.2% 0.4% 0.6% 1.5% Jul % 0.7% 1.1% 2.8% 0.4% 0.4% 1.8% Aug % 0.7% 0.9% 2.4% 0.3% 0.5% 1.4% Sep % 0.6% 0.9% 2.3% 0.4% 0.5% 1.6% Oct % 0.7% 0.8% 2.1% 0.4% 0.5% 1.8% Nov % 0.7% 0.9% 2.3% 0.3% 0.2% 2.2% Dec % 0.7% 0.9% 2.0% 0.4% 0.3% 2.1% 2011 Avg. 6.7% 0.5% 0.9% 2.3% 0.4% 0.5% 2.0% 2012 Avg. 6.5% 0.5% 0.8% 2.4% 0.3% 0.4% 1.9% 2013 Avg. 6.5% 0.6% 0.9% 2.4% 0.4% 0.4% 1.8% Std. Dev. 0.4% 0.1% 0.1% 0.3% 0.1% 0.1% 0.2% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 26

27 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Reasons Tissues Were Not Released 76 U.S. Eye Banks Reporting Trends for medical record or autopsy findings as a reason for not releasing tissue for transplant between 2012 and 2013 remained the same in the U.S., but decreased significantly as reported by international banks (5.1% and 4.0%, respectively). Through networking with other eye bank professionals, there is potential that the value of "unknown cause of death" may be decreased. Further, more effective use of electronic medical record access prior to recovery may aid in decreasing all of these incidences. Use of a more recently developed clinical test for bacterial sepsis, procalcitonin, has been increasing in U.S. hospitals. This may be a laboratory value of interest for eye banks to review during screening of potential donors, to aid in the reduction of recovering donor tissue later determined ineligible due to sepsis. Reasons Tissue Recovered for Transplant Not Used for Transplant U.S. Eye Bank Data Subset: Medical & Social History Month All Medical / Social History Travel Dementia / Neuro Other Jan % 0.2% 0.2% 1.7% Feb % 0.3% 0.3% 1.4% Mar % 0.3% 0.3% 1.2% Apr % 0.3% 0.2% 1.5% May % 0.3% 0.2% 1.4% Jun % 0.3% 0.2% 1.6% Jul % 0.3% 0.2% 1.2% Aug % 0.2% 0.1% 1.5% Sep % 0.3% 0.1% 1.7% Oct % 0.4% 0.2% 1.6% Nov % 0.3% 0.1% 1.7% Dec % 0.3% 0.2% 1.7% 2011 Avg. 1.7% 0.3% 0.1% 1.3% 2012 Avg. 2.1% 0.3% 0.2% 1.6% 2013 Avg. 2.0% 0.3% 0.2% 1.5% Std. Dev. 0.2% 0.1% 0.1% 0.2% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 27

28 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Reasons Tissues Were Not Released 76 U.S. Eye Banks Reporting Tissue not released due to medical/social history findings was limited by the fact that when a donor risk assessment interview was performed prior to recovery and reveals information that determines a donor ineligible, the tissue was most often not recovered for transplant. Reducing instances of recovering prior to having the completed interview reduced the occurrence of these reported values, since only recovered tissue is reported. Increased use of donor registry as consent for donation has not demonstrated an increase in donor tissue found ineligible after recovery. The data reported by U.S. and international banks differed greatly. In the U.S., despite recovery using donor registry, there was a significantly lower occurrence of this reason compared to international banks (2.0% in the U.S., 3.6% at international locations). International banks reported travel exclusionary reasons at a rate twice that reported by the U.S., while dementia and neurological reasons were reported by U.S. banks as half that of the international reasons. "Other" reasons found in the donor risk assessment interview were 2.5% at international banks, compared with 1.5% in the U.S. in This suggested varied interview questions and methods, as there was no standard interview tool available during this period. Adoption of the Donor Risk Assessment Interview tool, developed in collaboration between AOPO, AATB, and the EBAA has endured slow adoption in the U.S. Other factors influencing the difference in the U.S. and international eye bank data were social, cultural, economic, and demographic. 28

29 Month 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Reasons Tissues Were Not Released 76 U.S. Eye Banks Reporting Reasons Tissue Recovered for Transplant Not Used for Transplant U.S. Tissue Suitability Data Subset All Tissue Suitability Reasons Epithelium Prior Refractive Surgery Scar Infiltrate Foreign Body Other Stromal Finding Descemet's Membrane Endothelium Jan % 0.6% 0.4% 1.4% 2.6% 0.1% 0.9% 0.4% 5.7% Feb % 0.2% 0.3% 1.3% 2.3% 0.2% 1.2% 0.2% 6.4% Mar % 0.3% 0.3% 1.3% 2.5% 0.2% 1.1% 0.3% 6.3% Apr % 0.2% 0.4% 0.9% 2.7% 0.1% 1.1% 0.5% 5.4% May % 0.2% 0.4% 1.1% 2.3% 0.2% 0.8% 0.1% 4.5% Jun % 0.1% 0.4% 1.1% 2.7% 0.2% 0.9% 0.3% 4.6% Jul % 0.2% 0.4% 1.1% 2.6% 0.2% 0.9% 0.4% 5.5% Aug % 0.2% 0.3% 1.0% 2.6% 0.2% 1.1% 0.3% 5.1% Sep % 0.3% 0.4% 1.3% 2.6% 0.2% 1.1% 0.3% 5.3% Oct % 0.3% 0.6% 1.3% 2.2% 0.1% 0.9% 0.4% 5.0% Nov % 0.2% 0.3% 1.3% 2.5% 0.1% 1.1% 0.2% 5.6% Dec % 0.1% 0.2% 1.5% 2.9% 0.2% 0.8% 0.2% 5.4% 2011 Avg. 11.0% 0.4% 0.3% 1.0% 2.2% 0.2% 1.0% 0.4% 5.5% 2012 Avg. 11.9% 0.3% 0.3% 1.0% 2.4% 0.2% 1.4% 0.4% 6.0% 2013 Avg. 11.2% 0.3% 0.4% 1.2% 2.5% 0.2% 1.0% 0.3% 5.4% Std. Dev. 0.8% 0.1% 0.1% 0.2% 0.2% 0.0% 0.2% 0.1% 0.6% 29

30 2013 Eye Banking Statistics: Analysis of Tissue Suitability Reasons for Non Release 76 U.S. and 10 International Eye Banks Reporting In the U.S., between 2011 and 2012, there was a significant increase in tissue not released for transplant due to tissue suitability. In 2013, while tissue recovery increased, the rate of tissue not released for transplant due to tissue suitability decreased to near 2011 rates. Endothelium, the most significant portion of this category, decreased (6.0% in 2012 compared with 5.4% in 2013) and a decrease in "other stromal findings" (1.4% in 2012 compared with 1.0% in 2013, were responsible for the largest portions of the overall categorical decrease. Notably, international banks found tissues to have lower quality endothelia and stroma at roughly the same magnitude as American banks (5.1% and 0.7%, respectively). Notable differences between data reported by U.S. banks and international banks were prior refractive surgery and epithelium. American banks reported prior refractive surgery as a reason for not releasing tissue for transplant at a rate of 0.4%, while international banks reported this reason at a rate of 0.2% in Both the U.S. banks and the international banks noted a modest increase of 0.1%. While the difference was not great, it may have represented a difference in the rate at which the general population in the U.S. had a history of prior refractive surgery compared with the rate in the international banks' locales. Epithelium was reported at 1.0% by international banks and 0.3% by U.S. banks. At the time of this report, there was no reasonable explanation for this value, though possible explanations may be related to values not measured by the EBAA (e.g. death to preservation interval or death to cooling interval). 30

31 2013 Eye Banking Statistics Reported by U.S. Banks: Quality Issues 76 U.S. Eye Banks Reporting Month Reasons Tissue Recovered for Transplant Not Used for Transplant U.S. Eye Bank Data Subset: Quality Issues and Other Reasons All Quality and Other Issues Storage Issue Labeling Issue Processing Issue (before release) Supply or Reagent Issue Environmental Control Issue Body Exam Other Serologic Testing Issue Jan % 0.1% 0.0% 0.3% 0.0% 0.0% 0.2% 0.3% 2.3% Feb % 0.2% 0.0% 0.3% 0.1% 0.0% 0.2% 0.4% 1.6% Mar % 0.1% 0.0% 0.3% 0.1% 0.1% 0.1% 0.6% 1.9% Apr % 0.1% 0.0% 0.2% 0.1% 0.0% 0.2% 0.3% 2.5% May % 0.1% 0.0% 0.1% 0.0% 0.0% 0.1% 0.4% 2.7% Jun % 0.0% 0.0% 0.1% 0.1% 0.0% 0.1% 0.3% 2.3% Jul % 0.1% 0.0% 0.2% 0.0% 0.1% 0.3% 0.2% 1.6% Aug % 0.1% 0.0% 0.2% 0.0% 0.0% 0.1% 0.2% 1.7% Sep % 0.1% 0.1% 0.2% 0.0% 0.0% 0.2% 0.3% 1.8% Oct % 0.1% 0.0% 0.2% 0.0% 0.0% 0.1% 0.6% 2.1% Nov % 0.0% 0.0% 0.2% 0.0% 0.0% 0.3% 0.3% 2.3% Dec % 0.1% 0.0% 0.1% 0.1% 0.0% 0.2% 0.2% 2.2% Other Issue 2011 Avg. 1.4% 0.2% 0.0% 0.1% 0.1% 0.0% 0.2% 0.2% 0.5% 2012 Avg. 3.1% 0.1% 0.0% 0.2% 0.0% 0.0% 0.3% 0.3% 2.2% 2013 Avg. 3.0% 0.1% 0.0% 0.2% 0.0% 0.0% 0.2% 0.3% 2.1% Std. Dev. 0.4% 0.0% 0.0% 0.1% 0.0% 0.0% 0.1% 0.1% 0.4% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 31

32 2013 Eye Banking Statistics Reported by U.S. Banks: Quality Issues 76 U.S. Eye Banks Reporting Regarding the overall rate of not releasing tissue that was recovered for transplant use, quality reasons were not a large portion of the reasons (0.3% in the U.S., 1.2% internationally). This was a testament to the quality assurance and quality control processes employed both in the U.S. and internationally. A great example of this was the rate of not releasing tissue for transplant due to labeling, which was 0.0% (though did account for 44 in the U.S. in 2011, 14 in the U.S. in 2012, 14 in the U.S. in 2013, 0 internationally in 2012, and 5 internationally in 2013). This was remarkable. However, quality reasons, by nature, are often avoidable and may continue to be an area of improvement for eye banks in the U.S. and abroad. By comparison, international banks experienced serologic testing issues twice as frequently as U.S. banks in 2012, but in 2013, while the U.S. banks reported no change in the rate of occurrence of these events, international eye banks reported a drop from 0.6% in 2012 to 0.1% in Storage was a more significant reason for not releasing tissue at international banks than at U.S. banks, by percentage, but represented fewer instances (127 in the U.S. in 2011, 116 in the U.S. in 2012, 101 in the U.S. in 2013, 10 internationally in 2012, and 22 internationally in 2013). As a general comparison, the quality systems of the U.S. and international banks accredited by the EBAA were comparable and worthy of pride. "Other issue" jumped significantly at international eye banks, mostly because of events in December The value of this reason for not releasing tissue rose to 6.6% (360 corneas) in 2013, compared to 5.1% (260 corneas) in In the U.S. this reason dropped to 2.1% in 2013 from 2.2% in 2012, after an initial change in magnitude between 2011 and The interpretation of how to categorize events as "other" appeared to have settled by those performing data collection both in the U.S. and at international banks. 32

33 2013 Eye Banking Statistics Reported by U.S. Banks: Reasons Tissue Intended for Surgery Was Not Suitable for Transplant 76 U.S. Eye Banks Reporting Reasons Released Tissues Were Not Transplanted Transportation Issue % % Surgeon Issue % % Recipient Issue % % Returned and Unable to Place Again % % Donor Information Not Available at the Time of Tissue Release % % Expired or Unable to Place Tissue 3, % 3, % Tissue Damaged During Processing % % Other Reason After Release of Tissue % % Total eyes/corneas released for transplant but not used for transplant 5,182 4,908 33

34 2013 Eye Banking Statistics Reported by U.S. Banks: Reasons Released Tissues Were Not Transplanted 76 U.S. Eye Banks Reporting Month Tissues Released Not Transplanted Transport Issue Surgeon Issue U.S. Eye Banks Recipient Issue Returned Tissue Unable to Place Again Donor Info Received after Release Expired Tissue / Unable to Place Processing Damage after Release Other Reason after Release Jan % 0.1% 0.2% 0.1% 0.3% 0.0% 3.8% 0.6% 0.7% Feb % 0.1% 0.2% 0.1% 0.2% 0.0% 2.7% 0.4% 0.5% Mar % 0.1% 0.1% 0.0% 0.1% 0.0% 2.7% 0.4% 0.6% Apr % 0.1% 0.2% 0.0% 0.2% 0.0% 2.8% 0.5% 0.5% May % 0.2% 0.2% 0.0% 0.2% 0.0% 3.3% 0.4% 0.4% Jun % 0.1% 0.1% 0.0% 0.2% 0.0% 3.1% 0.4% 0.9% Jul % 0.2% 0.2% 0.0% 0.4% 0.0% 2.8% 0.4% 0.5% Aug % 0.1% 0.2% 0.0% 0.4% 0.0% 4.0% 0.5% 0.8% Sep % 0.1% 0.1% 0.0% 0.2% 0.1% 2.9% 0.4% 1.0% Oct % 0.0% 0.1% 0.0% 0.2% 0.1% 2.3% 0.5% 1.1% Nov % 0.1% 0.1% 0.0% 0.3% 0.3% 3.0% 0.5% 0.4% Dec % 0.1% 0.1% 0.0% 0.2% 0.1% 3.8% 0.5% 0.5% 2011 Avg. 4.5% 0.1% 0.2% 0.1% 0.3% 0.0% 3.1% 0.3% 0.4% 2012 Avg. 4.7% 0.1% 0.1% 0.0% 0.3% 0.0% 3.7% 0.4% 0.3% 2013 Avg. 4.7% 0.1% 0.1% 0.0% 0.2% 0.0% 3.1% 0.5% 0.6% Std. Dev. 0.6% 0.0% 0.0% 0.0% 0.1% 0.1% 0.5% 0.1% 0.2% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 34

35 2013 Eye Banking Statistics Analysis of Reasons Released Tissues Were Not Transplanted 76 U.S. and 10 International Eye Banks Reporting Between 2011 and 2012, U.S. eye banks expressed a modest increase in reasons tissues were released but not transplanted (0.2%), but this increasing trend did not continue in 2013, despite an increase in recovered tissue. A notable drop in expired tissue unable to be placed was reported by U.S. and international banks (3.0% in the U.S. 2012, 3.7% in the U.S. in 2013, 4.9% internationally in 2012, and 3.6% internationally in 2013). International banks reported 6.0% of tissue released that did not get transplanted compared to 4.7% in the U.S. in The most significant reason for both U.S. and international banks not transplanting released tissue was expired tissue/unable to place. In 2013, the U.S. reported 24,168 processing events with a total of 726 corneas not transplanted due to processing damage (before and after release), for a rate of 3.0% processing damage (up from 2.1% in 2012). During this same period, international banks reported 451 processing events with a total of 55 corneas not transplanted due to processing damage (before and after release), for a rate of 12.2% processing damage (up from 6.1% in 2012). Interestingly, international banks reported an increase in processing damage, combined with a decrease in processing events, while U.S. banks continue an upward trend in processing events. 3,322 corneas reported by U.S. banks and 198 corneas reported by international banks were not transplanted due to expiration. Additionally, 267 corneas reported by U.S. banks and 53 corneas reported by international banks were returned and unable to place again. Disproportionate to the overall pool of corneas recovered for transplant, the corneas that suffer expiration were of lower tissue quality (though still of transplant suitability). Returned tissue, however, due to the time period to retrieve, test, evaluate, distribute, return, and reevaluate tissue were often of "normal" or high quality, but were not used for transplant due to aging of the tissue (not to be confused with expiration). A large percentage of these corneas could have transplanted with improved pipelines to locations in the world needing tissue of all tissue qualities and may represent an opportunity for either the eye banks or a third party to better aid in seeing tissue to these locations. While access to electronic medical records prior to recovery of tissue or prior to tissue release is on the rise, there is a risk of increasing incidence of released corneas not being transplanted due to information about the donor received after release. This scenario impacted 54 corneas in the U.S. in 2013, up from 12 in The cause is due to late entry of consultations and progress notes in the medical record at the hospital, a relatively commonplace practice that may pose a threat to donor safety. 35

36 2013 Eye Banking Statistics Reported by U.S. Banks: Outcomes of Tissue Recovered for Transplant 76 U.S. Eye Banks Reporting Donations % Change Eye Banks Reported *0.0% Total Whole Globes and Corneas Donated 123, , % Total Number of Donors 62,274 59, % Distribution % Change Intermediate-Term Preserved Corneas 68,526 66, % Sclera 3,693 3, % Long-Term Preserved Corneas 4,840 5,095 (-5.0%) Research 17,384 19,320 (-10.0%) Training 7,451 6, % * 5 Eye Banks now reporting as one corporate entity Outcomes of Tissue Recovered for Transplant - U.S. Eye Banks Month Corneas Recovered for Transplant Corneas Segmented Corneal Segments Produced Not Released Released but Not Transplanted Whole Corneas and Segments Transplanted Preserved Long-Term Jan % % % % Feb % % % % Mar % % % % Apr % % % % May % % % % Jun % % % % Jul % % % % Aug % % % % Sep % % % % Oct % % % % Nov % % % % Dec % % % % 2011 Total % % % % 2012 Total % % % % 2013 Total % % % % 2013 Avg N/A 432 N/A 5704 N/A 358 N/A Std. Dev % % % % *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 36

37 2013 Eye Banking Statistics Reported by U.S. Banks: Outcomes of Tissue Recovered for Transplant 76 U.S. Eye Banks Reporting 37

38 2013 Eye Banking Statistics Reported by U.S. Banks: Outcomes of Tissue Recovered for Transplant 76 U.S. Eye Banks Reporting 38

39 2013 Eye Banking Statistics: Analysis of Outcomes of Tissue Recovered for Transplant 76 U.S. and 10 International Eye Banks Reporting In eye banks that preserve tissue in intermediate-term preservation media at the time of recovery or shortly afterward, tissue recovered with intent for transplant will meet one of four potential outcomes within two weeks. Either tissue will not be released for transplant, be released for transplant but not transplanted, be transplanted, or be preserved in long-term preservation media. As an extreme historical example, in the U.S., a spike in transplanted tissue and tissue not released for transplant in December 2011 was consistent with a spike in tissue recovered for transplant due to a significant rise in referral activity. Total referrals were 27.6% above average, transplanted corneas were 11.8% above average, and tissue not released for transplant was 10.5% above average. Referral activity did not spike as dramatically since. In 2013, a less obvious pattern emerged with minor spikes in long-term preservation of tissue in April due to ASCRS, June due to decreased demand consistent with end of school and onset of summer, and December due to the holidays. In January, the increased recovery of corneas for transplant was complemented with a spike in tissue released, but not transplanted with expired tissue as a spike. In December, tissue released but not transplanted and a decreased rate of recovery were also associated with the holidays. Internationally, similar patterns emerged, with a reduction in transplanted tissue in December. As transplant rate is relatively steady, the trends of data reported by the U.S. banks shows that the surgical use of tissue was predictably and relatively steady as well. Surgical use of tissue was influenced mainly by holidays and ophthalmological society meetings. Due to the smaller sample size, activity at the international banks was more difficult to analyze and showed a greater correlation to transplant rate. At the international banks, it was notable that the decreased demand during December 2012 resulted in a 229% increase in preservation of tissue long-term. This did not repeat in 2013; however the tissue not released for transplant was at its highest level in December at the international banks. 39

40 2013 Eye Banking Statistics Reported by U.S. Banks: Use of Donated Tissues 76 U.S. Eye Banks Reporting Distribution Corneal Grafts Total 72,736 68,681 67,590 59,271 59,784 Penetrating Keratoplasty 36,998 36,716 36,144 21,970 23,269 Anterior Lamellar Keratoplasty 2,009 1,855 1,778 1, Endothelial Keratoplasty 27,298 24,277 23,287 19,159 18,221 Keratolimbal Allograft Keratoprosthesis (K-Pro) Glaucoma Shunt Patch or other nonkeratoplasty use Other keratoplasty (experimental surgery) Unknown or Unspecified ,554 2, Sclera 3,693 3,497 5,507 6,746 7,634 Long-Term Preserved Corneas 4,840 5,095 4,409 3,518 2,053 Keratoplasty Glaucoma Shunt Patching 4,040 4,435 3, Other Surgical Uses Research 17,384 19,320 19,230 17,260 14,547 Training 7,451 6,850 6,940 5,726 7,113 The highlighted numbers reflect tissues distributed and used within the U.S. only. Data for tissue distributed internationally in these years were not collected by surgery type. Data from previous years included U.S. and international distribution of tissues. In 2010, Corneal Grafts Total did not include long-term preserved corneal tissue. In 2011 and beyond, long-term preserved corneal tissue is included in the total. 40

41 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Annual Number of Corneal Transplants Supplied by U.S. Banks 76 U.S. Eye Banks Reporting Year Total Provided Performed in by U.S. U.S ,515 35, ,973 35, ,215 35, ,539 35, ,740 35, ,711 34, ,492 35, ,579 35, ,765 33, ,949 33, ,532 33, ,440 32, ,436 32, ,841 32, ,329 31, ,035 33, ,122 39, ,487 41, ,784 42, ,271 42, ,590 46, ,681 46, ,736 48,229 41

42 2013 Eye Banking Statistics Reported by U.S. Banks: Domestic Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting Intermediate-Term Tissue Domestic Distribution of Source Eye Bank Corneas Intermediate-term preserved corneas processed into corneal segments 2 4 Number of intermediate-term preserved corneas segments produced 4 7 Intermediate-term preserved corneas, corneal segments or whole eyes transplanted in the U.S for: 48,229 46,684 PK 20,954 21,422 Optical or Elective PK 20,651 21,073 Emergency of Full Thickness EK 24,987 23,049 DSEK, DSAEK, DLEK 23,465 22,301 DMEK or DMAEK 1, ALK DALK (Deep Anterior Lamellar Keratoplasty) SALK (Superficial Anterior Lamellar Keratoplasty) Other ALK (e.g. peripheral, eccentric, etc.) KLA Keratoprosthesis (K-Pro) Glaucoma shunt patch or other non-keratoplasty use Other Keratoplasty (e.g. experimental surgery type) 4 43 Unknown or Unspecified

43 2013 Eye Banking Statistics Reported by U.S. Banks: Domestic Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting 43

44 2013 Eye Banking Statistics Reported by U.S. Banks: Domestic Surgery Use of Intermediate-Term Preserved Tissue 44

45 Eye Banking Statistics Reported by U.S. Banks: Domestic Use of Intermediate-Term Preserved Tissues Annual Comparison Domestic Surgery Use Penetrating Keratoplasty 20,954 21,422 21,620 21,970 23,269 32,524 34,806 37,776 42,063 Endothelial Keratoplasty 24,987 23,049 21,555 19,159 18,221 17,468 14,159 6,027 1,398 Anterior Lamellar Keratoplasty , , Keratolimbal Allograft

46 2013 Eye Banking Statistics Reported by U.S. Banks: Domestic Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting Month PK (Optical, Elective) PK (Emerg.) EK (DSEK) EK (DMEK) ALK (DALK) ALK (SALK) ALK (Other) KLA K- Pro Shunt Patch Other Unknown Jan % 0.6% 49.5% 2.2% 1.5% 0.1% 0.0% 0.1% 0.2% 2.1% 0.0% 0.3% Feb % 0.6% 47.8% 2.5% 2.0% 0.2% 0.1% 0.4% 0.5% 1.3% 0.0% 0.3% Mar % 0.5% 47.8% 3.1% 1.9% 0.1% 0.1% 0.3% 0.5% 1.3% 0.0% 0.3% Apr % 0.6% 47.9% 2.6% 1.8% 0.1% 0.1% 0.3% 0.5% 1.6% 0.1% 0.2% May % 0.7% 48.6% 2.6% 2.4% 0.1% 0.1% 0.1% 0.4% 1.4% 0.0% 0.4% Jun % 0.8% 49.3% 2.4% 1.9% 0.1% 0.1% 0.2% 0.5% 1.1% 0.0% 0.3% Jul % 0.5% 49.3% 2.6% 2.1% 0.0% 0.2% 0.2% 0.6% 1.3% 0.0% 0.5% Aug % 0.6% 49.8% 3.3% 1.4% 0.0% 0.2% 0.0% 0.5% 1.5% 0.0% 0.5% Sep % 0.4% 50.8% 3.7% 1.3% 0.1% 0.1% 0.3% 0.4% 0.9% 0.0% 1.9% Oct % 0.5% 50.3% 4.1% 1.5% 0.0% 0.2% 0.2% 0.6% 1.4% 0.0% 1.3% Nov % 0.7% 48.2% 4.5% 1.8% 0.0% 0.1% 0.2% 0.4% 1.2% 0.0% 0.9% Dec % 1.1% 43.0% 4.0% 2.0% 0.0% 0.2% 0.1% 0.4% 1.8% 0.0% 1.8% 20.7% 0.5% 20.8% 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2011 Avg. 45.7% 1.1% 45.9% 0.7% 1.4% 0.1% 0.5% 0.1% 0.7% 1.2% 0.0% 2.4% 2012 Avg. 45.1% 0.7% 47.8% 1.6% 1.6% 0.1% 0.2% 0.2% 0.5% 1.4% 0.1% 0.7% 2013 Avg. 42.8% 0.6% 48.7% 3.2% 1.8% 0.1% 0.1% 0.2% 0.5% 1.4% 0.0% 0.7% Std. Dev. 1.7% 0.2% 2.0% 0.8% 0.3% 0.0% 0.1% 0.1% 0.1% 0.3% 0.0% 0.6% *Percentages read from this table should be read as "of the tissue distributed for transplant use domestically" In 2013, 70.5% of U.S. intermediate-term preserved corneal tissue used for surgery was transplanted in the U.S., the same as in Of the 48,229 corneas distributed to U.S. patients in 2013, information on surgical type was typically known prior to surgery. This number of intermediate-term preserved corneas used for surgery in the U.S. was up from 46,684 in 2012 and 46,196 in Looking at trends of each surgery type one by one, the rate of PK was steady, but down 2.2% from The rate of DSEK continued to slowly climb, up 8.8% from The trend for DMEK shows a linear increase with a slope of one - a continuation of the trend in DALK surgical use of tissue is inconsistent, month to month, but was up 7% in 2013 over In 2012, international banks began reporting using the same ledger as U.S. banks. From the international bank's perspective, "domestic use of tissue" refers to the use of tissue within the country of origin. This provided the EBAA with the ability to compare the activity of surgical use of tissue in a manner analogous to U.S. banks. Due to the lower volume of surgeries reported by international banks, the trends are more susceptible to variation. From the data reported, international banks reported a relatively flat trend of PK use and a 29% increase in DSEK use of tissue within the country of origin. DMEK began to appear in November 2012 and has vacillated around 8 corneas used for DMEK per month. As in the U.S., DALK use of tissue appeared inconsistent. 90.1% of the tissue recovered by international banks was transplanted in the country of origin - a rate of stability very similar to U.S. domestic use of tissue. International banks reported 7.4% of intermediate-term corneas transplanted as "unknown or unreported" surgical type, down from 8.8% in 2012 and compared to 0.7% with U.S. tissue distributed in the U.S. This demonstrated improvement in recipient data collection. 46

47 2013 Eye Banking Statistics Reported by U.S. Banks: International Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting Intermediate-Term Tissue International Distribution of Source Eye Bank Corneas Intermediate-term preserved corneas, corneal segments or whole eyes transplanted internationally for: 20,213 19,546 PK 16,044 15,294 Optical or Elective PK 15,849 15,074 Emergency of Full Thickness EK 2,311 1,976 DSEK, DSAEK, DLEK 2,257 1,957 DMEK or DMAEK ALK 1, DALK (Deep Anterior Lamellar Keratoplasty) SALK (Superficial Anterior Lamellar Keratoplasty) Other ALK (e.g. peripheral, eccentric, etc.) KLA Keratoprosthesis (K-Pro) Glaucoma shunt patch or other non-keratoplasty use Other Keratoplasty (e.g. experimental surgery type) 13 1 Unknown or Unspecified Total intermediate-term preserved corneas, corneal segments, and whole eyes used for KERATOPLASY 67,755 65,554 Total intermediate-term preserved corneas, corneal segments, and whole eyes used for TRANSPLANT 68,526 66,227 47

48 2013 Eye Banking Statistics Reported by U.S. Banks: International Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting 48

49 2013 Eye Banking Statistics Reported by U.S. Banks: International Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting 49

50 2013 Eye Banking Statistics Reported by U.S. Banks: International Surgery Use of Intermediate-Term Preserved Tissue 76 U.S. Eye Banks Reporting Month PK (Optical, Elective) PK (Emerg.) EK (DSEK) EK (DMEK) ALK (DALK) ALK (SALK) ALK (Other) KLA K- Pro Shunt Patch Other Unknown Jan % 1.3% 11.8% 0.1% 2.8% 0.6% 1.1% 0.1% 0.1% 0.9% 0.0% 4.1% Feb % 1.1% 11.1% 0.1% 4.1% 0.4% 0.9% 0.2% 0.3% 0.0% 0.0% 3.8% Mar % 1.1% 10.6% 0.2% 3.3% 0.3% 1.0% 0.0% 0.1% 0.1% 0.0% 3.6% Apr % 1.1% 11.1% 0.2% 3.0% 0.2% 1.5% 0.0% 0.2% 0.0% 0.1% 4.2% May % 0.5% 11.0% 0.1% 4.1% 0.0% 1.4% 0.2% 0.0% 0.1% 0.0% 3.9% Jun % 1.0% 11.1% 0.2% 4.1% 0.1% 1.4% 0.2% 0.0% 0.0% 0.2% 3.1% Jul % 0.9% 12.1% 0.1% 5.9% 0.1% 1.0% 0.1% 0.3% 0.0% 0.1% 3.0% Aug % 0.7% 10.4% 0.0% 5.5% 0.1% 0.6% 0.2% 0.4% 0.1% 0.2% 4.6% Sep % 0.7% 13.7% 0.1% 4.1% 0.4% 1.5% 0.0% 0.1% 0.0% 0.0% 2.8% Oct % 1.1% 13.8% 0.6% 5.7% 0.3% 0.7% 0.1% 0.3% 0.0% 0.0% 2.0% Nov % 0.9% 11.0% 1.1% 3.6% 0.2% 0.6% 0.1% 0.2% 0.0% 0.1% 2.4% Dec % 1.2% 7.3% 0.2% 2.4% 0.2% 0.5% 0.0% 0.1% 0.1% 0.0% 4.6% 20.7% 0.5% 20.8% 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2011 Avg. 77.3% 2.0% 9.4% 0.0% 2.9% 0.5% 1.3% 0.1% 0.1% 0.2% 0.0% 6.1% 2012 Avg. 77.1% 1.1% 10.0% 0.1% 3.7% 0.1% 1.2% 0.1% 0.1% 0.1% 0.0% 6.4% 2013 Avg. 78.4% 1.0% 11.2% 0.3% 4.0% 0.2% 1.0% 0.1% 0.2% 0.1% 0.1% 3.5% Std. Dev. 2.1% 0.2% 1.6% 0.3% 1.1% 0.2% 0.4% 0.1% 0.1% 0.2% 0.1% 0.8% *Percentages read from this table should be read as "of the tissue distributed for transplant use internationally" In 2013, 29.5% of U.S. intermediate-term preserved corneas were sent to international locations and used for surgery. Of the 20,213 U.S. intermediate-term preserved corneas used internationally, 3.5% were reported as "unknown or unreported" surgical type, compared with 0.7% when tissue is used in the U.S. This was attributable to the nature of the scheduled surgery system in the U.S., in which banks usually have the recipient information prior to the surgery. By contrast, when tissue is distributed for international use, banks were not informed of the surgical type in all scenarios. Prior to 2011 and the introduction of the "unknown or unreported" category, this often led to presumptive reporting. The number of intermediate-term preserved corneas sent to international locations was up from 19,546 in 2012 and 18,307 in In 2013, U.S. intermediate-term preserved corneas used for PK rose by 4.9%, while those used for ALK rose by 8.8% and those used for EK rose by 16.9%. A spike in DMEK use at the end of 2013 was comparatively large, but numerically small enough to suggest that this increase was due to use in one or two locations only. DALK use of tissue was similar in volume to DALK in the U.S. and showed a similar pattern of inconsistency. International banks distributed intermediate-term preserved tissue outside of the country of origin far less frequently than U.S. banks, at only 9.9% or 336 reported surgeries. With the order of magnitude of these occurrences, trends were less reliable than in the analogous U.S. tissue scenarios. However, from the international data, intermediate-term preserved corneas sent outside of the country of origin showed a nearly doubled use for PK, steady use for DALK, and more than 50% decrease in DSEK use. There was no reported use for DMEK of corneas recovered by international eye banks and distributed outside of the country of origin. 50

51 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Long-Term Preserved Tissue Distribution 76 U.S. Eye Banks Reporting Long-Term Preserved Tissue Preservation and Distribution Long-term preserved corneas or whole globes PRESERVED for transplant 4,294 2,454 Long-term preserved corneas, corneal segments, or whole globes DISTRIBUTED for: 4,840 5,095 Keratoplasty Glaucoma Shunt patching 4,040 4,435 Other Surgical Uses Long-term preserved corneas, corneal segments, or whole globes FORWARDED to another entity for final distribution Sclera or sclera segments PRESERVED for transplantation 8,452 6,913 Sclera or sclera segments DISTRIBUTED for: 3,693 3,497 Prosthesis following enucleation Glaucoma shunt patching 2,293 2,260 Other surgical uses Sclera or sclera segments FORWARDED to another entity for final distribution 3,935 2,709 For the purpose of ensuring that corneal outcomes may be accurately counted, the data system has been designed to collect information on the number of corneas preserved long term. However, these corneas may be preserved whole or bisected. By contrast, in the data system eye banks were asked to report the number of "sclera or sclera segments" preserved, giving a more accurate count of supply. Neither long-term preserved corneas nor sclera segments counted as preserved were corrected for the number that were discarded or found not suitable. This was important to consider during analysis of the trends. Preservation of corneas in long-term storage media increased by 75% in 2013 over Surgical use of longterm preserved corneas decreased by 5.0% in the same period. International eye banks had a decrease of 27.0% in corneas preserved long-term and a 20.6% decrease in surgical use of long-term preserved corneas in 2013 compared to After a significant increase in use of corneas for glaucoma shunt patching in 2012 compared to 2011, in 2013 that rate dropped by 8.1%, although long-term preserved corneas continue to be the dominant tissue used for this procedure. Internationally, sclera continues to dominate the material of choice for glaucoma shunt patching when compared to long-term preserved corneas data continued to suggest that either glaucoma shunt patching was in significant decline or that use of non-ocular materials for these procedures was on the rise. Comparing the use of sclera to the preservation of sclera, preservation clearly exceeds tissue use, showing that demand was easily met. Since long-term corneal segments were not measured, a similar comparison may not accurately be made regarding long-term preserved cornea preservation and use. 51

52 2013 Eye Banking Statistics Reported by U.S. Banks: Long-Term Preserved Tissue Distribution 76 U.S. Eye Banks Reporting Month Long-Term Preserved Corneas Long Term Tissue Trends Reported by U.S. Eye Banks Long-Term Cornea Use - Keratoplasty Long-Term Cornea Use - Glaucoma Long-Term Cornea Use - Other Scleral Segments Preserved Sclera Use - Prosthesis Sclera Use - Glaucoma Sclera Use - Other Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Total Avg Std. Dev

53 2013 Eye Banking Statistics Reported by U.S. Banks: Long-Term Preserved Tissue Distribution 76 U.S. Eye Banks Reporting 53

54 2013 Eye Banking Statistics Reported by U.S. Banks: Long-Term Preserved Tissue Distribution 76 U.S. Eye Banks Reporting 54

55 2013 Eye Banking Statistics Reported by U.S. Banks: Tissue Processing for Transplant 76 U.S. Eye Banks Reporting Tissue Processing for Transplant Eye Processing (does not include in situ excision) 3,655 5,262 Processed for corneal preservation only 901 3,226 Processed for sclera preservation 2,190 1,900 Processed for other ocular materials Cornea Processing 24,168 22,599 Processed by microkeratome 20,267 18,900 Processed by laser Processed by hand dissection 1, Processed by transfer into long-term preservation 2,582 2,583 Processed by other methods

56 2013 Eye Banking Statistics Reported by U.S. Banks: Tissue Processing for Transplant 76 U.S. Eye Banks Reporting Month Processing - Microkeratome U.S. Eye Banks Processing - Laser Processing - Manual Processing - Long-Term Preservation Processing - Other Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Total Avg Std. Dev

57 2013 Eye Banking Statistics Reported by U.S. Banks: Tissue Processing for Transplant 76 U.S. Eye Banks Reporting 57

58 2013 Eye Banking Statistics Reported by U.S. Banks: Tissue Processing Analysis 76 U.S. and 10 International Eye Banks Reporting As is consistent with the surgical types reported by U.S. banks, DMEK processing by eye banks (manual dissection) rose at a significant rate, though not as much as in DSEK was relatively flat as a surgical type, however microkeratome processing by U.S. banks rose slowly over the course of This suggested that surgeons increasingly rely on U.S. banks for processing tissue for DSEK, though the trend has not yet plateaued. The laser processing trend spiked suddenly in the U.S. eye banks in the last quarter of 2012, then settled to the same rate as has been in place since International eye banks reported minimal laser processing activity in This was consistent with the low volume of this activity in the U.S., suggesting little potential for growth in this area of processing. Microkeratome processing at international banks was disproportionately smaller than at U.S. banks. Given that an eye bank must have enough processing activity to warrant running such a costly program and keeping skilled technicians active, and considering the size of the international eye banks reporting, this was appropriate. Interestingly, manual dissection of tissue reported by international banks was disproportionately higher in 2012, then at U.S. banks, but in 2013, manual processing dropped to near zero. DMEK, reported by international eye banks, rose within the country of origin for each reporting bank (13 DMEK surgeries in 2012, 92 in 2013), but dropped with respect to tissue exported outside of the country of origin to zero in 2013 (from 19 in 2012). U.S. banks have historically trended away from the practice of recovering tissue by enucleation in favor of recovering tissue by in situ excision. International banks continue, by and large, to recover tissue by enucleation nearly three times more often than by in situ excision. Interestingly, at international eye banks, there was growth in enucleation followed by laboratory excision, compared to in situ excision. This is the reverse of the historical trend within the U.S. 58

59 2013 Eye Banking Statistics Reported by U.S. Banks: Forwarded Tissue 76 U.S. Eye Banks Reporting Month Imported Tissue Exported Tissue (to EBAA Accred.) Exported Tissue (to non-ebaa Accred.) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Total Avg Std. Dev

60 2013 Eye Banking Statistics Reported by U.S. Banks: Analysis of Tissue Forwarding Trends 76 U.S. and 10 International Eye Banks Reporting The difference between the number of corneas reported by U.S. banks as imported from another eye bank in the U.S. and those exported to an EBAA accredited entity suggested that a large volume of corneas were distributed from U.S. banks to EBAA accredited entities outside of the U.S. The manner of phrasing of the data system did not create a balance in the data reported by the international banks, since the phrasing suggested the counting of corneas imported from other banks inside the country of each international bank. The U.S. banks reported a trend of decreasing distribution to non-ebaa accredited entities and a simultaneous increase of distribution to EBAA accredited entities. As a sum, exportation to other eye banks (whether accredited or not) was 14,442 in 2011, 14,718 in 2012, and 14,953 in 2013, as reported by U.S. banks. International banks reported a sum of 486 exported corneas in 2012 and 300 in U.S. banks reported an increase in importing activity by 95% in 2013 over 2012, while international banks reported nearly the same volume of activity in 2013 compared to The significant increase in importation in 2013 may be related to a combination of increased demand for eye bank processed tissue and the logistical demands of supplying tissue from multiple locations to a central eye bank for processing. 60

61 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting Indications for Penetrating Keratoplasty A. Post-cataract surgery edema 3, % 3, % B. Keratoconus 6, % 6, % C. Fuchs' Dystrophy 1, % 1, % D. Repeat Corneal Transplant 4, % 4, % E. Other degenerations or dystrophies 1, % 1, % F. Post-refractive surgery % % G. Microbial changes % % H. Mechanical or chemical trauma 1, % 1, % I. Congenital opacities % % J. Pterygium % % K. Non-infectious ulcerative keratitis or perforation 1, % 1, % L. Other causes of corneal dysfunction or distortion (non-endothelial) 3, % 3, % M. Other causes of endothelial dysfunction 1, % 1, % Z. Unknown, unreported, or unspecified 11, % 9, % Total Indications for Penetrating Keratoplasty 36,998 36,716 Indications for Anterior Lamellar Keratoplasty B. Keratoconus % % D. Repeat Corneal Transplant % % E. Other degenerations or dystrophies % % F. Post-refractive surgery % 6 0.3% G. Microbial changes % % H. Mechanical or chemical trauma % % I. Congenital opacities % % J. Pterygium 5 0.2% 3 0.2% K. Non-infectious ulcerative keratitis or perforation % % L. Other causes of corneal dysfunction or distortion % % Z. Unknown, unreported, or unspecified % % Total for Anterior Keratoplasty 2,009 1,855 Indications for Endothelial Keratoplasty A. Post-Cataract Surgery Edema 4, % 4, % C. Fuchs Dystrophy 12, % 11, % D. Repeat Corneal Transplant 2, % 2, % M. Other Causes of Endothelial Dysfunction 2, % 2, % Z. Unknown, unreported, or unspecified 4, % 3, % Total for Endothelial Keratoplasty 27,298 25,025 61

62 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting 62

63 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting Indications for Penetrating Keratoplasty - U.S. Eye Banks Month A B C D E F G H I J K L M Z Jan % 17.6% 3.7% 11.7% 4.4% 0.0% 2.4% 3.1% 2.1% 0.0% 3.1% 11.1% 1.9% 29.3% Feb % 17.3% 3.1% 11.7% 4.4% 0.3% 2.0% 4.1% 1.7% 0.0% 2.7% 10.2% 3.1% 30.7% Mar % 16.4% 3.8% 11.4% 4.5% 0.2% 1.7% 2.8% 2.1% 0.1% 2.7% 10.5% 2.5% 32.8% Apr % 16.9% 2.8% 13.4% 4.4% 0.2% 2.2% 2.6% 2.0% 0.0% 3.2% 7.1% 3.5% 32.3% May % 17.1% 2.5% 11.0% 7.5% 0.3% 2.1% 2.3% 2.0% 0.1% 3.0% 8.8% 2.3% 31.5% Jun % 17.9% 3.9% 10.4% 5.6% 0.4% 1.8% 3.1% 2.0% 0.0% 2.9% 8.4% 2.0% 32.4% Jul % 17.3% 3.6% 11.9% 6.1% 0.4% 1.9% 3.0% 1.7% 0.0% 3.4% 9.2% 3.5% 27.2% Aug % 16.0% 3.4% 11.5% 4.6% 0.5% 2.1% 3.1% 1.9% 0.1% 2.8% 10.0% 4.1% 30.4% Sep % 16.0% 3.6% 12.8% 5.0% 0.6% 1.8% 3.4% 1.5% 0.0% 2.7% 9.3% 4.1% 29.9% Oct % 17.1% 4.3% 11.6% 4.5% 0.5% 2.6% 2.9% 1.6% 0.1% 3.2% 7.1% 5.1% 29.7% Nov % 16.7% 2.9% 11.0% 4.0% 0.3% 2.1% 3.3% 1.6% 0.0% 2.7% 6.2% 3.3% 36.6% Dec % 15.3% 2.3% 9.8% 4.2% 0.4% 2.0% 2.9% 1.7% 0.0% 2.6% 5.0% 4.2% 42.3% 20.7% 0.5% ##### 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2011 Avg. 10.3% 20.3% 3.9% 11.8% 6.8% 0.3% 2.3% 2.7% 1.6% 0.1% 2.9% 11.4% 2.9% 22.8% 2012 Avg. 10.0% 18.1% 3.8% 12.1% 4.7% 0.2% 2.5% 3.5% 1.8% 0.0% 3.3% 10.3% 3.1% 26.6% 2013 Avg. 9.2% 16.8% 3.3% 11.5% 4.9% 0.3% 2.1% 3.0% 1.9% 0.0% 2.9% 8.5% 3.3% 32.2% Std. Dev. 0.8% 0.8% 0.6% 1.0% 1.0% 0.1% 0.3% 0.4% 0.2% 0.0% 0.3% 1.9% 1.0% 4.0% *Percentages read from this table should be read as "of the tissue used for PK" Analysis of the Surgical Indications for Penetrating Keratoplasty Over the last two years, as reported by U.S. eye banks, ectasias/thinnings and other stromal degenerations or dystrophies have declined as a surgical indication for penetrating keratoplasty, though the rate of decrease slowed in By contrast, international eye banks reported a slight increase in ectasias/thinnings as the indication for PK in 2013 over It is unclear if alternative treatments for ectasias/thinnings (e.g. crosslinking, improvements in therapeutic contact lenses) were having an impact on surgical treatment for these conditions in the U.S., though the data suggests that in the setting of increased surgical demand for tissue in the U.S., this may be a causal factor for this trend. In 2013, the leading surgical indication for PK surgery was ectasias/thinnings, followed by graft failure, post-cataract surgery edema, and "other causes of corneal opacification or distortion," respectively. In 2011 and 2012, "other causes of corneal opacification or distortion" was more significant than post-cataract surgery edema. 63

64 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting 64

65 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting Indications for Anterior Lamellar Keratoplasty - U.S. Eye Banks Month A B C D E F G H I J K L M Z Jan % 1.4% 2.1% 0.0% 1.4% 3.4% 1.4% 0.0% 3.4% 10.3% 31.5% Feb % 4.1% 4.1% 0.0% 1.2% 2.9% 2.9% 0.0% 3.5% 8.2% 41.2% Mar % 2.4% 1.8% 0.6% 1.8% 4.2% 1.2% 0.0% 2.4% 7.2% 42.8% Apr % 3.8% 3.8% 0.6% 1.3% 2.5% 2.5% 0.6% 3.1% 4.4% 42.8% May % 2.5% 5.4% 0.0% 2.5% 3.0% 0.5% 0.0% 4.9% 7.4% 45.3% Jun % 0.0% 7.4% 1.1% 2.3% 5.7% 0.6% 0.0% 3.4% 4.5% 43.8% Jul % 2.0% 3.6% 1.5% 3.0% 2.0% 3.0% 1.0% 3.0% 5.6% 41.6% Aug % 0.0% 9.9% 0.6% 4.1% 3.5% 2.3% 0.6% 1.7% 5.8% 38.4% Sep % 2.7% 4.1% 0.0% 2.7% 3.4% 1.4% 0.0% 1.4% 6.8% 42.5% Oct % 2.2% 3.9% 0.6% 5.0% 6.1% 1.7% 0.6% 2.2% 8.8% 38.7% Nov % 0.6% 3.7% 1.2% 3.7% 3.1% 1.9% 0.0% 1.9% 6.2% 42.6% Dec % 1.5% 2.3% 0.8% 0.0% 1.5% 3.1% 0.0% 2.3% 8.4% 45.0% 20.7% 0.5% ##### 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2011 Avg. 41.6% 2.6% 11.1% 0.7% 1.2% 3.3% 1.4% 0.3% 3.8% 9.6% 24.4% 2012 Avg. 43.4% 1.6% 6.2% 0.3% 1.9% 3.0% 1.5% 0.2% 4.2% 8.1% 29.6% 2013 Avg. 33.8% 1.9% 4.4% 0.6% 2.5% 3.5% 1.8% 0.2% 2.8% 6.9% 41.4% Std. Dev. 4.1% 1.3% 2.3% 0.5% 1.4% 1.3% 0.9% 0.4% 1.0% 1.8% 3.8% *Percentages read from this table should be read as "of the tissue used for ALK" Analysis of the Surgical Indications for Anterior Lamellar Keratoplasty U.S. banks reported data for anterior lamellar keratoplasty that suggested all surgical indications continued with steady trends in 2011 and 2012, except a notable decrease in ectasias/thinnings in This may be attributable to alternative treatments for ectasias/thinnings (e.g. crosslinking, improvements in therapeutic contact lenses). International eye bank data showed a steady trend of ectasias/thinnings as a surgical indication for ALK between 2012 and Domestically and internationally in all reporting years, the leading surgical indication for ALK was ectasias/thinnings. 65

66 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting 66

67 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting Indications for Endothelial Keratoplasty - U.S. Eye Banks Month A B C D E F G H I J K L M Z Jan % 49.6% 8.9% 9.4% 15.1% Feb % 46.9% 8.0% 10.2% 16.0% Mar % 46.3% 7.9% 9.9% 17.7% Apr % 46.4% 9.5% 11.4% 15.3% May % 47.1% 8.3% 10.6% 16.0% Jun % 45.5% 7.9% 12.7% 16.2% Jul % 46.1% 7.1% 10.9% 18.4% Aug % 46.0% 7.9% 12.0% 16.6% Sep % 50.3% 7.6% 10.0% 15.2% Oct % 47.0% 8.5% 11.0% 14.8% Nov % 47.9% 9.8% 9.0% 15.0% Dec % 48.8% 9.7% 10.2% 15.1% 20.7% 20.8% 0.3% 0.6% 0.6% 2011 Avg. 19.2% 47.7% 8.5% 12.3% 12.4% 2012 Avg. 19.1% 46.8% 8.3% 11.6% 14.2% 2013 Avg. 17.8% 47.3% 8.4% 10.6% 15.9% Std. Dev. 0.8% 1.5% 0.9% 1.1% 1.1% *Percentages read from this table should be read as "of the tissue used for EK" Analysis of the Surgical Indications for Endothelial Keratoplasty In 2011, 2012, and 2013, U.S. eye banks reported endothelial dystrophies (including Fuch's dystrophy) as the leading surgical indication for endothelial keratoplasty. Post-cataract surgery edema was the second leading surgical indication for EK. International eye banks reported data that showed the same pattern as the U.S. banks. There was a notable drop in post-cataract surgery edema as a cause for EK surgery as reported by U.S. eye banks in 2013; however there was a corresponding increase in "unknown or unreported" indications as well. 67

68 2013 U.S. Eye Banking Statistics Reported by U.S. Banks: Indications for Corneal Transplant Reported by U.S. Banks 76 U.S. Eye Banks Reporting Surgical Indications for Keratoplasty - U.S. Eye Banks A B C D E F G H I J K L M Z PK EK 4846 N/A N/A N/A N/A N/A N/A N/A N/A N/A ALK N/A 679 N/A N/A

69 Eye Banking Statistics From EBAA International Members 69

70 2013 Eye Banking Statistics Reported by International Banks: Donations and Tissue Recoveries 10 International Eye Banks Reporting Donations Number of Eye Banks Reporting Total Whole Globes and Corneas Donated 6,482 6,330 12,851 9,726 Total Number of Donors 3,305 3,177 6,433 4,886 Death Referrals Total Death Referrals 21, ,391 Death referrals Determined Eligible 4, ,695 Tissue Recoveries Total Donors 3,305 3,177 Eyes or Corneas Recovered with Intent for Surgical Use 5,427 5,058 Eyes or Corneas Recovered for Other Uses 1,055 1,272 1 Excludes Death Referral data from the Eye Bank of Canada, Ontario Division 70

71 2013 Eye Banking Statistics Reported by International Banks: Donations and Tissue Recoveries 10 International Eye Banks Reporting International Eye Banks Recovered Corneas < , ,001-2, ,001-3, ,001-4, ,001-5, ,001-6, ,001-7, ,001-8, ,001-9, ,001-10, >10, Avg. Corneas Recovered for Transplant

72 2013 Eye Banking Statistics Reported by International Banks: Referral Trends, Transplant and Conversion Rates 10 International Eye Banks Reporting Month Transplant Rate Conversion Rate Death Referrals Transplant Eligible Referrals Transplant Intended Corneas Recovered Jan % 69.0% Feb % 67.4% Mar % 64.6% Apr % 65.8% May % 60.2% Jun % 63.1% Jul % 70.6% Aug % 61.9% Sep % 57.1% Oct % 65.4% Nov % 66.7% Dec % 59.7% Total 64.7% 43.3% Total 64.8% 64.1% Avg. N/A N/A Std. Dev. 4.6% 4.0% *Transplant rate is the number of corneas used for transplant divided by the number recovered for transplant. Conversion rate is the number of transplant donors divided by the number of transplant eligible referrals. 72

73 2013 Eye Banking Statistics Reported by International Banks: Referral Trends, Transplant and Conversion Rates 10 International Eye Banks Reporting Note: One Bank Partially Reported Referral Information 73

74 2013 Eye Banking Statistics Reported by International Banks: Transplant and Conversion Rates 10 International Eye Banks Reporting Note: One Bank Partially Reporting Referral Information 74

75 2013 Eye Banking Statistics Reported by International Banks: Donor Profiles: Age 10 International Eye Banks Reporting Age Under One Year 0 0.0% 0 0.0% Age % 9 0.3% Age % % Age % % Age % % Age % % Age % % Age , % 1, % Age % % Over % % Total Donors by Age 3,305 3,177 75

76 2013 Eye Banking Statistics Reported by International Banks: Donor Profiles: Gender and Cause of Death 10 International Eye Banks Reporting Donors by Gender Male 1, % 1, % Female 1, % 1, % Total Donors 3,305 3,177 Cause of Death Heart Disease % % Cancer 1, % 1, % Trauma % % Respiratory Disease % % Cerebral Vascular Accident % % Other Diseases % % Total Donors by Cause of Death 3,305 3,177 76

77 2013 Eye Banking Statistics Reported by International Banks: Donor Profiles: Cause of Death 10 International Eye Banks Reporting International Eye Banks - Cause of Death Profile Month Heart Cancer CVA Respiratory Trauma Other Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Monthly Avg Std. Dev

78 2013 Eye Banking Statistics Reported by International Banks: Reasons Tissue Intended for Surgery Was Not Suitable For Transplant 10 International Eye Banks Reporting Contraindications for Transplant Donor Eligibility % % Positive or reactive test for communicable disease agent or disease % % Other communicable disease testing issue 8 0.5% % Medical record or autopsy findings % % Medical/social history interview % % Body Exam % % Tissue Suitability % % Quality Issue % % Other reason prior to tissue release % % Total eyes/corneas intended for transplant but not released for transplant 1, Some tissues had multiple contraindications. 78

79 2013 Eye Banking Statistics Reported by International Banks: Reasons Tissue Intended for Surgery Was Not Suitable For Transplant 10 International Eye Banks Reporting Reasons Released Tissues Were Not Transplanted Transportation Issue 0 0.0% % Surgeon Issue % % Recipient Issue 3 0.9% 5 1.3% Returned and Unable to Place Again % % Donor Information Not Available at the Time of Tissue Release 0 0.0% 0 0.0% Expired or Unable to Place Tissue % % Tissue Damaged During Processing % % Other Reason After Release of Tissue 9 2.8% % Total eyes/corneas released for transplant but not used for transplant

80 2013 Eye Banking Statistics Reported by 10 International Banks: Reasons Tissue Intended for Surgery Was Not Suitable For Transplant Month Reasons Tissue Recovered for Transplant Not Used for Transplant: Overview International Eye Bank Data Subset Medical All Medical Record Reasons Serology Testing / Social Body Tissue Quality / Not Tests Issue History Exam Suitability Issue Autopsy Released Finding Finding Other Reason Jan % 7.5% 0.0% 4.2% 4.2% 0.0% 9.6% 0.9% 0.5% Feb % 6.2% 0.0% 2.7% 4.0% 0.0% 5.1% 2.7% 4.7% Mar % 7.0% 0.9% 3.1% 3.5% 0.0% 12.3% 0.7% 2.0% Apr % 6.0% 0.0% 4.1% 3.0% 0.0% 10.0% 1.9% 3.0% May % 5.7% 0.0% 5.3% 2.9% 0.5% 7.2% 1.4% 6.5% Jun % 6.0% 0.0% 4.6% 1.4% 0.0% 10.3% 0.0% 6.7% Jul % 7.7% 0.0% 6.0% 3.4% 0.4% 12.0% 2.1% 8.1% Aug % 4.5% 0.0% 2.2% 6.0% 0.0% 10.7% 1.3% 7.4% Sep % 5.5% 0.0% 4.2% 4.2% 0.8% 11.6% 0.4% 6.8% Oct % 8.4% 0.0% 2.8% 2.8% 0.4% 11.0% 0.0% 7.8% Nov % 4.9% 0.9% 6.3% 5.4% 0.0% 8.7% 0.4% 7.8% Dec % 2.3% 0.0% 3.2% 2.8% 1.8% 15.1% 1.6% 18.6% 2012 Avg. 27.6% 5.9% 0.6% 5.1% 3.7% 0.2% 10.0% 0.8% 5.1% 2013 Avg. 29.3% 6.0% 0.1% 4.0% 3.6% 0.3% 10.3% 1.1% 6.6% Std. Dev. 4.1% 1.6% 0.3% 1.3% 1.2% 0.6% 2.6% 0.9% 4.5% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 80

81 2013 Eye Banking Statistics Reported by 10 International Banks: Serologic Reasons Tissue Intended for Surgery Was Not Suitable For Transplant Month Reasons Tissue Recovered for Transplant Not Used for Transplant International Eye Bank Data Subset: Serologic Testing All Serology Tests HIV Ab HIV NAT HBsAg HBcAb HCV Ab HCV NAT Syphilis HTLV Ab Other Test Jan % 0.0% 0.9% 0.5% 3.3% 1.4% 0.9% 0.0% 0.5% 0.0% Feb % 0.9% 0.0% 0.0% 4.4% 0.9% 0.0% 0.0% 0.0% 0.0% Mar % 0.0% 0.9% 0.4% 3.9% 0.4% 0.9% 0.4% 0.0% 0.0% Apr % 0.4% 0.0% 0.4% 3.8% 0.9% 0.0% 0.0% 0.0% 0.4% May % 0.0% 0.0% 1.4% 3.3% 0.5% 0.0% 0.5% 0.0% 0.0% Jun % 0.0% 0.0% 0.0% 5.5% 0.0% 0.0% 0.5% 0.0% 0.0% Jul % 0.0% 0.0% 0.9% 3.4% 2.4% 0.4% 0.4% 0.2% 0.0% Aug % 0.0% 0.0% 0.0% 1.8% 0.4% 0.4% 0.4% 0.0% 1.3% Sep % 0.0% 0.0% 0.0% 3.0% 0.8% 0.0% 0.0% 0.4% 1.3% Oct % 0.0% 0.8% 0.4% 3.2% 1.2% 0.8% 0.4% 1.2% 0.4% Nov % 0.0% 0.0% 0.0% 3.1% 0.4% 0.0% 0.9% 0.0% 0.4% Dec % 0.0% 0.0% 0.5% 0.9% 0.0% 0.0% 0.0% 0.0% 0.9% 2012 Avg. 5.9% 0.2% 0.0% 0.1% 3.1% 1.5% 0.2% 0.1% 0.2% 0.4% 2013 Avg. 6.0% 0.1% 0.2% 0.4% 3.3% 0.8% 0.3% 0.3% 0.2% 0.4% Std. Dev. 1.6% 0.3% 0.4% 0.4% 1.2% 0.7% 0.4% 0.3% 0.4% 0.5% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 81

82 2013 Eye Banking Statistics Reported by 10 International Banks: Reasons Tissue Intended for Surgery Was Not Suitable Month International Eye Bank Data Subset: Medical Record and Autopsy All Medical Record Dementia / Neuro Sepsis (Cultures) Sepsis (Other) Plasma Dilution Unknown Cause of Death Other Jan % 0.5% 0.5% 1.4% 0.0% 0.9% 0.9% Feb % 0.0% 0.4% 0.9% 0.0% 0.9% 0.4% Mar % 0.0% 0.9% 1.3% 0.0% 0.4% 0.4% Apr % 0.4% 0.4% 1.7% 0.0% 1.1% 0.4% May % 0.5% 0.5% 3.1% 0.5% 0.0% 0.7% Jun % 0.0% 0.2% 1.8% 0.0% 0.0% 2.5% Jul % 1.7% 0.4% 1.3% 0.0% 0.9% 1.7% Aug % 0.0% 0.4% 0.9% 0.0% 0.4% 0.4% Sep % 0.4% 0.4% 3.0% 0.0% 0.0% 0.4% Oct % 0.4% 0.8% 0.4% 0.0% 0.0% 1.2% Nov % 0.4% 1.8% 1.6% 0.9% 1.1% 0.4% Dec % 0.0% 1.8% 0.5% 0.0% 0.0% 0.9% 2012 Avg. 5.1% 0.3% 1.3% 1.6% 0.2% 0.7% 1.0% 2013 Avg. 4.0% 0.4% 0.7% 1.5% 0.1% 0.5% 0.9% Std. Dev. 1.3% 0.5% 0.5% 0.9% 0.3% 0.5% 0.7% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 82

83 2013 Eye Banking Statistics Reported by 10 International Banks: Reasons Tissue Intended for Surgery Was Not Suitable Month International Eye Bank Data Subset: Medical & Social History All Medical / Social History Travel Dementia / Neuro Other Jan % 0.9% 0.5% 2.8% Feb % 0.9% 0.0% 3.1% Mar % 0.4% 0.4% 2.6% Apr % 0.4% 0.0% 2.6% May % 1.0% 0.5% 1.4% Jun % 0.5% 0.0% 0.9% Jul % 0.9% 0.0% 2.6% Aug % 1.3% 0.4% 4.2% Sep % 0.4% 0.4% 3.4% Oct % 0.4% 1.2% 1.2% Nov % 0.4% 1.8% 3.1% Dec % 0.5% 0.0% 2.3% 2012 Avg. 3.7% 0.7% 0.0% 2.7% 2013 Avg. 3.6% 0.7% 0.4% 2.5% Std. Dev. 1.2% 0.3% 0.6% 1.0% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 83

84 2013 Eye Banking Statistics Reported by 10 International Banks: Tissue Suitability Reasons Tissue Was Not Released Month All Tissue Suitability Reasons International Eye Bank Data Subset: Tissue Suitability Prior Other Foreign Epithelium Refractive Scar Infiltrate Stromal Body Surgery Finding Descemet's Membrane Endothelium Jan % 0.9% 0.0% 0.0% 0.9% 0.2% 1.2% 0.0% 6.3% Feb % 0.0% 0.0% 1.8% 0.4% 0.0% 0.0% 0.0% 2.9% Mar % 0.0% 0.0% 1.3% 1.1% 0.0% 1.5% 0.0% 8.3% Apr % 0.9% 0.4% 2.1% 0.6% 0.0% 0.4% 0.0% 5.5% May % 0.2% 0.5% 1.7% 1.2% 0.0% 1.7% 0.0% 1.9% Jun % 1.1% 0.0% 0.9% 2.8% 0.0% 0.0% 0.2% 5.3% Jul % 2.4% 0.0% 1.5% 2.1% 0.0% 1.3% 0.0% 4.7% Aug % 1.3% 0.2% 1.3% 2.2% 0.0% 0.4% 0.4% 4.7% Sep % 0.8% 0.0% 2.7% 1.3% 0.2% 0.8% 0.0% 5.7% Oct % 0.6% 0.0% 1.8% 2.4% 0.2% 0.4% 0.0% 5.6% Nov % 0.9% 0.4% 0.9% 0.9% 0.0% 0.9% 0.0% 4.7% Dec % 3.0% 0.5% 4.4% 1.8% 0.0% 0.2% 0.0% 5.3% 2012 Avg. 10.0% 0.6% 0.1% 1.3% 1.5% 0.1% 1.2% 0.1% 5.1% 2013 Avg. 10.3% 1.0% 0.2% 1.7% 1.5% 0.1% 0.7% 0.1% 5.1% Std. Dev. 2.6% 0.9% 0.2% 1.1% 0.8% 0.1% 0.6% 0.1% 1.6% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 84

85 2013 Eye Banking Statistics Reported by 10 International Banks: Quality Reasons Tissue Intended for Surgery Was Not Released Month All Quality and Other Issues International Eye Bank Data Subset: Quality Issues and Other Reasons Storage Issue Labeling Issue Processing Issue (before release) Supply or Reagent Issue Environmental Control Issue Body Exam Other Serologic Testing Issue Jan % 0.5% 0.0% 0.2% 0.2% 0.0% 0.0% 0.0% 0.5% Feb % 0.9% 0.0% 0.9% 0.9% 0.0% 0.0% 0.0% 4.7% Mar % 0.2% 0.0% 0.4% 0.0% 0.0% 0.0% 0.9% 2.0% Apr % 0.4% 0.0% 0.2% 1.3% 0.0% 0.0% 0.0% 3.0% May % 0.0% 0.5% 0.5% 0.5% 0.0% 0.5% 0.0% 6.5% Jun % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 6.7% Jul % 1.3% 0.4% 0.4% 0.0% 0.0% 0.4% 0.0% 8.1% Aug % 1.1% 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 7.4% Sep % 0.4% 0.0% 0.0% 0.0% 0.0% 0.8% 0.0% 6.8% Oct % 0.0% 0.0% 0.0% 0.0% 0.0% 0.4% 0.0% 7.8% Nov % 0.0% 0.0% 0.2% 0.2% 0.0% 0.0% 0.9% 7.8% Other Issue Dec % 0.0% 0.0% 0.2% 0.0% 1.4% 1.8% 0.0% 18.6% 2012 Avg. 0.8% 0.3% 0.0% 0.4% 0.0% 0.0% 0.2% 0.6% 5.1% 2013 Avg. 8.2% 0.4% 0.1% 0.3% 0.3% 0.1% 0.3% 0.1% 6.6% Std. Dev. 5.1% 0.5% 0.2% 0.3% 0.4% 0.4% 0.6% 0.3% 4.5% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 85

86 2013 Eye Banking Statistics Reported by International Banks: Reasons Released Tissues Were Not Transplanted 10 International Eye Banks Reporting International Eye Bank Data Subset: Released but Not Transplanted Month Tissues Released Not Transplanted Transport Issue Surgeon Issue Recipient Issue Returned Tissue Unable to Place Again Donor Info Received after Release Expired Tissue/ Unable to Place Processing Damage after Release Other Reason after Release Jan % 0.0% 0.2% 0.0% 1.2% 0.0% 3.0% 1.6% 0.2% Feb % 0.0% 0.7% 0.2% 0.2% 0.0% 6.4% 0.7% 0.0% Mar % 0.0% 0.7% 0.0% 0.7% 0.0% 4.2% 0.0% 0.0% Apr % 0.0% 0.0% 0.0% 2.1% 0.0% 3.0% 0.9% 0.6% May % 0.0% 0.0% 0.0% 2.6% 0.0% 2.6% 0.7% 0.0% Jun % 0.0% 0.0% 0.0% 1.1% 0.0% 3.9% 0.5% 0.0% Jul % 0.0% 0.0% 0.0% 1.1% 0.0% 3.4% 0.6% 0.4% Aug % 0.0% 0.4% 0.2% 0.7% 0.0% 1.1% 0.7% 0.0% Sep % 0.0% 0.0% 0.0% 0.2% 0.0% 2.7% 0.4% 0.0% Oct % 0.0% 0.0% 0.2% 1.0% 0.0% 3.8% 1.0% 0.6% Nov % 0.0% 0.2% 0.0% 0.7% 0.0% 4.7% 1.1% 0.0% Dec % 0.0% 0.2% 0.0% 0.2% 0.0% 4.8% 0.9% 0.0% 2012 Avg. 7.8% 0.2% 0.5% 0.1% 1.1% 0.0% 4.9% 0.6% 0.2% 2013 Avg. 6.0% 0.0% 0.2% 0.1% 1.0% 0.0% 3.6% 0.8% 0.2% Std. Dev. 1.5% 0.0% 0.3% 0.1% 0.7% 0.0% 1.3% 0.4% 0.3% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 86

87 2013 Eye Banking Statistics Reported by 10 International Banks: Outcomes of Tissue Recovered for Transplant Month Corneas Recovered for Transplant International Eye Banks - Outcomes of Tissue Recovered for Transplant Corneas Segmented Corneal Segments Produced Not Released Released but Not Transplanted Whole Corneas and Segments Transplanted Preserved Long-Term Jan % % % % Feb % % % 7 1.6% Mar % % % 7 1.5% Apr % % % 3 0.6% May % % % % Jun % % % % Jul % % % % Aug % % % % Sep % % % 5 1.1% Oct % % % 7 1.4% Nov % % % 2 0.4% Dec % % % 8 1.8% 2012 Total % % % % 2013 Total % % % % 2013 Avg N/A 27 N/A 285 N/A 8 N/A Std. Dev % 7 1.5% % 4 1.0% *Percentages read from this table should be read as "of the tissue recovered with transplant intent" 87

88 2013 Eye Banking Statistics Reported by 10 International Banks: Outcomes of Tissues Recovered For Transplant 88

89 2013 Eye Banking Statistics Reported by International Banks: Use of Donated Tissues 10 International Eye Banks Reporting Distribution Corneal Grafts Total 3, , , ,758 Penetrating Keratoplasty 1,356 1,246 2,460 2,931 Anterior Lamellar Keratoplasty Endothelial Keratoplasty 1,491 1,271 2,293 1,540 Keratolimbal Allograft Keratoprosthesis (K-Pro) Glaucoma Shunt Patch or other nonkeratoplasty use Other keratoplasty (experimental surgery) Unknown or Unspecified Sclera ,496 - Long-Term Preserved Corneas Keratoplasty Glaucoma Shunt Patching Other Surgical Uses Research , Training 1,462 1,445 2,596 1,211 3 In 2011 & 2012, Corneal Grafts Total includes long-term preserved corneal tissue. 89

90 2013 Eye Banking Statistics Reported by International Banks: Intermediate-Term Tissue Distribution 10 International Eye Banks Reporting Intermediate-Term Tissue Distribution of Source Eye Bank Corneas For Domestic Use Intermediate-term preserved corneas, corneal segments or whole eyes transplanted for: 3,079 2,035 PK 1,356 1,189 Optical or Elective PK 1,294 1,060 Emergency of Full Thickness EK 1,491 1,239 DSEK, DSAEK, DLEK 1,399 1,085 DMEK or DMAEK ALK DALK (Deep Anterior Lamellar Keratoplasty) SALK (Superficial Anterior Lamellar Keratoplasty) 3 17 Other ALK (e.g. peripheral, eccentric, etc.) 4 3 KLA 0 0 Keratoprosthesis (K-Pro) Glaucoma shunt patch or other non-keratoplasty use Other Keratoplasty (e.g. experimental surgery type) 0 1 Unknown or Unspecified Total intermediate-term preserved corneas, corneal segments, and whole eyes used for KERATOPLASY 3,188 2,964 Total intermediate-term preserved corneas, corneal segments, and whole eyes used for TRANSPLANT 3,415 3,133 90

91 2013 International Eye Banking Statistics Domestic Surgery Use of Intermediate-Term Preserved Tissue Month 2013 Surgery Types Using Corneas Preserved in Intermediate-Term Media Domestically Distributed Tissue International Eye Banks PK (Optical, Elective) PK (Emerg.) EK (DSEK) EK (DMEK) ALK (DALK) ALK (SALK) ALK (Other) KLA K- Pro Shunt Patch Other Unknown Jan % 2.6% 39.9% 5.2% 5.6% 0.0% 0.0% 0.0% 0.4% 9.0% 0.0% 0.0% Feb % 1.1% 44.1% 0.0% 5.7% 0.0% 0.0% 0.0% 0.4% 5.3% 0.0% 9.6% Mar % 0.7% 39.6% 0.0% 6.7% 0.0% 0.0% 0.0% 1.1% 4.1% 0.0% 13.4% Apr % 2.3% 44.7% 4.7% 5.1% 0.0% 0.8% 0.0% 0.0% 10.5% 0.0% 0.8% May % 1.2% 46.0% 3.2% 3.6% 0.0% 0.0% 0.0% 0.0% 7.3% 0.0% 0.0% Jun % 0.7% 45.4% 4.6% 3.6% 0.0% 0.0% 0.0% 0.4% 10.4% 0.0% 0.0% Jul % 0.9% 38.7% 3.6% 5.9% 0.5% 0.0% 0.0% 0.5% 4.5% 0.0% 0.0% Aug % 1.9% 38.9% 2.3% 5.4% 0.4% 0.0% 0.0% 0.0% 7.0% 0.0% 12.5% Sep % 0.7% 43.8% 3.2% 3.9% 0.4% 0.0% 0.0% 0.4% 7.4% 0.0% 8.5% Oct % 2.1% 45.6% 2.5% 3.9% 0.0% 0.0% 0.0% 0.4% 6.0% 0.0% 0.0% Nov % 1.6% 47.2% 3.1% 1.6% 0.0% 0.0% 0.0% 0.0% 5.9% 0.0% 9.1% Dec % 0.0% 41.7% 3.9% 5.6% 0.0% 0.6% 0.0% 1.1% 12.2% 0.0% 0.0% 20.7% 0.5% 20.8% 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2012 Avg. 20.7% 0.2% 21.1% 0.0% 1.1% 0.0% 0.0% 0.0% 1.3% 2.0% 0.0% 8.8% 2013 Avg. 35.3% 1.4% 43.1% 3.0% 4.7% 0.1% 0.1% 0.0% 0.4% 7.4% 0.0% 4.7% Std. Dev. 4.3% 0.8% 3.0% 1.7% 1.4% 0.2% 0.3% 0.0% 0.4% 2.6% 0.0% 5.6% *Percentages read from this table should be read as "of the tissue distributed for transplant use domestically" 91

92 2013 International Eye Banking Statistics Trends of Domestic Use 10 International Eye Banks Reporting 92

93 2013 International Eye Banking Statistics Trends of Domestic Use 10 International Eye Banks Reporting 93

94 2013 Eye Banking Statistics Reported by 10 International Banks International Surgery Use of Intermediate-Term Preserved Tissue 2013 Surgery Types Using Corneas Preserved in Intermediate-Term Media Internationally Distributed Tissue International Eye Banks Month PK (Optical, Elective) PK (Emerg.) EK (DSEK) EK (DMEK) ALK (DALK) ALK (SALK) ALK (Other) KLA K-Pro Shunt Patch Other Unknown Jan % 0.0% 57.1% 0.0% 7.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Feb % 0.0% 37.5% 0.0% 6.3% 0.0% 0.0% 0.0% 6.3% 0.0% 0.0% 0.0% Mar % 0.0% 31.6% 0.0% 0.0% 0.0% 0.0% 0.0% 10.5% 0.0% 0.0% 0.0% Apr % 17.1% 26.8% 0.0% 4.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% May % 10.0% 40.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Jun % 0.0% 21.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 57.9% Jul % 0.0% 13.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 8.1% Aug % 15.2% 13.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Sep % 17.9% 10.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Oct % 0.0% 30.8% 0.0% 11.5% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 34.6% Nov % 0.0% 31.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Dec % 0.0% 10.9% 0.0% 3.1% 0.0% 1.6% 0.0% 0.0% 0.0% 0.0% 0.0% 20.7% 0.5% 20.8% 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2012 Avg. 41.2% 0.0% 49.2% 6.1% 2.2% 0.0% 0.0% 0.0% 0.6% 0.3% 0.3% 0.0% 2013 Avg. 61.6% 1.0% 11.2% 0.3% 4.0% 0.2% 1.0% 0.1% 0.2% 0.1% 0.1% 3.5% Std. Dev. 20.8% 7.6% 14.1% 0.0% 3.9% 0.0% 0.5% 0.0% 3.4% 0.0% 0.0% 18.5% *Percentages read from this table should be read as "of the tissue distributed for transplant use internationally" 94

95 2013 International Eye Banking Statistics Trends of International Use 10 International Eye Banks Reporting 95

96 2013 International Eye Banking Statistics Trends of International Use 10 International Eye Banks Reporting 96

97 2013 Eye Banking Statistics Reported by International Banks: Long-Term Tissue Distribution 10 International Eye Banks Reporting Long-Term Preserved Tissue Preservation and Distribution Long-term preserved corneas or whole globes PRESERVED for transplant Long-term preserved corneas, corneal segments, or whole globes DISTRIBUTED for: Keratoplasty 1 11 Glaucoma Shunt patching Other Surgical Uses 1 11 Long-term preserved corneas, corneal segments, or whole globes FORWARDED to another entity for final distribution 5 1 Sclera or sclera segments PRESERVED for transplantation 1,325 1,210 Sclera or sclera segments DISTRIBUTED for: Prosthesis following enucleation Glaucoma shunt patching Other surgical uses Sclera or sclera segments FORWARDED to another entity for final distribution 9 13 Tissue Processing for Transplant Cornea Processing Processed by microkeratome Processed by laser 8 0 Processed by hand dissection Processed by transfer into long-term preservation Processed by other methods

98 2013 International Eye Banking Statistics Long-Term Tissue Trends 10 International Eye Banks Reporting Month Long-Term Preserved Corneas Long-Term Cornea Use - Keratoplasty Long-Term Cornea Use - Glaucoma Long-Term Cornea Use - Other Scleral Segments Preserved Sclera Use - Prosthesis Sclera Use - Glaucoma Sclera Use - Other Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Avg Std. Dev

99 2013 International Eye Banking Statistics Long-Term Tissue Trends 10 International Eye Banks Reporting 99

100 2013 International Eye Banking Statistics Long-Term Tissue Trends 10 International Eye Banks Reporting 100

101 Month 2013 International Eye Banking Statistics Tissue Processing 10 International Eye Banks Reporting Processing - Microkeratome International Eye Banks Processing - Laser Processing - Manual Processing - Long-Term Preservation Processing - Other Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Avg Std. Dev

102 2013 International Eye Banking Statistics Tissue Processing 10 International Eye Banks Reporting 102

103 2013 International Eye Banking Statistics Tissue Processing 10 International Eye Banks Reporting 103

104 2013 International Eye Banking Statistics Forwarded Tissue 10 International Eye Banks Reporting Month Imported Tissue Exported Tissue (to EBAA Accred.) Exported Tissue (to non-ebaa Accred.) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Total Avg Std. Dev

105 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting Indications for Penetrating Keratoplasty A. Post-cataract surgery edema % % B. Keratoconus % % C. Fuchs' Dystrophy % % D. Repeat Corneal Transplant % % E. Other degenerations or dystrophies % % F. Post-refractive surgery 3 0.2% 6 0.5% G. Microbial changes % % H. Mechanical or chemical trauma % % I. Congenital opacities % % J. Pterygium 0 0.0% 0 0.0% K. Non-infectious ulcerative keratitis or perforation % % L. Other causes of corneal dysfunction or distortion % % (non-endothelial) M. Other causes of endothelial dysfunction % 7 0.6% Z. Unknown, unreported, or unspecified % % Total Indications for Penetrating Keratoplasty 1,356 1,246 Indications for Anterior Lamellar Keratoplasty B. Keratoconus % % D. Repeat Corneal Transplant 4 2.5% 4 3.3% E. Other degenerations or dystrophies % 6 4.9% F. Post-refractive surgery 0 0.0% 0 0.0% G. Microbial changes % 6 4.9% H. Mechanical or chemical trauma % 4 3.3% I. Congenital opacities 5 3.1% 5 4.1% J. Pterygium 0 0.0% 0 0.0% K. Non-infectious ulcerative keratitis or perforation 5 3.1% 2 1.6% L. Other causes of corneal dysfunction or distortion % 3 2.5% Z. Unknown, unreported, or unspecified % % Total for Anterior Keratoplasty Indications for Endothelial Keratoplasty A. Post-Cataract Surgery Edema % % C. Fuchs Dystrophy % % D. Repeat Corneal Transplant % % M. Other Causes of Endothelial Dysfunction % % Z. Unknown, unreported, or unspecified % % Total for Endothelial Keratoplasty 1,491 1,

106 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting 106

107 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting 2013 Indications for Keratoplasty - PK International Eye Banks Month A B C D E F G H I J K L M Z Jan % 25.0% 2.7% 25.9% 4.5% 0.0% 13.4% 5.4% 0.0% 0.0% 4.5% 3.6% 2.7% 0.0% Feb % 22.6% 0.9% 26.4% 3.8% 0.0% 12.3% 6.6% 0.9% 0.0% 0.9% 4.7% 5.7% 0.9% Mar % 33.3% 1.0% 17.1% 6.7% 1.0% 6.7% 4.8% 3.8% 0.0% 2.9% 3.8% 1.9% 1.0% Apr % 24.6% 7.0% 21.1% 6.1% 0.0% 13.2% 4.4% 0.9% 0.0% 1.8% 4.4% 2.6% 0.9% May % 27.6% 4.8% 19.0% 4.8% 1.9% 9.5% 5.7% 1.0% 0.0% 3.8% 3.8% 5.7% 0.0% Jun % 21.2% 3.8% 26.9% 1.0% 0.0% 7.7% 6.7% 0.0% 0.0% 3.8% 5.8% 3.8% 5.8% Jul % 11.4% 6.8% 12.9% 3.0% 0.0% 9.1% 6.1% 0.8% 0.0% 5.3% 3.0% 9.8% 22.0% Aug % 15.1% 2.4% 19.0% 3.2% 0.0% 7.1% 6.3% 2.4% 0.0% 3.2% 6.3% 9.5% 15.9% Sep % 17.9% 0.9% 20.5% 0.0% 0.0% 9.4% 6.0% 0.9% 0.0% 8.5% 0.0% 5.1% 27.4% Oct % 20.3% 1.6% 24.4% 3.3% 0.0% 8.9% 5.7% 2.4% 0.0% 4.1% 2.4% 8.1% 3.3% Nov % 14.7% 4.2% 18.9% 2.1% 0.0% 10.5% 8.4% 0.0% 0.0% 2.1% 1.1% 6.3% 9.5% Dec % 19.7% 5.1% 23.9% 3.4% 0.0% 9.4% 6.0% 0.0% 0.0% 0.0% 3.4% 3.4% 17.1% 20.7% 0.5% ##### 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2012 Avg. 10.0% 18.1% 3.8% 12.1% 4.7% 0.2% 2.5% 3.5% 1.8% 0.0% 3.3% 10.3% 3.1% 26.6% 2013 Avg. 12.3% 20.9% 3.5% 21.2% 3.5% 0.2% 9.7% 6.0% 1.1% 0.0% 3.5% 3.5% 5.5% 9.1% Std. Dev. 4.6% 6.1% 2.2% 4.3% 1.9% 0.6% 2.2% 1.0% 1.2% 0.0% 2.2% 1.8% 2.7% 9.6% *Percentages read from this table should be read as "of the tissue used for PK" 107

108 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting 108

109 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting 2013 Indications for Keratoplasty - ALK International Eye Banks Month A B C D E F G H I J K L M Z Jan % 18.8% 6.3% 0.0% 0.0% 6.3% 0.0% 0.0% 0.0% 0.0% 0.0% Feb % 0.0% 0.0% 0.0% 5.9% 0.0% 11.8% 0.0% 5.9% 5.9% 23.5% Mar % 5.6% 5.6% 0.0% 5.6% 0.0% 0.0% 0.0% 0.0% 5.6% 27.8% Apr % 0.0% 11.8% 0.0% 5.9% 5.9% 0.0% 0.0% 11.8% 11.8% 0.0% May % 0.0% 0.0% 0.0% 11.1% 0.0% 0.0% 0.0% 0.0% 33.3% 0.0% Jun % 0.0% 0.0% 0.0% 10.0% 0.0% 0.0% 0.0% 10.0% 10.0% 40.0% Jul % 0.0% 7.1% 0.0% 14.3% 0.0% 0.0% 0.0% 7.1% 0.0% 14.3% Aug % 0.0% 13.3% 0.0% 0.0% 6.7% 0.0% 0.0% 0.0% 0.0% 6.7% Sep % 0.0% 0.0% 0.0% 16.7% 16.7% 0.0% 0.0% 0.0% 0.0% 0.0% Oct % 0.0% 7.1% 0.0% 0.0% 35.7% 21.4% 0.0% 0.0% 0.0% 7.1% Nov % 0.0% 25.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 25.0% 0.0% Dec % 0.0% 7.1% 0.0% 7.1% 0.0% 0.0% 0.0% 0.0% 7.1% 7.1% 20.7% 0.5% ##### 0.3% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 0.6% 2012 Avg. 56.6% 3.3% 4.9% 0.0% 4.9% 3.3% 4.1% 0.0% 1.6% 2.5% 18.9% 2013 Avg. 55.0% 1.9% 4.4% 0.6% 2.5% 3.5% 1.8% 0.2% 2.8% 6.9% 41.4% Std. Dev. 14.7% 5.5% 7.3% 0.0% 5.8% 10.7% 6.8% 0.0% 4.5% 10.8% 13.3% *Percentages read from this table should be read as "of the tissue used for ALK" 109

110 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting 2013 Indications for Keratoplasty - EK International Eye Banks Month A B C D E F G H I J K L M Z Jan % 45.0% 13.2% 3.1% 0.0% Feb % 48.5% 8.5% 6.2% 1.5% Mar % 44.6% 15.2% 2.7% 0.9% Apr % 49.3% 10.9% 4.3% 0.7% May % 56.3% 9.5% 2.4% 0.0% Jun % 49.3% 11.1% 4.2% 13.9% Jul % 42.4% 13.1% 6.1% 15.2% Aug % 49.1% 17.0% 6.3% 2.7% Sep % 43.4% 13.2% 3.7% 2.2% Oct % 30.1% 18.9% 4.2% 14.7% Nov % 51.1% 13.5% 8.3% 3.0% Dec % 39.3% 9.0% 4.5% 2.2% 20.7% 20.8% 0.3% 0.6% 0.6% 2012 Avg. 29.2% 46.8% 12.7% 3.9% 7.4% 2013 Avg. 31.9% 45.8% 12.8% 4.6% 4.8% Std. Dev. 7.3% 6.7% 3.2% 1.7% 6.0% *Percentages read from this table should be read as "of the tissue used for EK" 110

111 2013 International Eye Banking Statistics Indications for Corneal Transplant 10 International Eye Banks Reporting 111

112 Eye Banks Submitting Data for the 2013 Eye Banking Statistical Report STATE EYE BANK NAME CITY AL Alabama Eye Bank Birmingham AR Arkansas Lions Eye Bank & Laboratory Little Rock AZ Donor Network of Arizona Phoenix CA California Transplant Services Carlsbad Doheny Eye & Tissue Transplant Bank Los Angeles TBI San Francisco Richmond One Legacy Los Angeles Sierra Donor Services Sacramento San Diego Eye Bank San Diego CO Rocky Mountain Lions Eye Bank Aurora CT Connecticut Eye Bank & Visual Research Foundation, Inc. New Britain FL Florida Lions Eye Bank Miami International Sight Restoration Tampa Lions Eye Institute for Transplantation and Research Tampa Medical Eye Bank of Florida Orlando GA Georgia Eye Bank Atlanta HI Hawaii Lions Eye Bank & Makana Foundation Honolulu IA Iowa Lions Eye Bank Coralville ID Idaho Lions Eye Bank Boise IN Indiana Lions Eye & Tissue Transplant Bank Indianapolis KS Kansas Eye Bank & Cornea Research Center Wichita KY Lions Eye Bank of Lexington Lexington University of Louisville Lions Eye Bank Louisville LA Baton Rouge Regional Eye Bank Baton Rouge Southern Eye Bank Metaire Louisiana Lions Eye Bank Shreveport MA New England Eye & Tissue Transplant Bank Boston MD Medical Eye Bank of Maryland & Washington Eye Bank Baltimore MI Midwest Eye-Banks Ann Arbor MN Minnesota Lions Eye Bank Minneapolis MO Saving Sight Columbia Mid-America Transplant Services St. Louis MS Mississippi Lions Eye Bank Flowood NC Lifeshare of the Carolinas Charlotte The North Carolina Eye Bank, Inc. Winston-Salem ND Lions Eye Bank of North Dakota Bismarck NE Lions Eye Bank of Nebraska, Inc. Omaha NM New Mexico Lions Eye Bank Albuquerque NV Nevada Donor Network, Inc. Las Vegas 112

113 STATE EYE BANK NAME CITY NY Sight Society of Northeastern NY (Lions Eye Bank at Albany) Albany Upstate New York Transplant Services, Inc. Buffalo The Lions Eye Bank for Long Island Valley Stream The Eye-Bank for Sight Restoration New York Rochester Eye & Human Parts Bank Rochester Central New York Eye Bank Syracuse OH Central Ohio Lions Eye Bank, Inc. Columbus Cincinnati Eye Bank for Sight Restoration, Inc. Cincinnati Lions Eye Bank of West Central Ohio Dayton OK Oklahoma Lions Eye Bank Oklahoma City OR Lions VisionGift Portland PA Northeast Pennsylvania Lions Eye Bank Bethlehem Lions Eye Bank of Northwest Pennsylvania, Inc. Erie Gift of Life Donor Program Eye Bank Hershey Lions Eye Bank of Delaware Valley Philadelphia Center for Organ Recovery & Education (CORE) Pittsburgh PR Lions Eye Bank of Puerto Rico San Juan SC LifePoint, Inc. Charleston SD South Dakota Lions Eye Bank Sioux Falls TN Tennessee District 12-0 Lions Eye Bank Chattanooga East Tennessee Lions Eye Bank, Inc. Knoxville Mid-South Eye Bank for Sight Restoration, Inc. Memphis The National Eye Bank Center Memphis Tennessee Donor Services Nashville TX Transplant Services Center, UT Southwestern Medical Center Dallas Fort Worth Eye Bank Fort Worth Lions Eye Bank of Texas at Baylor College of Medicine Houston Great Plains Lions Eye Bank, Inc. Lubbock Lone Star Lions Eye Bank Manor Western Texas Lions Eye Bank Alliance San Angelo San Antonio Eye Bank San Antonio UT Utah Lions Eye Bank Salt Lake City VA Lions Medical Eye Bank & Research Center of Eastern VA, Inc. Norfolk Old Dominion Eye Foundation, Inc. Richmond WA SightLife Seattle WI Lions Eye Bank of Wisconsin Madison WV Medical Eye Bank of West Virginia Charleston 113

114 International Eye Banks Submitting Data for the 2013 Eye Banking Statistical Report Country Eye Bank Name City Canada Lions Eye Bank Calgary, AB Eye Bank of British Columbia Vancouver, BC Misericordia Lions Eye Bank Winnipeg, MB New Brunswick Organ and Tissue Donor Program- Ocular Division Saint John, NB Regional Tissue Bank Halifax, NS Eye Bank of Canada, Ontario Division Toronto, ON Eye Bank of Saskatchewan Saskatoon, SK Japan Cornea Center & Eye Bank Ichikawa City Hong Kong Hospital Authority Lions Eye Bank Kowloon China Daqing Eye Bank Daqing 114