The history and future of eye banking in the Philippines

Looking forward to the harvest
Like all significant journeys, the Eye Bank’s story has been full of twists and turns, frustrations, and
trials. But all in all, the twists of fate have been serendipitous, and the frustrations have been far
outweighed by the fulfillment and satisfaction the work has brought to all who have been touched by it.

Correspondence to
Ma. Dominga B. Padilla, MD
President and Chair
Eye Bank Foundation of the Philippines
Santa Lucia International Eye Bank of Manila
Second Floor, Sentro Oftalmologico Jose Rizal
Philippine General Hospital
Taft Avenue, Ermita
1000 Manila, Philippines
Telephones : +63-2-3026282, +63-2-3026287
Fax : +63-2-3026285
Email : mpadillamd@yahoo.com

THE SANTA Lucia International Eye Bank of Manila,
the medical eye bank of the Eye Bank Foundation of the
Philippines, turned 10 years old in October. And despite
what can be considered a success story in many ways, we
have really only started to plant the seeds.
How the country’s first internationally accredited eyebanking facility came to fruition and continues to
survive is a story worth telling, not so much because of
what it can teach about eye banking, but because it is
living proof of how “out of the box” thinking and
tenacity can move mountains. Its lessons can apply, not
just to eye banking, but to virtually all endeavors that
have to be accomplished against odds daunting and
formidable.
Dr. Salvador Salceda, in his History of Ophthalmology
in the Philippines (unpublished), has this to say about
the history of eye banking: “For more than a quarter of
a century, from 1948 to the 1980s, eye banking for sight
restoration in the Philippines has been a fascinating, if
not frustrating story.” Indeed, it was.
From 1948 to the late 1980s, eye banking was a touchand-go affair. While several efforts had been undertaken, too many obstacles stood in the way of a sustainable, functional, and efficient eye-banking system. Dr.
Salceda identifies these obstacles as:
• Filipinos’ cultural bias against organ donation;
• Raging professional rivalries;
• Lack of committed, dedicated, and selfless
leadership; and
• Lack of the knowledge and capacity for “managing
interdependence” among varied but complementary
expertise and resources.
These were among the main reasons that efforts at
eye banking in the past did not take off, and the first
eye bank withered in the vine. Until the early 1990s,
the only regular sources of eye tissue were the eyeballs
from Sri Lanka that arrived in styrofoam containers in
conditions far from ideal. Occasionally, we also received
from the United States “gratis” tissues that could not
find “homes” among American surgeons.
In the 1960s, there were also efforts to harvest eyes
from death-row convicts whose consent were obtained
before their execution. Present eye-banking safety
standards consider prison inmates far from ideal; to some
countries, incarceration for 72 hours or more is a
contraindication for corneal donation.
1
In the 1960s,
however, this was not the case. Hospitals got tissues from
where they could, and death-row convicts were a logical
source. Up to the late 1980s, some major training
institutions had residents practically stealing eye balls
under cover of darkness, while patients wait in university
morgues to ask relatives of decedents to donate their
loved ones’ eyes. As one can imagine, results from these
routes were unsatisfactory and the efforts unsustainable.
Needless to say, the situation remained grim, and the
dream of systematically and efficiently addressing
corneal blindness remained elusive. It was under these
circumstances in the early 1990s when yet another
group of ophthalmologists decided, against all odds,
to “go where no man had yet gone,” as far as Philippine
eye banking was concerned.
Aside from the original obstacles already identified,
other factors had to be considered in the strategy to
finally get an eye bank off the ground. Among these
grim realities were that we were trying to establish a
very high-tech, capital- and skills-intensive operation to
address a tertiary-health-care concern in a country that
did not even have enough funds to address primaryhealth concerns. In 1992, when the foundations of the
present eye bank were being laid, the health and
socioeconomic landscapes were grimmer than they are
today. Roughly 40% of the population lived below the
poverty level, 50% had no access to health care, and
about 50% of Filipinos who died did not get any medical
attention.
2
It was clear that the government could not take the
lead in this endeavor, the road was not going to be easy,
and we had to think “outside the box.”

Unite to fight
While past efforts at eye banking had failed, three
major factors raised the chances of success of the new
endeavor.
First, we were able to form the Eye Bank Foundation
of the Philippines (EBFP) in March 1994. This nonfor-profit, nongovernment, humanitarian organization
achieved two things at its onset. It united the major
stakeholders and movers in the eye-banking field from
the various institutions, both private and government,
some of whom had been at odds with each other. This
helped ease the “raging professional rivalries” that were
a major stumbling block in the past. The foundation
also provided a venue for fund raising, something that
we needed badly since the entire effort had to take off
and sustain itself minus government support.
Then we were able to get technical help from the
International Federation of Eye and Tissue Banks
(IFETB). The IFETB was formed in 1989 as an offshoot
of Tissue Banks International (TBI), the biggest eyeand tissue-banking network in the United States. IFETB
was formed to help different countries establish their
own eye-banking systems with their own resources. To
get the support from IFETB, however, we had to prove
that we could do what needed to be done, particularly
having a law passed to ensure that an eye bank will take
strong roots in the Philippines.
Thus, Republic Act 7885 or “Act to Advance Corneal
Transplantation in the Philippines” was passed—a major
breakthrough in the struggle for the establishment of a
Philippine eye bank. Patterned after the “presumed
consent law” of the State of Maryland in the US, RA
7885 allows corneal tissues to be harvested from
deceased victims of accident and trauma even in the
absence of any document of organ donation as long as
the hospital has exerted reasonable efforts to locate the
victims’ nearest relatives within 48 hours from death.
The EBFP lobbied hard for the passage of this law
since it was necessary to overcome another obstacle to
eye banking—the cultural bias of Filipinos against
organ and tissue donation. It was the EBFP’s hope to
change the bias in time, but while the change was yet
forthcoming, the “presumed consent law” was the
battery we needed to jump-start the eye bank. We
needed success stories to inspire people to donate their
eyes or corneas. But to get the necessary number of
success stories, we first needed enough tissues to go
around. It was a catch-22 situation, and the new law
would help ensure that we did not get stuck in the
quagmire.
Armed with the legislation, the expertise and
training from IFETB, and the start-up funding from
the foundation, the EBFP inaugurated its first eye bank
at the Makati Medical Center on October 16, 1995. It
was named the Santa Lucia International Eye Bank
(SLIEB), after Santa Lucia, patron saint of vision on
special request of Dr. Robert Caro of Staten Island, the
major benefactor of the facility. And as history has
shown, St. Lucy has been good to us.

Sending out the Message, Bringing in the Tissue,
Spreading the Gift
Having the law to help get the tissues was one thing,
making it work was another. Two major groups had to
be conquered, each with its own culture to boot: the
police and the media. And this was where much “out
of the box” thinking had to be employed, none more
so than with the police.
We had to penetrate the wall of the Philippine
National Police (PNP) crime-laboratory culture to
achieve several things. We had to overcome their fear
of helping implement a new and very progressive law
that the public may not take kindly and the media could
easily misinterpret or misrepresent, both of which
would end up killing our efforts at conception.
We made sure, therefore, from the very start that we
had the media on our side. We wanted the law to work,
yet we wanted to be able to sleep well at night. We could
not afford a hostile media.
We also had to win the minds and hearts of the PNP
crime laboratory by making the SLIEB personnel
practically part of their staff, allowing them to use the
Eye Bank’s cars almost like service vehicles as they went
from morgue to morgue, and helping them improve
their facilities by coursing donations to them through
our foundation. We even had to win points with the
various morgues and funeral homes where autopsies
were usually performed. One has only to see the conditions in these morgues to know that so much can be
done to improve their lot, and this we have tried to do
through the years. In time, both the crime-laboratory
staff and the morticians saw the good that came from
it all. In time, they came to appreciate how they could
bring so much joy to others even if they dealt with
something tragic.
We also had to prove ourselves to our own community of ophthalmologists. We had to overcome their
cynicism and show that the Eye Bank was there to serve
the entire community and not just the members of the
board. As a first resolution, therefore, the board
members agreed not to receive any tissue from the Eye
Bank during the first 6 months of its operations. They
would be given to others around the country. This was
a very important act of goodwill that had far-reaching
results. We also had to make sure that none of the
members of the board was given preferential treatment.
We had to wait in line like all the rest. We still do.
With the tissues came the transplants done by
doctors from various institutions—and the trust. This
was followed by the human-interest and heart-warming
success stories played up by a friendly media. And in
time we were able to start working on the “voluntary
donors” inspired by the good they had heard about
and seen. We are still struggling to get more voluntary
donors, but their number is growing. We could not have
started building on this aspect of eye banking, however,
without having effectively implemented the “presumed
consent law” first.
The media exposure earned for us the trust of many
important institutions. We entered into an agreement
with Philippine Airlines, Cebu Pacific, and FedEx so
that our tissues could be transported free of charge
around the country. In 1999, ABS-CBN supported our
surgical fund so that we could go beyond supplying
free corneas and pay for ancillary expenses for
transplant surgery. In 2001, some memorial homes led
by Loyola Memorial Chapels started to routinely ask
clients to consider eye or corneal donation.
In 2004, the Department of Health (DOH) entered
into an agreement with the Eye Bank to encourage
DOH hospitals to participate in the eye- and cornealdonation program. Advertising companies created
television and radio ads for the eye bank free of charge,
and these were aired free of charge as well. The Armed
Forces of the Philippines (AFP) signed an agreement
with the Eye Bank last November so that the AFP may
participate more actively in eye and tissue donation.
We have yet to fully implement this, however.
From October to June this year, an unprecedented
number of celebrities lent their images and talents for
the tri-media “Tears of Hope, Tears of Health” campaign
of the eye bank and Visine Refresh in the hope that
they could encourage more people to become eye and
cornea donors. A coffee table book documenting this
campaign is in the offing and will be launched next
year. Indeed, the list of those who have helped and
continue to help has grown, and will keep growing.
But so much has yet to be done. A major challenge
is maximally translating all this goodwill, support, and
exposure to actually increasing eye-tissue yield and
distribution. The eye bank is still struggling to do so
and is far from achieving its vision of making corneal
transplant surgery available to all whenever and
wherever it is needed.

Eye Tissue and Beyond Thus far, more than 8,000 eye tissues have been
processed by the eye bank. We are presently averaging
50 to 60 tissues a month, a decent number by any
standard, but still insufficient to meet the exponential
growth of corneal demand so much so that the waiting
period has gone to as long as 6 months.
This year had been a difficult one. The Eye Bank’s
move to the Sentro Oftalmologico Jose Rizal in
October was a tumultuous one, what with the lack of
electricity in the eye center up to this day. But things
are looking good for next year and beyond.
Strategic plans have been put in place that should
double tissue yield in the next two years. Improvements
in the business processes will help ensure more efficient
and professional service delivery. The larger facility and
staff will also allow us to venture into other undertakings
such as producing our own tissue storage and culture
media, processing other tissue like pericardium, and
resuming processing of amniotic membrane. The
acquisition of a femtosecond laser to prepare lamellar
grafts is also in the works.
We have also started laying the groundwork for
satellite eye-tissue-retrieval facilities in Pampanga and
Cebu, and we hope to make headway in these projects
in the next two years. We are also working on more
government funding and sustainable grants so we can
expand without having to raise processing fees too much.
Like all significant journeys, the Eye Bank’s story
has been full of twists and turns, frustrations and trials.
But all in all, the twists of fate have been serendipitous,
and the frustrations have been far outweighed by the
fulfillment and satisfaction the work has brought to all
who have been touched by it.
These last ten years have been a time to plant the
seeds. We look forward to the harvest.

References
1. Tissue Banks International Manual on Eye Banking, 2005
2. National Statistics Office, Republic of the Philippines