Review for special issue: Corneal lamellar surgery: Present outcomes and future perspectives.

Since the establishment of the first eye bank in the 1940s, their role has evolved to face new challenges. With the recent development of lamellar keratoplasties, eye banks play an even bigger role in the selection and preparation of donor tissues. The increasing number of keratoplasty techniques and the high demand for "ready-to-use" tissues are challenging eye banks to improve and develop new preparation techniques. Besides necessary examinations, new approaches of tissue analysis in eye banks allow a better/optimized selection of corneal tissues. These new challenges in tissue preservation, preparation, and selection are propelling eye banks into a new era of modern eye banking.

Impact of demographic factors on corneal donor recovery.

PURPOSE: Death-to-preservation time (DTP) is a commonly reported, but infrequently studied, measure of efficiency for the corneal tissue procurement process and is a key screening component for corneal tissue suitability for transplantation. It is unknown whether demographic factors such as race, age, or gender may affect DTP. METHODS: This retrospective cross-sectional study included all deceased-donor eye tissue collected by CorneaGen Eye Banks between June 1, 2012 and June 30, 2016. Exposure variables of race, age, and gender were independently analyzed with the outcome variable, DTP, using three simple linear regression analyzes. Associations were then confirmed by a multiple linear regression analysis within a single model. RESULTS: A total of 24,138 unique donors were identified from 48,207 donor eyes. Simple linear regression analysis showed that relative to White donors, Black and Hispanic donors were associated with a 2.40 h (95% CI 2.07-2.74 h, p < 0.001) and 2.48 h (95% CI 2.15-2.80 h, p < 0.001) longer mean DTP, respectively. DTP decreased with increasing age, at a rate of 30 min per every 10 years (95% CI 27-33 min, p < 0.001). Male donors were associated with a 35 min (95% CI 26-44 min, p < 0.001) longer DTP relative to female donors. A multiple linear regression confirmed the results of the three simple linear regressions. CONCLUSIONS: In a large cohort of corneal donors, non-White race, younger age, and male gender were associated with longer DTP.

EBEI: A new index of eye bank efficiency.

PURPOSE: To describe a new proxy of the Eye Bank (EB) activity named "Eye Bank Efficiency Index" (EBEI), calculated as the ratio between the number of corneal tissues distributed by an EB within a certain time period, and the difference between the number of procured and discarded tissues. METHODS: To demonstrate the effectiveness of the new metric as compared to traditional statistics, an analysis was conducted using data from the largest Italian Eye Bank (Fondazione Banca degli Occhi del Veneto Venice, Italy). Collected data included: the number of corneas retrieved, the number of discarded grafts, and the number of distributed tissues. The analysis focused on three defined timeframes: January to December, March to May (the "Italian Lockdown period"), and June to December (the "Italian post-lockdown period"). RESULTS: In 2020, the annual variation of the EBEI showed a significant increase of up to 3.4% compared to the previous year (0.986 in 2019; 1.020 in 2020), but then gradually decreased to 0.993 in 2022. However, during the months of lockdown in 2020, there was a significant decline of -13.8% in the EBEI compared to the same period in the previous year. The variation in the EBEI during the post-lockdown months was minimal in 2020 and 2021, with the lowest EBEI value of 0.976 being reached in 2022 (-7.8% compared to 2019). CONCLUSION: The EBEI is a simple and reliable new measure of the EB activity. Its widespread adoption could ensure a more accurate and reliable analysis of EB data for academic, political, and economic purposes.

Impact of cornea recovery training and certification on ophthalmology residents.

Background: In Asian countries, such as Taiwan, social taboos regarding organ and tissue donation decreases the prevalence of organ and tissue transplants. This also applies to cornea recovery, which is a skill that requires precision and practice to perform well. In Taiwan, to ensure the maintenance of high-quality corneas, a comprehensive training program and certified examination has been implemented. This study aims to investigate the impact of these programs and examinations on cornea recovery. Methods: Researchers evaluated the efficiency of the training and certified examination process by comparing the corneoscleral rim width, Descemet's membrane folds, endothelial layer stress lines, and endothelial cell density performed by ophthalmology residents in 2018 and 2019. Results: After training and certification, the Descemet's membrane folds rate decreased from 14.3 % to 2.0 % and endothelial layer stress lines rate decreased from 22.5 % to 5.0 %. The endothelial cell density of donor grafts significantly improved from 2681.9 cells/mm2 to 2869.7 cells/mm2 (p < 0.001). Conclusions: This study used objective data to evaluate cornea recovery quality after training and certification. The training and certified examination significantly improved the surgical skills of ophthalmology residents and could be applied in other tissue or organ recovery procedures to maintain and improve quality.

Hemi-Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (Hemi-UT-DSAEK) Using Pediatric Donor Corneas: A Case Series.

OBJECTIVE: We sought to evaluate the clinical outcomes of hemi-UT-DSAEK grafts from the pediatric donor corneas of patients affected by Fuchs Endothelial Corneal Dystrophy (FECD). METHODS: A prospective, interventional case series was conducted at the Ophthalmology Department of Venice Civil Hospital and the Veneto Eye Bank Foundation (Venice, Italy). Six eyes of six patients affected by FECD received large-diameter, semicircular hemi-UT-DSAEK grafts obtained from three pediatric donor corneas using the standard pull-through method. Endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and intraoperative and postoperative complications were recorded at different time intervals up to 12 months. RESULTS: The average donor age was 64.6 ± 8.6 years, and the pre-operative ECD was 3266 ± 225 cells/mm2. At 12 months postoperatively, the average ECD was 1376 ± 509 cells/mm2 with a mean decrease of 56.8 ± 19.1% from the preoperative donor count. At 12 months, four out of six eyes had significantly improved and reached a BCVA of ≥20/25 (Snellen equivalent). The mean CCT significantly decreased from 788 ± 138 µm before surgery to 576 ± 30 µm at 12 months postoperatively (p < 0.01). CONCLUSIONS: Hemi-UT-DSAEK grafts using pediatric donor corneas are surgically feasible and can provide similar clinical outcomes compared to conventional UT-DSAEK. Transplanting pediatric donor tissues with high ECD into two patients could potentially increase the donor tissue pool to treat endothelial disease.

Corneal Endothelial Cell Cultures from Organotypic Preservation of Older Donor Corneas Are Suitable for Advanced Cell Therapy.

INTRODUCTION: The purpose of this work was to evaluate the in vitro growth capacity and functionality of human corneal endothelial cells (hCEC) expanded from corneas of elderly (>60 years) donors that were preserved using an organotypic culture method (>15 days, 31°C) and did not meet the clinical criteria for keratoplasty. METHODS: Cell cultures were obtained from prior descemetorhexis (≥10 mm) and a controlled incubation with collagenase type I followed by recombinant trypsin. Cells were seeded on coated plates (fibronectin-albumin-collagen I) and cultures were expanded using the dual supplemented medium approach (maintenance medium and growth medium), in the presence of a 10 µm Rho-associated protein kinase inhibitor (Y-27632). Cell passages were obtained at culture confluency (∼2 weeks). A quantitative colorimetric WST-1 cell growth assay was performed at different time points of the culture. Morphometric analysis (area assessment and circularity), immunocytochemistry (ZO-1, Na+/K+-ATPase α, Ki67), and transendothelial electrical resistance (TEER) were performed on confluent monolayers. RESULTS: There was no difference between the cell growth profiles of hCEC cultures obtained from corneas older than 60 years, whether preserved cold or cultivated organotypic corneas. Primary cultures were able to maintain a certain cell circularity index (around 0.8) and morphology (hexagonal) similar to corneal endothelial mosaic. The ZO-1 and Na+/K+-ATPase pump markers were highly positive in confluent cell monolayers at 21 days after isolation (passage 0; P0), but significantly decreased in confluent monolayers after the first passage (P1). A weak expression of Ki67 was observed in both P0 and P1 monolayers. The P0 monolayers showed a progressive increase in TEER values between days 6 and 11 and remained stable until day 18 of culture, indicating a state of controlled permeability in monolayers. The P1 monolayers also showed some functional ability but with decreased TEER values compared to monolayers at P0. CONCLUSIONS: Our results indicate that it is possible to obtain functional hCEC cultures in eye banks, using simplified and standardized protocols, from older donor corneas (>60 years of age), previously preserved under organotypic culture conditions. This tissue is more readily available in our setting, due to the profile of the donor population or due to the low endothelial count (<2,000 cells/mm2) of the donated cornea.

Corrective and preventive actions (CAPAs) in eye bank.

This case series highlights the challenges in eye banking and the importance of a quality assurance program. Three cases triggered corrective and preventive actions (CAPAs) to improve the processes. Case 1 emphasized training to prevent retrieval failures. Case 2 stressed the need for blood samples and comprehensive documentation. In Case 3, mishandling led to policy revisions and staff training. CAPA involved identifying concerns, root cause analysis, action plans, implementation, checks, and closure. Errors can occur in man, machinery, process, and policies. Continuous CAPA ensures continuous quality improvement and safe corneal tissue transplantation, benefiting patients in need.

Anti-fungal efficacy of combination of amphotericin B with colistin and gentamicin in McCarey-Kaufman corneal preservation medium.

Purpose: To curtail the potential of donor corneal tissue disseminating fungi to the recipient's eye, we evaluated the addition of amphotericin B to McCarey-Kaufman (M-K)-corneal storage medium supplemented with colistin. Methods: Amphotericin B was examined for its ability to inhibit the growth of Candida albicans and Aspergillus flavus using a microbroth dilution test and checkerboard assay in combination with only gentamicin and a combination of colistin, gentamicin, and amphotericin B. The safety on epithelium and endothelium was evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Results: The minimal inhibitory concentration of gentamicin was found to be >256 µg/ml against both C. albicans and A. flavus, whereas that of amphotericin B was found to be in a range of 0.25-0.5 and 1-2 µg/ml for C. albicans and A. flavus, respectively. According to the checkerboard assay, 80% (4/5) of C. albicans isolates and 100% (5/5) of A. flavus isolates responded synergistically to the combination of amphotericin B and gentamicin, but only 20% (1/5) of C. albicans isolates showed an additive effect. None of the tested isolates displayed antagonism. The combined effect of the three drugs also did not display any antagonistic effect. Additionally, the MTT assay reveals no toxic effect of the antimicrobials used on corneal epithelial and endothelial cells. Conclusion: In vitro experiments demonstrate that amphotericin B is not toxic to either epithelium or endothelium and is a promising additive to the M-K medium supplemented with colistin.

Global impact of COVID-19 on corneal donor tissue harvesting and corneal transplantation.

Introduction: The purpose of this review is to consolidate and examine the available literature on the coronavirus disease 2019 pandemic and its effect on corneal transplantation and eye banking. Methods: A primary literature search was conducted using the PubMed (Medline) database with keywords and MeSH terms such as "corneal transplantation," "eye banks," "keratoplasty" and then were combined with COVID-19. Relevant articles through September 2022 were assessed and 25 articles were included in this review. Results: Donor tissue volumes declined globally during lockdown periods due to a lower number of referrals and tighter tissue screening guidelines. Rates of elective surgeries decreased in the lockdown period compared to respective periods in previous years. However, changes in rates of emergency procedures were not uniform across different regions. Moreover, rates of different elective corneal grafts [i.e., penetrating keratoplasty (PK), endothelial keratoplasty (EK), or anterior lamellar keratoplasty (ALK)] were affected differently with the pattern of change being dependent on region-specific factors. Conclusion: Both donor tissue volumes and rates of corneal transplant procedures were affected by lockdown restrictions. The underlying etiology of these changes differed by region. Examining the range of impact across many countries as well as the contributing factors involved will provide guidance for future global pandemics.

DMEK surgical training: An instructional guide on various wet-lab methods.

Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of the Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques, such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection, and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be more challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool, especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and nonhuman models with instructional videos. This article should eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques.

Comparison of conjunctiva-related complications between scleral and corneal patch grafts in Ahmed glaucoma valve implantation.

Purpose: Comparison of the conjunctiva related complication rates and success rates among eyes with Ahmed glaucoma valve (AGV) implantation in which eye bank derived scleral and corneal patch grafts had been used to cover the tube. Methods: Retrospective comparative study. Patients who underwent AGV implantation between January 2000 to December 2016 were included. Demographic, clinical data, intra and post operative data was obtained from electronic medical records. Conjunctiva related complications were divided into two groups: with and without implant exposure. Conjunctiva related complication rates, success rate, risk factors among eyes with corneal and scleral patch graft were compared. Results: Three hundred and twenty three eyes of 316 patients underwent AGV implantation. Scleral patch graft was used in 214 eyes of 210 patients (65.9%) and corneal patch graft was used in 109 eyes of 107 patients (34%). Median follow up was 14 months. There was no significant difference in the conjunctiva related complication rate (7.3 % in corneal patch graft versus 7.0% in scleral patch graft;p=0.5) and conjunctival dehiscence rate (3.7% versus 4.6%, P = 0.7) among the two groups. Success rate was significantly higher in the corneal patch graft group versus the scleral patch graft group (98% versus 72%; p=0.001). Eyes with corneal patch graft had a higher survival rate (P = 0.01). Conclusion: There was no significant difference in the rate of conjunctiva related complications following corneal and scleral patch grafts used to cover the AGV tube. Eyes with corneal patch graft had a higher success rate and survival rate.

[Risk factors for failure of pre-cut eye bank UT-DSAEK grafts]. / Évaluation des greffes UT-DSAEK prédécoupées en banque multi-tissus.

INTRODUCTION: The main risk factors for graft failure in penetrating keratoplasty are well known. However, few studies have examined donor characteristics or more precise data on endothelial keratoplasty. MATERIALS AND METHODS: This was a retrospective, single-center study at the Nantes University Hospital, aiming to identify factors predictive of one-year success or failure of eye bank UT-DSAEK endothelial keratoplasty grafts prepared between May 2016 and October 2018. The outcome measure was success or failure at 12months post keratoplasty. RESULTS: One hundred and five grafts were included: 93 successes and 12 failures at 12months. The failure rate was higher in 2016 compared to 2017 and 2018. The characteristics associated with higher failure rate were elderly donor, shorter time between harvesting and grafting, lower endothelial cell density, significant pre-graft endothelial cell loss, re-graft for Fuchs dystrophy, history of corneal transplant. DISCUSSION: Our results are consistent with those in the literature. However, some factors, such as the type of corneal harvesting or pre-graft endothelial cell loss, were not found. UT-DSAEK has demonstrated better results than DSAEK, but still appears to be somewhat inferior to DMEK. CONCLUSION: The main factor for graft failure in our study was an early re-graft within 12months. However, the low incidence of graft failure limits interpretation of these results.

Pterygium surgery with lyophilized versus cryopreserved amniotic membrane graft.

PURPOSE: To evaluate surgical outcomes (recurrence rate, aesthetics and symptoms) of pterygium surgery with two different amniotic membrane preservation approaches - lyophilized (LAM) and cryopreserved (CAM). METHODS: Primary pterygium patients were randomized to either LAM or CAM surgery. Demographic data, ocular surface disease index (OSDI), aesthetic grading (1 to 4), recurrences and complications were recorded over a 6-month follow-up period. RESULTS: Twenty-nine patients were recruited. Recurrence at month 6 was detected in 11 cases (37.9%) and was more prevalent with CAM grafts, without reaching statistical significance (P=0.196). Aesthetic outcome grading showed no differences between LAM and CAM at month 6 (P=0.124). Aesthetic results were mostly unsatisfactory (grade 3 and 4) without statistical differences between groups (P=0.514). Baseline OSDI was similar in both groups (P=0.888), and it significantly decreased by the last follow-up visit (P<0.001) for both the LAM and CAM groups. This decrease did not significantly differ between amniotic membrane preservation approach surgery groups (P=0.714). CONCLUSION: LAM might be considered a legitimate alternative to CAM, showing no inferiority in outcomes, since clinical and aesthetic outcomes were similar for both groups.

Effect of Low-Temperature Preservation in Optisol-GS on Preloaded, Endothelium-Out DMEK Grafts.

The aim of the study was to assess different temperature ranges for the preservation of pre-loaded Descemet Membrane Endothelial Keratoplasty (DMEK) grafts in the DMEK RAPID Mini device. METHODS: Three groups of 15 DMEK grafts (five per group) were pre-loaded in the DMEK RAPID Mini and preserved in Optisol-GS for 72 h at different temperatures: group A at >8 °C, group B between 2-8 °C and group C at <2 °C. After stripping and preservation, the viability of the endothelium, cell loss and morphology were assessed through light microscopy following trypan blue and alizarin red staining. RESULTS: Overall mortality was 4.07%, 3.97% and 7.66%, in groups A, B and C, respectively, with percentages of uncovered areas of 0.31%, 1.36% and 0.20% (all p > 0.05). Endothelial cell density variation was 5.51%, 3.06% and 2.82% in groups A, B and C, respectively (p = 0.19). Total Endothelial Cell Loss (ECL) was 4.37%, 5.32% and 7.84% in groups A, B and C, respectively (p = 0.39). Endothelial cell morphology was comparable in all three groups. CONCLUSIONS: In the DMEK RAPID Mini, low temperatures (<2 °C) may affect the quality of pre-loaded grafts, inducing a higher ECL after 72 h of preservation, although no significant differences among groups could be proved. Our data would suggest maintaining grafts loaded in the DMEK RAPID Mini at temperatures between 2-8 °C for appropriate preservation.

The usefulness of lutein/trypan blue vital dye for the staining of corneal endothelium: a pilot study on DMEK pretreated tissues.

PURPOSE: The study aims to evaluate the usefulness of lutein/trypan blue vital dye for the staining of corneal tissues and endothelium-Descemet membrane (EDM) for Descemet membrane endothelial keratoplasty (DMEK). METHODS: Sixteen human corneal tissues (Eye Bank, Rome, Italy) were used. Corneal endothelium was tested at 25 s (T0), 1 min (T1), 2 min (T2), and 4 min (T4) from dye addition. Staining intensity and cell counting were compared. Stripped EDM was analyzed for selected apoptotic (AP, caspases, BCL2, BAX) and differentiation (VEGF-A, TGF-ß1RI, SMAD3/7, SMA) targets and changes in target expression. Protein extracts were analyzed through SDS-PAGE/IB. RESULTS: Although trypan blue staining produced the same color intensity of lutein/trypan blue dye in half the time, lutein/trypan blue reached a good and adequate color intensity at T4, which persisted even on excised and washed EDM grafts. Lutein/trypan blue-stained EDM showed a reduced number of blue-stained cells and AP immunoreactivity was significantly reduced in the same samples. An increased BCL2 transcript and a reduced BAX transcript were detected in lutein/trypan blue-stained EDM. No significant changes were observed for the main effector caspases (3/9) upon both treatments and the target genes representative of endothelial cell trans-differentiation (TGF-ß1RI, SMAD3/7, SMA). A trend in vascular endothelial growth factor (VEGF-A) regulation was observed in lutein/trypan blue-treated EDM grafts. CONCLUSION: Obtained results suggest that lutein/trypan blue dye deserves attention in the DMEK field and support the potential routine use of this dye as a valid alternative to trypan blue for all procedures devoted to the assessment of endothelial cell viability and visualization of EDM graft before DMEK grafting.

Comparison of corneal endothelial cell density and morphology with Optisol GS and Life4C storage media in the eye bank: a 5-year retrospective analysis.

Purpose: Optisol GS and Life4C are corneal storage media used by eye banks worldwide. We sought to determine if either solution was associated with superior corneal endothelial cell density (ECD) or morphology in a large cohort of donor corneas. Methods: From January 2016 through December 2020, 10,316 corneas from 5,624 unique donors were acquired and analyzed at Rocky Mountain Lions Eye Bank. In April 2019, Life4C replaced Optisol GS as the sole storage medium. We compared ECD and morphology before and after April 2019, and excluded corneas processed within the transition period. Univariable and multivariable regression analyses accounted for age, sex, tobacco use, heavy alcohol use, and diabetes. Only right corneas were analyzed to account for the correlation between eyes. Results: Of 5042 right corneas analyzed, 3486 were stored in Optisol GS and 1556 in Life4C. There was no significant difference in ECD across groups (2794 vs. 2793 cells/mm2 in Optisol GS and Life4C, p=0.88). In multivariate analyses, there was no significant difference in corneal ECD (0.6 cells/mm2 higher with Life4C, p=0.96) or hexagonality (0.22% higher with Life4C, p=0.31). However, the coefficient of variation was significantly lower in the Life4C group (-0.0039, p=0.03). After adjustment for above factors, corneas in Life4C demonstrated a 3.1% decreased likelihood of exhibiting CV values greater than 0.40 (p=0.009). Conclusions: This study demonstrates comparable and favorable outcomes using both storage media and confirms their overall efficacy. The decreased CV in Life4C is not of clinically significant magnitude, but merits further research in clinical and long-term settings.

Transcriptional Profiling Provides New Insights into Organ Culture-Induced Changes in Human Donor Corneas.

Corneal transplantation is one of the most common forms of tissue transplantation worldwide. Donor corneal tissue used in transplantation is provided by eye banks, which store the tissue in culture medium after procurement. To date, the effects of cell culture on human corneal tissue have not been fully elucidated. Using the 3' RNA sequencing method for massive analysis of cDNA ends (MACE), we show that cultivation of corneal tissue leads to significant changes in a variety of molecular processes in human corneal tissue that go well beyond aspects of previously known culture effects. Functionally grouped network analysis revealed nine major groups of biological processes that were affected by corneal organ culture, among them keratinization, hypoxia, and angiogenesis, with genes from each group being affected by culture time. A cell type deconvolution analysis revealed significant modulations of the corneal immune cell profile in a time dependent manner. The results suggest that current culture conditions should be further refined and that prolonged cultivation may be detrimental. Recently, we showed that MACE enables transcriptional profiling of formalin-fixed and paraffin-embedded (FFPE) conjunctival tissue with high accuracy even after more than 10 years of storage. Here we demonstrate that MACE provides comparable results for native and FFPE corneal tissue, confirming that the technology is suitable for transcriptome analysis of a wide range of archived diseased corneal samples stored in histological archives. Finally, our data underscore the feasibility of bioinformatics cell-type enrichment analysis in bulk RNA-seq data to profile immune cell composition in fixed and archived corneal tissue samples, for which RNA-seq analysis of individual cells is often not possible.

Microbiological Testing of Split-Cornea Transplantation.

PURPOSE: By splitting a donor cornea into an anterior and a posterior donor lamella, the need for donor tissue can be reduced in times of lack of donors. Current eye bank regulations limit the use of each donor cornea to one recipient. METHODS: The anterior lamella not applied to the patient after each sterile DMEK preparation performed was stored for one week and was microbiologically controlled on day 7. RESULTS: Between October 2020 and December 2021, microbiological controls of 108 consecutive anterior lamellae were performed at the Department of Ophthalmology, University of Duesseldorf, without any contamination found. CONCLUSION: Our data suggest split-cornea transplantation is a microbiologically safe procedure.

Impact of the COVID-19 pandemic on the trends in corneal donor mortality data from Eye Bank records in India.

Purpose: To describe the causes and trends of corneal donor mortality from eye bank data in India during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This retrospective eye bank-based study included 13,529 donors who donated their cornea between January 2018 and December 2021. Donors in whom the cause of mortality was documented were included as cases. The data were collected from the eye bank records. Results: Overall, 13,529 corneal donors were included in the study. Most of the donors were males (69.71%). The mean age of the donors was 51.55 ± 20.54 years, whereas the median age was 51 (inter-quartile range: 35-68) years. The mean age of males (49.3 ± 19.47 years) was lesser than the mean age of females (56.72 ± 21.94 years) at the time of donation. The most common age group at the time of donation was during the sixth decade of life with 2,139 (15.81%) donors. The mean age of the donors decreased by a decade from 54.95 ± 20.51 years in 2018 to 44.35 ± 18.88 years in 2021. The most common cause of donor mortality was cardio-respiratory arrest in 5,190 (38.36%) donors and trauma in 3,469 (25.64%) donors, followed by suicide in 2,790 (20.62%) donors. The trend of cardio-respiratory arrest decreased from 53.01% to 9.5% (p = <0.00001), whereas the trends of trauma increased from 21.93% to 36% (p = <0.00001) and suicide increased from 12.71% to 36.41% (p = <0.00001) between 2018 and 2021. Conclusion: Corneal donors are more commonly males in their sixth decade of life. The most common cause of donor mortality was related to cardio-respiratory arrest with a concerning rising trend in suicide cases over the years seen significantly during the pandemic.