Australian Nurse Engagement in Eye Care: A National Survey.

Purpose: An estimated 13 million Australians live with one or more chronic eye conditions, with prevalence increasing. Eye care services today and in the future rely on effective workforces, in which nurses play a pivotal role. Despite nurse involvement in eye care, there is no information describing their engagement, deployment, training, and opinion. This paper offers the first review of nurse engagement in eye care in Australia. Methods: We conducted an e-survey on Australian nurse engagement in eye care. Quantitative questions were analysed by descriptive, chi-square and bivariate correlation coefficients with assumed power of 0.80, and significance of p=0.05. Grounded theory, sentiment and saturation analysis extracted key themes, meaning and opinion from the qualitative questions. Results: There were n=238 Australian nurse participants. Results indicated they were satisfied with their role, engaged in a wide range of healthcare and eye care setting and organisations, and adapted to their employer. Task-shifting "to" and "from" nurses was not universally supported but recognised by participants as necessary. Of concern, the results suggested that 68.6% of our participants would exit eye care over the next ten years, with insufficient entry pathways into the field for graduate and early-career nurses. Conclusion: For Australia to meet and sustain eye care services for its population, steps must be taken to improve exposure and entry to the field for students, graduates, and early-career nurses. Strategies to train and prepare nurses for task-shifting are urgently required and the eye care nursing sector must professionalise to achieve positive change.

Exploring single-cell RNA sequencing as a decision-making tool in the clinical management of Fuchs' endothelial corneal dystrophy.

Single-cell RNA sequencing (scRNA-seq) has enabled the identification of novel gene signatures and cell heterogeneity in numerous tissues and diseases. Here we review the use of this technology for Fuchs' Endothelial Corneal Dystrophy (FECD). FECD is the most common indication for corneal endothelial transplantation worldwide. FECD is challenging to manage because it is genetically heterogenous, can be autosomal dominant or sporadic, and progress at different rates. Single-cell RNA sequencing has enabled the discovery of several FECD subtypes, each with associated gene signatures, and cell heterogeneity. Current FECD treatments are mainly surgical, with various Rho kinase (ROCK) inhibitors used to promote endothelial cell metabolism and proliferation following surgery. A range of emerging therapies for FECD including cell therapies, gene therapies, tissue engineered scaffolds, and pharmaceuticals are in preclinical and clinical trials. Unlike conventional disease management methods based on clinical presentations and family history, targeting FECD using scRNA-seq based precision-medicine has the potential to pinpoint the disease subtypes, mechanisms, stages, severities, and help clinicians in making the best decision for surgeries and the applications of therapeutics. In this review, we first discuss the feasibility and potential of using scRNA-seq in clinical diagnostics for FECD, highlight advances from the latest clinical treatments and emerging therapies for FECD, integrate scRNA-seq results and clinical notes from our FECD patients and discuss the potential of applying alternative therapies to manage these cases clinically.

A Scoping Review on Determining Australian Nurse Engagement in Eye Care Settings.

Purpose: As the Australian population grows and ages, the demand for eye care services, and nurses to provide the services, is expected to increase. This will impact nurses, who are Australia's largest health-care provider group. Understanding and mapping the current role and use of nurses in eye care is an essential first step for future health workforce planning and development. To map their engagement, we undertook a scoping review to gain an understanding of the current Australian nurse eye care workforce landscape, to help guide and support future workforce development activities. Secondly, we evaluated if publications in this field incorporated or mentioned the Australian Ophthalmic Nursing Association's National Standards (Practice standards) in their publication. This review also offers other nations and eye care providers the opportunity to evaluate their own health workforce plan and nurse utility. Study Design and Methods: We conducted a review of academic and grey literature, via various search engines, and an inclusion and exclusion criteria. Results: We uncovered 11 publications. Of those, five were academic papers examining extended and advanced nursing practice, one was a letter to the editor, two were industry feature reviews, two were industry reports and the final was the Practice Standards. Key themes throughout indicated the benefit of nurse training and nurse involvement in eye care. Overall, there was insufficient information or data to describe nurse deployment, practice and utility. Finally, the Practice Standards were not referenced in any publication. Conclusion: There is insufficient published information to calculate the level and involvement of nurses, or describe their existing role, advancement or future deployment in eye care in Australia. Without clear information, Australia is unable to develop effective health workforce strategies to attract, train, retain, and appropriately deploy nurses to meet future eye care needs.

Examining Corneal Tissue Exportation Fee and Its Impact on Equitable Allocation.

METHODS: We conducted grounded theory semistructured interviews, purposively inviting participants until themed saturation was met. Sentiment analysis was used to determine opinion. RESULTS: We interviewed n = 92 global eye tissue and eye bank professionals. We determined that corneal tissue, which is exported, costs between US $100 and US $6000 or is provided as gratis. Collectively, interviewees indicated that, globally, there were no fixed fee structures in place, and the fee was influenced by multiple factors on both export and import sides. They indicated that ultimately corneas were allocated based on the importers' ability to pay the price determined by the exporting eye bank. DISCUSSION: Allocation of corneal tissue, which is exported, is influenced by the fees charged by the exporters to meet their bottom line and the funds available to importers. Therefore, export allocation is not equitable, with those who can pay a higher fee, prioritized. Steps to guide and support exporters with the development of fee structures that promote equitable allocation are essential. This will assist both export and import eye bank development, corneal tissue access development, and those awaiting a corneal transplant.

Do Corneal Tissue Providers Inform Their Community That They Export Corneas? An Audit of Publicly Available Sector Websites.

AIM: The exportation of corneas from one nation to another, for transplantation services, is responsible for 23% of all global transplants. Global allocation is possible because of the end-of-life donations from citizens and residents of export nations. To date, there is no information indicating if export nation donors are aware that their corneas may be exported, nor if organizations that export provide information regarding their export engagement to their community. To ascertain if and how exporters inform their community, we audited known export organization public websites. MATERIALS AND METHODS: We designed and conducted a double-blind audit of known exporting eye banks, eye tissue sharing and distributor organization websites. RESULTS: We audited 79 websites, from 9 nations. Of the 79, 46 (58.2%) did not mention corneal tissue exportation, 17 (21.5%) implied exportation, and 16 (10.2%) explicitly mentioned it. Of the 16 that mentioned they exported, 75% (12/16) provided information regarding their export license, and 12.5% (2/16) indicated partnership with a third party. We could not locate information explaining how organizations decided on how and to whom they export. DISCUSSION: Organizations that export corneal tissue across national borders do not share sufficient information regarding their export activities on their website. The general public and donors within export nations may not be aware that this practice occurs or could occur with their donation. Export organizations and the eye tissue sector must evaluate their communication strategies and collaborate, preferably nationally, to develop publicly appropriate information regarding corneal tissue exportation.

Corneal supply and the use of technology to reduce its demand: A review.

Recovery and access to end-of-life corneal tissue for corneal transplantation, training and research is globally maldistributed. The reasons for the maldistribution are complex and multifaceted, and not well defined or understood. Currently there are few solutions available to effectively address these issues. This review provides an overview of the system, key issues impacting recovery and allocation and emphasises how end-user ophthalmologists and researchers, with support from administrators and the wider sector, can assist in increasing access long-term through sustaining eye banks nationally and globally. We posit that prevention measures and improved surgical techniques, together with the development of novel therapies will play a significant role in reducing demand and enhance the equitable allocation of corneas.

Determining the willingness of Australians to export their corneas on death.

BACKGROUND: 12.7 million people await a corneal transplant, but 53% are without access to corneal tissue. Sharing corneal tissue across nations can provide some access, however the willingness of export populations, like Australians, to export their donation on death, has never been evaluated. Our research samples the Australian population, determining their willingness to export. MATERIALS AND METHOD: We conducted e-surveys. N = 1044 Australians participated. The sample represented the Australian population, based on population demographics. Chi-Square and bivariate correlation coefficients examined associations between categorical variables, with a sample size of N = 1044, power of 0.80, and alpha of p = 0.05. Outcome measures were based on population sampling, by exploring willingness export, through the e-survey method. RESULTS: 38% (n = 397) of respondents said yes to exportation, 23.8% (n = 248) said no, and 38.2% (n = 399) were undecided. We found no relationship between willingness to export and general demographics, though those registered on the Donatelife Register (p = < .001), and those already willing to donate their eyes (p = < .001) were significantly more willing to export. DISCUSSION: More Australians are willing to export their corneas than not, though a significant portion remain undecided. The Donatelife Register, and donation awareness, are key components of respondent decision making. Therefore, the provision of information about exportation prior to, and at the point-of-donation, is essential for assisting Australian's to decide to export or not. Further examination and development of consent-for-export systems are necessary before routine exportation is undertaken.

Do Eye Bank Models and Competitive Practice Affect International Cornea Allocation?

PURPOSE: International export and import of corneas is dependent on the stakeholders involved in the process and how those organizations engage to move corneas from one point to another. Our article presents the pathway of corneal donation from the export nation until its use in the import nation. It presents opinion on how aspects, such as competition and promotional behaviors, the use of online systems, and third-party engagement may influence allocation. METHODS: We interviewed n = 92 international eye tissue and eye bank (EB) professionals to garner their opinion. We used saturation and sentiment methods to extract and consolidate group opinion. RESULTS: Interviewees indicated that competition and promotional behaviors existed in some EB nations-although it was not universal. They indicated that the behavioral approach used by the individual EB, rather than the act of information sharing, influenced allocation. They also indicated that organizational models and allocation systems (eg, online ordering) and engagement with nonstate actors were important in allocation practice and decision making. CONCLUSION: We mapped the pathways for corneas involved in export and import from the point of recovery to their point of transplantation. Although generalist in nature and limited by the paucity of the existing literature, our article outlines that different business models, partnerships, and applied methods influence corneal export and import.

Should Donors Consent to Export Their Corneas? Examination of Eye Tissue and Eye Care Sector Opinion.

PURPOSE: Corneal tissue international activity is only possible because of the willingness of export populations to donate their corneas on their death. Current predonation public education campaigns and at-the-point-of-donation consent practice generally includes consent for transplantation, research, and/or training. It is unclear whether a consent-for-export step is universally included in the consent process or, indeed, whether it should. We interviewed eye tissue and eye care professionals from around the world, who exported, imported, or did neither to understand current consent-for-export awareness and determine opinion on future practice. METHOD: During wider qualitative grounded-theory semistructured interviews with sector experts, to determine whether Australia should export, we captured sector opinion on consent-for-export. We used saturation and sentiment methods to determine opinion and χ2 correlation coefficients to examine association, using an α of P = 0.05. RESULTS: We interviewed 92 individuals, 83 of whom discussed consent-for-export. Of those, 51% (42/83) demonstrated some awareness of the practice; however, there were contradictions between interviewees from the same location. Regardless of current awareness, 57% (41/72) believed donors should be informed or consented for export. Their approval did not extend to donor-directed decisions, which would allow donors to decide which nation their donation should be sent, with 62.5% (45/72) opposing that notion. CONCLUSIONS: Our research indicates that the consent-for-export practice is not universally applied by exporting nations and that eye tissue and eye care professionals have limited awareness of the practice. Universally implementing a consent-for-export step within general consent practice would improve awareness, reduce confusion, and support donor wishes.

Supply and Demand of Domestic Corneal Tissue and Its Implications on Export Potential-Using Australia as an Example.

PURPOSE: Corneal tissue importation is only possible if another country is able to export corneas without impacting its own domestic demand. Currently, there is little evidence to indicate whether export nations have such surplus capacity and in a position to export. To explore this concept, we examined our nation, Australia, which is reported to routinely decline donations because of its ability to meet domestic corneal transplant demand. Our research offers insights and opportunities for Australia and other nations to evaluate their domestic and international supply and allocation of corneal tissue in this space. METHOD: We collated 12 months of data on collected and noncollected donations, through participating Australian Eye Banks. The explanation of why some known donors were declined or not pursued indicated if demand was met and potential surplus-for-export levels. RESULTS: There were 7.5% (n = 11,889) of deaths in Australia that were notified to Australian Eye Banks during our reporting period. Of those, 9.3% (n = 1106/11,889) were recovered and allocated, 15.7% (n = 1863/11,889) were known but declined, and 75% (n = 8920/11,889) were not pursued. Of those that were declined, 64.3% (n = 1197/1863) were declined because of limitations with service/manpower at the eye bank, whereas 35.7% (n = 666/1863) were declined because demand was met. CONCLUSIONS: Australia did not meet demand all the time, during our data period. There were adequate quantities of potential donors to support increasing recovery for domestic allocation and provide for exportation without hindrance to Australian demand. Further examination of domestic supply and demand cycles and the export process is required before routine exportation.

Ocular Tissue for Research in Australia: Strategies for Potential Research Utility of Surplus and Transplant-Ineligible Deceased Donations.

A 2016 Price Waterhouse Cooper Report, commissioned by the Australian Commonwealth Government's Organ and Tissue Authority, indicated that Australia had been meeting its human ocular tissue for transplant needs. It further suggested that Australia should consider exportation as a management strategy for excess tissue. Although we do not seek to discuss how the Price Waterhouse Cooper Report determined that need was being met, nor the potential value of exportation in this article, we propose that Ocular Tissue for Research (OTR), and particularly identification of donors for research, and timely access to fresh domestic tissue, be considered as an alternate or simultaneous surplus management strategy. A robust OTR system could provide long-term domestic support and investment into research and development of therapies in Australia. Such a system would also provide a meaningful donation option for those otherwise unable to donate for transplant. This article attempts to document, for the first time to our knowledge, the current recovery and distribution processes of deceased OTR in Australia. It maps the process steps, identifies the stakeholders and needs, discusses the limitations and barriers, and proposes key policy and practice reform strategies that may assist in improving access to OTR. Translational Relevance: To improve and increase access to human ocular tissue for research, and in turn, advance vision science and clinical application.

Should Nations With Surplus Donated Corneal Tissue Export to Those Without? A Review of Sector Opinion Through the Example of One Nation-Australia.

PURPOSE: There is a global demand for corneal tissue (CT) for transplantation, with some nations potentially able to export donations to those nations without. Unfortunately, there remains a global paucity of information that explains the process of exportation and importation (transnational activity), supports or defines practice, or informs those seeking to engage. Without knowledge, inclusive of the pros and cons, participating nations and decision makers are unable to make effective and informed decisions. METHODS: Through the example of our own nation, Australia, which may be entering a surplus-to-domestic demand phase and able to export, we conducted qualitative grounded-theory semistructured interviews with sector experts. Our approach ascertained whether Australia should export and under what arrangements. Through saturation and sentiment methods, we capture for the first time, global opinion on CT transnational activity (although primarily exportation), key themes, and finally determine whether Australia should engage. RESULTS: Eighty-four (91%) of 92 participants directly commented on our question "should Australia export corneal tissue?" Of 84, n = 67 (80%) stated yes, n = 17 (20%) indicated mixed opinions. No participant categorically stated that there should be no export. CONCLUSIONS: Eye tissue and eye care experts whom we interviewed, supported the concept of Australia exporting CT; however, they advise several safeguards to protect both import and export nations. Principally, they recommended practice be transparent with donors, nationally coordinated, part of a wider humanitarian program, nonprofit, short term for the importing nations as they move toward self-sufficiency and that Australia must define and confirm domestic need and ensure that demand is met before routine exportation.

Examining the Impact of Corneal Tissue Transnational Activity, and Transplantation, on Import and Export Nations: A Review of the Literature.

PURPOSE: Globally, an estimated 12.7 million people await a corneal transplant. Of these, 53% are without routine access to a domestic supply and are reliant on transnational activity (TNA) (importation) of corneal tissue (CT) for transplantation. Although CT TNA commenced in 1961, there has been no evaluation of its impact on import and export nations. METHODS: We wished to examine the impact of clinical and nonclinical CT TNA on export and import nations, with nonclinical aspects our primary focus, to help guide future practice. We conducted a review of the academic literature through various search engines. We prefix and place our review in the relevant historical practice and global context. RESULTS: Despite commencement in 1961, we only located 14 studies (11 clinical and 3 nonclinical) pertaining to CT TNA. These were published between 1991 and 2018. Clinical papers reported death-to-preservation time, preservation-to-transplantation time, logistics, donor and recipient selection, and quality as relevant. Nonclinical studies identified emerging themes pertaining to financial, ethical, and sustainability aspects of TNA. CONCLUSIONS: All aspects of CT TNA are grossly under-reported, resulting in our inability to effectively analyze the overall impact to export and import nations. The few clinical studies in our review concluded that despite endothelial cell loss and other risk factors, imported CT appears comparable with domestic CT and remains an option in the absence of domestic supply. Nonclinical aspects (eg, ethical, equitable, and economic) have also not been adequately addressed.

Ethical Issues in Transnational Eye Banking.

PURPOSE: To review ethical issues that may arise in the setting of transnational eye banking activities, such as when exporting or importing corneal tissue for transplantation. METHODS: A principle-based normative analysis of potential common dilemmas in transnational eye banking activities was performed. RESULTS: Transnational activities in eye banking, like those in other fields involving procurement and use of medical products of human origin, may present a number of ethical issues for policy makers and professionals. Key ethical concerns include the potential impact of export or import activities on self-sufficiency of corneal tissue supply within exporting and importing countries; potential disclosure requirements when obtaining consent or authorization for ocular tissue donation when donations may be exported; and difficulties inherent in assuring equity in the allocation of tissues available for export and in establishing and respecting standards of safety and quality across different jurisdictions. CONCLUSIONS: Further analysis of specific ethical issues in eye banking is necessary to inform development of guidelines and other governance tools that will assist policy makers and professionals to support ethical practice.