VISION of MERCY

On the afternoon of Oct. 1, a violent death set in motion a chain of events that ended with a minor medical miracle. Involved in the outcome were ordinary people inextricably linked by grief and hope who would never know one another, and medical professionals who deal every day with death in order to enhance life. Chance, coincidence, fortunate and tragic circumstance, luck both good and bad, senselessness and selflessness and skill all played a hand. They were linked by a sliver of transparent human tissue smaller than a dime.

THE DONOR

No one can know the last image that passed into the eyes of the 15-year-old boy before he died. It might have been a final painful snapshot of the hard ground beneath his body, or of the sky above it, or it might have been an indelible picture of the gun barrel that protruded from the car window a few feet away.

The documentation of the incident is clinical: time of death, 5:17 p.m.; cause of death, a gunshot wound to the back, suffered during a drive-by shooting in Los Angeles.

It is the next fact on the sheet, however, that will galvanize a handful of people 25 miles away and set the drama in motion: slightly more than six hours after the boy died, at exactly midnight, both of his corneas--the clear “windows” that cover the colored irises--were listed as having been removed and were floating in separate small containers of pink antibiotic solution.

They resembled nothing more than clear contact lenses with a slightly ragged white edge, seemingly inconsequential. But one of those corneas--clear, healthy, undamaged, only 15 years old--would be used to restore sight and alleviate excruciating pain in a 71-year-old woman from Westminster.

THE RECIPIENT

Dorothy Radulovich never had eye problems until 1975, but after she began wearing glasses for the first time in that year, things went from bad to worse. She had cataract surgery on one eye three years later, and a second cataract surgery on the other in 1986, in which a synthetic lens was implanted in her left eye. As a result of that surgery, she said, the left cornea was damaged. It began to cloud, obscuring her vision in that eye to the point that she could barely discern colors and shapes and could make out only the outlines of objects.

Worse, the cornea developed a condition about a year ago called pseudophakic bullous keratopathy -- tiny blisters that form on the surface of the cornea. When the blisters ulcerated, said Radulovich, “it felt like ground-up glass in my eye. I never knew an eye could hurt as badly as that.”

As the condition worsened, it became clear that the only way to alleviate the pain permanently was to remove the cornea and replace it with transplanted tissue. Michael Farley, a Newport Beach ophthalmologist and one of a handful of surgeons in Orange County who specialize in cornea transplantations, put Radulovich’s name on a priority list for a donor cornea.

Meanwhile, Radulovich stayed near the telephone, waiting for the call that would summon her to surgery as soon as a suitable cornea was located.

THE EYE BANK

The boy’s body has barely arrived at the Los Angeles County Coroner’s office when technicians from the Los Angeles-based Lions Doheny Eye Bank arrive and quickly prepare to remove the cornea. Because it is a highly perishable bit of human tissue -- easily damaged, infected or dried out -- any cornea has to be removed within a few hours of death in order to remain suitable for transplant.)

In what might appear at first to be an unusual procedure in a morgue, the eye bank technicians scrub, gown and mask and prepare the sites around both eyes as they would be if the boy were alive and in surgery: the area is cleaned and disinfected, isolated and draped.

The corneas are then cleaned and gently scraped with a scalpel to remove any impurities, an incision is made around their outer edges with tiny curved scissors, and they are lifted away from the iris. A part of the white of the eye--about three millimeters worth--remains on the outer edges, ensuring that the each entire cornea is intact. The corneas are then placed immediately in antibiotic solution. The entire procedure takes about 20 minutes.

Time, however, is still short. The corneas remain usable--technically--for up to a week, but eye bank technicians say that most doctors prefer to use them within four days.

Each cornea is screened for the presence of a handful of diseases, including HIV, hepatitis and syphilis, and is “rated” according to its condition, clarity, age and other characteristics. Once this data is collected, it is entered into a computerized network used by eye banks throughout the United States and Canada and, in many cases, cleared through Tissue Banks International, based in Baltimore.

The Baltimore facility then compares the characteristics of particular corneas to the current list of requirements submitted by ophthalmologists throughout North America, and if the computer spits out a match between an available cornea and a waiting patient, the doctor and the eye bank closest to the patient are informed and the wheels begin to turn again.

Thus, on the day after the killing, and only hours after the boy’s corneas had been removed, one of them was on its way south, to the Tustin-based Eye and Tissue Bank of Orange County.

THE EYE BANK

In existence since 1970, the Eye and Tissue Bank of Orange County is, like all eye banks, a clearinghouse not only for human tissue, but for the most elemental of human emotions. Each day, the small staff is obliged to face the deep sorrow of death in order to perform what they consider their true job: restoring health.

“I’ve been in tissue banking for eight years,” said Larry Hierholzer, the eye bank’s technical program manager. “I was a pre-med student for a while, but I got sidetracked into this. My original motivation for getting into medicine was to help people, but I found that I got all the satisfaction I wanted to get out of being a doctor by doing this.”

And so, nearly every working day, Hierholzer finds himself in the morgue, at the Orange County Coroner’s office in Santa Ana. It is almost exactly that often, he said, that coroner’s deputies call the eye bank with word of a possible suitable donor. Hierholzer and other eye bank staff technicians are the ones who have not only the first contact with the just-deceased donor, but often with the donor’s family. It is their job to gently cut through the curtain of tragedy and persuade the family that tissue donation can help in some way to mitigate that tragedy. It may be business as usual for them, but it is always difficult.

“We shed some tears around here,” said the eye bank’s executive director, Merle Wingate, “but there’s such a payoff. In most cases, cornea donation is the only positive thing to come out of a tragedy. For some families, it’s like a hole in that big bubble of grief that they can breathe through.”

Within days of procuring corneas, Wingate writes a letter to the family of the donor. It offers condolences, and a reminder. A part of one recent letter was worded this way:

“Could there, in this world, be a greater gift? The giving of oneself to someone we will never know is surely man’s noblest act.”

Often, said Wingate, “three or four months later, we’ll get a call from a family member, just wanting to talk, and maybe not knowing quite what to say. And I’ll just say, ‘Mrs. so-and-so...tell me about your son.’ That’s a very positive part of what I do, and I really like what I do.”

Sometimes, she said, grateful cornea recipients want to contact donor families, but the eye banks’ codes of ethics don’t permit it. Occasionally, however, Wingate said she will forward on a particularly compelling--and anonymous--letter from a recipient to a family.

Nothing is wasted, not emotion, not tissue. Even if a donor cornea is unusable for transplant, it can be used for research and practice surgery, said Wingate. Sometimes entire eye globes, as well as corneas, are donated. Orange County surgeons and researchers have a priority claim on the tissue, but every bit of it is put to use somewhere in the North American eye bank network, said Wingate.

“We’ve had people--surgeons, families, researchers--tell us that those eyes are like precious jewels,” said Wingate.

THE SURGERY

“This isn’t really high-tech surgery,” said a gowned and masked Dr. Michael Farley, indicating the small table of very small instruments in a yellow-walled operating room in Hoag Hospital. “What it is, is cookie cutter surgery.”

It seems like an odd analogy until Farley begins measuring the dimensions of the edges of a fully anesthetized Dorothy Radulovich’s left cornea with a tiny pair of calipers. Radulovich, by this time, has been draped with sterile green cloth, the surgical site has been isolated and the eyelids are being held open with a metal speculum. Dr. Robert DaVanzo, who is assisting Farley, periodically irrigates the eye with sterile saline solution.

Farley is young, pleasant, possessed of the soft-spoken enthusiasm of the man who enjoys his work and is confident of doing it well. All his movements in the operating room are easy but deliberate, and he keeps up a running description of each stage of the operation in a matter-of-fact voice.

He became an ophthalmologist and surgeon, he says, because of the “aggressive” nature of treatment available in that specialty, the abiltity to intervene in disease or injury and engineer often dramatic results.

Farley steps to the other side of the small room and carefully lifts the donor cornea from its solution. He then places it on a small Teflon block and, with a scalpel, cuts around the edge of the cornea, removing the residual white tissue, or sclera. It comes off in a single strip, similar to an orange peel.

He inserts the cornea into a cylindrical metal cutting device called a trephine and authoritatively snaps the upper part of it downward. Inside the trephine, a sterile circular blade makes a cut a quarter millimeter larger than the incision Farley will make at the edges of Radulovich’s left cornea. This allows for a more forgiving fit.

Farley moves back to a rolling stool placed at the head of the operating table and, with DaVanzo’s help, places a second trephine--this time made mostly of white plastic--over Radulovich’s eye and fixes it in place. A syringe is connected to the assembly, and will provide suction to help seat the trephine on the cornea.

With thumb and forefinger, Farley takes a few careful turns on the trephine, incising down through the tissue around the outer edges of the cornea. He removes the trephine.

Farley now leans in and peers into the twin eyepieces of a microscope that hangs over the eye and illuminates it in a bright light. For the next hour, he will seldom back away from those eyepieces (DaVanzo assists while looking through a separate set of eyepieces mounted at a right angle to Farley’s). Working with two tiny curved scissors--one left-curving for the top edge and a right-curving one for the bottom--he deliberately snips around the edges of the cornea, making a bevel cut in the tissue. When the cuts eventually join, he lifts the cornea away from the eye.

The donor cornea, resting on the tines of a handled spatula-like metal instrument about the size of a short pencil, is then gently laid over Radulovich’s exposed iris.

The rest of the operation is almost all stitching, but it is breathtakingly precise and stunningly close work, done entirely under the microscope. A video camera in the scope shows the eye the size of a basketball on a nearby television monitor, but at the actual surgical site it is Last-Supper-on-the-head-of-a-pin work.

Two types of suturing will be done: the cornea will be tacked down at its edges with approximately a dozen individual--or “interrupted”--stitches set roughly perpendicular to the incision, and a single running suture, in a zigzag pattern, will be taken around the entire perimeter of the incision. The sutures, about the diameter of a human hair, are all but invisible to the unaided eye, and the curved needles used with each of them are about the length of a short eyelash, and not much thicker. They are, nevertheless, finely machined: not only are they pointed, but they are sharpened on both edges, like a dagger or a hunting arrow.

The goal is to create a seal so precise that it not only fits perfectly but is also liquid-tight.

Farley is deliberate, patient. He manipulates each needle on the end of a small pair of tweezers, prodding it gently through the transparent tissue. After each of the interrupted sutures is taken, he ties it off with a slip knot, which allows him to check the proper placement of the suture. If he is satisfied, he loosens the slip knot and ties off the suture with a permanent knot and snips off the ends with tiny scissors.

Periodically, Farley inserts a syringe needle into the eye and inflates it slightly with fluid. Then, using a tiny synthetic surgical sponge attached to a stick of blue plastic, he gently pokes at the edges of the incision, checking for leaks.

He ends up replacing two of the sutures.

“This’ll help me sleep better tonight,” he says as he ties off the first one. Two minutes later, after another check of the incision, his eyes crinkle. “This is where we get a little obsessive,” he says, and replaces a second suture.

Finally, satisfied with the snugness of the fit at the incision, Farley removes the speculumfrom Radulovich’s eyelids, gently closes the eye and tapes gauze patches and a green plastic shield over it. Radulovich is just beginning to wake up.

By the time she is disconnected from the intratracheal tubes and is starting to be wheeled out of the operating room, Radulovich is awake enough to recognize Farley, even behind his mask. She reaches up and gives his hand a squeeze.

Farley is pleased. He knows that he has performed one of the primary functions of the physician: to alleviate pain.

“That’s primarily what we were after,” he said. “People have likened the pain of her condition to kidney stones and childbirth. Whatever vision you get back is really secondary.”

More good news: the chances of Radulovich’s body rejecting the cornea are less than 10%, said Farley, primarily because there are no blood vessels in the cornea. And about 95% of the rejections are reversible through drug therapy.

THE RECOVERY

Radulovich is discharged from the hospital the next morning, and goes home. That afternoon, she says she has a bit of a headache, but feels fine. And the grating pain that had plagued her only 24 hours before is gone.

A week later, with the gauze permanently removed from the eye, Radulovich has begun to see things through her left eye that were impossible before. She knows, she says, that it will likely take months for the new cornea to adapt and shape itself more closely to her eye, and thereby improving her vision, but for the time being she can cover her good eye and discern something other than monochromatic outlines.

“Oh, yes,” she says with delight. “I can recognize you now, and I can see colors and shapes, not just outlines. But the wonderful thing is, I’m not in pain like I was before.

“I wish I could thank that boy’s family. I hope the other cornea helped someone else the way mine helped me.”

It did. Records at the Lions Doheny Eye Bank indicate that the boy’s second cornea went to a 39-year-old Los Angeles woman suffering from a condition called keratoconis--a progressive misshaping of the cornea that can cause drastic image distortion.

As of this writing, the woman’s sight in the eye has improved dramatically.

How a Cornea Is Transplanted The cornea is a clear membrane that protects the iris and pupil. When it becomes damaged or cloudy, it can be removed and replaced by the cornea from a donor. How the damaged cornea is replaced: 1) Recipient’s cornea is cut with a special circular blade; tube and syringe provide suction to keep blade securely on the eye; cut is made by turning the blade. 2) Surgeon uses curved scissors to snip away recipient’s cornea. 3) Donor cornea is dropped into place with a spatula. 4) Twelve individual stitches and one long, zigzag stitch provide a watertight seal. Source: “Color Atlas of Ophthalmic Surgery,” Kenneth W. Wright.