The study was conducted among the attendants of patients (relatives or friends) visiting outpatient departments of the General Hospital and two peripheral clinics in Melaka, Malaysia. The study period was from August 2007 to October 2007. Anticipating a prevalence of 80% awareness, 4% absolute precision, and 95% confidence level, the minimum sample size required was 384.[⁵]

Malaysia being a multiracial country, a total of 400 subjects of Malay, Chinese, and Indian races participated in the study. The mean age of participants was 37.93 years (standard deviation [SD] 15.1 years) with a range of 18–75 years. A slight female preponderance of 55.7% was seen. The ethnic distribution was 269 (67.3%) Malays, 77 (19.3%) Chinese, and 54 (13.5%) Indians. Fifty-three subjects (13.2%) had either no formal education or primary education only, 245 (61.3%) had secondary education, and 102 (25.5%) were graduates or postgraduates.

The awareness of eye donation was found to be 69% (n = 276). Univariate analysis [Table 1] showed that individuals with a higher education level (graduate and above), the younger age group (18–45 years), individuals of paramedical occupation, and females were more aware of eye donation (P < 0.05). However, on multivariate analysis [Table 2], only the female gender was significantly associated with the awareness of eye donation (P = 0.009).

Of the 276 participants, who were aware of eye donation, 95 (34.42%) were willing to donate eyes. Univariate analysis showed that Indian race and males were more in favor of donating eyes (P < 0.05) [Table 3]. Multivariate analysis [Table 2] confirmed that gender and race are independent factors contributing to willingness to donate eyes.

Among those who were aware (n = 276) about eye donation, 88% knew that eyes could be donated only after death. No disfigurement of the face as a result of eye donation was documented by 76.2% of participants. Anonymity about the donor and recipient was known to 74.5% of participants. The most important source of awareness was the media (55.4%) with newspapers topping the list (36.7%). The fact that the next of the kin had the right to give consent was known to 55.6%, but 36.2% were not aware that the eyes could be preserved after retrieval. The following were misconceptions: 90.3% of the participants thought that eyes could not be retrieved at the house of the deceased, and 43.3% felt that the whole eyeball was transplanted to the patient.

There was no statistically significant association between most questions (appendix) regarding the knowledge of eye donation and race; however, 31% of Indians reported that eye donation was against their religion while the corresponding percentages reported by Chinese and Malays were only 12% (P = 0.011).

In the present study, 69% of the participants were aware of eye donation; the Chinese population was less aware of eye donation compared to Malays and Indians. In contrast, a study by Yew et al. showed a better awareness (80.7%) among Singaporeans, and Chinese were more aware of eye donation when compared to Malays and other races.[⁵]

The region-specific factors may influence the knowledge of eye donation in different parts of the world. A study by Priyadarshini et al. showed an awareness of 50.69% among the patients attending two outreach clinics in southern India.[⁷] However, the awareness was only 30.7% in the rural population of south India, compared to 73.8% in the urban population of India.[^{8, 9}] A study by Tandon et al. in Delhi found that 55.4% next of kin were aware of the concept of eye donation.[¹⁰]

Although 69% of the participants had the awareness about eye donation, the willingness to donate eyes was seen in only 34.42%. This finding of better awareness than willingness to donate eyes is well observed in the study by Yew et al. in Singapore (awareness 80.7% and willingness 67%).[⁵] Also, the study by Tandon showed that the prior knowledge of eye donation, literacy, and socioeconomic status had no influence on willingness for eye donation and major reasons for not donating eyes included refusal to discuss the issue and dissuasion by distant relatives, legal problems, and religious beliefs.[¹⁰]

In our study, Indians were more willing to donate eyes compared to Malays and Chinese, although our study showed that 31% of the Indians felt eye donation is against their religion while only 12% of Malays and Chinese shared the same opinion. Many studies have shown that ethnicity has an important role in the willingness of organ donation.[¹¹–¹³] Probably, the reasons for the unwillingness could have been culture-specific issues arguing against donation including a sense of the sacredness of the body, belief that it is important to have an intact body after passing away and fear of illegal trade in organs and the poor would suffer.[^{5, 11, 14}]

In the present study, 84.5% were aware that eye donation is not against their religion and 76.2% knew that it does not cause any disfigurement of the face. In contrast, other studies have shown a concern among the respondents, like disfigurement of the face of the deceased, fear that it is against their religious belief, and may be time-consuming thus delaying the funeral process.[¹⁵]

Educational status showed a positive impact on the awareness of eye donation but did not show any statistically significant effect on the willingness to donate eyes. However, Yew et al. have found that the knowledge and willingness is more due to the higher educational status in Singaporeans.[⁶] According to a study by Shahbazian et al., “age, sex, and occupation did not influence the attitudes; however ethnicity, educational level, economic status, and having a loved one in need of an organ significantly increased the willingness for organ donation.”[¹²]

In our study, although females were more aware of eye donation, similar to the observations by Krishnaiah et al., they were reluctant to donate eyes.[⁸] Unwillingness among females may be because of their family ties and the necessity to seek permission from the family members before pledging their eyes. Hayward et al. have shown that women were more concerned about the transmission of diseases or of personality following organ donation.[¹⁶] The older age group was more willing to donate eyes compared to the younger age group again consistent with the Indian study.[⁸]

According to the National Eye Survey 1996, corneal pathology accounts for 15.1% of the childhood blindness in Malaysia.[²] The majority of the donor corneas were imported from the USA (n = 112 or 71%) and Sri Lanka (n = 27 or 17%).[¹⁷] The eye donation among the local ethnic groups was a total of 19, of whom 8 were Chinese (42%), 6 Indians (32%), and 4 were Malays (21%) in year 2005 and data was not available in one case.[¹⁷] In year 2004, none of the Malays had donated eyes and the new transplant rate was 7 per million populations in 2004.[¹⁷] This clearly indicates though there is a great demand of donor eyes, the donation in the community is very less. Studies show that there was poor awareness about the “Fatwa” regarding organ donation, passed by the Muslim law council in 1995.[^{15, 18}] This lack of awareness has led to the fear of doing something against religion by donating organs among the population.[^{15, 18}]

Thus, to make this dream of reducing the burden of avoidable corneal blindness, the ophthalmologists, general physicians, nongovernmental organizations (NGOs), and especially the religious leaders have to work in unison to educate and motivate people to donate eyes.

Source of Support: Nil

Conflict of Interest: None declared.

Melaka Manipal Medical College, Melaka, Malaysia, General Hospital, Melaka, Klinik Kesihatan Peringgit, Melaka, Klinik Kommunity Ayer Keroh, Melaka

Dr. Anusiah Head of Department of Ophthalmology, General Hospital, Melaka, Dr. Manjunath Nandannevar Assistant professor Department of Medicine. Melaka Manipal Medical College, Melaka, Malaysia, Dr Aadi Negera, Associate professor Department of Conmmunity Medicine, Melaka, Manipal, Medical college.

We would thank the above for helping us to conduct the study and those patients who participated in our study.