Blazing the Trail
Gary Wörtz, MD: Open, outspoken. It’s Ophthalmology off the Grid—an honest look at controversial topics in the field. I’m Gary Wörtz, MD.
Modern laser vision correction procedures are so sophisticated that, sometimes, performing surgery feels like pushing a magic button. While no attempt to minimize the skills needed for superior outcomes, laser vision correction has become incredibly refined and automated. But it wasn’t always that way.
This year marks the 30th anniversary of laser vision correction. To help celebrate this important landmark, I thought, who better to speak to than the fearless, talented surgeon who brought it to us in the first place?
“At that point, my cornea fellow said, ‘I can't stand this. It's too depressing. I'm leaving,’ and she left the project. My research coordinator said, ‘This is too depressing. I can't stand it. I'm leaving.’ All in 1 week, these bad things were happening. We each had one of our many, many, many conference calls, and we decided maybe the problem is that these ablations aren't smooth.“
That’s Dr. Marguerite McDonald. For those of you who don’t know, Marguerite was the first surgeon in the world to perform PRK. In this episode, Marguerite walks us through her own personal journey with myopia, her early days in a retinoblastoma clinic, and her relentless efforts to introduce a disruptive surgical procedure. Coming up, on Off the Grid.
Speaker 1: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.
Gary: Welcome back to a very special edition of Ophthalmology off the Grid. I am just so pleased to have Dr. Marguerite McDonald with us today. We're going to be talking about the very first excimer laser procedure that she performed just over 30 years ago, the first in the world. Marguerite is well known and well loved by all of her colleagues. She is a Clinical Professor of Ophthalmology at NYU and Tulane, and a cataract, cornea, and refractive surgeon at Ophthalmic Consultants of Long Island, where she practices a majority of her time at Lynbrook, New York.
Marguerite, I am just so thrilled to have you on the podcast, because your story, for those who don't know, is so interesting. As I've gotten to know you even a little bit tonight, as you've been talking, I am so excited for you to share your story, not only about how you got started in refractive surgery, but I actually want to back up a little bit and really talk about your experience as a myopic patient starting in childhood. I think it puts such a different spin on what refractive surgery means to you and what it can mean to our patients.
With that little preamble, Marguerite, give us a little bit of a taste for what myopia was like for you as a child.
Marguerite McDonald, MD: Well, I didn't know I was myopic. I thought everybody saw the world the way I did. I was already -8.00 at age 5, I was later to find out. Squinting doesn't help all that much. I sort of got through life by smell. I could smell my aunt coming in the front door because I knew what perfume she wore. I would run up to my mom and hug her, and while my face was buried in her dress, I'd say, "Oh, mom's going to be the pink blob today." I would look at this pink blob and talk to her. I really thought everybody was just like that.
One day, my mother and her best friend piled their kids into a station wagon and go to this new thing called a strip mall. They said, "All these shops right next to each other, isn't that marvelous?" There was a playground across the street. They said, "You guys play there while we shop." I go running across the lawn. The lawn was a green blob. There was a brown blob, and I thought those were trees, so I go running full-tilt, and, all of a sudden, I'm underwater. It was a pond covered with scum.
All of a sudden, my legs are trapped under some lumber, and I'm not coming up. I was as stunned to be underwater as I would be now. The little kids who were with me, my friends, were screaming. A 12-year-old boy went by, an Eagle Scout, who had just finished a training in how to resuscitate people. He dove in, extricated my legs, brought me up, and did CPR. All these screams brought the parents out of the strip mall. My mother and her friend came running over. I'm covered with mud and wrapped in a blanket and everybody's still screaming. She said, "Marguerite, you dove under that lake." I said, "What lake? I didn't see a lake."
She brought me, that day, still wrapped in the blanket, to this optometrist's office. It was next to my father. My father was an orthopedic surgeon. This was the office next door. He's refracting away and refracting away. He turned to my mother and he said, "She's so incredibly myopic she'll be blind when she grows up." I started to cry, and he said, "Shut up." He quickly goes back, makes a pair of glasses in his lab, a little pair together in a tiny frame. He comes back and he puts it on my face. I look straight ahead. The first thing I saw was my mother's face. I'd seen her eye. I'd seen her nose and her lip, but I'd never seen her whole face all at once. I thought she was beautiful. Now, everybody thinks their mother is beautiful. Mine really was. She was a stand-in for Audrey Hepburn. She was a fashion model. I'm looking at this astonishing face, and her voice is coming out of this amazing face.
Then I turned and I looked up out the window. I was still in the exam chair. I used to find these leaves on the ground, and I'd hold them up to my nose and stare at them. They all were together, way up high. It was a tree. I was so stunned at what the world looked like that I tied the glasses on my face, and I would not let anyone take them off for 6 weeks. My mother had to try to wash around them. Finally, she said, "Marguerite, if we put them on your nightstand, they will be there in the morning." I let her take them off.
I wore these thick glasses. I was thrilled to death to have them. I had a backup pair and a backup pair because I knew that I was lost without them. There was a rule or a law in Illinois at that time, I lived in Chicago, that you had to be 16 to get contact lenses. I'm back in the same optometrist's office when I was 16, on my birthday, and I got gigantic polymethyl methacrylate contact lenses. They were awful, they were painful, but I loved them, because I could finally get those glasses off. I go screaming out of the office over to my best friend's home, knock on her door. She was one of eight children. Her older brother opens the door. I'd known him forever. He looks down at me and says, "Marguerite, is that you?" I said, "Yes, I just got contacts." He said, "Do you want to go to the movies this Friday?" I thought, "Contact lenses are the key to social success."
Gary: Yes, indeed.
Marguerite: Someday, we're all going to be able to see without wearing these painful things. That really stuck with me. The whole thing from age 5 to 16 was very motivating, you might say.
Gary: I think this part of the story, which actually I'm just learning as you're telling me this, it puts the center of the why so clearly in focus, no pun intended, as to why you would want to pursue ophthalmology, but even more so, pursue refractive surgery for your patients. You realized at a very tangible level how important clear vision is, not only for your safety and your health, but also, like you said, for social success, for actually achieving the things that you want out of life.
I assume it was that very tangible sense of what vision means that spurred you on into ophthalmology. Walk me through that. Your father's an orthopedic surgeon. You've had this dramatic experience as a high myope. When did you decided to become a doctor, and then when did ophthalmology get on the radar for you as a possible specialty choice?
Marguerite: I'd be glad to tell you one last funny anecdote back from age 5. As I'm sitting there with my new pair of glasses on, my mother looked at me and said, "Marguerite, we've been letting you cross the street for a year by yourself. This terrifies me. How have you been doing it?" I said, "Like everybody else, mom. I stand on the curb, and I listen for cars."
Gary: Oh my gosh.
Marguerite: So anyway, I could see that my dad loved what he did as an orthopedic surgeon. He would come home every day and tell us stories. He was also the director of the emergency room at the hospital where he practiced, so there were all these exciting stories every day. I thought about being an orthopedic surgeon, but I liked the idea of microsurgery. He had, he and all of his friends, had terrible varicose veins from standing all day. I mean, really terrible. I said, "You know, I like to operate, but I'm sitting down." Ophthalmologists have been doing seated surgery for a long time, plus there was the connection with my own personal vision issues.
In medical school, I decided ophthalmology was for me. I did a rotation in the very famous Algernon Reese Retinoblastoma Clinic, which was staffed at that time by the chief of service Bob Ellsworth, MD. There were all these young parents; of course, retinoblastoma is a terrible cancer of children, so the parents are young. They would come from all over. They would fly in from out of state and out of the country. A lot of times, Dr. Ellsworth would say, "I can't tell if your baby has Coats' disease or retinoblastoma. It's bilateral, and we've got to take these eyes out. I could be wrong. There's no way to tell. But if we wait to see what happens, your baby will die of cancer if it's retinoblastoma. If I take out the eyes and I'm wrong, they have Coats' disease. They will have lost their vision, but they'll still be alive."
These terrible gambles, and these young parents with no money, sobbing. I was there when he, many times, told people, "We took the eyes out, and the good news is it's not cancer." But now they've got a blind child for life. It was like descending Hieronymus Bosch’s vision of hell. I said, "We have to somehow figure this out before we take these babies' eyes out." I discovered, by reading, that retinoblastoma elutes a lot of LDH and that LDH has isoenzymes. I thought, "I wonder if there's a pattern to the LDH isoenzymes. There are five of them. Maybe number one is high, number two is low. Maybe there's some way to compare the LDH and regular aqueous humor versus retinoblastoma." To make a long story short, there was. It was a very distinct isoenzyme pattern.
For many years, until imaging became better, they took babies for an exam under anesthesia, tapped their aqueous humor, and ran the isoenzyme pattern. It was so gratifying because a whole lot of babies were able to keep their eyes. I said to myself, "I love this," but I was always drawn to refractive surgery. Also, it was still so hard dealing with all those young parents. I thought, I’m not sure I want to go into pediatric ophthalmology. I kept coming back to my love for refractive surgery.
When I ended up as a cornea fellow with Herb Kaufman, MD, I got immediately involved in epikeratophakia, and doctors of a certain age will remember this, the living contact lens …
Marguerite: ... and with radial keratotomy. Aaron Safir, MD, was the LSU PRK surgeon in the PERK study, but he had to leave LSU shortly after becoming the PRK surgeon, so I stepped in and became, at a very young age, the youngest PRK surgeon and the only female PRK surgeon. I was into refractive surgery in a major way. I read Dr. Steve Trokel's astonishing 1983 paper, where, in the AJO, he described taking an industrial laser that had been used to make computer chips in Silicon Valley and dragging it across some cadaver animal eyes. He said, "Look, there's no thermal damage. Maybe we could use this for refractive surgery."
Gary: It was another “aha” moment, it sounds like.
Marguerite: An “aha” moment, and because I had graduated from Columbia, and because Dr. Trokel had given me the aqueous humor samples that I needed for my retinoblastoma project when I was in medical school, I called him up. I said, "Hey, remember me? A few years ago, I was there as a medical student. We did research together. I know you don't have animals up in Manhattan. I do. I'm down here in Louisiana. Plenty of room, plenty of lab space, lots and lots of animals. A huge vivarium. Can we work together?" The third leg of that stool was Charles Munnerlyn, PhD, a brilliant physicist in California.
From California to New York to Louisiana, we started working for years and years. First, we shot just at a whole lot of plastic. Then we shot at cadaver animal eyes, always changing everything, the shot pattern, everything. We finally got to the point where we could do animals. We started with rabbits because they're inexpensive, even though they don't have a Bowman layer. The original clinical outcomes were dismal. They developed huge hyperplastic scars. This was when we were shooting at bunnies that were several feet away from the laser, and we were using a diaphragm. We tried to immobilize them and sedate them as best we could, but they were a few feet away, and we used a diaphragm that opened or closed with a hand crank. I would shoot for a few seconds, crank down the diaphragm, shoot for a few more seconds, crank down the diaphragm, and they got these terrible scars.
At that point, my cornea fellow said, "I can't stand this. It's too depressing. I'm leaving," and she left the project. My research coordinator said, "This is too depressing. I can't stand it. I'm leaving." All in 1 week, these bad things were happening. We each had one of our many, many conference calls, and we decided maybe the problem is that these ablations aren't smooth. This seems incredibly obvious in hindsight, Gary.
Gary: Right, but at the time, who was to say?
Marguerite: Nobody knew anything. We said, "Well, let's just try increasing the number of steps." We went from five to 40, and we automated it. Charles, of course, the brilliant physicist, saw to that. And, all of a sudden, the rabbits started to look pretty good. They didn't get big, thick hyperplastic scars. Still, we had no fixation devices, no tracking, nothing. We moved to monkeys and were slowly plodding along, getting better, increasing the number of steps. We kept going higher, higher, 40. We had all these really interesting fixation devices.
We were showing our data to the FDA. We'd fly in occasionally and show them animal data. They told us to go back and do more. Then, one day, even though the results were getting pretty good, we find Mrs. Alberta Cassady, who was a patient in the oculoplastic service at LSU. She was a lower-middle class 62-year-old Caucasian woman with a massive orbital cancer wrapped around a 20/20 uncorrected eye. She was facing an exenteration. The oculoplastics service told her, "Your only chance of survival is with an exenteration." They described what that was, and they said, "It's not a high chance at that, but it's your only chance." She said, "I'll take it." They said, "We'll take to get you medically cleared, get everything we need. It will take just a few days." She turned and said, "If I'm going to lose my eye, would anybody like to do an experiment on it before I lose it?"
Gary: That was her? It was actually her who brought that up?
Marguerite: We were numb with grief for her. We would never have suggested such a thing. Oculoplastics calls me and says, "Guess what? We have this woman here." I go barreling over, and we talk to her. We contacted the FDA on an emergency basis. We said, "This woman is about to have an exenteration. If we're going to get a chance to do the laser, we have to do it now. Do we have your permission?" They got it. They said yes. There was no time to move the laser. It's still out at the Delta Primate Center in Covington, Louisiana. We raced her across this huge 28-mile bridge to the other side. We take her out to the primate center. She is rushed by all the monkey cages, where they're shrieking and hissing and spitting at her. We lay her down under the laser, and I had the honor of doing that surgery. Even though, not only did we put her in discomfort, we didn't know that PRK was painful. We assumed it was, because it's …
Gary: Taking off the epithelium?
Marguerite: … the abrasions, but we didn't know. We hadn't done a human yet. We put her in discomfort, and we gave her a -4.50 myopic ablation that she didn't need. For the next few days, she couldn't see well out of that eye. We photographed her every day. We measured her every day, and 11 days later, we got the specimen. But we got exactly a 4.50-D correction. She healed beautifully with minimal subepithelial haze. We sent it all to the FDA, and they were super impressed. They said, "Well, okay." They were going to have us do monkeys for God knows how long. We might still be doing monkeys.
Marguerite: They said, "Well, okay, we'll let you move on to the blind-eye studies." These are people with healthy corneas who are blind in one eye from devastating retinal detachments or whatever. Mrs. Cassady lost her battle, and, just a few short months later, she died. We were allowed to take the laser out of the Delta Primate Center, move it back across Lake Pontchartrain, and put it in LSU. The university officials were terrified that it was going to leak gas and kill everybody, so they made us put it in a trailer. We were depressed that we were in a trailer and that we would have to march our patients into a trailer. It turned out to be a blessing in disguise because we were right next to the LSU trash compactor. The LSU trash compactor, when it was firing, would shake our trailer just a little tiny bit. We got much smoother ablations than we deserved to get.
Gary: You got a blend zone from the trash compactor.
Marguerite: We did. We actually did an analysis of our data. We said, "What? The people that were done on Monday and Tuesday did better than the people on Thursday and Friday." Then we finally put it together. It's the trash compactor. It's the super-smoothness. We also insisted that the university let us name the trailer after Alberta Cassady, who had died. They said, "No, no, no. We only allow buildings and facilities to be named after rich people who've given us a lot of money." We said, "She has given us everything.” We threw a long, loud fit, and they finally let us do it. We have pictures of the team standing outside the trailer, which had a big sign on it: The Alberta H. Cassady LSU Lions Excimer Laser Laboratory.
Gary: This story is so poetic in so many ways. I'm sitting here thinking about the fact that your journey in ophthalmology started with something that was almost a personal tragedy, then it came as a medical student, where you were actually having to look at people, look at young parents, who are dealing with a child who may have cancer, and then you were able to have a key insight into helping save the vision of young babies who had Coats' disease, as it turned out. Then, so many years later, a woman who was afflicted with a malignancy became a key in actually advancing a huge field. Did you ever just sit back sometimes and think about the poetry of all that, just the poetic justice of that whole story? It really is profound, as I'm sitting here, hearing this.
Marguerite: Well, I think about how important serendipity is. What if we hadn't ... still, we were clueless about exactly how smooth ablations had to be. We knew that when we went from five steps to 40 that we got better results, but serendipity all the way. The guy on the oculoplastic service that had the presence of mind to call me and tell me about Mrs. Cassady, he could have said, "Oh no, dear, no, no, no. You just really enjoy your last few days here." All the lucky breaks, and keeping your mind open all the time.
I did my fellowship with Herb Kaufman, and everybody would look at a certain problem in a certain way, and he always came at it from a different direction. He kept his mind open. I really learned from him to keep your mind open. Just because somebody in the textbook said something, don't assume that's true. Try to take advantage of every little bit of opportunity that comes your way. Also, nothing happens in a vacuum. This is all a big team effort.
Steve Klyce, PhD, was one of the earliest people to join our team. It was the three of us. We were working very hard together, but we realized we needed to assemble a team. We assembled a great team. Steve was critical as a PhD in physiology, and he had spent his entire career in studying corneal physiology. He was instrumental. Without the right people who all got along together, without communicating and taking advantage of these lucky little breaks that come our way. The other thing it taught me is don't give up. There were dark, dark days. We were the laughing stock. As a matter of fact, when we got to the blind-eye study, we had to document that they were completely blind in one eye—I mean, really blind.
Gary: Right. NLP.
Marguerite: Well, way worse than 20/200—like 400 or hand motion.
Marguerite: And that all refractions had been tried, that they had done. We had to document it. One of the first 10 blind-eye patients was a young lady. She's well-known, and she doesn't mind that her name is used: Caroline Henry. Caroline had a complete retinal detachment in one eye, and she had a brain tumor. They said, "When we finish resecting this brain tumor, that eye that you had the retinal detachment in, that you had a little bit of vision in, it'll be completely blind." It was a pituitary adenoma that was very big. She had it put in her head that she was going to be blind. She went to three different institutions. Everybody documented she was blind.
Marguerite: We did an ablation on her, and it happened to match what her true refractive error was. All the other blind eyes, we just said, "Okay, this one gets -1.00, this one gets -2.00, this one gets -4.00." This happened to match, just truly by serendipity. About 2 months after we did her, she calls me up and says, "I can see great out of this eye." I said, "No you can't." She said, "No, no, I can. My son hit me in the eye with a piece of birthday cake, and, as I wiped away the cream, I can see." I said, "No, come on in." She comes in, we tape up her good eye, and we test her, and she gets right down to 20/20 uncorrected.
I had a wave of nausea pass over me because I thought, "People are going to think that I did this to get the scoop, to get ahead," even with all these documents from Tulane and other universities that she was blind. We call up the FDA. We notify them. We send in all the supporting evidence and also the evidence that she'd been declared blind. Even somebody who had noted blindness at Tulane. It was a true case of hysterical blindness, where two doctors, her retina surgeon, and the brain surgeon told her she'd be blind in that eye, so …
Gary: She just decided she's going to be blind.
Marguerite: She was blind. When we wrote her up in the AJO, one of the most famous living ophthalmologists at the time wrote a castigating editorial. Not only did he hate refractive surgery, it was personal, about what a dishonest person I was and the depths of depravity, etc. Here he is, one of the most famous living ophthalmologists at the time, an institution. I was a 30-something female ophthalmologist that nobody had ever heard of down at a southern state university. It really scarred my soul for a while. I got teased about it. People talked about it for years and years.
Not long after he wrote that, his son died of malignant melanoma of the choroid that had metastasized. He had a terrible death. His dad, the man who wrote this, died shortly thereafter. I remember thinking he wrote what he felt, what he thought was right at the time. He thought refractive surgery was horrible, and it sure looked, from the evidence, like I had tried to do this just to get another first, in spite of all the supporting evidence we had sent in. I just felt great sorrow for him that his last few years were so terrible. It made me realize you really have to look at what the other guy sees. You have to really try to walk a mile in his moccasins. He's still at the wayside. You know?
Gary: Right, right. Well, Marguerite, that's very gracious. I know a lot of people, when they're attacked like that, when you know you've done the right thing, it's really easy to hold a grudge for life. It's so refreshing to hear your perspective on this, and reflecting back. When I think about Marguerite McDonald, I've never even heard of that scathing editorial, so I can tell you that whatever was written about you is old and cold, and all your friends who know you now see you as a hero, not just in refractive surgery, but a giant in our profession.
I cannot thank you enough for being willing to stick it out during the dark days. Because of the work that you and others, as you mentioned others have worked on this, because of the pioneering work that you all did, I get to live in an era when patients want to have their vision fixed, I have a magic button, essentially, that I can press. I tell patients, we live in the weirdest time in all of human history, where we have a button that we can press to almost magically correct your vision.
Marguerite, it's thanks to you persevering through those tough times and thanks to patients like Ms. Cassady and others who were willing to sacrificially give of themselves. Marguerite, with all of that, I just want to, from the bottom of my heart, say thank you for being a pioneer, for sticking it out, and giving us the gift of laser refractive surgery. We really appreciate it.
Marguerite: Thank you, Gary. It's been a huge honor and pleasure for me to be on your podcast, so you just have to promise me to come please be a guest on my podcast.
Gary: I will. Yes. For those of you who don't know, Marguerite has a fantastic podcast called Informed Consent: Getting to Yes. If you've not had a chance to check that out, you can find that wherever you get your favorite podcasts from. Marguerite, you are always welcome to come back. If you ever have a topic you'd like to talk about, you are always welcome to come back as a guest. Thanks again.
Marguerite: Thank you, Gary.
Gary: We are fortunate to practice in a time when laser vision correction is so advanced. But that didn’t happen overnight, and it would not have happened at all without the passion, dedication, and bravery of Marguerite and her team.
So, many thanks to Marguerite, and thanks for listening to another episode of Ophthalmology off the Grid. Next time, we’ll hear from some young ophthalmologists on what’s got them traveling to Austin this September. Catch you then.
Speaker 1: Ophthalmology off the Grid is an independent podcast supported with advertising by Alcon.