National Public Radio
March 7, 1997
Interview with Andrew I. Caster, M.D.
Q: It seems like everyone’s vision is getting worse in every way. What can you tell me about the new laser surgical procedures? What can they do for us?
Dr. Caster: People who have poor vision at distance and who need glasses or contact lenses in order to see well at distance can have this laser procedure performed which takes about a minute, and it can eliminate their need for glasses or contact lenses.
Q: Now which procedure is this?
Dr. Caster: The excimer laser procedure.
Q: And we’ve got… with the PRK and LASIK and laser thermal keratoplasty — are these all the same thing?
Dr. Caster: No they aren’t. There are two versions of the excimer laser procedure. One is known as PRK, and the other is known as LASIK. The PRK procedure involves applying the laser energy to the front surface of the cornea. The cornea is the clear tissue in the front of your eye when you wear a contact lens — that’s where your contact lens is touching. So the PRK — we apply the laser energy to the front surface of the cornea. In the LASIK variation of the procedure, we make a little flap in the front of the cornea and apply the laser energy underneath the flap and then fold the flap back, so thereby we’re applying the laser energy deep within the cornea.
Q: Now, are these both approved?
Dr. Caster: The PRK procedure has been specifically approved by the FDA and the LASIK procedure which is becoming very, very popular is what you call a choice of medicine issue. In other words, we’re using approved devices, but in a way that hasn’t been specifically studied yet by the FDA.
Q: Now, who are good candidates for these procedures?
Dr. Caster: Well, anybody who needs glasses or contact lenses in order to see far away, because they have astigmatism or nearsightedness, would be a candidate for the procedure. The less that we have to correct, obviously the more accurate the correction will be. But people who require large amounts of correction because they have very thick glasses or contact lenses can often achieve a perfect correction through this procedure.
Q: What about if things are just kind of blurry out there? Over time, you know? I used to have great sight. Now, they’re just a little blurry. So many baby boomers are nodding in their cars as we speak. What about that?
Dr. Caster: Well, if it’s just a little blurry, then maybe you don’t want to have the procedure. But if it’s blurry enough that you feel that you need glasses or contact lenses in order to get rid of the blur, then you would be a candidate for the procedure.
Q: …be a candidate. You know, I was a little reluctant to do this interview because I remember the radial keratotomy business had a terrible reputation. And I don’t know if it was a medical reputation, or — can you review that for me… the RK procedure?
Dr. Caster: Sure. Radial keratotomy was invented in Russia in 1973, and it was first performed here in the United States in 1978. It always was somewhat controversial, both because for one it was completely revolutionary, and people had a philosophical problem with performing a surgery on an eye that could wear glasses or contact lenses because obviously every surgical procedure carries some risk with it. So a lot of people had this philosophical problem with radial keratotomy. Also, there are a lot of people who started promoting their procedure, and maybe weren’t promoting it in a fair and accurate way. In other words, maybe they weren’t presenting all the pluses and the minuses in a balanced fashion. That’s really why I wrote this book. This book is designed to explain to the average person all about the radial keratotomy procedures and the excimer laser procedures — what it can do for you, what it can’t do, what types of problems you might encounter. How to select a doctor. Who’s knowledgeable in this area, and we talk about the most commonly asked questions that people have and give the answers to those questions.
Q: Now, was the RK surgery for the same kinds of things — not being able to see at a distance?
Dr. Caster: Correct. For the same things: nearsightedness and astigmatism. And many people today still perform radial keratotomy surgery. And for people with small amounts of nearsightedness, I think that radial keratotomy is an excellent procedure. When you start to get into larger amounts of nearsightedness, the excimer laser has some very distinct advantages.
Q: If you’ve had the RK surgery, can you then go on to this new laser technique?
Dr. Caster: Yes. If you’ve had the radial keratotomy and gotten less of a correction than you want, then an excimer laser procedure can be performed. That would be something to talk carefully with your doctor about.
Q: How significant is this laser surgery option?
Dr. Caster: Well, last year in the United States, about 200,000 people had the procedure done, and many people are predicting that by the year 2000, this will be the most commonly performed medical procedure in the United States.
Q: ou’re listening to Technation, Americans and Technology. My guest today is ophthalmologist, Dr. Andrew Caster. With training at Harvard Medical School and the UCLA School of Medicine, he’s published his experience with the new laser surgery techniques in the book, “The Eye Laser Miracle.” Now, I guess part of the reason — it’s like so many people say, “Gee, surgery. This is really terrible” — let’s go through — when you’re saying “laser surgery” here on your eye — we’re not talking about weeks in the hospital, you know, horrible scalpels, and let’s go through from beginning to end and pick whichever you like — PRK, LASIK — I don’t care. What happens to a person. How do they find out if they’re a good candidate, and how do you go from soup to eye sight — from soup to nuts, here?
Dr. Caster: Okay, well the first thing that you’ll want to do is to go have a consultation with the ophthalmologist. So, you’ll go into his office and the ophthalmologist will then explain to you what your different options are and help you to decide whether this is something that you want to have. The doctor will then perform a complete eye examination and will measure your eyes for the correction that’s needed. Generally, on another day you’ll come back to have the procedure performed. On that day when you come in, they’ll give you a little Valium, usually to help relax you, so it will be like you’ve had a drink or two just to help relax you.
Q: But don’t have a drink or two.
Dr. Caster: Don’t have a drink or two because you’ll probably get the Valium at the doctor’s office. They will then ask you to lie down underneath the laser machine. Your eye will be held open with a little lid holder. People always ask, “What happens if I blink? Is that going to cause a problem.” Well, your eyes are gently held open with this little lid holder, so you don’t have to worry about blinking. You’ll be asked to look at a flashing red light which is in the middle of the laser, and then the laser energy will be applied to your eye. The laser itself is invisible. It’s ultraviolet light, so you can’t see it. It takes about 30-60 seconds of laser energy to perform the procedure. So after 30 or 60 seconds, the procedure is over. You get up and you go home. It’s that simple. There are no shots needed. There are no IV’s needed, and by the next day you will notice a pretty significant improvement in your vision. It takes several weeks for the vision to really stabilize, but many people see well enough to drive the next day after the procedure, particularly if they have the LASIK variation of the procedure. The PRK version takes a little longer for the vision to stabilize.
Q: How painful is this?
Dr. Caster: There is no pain at all when you’re having the procedure. None whatsoever. Afterwards, some people have no pain at all. Some people have very mild pain, and a very rare person will come back saying that they really had significant pain. So most people have virtually no pain afterwards. We do give people some pain medicine to take home with them, so if they’re having pain, they can take these pills, and generally they only take the pills for the first night.
Q: So, basically this sort-of laser surgery or procedure — I mean, I’m having a hard time calling it surgery given what you’ve described — it just takes a minute or two.
Dr. Caster: You’ll be lying underneath the laser for maybe 5 minutes because…
Q: Oh, 5 minutes, excuse me…
Dr. Caster: e have to set you up, get everything lined up. The information is then put into the computer that runs the laser, and the main job of the doctor is to make sure that everything’s lined up properly.
Q: How new is this procedure?
Dr. Caster: It was invented in 1988, and since 1988 it began to be performed in every major country in the world except for Japan and the United States. The FDA here in the United States has been studying the procedure since that time, and finally in 1995, the FDA approved it for general use here in the United States.
Q: Is it hard to find doctors who can do this?
Dr. Caster: No, there are many doctors in every community who perform the procedure. As I say in the book, I recommend that you try to go to someone who has a fair amount of experience with the procedure — like everything else, experience is an important thing, and some doctors do have more experience than other doctors with these laser procedures.
Q: Alright, now I’m gonna get to the bottom line. How much does this cost? And will your insurance cover it?
Dr. Caster: Well, it costs about $2,000 an eye. The LASIK procedure will cost a little bit more than the PRK procedure. Very, very few insurance companies are covering it. Most of them call it elective surgery, so they won’t cover it. There are a few self-insured plans that do cover it, but those are few and far-between.
Q: Now, you’ve got two eyes. You don’t want anything to go wrong. Can you have both eyes — do you do both eyes at the same time, or do you, one — and then you go on to the other? What do you do?
Dr. Caster: Some people have both eyes done at the same time. Some people have one eye done, and then the other eye at a later time. When I had the procedure done, which was about six months ago, I chose to have one eye done the first day, and then the next day I had my other eye performed, and the day after that I was driving a car very, very comfortably, and I was back at work two days after that.
Q: Now what kind of improvement did you see?
Dr. Caster: Well, I had been wearing glasses since I was 12, and contact lenses since I was 17. I’m now 42 years old. I don’t wear glasses or contacts anymore. It’s been wonderful.
Q: Now what was your vision and what did it become?
Dr. Caster: Well, I was about 2800 in each eye, which means I really couldn’t even see the big “E” on the eye chart without my glasses or contacts. Now, my right eye is 20/20, virtually perfect. The left eye is 20/25, close to perfect.
Q: How has that changed your life?
Dr. Caster: Well, I wake up in the morning. I don’t have to reach for my glasses. I like to do a lot of sports, so I don’t have to worry about glasses or contact lenses, and — actually, most importantly, I just have a feeling of being whole or complete. I don’t have to depend on a crutch like glasses or contact lenses in order to see well. So, it’s more a feeling I have about myself.
Q: Have people trusted your surgery now that your — you know, you got this work done on your eyes? You learned all these techniques with your glasses, I don’t know.
Dr. Caster: Well, my vision is great, and I think the fact I’ve had the surgery, I think it really helps me relate better to my patients.
Q: Right. Now, the FDA has just approved the PRK, and is the LASIK — that’s in approval, in clinical trials now, I understand?
Dr. Caster: Yeah, you have to understand the way the FDA works. When manufacturers have a new product, they need to get it approved by the FDA, and generally the manufacturer will choose one specific, narrow area to study because it’s very expensive to do these studies. Once the device is approved for one of the narrow uses, the doctors can then use that device to perform any procedure that they want. So, once the laser became approved for PRK which is what the manufacturers chose to study in front of the FDA, doctors can then perform the LASIK procedure as well with the machines.
Q: With the experience of the radial keratotomy — how do you say it?
Dr. Caster: RK, for short.
Dr. Caster: Radial keratotomy.
Q: There you go. With the experience of the RK in mind, is there any comparable controversy regarding this laser surgery on the eye??
Dr. Caster: This laser surgery has been very well accepted by the ophthalmic community in a way that radial keratotomy really wasn’t. And I think one of the reasons that it’s been so well accepted is that the FDA took so long and spent so much time and money studying it that people now feel very, very comfortable with it. Radial keratotomy actually fell outside of the purview of the FDA, and it was something that the FDA didn’t have any jurisdiction over because it didn’t use a new type of machine. Radial keratotomy involves using a scalpel. So scalpels are not new machines. The FDA does not approve techniques, they only approve machines or drugs.
Q: Well, is there someone or somebody that approves techniques?
Dr. Caster: There is nobody, no.
Q: So, who was performing the RK?
Dr. Caster: Well, ophthalmologists can perform the RK.
Q: But who else?
Dr. Caster: Just ophthalmologists?
Q: Just ophthalmologists. And they are M.D.’s?
Dr. Caster: They are M.D.’s, right.
Q: Okay. So now with this new laser surgery, only ophthalmologists again?
Dr. Caster: Only ophthalmologists can perform these surgeries. That’s correct. You have to be an eye surgeon in order to perform this surgery. You said earlier that you wouldn’t really call it a surgery. It is a surgery. We are removing some tissue from the front of the eye. It’s very precise. A lot more precise than a knife is, but it’s still a form of surgery because we’re still removing some tissue from the eye.
Q: You know, every engineer has been trained right from day one, don’t look at the laser. It’ll hurt your eye. Now we’re looking at lasers. What’s the difference?
Dr. Caster: This laser, the reason it works so well, is it can remove tissue — and by the way, it’s a cold laser. It doesn’t create burning of the tissue, it actually breaks the carbon-carbon bonds and vaporizes the tissue. And the great thing about the excimer laser is it’s very, very precise, and it doesn’t damage the tissue next to it or the tissue beneath the tissue that’s been removed. So it doesn’t penetrate into the eye.
Q: And what exactly is it doing so that you can correct your vision?
Dr. Caster: It’s removing a small amount of tissue from the front of the eye. Each pulse removes 0.25 microns, which is a very, very, very small amount of tissue, and by having repeated pulses of this energy applied to the eye, a typical treatment might involve 300 or 400 pulses. We gently reshape the front of the eye, leaving it with a slightly different curvature, and when the eye has a slightly different curvature, it focuses the light differently.
Q: So, you’re basically sort of regrinding the lens on the outside of your eye.
Dr. Caster: Exactly. With a cold laser that’s just vaporizing the tissue.
Q: My guest today is ophthalmologist, Dr. Andrew Caster. He was the first American doctor to perform the new laser surgery technique known as thermal keratoplasty, a procedure used to correct farsightedness, and currently in clinical trials with the FDA. You’re listening to Technation, Americans and Technology. Now, while everyone’s eye sight seems to be degrading, more and more recently I’ve been hearing about a condition that either baby boomers have been talking about or frequently their parents have — that I’ve been getting it from all sorts of directions — and that’s macular degeneration. What is it? And why is there nothing that can be done about it?
Dr. Caster: Well, macular degeneration is the most common cause of blindness in the United States today. It has to do with generally an aging change in the back of the eye — the retina — which is the part of the eye that receives the light rays. There are some forms of macular degeneration that can be treated with lasers, but the most common type cannot be treated. This is an area that’s undergoing intense research — trying to find preventions, trying to find cures. I should say that we recently discovered that smoking cigarettes seems to increase the changes of developing macular degeneration by three or four-fold. So the one thing we know that you can do to help prevent the formation of macular degeneration is to stop smoking cigarettes.
Q: Does it run in families?
Dr. Caster: To a small degree it does. Most commonly, it does not.
Q: This seems to be one of those things that happen now that technology is keeping us alive longer and longer — all of the other aging things come into play. I guess what I’m sort of wondering is: what other kinds of things can we see with our eyes. I mean, today you’ve had this laser surgery. Your eyes are, you know, restored to a wonderful degree here. You’re going to continue to age. Is your eyes doing to degenerate now? Is your vision going to degenerate?
Dr. Caster: Well, like everybody else who gets into their 40’s or 50’s, I’m going to begin to lose my close-up vision. I’m 42. I’m close to that stage now, but pretty soon I’m going to need to wear some reading glasses in order to see up close. Because as we get older, the lens inside of our eye, which is known as the crystalline lens — and that’s the lens, by the way, where cataracts form — this lens gets stiffer as we get older, and it’s harder and harder for us to focus on things up close. So even if you have this laser procedure, like I had, to correct your distance vision, you will still need to wear reading glasses to see up close when you get into your 40’s and 50’s or older.
Q: Now what about your distance vision? I mean, will that continue to degrade?
Dr. Caster: No. My distance should remain stable for the rest of my life.
Q: If you have differences, say, in your distance vision — when you’re beyond, say 30 — is this an indicator that there could be other problems?
Dr. Caster: Well, in rare cases, the vision can change as a result of — for instance, diabetes can change the distance vision. Pregnancy changes the distance vision, usually on a temporary basis. And, of course, other diseases of the body can affect the vision in many different ways. That’s why it’s important to go to see an ophthalmologist every couple of years to make sure that things are going fine.
Q: Now you worked with people in China, as I recall, instructing them on certain techniques. What did you do there?
Dr. Caster: Well, I had a really interesting time. I went to a large city in southern China called Xiamen, which is a city of about a million people, and they had a large convention of eye doctors from China, and I performed cataract surgery on some of the Chinese patients. And we then discussed the case with each of the ophthalmologists afterwards. They had a videotape system there. It was really very, very interesting.
Q: How would you compare the work going on in eye surgery, say in China, with the United States?
Dr. Caster: They are very backward in terms of technology. They have not been spending very much money on health care, so they really don’t have the equipment. The medications that they manufacture in China were not very effective, and they just don’t have the level of training that we have here. Hopefully, as their society opens up more, they will gain the level of training that’s necessary to use these new modern techniques that are available.
Q: Well, as always in the U.S., once the technology is approved and ready to go and working, there is a proliferation of it. But still, can you go to any ophthalmologist, or do you have to find an ophthalmologist who has particular equipment to get these techniques done.
Dr. Caster: There are about 200 of these excimer lasers in the United States.
Q: So that’s not many.
Dr. Caster: No. No. They’re very expensive. They cost over $500,000 each. But each major city has several of these around.
Q: And how do you go about finding them?
Dr. Caster: Well, you have to try to find a doctor in your area who has a lot of experience with the procedure.
Q: So if you call an ophthalmologist and you say, “have you worked with this laser surgery?”
Dr. Caster: Yes, and then I would go in and interview the doctor and see how much experience he has. I think it’s good if your doctor has been performing radial keratotomy in the past because then he’ll be much more attuned to these types of issues, and it’s nice if the doctor also has performed other types of surgeries to correct nearsightedness and astigmatism.
Q: Well so far we’ve been talking about basically adults and adults whose eyes are out of time, if you will. How about children? I mean, is this a procedure you would perform on children?
Dr. Caster: No. Because children’s eyes are still changing. Most people develop nearsightedness in their teenage years, and the nearsightedness will get worse and worse throughout the teenage years, and usually stabilizes sometime in the early 20’s. The surgery can set your eyes back to zero. We can get you so you’re seeing well now at distance, but if you’re still undergoing changes, then you will undergo changes afterwards. So you want to wait until your eyes have stopped changing before you have this procedure done. So generally we say that the person should be at least 18 and they should not have undergone any significant change in their nearsightedness over the last year.
Q: If you have laser surgery, is this a one time thing? You can only do it once?
Dr. Caster: Actually 5-10% of people come back for what we might call a touch-up or a retreatment. The main problem with the procedure is that it is not 100% accurate in 100% of the patients. About 95% of the people will see well enough to pass their driver’s license test without glasses or contacts afterwards. But about 5% of the patients will have the procedure done, be made better, but not good enough to pass their driver’s license exam. Those people can often come back and have a retreatment or a touch-up type of procedure.
Q: What happens if you take too much lens away?
Dr. Caster: If you over-treat, then the person will have farsightedness. Currently there are no approved lasers to correct farsightedness, but there are two lasers that are being studies by the FDA right now in which we think we’ll get approval in the not-too-distant future to correct farsightedness
Q: So it looks like the laser techniques — it’s not just we have one laser technique with one laser and it’s doing, you know, one thing for eyes. It looks like there’s a whole family of lasers, and there’s a whole family of techniques as well for treating the eye.
Dr. Caster: That’s exactly right.
Q: How new is that?
Dr. Caster: Well, as I said, the first excimer laser was used on human eyes in 1988, and since then there have been a lot of companies around the world who have developed lasers in order to correct nearsightedness or astigmatism. So there are a couple of companies here in the United States that make excimer lasers. There are German companies. There are Japanese companies. This procedure is being performed all over the world right now. It’s really very popular throughout Asia, throughout South America, throughout Europe.
Q: So, it’s actually, sort of, had a delayed arrival here in the U.S.
Dr. Caster: It’s definitely had a delayed arrival here as the FDA has been studying it and has held off letting patients in the United States have it performed until the FDA had completed their studies.
Q: Well, Dr. Caster. Thank you so much for joining me.
Dr. Caster: It’s been a real pleasure. Thank you.
Q: My guest today has been ophthalmologist, Dr. Andrew Caster. His new book, The Eye Laser Miracle, The Complete Guide to Better Vision,” is published by Ballentine. You’re listening to Technation, Americans and Technology. His new book, “The Eye Laser Miracle, The Complete Guide to Better Vision,” is published by Ballentine.