Frank D. Costenbader, M.D.
Frank D. Costenbader is universally recognized as the first general ophthalmologist to limit his practice to children. With that decision in 1943, he unknowingly became the “Father of Pediatric Ophthalmology” and by association, the founder of ophthalmology’s first sub-specialty.
Ophthalmology had always been known as a geriatric specialty, primarily concerned with the ocular afflictions of adults and the aged. The vision disorders of infants and children were poorly understood, generally ignored and often considered as a disruption to the normal office routine of an adult practice. Ocular motility and strabismus disorders were studied by only a small group of investigators with little attention to those occurring in children. There were few related publications until children became the primary focus of Costenbader’s attention and research. It was through his personal efforts and commitment to the unique needs of the young patients in his Washington, DC practice that parents and pediatricians began to appreciate the special benefits and individualized attention their children received under his care.
Essential to understanding the early years of pediatric ophthalmology is the role of Dr. Marshall Parks, who, following completion of his wartime service as a general medical officer in the Navy – mainly in the South Pacific – joined Costenbader in his Washington office as a preceptee. After one year he joined Costenbader as his first associate in his pediatric ophthalmology practice. The office was in a stately brownstone residence located at 1605 22nd Street, adjacent to Massachusetts Avenue on Embassy Row. Thus began the lifelong personal friendship and close professional relationship from which this new specialty developed and flourished. Costenbader and Parks became known not only for their excellent care, insightful writings and lucid lectures, but also for their sensible emphasis on the importance of early diagnosis and treatment of children’s eye disorders. Their diligence, personal commitment and willingness to teach others gradually gained acceptance, heralding and promoting pediatric eye care through its formative years and insuring its position as an essential new field in ophthalmology and pediatric medicine.
Frank Duncan Costenbader was born in Norfolk, Virginia, February 15, 1905, the eldest son of John Henry Costenbader and Cecelia Rider Duncan. He grew up in a stable home surrounded by a loving family, an environment which surely contributed to his future love of medicine and his lifelong dedication to children’s welfare. His father and two brothers were dentists in the Norfolk area.
Dr. Costenbader was Virginia born, bred and educated and never lost his love and close attachments for his native Tidewater Area. His demeanor bespoke the presence of a true Virginia gentleman. Dr. Costenbader’s appearance, bearing and attitudes have been described in many ways. He was said to be a giant among men, tall and serious but with a ready twinkle in his eye. He was clear thinking, articulate and beautifully spoken. His Children’s Hospital associates spoke of him as an even handed “elder statesman”, a philosophical and intellectual leader. He was a gentleman and aristocrat, always attired in fine conservative clothes (although sometimes chided by Dr. Parks for his conservative habit of wearing both suspenders and a belt). Dr. Costenbader’s erect stature and impeccable behavior often set him apart from others, but never obscured his underlying charm. In essence, the standards and objectives he set for himself and thereby for others was that of excellence.
Dr. Costenbader received his Bachelor of Science degree from Hampden-Sydney College in 1925 and maintained close ties to his college, serving on its Board of Trustees for many years. He received his medical degree from the University of Virginia in 1929 and combined his rotating internship with a special EENT program in Norfolk. He came to Washington, DC for his EENT residency in 1931 at the Episcopal Eye, Ear and Throat Hospital. He often said that the only reason for coming to Washington was for a pretty young woman from Southern Virginia was working as a medical librarian at the Episcopal Hospital. The pretty librarian, Mary Barner and he were married later in 1931. The residency at Episcopal was a one year program with two residents alternating, six months on ophthalmology and six months, otolaryngology. Costenbader’s residency mate was Dr. Victor Alfaro whose father had been president of Panama and was currently Panama’s Ambassador to the US in Washington. The two young residents spoke of gaining most of their meals during residency from Embassy cocktail parties and receptions. The following year they opened an office together at 1726 Eye Street, and soon realized that neither could afford to buy both eye and otolaryngology equipment. Since Alfaro greatly preferred practicing otolaryngology and Costenbader strongly preferred ophthalmology, each invested in the necessary instruments for their preferred specialty and in their time, each became eminently successful in their respective fields.
During the first decade of his practice of general ophthalmology, Costenbader spent increasing time building and developing the eye clinic at Children’s Hospital. That experience convinced him that ophthalmologists should become more knowledgeable and skilled in treating children’s eye problems. It disturbed him to hear his peers comment, “bring your cross-eyed child back when he is old enough that I can examine and talk to him”. He became resolved to change the traditional practice of adult ophthalmology and after 11 years in general ophthalmology practice he made the important decision to devote his career to improving children’s eye care. At first he limited his practice to children age 16 and under but later changed that to age 12, and did not see adult patients after than time. Several friends cautioned that he might never be able to support his family, but his practice and reputation continued to grow. When asked why such a major change in his life and practice, he often smiled and said “it is always more fun working with the children”.
During those 11 years in general practice and prior to his deeper involvement in the pediatric realm, Costenbader was introduced to the ocular motility research of Lancaster, Burian and Cogan at the Dartmouth Eye Institute. The stature of the Dartmouth Eye Institute greatly increased in 1935 with the appointment of Bielschowsky as the new director and it gained additional attention when the AJO published his lecture series in 1938-1939. Through the influence of these men, and coupled with his own intense interest, he became an avid strabismologist in study and practice. The Bielschowsky “Lectures on Motor Anomalies” published in 1943 became a treatise which Dr. Costenbader treasured through all his years. Dr. Costenbader’s more personal involvement with strabismus and ocular motility disorders (still often called ”Squint”) created the opportunity for him to participate with Burian, Adler, Brown, Swan and others in several national symposia. Costenbader gradually gained a national reputation in strabismus teaching, and Heed Fellows began rotating through his office. His reputation further improved after the publication of his AOS thesis in 1961 detailing the diagnosis and treatment of 1150 cases of infantile esotropia. Reflecting his enhanced stature, Costenbader was a founding member and prime mover in the formation of the Association for Research in Strabismus, called the Squint Club.
Dr. Costenbader found many areas in strabismus fascinating. Understanding that it was a confounding and complex condition with possibly multiple etiologies, he was pleased when Maddox in London re-introduced a scientific method of eye exercises utilizing a stereoscope to train the brain and eye muscles. Costenbader was an early supporter of orthoptics in his own office and participated in the formation of the Orthoptic Council of which he was president from 1960-1962. Dorothy Bair, a British trained orthoptist, was hired by Costenbader as his first orthoptist and she later supervised and trained other orthoptists in their private office. She continued as Costenbader’s assistant, collaborator and co-author on several ocular motility papers until 1970 when he was medically retired.
He was intrigued by both the sensory and motor aspects of strabismus, particularly that of accommodation in children. His studies of accommodative esotropia encouraged him to devise two patents, the first an instrument patented as the “Costenbader Accommodometer” to clinically measure accommodation in children. This instrument allowed him to measure accommodation in children at an early age. His other patent was a trial frame that clipped onto a child’s glasses. One could place trial lenses in these clip-on frames to measure the lens power that would be needed to maintain good alignment for distance and near for children with accommodative esotropia. His understanding and lucid explanations of previously confusing concepts gained wide acceptance and were further enhanced by his own writings. Of his 65 published papers, the majority (75%), were on strabismus topics and most of these generously included authorship with his fellows or associates.
In 1950, in consultation with Dr. Reginal Lurie, a psychiatrist at Children’s Hospital, he introduced the practice of one day surgery for strabismus, replacing the former policy of admission the day before surgery and remaining another day post-operatively. In subsequent years, in conjunction with Drs. Parks and Albert, they eliminated most post-operative bandaging and encouraged parental presence during the induction of anesthesia and early presence during the recovery phase. Having concern for the parents needs and the expenses involved with hospitalization and surgery, Costenbader and a group of physicians founded the Medical Services Plan of the District of Columbia which later became into the Blue Cross/Blue Shield plan for DC.
In addition to his large clinical practice, now enhanced by many national and international referrals, Costenbader kept busy with writing, teaching and monitoring his ever-present fellows. He was always involved and active in one of many civic, community, church or medical activities. The American Academy of Ophthalmology and Otolaryngology (which divided into two separate Academies in 1975) was dear to his heart, and he taught strabismus instructional courses annually and participated frequently in strabismus symposia. He never missed the annual meeting of his beloved American Ophthalmological Society (AOS) until 1970 when his professional life was suddenly interrupted by illness.
In November, 1970, Costenbader was the first honoree of a new prestigious award of the National Society for the Prevention of Blindness in New York City. This special award recognized his unique contributions and pioneering work in training pediatric ophthalmologists. The citation noted that he was largely responsible for the important attention now given to the early recognition and treatment of children’s eye disorders. The ceremony was attended by four of his closest friends and associates from Washington, DC: Drs. Parks, Albert, O’Neill and Friendly. Following the ceremony, Dr. and Mrs. Costenbader left for their vacation home recently established in Naples, Florida. The following week Dr. Costenbader suffered a stroke and was medically retired at age 65. His condition gradually deteriorated due to an unrelenting Parkinson Disease process and he died on March 16, 1978 at the age of 73.
In 1975, in the early years of his illness, his Costenbader Society fellows honored their founder and mentor with the following citation:
IN RECOGNITION OF FRANK D. COSTENBADER’S PIONEERING ACHIEVEMENTS;
IN GRATEFUL ACKNOWLEDGEMENT OF THE STANDARD OF EXCELLENCE WHICH HE
ESTABLISHED AS A GENTLE PRACTICIONER, PATIENT TEACHER AND INNOVATIVE
RESEACHER; AND IN APPRECIATION OF HIS SUSTAINING INTEREST AND SUPPORT OF HIS
STUDENTS AND COLLEAGUES, THE MEMBERS OF THE COSTENBADER SOCIETY HEREBY
ACKNOWLEDGE THEIR GRATITUDE TO THE FOUNDER OF PEDIATRIC OPHTHALMOLOGY.
Author: JOHN F. O’NEILL MD. Dr O’Neill was the last associate and partner through the final years of Dr Costenbader’s active practice from 1966 until his mentor’s medical retirement in 1970. Dr Jack Baker provided essential editorial assistance on this project.