Pediatric Ophthalmology & AAPOS History

History of pediatric ophthalmology and the America Association of Pediatric Ophthalmology and Strabismus

By Marshall M. Parks, M.D.

George Washington University, Washington, USA 

History of pediatric ophthalmology

The beginning of pediatric ophthalmology occurred in 1943 when Frank D. Costenbader, a Washington, D.C., ophthalmologist, restricted his practice of eleven years to children. For some years, he had organized and supervised the Ophthalmology Department at Children’s Hospital, through which residents from the Episcopal Eye, Ear, Nose and Throat Hospital rotated.

Strabismus and amblyopia comprised the largest component of pediatric ocular pathology in children, which accounted for Dr. Costenbader’s interest and talent developing these areas. Already, the subspecialty of strabismus was recognized, but not pediatrics. By Constenbader’s skill in introducing the importance of early diagnosis and therapy into the management of strabismus, he revolutionized the subspecialty by advocating examining and initiating therapy during infancy.   This produced a sea of change in strabismology and for the first time brought strabismologists and pediatricians together.

During my training in 1946, it became apparent that ophthalmology was primarily a geriatric specialty. Both the attendings and their trainees were obviously ill prepared for examining and treating infants and preschool children; nor was there any inclination manifest for improving their deficiency. Children were unwanted as patients. From this observation came my resolve to change that scenario. After learning about the only pediatric ophthalmologist in the world at the time, who was located in Washington, D.C., I contacted him. Dr. Costenbader invited me to visit, I accepted, which led to my becoming his first trainee in 1947; 55 years later, I am still part of the same program. Dr. Costenbader retired in 1970 due to illness.

By 1947, Dr. Costenbader had established an enviable reputation among strabismologists as one with a fresh message. His new thoughts and techniques for examining infants and children, advocating surgery for what he called congenital esotropia by one year of age, advocating symmetrical surgery, i.e., bimedial rectus recession rather than recess-resect in one eye; one-day hospitalization; claiming that binocular vision results from early surgery – all which were heresy to the strabismologists of that era; he indeed got their attention. Pre-Constenbader, strabismus investigation and therapy conventionally began at school age. Ophthalmologists were neither trained nor interested in introducing a pediatric approach to their routine for managing strabismus. Strabismologists of this era had no relationship with pediatricians. It soon became apparent to strabismologists that, if they were going to advance to the level of care provided by Costenbader, a pediatric approach to their regime must be added. Also, those few of us early and eager ophthalmologists who devoted their careers to children realized that the number one pathology with which we had to contend was strabismus. From these two facts alone, it was obvious strabismology and pediatric ophthalmology needed each other.

Strabismology is, by no means, exclusively a pediatric specialty. It also has a large adult component. Which of the two sources for strabismus is the larger component, is uncertain to this author. However, a large proportion of adult strabismus is a continuum or return of pediatric strabismus. So, the pediatric ophthalmologist who chooses to follow the childhood strabismic patient throughout his life becomes an experienced adult strabismologist as well as a pediatric ophthalmologist. Consequently, the reasonable method for managing the overall strabismus problem has assumed the all-inclusive phrase of ‘pediatric ophthalmology and adult strabismus’. This phrase correctly states what the subspecialty of strabismus consists of. The clinical association for our subspecialty captures the essence of this truth by having adopted the title: America Association of Pediatric Ophthalmology and Strabismus (AAPOS).


History or AAPOS

Establishing a specialty requires the trained manpower. Achievement of this goal results from establishment of a training program. At the Children’s Hospital in Washington, such a program began in 1947. It had a duration of one year, included one faculty member and one student, and was called a preceptorship. Soon, both the faculty and student size doubled, tripled, quadrupled, etc., and became known as a fellowship. Other fellowship training programs were also developing at that time in both strabismology and pediatric ophthalmology, and many of our alumni established pediatric ophthalmology programs as soon as they had completed their training. Another training program, which began almost as early as Washington’s, was Toronto’s Sick Children’s Hospital under the direction of Jack Crawford. It also became attractive to some fellows to split their year of training between two or more programs. For example, Washington shared fellowship training with Wills Eye Hospital in Philadelphia and with Smith-Kettlewell in San Francisco.

By the later half of the 1960s, the number of Washington-trained pediatric fellows had reached the critical mass to pressure for the formation of an alumni association. This became a reality in 1969, with bylaws and plans to do big things nationally for pediatric ophthalmology. We consisted of 24 members, and the criteria to be included as an alumnus was to have completed six months in the Washington fellowship program. We named ourselves the Costenbader Alumni Society and agreed that success would be measured by doing something more than simply meeting annually to express our good fellowship toward one another. We inaugurated a national meeting of pediatric ophthalmology of three days, choosing a different city each year, followed by a private alumni meeting of two days. The first meeting took place in Washington in 1970, followed yearly intervals in Miami, Hawaii, and Sea Island, Georgia, before recognizing that, despite excellent attendance and financial success, our model controlling the program by the Costenbader Alumni Society engendered ill feelings between the Washington Group and other pediatric ophthalmologists. The following year, during the 1974 meeting in Los Angeles, we voted to end our exclusive policy, created a national pediatric ophthalmology society to include everyone who practiced strabismology or pediatric ophthalmology, and named it the American Association of Pediatric Ophthalmology (AAPO). It was financed by the Costenbader Alumni fund, including the upcoming 1975 meeting in Lake Tahoe, which had already been scheduled. The charter membership of the AAPO would then establish their by-laws, select their officers, and committee structure. Despite some naysayers, it became an immediate success. The AAPO began a bimonthly journal, created an editorial board, and most importantly, became the single voice that spoke for pediatric ophthalmology. The annual meetings have become the richest source of continuous education for the membership. The AAPO is related to the American Academy of Ophthalmology (AAO), the American Academy of Pediatrics (AAP), the American Board of Ophthalmology (ABO), the American Ophthalmological Society (AOS), and the American Orthoptic Council (AOC).

At a business meeting in 1976, Dr. Jampolsky proposed that the name changed to AAPOS, adding the importance of strabismology to the name that initially included only pediatric ophthalmology. The very important proposal was accepted forthrightly, and probably thwarted the possibility of creating another competing association of strabismologists. In 1977, a bylaws change gave the organization its new name.

Only a few months ago, the APPOS created a foundation which should improve its position for garnering funds to institute new programs. The foundation known as the National Children’s Eye Care Foundation (NCECF) is being folded into the AAPOS; receiving its funds; assuming a new name; establishing a new board of directors and officers – all selected by the AAPOS. The NCECF was formed in Washington, D.C., in 1970 as a not-for-profit 501(C)(3) corporation. Its mission was to optimize the quality of life of infants, children, and families fostering normal development and protection of vision through promoting programs of prevention, detection, treatment, research and education. The NCECF fulfilled it purpose by funding post-residency fellowships: funding research dedicated to correcting children’s eye disorders and diseases; sponsoring national symposia for professional medical personnel to further their knowledge of children’s eye care; and conducting public education projects that promote early detection and treatment.

Having the AAPOS take over NCECF results in one foundation, possibly avoiding competition between two foundations working on the same mission. There is no doubt that the AAPOS is better positioned to b become the dominant of the two. Above all, there should only be one foundation dedicated to children’s eye care nationally.

Annual meetings draw many foreign attendees by virtue of the APPOS’ foreign membership status. Orthoptics membership is also included. The charter membership or AAPOS was 78 in 1974. By 2002, this had increased to over one thousand and it continues to increase at a rapid rate. What better proof could we have of the need for a subspecialty of pediatric ophthalmology and strabismus within the overall discipline of ophthalmology?

At the Crossings: Pediatric Ophthalmology and Strabismus, pp. 15-17

Proceedings of the 52nd Annual Symposium of the New Orleans Academy of Ophthalmology, New Orleans, LA, USA February 14-16, 2003 edited by

Robert J. Balken, George S. Ellis Jr. and H. Sprague Eustis

© 2004 Kugler Publications, The Hague, The Netherlands