Introduction of the Costenbader Lecturer
Erick D. Bothun, MD
8:20 AM – 8:45 AM
44th Annual Frank D. Costenbader Lecture
Steven M. Archer, MD
“Why Strabismus Surgery Works: The Legend of the Dose-Response Curve”
8:45 AM – 8:48 AM
John D. Baker, MD
Why Strabismus Surgery Works:
The Legend of the Dose-Response Curve
Steven M. Archer, M.D.
University of Michigan
Introduction: Understanding the dose-response relationship has historically been regarded as an important approach to improve the success of strabismus surgery. Paradoxically, studies generally confirm the initial dose-response curve assumption, even when each author’s assumption is different.
Purpose: To explore the role of pre-operative deviation as an independent predictor of the response to strabismus surgery and how this makes any dose-response assumption, to some extent, a self-fulling prophecy.
Methods: Strabismus surgery dose-response data from a variety of sources is analyzed using multivariate regression techniques that include both the pre-operative deviation and the surgical dose as predictors. The p values and partial correlations from these regressions are used to investigate the relative contribution of each factor.
Results: In spite of the confounding effect of strong covariance, these analyses consistently show that the pre-operative deviation is statistically a better predictor of the response to surgery than the amount of surgery. In two historical data sets where one factor is constant and the effect the other can be analyzed in isolation, the pre-operative deviation alone accounts for 78% and the amount of surgery alone accounts for 46% of the surgical response.
Discussion: The importance of pre-operative deviation as an independent predictor implies a biologic response to strabismus surgery that tends to produce more change in alignment when the deviation is large and less when it is small. While the amount of surgery is also, to some extent, an independent predictor, much of its apparent relationship to the surgical outcome in many studies may simply be secondary to its being a function of the pre-operative deviation. Because of its lesser role as an independent predictor, precise titration of the amount of surgery by meticulous measurement of the pre-operative deviation, refinement of the dose-response curve or adjustable sutures may be less important to the surgical outcome than generally believed.
Frank D. Costenbader Lecture
The Frank D. Costenbader Lecture was inaugurated in 1974 at the Annual Meeting of the Costenbader Society to honor Dr. Costenbader. The American Association for Pediatric Ophthalmology, later the American Association for Pediatric Ophthalmology and Strabismus was created at this meeting. From its inception, AAPOS undertook to sponsor the Costenbader Lecture as the keynote presentation at its annual meeting. Due to failing health, Dr. Costenbader was unable to attend any of the lectures which honored him.
Dr. Costenbader was born and educated in Virginia and was a true Virginia Gentleman. He received his undergraduate education at Hampton-Sydney College, his medical degree from the University of Virginia and completed his residency at the Episcopal Eye, Ear and Throat Hospital in Washington, DC.
Dr. Costenbader started practice in 1932 in the depression and began a lifetime commitment to teaching, which set the stage for the tremendous influence he had on ophthalmology when he began to only see children. In 1933, Dr. Costenbader was appointed Instructor in Ophthalmology at Georgetown University and he became Special Lecturer and Conferee there in 1964. He also was on the faculty of George Washington University advancing to the rank of Clinical Professor. He was known for his enormous patience, generous with his time, always offering complete answers to even the weakest questions, and he rarely lost his equanimity. He changed the Children’s Hospital Clinic from one of service only to teaching and clinical care. He committed a full day a week to teaching for many years, spending Tuesday afternoons at Children’s and another half day a week at the Episcopal EET Hospital. In 1946, the Episcopal residents started rotating at Children’s, and he was able to focus his teaching efforts there.
Dr. Costenbader is referred to as the Father of Pediatric Ophthalmology. That designation is because of his decision in 1943 to limit his practice to pediatric ophthalmology, and he was the first ophthalmologist to do so. He moved his office to a stately brownstone townhouse on 22nd Street in Washing- ton, DC. His waiting room was referred to as Dr. Costenbader’s living room by many of his young patients because of its small furniture. He had two exam rooms on the first floor, which he used, and there were additional exam rooms on the lower level for his orthoptist, Ms. Dorothy Bair, and associates, fellows and preceptors. It was a center for wonderful patient care and the first real education or training center for pediatric ophthalmology. His exam tools were limited. Dr. Costenbader had a picture of an airplane and a phone on a rotating box at the end of his room and kids would beg to come in and see his airplane and talk to him about it. The patient’s examination chair was a kitchen chair placed on a small wooden platform.
When asked why he limited his practice to pediatrics, the first thing Dr. Costenbader would say was that kids are just so much more fun. He also was fascinated with the eye problems of children and at that time, ophthalmologists interested in strabismus were more interested in adults and older children and in cosmetic alignment.
Dr. Costenbader was an advocate for children. His concern for their health and the financial welfare of families in providing for the health of their children led him to establish and financially support the Eye Fund at Children’s Hospital to pay for indigent patient surgery. This fund is now used to support the training program at the Children’s National Medical Center in Washington, DC.
Continuing with his concern for providing for children’s health care, he was co- founder of the Medical Service Plan (today Blue Shield) of the District of Columbia and was the first president from 1946 to 1951. He remained on the board for many years. In addition, he started having parents be with their child in the anesthesia induction room before surgery, he eliminated bandages on eyes following strabismus surgery, and he changed strabismus surgery from two inpatient nights to same-day surgery. Dr. Costenbader was Chief of Ophthalmology at Children’s Hospital of Washington, DC, now The Children’s National Medical Center from 1938 to 1965. He had a remarkable effect on children’s eye care and children’s health in general.
This lecture memorializes the man who had the foresight and the courage to begin a subspecialty in ophthalmology and the talent and dedication to train and mold the nest generation according to his ideals.
Past Costenbader Lectures
1974 Los Angeles Marshall M. Parks, MD
1975 Lake Tahoe Robert N. Shaffer, MD
1976 Bermuda Lorenz E. Zimmerman, MD
1977 San Francisco T. Keith Lyle, MD
1978 Williamsburg Jules Francois, MD
1979 Toronto Robison D. Harley, MD
1980 San Diego David G. Cogan, MD
1981 Orlando Philip Knapp, MD
1982 Monterey Joseph Lang, MD
1983 Vancouver Jack C. Crawford, MD
1984 Vail Gunter K. von Noorden, MD
1985 Puerto Rico Arthur J. Jampolsky, MD
1986 Maui Robert M. Ellsworth, MD
1987 Scottsdale John E. Wright, MD
1988 Boston Alan B. Scott, MD
1989 Kiawah Kenneth C. Swan, MD
1990 Lake George John T. Flynn, MD
1991 Montreal John A. Pratt-Johnson, MD
1992 Maui Eugene M. Helveston, MD
1993 Palm Springs Henry S. Metz, MD
1994 Vancouver William E. Scott, MD
1995 Orlando Eugene R. Folk, MD
1996 Snowbird Marilyn T. Miller, MD
1997 Charleston Robert D. Reinecke, MD
1998 Palm Springs David L. Guyton, MD
1999 Toronto Malcolm L. Mazow, MD
2000 San Diego David R. Stager, Sr., MD
2001 Orlando Forrest Daryel Ellis, MD
2002 Seattle Creig S. Hoyt, MD
2003 Hawaii Burton J. Kushner, MD
2004 Washington, DC Arthur L. Rosenbaum, MD
2005 Orlando Albert W. Biglan, MD
2006 Keystone Earl A. Palmer, MD
2007 Seattle John D. Baker, MD
2008 Washington, DC Edward G. Buckley, MD
2009 San Francisco Richard A. Saunders, MD
2010 Orlando, FL A. Linn Murphree, MD
2011 San Diego Susan H. Day, MD
2012 San Antonio Michael X. Repka, MD
2013 Boston M. Edward Wilson, MD
2014 Palm Springs John F. O’Neill, MD
2015 New Orleans David S. Walton, MD
2016 Vancouver Edward L. Raab, MD, JD
Supported by the Children’s Eye Foundation