Maino D. Agenda Driven Research. Vis Dev Rehab 2015; 1(1):7-11. Read the editorial..... Conclusion It is time for all to put aside our agendas, our biases, our preconceived notions. It is time to work together to determine best practices even if it is contrary to prevailing opinion. The world is not flat. Amblyopia can be treated at any age. And optometric vision therapy is an appropriate treatment modality for disorders of he binocular vision system.

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Vision Development & Rehabilitation Volume 1, Issue 1 • April 2015
Last summer I was present at a meeting hosted
by the School of Optometry at the University of
Waterloo. This meeting was attended by the best
and the brightest of Europe’s researchers with
expertise in pediatric eye problems, amblyopia,
strabismus, and issues adversely affecting vision
development. I decided to attend the Child
Vision Research Society’s meeting for a number
of reasons including the outstanding keynote
speakers. Another reason I wanted to attend
was that one of the attendees was an individual
that I had collaborated with on a project whom
I had never met in person. She was delightful
to work with and was also a very well-known
and respected researcher. Researchers, faculty,
clinicians, and orthoptists from New Zealand,
Nepal, Korea, Israel, the UK and the USA were in
attendance.
Besides the great keynote speakers (Drs.
Susan Cotter, Professor, Southern California
College of Optometry; Daphne Maurer,
Professor, Department of Psychology, McMaster
University; Saint-Amour, Associate Professor,
Department of Psychology at the Université
du Québec a Montréal), this exceptional
program featured various paper and poster
presentations. The final day we were all bussed
to The Hospital for Sick Children in Toronto for
additional lectures and tours of the facility.
I soon realized that this particular meeting
was somewhat different than those I usually
attend. For instance, I noticed that several
of the research projects did not appear to be
completed but rather ongoing in nature.
When one of these not quite completed
research papers was presented to the 100+
member audience, something rare occurred. The
audience, in a non-critical, helpful, “let me be
your friendly advisor” way offered constructive
criticism on how the project could be improved,
altered and/or changed to make it more
meaningful and robust. None of the meetings
I usually go to allow uncompleted research to
be presented and do not often have this friendly
critique assistance for the researcher. I found this
an excellent way to introduce new researchers
into the peer research relationship that allows
a much gentler approach then what I’ve
experienced in the past.
During the meeting a paper entitled “Does
– And How Does – Vision Therapy (Orthoptic
Treatment) Work?” was then presented. No
constructive criticism was offered even though
there were some serious flaws in the research
design and interpretation of the outcomes.
The conclusion of this research was “While
vergence exercises have some effect, effort and
possibly voluntary influences are a major factor
in effecting change … Very careful attention
should be paid to these effects when studying
eye exercises.” The impression given and
actually stated was that “eye exercises” did not
cause the improvement and all the subject had
to do was to “try harder”.
At noon the group broke for lunch and I
deliberately sought out the presenter. She was a
dedicated, excellent researcher. She had a sharp
mind and congenial demeanor. I did not discuss
my concerns about her research over lunch. I
wanted to use that time primarily to get to know
her in a friendly non-antagonistic environment.
Since this presentation was made to a small
Guest Editorial: Agenda Driven Research
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor of Pediatrics/Binocular Vision Illinois College of Optometry;
Lyons Family Eye Care, Chicago, Illinois

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Vision Development Rehabilitation Volume 1, Issue 1 • April 2015
group, during a single meeting, I figured this was
not a fight worth fighting at this time.
I was wrong.
Several months later, the article “Change in
convergence and accommodation after two
weeks of eye exercises in typical young
adults” by Horwood, Tor, and Riddle appeared
digitally as a Major Article in press for the
Journal of the American Academy of Pediatric
Ophthalmology and Strabismus. It was obvious
to me that the peer review system of AAPOS
either broke down or was a willing partner
in this agenda driven research publication.
This was not the first time I had seen what
appears to be a deliberate misuse of the peer
review system resulting in the publication of
an article with significant problems and/or
questionable conclusions.3
[I addressed many of
these problems in an editorial that is available
online of your review (Ophthalmology Causes
Myopia!).3
http://goo.gl/n0RONA]
Specific Problems with the Paper
To the authors’ credit they did list several
areas of concern that could have affected
the outcomes and conclusions of this article.
However they did not point out many of the
most important shortcomings of this particular
publication. These areas are discussed below:
1) Poor or a total absence of under­stand­ing
what optometric vision therapy is and/or
does. Terms used such as eye exercises
and the use of quotations around the
phrase vision therapy, clearly demonstrate
this lack of knowledge and experience
and the disdain the researchers have for
this form of intervention.
2) They single out optometric vision therapy
as too time consuming and intensive.
This shows a lack of understanding
of the concept of therapy. Physical
therapy, occupational therapy, speech
and language therapy and psychological
therapeutic intervention often require
weeks, months and in some situations,
years to be effective. I have not
heard from our medical and scientific
colleagues that this a major burden for
their patients when these therapists help
their patients, it appears that only vision
therapy is judged in this manner.
3) The researchers failed to include a single
individual (unlike the CITT study) that had
the training, knowledge and perhaps an
opposing viewpoint promoted by this
agenda driven article. If all researchers
start with the same assumptions,
biases and predispositions; what is the
possibility that the research conclusions
would be something other than a
reflection of these assumptions, biases
and predispositions?
Tavris and Aronson, in their text,
Mistakes were made, but not by Me:
Why we justify foolish beliefs, bad
decisions and hurtful acts, nicely
reviews why we find it so difficult to
admit when we are wrong. Unfor­
tunately, even when the facts are
present­ed, we choose to ignore
them and hold on to these erroneous
beliefs.4
We do not respond well to
cognitive dissonance and often use
any available mechanism to resolve
this intellectual conflict in a way that
preserves the status quo.5
4) The researchers stated in their introduction
that the “Research [CITT] concentrated on
relief of symptoms … without changes to
the ocular responses…”. This, of course, is
incorrect. The CITT study not only showed
an improvement in symptoms (as a
primary outcome) but also in the measures
of vergence, accommodation and other
areas (a stated secondary outcome) with
in office vision therapy with home vision
therapy being the most efficacious.
5) The methods used in this study, have
no, to little relationship to the actual
procedures utilized by optometrists while

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Vision Development Rehabilitation Volume 1, Issue 1 • April 2015
conducting vision therapy, nor to those
methods used in the CITT clinical trials.
a. The subjects in this study were self-
reported asymptomatic college stu­
dents, 18-25 years of age. The CITT
subjects were symptomatic and were
shown clearly to have convergence
insufficiency using a mutually agreed
upon set of criteria. The CITT study
utilized a research supported survey to
determine if symptoms were present.
This study depended upon subjects
who considered themselves to have
“normal” eyes.
b. The CITT study used those diagnostic
and therapeutic tools frequently
utilized in clinical practice. This study
used Gabor images and other tools
usually not utilized when conducting
diagnostic testing or a program of
therapy.
c. They stated that “Instructions [to
the subjects] were minimal…”. The
clinician usually gives fairly detailed
instructions so that the patient knows
exactly what to do and how to perform
the therapy. Did these subjects have an
appropriate understanding of the tasks
and how to respond?
d. The 156 subjects were divided into 2
control groups or to one of six “eye
exercise” groups. The second control
group was just asked to “try harder”
at performing the task. This resulted in
8 experimental groups among 156 test
subjects resulting in a study with a very
small number of individuals assigned to
each of the experimental groups.
e. There was no description of any of
the home “eye exercises”. Depending
upon the experimental group, the
subjects were asked to do the exercise
3 times/day for 5 minutes each time.
The home therapy included monocular
push-ups, monocular “jump accom­
mo­dation”, monocular accom­mo­da­
tive facility (they did note that they
used +/-2.00 D); binocular vergence/
accommodation activities (they do not
state if there were any suppression
controls) and placebo therapy
(“Snakes” illusion, Necker cube,
yoked prisms). No rational was given
for using these placebo therapies.
Unlike the CITT clinical trials, no
research was conducted to show
that these placebo therapies were
appropriate to use.
f. The researchers depended upon the
honesty of their subjects to report
missed therapy sessions. They also
used cell phone alarms and diaries
which were “informally” examined
to determine if therapy was done.
Anytime you are conducting therapy at
home as part of a research study, you
must have an appropriate mechanism
to determine if therapy was actually
conducted or not. The CITT study
had such protocols. This study was
obviously lacking in this area.
g. One of the most significant and
major flaws of this study was the
total lack of understanding of therapy
and how it is conducted in the real
clinical world. They used the phrase
“try harder” with only one group
of subjects and then were surprised
that that group had such good
results. In the real world of therapy,
encouragement, asking the patient
to try harder, and other mechanisms
that improve outcomes and to achieve
success are always utilized.
h. Finally, as noted initially, but worth
repeating, these subjects were asymp­
to­matic, apparently had no binocular
vision problems and did not require
any therapy whatsoever.
One of the statements they made and one
I cannot disagree with was “It is clear that the

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Vision Development Rehabilitation Volume 1, Issue 1 • April 2015
greatest influence in changing responses to an
approaching target is how the participant is
instructed and the amount of effort exerted.”
Functional optometrists and their therapists use
a well-crafted instruction set when conducting
diagnostic and therapeutic activities and like
all therapists always encourage the very best
efforts from their patients.
One of the statements at the very end of the
paper that has little to no scientific support or
justification was “In the view of the importance
of effort in comparison to true treatment
effects of different exercises and the costs
in terms of professional time, loss schooling,
and many office visits of a long course of in-
office vision therapy, maximizing motivation
and feedback strat­e­gies or less costly home
exercises seems desirable.” Is it really less costly
to recommend a home therapy procedure,
when the CITT studies clearly showed in-office
therapy was the most efficacious? Out of office
therapy often involves multiple trips to the
office for progress evaluations and in the end a
recommendation for in-office therapy in most
instances.
This paper failed on many different levels
when trying to answer the question, “Does
– And How Does – Vision Therapy (Orthoptic
Treatment) Work?” If they had reviewed
Ciuffreda’s 2002 paper (The scientific basis for
and efficacy of Optometric vision therapy in
nonstrabismic accommodative and vergence
disorders)6
they would have had a better
understanding of the science supporting vision
therapy.
Why did this paper appear in print? The
answer is perhaps both simple and complex.
Medicine, various researchers and others may
fear that functional optometry has been right
all along.
Functional optometry was right about
amblyopia.a
We have always supported the
concept that neuroplasticity is present at all
ages.7
We have always known clinically that
amblyopia could be treated at any age. We
have always known that amblyopia was a
binocular vision problem and not just a problem
of visual acuity and used binocular vision
therapy to treat this dysfunction. We have
always known that the research of Hubel and
Wiesel was inappropriately interpreted and that
this resulted in delayed or no treatment for tens
of thousands of patients.
Research supports the ability to treat
amblyopia at any age.b
Research supports
that treating amblyopia as a binocular
vision problem using binocular therapy is
appropriate.8,9,10,11
Ophthalmology and those who supported
ophthalmology should have known this as well.
They should have known this since those adult
patients who were amblyopic and then lost
vision in the better seeing eye, almost always
had an improved visual acuity in the amblyopic
eye over time. They chose to ignore what they
were seeing clinically, in large part, because it
did not fit their beliefs and biases and because
it supported the views of functional optometry.
We were right about refractive error. The
environment does influence its development
and that if that environment is manipulated
appropriately, you can alter refractive error
outcomes.12,13,14
We were right about learning related vision
problems. Well, this one has support on both
sides of the issue. The CITT-ART study15
should
help resolve some of the questions regarding
vision therapy and how it affects academic
performancec,d
.
The more complex reason has to do with
agenda driven research and the mechanisms
involved when these papers are presented and
published. Agenda driven research does not
promote good science. It does not promote
honest inquiry and it does not support better
patient care.
It is time for all to put aside our agendas,
our biases, our preconceived notions. It is time
to work together to determine best practices
even if it is contrary to prevailing opinion. The
world is not flat. Amblyopia can be treated at
any age. And optometric vison therapy is an

5. 11
Vision Development Rehabilitation Volume 1, Issue 1 • April 2015
appropriate treatment modality for disorders of
he binocular vision system.
Footnotes
a. For a review of many of the PEDIG study see this Slideshare
presentation: http://goo.gl/3WjN4p
b. For a review of articles dealing with vision and learning
see: http://goo.gl/aZcY8S
c. Joint Statement on Vision, Learning and Dyslexia: http://
goo.gl/izyROZ
d. Care of the Patient with Learning Related Vision Problems:
http://goo.gl/gfuvpP
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“normal” preschool children? JAAPOS; 2004: 8(3):224–
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3. Maino D. Ophthalmology Causes Myopia! J Optom Vis
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4. Maino D. Mistakes were made (Yes by you!). Optom Vis
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5. Maino D. An Open Letter to David K Wallace, MD, MPH
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