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Agenda Driven Research


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Maino D. Agenda Driven Research. Vis Dev Rehab 2015; 1(1):7-11.

Read the editorial.....

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.

Published in: Education
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Agenda Driven Research

  1. 1. 7 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
  2. 2. 8 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] 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
  3. 3. 9 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
  4. 4. 10 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. 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: b. For a review of articles dealing with vision and learning see: c. Joint Statement on Vision, Learning and Dyslexia: http:// d. Care of the Patient with Learning Related Vision Problems: REFERENCES 1. Horwood AM, Tor SS, Riddle PM. Change in convergence and accommodation after two weeks of eye exercises in typical youg adults. Journal of the Amer Acad Pediat Ophthal Strab. 2014;1-7. 2. Donahue S. How often are spectacles prescribed to “normal” preschool children? JAAPOS; 2004: 8(3):224– 229. (available from 3. Maino D. Ophthalmology Causes Myopia! J Optom Vis Dev 2004;35 (2):67-69. 4. Maino D. Mistakes were made (Yes by you!). Optom Vis Dev 2011;42(2):66-69 5. Maino D. An Open Letter to David K Wallace, MD, MPH (and other disbelievers and holders of outdated and biased opinions and beliefs). Optom Vis Dev 2008;39(4):178- 180. 6. Ciuffreda KJ. The scientific basis for and efficacy of optometric vision therapy in nonstrabismic accommodative and vergence disorders. Optometry. 2002;73(12):735-62. 7. Maino D, Donati, R, Pang, Viola S, Barry S. Neuroplasticity. In Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs; Lippincott Williams Wilkins. New York, NY;2012:275-288. 8. Levi DW, Li RW. Perceptual learning as a potential treat­ment for amblyopia: A mini-review. Vis Research 2009;49(21): 2535–2549 9. Bavelier D, Levi DW, Li RW et al. Removing brakes on adult brain plasticity: from molecular to behavioral interventions. J Neuroscience 2010 30(45):14964-14971 10. Li RW, Ngo C, Nguyen J, Levi DM. Video-game play induces plasticity in the visual system of adults with amblyopia. 2011;PLoS Biol 9(8): e1001135. doi: 10.1371/journal. pbio.1001135. available from accessed 1/2015 11. Astle AT, Webb BS, McGraw PV. Can perceptual learning be used to treat amblyopia beyond the critical period of visual development? Ophthalmic Physiol Opt 2011;31:564-573. 12. Sankaridurg P, Holden B, Smith E, et al. Decrease in rate of myopia progression with a contact lens designed to reduce relative peripheral hyperopia: one-year results. Invest. Ophthalmol. Vis. Sci. 2011;52(13): 9362-9367. 13. Cheng D, Woo GC, Schmid KL. Bifocal lens control of myopic progression in children. Clin Experimental Optom 2011; 94(1):24–32 14. Rose KA, Morgan IG, Ip J. Outdoor activity reduces the prevalence of myopia in children. Ophthalmology 2008; 115(8):1279–1285 15. CITT-ART information: