This post appears as part of a series called Sit Down – candid conversations with real people detailing their journeys and experiences with Vision Therapy.
A Sit Down – with Dr. Dominick M. Maino
For the benefit of our readers, can you explain how you became interested in Optometry?
Like many future eye doctors, I became interested in the profession because my family optometrist was absolutely amazing! He took time to carefully perform the examination, all the while telling me what he was doing and why he was doing it. I knew I wanted to be an optometrist ever since 3rd grade after receiving my first pair of glasses and although I looked at many other professions over the years, I always came back to optometry as my best career choice.
My twin brother, Joseph (also an optometrist and former Chief of the Optometry program at the Kansas City VA Hospital) and I went to the same grade school, high school, college and optometry school together. During our undergraduate years at Beloit College in Wisconsin, we were involved in the pre-med track since they did not offer a pre-optometry program at that time. Although I majored in biology, I was also quite interested in philosophy, held various officer positions within the Beta Theta Pi fraternity and was a member of the “Pep Band” playing trumpet (mostly to annoy the opposing team).
I then attended the Illinois College of Optometry (ICO) and upon graduation was the founding Pediatric/Binocular Vision Resident. During my early tenure at ICO, I went to the University of Illinois at Chicago and was awarded the M.Ed. degree with a special emphasis on individuals with special needs. As a Professor of Pediatrics/Binocular Vision, I participate in all aspects associated with the academic lifestyle and am active in private practice (Lyons Family Eye Care) specializing in pediatrics, binocular vision, vision therapy and serving patients with special needs.
What led you to Developmental Optometry?
My interest in developmental, functional, and behavioral optometry was fostered by many of my outstanding ICO teachers such as Drs. Leo Manas (well known for his book on the OEP 21 point examination), Coleman Hatfield (who also authored books about the Hatfield and McCoy feud), Tony Nizza (my Peds/VT Resident advisor), Janice Scharre (former Chief of the Peds/BV Service and Dean of ICO) and Darrell Schlange (who is now a friend, colleague, and frequent research collaborator). Other professors that influenced me in many ways included Drs. Ernie Tennant (he made sure I passed and eventually did pretty well in geometric optics!), Wally Yasko (the director of ICO’s eye clinic) and Alfred Rosenbloom (former Dean and President of ICO and expert in geriatrics and low vision). My activities as a student at ICO not only included on campus involvement in various student groups, but also a high level of participation in the AOSA/AOA, COVD and OEPF organizations.
Several of optometry’s respected researchers and clinicians also influenced me. These individuals included Drs. John Streff and Gerry Getman (who came to ICO several times when I was a student). Although I only understood about half of what they were trying to teach, I was in awe of their clinical intuitiveness and ability to diagnose the functional problem areas each child exhibited just by watching the patient. I now tell my students how important it is to “watch the patient” while preforming an evaluation so that they can truly understand how they interact within their visual world. When I was a new faculty member at ICO, Drs. William Ludlam, Nate Flax, Sid Groffman, Don Getz, Israel Greenwald and many others associated with the Optometric Extension Program Foundation (OEPF) and the College of Optometrists in Vision Development (COVD), guided me in my pursuit of academic and clinical excellence in developmental optometry.
Finally, my interest in functional optometry was always based upon the answer to this question: “What have you done to make the life of your patient better?” I believe that I have successfully answered that question for a majority of my patients.
Dr. Maino lecturing at COVD
As a faculty member at ICO, what is your primary role?
Teaching. Teaching has been and will always be the most important role of any faculty member at a School and College of Optometry. I take that role seriously. Over the years, I’ve been involved in administration, research and college and community service activities as well. I’m in the classroom, laboratory and clinic depending upon my schedule.
Students often come to pediatrics and binocular vision with pre-conceived ideas…..and a bit of fear! I try to show them the joy of working with children and adults with functional vision problems and how we can significantly change lives for the better. This is also true for the patients with special needs that we serve as well.
Another important role is that of being an optometric educator others may want to emulate. I encourage many of my students to pursue a residency in pediatrics and binocular vision and then to bring these skills to other educational institutions and private practice. I suggest to all that Fellowship in COVD and membership in organizations such as OEPF and the Neuro-optometric Rehabilitation Association (NORA) are important as well.
You also conduct research at ICO, correct?
That’s correct. ICO has a very active research program. Individuals with various developmental and acquired disabilities were frequently ignored by those in eye care field and I often heard, “They have mental retardation, they don’t need to see as well as those without disability.” My research dispels this notion and emphasizes the importance of providing appropriate care for those with Fragile X Syndrome, intellectual disability and psychiatric illness and other disabilities. Currently, often in collaboration with Dr. Darrell Schlange, I am researching vision function and how vision therapy can be used to improve the quality of life for those with traumatic brain injury.
Over the years I have written, edited, or co-edited two books on the vision problems associated with disability, several chapters on the topic in other texts, and many papers. Developmental optometrists are well suited by training, clinical skill and dedication to the patient’s welfare to provide the very best care for those with disability. My latest book (co-edited and written by Drs. Marc Taub and Mary Bartuccio) recently was awarded 1st Prize by the British Medical Association (BMA) in the areas of health and social care. Although I am certainly biased, I believe that this text should be the “go to” book for optometrists who evaluate patients with special needs.
One of the BMA reviewers noted:
“There is literally no other book that covers this very important subject area. It is structured by common conditions that lead to special needs so that the reader can easily access areas they need more information in. The writing style and tone of the book are very clear and simple. This text could also be easily read by lay person carers of special needs patients. This area of work within eye health in the world is very much neglected. It is a groundbreaking piece of work to help the most disabled of people in our modern society. In addition they have done a great job of a most complex task.” — BMA Medical Book Award reviewer, 2013 BMA Medical Book Awards”
Since it is important for those of us in academia to share our knowledge and expertise beyond the “Ivory Towers”, this coming Fall I will be presenting a paper on Pediatric Cortical Visual Impairment (PCVI) and a poster on Pallister–Killian syndrome (this is a child with PCVI) at the International Congress of Behavioral Optometry in Birmingham, UK. Developmental optometrist should use their skills for improving the quality of life even for those with profound visual impairment. I hope to interest our international brethren to do just that with these presentations.
What is the history of Lyons Family Eye Care (LFEC)?
An optometric faculty member’s responsibility toward his students extends into a time frame well beyond graduation. I frequently communicate with or visit my former students to see how they are doing, offer congratulations on their many successes and provide assistance in establishing a peds/VT niche within their office when requested. About a year and a half ago, I read a story featuring Dr. Stephanie Lyons and her husband John (LFEC’s practice/business manager) who were developing a thriving urban practice in Chicago’s Lake View neighborhood.
The first thing I noticed when arriving at LFEC was that patients were not given pen and paper to fill out the preliminary case history information, but rather were handed an iPad. After completing the initial information intake process, the patient was then taken to the pre-testing area where a variety of tests were performed including autorefraction, autokeratometry, tonometry and more. While Dr. Lyons was getting ready for her next patient the iPad data was delivered digitally to her computer desktop and the pre-testing area data was placed on a small card the size of a credit card. This card was then loaded into the computer connected to a digital phoropter. Upon completion of the assessment, all the information was downloaded into the practice electronic health record (RevolutionEhR) and used to determine the most appropriate diagnosis and treatment.
Obviously this was an office dedicated to using the latest technology for patient care.
As a “geek” who has been involved in the use of computer aided tools for patient care for some time, I found this to be somewhat incredible for an office not yet a year old.
I had to go back a second time. During this visit I learned that two small, very fuzzy dogs belonging to the Lyons family, often visited the practice. When “Lucky” and “Chance” came to visit at the same time, they were frequently referred to as “Chucky!” Adults and children loved these puppies. (I now have patients who come to LFEC only if I assure them that “Chucky” will be there!) I also learned during this visit that the whole office raised funds to provide eye and vision care during a VOSH trip to Honduras. I did not know of any other office that could afford to take time off to provide this public service in their first year of operation. Yet, LFEC did exactly that!
I had discovered an office that was both high tech and high touch. They knew that the community in which they worked was very dog friendly and already had a vision therapist conducting vision therapy several days a week.
On my third visit, I made Stephanie and John an offer they couldn’t resist! (They were a bit surprised however.) And since my involvement at LFEC we now offer vision therapy 4 days a week, added a second therapy room and an additional therapist.
Since graduating from ICO, I have always worked in a private practice setting. It is important to bring real practice experience into my teaching at ICO. My time spent at Lyons Family Eye Care allows me to do this. We also have one of my students with us who provides vision therapy under my supervision as well. The potential for teaching and learning never stops. My LFEC colleagues, staff and students often mentor me as well.
Presenting a lecture on 3D Vision Syndrome (Dominick is an AOA spokesperson on Binocular Vision problems associate with watching simulated 3D)
Can you tell us about the Neumann Family Services and how you became involved?
Neumann Family Services provides housing, health care, educational, rehabilitation, vocational and many other services to a very unique special needs population. The majority of adults served at this facility have both an intellectual disability and a psychiatric illness. The medical director (Dr. Robert Jespersen) was told by his patients (in no uncertain terms) that they were tired of going to doctors all over town and that they wanted their doctors to come to them. Unlike the response most health care professionals would have given, Dr. Jespersen (a psychiatrist by training- which may have played a role in his believing that his patients request was most reasonable) thought this was an excellent idea.
Neumann now has MDs, DDSs, ODs and many other health care providers, coming to this facility to provide care. I bring 2 or more ICO students to Neumann and provide comprehensive eye and vision care as a part of the students’ requirements within the Peds/BV Service of ICO’s Illinois Eye Institute. These students have an opportunity to work with a very unique population and the patients at Neumann receive the best possible vision care. I have also conducted research at Neumann with Dr. Jespersen and we work together on various projects that highlight the health care needs of these intriguing individuals.
A point many people have made during these interviews is that most optometry students are exposed to Vision Therapy too late in their educational career, almost as if it’s an afterthought. As a result, many students have chosen their specialty within optometry without consideration for the developmental side. Do you agree with this idea?
Yes and No. How’s that for a definitive answer?
I’m not familiar with what other schools do, but at ICO we offer students a number of ways to learn about and become involved in developmental optometry. We have student organizations that encourage involvement in COVD, Neuro-optometric Rehabilitation Association (NORA) and the Optometric Extension Program Foundation (OEPF). Each of these organizations provides lectures and other activities open to all at ICO. Recently COVD Board member, Dr. Dan Press, visited ICO and made a very well attended presentation as a part of COVD’s Tour de Optometry program which was created to educate and excite optometry students about behavioral and developmental vision and vision therapy. When COVD, NORA and OEPF members are in the Chicago area, they often come to ICO to share their knowledge with the students. An example of this was a recent visit and presentation (Vision Therapy with a Vestibular Twist) by Dr. Curt Baxstrom who is active in all the organizations noted above and recently became the President of NORA.
ICO also requires students to spend time in our peds/BV area during their early years. Many of our students have binocular vision problems but may not realize this until they try to use the biomicroscope and indirect ophthalmoscope and then start to experience diplopia or other BV problems that significantly interfere with their educational requirements. These students then become VT patients and learn about functional optometry long before it is officially introduced into their course work.
ICO has an excellent reputation for encouraging our students to participate in the many pediatric/BV/VT residencies around the country. This year we have numerous graduates accepted into school and private practice based residency programs. These programs produce the future clinicians, educators and researchers that developmental optometry needs.
In my opinion, it is never too early, nor too late, to introduce a student or colleague to the realm of functional optometry. Not long ago I would receive a couple of calls a year from former students asking how to establish a vision therapy practice. Now that happens as often as once a month.
Dr. Maino and his ICO students presenting a poster at COVD
Incredibly, you have been involved in all aspects of optometry from examinations, to lecturing, to Vision Therapy, to mentoring aspiring Developmental Optometrists in your practice. With all this experience, is there one lesson you’ve learned along the way that really stands out?
My patients, students, residents and colleagues teach and mentor me every day. I have learned several lessons along the way.
Lesson #1: As a resident at ICO, I went to the Illinois School for the Visually Impaired to examined children with visual impairment. One of the children I examined had cerebral palsy. He was in a wheel chair, wearing a seat belt and crash helmet. I took one look at him and said to my fellow resident, “He’s never going to be able to read the eye chart.” My patient looked me in the eye and said, “Hey, doc…you wanna bet?”
My already short Italian frame shrunk down to a couple of inches in stature.
Lesson learned: Do not base what a patient can or cannot do upon your initial observation due to their physical appearance. I now approach each patient assuming all can do everything I want them to do until they prove me wrong.
Lesson #2: While at one of my off campus Easter Seals clinic, I saw a family who had a child with a disability called Fragile X Syndrome. I did the evaluation, determined an appropriate diagnosis, and suggested a treatment plan. Now I did not know much about (actually I knew nothing about) Fragile X at the time, but I thought, “Hey, I’m a big time, really smart eye doctor even if I don’t know much about this particular syndrome.” … and then continued about my day. The following week, I saw this family once again. They brought a second child in with Fragile X. We did an outstanding evaluation but thought yet again, “Hey, I’m a big time, really, really smart eye doctor even if I don’t know much about this particular syndrome.” The third week, the same family with a third child with….you guessed it…Fragile X Syndrome! This time a rather large anvil fell on my head and I realized that, “Hey maybe you are not such a big time eye doctor and not so smart after all!!” I not only looked up information about Fragile X, but also learned there was little known about the eye and vision problems associated with this syndrome. This realization allowed me to become an early researcher into Fragile X and now I am often involved in projects with the leading scientists in this area.
Lesson learned: I’m not such a big time eye doctor and I have a great deal to learn from every patient every day. Ignorance is not an option!!!
Lesson #3: My approach to patient care tends to mimic my approach to life. I am very enthusiastic and lively. One day I went into the clinic to examine a child with cerebral palsy who was sitting calmly in a wheel chair (no seat belt this time). I proceeded to bound into the room and excitedly said “Hi! I’m Dr. Maino!!!” The child then proceeded to fly out of the chair and making a very nice 3 point landing on the floor! The child was fine. I almost had a heart attack! It was then that I learned about the exaggerated startle reflex in individuals with cerebral palsy.
Lesson learned: I immediately learned that my personal approach to patient interaction may need to change depending upon the patient. I quickly learned how to become a “zen master”. Cool. Calm. Collected. (My family does not recognize me in this zen state, however.) I now alter my approach to obtain the best results (I have had many fewer patients flying across the room since adopting this new style of interaction!).
In the world of vision care, there is a big difference between seeking a “second opinion” and a “different opinion”. When this distinction is ignored or overlooked, much confusion is created and many parents are at a loss. Can you explain the difference in the world of eye care?
This is an interesting question that psychologists should probably investigate.
I frequently see patients who want a “second opinion” that is different from what they’ve heard from others. Less frequently I have those who only want a confirmation of what their previous doctor told them and not a “different opinion” at all. Some parents will visit many doctors until they hear the opinion they want to hear. So there may actually be 3 opinions sought: Second opinion, Different opinion, and the “What I Want to Hear” opinion.
Those who desire another opinion are typically families seeking alternatives to strabismus surgery and when children have major learning disabilities where the education only approach does not seem to be working very well.
I even have several families who work with me and an ophthalmologist, knowing full well our approaches significantly differ. I usually suggest that they pick one doctor and stick with him or her to avoid the cognitive dissonance often accompanying the disparate opinions and approaches between the OMD (ophthalmologist) and the functional OD. But they seldom do this because “they have full trust in me” and “because I actually talk to them and explain what’s going on”.
The difference in the world of eye care when it comes to second, different and “What I Want to Hear” opinions vary among families and practitioners. The bottom line is to always offer options that are the best for the patient and then let the families decide what is best for them.
What is your approach when treating a child younger than two years old, who has an eye turn? Is it different if the eye is turned in versus out?
Some research supports the belief that these young children should have strabismus surgery immediately, while other research suggests that strabismus surgery can be successful at any age. I’ve written papers, blogs and given PowerPoint presentations that review the literature on strabismus surgery outcomes.
Unfortunately, I found that strabismus surgery outcomes consistently show that 20-30% of the surgeries are not successful and that second and third surgeries are often required. There are also very few papers that have evaluated the long term effect of having strabismus surgery and those that are available do not suggest very positive outcomes over time. When you add in the rare, but possibly serious complications of any surgery, my first approach is rarely to suggest surgery for these patients. I always discuss the surgery option with parents however and give my reasons why this is not what I would recommend initially.
For any patient, especially for those under two years of age, you should do your best to determine the etiology of the eye turn. Is the etiology functional, traumatic, neurological or present because of some other condition?
Then you should consider if any amblyopia is present and if so, determine the best way to treat that amblyopia (glasses, patching, etc). I will monitor these little ones as often as once a month, but more frequently every 2-3 months.
Once the amblyopia appears to be improving, I begin (if needed) a more aggressive approach that can include the use of bifocals, prism, bi-nasal occlusion and active home and/or office vision therapy. Depending upon the outcomes of this approach, I may also consider surgery (especially if the magnitude of the strabismus is large). After surgery, I then initiate additional non-surgical intervention as needed.
In several areas of medicine (orthopedics for example), the approach would be to conduct physical therapy first, then surgery if needed (say a total knee replacement), and finally additional therapy to attain the best outcomes. Unfortunately, this well-established medical methodology of treatment flow is not utilized when many medical and even some of our optometric colleagues are involved. All too often surgery is the only option recommended.
I find that the etiology of the eye turn tends to be more of a factor when it comes to your treatment approach and success, rather than which way the eye turns. Clinically, for little ones my impression is that treatment tends to be more successful with esotropia and for those who are older you have a higher likelihood of success with exotropia. There are so many factors involved, that the reality is we probably do not know exactly what factors determine a better success rate.
I also want to point out that many believe if a child has a developmental disability and/or a history of traumatic brain injury; few options are available when a strabismus or other vision problems are present. This is NOT true.
Those with Down Syndrome have accommodative problems and strabismus that can be treated with glasses (usually a bifocal). In the past it was believed that little could be done for those with Cerebral Palsy who presented with various vision problems because the etiology was neurologically based. We now have research to suggest that this is not true. And for those with brain trauma, the work by many optometrists also support that intervention by a developmental optometrist can yield significant improvement in vision function and ones quality of life.
Children of any age and ability can often benefit from intervention by a developmental optometrist. We need to do all we can to make sure this option is available to the families and their children who need it most.
In your model of vision, what role might Occupational Therapy play in the overall development of a child, and when do you feel a referral to an OT is warranted?
In my model of care, occupational therapy, physical therapy, speech therapy, psychology/psychiatry, neurologists, various educational specialists and even ophthalmology, can play a role. Each brings to the table special skills that my patient may require. I utilize all as is appropriate.
When professionals put aside their “territorial obsessions” and concentrate on what the patient needs, the patient benefits. That should always be our main concern.
I have suggested to parents, especially those that have their children engulfed in many therapy programs, to not forget to let the child have time to just be…..a child. Time to play, time to be bored, time to think and just time to do nothing; are an important part of childhood. I will also ask them to prioritize which treatment programs must be done now versus those that could be conducted at a later date. If vision therapy is one of the latter, I work with the therapists and suggest numerous “visual interventions”. Most are quite thrilled to have me involved in the care of the child.
If in-office therapy is to be postponed, I frequently recommend various at home interventions including the use of computer programs, iPhone/iPad apps, and other appropriate interventions. I may also suggest various sports activities, hobbies, and involvement in the arts (music, painting, photography, theater) as well. After the child has accomplished those therapies deemed primary and have participated in the activities suggested, I find that vision therapy is much more enjoyable for the child (and the family) and success is attained at a faster rate.
Many people know you from COVD’s Annual Meetings as “the man with the camera”. How did you come to be the photographer at these meetings and where do your pictures end up?
Much like optometry, photography is both an art and a science. When you combine both the art and the science, you are making images that will impact many individuals. Even when you only take “pictures”, the possibility of touching another’s heart and mind is possible. If my images and pictures make someone smile, shed a tear, or remember an important event, I have done my job as a photographer.
I came to be the photographer at COVD’s annual meeting mostly by just showing up with my camera. I then offered my work to COVD to be used as they thought best.
I have held several exhibitions of my work in the Midwest and even sold some of my images (that means I must be a “professional” photographer!). Mostly I do it because it’s fun. I do it because it makes me a better optometrist. I do it because it introduces me to a wide range of people with extraordinary talent that I may not have otherwise had a chance to meet.
Many of my images can be found here.
Dr. Maino singing with the Northwestern University Summer Choir
On a personal note, you have a very interesting interest in the Filament Theatre Ensemble. Can you explain?
My dad played clarinet, had a 125 piece orchestra that he would bring together for Italian weddings and other festivities on the west side of Chicago and played bugle in the army during WWII. He also performed with Tommy and Jimmy Dorsey in one or more of their big bands during the swing era. Music has been in my blood forever.
It is no wonder then that I sing/cantor as a part of the St. Bartholomew Church Choir on a weekly basis. I’ve also had an opportunity to sing opera as a member of the choir backing up incredibly talented individuals who have sung at the Chicago Lyric and the Metropolitan Opera in New York; as well as with the 90 voice Northwestern University Summer Choir. One of my greatest thrills was when the American Optometric Association was in Chicago and the ICO Choir sung the Star Spangled Banner as a part of the opening ceremonies and often direct the ICO Choir at our graduation ceremonies.
I always tell my students to get out of their comfort zone. I encourage them to try new things where failure is a distinct possibility. When you push your limits, you learn. This is true for optometry and any other of life’s endeavors. I “knew” the arts of photography and music, but up until recently, I had no idea what involvement in the “theater arts” entailed. It was time to push my limits!
I live in a part of Chicago often referred to as Six Corners in the Portage Park neighborhood. When the recession hit, the area was adversely affected with many stores closing. About 3 years ago we elected a new Alderman who loves the arts. Soon after that we received TIF (Tax Increment Financing) money to rebuild the community. At that time the Filament Theatre Ensemble made its permanent home in my neighborhood.
The Filament Theatre Ensemble is composed of some of the most talented and dedicated individuals I have ever met. These men and women formed a professional, not-for-profit theatrical group that seldom results in any major personal fiscal rewards for the “players”. They represent the very best of the theatrical arts and frankly, I wanted to be a part of this endeavor.
I first became interested in Filament when they performed, Crossing Six Corners. This presentation was a series of re-enacted brief stories that told the history of the Six Corners and Portage Park . Several current residents were interviewed, old newspapers reviewed, and historical documents utilized as the basis of this docu-memoir-musical-play. They also performed this play at no cost to the theater goers. A continually updated Crossing Six Corners is now a Neighborhood Heritage Project that is offered 3 times a year with the help of an Illinois Arts Council grant.
The Filament Ensemble, within just a few weeks’ time frame, captured the essence of my community so well, that I knew I had to become involved in some manner. Since I have served on several boards (Illinois College of Optometry Board of Trustees, Illinois College of Optometry Alumni Council (President), Easter Seal Society of Metropolitan Chicago Medical Advisory Board (Chairman), ect.), I could bring to this group not only my leadership experience, but my connection to a neighborhood I’ve lived within for several decades.
The Filament Theatre is now in the process of raising funds to complete the build-out of the new theater space. With a $50, 000 grant and more than $71,000 raised towards our goal of $75,000, we will soon see this new performing arts center as a reality. (For more information on this build-out campaign click here)
The Filament Ensemble has not waited until the completion of the theater to bring their art to the Chicago-land area. We have presented Crossing Six Corners 3 times and a theatrical performance of The Snow Queen (think of Disney’s Frozen only with real people and not animated characters) with the plays Cyrano and Lifeboat coming in April and March. In-between these performances are various musical acts and this summer a variety show based on old time vaudeville entitled: Vaudeville at Six Corners will be performed.
My involvement is also somewhat selfish in nature. I want to be able to walk to one of the new restaurants that have or will be opening in my neighborhood, then go to a play at the Filament Theatre and afterwards have a cup of coffee in one of the new or remodeled coffee houses at Six Corners. After such a fine evening I will then walk home and place my head upon my pillow knowing that I helped to make all of this possible.
Functional optometrists make things happen. We are not observers. We help our patients and our communities thrive. Our quality of life improves when we improve vision function and when we improve the communities in which we live. And did I mention that it’s FUN!!!
Some Closing Thoughts – A great thanks to Dr. Maino for taking the time for this interview. Although I knew who he was (the man with the camera 🙂 ), I didn’t actually have the pleasure of meeting him until this past COVD Annual Meeting in Orlando. What a great man! His contributions are incredible. Please join me in wishing Dr. Maino and his family the absolute best! 🙂
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