Yes, it is important to have the versatility that iTTL or eTTL offers, but it is not mandatory for getting good flash exposures underwater with a DSLR.
I use an Ikelite iTTL converter with my D2x in an Aquatica housing with dual SunStrobe DS200s.
While on land I generally shoot either aperture or shutter priority mode for about 85 to 90% of the exposures that I make, with the rest in manual mode. However, underwater the reverse is true, where I shoot 90 – 95% of the exposures that I make in manual mode, with the rest dedicated to any of the automatic exposure modes.
While I can “ballpark” a completely manual exposure with flash illumination pretty well underwater, I usually rely on the iTTL converter.
My modus operandi is to set the basic aperture with which I want to work with while in manual mode, then set the iTTL controller to auto as a preventive measure so I don't blow out any highlights due to camera / subject movements. After that, I use the shutter speed control knob to vary the amount of natural background illumination. To a certain extent, I dumb it right down and think of the shutter speed knob in terms of lightening or darkening the background depending on which way I turn the knob and my particular objectives when executing the shot.
I only shoot in uncompressed RAW mode.
Hope that helps.