PONE-D-19-22134

“Association of Cataract and Sun Exposure in geographically diverse populations of India: The CASE study. First Report of the ICMR-EYE SEE (Indian Council of Medical Research-Eye Sun Exposure and Environment) Study Group”

PLOS ONE

Dear Dr. Tandon,

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Additional Editor Comments:

Well done on putting together such a good manuscript. Please could you address the minor comments and resubmit

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Summary & Overall Impression

This was a very large, comprehensive and well conducted study of the relationship of sun exposure in India. The authors were able to amass a large sample of over 12,000 subjects spread relatively evenly across 3 distinct geographic areas of India, and to collect clinical and subjective data on them. They present their data in a clear and logical fashion, and have employed adequate statistical rigor to their work. Their conclusion that cataracts were associated with increasing levels of sun exposure, smoking and in some cases, exposure to indoor kitchen smoke is consistent with other published studies, and they have pointed out nuances relevant to the population and conditions in India. I find this to be a relevant and important addition to the literature, and recommend that it be published after addressing some minor issues with consistency in the paper.

Issues to be addressed (minor)

At line 311, they discuss noting increasing prevalence in cataract with decreasing distance to the equator. However, their data in Table 1 shows that while the site closest to the equator (Prakasam at ~15 degrees N) had the highest rate of cataract reported (42.4%), the site at ~28 degrees N (Guwahati - 31.9%) actually had a higher rate than the site at ~26 degrees N (Gurgaon - 26.6%). Additionally, when looking at the total UV exposures reported in Table 2, neither is the median lifetime UV exposure data consistent with the rates of cataracts. The authors should discuss additional potential factors such as work on water, increase in UV exposure at higher elevations and differences due to living and working in proximity to an urban center vs. a more rural location.

At line 328 , the authors cite 2 studies discussing the association with sun exposure and cataract, but fail to mention a very important environmental factor - working over water, as was the case with Hong Kong fisherman and the waterman of Chesapeake Bay. In the paper, which the authors have cited as a basis of their UV exposure calculations, McCarty shows a LARGE influence of water (a factor of 1.9 applied to over water exposure times). This may be an interesting factors for the authors to characterize in future studies, particularly in the regions with ocean and large river influences. This comes up again at line 347.

Another issue which should be considered is the influence of solar angle, as described by Sasaki, which can influence ocular exposure differently based on time of year and time of day. This was not considered in McCarty’s calculations but adds an interesting point of discussion… the latitudes nearer the equator always have higher ambient exposure, but more northern sites (or southern for the southern hemisphere) have direct ocular exposures that may be as high in early and late hours of summer days, and all day during spring and autumn (Sasaki H, Sakamoto, Schnider C et al. (2011). UV-B Exposure to the Eye Depending on Solar Altitude. Eye & contact lens. 37. 191-5.)

At line 403-405, the numbers quote for exposure are not consistent with those quoted in table 1 (means versus median, perhaps). And again, the reported association of higher cataract in coastal areas followed by plain and hilly areas is out of order compared to data in table 2.

Reviewer #2: the paper is interesting and helps add to the literature.

However, there are quite a few instances where the first person is used in the manuscript so I believe this should be addressed to amend to the third person.

There also needs to be a little more about UV protection worn (hats, sunglasses, CLs) - it is mentioned briefly but not explored further.

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Reviewer #1: Yes: Cristina Schnider, OD, MSc, MBA, FAAO

Reviewer #2: No

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Association of Cataract and Sun Exposure in geographically diverse populations of India: The CASE study. First Report of the ICMR-EYE SEE Study Group

PONE-D-19-22134R1

Dear Dr. Tandon,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

James Wolffsohn, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for comprehensively addressing the reviewers comments