PONE-D-20-28142

Factors correlated with visual outcomes at two and four years after vitreous surgery for proliferative diabetic retinopathy

PLOS ONE

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Reviewers' comments:

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Comments to the Author

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: THis is a nice set of data regarding long-term outcomes for patients undergoing vitrectomy surgery for proliferative diabetic retinopathy. A few clarifications would be helpful:

1) Can the authors please describe the lens status of the patients? Did all patients receive cataract surgery at the time of vitrectomy? Were some already pseudophakic? Did any receive cataract surgery at a later time after the vitrectomy? (I ask, because cataract progression could affect final outcomes).

2) Did any patients receive anti-VEGF as a pre-operative adjunct to the surgery to reduce bleeding?

3) Did any patients develop macular edema after the vitrectomy requiring anti-VEGF therapy?

4) Of the patient with pre-operative rubeosis, did any need to go on to glaucoma surgery? What was the pre-vitrectomy stage of the rebeosis (early versus late stage)?

5) Can the authors provide some level of quantification of the proliferative membranes, and whether the extent of proliferation correlated with outcomes?

Reviewer #2: Dear authors

I would like to congratulate you on your work. The findings and results are important and can help surgeons make the right decisions. The advantages of the study are: large cohort of patients, long follow up and the fact that only two vitreoretinal surgeons performed surgeries.

The study has some major limitations:

• Effect of gauges on vitreoretinal surgery: There is considerable talk about functional and morphological results after vitreoretinal surgery performed with the help of 20G, 23 G , 25 G but no analysis on the effect of the different gauges. Did the evolution of vitreoretinal surgery have any effect on the results?

• No information on treatment regiments before and after surgery: Patients with PDR will most certainly need treatment with injection and perhaps laser treatment before and after surgery. There is only one short mention on the use of Triamncinolone before surgery but no mention on the use of injections or laser before and after surgery. I believe this is a very important part that will judge the anatomical and functional results and has to be mentioned with sub-analysis in each group. (lower initial BCVA means more or less post OP treatment with injections or laser?)

• Did the status of the fibrovascular membranes and the status of the posterior hyaloid play a role in the functional and morphological results? Did the manipulation of these mambranes have an effect on the RD rate and final BCVA?

• Lines 111 and 112 Explain: Among them, 91 eyes of 70 patients could be followed up for 4 years after 112 a primary surgery, and 37 eyes of 30 patients could be followed up for 2-3 years How is it possible to have data on 91 eyes with a 4 year follow up and only 37 eyes with a follow up up to 2-3 years. Is it opposite correct? What do you mean with 2-3 years? Not precise enough

• Lines 153 to 160: A statistical association between initial BCVA and improvement of vision after 2-3 year and 4 year is essential! Which patients profited more from surgery? Does initial BCVA is a prognostical factor?

• Discussion Line 214-220: Important and helpful results but these results are incomplete if the treatment regiments before and after surgeries are not elaborated (did patients with rubeosis iridis receive any or more post OP injections or laser treatments compared to patients with no rubeosis?)

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Reviewer Comments.docx

Factors correlated with visual outcomes at two and four years after vitreous surgery for proliferative diabetic retinopathy

PONE-D-20-28142R1

Dear Dr. Nishitsuka,

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

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Kind regards,

Andrzej Grzybowski

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

I agree with Reviewer 3, who confirms the original concerns noted by the reviewers have been adequately addressed.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for addressing my comments. I appreciate the clarifications and feel that your work adds new information to the literature.

Reviewer #2: Dear authors.

Thank you for the revision of your work. One major limitation of the work is the absence of anti VEGF parameters. The injection of steroids is not up to date. The major advantage of the work is the long term follow up. I regret to inform you that i would not recommend this papaer to be published.

Reviewer #3: This revised manuscript explores factors associated with better vision outcomes after vitrectomy for proliferative diabetic retinopathy (PDR). As the authors point out, patients with PDR often have vitrectomy in their 50's, but go on to live to an average age of 70. Therefore it is important to determine factors associated with preserved vision after vitrectomy for PDR. A total of 128 eyes in 100 patients operated between January 2008 and September 2012, followed for 2 to 4 years or more were evaluated. Of these, 91 eyes from 70 patients were followed for 4 years. Those followed for more than 2 years, but less than 4 years were described as a group followed for 2-3 years. Factors associated with better vision included:

1. No preoperative rubeosis, which, if present, would be a sign of severe retinal ischemia.

2. No preoperative fibrovascular membrane.

3. Preoperative vitreous hemorrhage did not adversely affect vision.

4. No reoperation.

Questions from two reviewers of the original manuscript were answered satisfactorily. The study was carried out in Japan, where anti-VEGF therapy was not approved, and was therefore unavailable during the study. Panretinal photocoagulation was utilized for retinal neovascularization and rubeosis. Triamcinolone and focal macular laser were used for diabetic macular edema.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No