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PONE-D-21-11420

The reliability of the angle of deviation measurement from Photo-Hirschberg tests and Krimsky tests

PLOS ONE

Dear Dr. tengtrisorn,

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The idea of the manuscript is interesting However, the manuscript needs some justification for the exclusion of  some patients, and explanation of how patients were intermittent exotropia were photpgraphed..

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PLOS ONE

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Reviewers' comments:

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Comments to the Author

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

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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: No

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: This study addresses an important issue and worked on a technique that may be useful in areas with no strabismus specialist. Although the idea is good yet the study is limited by the small number of cases and major exclusion criteria. The manuscript needs a lot of work to be suitable for publication. Below are the details.

Line 58: “Many studies have tried… “ What are those studies? No references mentioned.

Lines 55 to 82: This part should be moved to the discussion. The details of previous investigators’ approach can be included briefly in introduction only if needed to explain the purpose of the study. This section should be reduced in introduction and moved mostly to discussion.

Line 89: “Four subjects in the XT group were intermittent XT”: The authors described the diagnosis of four subjects out of the total cohort only. It is unclear why this diagnosis was singled out specifically here. Why not mention the breakdown of the diagnosis of all the test subjects?

Line 87-94: Inclusion criteria were mentioned, then diagnosis of 4 subjects, then the consent, then back to exclusion criteria. This order is not usual. I recommend keeping the exclusion criteria right after the inclusion criteria.

Lines 91-94: Why was accommodative ET excluded? Why were cases with amblyopia or pervious surgery excluded? These subgroups are very common diagnoses, especially in the difficult cases that will need to be sent to an expert for opinion. By such exclusions authors are suggesting that the test is no useful on these subgroups and hence not useful for a big chunk of the cases in the strabismus clinic. Cause of such exclusions should be discussed.

Lines 94-96: Revise sentence structure and avoid repetition (subjects received eye examination)

Line 96: I was expecting detailed description of how to Photo-Hirschberg test was done. This is mentioned later lines 108 onwards. I think this should be moved to be in the right place. It is confusing to have to go back and forth in the manuscript. As such it lacks the smoothness that readers expect.

Lines 99-100: “Time span..” It is not clear what the authors mean by time span. Time span between what and what? And why is that? This “time span” needs detailed description.

Lines 101 -106: The consent is repeated again here. It is mentioned earlier in line 90! I would recommend starting the methodology by stating the approval by the IRB and the consent and then proceeding with the rest of the methodology. Line 105: “and showed.. “ till the end should be deleted. At this point of reading the study didn’t show anything yet. We are still in the methods.

Line 117: “limbuson”: seems a spelling mistake

Line 118: “When the right eye is fixated”: I think the authors mean when the right eye “is fixing”. Please correct this throughout the text.

Line 108: How did the photographer deal with cases of intermittent exotropia to show the deviation?

Lines 170-187: All this data should be in detailed in the table and deleted from the text. It is very confusing to read or compare these number in paragraph format. A table only without text is enough to show results like this.

Lines 189-198: the first paragraph of the discussion is almost all a repetition from the introduction.

Lines 213-215: The angles of the cases should be in the results section. The analysis as to why this might have happened goes into the discussion section.

Lines 217: Do authors want to implicate that their method is not useful in intermittent exotropia cases? Need clarifications as to what is the authors conclusions about the use in intermittent exotropia cases.

Line 234: Conclusion should be in relation to the title and objective of the study. The study is testing “the reliability of Photo-Hirschberg and Krimsky”. The objective as per the abstract “to compare photo-H, Krimsky and APCT”. therefore this should be mentioned in the conclusion. This sentence “ Photo-Hirschberg test could be used to examine and monitor” is not informative. Any test could be used to measure and monitor! Same for saying “Krimsky can be used in uncooperative patients”: this is again basic knowledge and not the conclusion of this study.

Reviewer #2: The assessment of measurement reliability should not be done by Pearson's correlation but use the Intrasclass Correlation (ICC). Please refer to the recent comments on measurement reliability and its importance for individual differences research (https://www.nature.com/articles/s41562-019-0655-x). In https://www.sciencedirect.com/science/article/pii/S2095927318305784, the anatomy of ICC is introduced. Please update all the reliability analyses in terms of the basic requirement by the two references abovementioned.

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Reviewer #1: Yes: Amr ElKamshoushy

Reviewer #2: No

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The reliability of the angle of deviation measurement from Photo-Hirschberg tests and Krimsky tests

PONE-D-21-11420R1

Dear Dr. tengtrisorn,

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,

Ahmed Awadein, MD, Ph.D, FRCS

Academic Editor

PLOS ONE

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