PONE-D-21-25050Effects of aging and exercise habits on blood flow profile of the ocular circulationPLOS ONE

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Reviewer #1: No

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

Reviewer #1: No

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Reviewer #1: Yes

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Reviewer #1: Yes

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5. Review Comments to the Author

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Reviewer #1: In this manuscript, the authors report on the effects of exercise on ocular blood flow. They show that several of the markers decrease with age, which is consistent with prior reports. Interestingly, the data suggests that exercise has no beneficial effect on ocular blood flow and, if anything, may be detrimental. This is based on the finding that BOT decreased with age in the exercise group, whereas the no-exercise group did not exhibit the age-related decline. This finding is somewhat paradoxical. While a high number of relatively healthy patients have been recruited for this study and a large number of outcome measures are studied, there are many concerns with the manuscript in its current form. Moreover, due to the lack of detail provided regarding the inclusion/exclusion criteria and questions regarding the statistical analysis, the conclusions aren’t well supported. To the authors credit, they do attempt to address some of the limitations in the discussion.

(1) How are “healthy” people defined in this study. This is a major crux of this study. The inclusion/exclusion criteria and not defined well. Do any of the patients have systemic disease of any type that are treated (or not treated)? Metabolic syndrome is described but there is no data on the percentage of patients with metabolic syndrome nor is it included in the analysis. The lack of adequate patient group matching may have impacted the overall outcome. Sex-linked differences in blood flow suggest hormonal effects. Is the use of oral contraceptives or hormone replacement therapy evaluated?

(2) Patients were excluded if they had an ophthalmic disease. Was a comprehensive eye exam performed? If so, what parameters were evaluated? Was visual acuity measured using EDTRS? Any type of fundus evaluation? OCT of the RNFL? If the presence or absence of ophthalmic disease was based on a medical record, how recent was the medical exam? Were these patients that had all had a recent eye exam within the prior 12 months?

(3) Smoking and alcohol use both affect the vascular system. There is no mention of how alcohol use was quantified. With smoking, current smokers vs non-smokers are included, however prior history of smoking should have also been considered.

(4) Please spell out what MBR stands for.

(5) Was phlebotomy done at the exam? This is assumed but not described. Where was the blood analysis performed? Laboratory specific cut-offs need to be specified so that data can be properly interpreted.

(6) Line 149 states that IOP was measured using a commercial sphygmomanometer. This is incorrect. Please describe how IOP was measured and if repeat measurements were taken. Also of note, was corneal thickness accounted for in the IOP measurement? Thick corneas can artificially inflate pressure readings while thin corneas can give lower readings than actual.

(7) How were the numbers of steps per day calculated? Was this data point only collected for those with exercise watches? How were missed data points accounted for in the statistical analysis?

(8) Numerous questions surround the statistical analysis. It is recommended that a biostatistician review the data in this paper. In the tables, a high number of comparisons are made without accounting for multiple comparisons. For example, in Table 1, there are 31 parameters being compared. It is highly unlikely that a p value of 0.02 in this scenario is relevant. Also, the authors need to address the differences between statistical significance and clinical significance. Many parameters have a p value < 0.05 but have an actual numerical difference of 1 or even less. This isn’t likely to have any clinical meaning.

(9) The term demographics is incorrectly used in table titles. Serum lipid levels or blood pressure are biological metrics but no demographics.

(10) How was waist circumference measured? This is not included in the methods section. How was BMI calculated?

(11) Sex differences in Table 2 are not analyzed.

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Reviewer #1: No

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Effects of aging and exercise habits on blood flow profile of the ocular circulation

PONE-D-21-25050R1

Dear Dr. Hayashi,

We’re pleased to inform you that  after the revision your manuscript has been accepted for publication.

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Kind regards,

Barbora Piknova

Academic Editor

PLOS ONE