PONE-D-24-23473Intrastromal graft of anterior lens capsule. A substitute for Bowman layer graft transplantation for keratoconus.PLOS ONE

Dear Dr. Rodríguez,

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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: A nice research idea for treating advanced keratoconus. Great documentation in their pilot study. I wish to complement the authors for their novel idea and a good scientific research which can go a long way in treating corneal ectasias. It is a good option especially when donor corneas are scarce and also the surgical preparation of the implant is easy and can be easily reproduced. Since anterior len capsule is acellular, chances of rejection is also less.

Reviewer #2: Thank you for the opportunity to review this paper.

Whether ALC can substitute Bowman's layer in stabilising eyes with keratoconus is highly speculative. It would be good if the authors could provide any further research or evidence to demonstrate that the membrane function of ALC is in any way similar to that of Bowman's layer.

Nonetheless, I believe that this paper has explained the rationale for the study, and presented the methods and results clearly. The results appear to confirm the authors hypothesis, that intrastromal transplantation of an anterior lens capsule is feasible, and at least in this rabbit model, demonstrates no adverse effects. As such, I believe the paper deserves to be accepted.

I would advise the authors to make it a little clearer in the abstract and in the methods that the ALC is taken from porcine eyes. This is not explicit in the abstract. Also, in line 125-126, I think it would help if that authors started that the corneoscleral buttons and the iris were harvested within 24 hours of the death of the "porcine donor".

The authors may also wish to comment on the fact that in many countries, whole globes are no longer taken during cornea donation, which may limit the viability for ALC to be harvested with the technique they described. Conversely, they may wish to comment if taking ALC from patients undergoing cataract surgery might be viable, in which case the pool of ALC donors would be significantly larger. ALC that has been cut by a femtosecond laser during femtocataract surgery might provide a suitable round donor for this transplant. The donor size of course would not be as large, but at this point it is not clear if ALC transplants (or even Bowman's membrane transplants) require a large 9-10 mm graft to be effective, or whether a 6mm graft centered at the thinnest point of the cone will suffice.

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Reviewer #1: No

Reviewer #2: No

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Intrastromal graft of anterior lens capsule. A substitute for Bowman layer graft transplantation for keratoconus.

PONE-D-24-23473R1

Dear Dr. Rodríguez-Barrientos,

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,

Georgios Labiris, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments:

The authors have sufficiently answered all reviewers' comments and made the necessary corrections in the main manuscript. Moreover, this topic is timely and will be of high interest to the journal readers. As a result, this paper is appropriate for publication. Further research could contribute contemporary information to this important scientific topic.