Dear Dr. Zhou,

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We look forward to receiving your revised manuscript.

Kind regards,

Ali Faramarzi, MD, MPH

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: Yes

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: Thank you for submitting this paper for review, my comments are below. I have some comments relate dot content and a few more related to plot presentation.

I look forward to seeing your updated manuscript.

Introduction

“The COVID-19 pandemic has further exacerbated the situation. Lockdowns and social

distancing measures led to a dramatic increase in screen time and a reduction in outdoor activities,”

Please provide a reference here

The introduction section needs to include what the disease burden actually is, and why we should do something about it. Your paper rightly indicates that NVL is a problem and that something should be done bc its getting worse. But what does it actually mean for people, what is the burden.

You should also include a little more on how NVL comes about what what drives it. You discuss this in a very broad way, but this needs clarity.

Statistical Analysis

“To ensure accurate analysis, the “broom” and “dplyr” packages were loaded. These tools were crucial for efficiently extracting and organizing regression results,”

Consider instead “The “broom” and “dplyr” packages were used, as they were crucial for accurate analysis, efficiently extracting and organizing regression results….”

Tables – consider spaces after commas and parentheses for readability. i.e., 1739897.006 (805939.806, 3085387.571), not 1739897.006(805939.806,3085387.571)

Figure 1 – Consider standardising Y-axis on all plots. Currently, the differing Y-Max makes the plots less instructive than they could be

Global trends and variations across SDI regions

“In high, high-middle, and middle SDI regions, the age-standardized prevalence rate (ASPR) and age-standardized DALY rate (ASR of DALYs) initially peaked before experiencing a decline.”

Consider adding the years to this sentence to better orient the reader to peaks/declines.

“Of particular concern, low-middle SDI regions demonstrated the most rapid increase in disease burden. Between 1990 and 2021, prevalence and DALYs in these regions rose by 14.045% and 14.343%, respectively (Tables 1 & 2).”

Consider “Of particular concern, low-middle SDI regions demonstrated the most rapid increase in disease burden. Between 1990 and 2021, [the change in] prevalence and DALYs in these regions rose by 14.045% and 14.343%, respectively (Tables 1 & 2).”

Trends in Disease Burden Correlated with SDI

Your comment on the outlier of South Africa?

Figures 3C & D – the pink is hard to distinguish, consider a different colour choice. Figs 3 A&B are much easier to understand.

Figure 4 – Great plots, but for me to compare and contrast 1990 to 2021/see change over time, I find that quite hard. Not only is it difficult to estimate difference over time, but mentally comparing one region to another, the regions are in a different order on the Y-Axis (nice descending order, I get it). But as it stands, I think you can improve this plot to deepen reader understanding. Consider standardising the order of the Y-axis and potentially stacking the regions timewise to make it easier to compare the plots?

Figure 5 – standardise Y-Axis or overall all ages/lines on one plot.

Figure 6 - Standardise text size and correct aspect ratio of plots B & D. Also, Agestd. should probably read Age std.

Discussion

“Although NVL is currently closely associated with aging, it is also increasingly affecting younger populations22. Myopia, one of the most common and fastest-growing diseases globally, is driven by factors such as reduced outdoor time, increased near-work activities, and rising urbanization in developing countries23,24. Uncorrected or high levels of myopia can lead to NVL through various pathways, including myopic macular degeneration or its complications, cataracts, retinal detachment, and glaucoma25.

This information should be included in the introduction section.

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

Strengths: This manuscript offers a fresh perspective on visual impairment by focusing on near vision loss, a topic that receives less attention compared to distance vision loss, particularly in the pediatric population. This unique angle adds value and interest to readers.

The study provides detailed insights into near vision loss across various demographic regions and includes projections up to 2060, which are particularly valuable.

Main Considerations:

1. The manuscript does not define what "near vision loss" specifically means when extracting results from the Global Burden of Disease (GBD) Study. The reviewer found this definition: “presenting near vision worse than N6 or N8 at 40 cm, while maintaining best-corrected distance visual acuity of 6/12 or better.” If this is the definition used, near vision loss refers strictly to uncorrected presbyopia. However, if the definition includes only near vision worse than N6 or N8 at 40 cm, it may encompass individuals with distance vision loss as well. In pediatric populations, significant refractive errors (hyperopia, myopia, astigmatism), amblyopia, and other ocular conditions are the primary causes of near vision loss. To enhance the manuscript’s relevance, it is important to stratify or account for distance vision loss. For instance:

o Children with amblyopia may experience both distance and near vision loss.

o Children with mild to moderate myopia might face distance vision loss but not near vision loss.

o Children with moderate to high hyperopia may not have distance vision loss but could experience near vision loss.

2. Clarification is needed regarding the choice of age 20 as the upper limit for the study, especially considering the focus on early intervention. The reviewer noted that the GBD results website offers different age ranges and would like to see the rationale for selecting this specific range.

3. The manuscript appears to center its discussion of near vision loss on the increase in myopia and its environmental risk factors. While this is a valid contributing factor, it may not represent the entire picture. The authors should address other potential reasons for the observed increase in near vision loss, such as population growth or improved reporting of cases.

4. Reporting prevalence in terms of case numbers rather than as a rate (e.g., %) is misleading. Throughout the manuscript, prevalence cases are discussed in absolute numbers. Prevalence is typically presented as a rate, and revising this would improve clarity and accuracy.

5. The manuscript uses many abbreviations, which can hinder readability. It is recommended to limit abbreviations to widely recognized terms or include a table listing all abbreviations and their meanings to help readers follow the content more easily.

6. Some figures lack units on the axes. For example, graphs reporting prevalence cases do not specify units, which makes the data presentation unclear. Additionally, presenting prevalence over time with only case numbers can be misleading and should be corrected.

Reviewer #3: In this manuscript the authors have presented a clear picture of the global burden of near vision loss and its future projections in the age group of under 20 years.

The authors use “australasia” in the abstract and tables. I am unaware of such a regional term. Please define the term or edit it to a more familiar term.

In the abstract “Notably, NVL burden in higher SDI regions rebounded post-COVID-19, reversing previous declining trends” seems to be at odds with the rest of the manuscript and the fact that known risk factors such as indoor time increased during the COVID-19 pandemic.

Reviewer #4: This study analyzes the global, regional, and national burden of NVL from 1990 to 2021 and projects future trends up to 2060 using data from the Global Burden of Disease (GBD) Study 2021. The results indicate significant increase in NVL cases, rising to 31.7 million in 2021, with projections reaching 33 million by 2060. A strong negative correlation was observed between the Social Development Index (SDI) and NVL burden. NVL burden in higher SDI regions rebounded post-COVID-19, reversing previous declining trends. The results also indicate the COVID-19 outbreak has led to a marked increase in the incidence and progression of NVL among children and adolescent under the age of 20 years, a trend not captured in previous studies. This study reveals the characteristics and severity of NVL in the post-COVID-2019 era, providing critical data-driven insights for global health strategies. It highlights how the COVID-19 pandemic exacerbated NVL trends through increased screen exposure and reduced outdoor activities, while emphasizing the urgent need for equitable interventions to address disparities in disease burden across socioeconomic contexts. The manuscript should be polished by a native speaker to make it more fluent and sound.

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: No

Reviewer #2: Yes:  Anh V Bui

Reviewer #3: No

Reviewer #4: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Global, regional, and national burden of near vision loss in children and adolescents under 20 years from 1990–2021 and prediction to 2060: a cross-sectional study based on the Global Burden of Disease Study 2021.

PONE-D-25-07176R1

Dear Dr. Zhou,

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.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ali Faramarzi, MD, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: N/A

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

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??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: (No Response)

Reviewer #2: Thank you for being receptive to feedback and addressed all my comments and reflect it in the revision.

Reviewer #3: (No Response)

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: No

Reviewer #2: Yes:  Anh V Bui

Reviewer #3: No

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