Incidence of dry eye symptoms and behavioural-cultural risk factors among university students population in Jordan

May M. Bakkar; Mona Aridi; Mohammad A. Alebrahim; Wissam Ghach

doi:10.1371/journal.pone.0328235

Peer Review History

Original SubmissionFebruary 21, 2025
17 Apr 2025 Decision Letter - Liat Gantz, Editor PONE-D-25-09013Prevalence of Symptomatic Dry Eye Disease and Behavioural-Cultural Risk Factors among University Students population in JordanPLOS ONE Dear Dr. Ghach, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Namely, the reviewers have both asked to more accurately describe the actual study findings- prevalence of symptoms of dry eye, rather than clinical dry eye. In addition, the authors should be more careful in their wording about the results and implications of their findings. Please submit your revised manuscript by Jun 01 2025 11:59PM. 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Additional Editor Comments: The manuscript has been reviewed by two external reviewers who agree that this manuscript should be revised to more accurately state what the authors have examined, symptoms of dry eye rather than clinical diagnosis of dry eye. One reviewer asked to re-analyze based on an OSDI score greater than 20. I would ask that you specify this in addition to the >13 cut off. The manuscript can be further improved based on additional comments below: Abstract Line 35 Google forms and not survey The prevalence of symptoms of DED, not DED- as DED is not diagnosed just based on symptoms Line 169: The word “Although” is inappropriately used in this sentence Line 170: Were they not diagnosed with DE clinically or based only on the OSDI questionnaire, in which case the authors mean that 61.3% did not report symptoms of DE Line 173: As seen in Table 1 instead of “according to Table 1” What is “history of DED” in Table 1? Is it a self-report? Based on symptoms or an actual diagnosis? The whole concept of DED severity based on OSDI score value vs. DED diagnosis based on OSDI>13 is unfounded (such as in Line 199). One could say that the population with OSDI scores > 13 are considered having symptoms of DE and higher scores indicate higher symptomology. However, no claim can be made about DE severity or the existence of DE. Line 193: what is harmonic relationship Line 197: Also? In any case better replaced with “In addition,” Table 2- include numbers and not just percentages Don’t multiple regressions require a different p-value that takes into account the multiple calculations (Bonferroni corrected)? Lines 263-272: should be rephrased to emphasize the minor role of study hours accounting for under 2% of the score rather than to state several times that this is a predictor with a unique contribution. Line 291: what does harmonic mean? Line 295: wore instead of had utilized Line 298: used instead of had utilized Line 308: estimated the prevalence of symptoms of DE amongst.. not the prevalence of symptomatic DED as no clinical measure was tested Lines 312-315: very far fetched, suggest removing: “The anticipated outcome is to provide ophthalmologists and eye health researchers with valuable new evidence on the prevalence and risk factors of DED in Jordanian universities.” Discussion, second paragraph: The previous study reporting 59% of non clinical populations with symptoms of DE used a cut-off of OSDI>20 and was careful not to state prevalence of DE but symptoms of DE. The other study used only OSDI and considered a score >13 as the only determinant of DE (which is incorrect) and found a similar prevalence of symptoms of DE to the present study. This should be emphasized in the discussion. Line 366: Cleansing creams should be the beginning of a new sentence Line 369: less effective in cleaning Line 370: “due to”- you have no proof what this is due to. Please rephrase. “This could be due to the chemical components and characteristics.. as shown in XXX”. Modify conclusions based on what was examined- symptoms only: Nearly three-quarters of university students in Jordan exhibited symptoms of DED as assessed by the validated Arabic version of the Ocular Surface Disease Index (OSDI). Symptoms of DED were significantly positively associated with female gender, older age (≥27 years), contact lens use, smoking, and eye makeup usage. Etc. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. 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: No ****** 4. 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 ******** 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 study assessed the prevalence of symptomatic dry eye disease (DED) among university students in Jordan and its association with behavioral and cultural risk factors. Defined by an OSDI score ≥ 13, DED prevalence was 74.2%. They concluded that symptomatic DED is highly prevalent among university students in Jordan and is significantly associated with factors such as age, gender, contact lens use, cosmetic application, and tobacco consumption. The manuscript contains important findings; however, it needs to undergo revision to enhance its significance. Abstract: * The research objective needs to be more precise. You stated: "To estimate the prevalence of symptomatic dry eye disease (DED) among university students in Jordan and examine the relationship between behavioral and cultural risk factors and the severity of DED." However, you did not assess the prevalence of dry eye disease, as you did not diagnose DED according to standard criteria (OSDI symptom questionnaire≥ 13 plus at least one positive clinical test—NITBUT, osmolarity, or staining), as recommended by TFOS. Instead, you assessed the prevalence of dry eye symptoms, not the prevalence of individuals with dry eye disease who exhibit symptoms. Rephrasing the objective and conclusions is necessary, especially considering that 61.3% of the participants had not been clinically diagnosed with DED. The results section of the abstract should include the mean age of the participants, standard deviation, and age range. It is standard to include P-values and significant results within the results section of the abstract. Introduction: On page 3, lines 67-68, it is stated that the prevalence of dry eye disease in Jordan is 59%. How was dry eye diagnosed? Was it through a questionnaire alone, or were clinical signs also used? Methods: The statistical analysis lacks a sample size calculation. It is not stated whether a distribution test was performed on the data. Is the distribution normal or not? Results: The mean age of the participants and standard deviation should be added. If the age distribution is not normal, the median and quartiles (Q1, Q3) should also be included. Discussion: It should be clarified that you assessed the prevalence of dry eye symptoms and not the prevalence of individuals with dry eye disease who are symptomatic (page 15, lines 308-310). It is recommended to discuss potential biases or methodological limitations that could account for the higher prevalence observed in this study compared to previous research. Reviewer #2: This represents an interesting study regarding the prevalence of dry eye symptoms. What instructions were given to participants? The OSDI questionnaire contains questions referring to blurred vision that may be confused with uncorrected refractive error. Why was the OSDI Cutoff Score of 13 used, rather than 20 as in previous study? (Bakkar et al Epidemiology of symptoms of dry eye disease (DED) in Jordan: Across-sectional non-clinical population-based study. Contact Lens and Anterior Eye 39 (2016) 197–202). For better comparison with the general population in Jordan it would make sense to use the same cutoff score. Especially, as a score of 13 represents very mild symptoms. Line 68: the study only explored symptoms of DED, please adjust accordingly. Line 169: please delete ‘although’ – Does this mean that 38.7 % of the participants have been previously diagnosed with DED? Please explain. If indeed, this large proportion of participants already have a DED diagnosis, a sub analysis of this group in view of risk factors may be warranted in view of the large sample size in this study. Results: In view of the very large standard deviations, it would be very interesting to include histograms similar to Figures 1-3 in your previous publication (Bakkar et al 2016). ******** 6. 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. 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: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". 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Revision 1
13 May 2025 Author Response Response to Reviewers We would like to sincerely thank the reviewers for their thorough evaluation of our manuscript and for providing valuable and insightful comments. We appreciate the time and effort invested in reviewing our work and recognize that the suggestions offered have significantly contributed to improving the clarity, rigor, and overall quality of the manuscript. In the following document, we have addressed each comment carefully and made the necessary revisions to strengthen the study. We hope that the changes meet the reviewers’ expectations and enhance the impact of our research. Reviewer #1: This study assessed the prevalence of symptomatic dry eye disease (DED) among university students in Jordan and its association with behavioral and cultural risk factors. Defined by an OSDI score ≥ 13, DED prevalence was 74.2%. They concluded that symptomatic DED is highly prevalent among university students in Jordan and is significantly associated with factors such as age, gender, contact lens use, cosmetic application, and tobacco consumption. The manuscript contains important findings; however, it needs to undergo revision to enhance its significance. Abstract: * The research objective needs to be more precise. You stated: "To estimate the prevalence of symptomatic dry eye disease (DED) among university students in Jordan and examine the relationship between behavioral and cultural risk factors and the severity of DED." However, you did not assess the prevalence of dry eye disease, as you did not diagnose DED according to standard criteria (OSDI symptom questionnaire≥ 13 plus at least one positive clinical test—NITBUT, osmolarity, or staining), as recommended by TFOS. Instead, you assessed the prevalence of dry eye symptoms, not the prevalence of individuals with dry eye disease who exhibit symptoms. We acknowledge the distinction that the reviewer has highlighted between symptomatic dry eye and clinically diagnosed dry eye disease as defined by the TFOS DEWS II criteria. It is correct that our study utilized the OSDI questionnaire alone without accompanying clinical tests such as NITBUT, osmolarity, or ocular surface staining. Therefore, our findings pertain specifically to the prevalence of dry eye symptoms rather than confirmed dry eye disease. This is stated clearly in the manuscript title /aims: “Prevalence of Symptomatic Dry Eye Disease and Behavioural-Cultural Risk Factors among University Students population in Jordan” In response to the reviewer’s comment, we will revise the objective in the manuscript to more accurately reflect this, as follows: "To estimate the prevalence of dry eye symptoms among university students in Jordan and examine the relationship between behavioral and cultural risk factors and symptom severity. Additionally, the limitation of relying solely on symptoms without clinical confirmation of DED was acknowledged in the study limitations (lines 388-398) Rephrasing the objective and conclusions is necessary, especially considering that 61.3% of the participants had not been clinically diagnosed with DED. Thank you for your insightful comment. We have revised both the objective and conclusions to clearly state that our results pertain to dry eye symptoms rather than clinically diagnosed dry eye disease. These revisions aim to ensure clarity and alignment with the data presented. The results section of the abstract should include the mean age of the participants, standard deviation, and age range. It is standard to include P-values and significant results within the results section of the abstract. We sincerely thank the reviewer for this valuable comment. In response, we have revised the Results section of the abstract to include the mean age (21.87 years), standard deviation (3.824), and age range (18–45 years) of the study participants. Furthermore, we have incorporated the p-values corresponding to statistically significant findings to enhance the clarity and rigor of the results presentation. The revised abstract has been updated accordingly. Introduction: On page 3, lines 67-68, it is stated that the prevalence of dry eye disease in Jordan is 59%. How was dry eye diagnosed? Was it through a questionnaire alone, or were clinical signs also used? Thank you for your comment and for pointing this out. The reported 59% prevalence of dry eye disease in Jordan, as cited on page 3 (lines 71-75), was based on symptoms only and assessed using a non-validated version of the OSDI questionnaire. No clinical signs or diagnostic tests were used in that previous study. We also note that this earlier report was co-authored by one of the current co-authors of this submission, which we acknowledge in the context of the literature cited. To avoid any confusion, we will clarify this point in the manuscript lines 67-68 to ensure an accurate interpretation of the referenced prevalence figure. Methods: The statistical analysis lacks a sample size calculation. We acknowledge that a formal sample size calculation was not conducted prior to data collection, as the study adopted a convenience sampling method targeting university students across all Jordanian governorates. Our primary aim was to maximize participation by distributing the survey widely through social media platforms and university research departments, rather than limiting the sample to a predefined number. Nonetheless, with a final sample of 788 participants, the study achieved a sufficiently large cohort to provide robust and generalizable findings for the target population. To strengthen the methodological transparency, we have now added a statement to the "Materials and Methods" section clarifying the sampling strategy and the absence of a priori sample size calculation. It is not stated whether a distribution test was performed on the data. Is the distribution normal or not? ANOVA is known to be robust to violations of normality, particularly with large sample sizes. Given that the current sample size is 788, well above the commonly accepted thresholds (n > 30–40), the Central Limit Theorem ensures that the sampling distribution of the mean approximates normality. Therefore, the use of one-way ANOVA remains appropriate, and there was no need to switch to a nonparametric alternative [1]. Results: The mean age of the participants and standard deviation should be added. If the age distribution is not normal, the median and quartiles (Q1, Q3) should also be included. We have revised the Results section to include the mean age and standard deviation of the participants. The mean age of the participants was 21.87 years (SD = 3.824). Discussion: It should be clarified that you assessed the prevalence of dry eye symptoms and not the prevalence of individuals with dry eye disease who are symptomatic (page 15, lines 308-310). Thank you for your comment. We have revised the manuscript to clarify that our study assessed the prevalence of symptomatic dry eye rather than the prevalence of clinically diagnosed dry eye disease. The objective, results, discussion and conclusion sections have all been amended accordingly to accurately reflect this distinction. The text, has also been updated to ensure consistency with this clarification. It is recommended to discuss potential biases or methodological limitations that could account for the higher prevalence observed in this study compared to previous research. We have expanded the discussion section to address potential biases and methodological limitations that may have contributed to the higher prevalence of dry eye symptoms observed in our study compared to previous research. Refer to Lines 392-401 Reviewer #2: This represents an interesting study regarding the prevalence of dry eye symptoms. What instructions were given to participants? The OSDI questionnaire contains questions referring to blurred vision that may be confused with uncorrected refractive error. Why was the OSDI Cutoff Score of 13 used, rather than 20 as in previous study? (Bakkar et al Epidemiology of symptoms of dry eye disease (DED) in Jordan: Across-sectional non-clinical population-based study. Contact Lens and Anterior Eye 39 (2016) 197–202). For better comparison with the general population in Jordan it would make sense to use the same cutoff score. Especially, as a score of 13 represents very mild symptoms. Thank you for your thoughtful feedback. Participants were instructed to complete the OSDI questionnaire based on their subjective experience of dry eye symptoms during the previous two weeks, without consideration of any known refractive error or visual correction. We acknowledge that certain questions, particularly those referring to blurred vision, may have been influenced by uncorrected refractive error, which could introduce some response bias. Regarding the cutoff score, yes, a previous report by Bakkar et al. used a cutoff of 20; however, we relied on more recent studies that use a cutoff value of 13 to define symptomatic dry eye, as this has become a widely accepted threshold in current literature. Using this cutoff improves consistency with more recent research and facilitates broader comparisons. This rationale has been clarified in the methods and discussion sections of the manuscript. Line 68: the study only explored symptoms of DED, please adjust accordingly. Thank you for your comment. We have revised the manuscript to clarify that our study assessed the prevalence of symptomatic dry eye rather than the prevalence of clinically diagnosed dry eye disease. The objective, results, discussion and conclusion sections have all been amended accordingly to accurately reflect this distinction. The text, has also been updated to ensure consistency with this clarification. Line 169: please delete ‘although’ – Does this mean that 38.7 % of the participants have been previously diagnosed with DED? Please explain. If indeed, this large proportion of participants already have a DED diagnosis, a sub analysis of this group in view of risk factors may be warranted in view of the large sample size in this study. We have removed the word "although" for clarity. To clarify, 38.7% of the participants self-reported a previous diagnosis of DED by an eye care professional. However, we acknowledge that this was based on self-reporting and not verified through medical records or standardized clinical criteria, which may introduce recall or reporting bias. Given your helpful suggestion and the size of the sample, we agree that a sub-analysis of this subgroup could provide additional insights into potential differences in risk factor profiles. We have now included this as a consideration for future research in the discussion section. Results: In view of the very large standard deviations, it would be very interesting to include histograms similar to Figures 1-3 in your previous publication (Bakkar et al 2016). We have included two histograms in the revised manuscript (Figure1 and Figure 2) to illustrate the distribution of electronic device usage hours and study hours across different DED severity groups. These visualizations provide a clearer understanding of the observed variability and support the interpretation of the relatively weak associations between these predictors and DED severity. [1] M. Blanca, R. Alarcón, J. Arnau, R. Bono, and R. Bendayan, ‘Non-normal data: Is ANOVA still a valid option?’, Psicothema, vol. 4, no. 29, pp. 552–557, Nov. 2017, doi: 10.7334/psicothema2016.383. Response to Additional Comments from the Editor We would like to sincerely thank the Editor for the careful evaluation of our manuscript and for overseeing the review process. We appreciate the constructive feedback and the opportunity to revise our work. All comments and suggestions have been thoroughly addressed, and we believe the manuscript has been significantly improved as a result. The manuscript has been reviewed by two external reviewers who agree that this manuscript should be revised to more accurately state what the authors have examined, symptoms of dry eye rather than clinical diagnosis of dry eye. One reviewer asked to re-analyze based on an OSDI score greater than 20. I would ask that you specify this in addition to the >13 cut off. Thank you for your comment. We have revised the manuscript to clarify that our study assessed the prevalence of symptomatic dry eye rather than the prevalence of clinically diagnosed dry eye disease. The objective, results, discussion and conclusion sections have all been amended accordingly to accurately reflect this distinction. The text, has also been updated to ensure consistency with this clarification. Regarding the cutoff score, yes, a previous report by Bakkar et al. used a cutoff of 20; however, we relied on more recent studies that use a cutoff value of 13 to define symptomatic dry eye, as this has become a widely accepted threshold in current literature. Using this cutoff improves consistency with more recent research and facilitates broader comparisons. This rationale has been clarified in the methods and discussion sections of the manuscript. The manuscript can be further improved based on additional comments below: Abstract Line 35 Google forms and not survey Adjusted. The prevalence of symptoms of DED, not DED- as DED is not diagnosed just based on symptoms We have revised the manuscript to clarify that our study assessed the prevalence of symptomatic dry eye rather than the prevalence of clinically diagnosed dry eye disease. Line 169: The word “Although” is inappropriately used in this sentence The word “Although” is now replaced by “Additionally” which is more convenient. Line 170: Were they not diagnosed with DE clinically or based only on the OSDI questionnaire, in which case the authors mean that 61.3% did not report symptoms of DE The 61.3% figure refers to participants who did not report symptoms of dry eye disease (DE) based on their OSDI questionnaire scores. These participants were not clinically diagnosed with DE; rather, symptom assessment was based solely on the OSDI, as noted in the methodology. Line 173: As seen in Table 1 instead of “according to Table 1” Adjusted. What is “history of DED” in Table 1? Is it a self-report? Based on symptoms or an actual diagnosis? The whole concept of DED severity based on OSDI score value vs. DED diagnosis based on OSDI>13 is unfounded (such as in Line 199). One could say that the population with OSDI scores > 13 are considered having symptoms of DE and higher scores indicate higher symptomology. However, no claim can be made about DE severity or the existence of DE. We thank the reviewer for this important observation. In Table 1, “history of DED” refers to participants’ self-reported history of a prior dry eye disease diagnosis by a healthcare professional. We agree with the reviewer that OSDI scores alone cannot establish a clinical diagnosis or severity of DED. Accordingly, we have revised the manuscript to clarify that OSDI scores >13 indicate the presence of dry eye symptoms, not a definitive diagnosis or clinical severity of DED. We have also modified the language in Line 199 and related sections to reflect this distinction more accurately. Line 193: what is harmonic relationship It means correlated. For much more accurate writing the word harmonic replaced with graded. Line 197: Also? In any case better replaced with “In addition,” Adjusted. Table 2- include numbers and not just percentages Done Don’t multiple regressions require a different p-value that takes into account the multiple calculations (Bonferroni corrected)? We appreciate the opportunity to clarify our approach. In the multiple regression analysis conducted, Bonferroni correction was not applied because the predictors were evaluated simultaneously within a single regression model rather than through multiple independent hypothesis tests. In standard practice, the overall model significance (as indicated by the ANOVA test, p < 0.001) controls for Type I error at the model level. Furthermore, the individual p-values for the predictors assess the significance of each variable conditional on the others included in the model. Th Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0328235.r002
16 Jun 2025 Decision Letter - Liat Gantz, Editor <div>PONE-D-25-09013R1Prevalence of Symptomatic Dry Eye Disease and Behavioural-Cultural Risk Factors among University Students population in JordanPLOS ONE Dear Dr. Ghach, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact. Both reviewers feel that the revision addresses the comments. I still would like to see the authors refining their use of "symptomatic DED" which implies that the authors examined the presence of DED- which they did not, by replacing it with "dry eye symptoms". Similarly "severity of DED" should be replaced with "Severity of symptoms". Additional minor comments below as well. Please submit your revised manuscript by Jul 31 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Liat Gantz, PhD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: Both reviewers feel that the revision addresses the comments. I still would like to see the authors refining their use of "symptomatic DED" which implies that the authors examined the presence of DED- which they did not, by replacing it with "dry eye symptoms". Similarly "severity of DED" should be replaced with "Severity of symptoms". Additional minor comments below as well: Abstract Your study only assessed incidence of symptoms and not of symptomatic dry eye disease- therefore, you must correctly refer to your study as assessing dry eye symptoms Page 3 Line 88: the prevalence of dry eye symptoms, not symptomatic DED Page 4 Line 101: dry eye symptoms, not symptomatic DED Page 4: please calculate the power of a sample with 788 respondents precisely and not “provided a sufficiently large database” Page 8 Line 179: instead of “Regarding the participants’ field and year of study,” please rephrase: “Of the participants,” Pages 9-10 Line 201, 203, 207, 208, 215: it is not DED severity, it is dry eye symptom severity Tables 2, 4, 5: severity of SYMPTOMS, not of DED- you do not know the severity of DED as you did not measure it at all Line 288, Line 293, Line 295, Line 304, Line 315, Line 326, Line 327m Line 329Line 331,Line 334, Line 341 (here it is stated as DED prevalence and severity, both were not examined), Line 342, Line 350,: It is NOT DED severity, it is Symptoms severity Line 348: used instead of utilized Page 19 Line 357: dry eye symptoms and not symptomatic DED Line 359: severity of symptoms, not symptomatic DED Line 378: dry eye symptoms Line 389: dry eye symptoms Line 423: dry eye symptom severity Line 431: studies instead of research Line 449: dry eye symptoms instead of symptomatic DED Line 451: the Jordanian population [Note: HTML markup is below. 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Revision 2
18 Jun 2025 Author Response Rebuttal letter Both reviewers feel that the revision addresses the comments. I still would like to see the authors refining their use of "symptomatic DED" which implies that the authors examined the presence of DED- which they did not, by replacing it with "dry eye symptoms". Similarly "severity of DED" should be replaced with "Severity of symptoms". All the terms “prevalence”, “symptomatic DED”, and “DED severity” were replaced by “incidence”, “Dye eye symptoms”, and “severity of symptoms”, respectively Additional minor comments below as well: Abstract Your study only assessed incidence of symptoms and not of symptomatic dry eye disease- therefore, you must correctly refer to your study as assessing dry eye symptoms Page 3 Line 88: the prevalence of dry eye symptoms, not symptomatic DED(corrected) Page 4 Line 101: dry eye symptoms, not symptomatic DED (corrected) Page 4: please calculate the power of a sample with 788 respondents precisely and not “provided a sufficiently large database” A post hoc power analysis was conducted using GPower (version 3.1.9.7) for the one-way ANOVA tests applied in the study. The total sample consisted of 788 university students, and power calculations were performed for the two primary categorical independent variables used in the ANOVA models, which included variables with 4 groups (smoking rate, smoking areas, and all the cosmetics variables) and 6 groups (smoking type). For the variable with 4 groups, the analysis yielded a non-centrality parameter (λ) = 49.25, numerator degrees of freedom (df) = 3, denominator df = 784, a critical F value = 2.616, and a statistical power (1 − β) = 0.999995. Similarly, for the variable with 6 groups, the parameters were: λ = 49.25, numerator df = 5, denominator df = 782, critical F value = 2.226, and statistical power = 0.999977. These results confirm that the achieved sample size was statistically robust and sufficiently powered to detect moderate effects across all ANOVA tests used in the study, thereby justifying the absence of an a priori sample size calculation. This is now clearly addressed in the text in page 4, as follows: “To further verify the adequacy of the sample size, a post hoc power analysis was conducted using GPower (version 3.1.9.7) for the One-way ANOVA tests employed in the study. Power estimates were calculated for variables with four groups (smoking rate, smoking areas, and all the cosmetics variables) and 6 groups (smoking type), which represent the range of groupings used in the analysis. For the variable with four groups, the analysis yielded a non-centrality parameter (λ) = 49.25, numerator df = 3, denominator df = 784, critical F = 2.616, and a power of 0.999995. For the variable with six groups, the results were similarly robust: λ = 49.25, numerator df = 5, denominator df = 782, critical F = 2.226, and power = 0.999977. These results confirm that the sample size was statistically robust and sufficiently powered to detect moderate effects across the ANOVA models used in the study.” Page 8 Line 179: instead of “Regarding the participants’ field and year of study,” please rephrase: “Of the participants,” (corrected) Pages 9-10 Line 201, 203, 207, 208, 215: it is not DED severity, it is dry eye symptom severity Tables 2, 4, 5: severity of SYMPTOMS, not of DED- you do not know the severity of DED as you did not measure it at all (corrected) Line 288, Line 293, Line 295, Line 304, Line 315, Line 326, Line 327m Line 329Line 331,Line 334, Line 341 (here it is stated as DED prevalence and severity, both were not examined), Line 342, Line 350,: It is NOT DED severity, it is Symptoms severity (corrected) Line 348: used instead of utilized (corrected) Page 19 Line 357: dry eye symptoms and not symptomatic DED (corrected) Line 359: severity of symptoms, not symptomatic DED (corrected) Line 378: dry eye symptoms (corrected) Line 389: dry eye symptoms (corrected) Line 423: dry eye symptom severity (corrected) Line 431: studies instead of research (corrected) Line 449: dry eye symptoms instead of symptomatic DED (corrected) Line 451: the Jordanian population (corrected) Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0328235.r004
20 Jun 2025 Decision Letter - Liat Gantz, Editor PONE-D-25-09013R2Incidence of Dry Eye Symptoms and Behavioural-Cultural Risk Factors among University Students population in Jordan PLOS ONE Dear Dr. Ghach, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The authors should re-read their manuscript and refer to symptoms of dry eye when they are referring to their study which is only based on OSDI. However, in the introduction and discussion - in instances where the authors quote previous studies which examined dry eye disease using clinically acceptable diagnostic criteria- they should not refer to dry eye symptoms. The way the paper was submitted appears as if the authors replaced every single instance of the words "dry eye" with "dry eye symptoms (DES)" including places such as the TFOS guidelines for diagnosing dry eye disease (and not just symptoms). Further DES- is often used for digital eye strain and even dry eye syndrome. Please refrain from the abbreviation and write DE symptoms. The authors are requested to please seriously review and read their paper before resubmitting a manuscript in the current state. Please submit your revised manuscript by Aug 04 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Liat Gantz, PhD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: The authors should re-read their manuscript and refer to symptoms of dry eye when they are referring to their study which is only based on OSDI. However, in the introduction and discussion - in instances where the authors quote previous studies which examined dry eye disease using clinically acceptable diagnostic criteria- they should not refer to dry eye symptoms. The way the paper was submitted appears as if the authors replaced every single instance of the words "dry eye" with "dry eye symptoms (DES)" including places such as the TFOS guidelines for diagnosing dry eye disease (and not just symptoms). Further DES- is often used for digital eye strain and even dry eye syndrome. Please refrain from the abbreviation and write DE symptoms. The authors are requested to please seriously review and read their paper before resubmitting a manuscript in the current state. [Note: HTML markup is below. Please do not edit.] [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] 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. https://doi.org/10.1371/journal.pone.0328235.r005
Revision 3
24 Jun 2025 Author Response The authors should re-read their manuscript and refer to symptoms of dry eye when they are referring to their study which is only based on OSDI. However, in the introduction and discussion - in instances where the authors quote previous studies which examined dry eye disease using clinically acceptable diagnostic criteria- they should not refer to dry eye symptoms. The way the paper was submitted appears as if the authors replaced every single instance of the words "dry eye" with "dry eye symptoms (DES)" including places such as the TFOS guidelines for diagnosing dry eye disease (and not just symptoms). Further DES- is often used for digital eye strain and even dry eye syndrome. Please refrain from the abbreviation and write DE symptoms. The authors are requested to please seriously review and read their paper before resubmitting a manuscript in the current state. Answer: All the suggested comments by the editor were considered in the revised manuscript. Attachments Attachment Submitted filename: Response to Reviewers (2).docx https://doi.org/10.1371/journal.pone.0328235.r006
29 Jun 2025 Decision Letter - Liat Gantz, Editor Incidence of Dry Eye Symptoms and Behavioural-Cultural Risk Factors among University Students population in Jordan PONE-D-25-09013R3 Dear Dr. Ghach, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. 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, Liat Gantz, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Dear authors- thank you for addressing the DED/DES issue stated earlier. I think it is ready for publication now. I encourage you to review the proofs carefully as I have noticed two instances of usage of "DED" instead of "DE symptoms". Good luck and thank you for your contribution. Reviewers' comments: https://doi.org/10.1371/journal.pone.0328235.r007
Formally Accepted
Acceptance Letter - Liat Gantz, Editor PONE-D-25-09013R3 PLOS ONE Dear Dr. Ghach, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Liat Gantz Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0328235.r008

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