Dear Dr. Kyei,

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.

==============================

ACADEMIC EDITOR: 

• Please address reviewers' concerns

Please submit your revised manuscript by Jun 08 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Nader Hussien Lotfy Bayoumi, M.D., FRCS (Glasgow)

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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2. As required by our policy on Data Availability, please ensure your manuscript or supplementary information includes the following:

A numbered table of all studies identified in the literature search, including those that were excluded from the analyses.

For every excluded study, the table should list the reason(s) for exclusion.

If any of the included studies are unpublished, include a link (URL) to the primary source or detailed information about how the content can be accessed.

A table of all data extracted from the primary research sources for the systematic review and/or meta-analysis. The table must include the following information for each study:

Name of data extractors and date of data extraction

Confirmation that the study was eligible to be included in the review.

All data extracted from each study for the reported systematic review and/or meta-analysis that would be needed to replicate your analyses.

If data or supporting information were obtained from another source (e.g. correspondence with the author of the original research article), please provide the source of data and dates on which the data/information were obtained by your research group.

If applicable for your analysis, a table showing the completed risk of bias and quality/certainty assessments for each study or outcome. Please ensure this is provided for each domain or parameter assessed. For example, if you used the Cochrane risk-of-bias tool for randomized trials, provide answers to each of the signalling questions for each study. If you used GRADE to assess certainty of evidence, provide judgements about each of the quality of evidence factor. This should be provided for each outcome.

An explanation of how missing data were handled.

This information can be included in the main text, supplementary information, or relevant data repository. Please note that providing these underlying data is a requirement for publication in this journal, and if these data are not provided your manuscript might be rejected.

3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

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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: Yes

Reviewer #3: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: No

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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

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Reviewer #1: Peer Review Report

This manuscript, "Prevalence of Glaucoma in Africa: A systematic review and Bayesian Meta-Analysis" presents a timely and methodologically rigorous systematic review and meta-analysis on glaucoma prevalence in Africa. The study addresses a critical gap in understanding regional epidemiological trends and provides valuable insights for public health strategies. However, major revisions are needed to enhance clarity and address methodological limitations & contextual interpretation.

Major Comments

1. Acronyms and Definitions

Acronyms (e.g., PACG, SG) are not consistently defined upon first use in the abstract and introduction. Please define all acronyms (e.g., PACG = Primary Angle-Closure Glaucoma; SG = Secondary Glaucoma) when first introduced to improve readability for non-specialist audiences.

2. The introduction is overly verbose, with some paragraphs containing redundant information. Condense lengthy sections (e.g., glaucoma subtypes, risk factors) and ensure a sharper focus on the study’s rationale.

3. Methods

Justification for Bayesian Approach: Briefly justify why Bayesian meta-analysis was chosen over frequentist methods.

Translation Limitations: Acknowledge potential biases/errors from relying on Google Translate for non-English studies. Suggest validation steps (e.g., professional translation for key studies).

Risk of Bias Assessment: Expand on the results of the Joanna Briggs Institute tool. Specify how many studies were classified as high/moderate/low quality and summarize key methodological weaknesses (e.g., sampling bias).

4. Results

Clarity in Presentation: Ensure tables/figures (e.g., Table 1, Figure 2) are explicitly referenced in the text and described in sufficient detail. For example, clarify what "ISGEO" and "VF/IOP" codes represent in Table 1.

Subgroup Analyses: Highlight the limited statistical power for PACG/SG due to small study numbers earlier in the results to contextualize their uncertain estimates.

5. Discussion

Exploration of Sex Differences: While estrogen’s role is discussed, consider alternative explanations for male predominance (e.g., occupational exposures, healthcare-seeking behavior).

Geographical Variations: Expand on potential drivers of higher POAG prevalence in West Africa (e.g., genetic factors, environmental triggers).

Discuss why glaucoma prevalence remains stable despite global advancements in awareness. Link this to systemic barriers (e.g., under-resourced healthcare systems).

6. References: Ensure all in-text citations (e.g., references 42, 43) are included in the reference list. Cross-check numbering to avoid mismatches.

Minor Comments

1. Abstract: Clarify that "unclassified glaucoma" refers to cases not categorized into specific subtypes.

2. Methods: Specify the search period (e.g., "from inception to January 25, 2025" appears in eligibility criteria but is not explicitly tied to database searches).

3. Results: Simplify technical language (e.g., "log-odds estimates") for broader accessibility.

4. Tables/Figures:

• Format Table 1 to improve readability (e.g., align columns, use consistent abbreviations).

• In Table 2, define "Half-Normal(0.5)" & other priors in a footnote for clarity

5. Limitations: Explicitly mention the exclusion of North/Central African studies as a limitation affecting generalizability.

Reviewer #2: please consider the following

first: no abbreviations in the abstract , replace with the full name

second :many difficult words were used in the manuscript might be replaced by simpler ones

third; in the PRISM chart: please replace wrong outcome by different outcome, different study design and different setting

Fourth: add the full title of the figure and its number below the figure

Reviewer #3: Reviewer Comments for Manuscript ID: PONE-D-25-14594

Title: Prevalence of Glaucoma in Africa: A systematic review and Bayesian meta-analysis

General Comments:

This manuscript addresses an important and underexplored topic—the prevalence of glaucoma and its subtypes across African populations—using a systematic review and Bayesian meta-analysis. The methodological approach is sound, and the inclusion of a Bayesian framework is commendable, given the small number of eligible studies and the expected heterogeneity across settings.

However, several methodological clarifications and contextual discussions are needed to enhance the manuscript’s scientific interpretability. I offer the following major and minor suggestions for the authors’ consideration.

Major Comments:

1. Justification of Priors in Bayesian Analysis:

The authors should provide more detailed justification for the choice of prior distributions, particularly the half-normal distribution with a scale of 0.5 for heterogeneity. Although sensitivity analyses were conducted, a rationale for the selection of informative priors and how they align with previous literature or expert consensus would be valuable.

2. Scope and Limitations of Included Studies:

Only nine population-based studies were included over a two-decade span. This small number significantly limits the generalizability of the findings, especially for PACG and secondary glaucoma, where convergence was not reached in some models. This limitation warrants greater emphasis in the discussion.

3. Regional Representation and Gaps:

The analysis lacks data from North and Central Africa, which limits the applicability of the findings to the entire continent. The authors should highlight this gap more explicitly and suggest how future research can address it.

4. Risk of Bias Assessment Interpretation:

The use of the JBI-PCAT tool is appropriate. However, two studies with notable methodological concerns (e.g., recruitment strategy, sample size) were still classified as “low risk.” Further clarification of how the scoring was applied and interpreted would improve transparency.

5. Interpretation of Temporal Trends:

The lack of significant change in glaucoma prevalence over time is an important finding. The authors should explore possible explanations (e.g., stagnant healthcare infrastructure, limited uptake of screening programs) and relate this to policy implications more clearly.

Minor Comments:

1. Language and Grammar:

The manuscript would benefit from careful proofreading to correct minor grammatical issues and improve clarity. For instance, the sentence “The title provided in the protocol was amended to suit available evidence” could be made clearer.

2. Terminology Clarity:

Please define the term “glaucoma (unclassified)” clearly in the methods section and use it consistently throughout the text.

3. Figures and Tables:

Consider incorporating brief descriptions or legends of figures directly in the main text. Table 2 should include an explanation of "CrI" (Credible Interval) for readers less familiar with Bayesian statistics.

4. Discussion on Gender Differences:

The discussion on the higher prevalence of glaucoma among males and the potential protective role of estrogen is intriguing. However, these statements are speculative and should be clearly presented as hypotheses supported by limited evidence.

5. Typographical Errors:

o “Cape Coat” should be corrected to “Cape Coast” in the author affiliation.

o The ISGEO/VF/IOP codes in Table 1 should be briefly explained or a legend added to aid interpretation.

6. Overstatement of Impact (Introduction, Lines 73–76):

The statement that this study “holds great potential in providing the needed information for the realization of Sustainable Development Goal 3… and to reduce untimely deaths resulting from blindness from glaucoma” appears to overstate the manuscript’s impact. While the study’s findings are certainly valuable for public health planning, glaucoma does not directly cause death, and a prevalence estimate alone is unlikely to significantly influence the broader achievement of SDG 3. I recommend rephrasing this sentence to present a more measured and accurate interpretation of the study’s contribution.

7. Undefined Abbreviations in the Abstract:

In the abstract, the abbreviations POAG, PACG, and SG are introduced without being defined. While POAG (Primary Open-Angle Glaucoma) and PACG (Primary Angle-Closure Glaucoma) are commonly used terms in ophthalmology, SG is not widely recognized and may be ambiguous. I assume it refers to Secondary Glaucoma, but this should be clearly stated. Please define all abbreviations at first use in the abstract to ensure clarity for a broader readership.

Recommendation:

With revisions addressing the points above, this manuscript would make a valuable contribution to the literature on glaucoma epidemiology in Africa. I recommend major revision.

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

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Reviewer #1: No

Reviewer #2: Yes:  Prof.Dr Heba Elweshahi

Reviewer #3: No

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Attachments

Attachment

Submitted filename: Peer Review Report.pdf

Attachment

Submitted filename: WS_Review.pdf

Dear Dr. Kyei,

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.

==============================

ACADEMIC EDITOR: 

• Please attend to the minor comments raised by the reviewer.

Please submit your revised manuscript by Aug 28 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.

• 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 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,

Nader Hussien Lotfy Bayoumi, M.D., FRCS (Glasgow)

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

Reviewer #1: This manuscript makes a valuable contribution to the literature on glaucoma epidemiology in Africa. The authors addressed comments thoroughly & their revisions align well with the peer review recommendations, making the manuscript stronger and more accessible. The responses were systematic & well-documented, demonstrating a commitment to improving the study's quality. While the manuscript is now robust, a few minor tweaks could polish it further:

�The term "unclassified glaucoma" is clarified but may be confused with "cases not categorized into specific subtypes." Standardizing this phrasing (e.g., always using "unclassified glaucoma") would avoid confusion.

�The forest plots (Figures 2–5) are informative, but adding subtle color differentiation (e.g., for regional subgroups) could enhance interpretability at a glance.

�A few sentences remain slightly verbose (e.g., "The necessity for epidemiological, population-based glaucoma studies in these regions is evident…"). Simplifying to "Population-based studies in these regions are needed…" would tighten the prose.

Final Recommendation:

I recommend acceptance pending these small edits & I look forward to seeing it published.

Reviewer #3: (No Response)

**********

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 #3: 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". 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

Attachments

Attachment

Submitted filename: Final report.pdf

Prevalence of Glaucoma in Africa: A systematic review and Bayesian meta-analysis

PONE-D-25-14594R2

Dear Dr. Kyei,

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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Kind regards,

Nader Hussien Lotfy Bayoumi, M.D., FRCS (Glasgow)

Academic Editor

PLOS ONE

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