-->PONE-D-25-53959-->-->Impact of axial length correction in high intraocular pressure eyes on intraocular lens power calculation-->-->PLOS One

Dear Dr. Kojima,

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Kind regards,

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

Academic Editor

PLOS One

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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-->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: Yes

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-->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

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-->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 investigates the impact of axial length (AL) correction based on anticipated intraocular pressure (IOP) reduction on refractive prediction error after cataract surgery in eyes with high IOP. The topic is clinically relevant, and the use of segmental AL measurement is a strength. However, several methodological issues significantly limit the strength of the conclusions and require clarification and careful discussion.

Key Points for Revision

1.Major Confounding Factor: The primary intervention (cataract surgery/lens extraction) itself is a known cause of AL shortening. The reported AL change (0.005 mm per 1 mmHg IOP drop) is therefore a composite of both the surgical effect and the IOP-lowering effect. The analysis does not adequately control for or disentangle this fundamental confounding. The authors must substantially expand the discussion to explicitly acknowledge this limitation and compare their findings to studies on non-surgical IOP normalization (e.g., Kim et al., 2016).

2.Lack of Methodological Detail: The manuscript states that "optimized IOL constants for each IOL type were applied" but provides no information on how these constants were optimized (e.g., institutional retrospective data, manufacturer's recommendation). This is a critical omission for reproducibility and validation. Please specify the source or method of optimization for the constants used.

3.Small and Heterogeneous Cohort: The study cohort (19 eyes) is small and includes varied concomitant surgical procedures (goniosynechialysis, trabeculotomy, vitrectomy). This heterogeneity may influence the results. The limitations section should more forcefully address how this affects the generalizability of the findings and the proposed AL correction factor.

Reviewer #2: 1.L83: The system used for visual acuity notation needs to be mentioned.

2.It is not clear why the AL correction value was calculated based on the mean postoperative IOP and not based on the change in IOP for each eye.

3.It is confusing to exclude cases of concomitant vitrectomy and zonule ligament rupture (L85) from the study while including an eye with lens dislocation (L120) and two eyes with concomitant vitrectomy (L122).

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Reviewer #1: No

Reviewer #2: No

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-->

Impact of axial length correction in high intraocular pressure eyes on intraocular lens power calculation

PONE-D-25-53959R1

Dear Dr. Kojima,

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

Additional Editor Comments (optional):

Thank you for the elaborate responses to review comments

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: All comments have been addressed

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-->2. 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 #2: Yes

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

Reviewer #2: I Don't Know

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-->4. 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 #2: Yes

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-->5. 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 #2: Yes

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-->6. 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 #2: No further comments.

By visual acuity notation, I meant which system was used i.e. decimal, Snellen, LogMAR, .. etc

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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 #2: No

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