-->PONE-D-25-40249-->-->Evolution of intraocular pressure after cataract surgery in nonglaucomatous patients: a post-hoc analysis of PERCEPOLIS clinical trial data-->-->PLOS ONE

Dear Dr.  Perone,

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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: Yes

Reviewer #2: No

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

Reviewer #1: Yes

Reviewer #2: No

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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: No

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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: As the statistical reviewer I will focus on methods and reporting. the paper is well-written and the limitations are discussed in detail by the authors.

Major

1) the study is now observational and needs to adhere to STROBE principles, please use an appropriate research checklist.

2) Analyses are generally appropriate but I would urge the authors to move away from statistical tests that only report p-values, in a cohort of limited size. Why aren't all relevant analyses conducted in a regression framework so association sizes and differences can be easily quantified, alongside their uncertainty in the form of 95% confidence intervals? these are more informative than p-values as well, and the focus should be on estimated effect sizes which should be interpreted cautiously and conservatively, considering the limited sample size (to answer this secondary research question, not the original question posed by the RCT).

3) what do the univariable (not univariate) analyses add? I'd recommend removal (unless justification is provided).

4) considering the levels of attrition I would expect to see sensitivity analyses using a multiple imputation framework as a mininum and even the exploration of best/worst case scenarios for the outcomes.

Minor

1) multivariable not multivariate (implies numerous outcomes)

2) please refrain from describing methods in the introduction, state the aims only, as you have done.

3) limited power is mentioned only for one subgroup analysis, it's arguably relevant for all analyses, please clarify that and rephrase to something like "power was limited and we would only be able to identify large associations with a high degree of certainty". I would also recommend removal of the outdated 10 subjects per covariate rule. this is so rough and depend on the type and distribution of the covariates, that is of very little use.

Reviewer #2: Abstract

• The abstract does not provide a clear and balanced overview of the study. It lacks precise reporting of the key outcomes (mean ± standard deviation) and does not fully reflect the depth of the analysis.

• The writing style is vague in places and does not capture the study's main strengths. A sharper, more structured abstract would enhance accessibility.

Introduction

• The introduction is generally well written, but the authors rely heavily on older references when discussing mechanisms of intraocular pressure reduction after cataract surgery.

• More recent studies using UBM and OCTA imaging should be cited, as they provide essential insights into angle parameters and trabecular meshwork morphology. Including such literature would significantly raise the relevance of the background section. DOI: 10.1097/IJG.0000000000001977, https://doi.org/10.1177/1120672119879331

DOI: 10.4103/meajo.MEAJO_20_19

• Overall, the reference list is outdated and should be updated with high-impact references.

Methods

• The surgical description is incomplete. While it is stated that one surgeon performed 88% of procedures, the level of experience of the other surgeons is not mentioned. Were they junior or senior surgeons? Was any comparison made across surgeons? This information is essential, as surgical experience may bias the outcomes. https://doi.org/10.1007/s10792-021-02103-6

• Given the large sample size, reporting data from the primary surgeon separately would be more rigorous, which could reduce statistical bias.

• The section on tonometry raises methodological concerns. The manuscript states that if the first two readings differed, a third was taken and the mean reported. However, it is unclear what proportion of patients required a third reading. A more robust approach would be three masked measurements for all participants, performed by an experienced ophthalmologist, with the mean reported.

• For each measurement device, the manufacturer, model, year, and country of origin should be specified in parentheses. This is standard practice and enhances reproducibility.

• More detail is needed regarding randomisation, masking, and handling of missing data.

Results

• The results section mixes data reporting with interpretation. For example, lines 219–220, 224–225, 229–230, 243–248, and 280–282 contain interpretative statements that should be moved to the Discussion.

• Reporting should follow a strict descriptive format (mean ± SD, p-values with exact numbers, and confidence intervals where appropriate).

• Tables and Figures:

o Table 1 appears redundant and could be removed, with its information integrated into the Introduction or Discussion.

o Graphs are visually complex and confusing. The authors should seek input from a statistician or biostatistician to simplify the visual presentation. Improved data visualisation (clearer legends, fewer but more focused figures) would strengthen the impact.

Discussion

• The discussion is overly long, repetitive, and at times speculative. Key results should be summarised more concisely, and interpretation should be better distinguished from the data.

• Mechanistic explanations (e.g., regression to the mean) are relevant but present with excessive certainty. The tone should be more cautious and evidence-based.

• Readers may find it challenging to identify the central message because of repeated statements and diffuse argumentation. A sharper, more structured discussion would be beneficial.

References

• The reference list contains a large number of outdated studies. Replacing these with recent (last 5–7 years) peer-reviewed articles would considerably enhance the manuscript’s credibility and relevance.

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Reviewer #1: No

Reviewer #2: Yes: Farshid Karimi

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Attachments

Attachment

Submitted filename: Dear Editor Pols.docx

Evolution of intraocular pressure after cataract surgery in nonglaucomatous patients: a post-hoc analysis of PERCEPOLIS clinical trial data

PONE-D-25-40249R1

Dear Dr. Perone,

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,

Natasha Gautam, MBBS, MS

Academic Editor

PLOS One

Additional Editor Comments (optional):

The authors have appropriately addressed all the comments.

Natasha

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 #1: 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 #1: Yes

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

Reviewer #1: Yes

**********

-->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 #1: 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 #1: 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 #1: I am satisfied with the authors' responses and the resulting changes to the paper. Nothing further to add.

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-->7. 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

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