Dear Dr. Hwang,

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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: 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

Reviewer #1: Yes

Reviewer #2: 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

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Reviewer #1: This manuscript addresses a clinically relevant question by evaluating the agreement of anterior corneal astigmatism measurements obtained with the KR-800, IOLMaster 500, and Pentacam HR in routine cataract surgery work-up. The study has several notable strengths, including a reasonably large sample size, the use of power-vector analysis for astigmatism comparison, and a meaningful distinction between population-level agreement and individual-level agreement. The finding that mean differences between devices are small while individual-level discrepancies may still be clinically relevant is important and potentially valuable for toric IOL planning. Overall, I consider the manuscript promising and potentially suitable for publication after revision. However, several issues should be addressed before acceptance. My main concern is that the discussion sometimes interprets the findings more strongly than the data directly support. In particular, the authors attribute the relatively wide limits of agreement to “real-world” factors such as multiple technicians, variable examination sequence, lack of repeated averaging, older patient age, and compromised ocular surface conditions. These explanations are certainly plausible and clinically sensible, but they were not directly measured or tested in the present study. For that reason, this interpretation should be presented more cautiously and explicitly framed as a hypothesis rather than as a demonstrated explanation. A second important issue is that the clinical significance of the observed differences is inferred only indirectly. The manuscript uses vector-difference thresholds and prior literature on residual postoperative astigmatism to argue that the inter-device differences may be clinically meaningful for toric IOL planning. However, the study did not assess whether the measurement differences actually changed toric IOL cylinder selection, axis choice, predicted residual astigmatism, or postoperative refractive outcomes. Therefore, the conclusions regarding clinical impact should be moderated. Ideally, the manuscript would be strengthened by an additional analysis showing how often these inter-device differences would have resulted in a different toric IOL recommendation. If such an analysis is not feasible, the discussion and conclusion should make clearer that the clinical implications remain inferential rather than directly demonstrated. The axis analysis is also somewhat difficult to interpret in the full cohort, because axis values are inherently less stable at low astigmatism magnitudes. The authors themselves demonstrate a significant inverse relationship between astigmatism magnitude and axis difference, which is an important and expected finding. However, from a clinical perspective, the subgroup with higher astigmatism is much more relevant for toric IOL planning than the entire study population. I would therefore recommend placing greater emphasis, both in the abstract and in the discussion, on the subgroup with corneal astigmatism of at least 1.0 D. In addition, the manuscript should explain more explicitly that large axis differences in eyes with very low astigmatism do not necessarily translate into clinically meaningful disagreement for toric planning. Several methodological points would also benefit from clarification. The authors should specify more clearly whether all cylinder values were converted into a uniform minus-cylinder notation before transformation into J0 and J45. Although this may be implied, it should be stated explicitly. It would also be helpful to describe in slightly greater detail exactly which keratometric outputs from each device were used, whether measurements were obtained before any drops or other interventions, and whether any additional quality-control procedures were applied beyond the device-specific quality flags. These details would improve transparency and reproducibility. There are also some issues in the statistical reporting. The Methods state that 95% confidence intervals for the limits of agreement were calculated, but these intervals are not presented in Table 2. The authors should either report them or remove that statement. In addition, the role of the intraclass correlation coefficient should be explained more carefully. ICC can be useful as a descriptive measure, but it is not itself a direct measure of interchangeability and may be strongly influenced by between-subject variability. Since the manuscript already uses Bland-Altman analysis appropriately, it would help to clarify that the Bland-Altman results are more directly relevant to the clinical question of interchangeability. I also noted a likely citation error in the Figure 2 legend. The statement about the 0.50 D threshold being associated with reduced uncorrected visual acuity appears to cite reference 15, which is the Koo and Li paper on ICC interpretation, whereas this statement seems to correspond instead to reference 17. This should be corrected. In addition, the manuscript would benefit from a careful language edit for minor stylistic and typographical improvements. Finally, because the Pentacam data are based on simulated keratometry from the anterior corneal surface only, it would be useful to emphasize again that the study concerns agreement of anterior keratometric measurements rather than comprehensive modern toric planning approaches that may incorporate posterior corneal astigmatism. In summary, this is a useful and clinically relevant study with an overall sound design and potentially publishable results. The major revisions required are less about fundamental flaws in the analysis and more about clearer methodological reporting and more cautious interpretation of the clinical implications. With these revisions, the manuscript would be substantially strengthened.

Reviewer #2: This paper reports the agreement among machines in measuring astigmatism. AS it can be expected, the measured astigmatism varies across devices, and especially so because of the non-experimental conditions: only one measurement per machine, ocular surface not controlled, perfect centration not addressed. While the outcome can be anticipated out of the existing literature, the value of the paper is in the limited variability detected in the examined patients. I would like the authors to add a comment about that.

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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:  Roberto Bellucci

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Agreement of keratometry measurements for toric IOL planning in routine clinical practice: KR-800, IOLMaster 500, and Pentacam HR

PONE-D-26-04357R1

Dear Dr. Hwang,

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,

Timo Eppig

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

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

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: 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

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Tahnk you for the invitation to review the revised version of themanuscript. No further comments. All comments have been adressed.

Reviewer #2: The paper has been modified and the analysis extended. Now it can be read both in a simple way only to pick up suggestions or in a more precise way taking into account the figures.

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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: No

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