Ocular Manifestations in Pediatric Traumatic Brain Injury Admitted to the ICU: A Prospective Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript addresses an important topic, providing a prospective analysis of ocular manifestations in pediatric traumatic brain injury (TBI) patients admitted to the ICU. The study offers valuable insights into the prevalence and characteristics of ocular findings in this vulnerable population. While the work is interesting and has potential clinical relevance, it is limited by the small sample size and single-center design, which may affect the generalizability of the findings. Additionally, a few issues regarding data reporting and clarity should be addressed to improve the interpretability of the results.

Below are my specific comments and suggestions:

1. The abstract states that data were collected prospectively from 2006–2024, whereas the Methods section specifies 2022–2024. This discrepancy should be corrected.
2. The manuscript does not report baseline ophthalmologic status (for example, pre-trauma BCVA or prior ocular conditions). Without this information, it is difficult to determine whether some findings were pre-existing. Please clarify whether baseline visual function was known, or discuss this as a limitation.
3. Tables 1 and 2 could be reformatted for clarity. Currently, some variables and values are misaligned, and certain categories (such as: site of head injury, “no ocular findings” variable) appear fragmented. For Table 2, either retain ‘(%)’ only in the header or repeat it in each row, but not both; retaining it in the header is recommended to improve readability.
4. Please include references in the first paragraph of the Discussion.
5. While the Methods section lists examples of ocular findings (visual loss, diplopia, photophobia, ocular motility disorders), it is unclear whether all features listed in Table 2, such as corneal defects or subconjunctival hemorrhage, were part of the criteria for assigning patients to the ocular group. For readers, it may appear that these symptoms automatically define the ocular group, which could create confusion. Clarifying the criteria for group classification would improve clarity and interpretation of the results.

 

Author Response

Response to Reviewer

We sincerely thank the reviewers for the constructive feedback and helpful suggestions, which have significantly improved our manuscript. Our responses to each point are detailed below:

 

Reviewer 1

This manuscript addresses an important topic, providing a prospective analysis of ocular manifestations in pediatric traumatic brain injury (TBI) patients admitted to the ICU. The study offers valuable insights into the prevalence and characteristics of ocular findings in this vulnerable population.

 

Author Response: We sincerely thank the reviewer for highlighting the importance and clinical relevance of our study.

 

 

Reviewer Comment: The abstract states that data were collected prospectively from 2006–2024, whereas the Methods section specifies 2022–2024. This discrepancy should be corrected.

Author Response: We thank the reviewer for identifying this error. The abstract has been corrected to indicate the accurate study period (2022–2024).

 

 

Reviewer Comment: The manuscript does not report baseline ophthalmologic status (for example, pre-trauma BCVA or prior ocular conditions). Without this information, it is difficult to determine whether some findings were pre-existing. Please clarify whether baseline visual function was known, or discuss this as a limitation.

Author Response: Because traumatic brain injuries usually occur suddenly, pre-injury ophthalmologic information is generally not available. We agree with the reviewer’s observation. Baseline ophthalmologic records were not available for our cohort. We have now acknowledged this in the Discussion section as a limitation.

 

 

Reviewer Comment: Tables 1 and 2 could be reformatted for clarity. Currently, some variables and values are misaligned, and certain categories (such as: site of head injury, “no ocular findings” variable) appear fragmented. For Table 2, either retain ‘(%)’ only in the header or repeat it in each row, but not both; retaining it in the header is recommended to improve readability.

Author Response: We have reformatted Tables 1 and 2 for improved clarity and consistency. Variable alignment has been corrected, fragmented categories reorganized, and the percentage notation retained only in the header row as suggested.

 

Reviewer Comment: Please include references in the first paragraph of the Discussion.

Author Response: References have been added in the opening paragraph of the Discussion to strengthen the background and contextualization of our findings.

 

 

 

Reviewer Comment: While the Methods section lists examples of ocular findings (visual loss, diplopia, photophobia, ocular motility disorders), it is unclear whether all features listed in Table 2, such as corneal defects or subconjunctival hemorrhage, were part of the criteria for assigning patients to the ocular group. Clarifying the criteria for group classification would improve clarity and interpretation of the results.

Author Response: We thank the reviewer for this important comment. We have clarified in the Methods section that all ocular findings listed in Table 2, including corneal defects and subconjunctival hemorrhage, were considered criteria for assigning patients to the ocular group.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The work is interesting and beneficial. A suggestion is to add more references. 

Author Response

Reviewer 2

Reviewer Comment: The work is interesting and beneficial. A suggestion is to add more references.

Author Response: We sincerely thank the reviewer for recognizing the value of our work. In response to the suggestion, we have added additional relevant references throughout the manuscript.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript “Ocular Manifestations in Pediatric Traumatic Brain Injury Admitted to the ICU: A Prospective Analysis” addresses an important and underexplored topic. By reporting a 52.6 % prevalence of ocular complications in pediatric ICU TBI patients and identifying several clinical predictors, the study highlights the critical need for systematic ophthalmologic assessment in this vulnerable population. Visual impairment during childhood can profoundly affect neurodevelopment, education, and quality of life, underscoring the clinical and public health significance of the work. The following points should be considered to strengthen the manuscript:

1. Chronological consistency – There is a discrepancy between the abstract (study initiation in 2006) and the methods section (recruitment from January 2022 to December 2024). Please revise the abstract to ensure internal consistency.
2. Epidemiological context – Strengthen the Introduction by including national and/or regional epidemiological data on the proportion of traumatic brain injuries (TBIs) occurring in children, as well as the fraction that require ICU admission. This will contextualise the study’s relevance and emphasise its public health importance.
3. Feasibility of ophthalmic assessment in children – Young age, sedation, and limited cooperation can compromise the reliability of eye examinations in critically ill pediatric patients. Please acknowledge this limitation explicitly and consider refining the exclusion criteria to omit children whose developmental stage precludes meaningful ophthalmic assessment.
4. Details of the ophthalmic work-up – The methods section should provide a comprehensive description of the baseline and follow-up ophthalmologic evaluation. Please specify whether the following tests were performed: best-corrected visual acuity using LogMAR charts, slit-lamp biomicroscopy, intraocular pressure measurement, fundus photography, OCT imaging, visual-evoked potentials (VEP), visual-field testing, and orthoptic assessment of extraocular muscle function.
5. Functional outcome measures – Currently, functional data are not reported, limiting the clinical interpretability of the findings. Please provide visual-acuity results and, if available, visual-field outcomes, VEP latency and amplitude, and OCT-derived retinal-layer thickness at each time point (baseline, 1 week, 4 weeks, and 24 weeks).
6. Diplopia – Diplopia is a frequent sequela of cranial-nerve palsy following TBI, but is not discussed in the current version. If observed, please include it among the reported ocular complications.
7. Longitudinal follow-up – Ocular sequelae of TBI may emerge or evolve, particularly delayed optic-nerve or retinal injuries. Please provide data on the persistence, resolution, or appearance of new ocular deficits at follow-up visits.
8. Statistical reporting – Present adjusted odds ratios with 95 % confidence intervals for the principal predictors (age, sex, Glasgow Coma Scale score, surgical intervention, orbital fractures, and basal skull fracture signs), rather than relying solely on p-values. 
9. Discussion improvements  

The discussion would benefit from a broader comparison with existing literature. For example, prevalence rates of ocular manifestations in mixed-severity pediatric TBI cohorts are typically lower, and this discrepancy should be attributed to the ICU-based selection of more severely affected children as well as examination challenges.

In addition, please comment on the absence of advanced modalities (VEP, OCT, retinal imaging). If these were not available due to resource limitations or feasibility constraints in the ICU, this should be stated explicitly. Referencing studies that employed such methods will also help highlight the added value of future work in this area.

 Emphasise the public-health significance of visual impairment in children, given its potential long-term consequences for neurodevelopment, academic performance, social integration, and quality of life. Highlighting these broader implications will increase the clinical and societal relevance of the findings.

 

Author Response

Response to Reviewer

We sincerely thank the reviewers for the constructive feedback and helpful suggestions, which have significantly improved our manuscript. Our responses to each point are detailed below:

Reviewer 3

 

Reviewer Comment: Chronological consistency – There is a discrepancy between the abstract (study initiation in 2006) and the methods section (recruitment from January 2022 to December 2024). Please revise the abstract to ensure internal consistency.

Author Response: The abstract has been corrected to reflect the accurate study period (January 2022 to December 2024), ensuring consistency with the Methods section.

 

Reviewer Comment: Epidemiological context – Strengthen the Introduction by including national and/or regional epidemiological data on the proportion of traumatic brain injuries (TBIs) occurring in children, as well as the fraction that require ICU admission. This will contextualise the study’s relevance and emphasise its public health importance.

Author Response 2: The Introduction has been strengthened with national and regional epidemiological data on pediatric TBI incidence and the proportion of cases requiring ICU admission, providing better context and emphasizing the public health relevance of the study.

 

 

Reviewer Comment: Feasibility of ophthalmic assessment in children – Young age, sedation, and limited cooperation can compromise the reliability of eye examinations in critically ill pediatric patients. Please acknowledge this limitation explicitly and consider refining the exclusion criteria to omit children whose developmental stage precludes meaningful ophthalmic assessment.

Author Response: We acknowledge that young age, sedation, and limited cooperation can compromise ophthalmic examinations. This limitation has been explicitly stated, and the exclusion criteria were refined to omit children whose developmental stage precluded meaningful ophthalmologic assessment.

 

Reviewer Comment: Details of the ophthalmic work-up – The methods section should provide a comprehensive description of the baseline and follow-up ophthalmologic evaluation. Please specify whether the following tests were performed: best-corrected visual acuity using LogMAR charts, slit-lamp biomicroscopy, intraocular pressure measurement, fundus photography, OCT imaging, visual-evoked potentials (VEP), visual-field testing, and orthoptic assessment of extraocular muscle function.

Author Response: The Methods section has been expanded to describe tests and follow-up ophthalmologic evaluation.

 

Reviewer Comment: Functional outcome measures – Currently, functional data are not reported, limiting the clinical interpretability of the findings. Please provide visual-acuity results and, if available, visual-field outcomes, VEP latency and amplitude, and OCT-derived retinal-layer thickness at each time point (baseline, 1 week, 4 weeks, and 24 weeks).

Author Response: OCT-derived retinal-layer measurements, VEP, and visual-field data were not routinely available, and this has been explicitly stated in the manuscript.

 

Reviewer Comment: Diplopia – Diplopia is a frequent sequela of cranial-nerve palsy following TBI, but is not discussed in the current version. If observed, please include it among the reported ocular complications.

Author Response: None of the patients in our cohort presented with diplopia. Therefore, diplopia was not observed or reported as an ocular complication in this study.

 

Reviewer Comment: Longitudinal follow-up – Ocular sequelae of TBI may emerge or evolve, particularly delayed optic-nerve or retinal injuries. Please provide data on the persistence, resolution, or appearance of new ocular deficits at follow-up visits.

Author Response: Thank you. No cases of delayed complications were reported.

 

Reviewer Comment: Statistical reporting – Present adjusted odds ratios with 95 % confidence intervals for the principal predictors (age, sex, Glasgow Coma Scale score, surgical intervention, orbital fractures, and basal skull fracture signs), rather than relying solely on p-values.

Author Response: Adjusted odds ratios with 95% confidence intervals for principal predictors have been added alongside p-values to enhance interpretability.

 

Reviewer Comment: Discussion improvements – The discussion would benefit from a broader comparison with existing literature. For example, prevalence rates of ocular manifestations in mixed-severity pediatric TBI cohorts are typically lower, and this discrepancy should be attributed to the ICU-based selection of more severely affected children as well as examination challenges. In addition, please comment on the absence of advanced modalities (VEP, OCT, retinal imaging). If these were not available due to resource limitations or feasibility constraints in the ICU, this should be stated explicitly. Referencing studies that employed such methods will also help highlight the added value of future work in this area. Emphasise the public-health significance of visual impairment in children, given its potential long-term consequences for neurodevelopment, academic performance, social integration, and quality of life. Highlighting these broader implications will increase the clinical and societal relevance of the findings.

 

 

Author Response: The Discussion now compares our findings with literature on mixed-severity pediatric TBI cohorts, highlighting higher prevalence in ICU patients due to severity and examination challenges. The absence of advanced modalities (VEP, OCT, retinal imaging) is explicitly acknowledged, and relevant studies using these techniques are cited to highlight avenues for future research. The public-health significance of pediatric visual impairment, including effects on neurodevelopment, academic performance, social integration, and quality of life, has been emphasized to underscore clinical and societal relevance.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

All suggestions were suitably considered, the requested changes were implemented, and all explanations were logical and grounded. This has resulted in an improved manuscript. Therefore, the manuscript can be accepted in its current form.