A decade ago, the American Journal of Ophthalmology (the Journal) completed a full peer review of almost all submitted manuscripts, feeling it was a responsibility of the Journal. Five years ago, with increasing submissions and a relatively stable, competent peer review pool, the Journal started to triage manuscripts, mainly at the Editor in Chief level, resulting in about 10% of manuscripts rejected at submission, along with a brief note to the authors. Over the past 3 years the Executive Editors have been further empowered to triage manuscripts and to decline further peer review of a manuscript if they are confident that it would not be accepted by the Journal. Still, this last year the Journal sent about 80% of manuscripts for full (or almost full) peer review. Based on a 300% increase in submissions over the past decade, it is now necessary to accelerate the process of declining full peer review of some manuscripts. The Journal is confident with this decision since the Editorial Board, specifically the Executive Editors, are very experienced and are capable of making these critical decisions. The authors of these rejected manuscripts will be advised that the manuscript is not competitive with current manuscripts either because the content is too specialized, the study is poorly designed, the manuscript is poorly written, or there is insufficient new information.

Most of the major journals have been triaging manuscripts for years now and some send only a small percentage (single digit) for full peer review. At the recent Peer Review Congress in Chicago during September 2013, a prospective study was reported indicating that editors were able to predict with high efficiency whether a manuscript will be acceptable to their journal with minimal risk of overlooking a manuscript that would be accepted following complete peer review. The discussion that followed at the Peer Review Congress indicated that almost all journals are performing some form of triage. JAMA Ophthalmology recently indicated that they are sending only one-third of submissions out for full peer review. Our Journal is going to institute more intensive triage and additionally accelerate the process of review or decision making. We anticipate sending about 50% of future submissions out to the voluntary peer reviewers. Manuscripts that are not reviewed outside the Editorial Board will be returned more quickly to the authors; ultimately this will assist authors in placing their manuscripts in the appropriate journal and hopefully provide a quicker review for those that the Journal chooses for full peer review.

Studies of our Journal reveal that reviewers, if they are going to review a manuscript, accept the invitation within a few days. In this new process, if the invitation to review is not accepted within 5 days, the manuscript invitation is withdrawn and another reviewer will be invited. A reviewer that accepts the invitation will then be given 14 days to complete a review or the manuscript invitation will be withdrawn and the next reviewer invited. For most manuscripts there will continue to be 3 reviewers in addition to the Editor in Chief. If the process is delayed, the Executive Editors are requested to perform more detailed peer reviews of their assigned manuscripts or request more assistance from members of the Editorial Board. Obviously this requires more commitment by Editorial Board members of this Journal. Another caveat is that an article will be rejected if 10 reviewers have declined the invitation to review the manuscript. Recently we have had 30–40 reviewers invited for some manuscripts without success in completing the review; returning the manuscript to the authors earlier seems the fairest process, since the manuscript has demonstrated a lower level interest to our reviewers.

In view of transparency, it is also disconcerting to report that many experts in ophthalmology, some being prolific authors who submit to this Journal, do not perform peer review for this Journal, or perhaps for any journal. This is a concern for all editors and even an ethical issue, probably initiated or accelerated by the large number of ophthalmology journals now being published in print and online, all needing peer reviewers. This Journal is fortunate to have a cadre of excellent reviewers, but this stable could be larger and better representative of publishing authors. This is most evident to the Editor in Chief when authors present a list of suggested reviewers. It is disconcerting that some or even many ignore the invitation to perform peer review for their colleagues. Peer review remains a voluntary process, except for Editorial Board members, and the Journal is unable to coax a peer reviewer to accept or complete a review. And we have no good mechanism for rewarding our excellent reviewers; please accept our sincere appreciation.

If a manuscript is sent back for revisions (all need revisions) the authors will now be given 1 month for revisions; otherwise the manuscript is rejected. Some authors languish with their manuscript revisions to the point that the content may become obsolete or stale. Incidentally, 90% of first revisions are still quickly returned to the authors as they fail to comply with specific requests, mostly formatting in nature (ie, they do not read the requests carefully). This further delays acceptance, and with multiple repeat revision requests this pattern questions the quality of the minute details of the research in the paper.

Other efforts at improved peer review by the Journal have had mixed success. Since the Journal is receiving a plethora of manuscripts from outside the United States, we have vigorously pursued more international reviewers. This has been minimally successful for a variety of reasons.

Rebuttals cannot really be entertained in this environment, as authors can be provided only 1 opportunity to present their content at this Journal. The peer review resources are no longer available for these additional efforts by the Editorial Board. A similar conclusion was echoed by Andrew Schachat as retiring editor of the journal Ophthalmology . Hopefully the one opportunity for submission will encourage authors to provide a more polished manuscript, as poor or even unintelligible writing has been a continual complaint of the peer reviewers.

These enhancements in the process by the Journal are in keeping with the environment in medical publishing and the pressure of increased numbers of submissions and the timely reporting of excellent content. They provide a quicker response to authors (positive or negative), expose peer reviewers of this Journal to fewer assignments, and lead to quicker publication of important content. Under this scenario, the Editor in Chief recognizes that the Editorial Board of this Journal will be assuming more of the brunt of peer review and decision making, and we all should appreciate their efforts.