Evaluation of Macular Thickness, Choroidal Thickness, and Choroidal Vascular Index in Patients with Polycystic Ovary Syndrome: An Observational Study

Evaluation of Macular Thickness, Choroidal Thickness, and Choroidal Vascular Index in Patients with Polycystic Ovary Syndrome: An Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Macular Thickness, Choroidal Thickness, and Choroidal Vascular Index in Patients with Polycystic Ovary Syndrome: An Observational Study Alper GÜNEŞ, Selim GÜLÜCÜ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6309404/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract AIM: To investigate the ocular effects of Polycystic Ovary Syndrome (PCOS) in reproductive-age women, specifically focusing on macular thickness, choroidal thickness, and the Choroidal Vascular Index (CVI). METHODS: A comparative study was conducted with forty-five diagnosed PCOS patients and forty-five sex-matched healthy volunteers. Optical Coherence Tomography (OCT) was used to measure choroidal and macular thicknesses. The innovative Choroidal Vascular Index (CVI) was utilized to identify potential vascular alterations in the choroid. Statistical analyses, including t-tests and regression models, were performed to interpret the data and discern differences between the two groups. RESULTS: The data showed that the PCOS group had a significant increase in choroidal thickness at specific measurement points compared to the control group (p<0.05). Differences were also observed in the total choroidal area and luminal area in the PCOS group. CVI values presented significant variations between the two groups (p<0.05). However, there was no statistically significant difference observed in the retinal nerve fiber layer and macular thickness between the two groups. CONCLUSION: PCOS appears to influence ocular health, especially in the choroidal region, which may be attributed to the vasodilation effects of estrogen. These findings underscore the importance of comprehensive ocular evaluations in PCOS patients. Healthcare professionals should consider these potential ocular manifestations while managing and advising patients with PCOS. Further research is needed to elucidate the broader implications of these findings. PCOS Choroidal Vascular Index Choroidal Thickness Figures Figure 1 Key Messages (Summary Box) What is already known on this topic: - PCOS is known to have systemic vascular effects, but its impact on ocular health remains unclear. What this study adds: - This study shows that PCOS is associated with increased choroidal thickness and vascularity index, suggesting hormonal influence on ocular microcirculation. How this study might affect research, practice, or policy: - These findings highlight the need for routine ocular assessments in PCOS patients to detect early vascular changes. Patient and Public Involvement Statement Patients and the public were not involved in the design, conduct, reporting, or dissemination plans of this research. Introduction Polycystic Ovary Syndrome (PCOS) is a prevalent endocrine disorder that primarily affects women of reproductive age, manifesting with symptoms such as anovulation, hyperandrogenism, and the presence of polycystic ovaries [1]. While the systemic implications of PCOS have been extensively studied, recent attention has been directed towards exploring its potential impact on ocular health. The eyes harbor essential structures crucial for precise vision and color perception, including the cone-rich macula and the highly vascularized choroid layer beneath the retina [2]. The intriguing connection between PCOS and ocular health has been discussed recently. Hormones, specifically androgens, play a pivotal role in the pathophysiology of PCOS. Interestingly, these hormones also modulate ocular structures [3]. The possible hormonal interplay raises questions about the underlying mechanisms connecting PCOS with ocular changes, specifically in the choroid and retina. In different ocular tissues, such as the conjunctiva, cornea, meibomian gland, choroid, retina, and lens, steroid hormone receptors have been shown quite recently [4,5,6]. Recent advancements in visual imaging techniques, particularly Optical Coherence Tomography (OCT), have provided new avenues for investigating the potential anatomical effects of PCOS on the eyes. Parameters such as macular and choroidal thickness have undergone comprehensive investigation. Furthermore, the emergence of novel indices like the Choroidal Vascular Index (CVI) presents a promising opportunity to assess choroid vascular architecture alterations. Nevertheless, a significant gap in the current understanding of PCOS-related ocular outcomes pertains to exploring the Choroidal Vascular Index (CVI). While macular and choroidal thickness have been extensively studied within PCOS populations [7, 8], research focusing on alterations in the Choroidal Vascular Index (CVI) and its potential clinical implications remains relatively scarce. This study aims to comprehensively assess the macular thickness, choroidal thickness, and Choroidal Vascular Index (CVI) in individuals diagnosed with polycystic ovary syndrome. By analyzing these parameters, we seek to gain insights into potential ocular consequences of PCOS and hint at the clinical significance of these anatomical and vascular changes occurring within the eye. In addition to anatomical changes, the functional aspect of the vascular supply to the eye in PCOS individuals is an area that warrants further exploration. Since the choroidal vasculature feeds the outer layers of the retina, alterations in this layer affect the nutritional supply, potentially influencing visual function. Thus, assessing the CVI, alongside thickness parameters, could offer a more nuanced understanding of the potential ocular consequences of PCOS [9]. Moreover, the psychological and emotional strain PCOS imposes on individuals is significant. Vision changes associated with PCOS might contribute to this strain, highlighting the possible benefits of a comprehensive care approach for PCOS patients. By investigating the ocular effects of PCOS, we can enhance our knowledge of the condition and help inform future interventions and preventive measures [10]. SUBJECTS/MATERIALS AND METHODS Ethical Approval This study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Written informed consent from all participants and institutional ethics committee approval was obtained. Clinical Trial Registry: The Clinical Research Registration number obtained from the clinical research ethics committee of Tokat Gaziosmanpaşa University Faculty of Medicine is 20-KAEK-235. Statistical Analysis: Utilizing SPSS 22.0, a statistical analysis was carried out. Visual and analytical techniques (Kolmogorov-Smirnov/Shapiro-Wilk test) were used to assess the data to ascertain whether or not the variables were normally distributed. Means and standard deviations for variables with a normally distributed distribution were used to present descriptive analysis. Data were compared between patients with PCOS and the control group, using the Student's t-test. Statistical significance was indicated by a p-value less than 0.05. Forty-five polycystic ovary syndrome (PCOS) patients and forty-five sex-matched healthy volunteers participated in the study. The research was carried out at the Tokat Gaziosmanpaşa University Faculty of Medicine's Departments of Ophthalmology and Infectious Diseases, which is situated in central Anatolia. The study's target population was female patients with PCOS who received their initial diagnosis at Tokat Gaziosmanpaşa University between August 2023 and September 2023 and were of reproductive age (18 to 49). Based on the 2003 Rotterdam ESHRE/ASRM consensus criteria, the diagnosis of PCOS was planned. As a result, the three primary criteria were identified as clinical or biochemical hyperandrogenism, anovulation or oligomenorrhea, and the presence of polycystic ovaries on sonography. Women who satisfied at least two of these criteria were accepted as having PCOS after endocrinopathies such as pituitary insufficiency, chronic hyperprolactinemia, and congenital adrenal hyperplasia were excluded (1). As a control group, it was intended to identify patients in a similar age range referred to the obstetrics and gynecology clinic by environmental health institutions with a pre-diagnosis of PCOS but who were not ultimately diagnosed. Axial length measurement, visual acuity assessment using a Snellen chart, anterior segment examination using slit lamp biomicroscopy, dilated fundus examination, and OCT measurement were all part of this examination. All subjects underwent evaluations of their right eyes. All measurements made during the hospitalization were carried out and verified by two qualified and independent ophthalmologists. The study excluded participants who had a spherical equivalent greater than ±2.0 D, axial length greater than 26 mm or less than 20 mm, a history of ocular disease, ocular surgery, or trauma, as well as any concurrent systemic diseases other than PCOS (such as diabetes mellitus and hypertension). Smokers and people who took systemic or ocular drugs for conditions other than PCOS were also excluded. The study received permission from the regional ethics committee and adhered to the principles of the Helsinki Declaration. Prior to the trial, each participant signed a form of informed permission. All measurements were made between 9:00 and 12:00 using a Zeiss Cirrus 5000 spectral domain optical coherence tomography (SD-OCT) equipment to reduce diurnal variation. Comparisons were made between the two groups for choroidal thickness (ChT), total choroidal area (TCA), stromal area (SA), luminal area (LA), choroidal vascular index (CVI), CVI at 1500 µm from the center (CVI 1500 ), and central macular thickness. For ChT evaluation, the enhanced depth imaging (EDI) mode was used. Choroidal thickness was calculated by measuring the distance between the inner sclera and the outer edge of the hyper-reflective retinal pigment epithelium (RPE). At intervals of 1000 µm, measurements were taken at five sites, including the subfoveal region and the temporal and nasal foveal quadrant. The Measurements of Choroidal Vascularity Index (CVI) Using the method described by Agrawal et al. in their study[11].CVI was determined from EDI mode images using the ImageJ software (version 1.53i, National Institutes of Health, USA). To prepare the images, Niblack's automatic local thresholding method was utilized to adjust, convert to 8-bit, and then binarize them. The reference line was aligned with the retinal pigment epithelium (RPE). The entire choroidal area was selected using a polygon tool. After processing, images were stored with the region of interest (ROI) management tool and reverted to their original RGB coloring. Setting white as the threshold color, the image was saved again through the ROI manager. Here, white pixels indicated the stromal region (SA), and dark ones represented the vascular luminal area (LA). Combining two images from the ROI manager produced a third, which was then added back into the tool. The SA was deducted from the total choroidal area (TCA) to identify the LA. The CVI was determined by the ratio of LA to TCA. This procedure was also applied to the foveal area within the 1500 µm radius (Figure 1). RESULTS Forty-one of the PCOS patients and forty-six of the controls were examined. Age, axial length, intraocular pressure, and spherical equivalent did not significantly differ between the patient and control groups (p = 0.354, 0.715, 0.532, and 0.672, respectively) (Table 1). At all five stages of measurement, it was discovered that the choroidal thickness was greater in the PCOS group than in the control group. The subfoveal, temporal (1000µm), and nasal (1000 µm) quadrant measures indicate significant changes (p=0.047, 0.026, and 0.011, respectively). On the other hand, temporal (2000µm) and nasal (2000 µm) quadrant values were not statistically significant (p=0.158 and 0.322, respectively). TCA, LA, total choroidal area at the macula's center (TCA 1500 ) and luminal area at the macula's center (LA 1500 ) were found to be significantly thicker in PCOS patients in the total choroidal measurements (p = 0.041, 0.036, 0.031, and 0.029, respectively). There were discernible differences between CVI and CVI 1500 (p=0.046 and 0.039, respectively). There was no statistically significant difference between the two groups regarding SA and stromal area at the macula's center (SA1500), (p=0.159 and 0.140, respectively). Similarly, macular thickness and retinal nerve fiber layer parameters were not statistically significant (p=0.181 and 0.981 repectively). Table 1. The Demographic and Clinical Characteristics of PCOS Patients and Healthy Individuals. Characteristic PCOS Eyes Control Group Eyes p-value Age (years) (mean±SD) 22.59±1.59 22.56±1.57 0.354 Axial Length (mm) (mean±SD) 22.4±0.3 22.8±0.6 0.715 Intraocular Pressure (mmHg) (mean±SD) 15.1±2.4 14.8±2.3 0.532 Spherical Equivalent (D) (mean±SD) -0.19±0.48 -0.16±0.61 0.672 Table 2 Comparison of Choroidal Parameters and Macular Thickness Between Eyes with PCOS and Control Group Variables PCOS Eyes (Mean ± SD) Control Group Eyes (Mean ± SD) p-value TCA (mm2) 0.68 ± 1.21 0.61 ± 0.18 0.041** LA (mm2) 0.49 ± 0.62 0.41 ± 0.74 0.036** SA (mm2) 0.23 ± 0.57 0.22 ±0.68 0.159 CVI (%) 0.65 ± 0.09 0.63 ± 0.04 0.046** TCA1500 (mm2) 0.18 ± 0.04 0.15 ± 0.01 0.031** LA1500 (mm2) 0.11 ± 0.02 0.10 ± 0.01 0.029** SA1500 (mm2) 0.07 ± 0.01 0.06 ± 0.01 0.140 CVI1500 (%) 0.66 ± 0.02 0.64 ±0.01 0.039** Sub-foveal Choroidal Thickness (µm) 353.8 ± 88.3 325 ± 74.1 0.047** Choroidal Thickness at 1000 µm Nasal to The Fovea (µm) 351.3 ± 77.9 321.3 ± 88.6 0.026** Choroidal Thickness at 2000 µm Nasal to The Fovea (µm) 324.6 ± 62.2 318.8 ± 77.7 0.158 Choroidal Thickness at 1000 µm Temporal to The Fovea (µm) 358.1 ± 50.5 333.0 ± 68.8 0.011** Choroidal Thickness at 2000 µm Temporal to The Fovea (µm) 316.4 ± 45.5 305.5 ± 79.1 0.322 Retinal Nerve Fiber Layer (µm) 149.6 ± 115.1 149.6 ± 111.2 0.981 Macular Thickness (µm) 224.6 ± 40.5 236.3 ±35.7 0.181 TCA (Total Choroidal Area), LA (Luminal Area), SA (Stromal Area), TCA 1500 (Total Choroidal Area at the Center of the Macula 1500µm), LA 1500 (Luminal Area at the Center of the Macula 1500 µm), SA 1500 (Stromal Area at the Center of the Macula 1500 µm), and CVI 1500 (Choroidal Vascularity Index at the Center of the Macula 1500µm). *,**,*** notations represent statistical significance at the 10%, 5% and 1% significance level, respectively. After looking at the statistical differences between the PCOS patients and control group, we applied multiple linear regression analysis to see the effect of hormones such as estradiol, prolactin, testosterone, and insulin on the subfoveal choroidal thickness for both groups. The econometric model used in the analysis is given in equation (1). Table 3 shows the results of the regression analysis. In Equation (1) SFCT variable is the dependent variable and shows the Subfoveal Choroidal Thickness, LHFSH variable is ratio of luteinizing hormone to follicle-stimulating hormone, EST variable is estradiol, PROL variable is prolactin, TEST variable is testosterone, INS variable is insulin and ε parameter represents the error term. Table 3 Multiple Linear Regression Analysis Results Dependent Variable Sub-foveal Choroidal Thickness PCOS Control Group Variables Coefficient ( b ) p-value Coefficient ( b ) p-value LHFSH 0.249 0.048 ** 0.312 0.032 ** EST 0.146 0.062 * 0.096 0.124 PROL -0.375 0.569 -0.352 0.353 TEST -0.138 0.108 -0.246 0.119 INS 0.075 0.264 0.107 0.297 Constant Term 0.591 0.000 *** 0.678 0.000 *** *,**,*** notations represent statistical significance at the 10%, 5% and 1% significance level, respectively. Considering the regression analysis results, the EST variable is statistically significant and positive at 10% significance level, the LHFSH variable at 5% significance level, and the Constant term at 1% significance level for PCOS patients. Therefore, the LHFSH and EST variables increase the choroidal thickness. When the regression results of the control group are examined, it is seen that the LHFSH and constant term variables are statistically significant at the 5% and 1% significance level, respectively. As noted here, the EST variable was not statistically significant. This shows that while the EST variable significantly affects the SFCT variable in PCOS patients, it is not significant in the control group. DISCUSSION Polycystic ovary syndrome (PCOS) is a commonly encountered endocrine disorder in women. This syndrome's impact is not limited to the reproductive system but can also influence various body systems. It is known that PCOS has numerous metabolic comorbidities, including obesity, hypertension, dyslipidemia, insulin resistance, atherosclerosis, cardiovascular disease, and diabetes mellitus[12]. Particularly due to the presence of sex steroid hormone receptors in various eye tissues, sex steroid hormones can have a significant effect on eye physiology and structure[13]. There was a meaningful relationship between the eye's axial length and the choroidal thickness. Therefore, a higher degree of myopia will lead to a decrease in choroidal thickness[14]. Corneal thickness has been shown to affect IOP readings, with thin corneas leading to falsely low IOP readings, and thick corneas resulting in falsely high IOP readings[15]. Given this information, age, axial length, intraocular pressure, and spherical equivalent did not significantly differ between the patient and control groups (p = 0.354, 0.715, 0.532, and 0.672, respectively) (Table 1). At all five stages of measurement, it was observed that the choroidal thickness was greater in the PCOS group than in the control group. The subfoveal, temporal (1000µm), and nasal (1000µm) quadrant measures indicated significant changes (p=0.047, 0.026, and 0.011, respectively). However, the temporal (2000µm) and nasal (2000µm) quadrant values were not statistically significant (p=0.158 and 0.322, respectively). In a study by Açmaz et al., similar to our study, they found a significant difference in choroidal thickness in the PCOS group. They suggested that the increase in choroidal thickness in PCOS patients might be due to an increased vasodilation effect of estrogen[16]. Ciccone and colleagues examined the ophthalmic artery vasodilation after intranasal estrogen use in postmenopausal women. This study reached similar results to the findings of Atalay and colleagues[17]. The results are consistent with our study and support the hypothesis they presented. Regression analysis concluded that estrogen increased the subfoveal choroidal thickness (sfct). Although the P probability value was 0.062, it can be considered statistically significant at the 10% significance level, which is consistent with other studies. However, Sagowa et al. investigated the relationship between choroidal thickness and choroidal blood flow in healthy young individuals. They concluded that there was no significant relationship[18]. Açmaz et al. hypothesized that the increased choroidal thickness in PCOS patients might indicate an increased estrogen-related vasodilation effect in the ophthalmic artery due to unopposed estrogen or relatively high estrogen levels[15]. The OCTA (Optical Coherence Tomography Angiography) study conducted by Yener and colleagues revealed that the capillary density in the macula and optic disc area in PCOS patients did not differ significantly from healthy controls. However, the thickness in the parafoveal superior, inferior, and temporal quadrants was significantly increased compared to the control group[19]. It is essential to note that currently, there is no article that precisely examines the relationship between PCOS and CVI (choroidal vascular index). Nevertheless, some surprising findings regarding the choroidal thickness of PCOS patients, especially the blood vessel density in the macular region, have been identified in the available research. In PCOS patients, the total choroidal area (TCA), lumen area (LA), and the total choroidal area at the center of the macula (TCA1500) were found to be significantly thicker in total choroidal measurements (with respective p-values of 0.041, 0.036, 0.031, and 0.029). There were significant differences between CVI and CVI1500 (p-values of 0.046 and 0.039, respectively). The observed increase in choroidal thickness, as determined by the CVI evaluation, was localized in the luminal area, while no significant difference was observed in the stromal area (with p-values of 0.036 and 0.159, respectively). This points to a possible association with unbalanced estrogen levels, as previously mentioned, reinforcing the results presented by Açmaz et al[16]. The retinal nerve fiber layer and macular thickness did not statistically differ in both groups with p-values of 0.981 and 0.181. In their study, Shiromani and colleagues similarly found that the retinal thicknesses in the two study groups were analogous, with no statistically significant difference. However, the Retinal Nerve Fiber Layer (RNFL) was significantly thicker than the control group (P = 0.0006). Yet, they found no significant difference in the Retinal Nerve Fiber Layer (RNFL) thickness in the disk and macula areas. This might be due to the younger age of our study, suggesting that they might have been diagnosed earlier, considering the average age of 26 in the patient group and 32 in the control group. Açmaz et al. examined the macula and retinal nerve fiber layer in women with PCOS. They found that the central fovea thickness and inner temporal macula (TIM) in the PCOS group were significantly thinner compared to the healthy control group. However, the age group of PCOS patients was considerably older, indicating the influence of age as a factor. When adjusted for age, it was found that the RNFL in the PCOS group was significantly thicker than in the healthy control group. This difference might be due to the similar age group and the younger patient group in our study. A study by de Souza-Júnior JE and colleagues using HD-OCT was categorized based on metabolic syndrome, inflammation, obesity, glucose intolerance, and/or insulin resistance. The results demonstrated that in the presence of insulin resistance, the total macular thickness in PCOS patients was increased compared to the control group. We speculate that this change initially relates to hypertrophy of the Müller cells and subsequently to intra- and extracellular edema in these cells[20]. Our regression analyses showed that an increase in the LH/FSH ratio was highly related to estrogen at a 10% significance level. However, no difference was observed between prolactin, testosterone, insulin levels and sub foveal choroidal thickness. Current literature has reviewed the use of the LH/FSH ratio in diagnosing PCOS, focusing on whether an LH/FSH ratio of 2:1 or higher is a factor raising suspicion of PCOS. However, a high ratio does not always indicate the presence of PCOS[21,22]. Our study revealed increased sub foveal choroidal thickness with an increased LH/FSH ratio. In conclusion, the choroidal vascular index was examined for the first time in our study on patients diagnosed with Polycystic Ovary Syndrome (PCOS). The findings indicated significant changes in the choroidal vascular index and choroidal thickness compared to a control group. These observations suggest a potential link between the hormonal changes caused by PCOS and alterations in the eye. The exact mechanisms and implications of these changes remain unclear. More comprehensive studies are needed to elucidate these findings. Declarations Ethics approval and consent to participate This study was approved by the Tokat Gaziosmanpaşa University Clinical Research Ethics Committee (Approval No: 20-KAEK-235). Written informed consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. Authors' contributions A.G. designed the study, performed ophthalmologic examinations and OCT analyses, conducted the statistical analysis, and wrote the main manuscript text. S.G. contributed to patient recruitment and provided support for the hormonal analysis and related sections during manuscript preparation. All authors reviewed and approved the final version of the manuscript. Acknowledgements Not applicable. 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Effects of corneal thickness, corneal curvature, and intraocular pressure level on Goldmann applanation tonometry and dynamic contour tonometry. Ophthalmology. 2007;114:20–26. Açmaz G, Albayrak E, Acmaz B, et al. Evaluation of the macula, retinal nerve fiber layer, and choroid in polycystic ovary syndrome: an optical coherence tomography study. J Obstet Gynaecol. 2013;33(6): 592–596. Ciccone MM, Favale S, Scicchitano P, et al. Reversibility of the endothelial dysfunction after CPAP therapy in OSAS patients. Int J Cardiol. 2012;158(3). Sogawa K, Nagaoka T, Takahashi A, et al. Relationship between choroidal thickness and choroidal circulation in healthy young subjects. Am J Ophthalmol. 2012;153(6):1129-1132. Yener NP, Ozgen G, Tufekci A, Ozgen L, Aydin GA. Optical Coherence Tomography Angiography Findings in Polycystic Ovary Syndrome. J Coll Physicians Surg Pak. 2021 Sep;31(9):1057-1063. de Souza-Júnior JE, Garcia CA, Soares EM, Maranhão TM, Lemos TM, Azevedo GD. Polycystic ovary syndrome: aggressive or protective factor for the retina? Evaluation of macular thickness and retinal nerve fiber layers using high-definition optical coherence tomography. J Ophthalmol. 2015;2015:193078. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19–25. Welt CK, Carmina E. Lifecycle of polycystic ovary syndrome (PCOS): from in utero to menopause. J Clin Endocrinol Metab. 2008;97(12):1-17. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6309404","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453394700,"identity":"8b78ac39-d0c6-420e-98a0-6a5e18e7de50","order_by":0,"name":"Alper GÜNEŞ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYDACdgST8QGETiCghRmJaQDXcoBILWwSRGnhb+Y9+LiCoTZxO3v7s8ovFXcY+NlzDJg/7sGtReIwX7LhGYbjiTt7zpjdljnzjEGy540Bw4FneKw5zGMm2cBwLHHDjRy225JthxkMbuQAteBxmfxhHvOfYC33nz8rBmmxJ6TFAGgLYwNDDdAWBjPGjyBbJAhoMQT6RbLB4IDxhjM5xtIMZ57xSJx5VnDgDB4tcsd7D35sqKiT3XD8+MOPPyruyPG3J298UIFHCwMDD9h5YCYzD8MBEBd/TEK0MNSBmYw/CCkeBaNgFIyCEQkAO1JZM8s5LjcAAAAASUVORK5CYII=","orcid":"","institution":"Tokat Gaziosmanpaşa University Faculty of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Alper","middleName":"","lastName":"GÜNEŞ","suffix":""},{"id":453394701,"identity":"e0115c90-8305-44ff-84b9-de80a58ff785","order_by":1,"name":"Selim GÜLÜCÜ","email":"","orcid":"","institution":"Private Yenişehir Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Selim","middleName":"","lastName":"GÜLÜCÜ","suffix":""}],"badges":[],"createdAt":"2025-03-26 06:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6309404/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6309404/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82355449,"identity":"c6b272ac-1ebd-4f6d-b4c9-7e3b140e3d78","added_by":"auto","created_at":"2025-05-09 11:14:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144285,"visible":true,"origin":"","legend":"\u003cp\u003eUsing the enhanced-depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) image, the Choroidal Vascularity Index (CVI) is calculated via binarization. A) An EDI SD-OCT image. B) The image underwent binarization utilizing Niblack’s auto-local threshold. The color thresholding tool identified the dark pixels indicative of the luminal area (denoted by yellow lines). C) CVI is computed by dividing the luminal area by the entire choroidal area. Binary processing was done with Niblack’s automatic local threshold centered at 1500 μm of the macula. The color threshold tool pinpointed dark pixels. E) CVI measurement at the 1500 μm center of the macula.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6309404/v1/213c7bbb26ffc41bb0f6224f.jpg"},{"id":84182855,"identity":"ee7dc42c-2704-40c0-ad38-e89850360582","added_by":"auto","created_at":"2025-06-09 04:31:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789360,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6309404/v1/d998cc31-d4ec-4a7d-ac3d-34436dacc2dd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEvaluation of Macular Thickness, Choroidal Thickness, and Choroidal Vascular Index in Patients with Polycystic Ovary Syndrome: An Observational Study\u003c/p\u003e","fulltext":[{"header":"Key Messages (Summary Box)","content":"\u003cp\u003eWhat is already known on this topic:\u003cbr\u003e\u0026nbsp;- PCOS is known to have systemic vascular effects, but its impact on ocular health remains unclear.\u003c/p\u003e\n\u003cp\u003eWhat this study adds:\u003cbr\u003e\u0026nbsp;- This study shows that PCOS is associated with increased choroidal thickness and vascularity index, suggesting hormonal influence on ocular microcirculation.\u003c/p\u003e\n\u003cp\u003eHow this study might affect research, practice, or policy:\u003cbr\u003e\u0026nbsp;- These findings highlight the need for routine ocular assessments in PCOS patients to detect early vascular changes.\u003c/p\u003e\n\u003cp\u003ePatient and Public Involvement Statement\u003c/p\u003e\n\u003cp\u003ePatients and the public were not involved in the design, conduct, reporting, or dissemination plans of this research.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003ePolycystic Ovary Syndrome (PCOS) is a prevalent endocrine disorder that primarily affects women of reproductive age, manifesting with symptoms such as anovulation, hyperandrogenism, and the presence of polycystic ovaries [1]. While the systemic implications of PCOS have been extensively studied, recent attention has been directed towards exploring its potential impact on ocular health. The eyes harbor essential structures crucial for precise vision and color perception, including the cone-rich macula and the highly vascularized choroid layer beneath the retina [2].\u003c/p\u003e\n\u003cp\u003eThe intriguing connection between PCOS and ocular health has been discussed recently. Hormones, specifically androgens, play a pivotal role in the pathophysiology of PCOS. Interestingly, these hormones also modulate ocular structures [3]. The possible hormonal interplay raises questions about the underlying mechanisms connecting PCOS with ocular changes, specifically in the choroid and retina.\u003c/p\u003e\n\u003cp\u003eIn different ocular tissues, such as the conjunctiva, cornea, meibomian gland, choroid, retina, and lens, steroid hormone receptors have been shown quite recently [4,5,6].\u003c/p\u003e\n\u003cp\u003eRecent advancements in visual imaging techniques, particularly Optical Coherence Tomography (OCT), have provided new avenues for investigating the potential anatomical effects of PCOS on the eyes. Parameters such as macular and choroidal thickness have undergone comprehensive investigation. Furthermore, the emergence of novel indices like the Choroidal Vascular Index (CVI) presents a promising opportunity to assess choroid vascular architecture alterations.\u003c/p\u003e\n\u003cp\u003eNevertheless, a significant gap in the current understanding of PCOS-related ocular outcomes pertains to exploring the Choroidal Vascular Index (CVI). While macular and choroidal thickness have been extensively studied within PCOS populations [7, 8], research focusing on alterations in the Choroidal Vascular Index (CVI) and its potential clinical implications remains relatively scarce.\u003c/p\u003e\n\u003cp\u003eThis study aims to comprehensively assess the macular thickness, choroidal thickness, and Choroidal Vascular Index (CVI) in individuals diagnosed with polycystic ovary syndrome. By analyzing these parameters, we seek to gain insights into potential ocular consequences of PCOS and hint at the clinical significance of these anatomical and vascular changes occurring within the eye.\u003c/p\u003e\n\u003cp\u003eIn addition to anatomical changes, the functional aspect of the vascular supply to the eye in PCOS individuals is an area that warrants further exploration. Since the choroidal vasculature feeds the outer layers of the retina, alterations in this layer affect the nutritional supply, potentially influencing visual function. Thus, assessing the CVI, alongside thickness parameters, could offer a more nuanced understanding of the potential ocular consequences of PCOS [9].\u003c/p\u003e\n\u003cp\u003eMoreover, the psychological and emotional strain PCOS imposes on individuals is significant. Vision changes associated with PCOS might contribute to this strain, highlighting the possible benefits of a comprehensive care approach for PCOS patients. By investigating the ocular effects of PCOS, we can enhance our knowledge of the condition and help inform future interventions and preventive measures [10].\u003c/p\u003e"},{"header":"SUBJECTS/MATERIALS AND METHODS ","content":"\u003ch2\u003eEthical Approval\u003c/h2\u003e\n\u003cp\u003eThis study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Written informed consent from all participants and institutional ethics committee approval was obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical Trial Registry:\u0026nbsp;The Clinical Research Registration number obtained from the clinical research ethics committee of Tokat Gaziosmanpaşa University Faculty of Medicine is 20-KAEK-235.\u003c/p\u003e\n\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\n\u003cp\u003eUtilizing SPSS 22.0, a statistical analysis was carried out. Visual and analytical techniques (Kolmogorov-Smirnov/Shapiro-Wilk test) were used to assess the data to ascertain whether or not the variables were normally distributed.\u003c/p\u003e\n\u003cp\u003eMeans and standard deviations for variables with a normally distributed distribution were used to present descriptive analysis. Data were compared between patients with PCOS and the control group, using the Student's t-test. Statistical significance was indicated by a p-value less than 0.05.\u003c/p\u003e\n\u003cp\u003eForty-five polycystic ovary syndrome (PCOS) patients and forty-five sex-matched healthy volunteers participated in the study. The research was carried out at the Tokat Gaziosmanpaşa University Faculty of Medicine's Departments of Ophthalmology and Infectious Diseases, which is situated in central Anatolia. The study's target population was female patients with PCOS who received their initial diagnosis at Tokat Gaziosmanpaşa University between August 2023 and September 2023 and were of reproductive age (18 to 49). Based on the 2003 Rotterdam ESHRE/ASRM consensus criteria, the diagnosis of PCOS was planned. As a result, the three primary criteria were identified as clinical or biochemical hyperandrogenism, anovulation or oligomenorrhea, and the presence of polycystic ovaries on sonography. Women who satisfied at least two of these criteria were accepted as having PCOS after endocrinopathies such as pituitary insufficiency, chronic hyperprolactinemia, and congenital adrenal hyperplasia were excluded (1). As a control group, it was intended to identify patients in a similar age range referred to the obstetrics and gynecology clinic by environmental health institutions with a pre-diagnosis of PCOS but who were not ultimately diagnosed. Axial length measurement, visual acuity assessment using a Snellen chart, anterior segment examination using slit lamp biomicroscopy, dilated fundus examination, and OCT measurement were all part of this examination. All subjects underwent evaluations of their right eyes. All measurements made during the hospitalization were carried out and verified by two qualified and independent ophthalmologists.\u003c/p\u003e\n\u003cp\u003eThe study excluded participants who had a spherical equivalent greater than ±2.0 D, axial length greater than 26 mm or less than 20 mm, a history of ocular disease, ocular surgery, or trauma, as well as any concurrent systemic diseases other than PCOS (such as diabetes mellitus and hypertension). Smokers and people who took systemic or ocular drugs for conditions other than PCOS were also excluded.\u003c/p\u003e\n\u003cp\u003eThe study received permission from the regional ethics committee and adhered to the principles of the Helsinki Declaration. Prior to the trial, each participant signed a form of informed permission.\u003c/p\u003e\n\u003cp\u003eAll measurements were made between 9:00 and 12:00 using a Zeiss Cirrus 5000 spectral domain optical coherence tomography (SD-OCT) equipment to reduce diurnal variation. Comparisons were made between the two groups for choroidal thickness (ChT), total choroidal area (TCA), stromal area (SA), luminal area (LA), choroidal vascular index (CVI), CVI at 1500 µm from the center (CVI\u003csub\u003e1500\u003c/sub\u003e), and central macular thickness. For ChT evaluation, the enhanced depth imaging (EDI) mode was used. Choroidal thickness was calculated by measuring the distance between the inner sclera and the outer edge of the hyper-reflective retinal pigment epithelium (RPE). At intervals of 1000 µm, measurements were taken at five sites, including the subfoveal region and the temporal and nasal foveal quadrant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe Measurements of Choroidal Vascularity Index (CVI)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUsing the method described by Agrawal et al. in their study[11].CVI was determined from EDI mode images using the ImageJ software (version 1.53i, National Institutes of Health, USA). To prepare the images, Niblack's automatic local thresholding method was utilized to adjust, convert to 8-bit, and then binarize them. The reference line was aligned with the retinal pigment epithelium (RPE). The entire choroidal area was selected using a polygon tool. After processing, images were stored with the region of interest (ROI) management tool and reverted to their original RGB coloring. Setting white as the threshold color, the image was saved again through the ROI manager. Here, white pixels indicated the stromal region (SA), and dark ones represented the vascular luminal area (LA). Combining two images from the ROI manager produced a third, which was then added back into the tool. The SA was deducted from the total choroidal area (TCA) to identify the LA. The CVI was determined by the ratio of LA to TCA. This procedure was also applied to the foveal area within the 1500 µm radius (Figure 1).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eForty-one of the PCOS patients and forty-six of the controls were examined. Age, axial length, intraocular pressure, and spherical equivalent did not significantly differ between the patient and control groups (p = 0.354, 0.715, 0.532, and 0.672, respectively) (Table 1).\u003c/p\u003e\n\u003cp\u003eAt all five stages of measurement, it was discovered that the choroidal thickness was greater in the PCOS group than in the control group. The subfoveal, temporal (1000\u0026micro;m), and nasal (1000 \u0026micro;m) quadrant measures indicate significant changes (p=0.047, 0.026, and 0.011, respectively). On the other hand, temporal (2000\u0026micro;m) and nasal (2000 \u0026micro;m) quadrant values were not statistically significant (p=0.158 and 0.322, respectively). TCA, LA, total choroidal area at the macula\u0026apos;s center (TCA\u003csub\u003e1500\u003c/sub\u003e) and luminal area at the macula\u0026apos;s center (LA\u003csub\u003e1500\u003c/sub\u003e) were found to be significantly thicker in PCOS patients in the total choroidal measurements (p = 0.041, 0.036, 0.031, and 0.029, respectively). There were discernible differences between CVI and CVI\u003csub\u003e1500\u003c/sub\u003e (p=0.046 and 0.039, respectively). There was no statistically significant difference between the two groups regarding SA and stromal area at the macula\u0026apos;s center (SA1500), \u0026nbsp;(p=0.159 and 0.140, \u0026nbsp;respectively). Similarly, macular thickness and retinal nerve fiber layer parameters were not statistically significant (p=0.181 and 0.981 repectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. The Demographic and Clinical Characteristics of PCOS Patients and Healthy Individuals.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCOS Eyes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group Eyes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eAge (years) (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e22.59\u0026plusmn;1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e22.56\u0026plusmn;1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eAxial Length (mm) (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e22.4\u0026plusmn;0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e22.8\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eIntraocular Pressure (mmHg) (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e15.1\u0026plusmn;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e14.8\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.532\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eSpherical Equivalent (D) (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-0.19\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e-0.16\u0026plusmn;0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0.672\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 2 Comparison of Choroidal Parameters and Macular Thickness Between Eyes with PCOS and Control Group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003ePCOS Eyes\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eControl Group Eyes\u003c/p\u003e\n \u003cp\u003e(Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eTCA (mm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.68 \u0026plusmn; 1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.61 \u0026plusmn; 0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.041**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eLA (mm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.49 \u0026plusmn; 0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.41 \u0026plusmn; 0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.036**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eSA (mm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.23 \u0026plusmn; 0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.22 \u0026plusmn;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eCVI (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.65 \u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.63 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.046**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eTCA1500 (mm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.18 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.15 \u0026plusmn; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.031**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eLA1500 (mm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.11 \u0026plusmn; 0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.10 \u0026plusmn; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.029**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eSA1500 (mm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.07 \u0026plusmn; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.06 \u0026plusmn; 0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eCVI1500 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.66 \u0026plusmn; 0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.64 \u0026plusmn;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.039**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eSub-foveal Choroidal Thickness (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e353.8 \u0026plusmn; 88.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e325 \u0026plusmn; 74.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.047**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eChoroidal Thickness at 1000 \u0026micro;m Nasal to The Fovea (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e351.3 \u0026plusmn; 77.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e321.3 \u0026plusmn; 88.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.026**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eChoroidal Thickness at 2000 \u0026micro;m Nasal to The Fovea (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e324.6 \u0026plusmn; 62.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e318.8 \u0026plusmn; 77.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eChoroidal Thickness at 1000 \u0026micro;m Temporal to The Fovea (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e358.1 \u0026plusmn; 50.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e333.0 \u0026plusmn; 68.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.011**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eChoroidal Thickness at 2000 \u0026micro;m Temporal to The Fovea (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e316.4 \u0026plusmn; 45.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e305.5 \u0026plusmn; 79.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eRetinal Nerve Fiber Layer (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e149.6 \u0026plusmn; 115.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e149.6 \u0026plusmn; 111.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eMacular Thickness (\u0026micro;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e224.6 \u0026plusmn; 40.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e236.3 \u0026plusmn;35.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;TCA (Total Choroidal Area), LA (Luminal Area), SA (Stromal Area), TCA\u003csub\u003e1500\u003c/sub\u003e (Total Choroidal Area at the Center of the Macula 1500\u0026micro;m), LA\u003csub\u003e1500\u003c/sub\u003e (Luminal Area at the Center of the Macula 1500 \u0026micro;m), SA\u003csub\u003e1500\u003c/sub\u003e (Stromal Area at the Center of the Macula 1500 \u0026micro;m), and CVI\u003csub\u003e1500\u003c/sub\u003e (Choroidal Vascularity Index at the Center of the Macula 1500\u0026micro;m).\u003c/p\u003e\n\u003cp\u003e*,**,*** notations represent statistical significance at the 10%, 5% and 1% significance level, respectively.\u003c/p\u003e\n\u003cp\u003eAfter looking at the statistical differences between the PCOS patients and control group, we applied multiple linear regression analysis to see the effect of hormones such as estradiol, prolactin, testosterone, and insulin on the subfoveal choroidal thickness for both groups. The econometric model used in the analysis is given in equation (1). Table 3 shows the results of the regression analysis.\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAA0wAAABDCAYAAACvI4X/AAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAAAJcEhZcwAAFiUAABYlAUlSJPAAABb1SURBVHhe7d3PbyNn/Qfwt7932k6yp6oHlMmBiqKtYAIVpEitRCfqqZVaHEDiVLXY6gXa7oLZFYcKqU4FSFVpHE6oahuHthIHEuIgLVKzRbB4UawWlcOOxQE4eWIKf8DDof7M95nHzzM/7NhJ2vdLmkNmPOPJPD8/M/M8riilFIiIiIiIiGjM/5kriIiIiIiI6CMMmIiIiIiIiBwYMBERERERETkwYCIiIiIiInJgwEREREREROTAgImIiIiIiMiBARMREREREZEDAyYiIiIiIiIHBkxEREREREQODJiIiIiIiIgcGDARERERERE5MGAiIiIiIiJyYMBERERERETkwICJiIiIiIjIgQETERERERGRAwMmIiIiIiIiBwZMREREREREDgyYiIiIiIiIHBgwEREREREROTBgIiIiIiIicmDARERERERE5MCAiYiIiIiIyIEBExERERERkQMDpnNqY2MDy8vLqFQqqFQqqNfriOPY/NiZc17Pm4A4jlGv17GwsIBKpYKFhQVsbGyYH6OCWBbOhr29PaysrCTpsLa2hl6vZ36MZoBlgOjs2tvbQ7vdNldn2trawvXr183VHw/qFA0GA1Wr1ZTv+wqAAqB831fValVFUZT6rGzPWsx9xPb2tgrDMPXZMAxVq9VSSilVq9XGjuVaBoOBefi5q9VqyvM8dXh4qJRS6ujoSHmep8IwND96ppzkeZvpksVMe/l+pZRqNpupbdVqNbWvud221Gq11D5KKbW7uzv2vXqeE+bxm81msu3w8DC1zfO81L7zNBgMVBAEKgiCpJxtb2+PnXNR5rWxLY1Gw9xNHR0dqWq1qjzPSz4XBEGSBnJORZbd3V3z8HNzkmXBzEOyeJ6nqtWqOjo6MneZaB+dWaf6vp+ZD8zvOSskv0i5lHzueV7hul5vv7KWIAhS+7nSIGsfVaAMRFE0dhzXYitj8zLLMmDmRX27rR5tNBqp/W2azaYKgiB1nDAMU+0J0cdFo9FQ29vb5mqlRn2TMAzHyplotVrOfc8ze80wB1EUKc/zVBAESYUzGAySRthsrI6OjhRGDbMpDENrJTgYDFS1Wk0qUDmmVJ6S2L7vpzqCrVZLwWhEfd+3fve8ybmbnT25bmfVSZ+35AcAuZ07ST89TXXSWIZhOJbvlFJJHjIrAAlozGPK8fQ8t7u7q+DooMjxzWBNaft5nue8ITAPUsbMc5DrVpaeJuYx5bqa11uuhX5DRa9HlKMTZl5bud7m987LSZcF5cijEgy4Ov+2fXZ3d5Xnec599ICi1Woln5E605a/VcnyOi+Sz8xzlvQp0hGW4KRWqyXXQq6r/J/yv9turNjSQI2us+d5Y/sUKQNmEKiUStJUSHqZ3zsvsywDtnpUadtt36uUSoIhW/6UPK9fL6nnbcciOs9ardZYvahG9VKr1UrKiitgUqPydlr1y6xMVjOdAHmqY3Zadnd3rYFJVqPTbDatlaSrMVKjjt7h4WHS2OidAzk3veKs1WrW75g3vWHUTdPQ5MkrGEWc9HlLfijaWTc7DLq8hi+rg23mE70DZQqCwJoXzQ6WLivQKkI6hUU6fy5yrW3nUCYNTJ7nWcu6Gh3XvN6umxaNRiO53r7vp/5XW+dxe3vbmRfynMWyoDLyqNRltvR35TvpzJo3ApTWqbQdT7bZAq2y5TXPSaSD/P/m+ZYJmLZHT9p0vu+P5S/f963X05VuapQfzPqiSBmo1WqpayN1kt5+yToz7Ys4iWs/yzLgSrdqtZp8xlY/h2FobeOlDjHTYjAYONMuy0nUyUSzInV1Vr6WPJxVD0xTx5xVpzaGSd6LXFpaSq1/+OGHcevWrdQ6APjggw8AAF/96lfNTbh06dLYe5btdhs7Ozuo1WpYX19PbcNHNTJWV1extLSE4+NjLC4uJtsODg4AABcvXkzWffrTn8bnP//55O/TsLe3h+FwiCeeeCK1Po5j3LhxA0EQpNafFbM473/+858AgAcffNDcNKbf72M4HOKhhx4yNwFaen/pS18yNwEAut0ufN8fy6sY5SM9n/zud78DRvnF9Oc//9maF7vdLjzPSx1HvPvuuwCAr3zlK+amufnVr34FAPj617+eWi/vKX/hC19IrS8ijuPMNFFKpa53r9dDFEVYXl5OfQ4AfvzjH+OVV14BANy6dQurq6vJtnfeeQcA8NnPfjZZd9ddd+GLX/xi8vc8zaIsQMtDZh615UORle8A4MMPP0z9vbGxgW63i0ajkbrGQupQqat1ZcrrPMRxjJ2dHVSr1VTdDwDXrl0DANx9992p9Tbr6+vY399P/u73+4iiaCx/LS8vp/KgiKLIWbfs7++n6ouiZeCVV17BpUuXkm03btwAgFT7Jd/nSvtZmmUZAGDNmxhtf/rpp+H7/lh/AaO644EHHjBX49e//jUwqjd0i4uLY/UU0Xl3+fJlVKvVqfP10tISwjDE5cuXzU3n1qkFTAsLC8CoESjivffeA4CxhsjlypUrAIBnn33W3JRJGrwwDFPrL126lGqEToN0nu+7777U+qtXr2I4HOJnP/tZav1ZMYvzlmN++ctfNjeN+dvf/gYA1sYwjmN0u10EQTDWcZLtURQ5O/am22+/HQDwl7/8xdxklXf8vGBuHg4ODsY61nEc47vf/S48z8P3vve91OeL+NOf/gSU6LB96lOfAkadmjKDwuX66Z2o1dXVVCd3nmZRFrLykHT+5foJ2cdWn0qgdM8996TWv/DCCwAwUXqXKa/zIPnPrBPa7TY6nQ6azaa1PsgjwYkZGO7v74915PW6p4hJy4DcNDCv/UcPi+ZvlmXAbLeFtOt33303qtUqhsMh9vb2xrab5wStr/LXv/7V3HRqer0e1tfXk8kyZLIS/X8iKqvX66HT6ZzYw4EHH3wQnU4H/X7f3HQunVrA9OSTTwKjBqvIjBoHBwepO3H9fh8rKyvY2toyP4q9vT1EUTRRlCyda7PBK2ptbS1ViRVZirp582aq4yqVZrvdxu7u7liDfFbM4rxv3rwJFLwL7GqgoXWcbJ1NaNv1J5tbW1tJI2r62te+Bs/zsLOzU2jGJ1fHDQWCuXnpdrup67O3t4e1tTUAwO9///uJzu39998HjDSp1+vJcU1ytyqKIqytrRWqgPM6UadhFmXBlYek8QuCYCwwlX3Mei6OY2xubsL3fTz88MPJ+na7jeFwiFqtNlF6lymv82Dmv36/j42NDXzjG99As9mc+OaY3NgzgxMbeRKnp1u73Xa2CZOUAYyebCPjycu8zbIMmPlZ3LhxA77vY3FxMXlS/pvf/Ca1HY4bON/85jcBAN/5znes/Y156/f7uPfee/Hvf/8bURRBKYXDw0N0Oh3cdttt5seJCut0OkDB+qsIuekmb96ce+Y7evMk79fDMT5CyLvCtsX2fqQc13znuAgZz3IW3y+GNgZA/kd9sPGsIOdd1TyzOG84ZpCykbEVWYsrr5izJ8lie9ddHI1me8JokhJbHhWu4+uL7X37oqZ9X958Vzlr8owyZKyCuWTlM5lwAKOJDFxpJmT8V9Yxy5r2eJhBWZA8JPlsMBgk47Q8z7PmP7OeGwwGand3VwVBYM2zcq6ucX5Kyxu2/wUlymsR06aDPlZGxqgE2sQ/k5L8WYSMlTIXc0yUrmwZkLYz65hlTXvt9fM56TLgqucajUaqzjbHmTUajcxrJHlEzn2ac522TpYJOybdn8hF6sW8vGX2C1zkc1ll6zwpVrPPkMzKJJWmjXR89E5as9kcG1grXLNvFZE1cPk02TKoXDvXdTsp5veWMYvzlmNmBdkir8MgFYQrrwSj2ZHEYDR7VV7AMNBmaHR1WlVOB0s6VHmdoizTNs5yDnrH+iRm2DLTRAaIFjlPvaOZdQ55k3lMwszLZcyiLCjHDQHf91Wj0XDWY7Z9JF/b9smrUyX9bBMSlCmvRZnXsSwY+e/o6EgFo2nzbf9/EVLXFA0M9aBN+DnTs4uiZWDaSWNsprn2sy4DLkEQpOpss24IgiD3f5I8Imk8aT6Ztk6ORhNVTRtkEpmkTsrLV7ZybCPtgqv/dd64a5g50u/I2zqWtrtHh4eHzrv80pBMQirDs8bsuArXDD6T0Bvhoot5PqZZnHeZQCLvKQMcnTyVEWyFYWjNpzZyB9WWV13HF3nBnEk+X2bJY+vUqYxZLotwdaBt3+Mi+cd100SVqPxtzktZKNtJV9o+er43O5Am+R9dsqYVL1NeTbNIB1djL437pB13V752gSXdwhK/61OkDMj1c6Vrlllc+2nLgC1t8sqAbNfrbJkJTI5nOyebgfaEL++mmZpRnay0mT5lHzMvE02iaB501aE2yOjjnDf5V2ZOpCK1VUJ5d49MkyZQ2QbPZlYVpGsKXFfGbTQaSYUahuFEHVthO35RZc87iiJVq9WsDaPImorXZAu2hZyD67vygq2i4OjU5B0fGcFcUfI/2v7/IjzH9L+2js+28WOm1Wp1LN2V1rmepBOnk+9yBa/I6ERNKiu98pQpC61WK3UtgyCw/p+TPEGQffR8n9fpRE6dKk+gbOdYprwWZV6vMrLyn+v/lH2ylAlOpMNeJt1s8srANDcNXKa59mXKgFxPfbGlTV4ZkO0meS1Pvts8Jxf5vO0mWBHT1MkSsPm+XyifEZUh9UVeXW0rry6ucnsendqkDy4yy5iu2+3OZeD2H/7wBwDA5z73OXNTYfv7+xgFooWXImTSC3PA9T/+8Y/U3xhN/7uzs4Nut4vBYIA4jlGtVs2PzUXR847jGBsbG6jX69jc3MycDtmcAET0+/2xyRiyBpvLrEe2qeqhDQw/iQGQ5nlBO745Gxm02SNdk1HMQ6/Xw3A4xMrKirkJf//731N/X79+HfV6HVeuXIEaDULe2dnB1atXU5/DaKIIAPjMZz5jbkK9XsfGxoa5OpM5Axy0Kc9t535aipYFjAaYP/roo1BKIYoiDIdD6/SskofKTDsv++j5fnFxEUEQoNvt5k5UYmq328kkO7ZB82XK6zy48p9rEoVer4cf/OAH5uoxMiOheVybP/7xj4CjrWm3287JT1xsZQCjQdy2PHdaypQBAGg2m6m20ja7ZV4ZePfdd639B5kt7+WXX55oYp3TyLtXr15Ft9vFwcFBalIWopP0r3/9y1w1kSITup0ncw+YlpeXrVNfSgfMnOZWPlvmt158309m+9DFcYyVlRXrbzCg5O9vzFPW7wj98pe/BIBUg/DCCy/gySefxNLSEhYXF/HMM8+g2+0WnsL9pJQ57w8//BD33HMP9vf3rY2bkE68bSreRqOR+q44jpNZwmyNoXSczN/XEG+++SZQMD+0221r51w6YbZrIMe3TRkuHaqswHHWXL99Fscx2u02PM9LZrRaXV3F8fFx6u8gCHB8fJzaFzkd6M3NzVSA2u/3UalUrJ34W7duWY8D7eaHrQN/GsqUBXx0OxxPPfUUMJodbXl5GXfccUeyXWTlIRfZx6xrJf/afkdJ6lQzHXq9Hur1OjzPw89//vPUNtletLzOi+t31d566y0AwKOPPppa/8QTT+D73/9+ap1Np9Ox/haWjdQ9Zhpg9JMY+mxvk5YB6azYrv1pKFsGisorAwcHB9bZ82S2vJ2dHWvdXa/X8cMf/tBcnQR3Zr04D9Ke2NKbaFq2cnISZnXceZtrwNQf/dbBj370o6Tgy5OFzc1NbG9vj1UEr776KjD6gb+innvuOWBU4Ukj0+v1sLa2hm63a22kZAres0imPG2320kj2O/3Ua/X0el00Gg0ko6hNEr6UwsJCP773/8m6+ahzHkvLS0VumMmgYQ5hfLW1hZ2dnbwyCOPJOukAzQcDsc6G71eDzs7OwCA//znP6ltsl1+CNF191P3zjvvoNvtpqadvX79OqrVKoIgwPPPP5/6fNbx4zjGiy++CFh+PHSe5PdbfvKTnyTlVcrRcDjEa6+9Zuzx//r9PrrdLr797W+n1rs60P1+P3kKqk8rLHno6tWrSRr2+32sr6/j+PgYb7/9dvJZEccxfvGLX5irT1WZsqDrj6a7BjD2lCMrD7no+5ikA/jGG2+Ym/DSSy8BRjq022088MADWFhYcE4vX6a8zoO0QVEUJWU1jmNsbW3h8uXLCIIgCVQxelr/0EMP5T5llmMtLCyM1TU28ttmensXxzHq9TqiKEp93yRlAABefvllc9WpmrQMZMkrA7LdfCKO0c0U3/cBR/BzcHCAzc3N1F3ydruNer2OWq1m/RHyWZMbx2Y7U6/Xz8SU53S+PfbYY4B2w9FF3s7J+71JOY4c99wz39GbpSiKVLVaTcYkyVKtVq3v88rAcllc7yjbtFqt5L16WcIwtI5XkffJ9cX1TvhpkHE4rVYrde2CIBgbJGt7P9q2rgwUfFfVVOa8dWEYWr9PZlMy00pf5N1bGUQsi/kOrbmfTgZ/60ve++0y5kQ/P5nxytzXdnydOQ5u0nRTU6a9vCvfbDZTZclVXoW8Z2+msT7LlGsxx9AcHh6qMAxT3y8zRLneszbziG1c5KQwx7Ig+cA2I5YtD5n5zJS3j77dVk/ujqYd18/dlr9FmfJaFiZMB328i4yngaOsHh4eJvlRypGNjG+SxTZeUQy02TOzFvM8ypYB8zsmHW9jgwmvfdkyYNY7QRCkxu3Y8rPO3G47Zzkn23Ws1WpjdbHrXMuYpk4eDAap8cme56lqtTr1ORGJMAzH+ks6s8xl5eVqtZp5rPPG3gLQmSId1yIk+NMr0GkqaDVFA1nmvHWugInKmzTtZRIAW8c5iytY+riYd1lQxpTX9JFJ0yGrg6wbDAbK136PSg+YPunpMOm1L1sGBoNBkk4SaHqel5t2Z92kdTLRPEgfctpyJn2Is/TwYVpzfSWPJtPtdq3vfdvIKw3yi/PQXjm78847k3VlKKUm+uX7MudNs7G6ugqlVOo1tyJc45eyxHGMtbU1PPPMM6fyuso8zKss6K8BXbx4EY8//rjzVbpPoknT4ebNm84xP7q33noLURTh3nvvRaVSwf333w8AqFQqn/h0mPTaly0Di4uLSTotLi7i6aefxnA4PLEB6adl0jqZaB4uXryI7e1tNBoNc1MpP/3pT9FqtUq/ZnuWMWA646TjVCbT1Wo1bG5uot/vI45jvPTSSwjDMLeTcJImOW+M3mm/desWrl27VmgsAM2GvHtcZMIL8a1vfQuPP/54EixJAPVJN0lZuP/++5PJafr9Pt58882xcV9UnkwCk+epp55KZmZTo1kfAWAwGOCjhyxUxiRloFKppMaZvfHGG/A8r1SdRETlra+v45FHHnFOkJan3W7j9ttvT40H/ThgwHTGScf1vvvuMzc5Pf/881hfX4fv+7hw4QLuuOMOvP766+bHZmqS865UKvB9H1EUodPp4MKFC+xwn5Jr167B87zCHZx2u41Op4PLly+jUqmgUqngwoUL5sc+kSYpC81mE1euXEGlUkEQBFhZWbFOqUzFSafdnIAiTxzH+O1vfwsAzNMTmqQM1Go1vPjii0ldcnx87JxchIhO1vr6Ou66667SQdPe3h5uu+22iZ5Cn3UVxdtlREREREREVnzCRERERERE5MCAiYiIiIiIyIEBExERERERkQMDJiIiIiIiIgcGTERERERERA4MmIiIiIiIiBwYMBERERERETkwYCIiIiIiInJgwEREREREROTAgImIiIiIiMiBARMREREREZEDAyYiIiIiIiIHBkxEREREREQODJiIiIiIiIgcGDARERERERE5MGAiIiIiIiJyYMBERERERETkwICJiIiIiIjIgQETERERERGRAwMmIiIiIiIiBwZMREREREREDgyYiIiIiIiIHBgwEREREREROfwPuDpaXg6vv44AAAAASUVORK5CYII=\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eIn Equation (1) SFCT variable is the dependent variable and shows the Subfoveal Choroidal Thickness, LHFSH variable is ratio of luteinizing hormone to follicle-stimulating hormone, EST variable is estradiol, PROL variable is prolactin, TEST variable is testosterone, INS variable is insulin and \u0026epsilon; parameter represents the error term.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Multiple Linear Regression Analysis Results\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"634\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDependent Variable\u003cbr\u003e\u003c/strong\u003eSub-foveal Choroidal Thickness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 299px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficient (\u003c/strong\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficient (\u003c/strong\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eLHFSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.048\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp; 0.032\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eEST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;0.062\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.124\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003ePROL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.353\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eTEST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eINS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 191px;\"\u003e\n \u003cp\u003eConstant Term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;0.000\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;0.000\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*,**,*** notations represent statistical significance at the 10%, 5% and 1% significance level, respectively.\u003c/p\u003e\n\u003cp\u003eConsidering the regression analysis results, the EST variable is statistically significant and positive at 10% significance level, the LHFSH variable at 5% significance level, and the Constant term at 1% significance level for PCOS patients. Therefore, the LHFSH and EST variables increase the choroidal thickness. When the regression results of the control group are examined, it is seen that the LHFSH and constant term variables are statistically significant at the 5% and 1% significance level, respectively. As noted here, the EST variable was not statistically significant. This shows that while the EST variable significantly affects the SFCT variable in PCOS patients, it is not significant in the control group.\u003c/p\u003e"},{"header":"DISCUSSION ","content":"\u003cp\u003ePolycystic ovary syndrome (PCOS) is a commonly encountered endocrine disorder in women. This syndrome's impact is not limited to the reproductive system but can also influence various body systems. It is known that PCOS has numerous metabolic comorbidities, including obesity, hypertension, dyslipidemia, insulin resistance, atherosclerosis, cardiovascular disease, and diabetes mellitus[12].\u003c/p\u003e\n\u003cp\u003eParticularly due to the presence of sex steroid hormone receptors in various eye tissues, sex steroid hormones can have a significant effect on eye physiology and structure[13]. There was a meaningful relationship between the eye's axial length and the choroidal thickness. Therefore, a higher degree of myopia will lead to a decrease in choroidal thickness[14]. Corneal thickness has been shown to affect IOP readings, with thin corneas leading to falsely low IOP readings, and thick corneas resulting in falsely high IOP readings[15].\u003c/p\u003e\n\u003cp\u003eGiven this information, age, axial length, intraocular pressure, and spherical equivalent did not significantly differ between the patient and control groups (p = 0.354, 0.715, 0.532, and 0.672, respectively) (Table 1). At all five stages of measurement, it was observed that the choroidal thickness was greater in the PCOS group than in the control group. The subfoveal, temporal (1000µm), and nasal (1000µm) quadrant measures indicated significant changes (p=0.047, 0.026, and 0.011, respectively). However, the temporal (2000µm) and nasal (2000µm) quadrant values were not statistically significant (p=0.158 and 0.322, respectively). In a study by Açmaz et al., similar to our study, they found a significant difference in choroidal thickness in the PCOS group. They suggested that the increase in choroidal thickness in PCOS patients might be due to an increased vasodilation effect of estrogen[16]. Ciccone and colleagues examined the ophthalmic artery vasodilation after intranasal estrogen use in postmenopausal women. This study reached similar results to the findings of Atalay and colleagues[17]. The results are consistent with our study and support the hypothesis they presented. Regression analysis concluded that estrogen increased the subfoveal choroidal thickness (sfct). Although the P probability value was 0.062, it can be considered statistically significant at the 10% significance level, which is consistent with other studies. However, Sagowa et al. investigated the relationship between choroidal thickness and choroidal blood flow in healthy young individuals. They concluded that there was no significant relationship[18]. Açmaz et al. hypothesized that the increased choroidal thickness in PCOS patients might indicate an increased estrogen-related vasodilation effect in the ophthalmic artery due to unopposed estrogen or relatively high estrogen levels[15]. The OCTA (Optical Coherence Tomography Angiography) study conducted by Yener and colleagues revealed that the capillary density in the macula and optic disc area in PCOS patients did not differ significantly from healthy controls. However, the thickness in the parafoveal superior, inferior, and temporal quadrants was significantly increased compared to the control group[19]. It is essential to note that currently, there is no article that precisely examines the relationship between PCOS and CVI (choroidal vascular index). Nevertheless, some surprising findings regarding the choroidal thickness of PCOS patients, especially the blood vessel density in the macular region, have been identified in the available research.\u003c/p\u003e\n\u003cp\u003eIn PCOS patients, the total choroidal area (TCA), lumen area (LA), and the total choroidal area at the center of the macula (TCA1500) were found to be significantly thicker in total choroidal measurements (with respective p-values of 0.041, 0.036, 0.031, and 0.029). There were significant differences between CVI and CVI1500 (p-values of 0.046 and 0.039, respectively). The observed increase in choroidal thickness, as determined by the CVI evaluation, was localized in the luminal area, while no significant difference was observed in the stromal area (with p-values of 0.036 and 0.159, respectively). This points to a possible association with unbalanced estrogen levels, as previously mentioned, reinforcing the results presented by Açmaz et al[16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe retinal nerve fiber layer and macular thickness did not statistically differ in both groups with p-values of 0.981 and 0.181. In their study, Shiromani and colleagues similarly found that the retinal thicknesses in the two study groups were analogous, with no statistically significant difference. However, the Retinal Nerve Fiber Layer (RNFL) was significantly thicker than the control group (P = 0.0006). Yet, they found no significant difference in the Retinal Nerve Fiber Layer (RNFL) thickness in the disk and macula areas. This might be due to the younger age of our study, suggesting that they might have been diagnosed earlier, considering the average age of 26 in the patient group and 32 in the control group. Açmaz et al. examined the macula and retinal nerve fiber layer in women with PCOS. They found that the central fovea thickness and inner temporal macula (TIM) in the PCOS group were significantly thinner compared to the healthy control group. However, the age group of PCOS patients was considerably older, indicating the influence of age as a factor. When adjusted for age, it was found that the RNFL in the PCOS group was significantly thicker than in the healthy control group. This difference might be due to the similar age group and the younger patient group in our study.\u003c/p\u003e\n\u003cp\u003eA study by de Souza-Júnior JE and colleagues using HD-OCT was categorized based on metabolic syndrome, inflammation, obesity, glucose intolerance, and/or insulin resistance. The results demonstrated that in the presence of insulin resistance, the total macular thickness in PCOS patients was increased compared to the control group. We speculate that this change initially relates to hypertrophy of the Müller cells and subsequently to intra- and extracellular edema in these cells[20]. Our regression analyses showed that an increase in the LH/FSH ratio was highly related to estrogen at a 10% significance level. However, no difference was observed between prolactin, testosterone, insulin levels and sub foveal choroidal thickness. Current literature has reviewed the use of the LH/FSH ratio in diagnosing PCOS, focusing on whether an LH/FSH ratio of 2:1 or higher is a factor raising suspicion of PCOS. However, a high ratio does not always indicate the presence of PCOS[21,22]. Our study revealed increased sub foveal choroidal thickness with an increased LH/FSH ratio.\u003c/p\u003e\n\u003cp\u003eIn conclusion, the choroidal vascular index was examined for the first time in our study on patients diagnosed with Polycystic Ovary Syndrome (PCOS). The findings indicated significant changes in the choroidal vascular index and choroidal thickness compared to a control group. These observations suggest a potential link between the hormonal changes caused by PCOS and alterations in the eye. The exact mechanisms and implications of these changes remain unclear. More comprehensive studies are needed to elucidate these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Tokat Gaziosmanpaşa University Clinical Research Ethics Committee (Approval No: 20-KAEK-235). Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.G. designed the study, performed ophthalmologic examinations and OCT analyses, conducted the statistical analysis, and wrote the main manuscript text. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS.G. contributed to patient recruitment and provided support for the hormonal analysis and related sections during manuscript preparation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004;19(1):41-47.\u003c/li\u003e\n\u003cli\u003eRabiolo A, Gelormini F, Marchese A, et al. Choroidal vascularity index: an in-depth analysis of this novel optical coherence tomography parameter. J Clin Med. 2020;9(1):263.\u003c/li\u003e\n\u003cli\u003eCioffi G, Liebmann J. Vascular anatomy of the optic nerve head. Can J Ophthalmol. 1999;34(5):237-247.\u003c/li\u003e\n\u003cli\u003eFuchsjager-Mayrl G, Nepp J, Schneeberger C, et al. Identification of estrogen and progesterone receptor mRNA expression in the conjunctiva of premenopausal women. Invest Ophthalmol Vis Sci. 2002;43(9):2841-2844.\u003c/li\u003e\n\u003cli\u003eVecsei PV, Kircher K, Kaminski S, Nagel G, Breitenecker G, Kohlberger PD. Immunohistochemical detection of estrogen and progesterone receptor in human cornea. Maturitas. 2000;36(3): 169-172.\u003c/li\u003e\n\u003cli\u003eEsmaeli B, Harvey JT, Hewlett B. Immunohistochemical evidence for estrogen receptors in meibomian glands. Ophthalmology. 2000;107(1):180-184.\u003c/li\u003e\n\u003cli\u003eMadendag Y, Acmaz G, Atas M, et al. The effect of oral contraceptive pills on the macula, the retinal nerve fiber layer, and choroidal thickness. Med Sci Monit. 2017;23:5657-5661.\u003c/li\u003e\n\u003cli\u003eShaaban YM, Badran TAF. The effect of oral contraceptive pills on the macula, the retinal nerve fiber layer, the ganglion cell layer and the choroidal thickness. BMC Ophthalmol. 2019;19(1):250.\u003c/li\u003e\n\u003cli\u003eSrinivas S, Tan O, Wu S, et al. Measurement of retinal vascular caliber from optical coherence tomography phase images. Invest Ophthalmol Vis Sci. 2017;58(9):3496-3503.\u003c/li\u003e\n\u003cli\u003eBaldwin DS, Anderson IM, Nutt DJ, et al. Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology. J Psychopharmacol. 2014;28(5):403-439.\u003c/li\u003e\n\u003cli\u003eAgrawal R, Gupta P, Tan KA, Cheung CM, Wong TY, Cheng CY. Choroidal vascularity index as a measure of vascular status of the choroid: Measurements in healthy eyes from a population-based study. Sci Rep. 2016;6:21090. Published 2016 Feb 12. doi:10.1038/srep21090\u003c/li\u003e\n\u003cli\u003eWild RA, Carmina E, Diamanti-Kandarakis E, et al. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the androgen excess and polycystic ovary syndrome (AE-PCOS) society. J Clin Endocrinol Metab. 2010;95(5): 2038\u0026ndash;2049.\u003c/li\u003e\n\u003cli\u003eLang Y, Lang N, Ben-Ami M, Garzozi H. [The effects of hormone replacement therapy (HRT) on the human eye]. Harefuah. 2002 Mar;141(3):287-290, 330.\u003c/li\u003e\n\u003cli\u003eMuhiddin HS, Mayasari AR, Umar BT, Sirajuddin J, Patellongi I, Islam IC, Ichsan AM. Choroidal Thickness in Correlation with Axial Length and Myopia Degree. Vision (Basel). 2022 Mar 2;6(1):16.\u003c/li\u003e\n\u003cli\u003eFrancis BA, Hsieh A, Lai MY, et al. Effects of corneal thickness, corneal curvature, and intraocular pressure level on Goldmann applanation tonometry and dynamic contour tonometry. Ophthalmology. 2007;114:20\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eA\u0026ccedil;maz G, Albayrak E, Acmaz B, et al. Evaluation of the macula, retinal nerve fiber layer, and choroid in polycystic ovary syndrome: an optical coherence tomography study. J Obstet Gynaecol. 2013;33(6): 592\u0026ndash;596.\u003c/li\u003e\n\u003cli\u003eCiccone MM, Favale S, Scicchitano P, et al. Reversibility of the endothelial dysfunction after CPAP therapy in OSAS patients. Int J Cardiol. 2012;158(3).\u003c/li\u003e\n\u003cli\u003eSogawa K, Nagaoka T, Takahashi A, et al. Relationship between choroidal thickness and choroidal circulation in healthy young subjects. Am J Ophthalmol. 2012;153(6):1129-1132.\u003c/li\u003e\n\u003cli\u003eYener NP, Ozgen G, Tufekci A, Ozgen L, Aydin GA. Optical Coherence Tomography Angiography Findings in Polycystic Ovary Syndrome. J Coll Physicians Surg Pak. 2021 Sep;31(9):1057-1063.\u003c/li\u003e\n\u003cli\u003ede Souza-J\u0026uacute;nior JE, Garcia CA, Soares EM, Maranh\u0026atilde;o TM, Lemos TM, Azevedo GD. Polycystic ovary syndrome: aggressive or protective factor for the retina? Evaluation of macular thickness and retinal nerve fiber layers using high-definition optical coherence tomography. J Ophthalmol. 2015;2015:193078.\u003c/li\u003e\n\u003cli\u003eRotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eWelt CK, Carmina E. Lifecycle of polycystic ovary syndrome (PCOS): from in utero to menopause. J Clin Endocrinol Metab. 2008;97(12):1-17.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PCOS, Choroidal Vascular Index, Choroidal Thickness","lastPublishedDoi":"10.21203/rs.3.rs-6309404/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6309404/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAIM: To investigate the ocular effects of Polycystic Ovary Syndrome (PCOS) in reproductive-age women, specifically focusing on macular thickness, choroidal thickness, and the Choroidal Vascular Index (CVI).\u003c/p\u003e\n\u003cp\u003eMETHODS: A comparative study was conducted with forty-five diagnosed PCOS patients and forty-five sex-matched healthy volunteers. Optical Coherence Tomography (OCT) was used to measure choroidal and macular thicknesses. The innovative Choroidal Vascular Index (CVI) was utilized to identify potential vascular alterations in the choroid. Statistical analyses, including t-tests and regression models, were performed to interpret the data and discern differences between the two groups.\u003c/p\u003e\n\u003cp\u003eRESULTS: The data showed that the PCOS group had a significant increase in choroidal thickness at specific measurement points compared to the control group (p\u0026lt;0.05). Differences were also observed in the total choroidal area and luminal area in the PCOS group. CVI values presented significant variations between the two groups (p\u0026lt;0.05). However, there was no statistically significant difference observed in the retinal nerve fiber layer and macular thickness between the two groups.\u003c/p\u003e\n\u003cp\u003eCONCLUSION: PCOS appears to influence ocular health, especially in the choroidal region, which may be attributed to the vasodilation effects of estrogen. These findings underscore the importance of comprehensive ocular evaluations in PCOS patients. Healthcare professionals should consider these potential ocular manifestations while managing and advising patients with PCOS. Further research is needed to elucidate the broader implications of these findings.\u003c/p\u003e","manuscriptTitle":"Evaluation of Macular Thickness, Choroidal Thickness, and Choroidal Vascular Index in Patients with Polycystic Ovary Syndrome: An Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 11:14:30","doi":"10.21203/rs.3.rs-6309404/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0b326d0-24d7-4f28-a92a-15bcdb6929dd","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T04:23:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-09 11:14:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6309404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6309404","identity":"rs-6309404","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}