Evaluation of Ophthalmic Vascular and Neural Structures in Female Patients with Fibromyalgia Syndrome and Their Relationship with Disease Severity

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Additionally, the relationship between these findings and disease severity was explored. Methods The study included 62 female FMS patients and 60 healthy controls, conducted between January 2022 and October 2022 at the Antalya Training and Research Hospital. FMS patients were assessed based on American College of Rheumatology criteria. Tear production and stability were evaluated using Schirmer and Tear Break-Up Time (TBUT) tests, while OCTA and OCT were used to examine vascular and choroidal structures. Results The mean age of the FMS group was 43.11 ± 7.94 years. No significant difference was found in the Schirmer test, but the TBUT was significantly lower in the FMS group (p < 0.0001). OCTA showed significantly lower deep capillary plexus (DCP) values in the FMS group, with a weak negative correlation between DCP and disease severity (r=-0.227, p = 0.012). Foveal avascular zone (FAZ), non-flow, and choroidal thickness were significantly higher in FMS patients (p < 0.05). Conclusion The study demonstrated a relationship between dry eye, vascular changes, and increased choroidal thickness with disease severity in female patients with FMS. The reduction in DCP, along with increases in FAZ, non-flow, and choroidal thickness, may be linked to vascular and inflammatory processes involved in FMS pathogenesis. The decrease in tear quality may be due to autonomic nervous system dysfunction. In conclusion, we suggest that autonomic dysfunction and inflammation in FMS may negatively affect retinal vascular structures and tear function. Fibromyalgia Optical coherence tomograpy Choroidal thickness Vascular changes Dry eye Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1. Introduction Fibromyalgia syndrome (FMS) is a chronic condition characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive dysfunction. Its prevalence ranges from 0.2–6.6%, occurring 6–9 times more frequently in women than in men [ 1 , 2 ]. The pathophysiology of FMS involves central and peripheral sensitization, sympathetic dysfunction, neuroendocrine and autonomic system anomalies, and psychosocial factors [ 3 ]. Central nervous system involvement in FMS may also lead to visual pathologies [ 4 ]. Symptoms such as dry eye, photopsia, diplopia, and blurred vision are commonly reported [ 5 ]. Dry eye in FMS may result from decreased corneal sensitivity, leading to reduced tear secretion, and suppression of tear film layer osmolarity following ocular surface inflammation [ 6 , 7 ]. In one study, 20–35% of FMS patients reported dry eye symptoms [ 8 ]. Perfusion anomalies in the brain, vascular changes in the thalamus and caudate nucleus, optic nerve involvement, and neuroretinal changes have been reported in FMS. Axonal loss in the retinal nerve fiber layer (RNFL) has been observed in various neurodegenerative diseases such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease [ 4 ]. Garcia-Martin et al. observed significant thinning of the RNFL in FMS patients, suggesting the presence of neurodegenerative processes in this condition [ 9 ]. The choroid, with its rich vascular structure, contributes to the circulation of the outer retina, optic nerve, and the avascular fovea. Autonomic system changes can affect choroidal structure and perfusion. Ulusoy et al. demonstrated reduced choroidal thickness in FMS patients, which was associated with disease activity, suggesting that these choroidal changes might be related to alterations in autonomic nervous system function [ 10 ]. The imbalance between the sympathetic and parasympathetic nervous systems in FMS, along with changes in neurotransmitter and catecholamine concentrations, may affect ocular vascular perfusion [ 11 ]. Optical coherence tomography angiography (OCTA) plays a crucial role in evaluating neuroretinal, retinal, and choroidal vascular structures. In this study, based on potential vascular and inflammatory changes in FMS pathogenesis, we aimed to compare macular and choroidal thickness and vascular structures in female FMS patients, assessed by OCTA and optical coherence tomography (OCT), with healthy controls, and to explore the relationship between these findings and disease severity. 2. Methods Patient Selection This study was designed as a single-center, prospective, cross-sectional study conducted in the Department of Physical Medicine and Rehabilitation at the University of Health Sciences (UHS) Antalya Training and Research Hospital. Before starting the study, ethical approval was obtained from the Clinical Research Ethics Committee of Antalya Training and Research Hospital (approval number 2/15, dated 20.01.2022). The study was conducted in accordance with the principles of the 2013 Declaration of Helsinki. Informed consent forms were signed by the patients. Between January 2022 and October 2022, 62 newly diagnosed female patients with FMS aged 18–65 years who visited the Physical Medicine and Rehabilitation outpatient clinic of UHS Antalya Training and Research Hospital were included in the patient group, along with 60 healthy female individuals of the same age group without any additional systemic diseases, who were selected as the control group. The diagnosis of FMS was made according to the 2016 revised criteria of the American College of Rheumatology (ACR). Widespread pain was defined as pain in at least 4 out of 5 body regions: the right and left sides of the body (jaw, shoulder, upper arm, forearm, hip, upper leg, lower leg) and the axial region (neck, back, lower back, chest, and abdomen), with pain lasting continuously for the past seven days. The widespread pain score (WPI) was calculated between 0 and 19. The symptom severity scale (SSS) assessed fatigue, unrefreshed sleep, and cognitive symptoms over the past week, with a score from 0 to 3 (0 = no problem, 1 = mild, 2 = moderate, 3 = severe). The presence of headaches, lower abdominal pain/cramps, and depression in the past six months was also evaluated (0 = no, 1 = yes). The total score was calculated. A WPI score of ≥ 7 and an SSS score of ≥ 5, or a WPI score of 4–6 and an SSS score of ≥ 9, met the FMS diagnostic criteria. The fibromyalgia severity scale was calculated by summing the WPI and SSS scores. Exclusion criteria included patients who had previously received or were receiving treatment for FMS; those with systemic, neurodegenerative, or rheumatologic diseases (rheumatoid arthritis, vasculitis, diabetes mellitus, hypertension, etc.); patients with spherical refractive errors outside the range of -3 to + 3 diopters or astigmatic refractive errors greater than 3 diopters; patients with retinal vascular pathologies such as diabetic retinopathy or retinal vein occlusion; patients with macular diseases such as senile macular degeneration or macular dystrophy; those with a history of uveitis, glaucoma, or optic nerve disease, or who had undergone ocular surgery or trauma; and participants with poor image quality due to movement artifacts or other factors, resulting in a signal quality score of less than 6/10. All participants underwent refraction assessment with an autorefractometer (Nidek AR600A, Nidek Co., Japan), intraocular pressure measurement with a pneumatic tonometer (Nidek NT-2000 NCT, Nidek Co. Ltd., Hiroishi Gamagori, Aichi, Japan), and visual acuity evaluation. Anterior segment and fundus structures were assessed by biomicroscopic examination. OCTA Evaluation OCTA is a non-invasive, rapid imaging method that provides a cross-sectional in vivo image of the dynamic microvascular system of the choroid and retina. In the OCT and OCTA imaging of the patients, the "Spectral-domain OCTA" (AngioVue; Optovue, Inc, Fremont, CA) device was used. OCTA measurements of the patient were performed at 6×6 mm HD angio retina and 4.5×4.5 mm angio disk scans. Images with poor quality due to motion artefact and other artefacts were not included in the study. Images with a signal quality greater than 8/10 were assessed. Foveal vascular density (FVD) was recorded as % of the vascular density in 1 mm diameter circle centered on fovea, parafoveal vascular density (PAFVD) was recorded as % of the vascular density in the circle from 1 to 3 mm, perifoveal vascular density (PEFVD) was recorded as % of the vascular density in the ring from 3 to 6 mm, and the total vascular density (TVD) was recorded as % of vascular density in 6 mm diameter circle centered on fovea. These areas provided the cross-sectional density measurement of the superfcial capillary area in automated mode (Fig. 1 .) (Fig. 2 .). The ratio of the vascular image in these areas (white areas) to the whole area provides the percentage of density. Foveal avascular zone (FAZ) was automatically calculated by the device; outer retinal flow (ORF) and choriocapillaris flow (CCF) automatically determined by the device were recorded as fow in mm² in the area with a central radius of 1 mm and area of 3.142 mm². Retinal nerve fiber thickness (RNFL) was measured and recorded automatically by the device on 3.4 mm diameter scanning circle centered on the optic disc (Fig. 3 .). Retinal thickness: The retinal thickness between ILM and RPE in foveal, parafoveal and perifoveal zones was automatically measured and recorded by the device (Fig. 4 .). Choroidal thickness: 2 diferent observers measured the subfoveal zone at “Enhanced HD line” cross-section. The average of values measured by the 2 observers was calculated (Fig. 5 .). The RPE and sclerachoroidal junction was the border of subfoveal choroidal thickness. Evaluation of Schirmer and Tear Break-Up Time Tests The Schirmer test is a method used to measure tear quantity and aqueous production. A 5 mm wide and 35 mm long Whatman filter paper was used without local anesthesia. It was placed at the junction of the middle one-third and outer one-third of the lower eyelid. After five minutes, the amount of wetting on the filter paper was measured. When evaluated for dry eye, values between 0–5 mm were considered low, between 5–10 mm were suspicious, and values above 10 mm were considered normal. A wetting measurement below 5 mm was regarded as significant for aqueous tear deficiency. The Tear Break-Up Time (TBUT) test is a method used to evaluate tear stability. The patients' tears were stained using fluorescein-impregnated strips without topical anesthesia. The patient was instructed to blink once to allow the dye to spread across the ocular surface. The evaluation was performed using a wide light with a cobalt blue filter on a biomicroscope. The time between blinking and the first break in the dye on the ocular surface was measured. The test was repeated three times, and the average was taken; a time of less than 10 seconds was considered significant for dry eye. All these procedures were performed by the same ophthalmologist. Measurements were made for both eyes; however, only the data obtained from the right eye were used for statistical analysis. Statistical Analysis Descriptive statistics were presented using frequency, percentage, mean, standard deviation, median, 25th percentile, 75th percentile, minimum, and maximum values. In the analysis of categorical data, if the percentage of cells with expected values less than 5 was greater than 20%, Fisher's Exact Test was used; otherwise, Pearson Chi-Square Test was employed. The normality assumption was checked using the Kolmogorov-Smirnov Test. For the analysis of the difference between numerical data of the two groups, if the data followed a normal distribution, the Independent Samples t-test was used; if not, the Mann-Whitney U Test was applied. Relationships between numerical data were evaluated using the non-parametric Spearman Correlation Test and the parametric Pearson Correlation Test. Analyses were performed using SPSS version 23.0, and a p-value of less than 0.05 was considered statistically significant. 3. Result A total of 62 women with fibromyalgia syndrome (FMS) had a mean age of 43.11 ± 7.94 years (range: 19-59), while the healthy control group consisted of 60 women with a mean age of 40 ± 12.26 years (range: 18-64). The mean duration of the disease in the FMS group was 5.08 ± 3.97 years (range: 1-17). There was no statistically significant difference between the groups in terms of age and body mass index (BMI). The widespread pain index, symptom severity scale, and fibromyalgia severity scale were significantly higher in the FMS group (p < 0.0001). While there was no statistically significant difference between the groups in the Schirmer test, the TBUT test was significantly lower in the FMS group (p < 0.0001) (Table 1). Table 1. Demographic and clinical characteristics of FMS patients and controls Parameters Group (n) Mean±SD (Min.-Max) Median (Q1-Q3) p Mean age, (years) FMS (n=62) 43,11±7,94(19-59) 43(39-49) 0,182 2 Control (n=60) 40±12,26(18-64 40(28,5-49,5 BMI (kg/m²) FMS (n=62) 26,01+4,26(16,42-35,25) 25,62 (23,53-28,91) 0,151 1 Control (n=60) 24,95±4,49(16,42-35,25) 24,53(21,64-27,99) Disease duration (years) FMS (n=62) 5,08±3,97 (1-17) 4 (1-7) - Control (n=60) - - Widespread pain index (WPI) FMS (n=62) 13,5±3,01(8-19) 14(11-15) <0,0001 2 Control (n=60) 0,58±1,08(0-4) 0(0-1) Symptom Severity Scale (SSS) FMS (n=62) 9,39±1,96(5-12) 10(8-11) <0,0001 2 Control (n=60) 0,53±1,08(0-4) 0(0-0,5) The fibromyalgia severity scale (FSS) FMS (n=62) 22,92±4,15(15-31) 23,5(20-25) <0,0001 2 Control (n=60) 1,12±2,03(0-6) 0(0-2) Schirmer test (mm) FMS (n=62) 17,19±9,65(3-35) 16,5(8-24) 0,437 2 Control (n=60) 18,33±8,72(3-36) 17(12-24) TBUT test (sn) FMS (n=62) 7,76±4,28(3-19) 6(5-12) <0,0001 2 Control (n=60) 10,47±3,87(4-18) 11(8-13) 1: Independent t test, 2: Mann Whitney U test were used. SD: Standard deviation, Q1: 25th percentile, Q3: 75th percentile Table 2 shows the comparison between vascular densities in the superficial capillary plexus (SCP) and deep capillary plexus (DCP), as well as the foveal avascular zone (FAZ), choriocapillaris flow (CCF), outer retinal flow (ORF), and non-flow values of FMS patients and controls. In patients evaluated with OCTA, there were no statistically significant differences between the groups in the SCP TVD, SCP FVD, SCP PAFVD and SCP PEFVD parameters (p > 0.05). However, the DCP TVD, DCP FVD, DCP PAFVD and DCP PEFVD parameters were significantly lower in the FMS group (p 0.05), the FAZ and non-flow parameters were found to be significantly higher in the FMS group (p < 0.05) (Table 2.). Table 2. Comparison of OCTA findings between fibromyalgia patients and healthy controls Retinal vasculer density(%) Group (n) Mean±SD (Min.-Max) Median (Q1-Q3) p SCP total vascular density FMS (n=62) 51,15±2,93(44,5-59,7) 51,45(49,3-53,6) 0,653 1 Control (n=60) 50,91±3,04(44,1-57,1) 51,3(48,75-52,8) SCP foveal vascular density FMS (n=62) 17,68±6,79(5,08-34,8) 16,15(13,04-22,5) 0,059 2 Control (n=60) 19,99±7,75(5,8-56,5) 18,8(15,55-24) SCP parafoveal vascular density FMS (n=62) 52,9±5,16(23,9-61,1) 53,45(51,1-56,1) 0,868 2 Control (n=60) 53,06±3,59(44,5-59) 53,7(50,7-55,8) SCP perifoveal vascular density FMS (n=62) 51,14±4,74(22,3-60,9) 51,4(50-53,7) 0,705 2 Control (n=60) 51,36±2,96(46,2-57,6) 51,35(49,15-53,7) DCP total vascular density FMS (n=62) 51,09±5,14(39-61) 51,3(47,2-54,9) 0,002 2 Control (n=60) 53,87±5,23(39,1-62,5) 54,8(51,15-56,95) DCP foveal vascular density FMS (n=62) 34,2±7,42(17,09-49,9) 33,9(28,4-39,6) 0,019 1 Control (n=60) 37,28±6,92(20,7-51,3) 37,2(32,9-42,7) DCP parafoveal vascular density FMS (n=62) 55,52±3,91(44,5-61,6) 56(53,6-58,7) 0,011 2 Control (n=60) 57,09±3,94(41-62,6) 57,65(55,35-59,8) DCP perifoveal vascular density FMS (n=62) 52,81±5,77(37,6-63,1) 52,7(48,9-57) 0,009 2 Control (n=60) 55,05±6,28(32,2-63,9) 56,6(52,75-58,75) Foveal avascular zone (FAZ) mm 2 FMS (n=62) 0,34±0,13(0,08-0,77) 0,34(0,25-0,41) 0,003 1 Control (n=60) 0,28±0,1(0,06-0,49) 0,30(0,2-0,35) Choriocapillaris flow (CCF) FMS (n=62) 2,066±0,112(1,781-2,291) 2,074(2,016-2,138) 0,784 2 Control (n=60) 2,071±0,135(1,582-2,29) 2,075(1,992-2,177) Outer retina flow (ORF) FMS (n=62) 0,6±0,341(0,12-1,571) 0,513(0,367-0,771) 0,786 2 Control (n=60) 0,614±0,332(0,178-1,774) 0,525(0,361-0,793) Nonflow FMS (n=62) 0,563±0,126(0,268-0,921) 0,596(0,474-0,65) 0,042 1 Control (n=60) 0,515±0,132(0,19-0,916) 0,513(0,426-0,583) 1: Independent t test, 2: Mann Whitney U test were used. SD: Standard deviation, Q1: 25th percentile, Q3: 75th percentile Table 3 presents the comparison of OCT findings between the FMS and control groups. There was no statistically significant difference between the groups in RNFL, TRFT, TRPAFT, and TRPEFT values (p>0.05); however, the choroidal thickness parameter was found to be significantly higher in the FMS group (p<0.05) (Table 3.). Table 3. Comparison of OCT findings between fibromyalgia patients and healthy controls Variables Group (n) Mean±SD (Min.-Max) Median (Q1-Q3) p Retinal nerve fber layer (RNFL) μm FMS (n=62) 117,92±11,67(85-145) 117(112-125) 0,162 1 Control (n=60) 114,97±11,51(93-139) 113(106-124) Total retinal foveal thickness μm (TRFT) FMS (n=62) 244,34±20,88(201-304) 243(231-257) 0,0521 Control (n=60) 251,42±18,93(218-298) 248(237-266) Total retinal parafoveal thickness μm (TRPAFT) FMS (n=62) 314,68±22,23(278-447) 313(303-322) 0,6652 Control (n=60) 314,18±12,76(289-340) 312(305-324) Total retinal perifoveal thickness μm (TRPEFT) FMS (n=62) 286,74±17,75(189-313) 289,5(280-297) 0,9842 Control (n=60) 287,78±10,73(262-309) 288(280,5-294,5) Choroidal thickness μm FMS (n=62) 321,55±62,12(180-569) 316(278-352) 0,004 2 Control (n=60) 287,08±46,1(180-379) 298(253-312) 1: Independent t test, 2: Mann Whitney U test were used. SD: Standard deviation, Q1: 25th percentile, Q3: 75th percentile In the correlation examined between FMS severity and OCTA values, there is a statistically significant, weak negative relationship between DCP TVD and DCP PAFVD (r=-0.227, p=0.012; r=-0.192, p=0.034) (Table 4). While there is a statistically significant, weak positive correlation between FMS severity and choroidal thickness (r=0.211, p=0.02), there is a weak negative correlation with the TBUT test (r=-0.250, p=0.005) (Table 5). No statistically significant relationship was found between FMS severity and other variables (p>0.05) (Table 4) (Table 5). Table 4. The correlation between OCTA values measured with FMS severity Variables r p SCP total vascular density 0,04 0,66 SCP foveal vascular density -0,108 0,237 SCP parafoveal vascular density 0,042 0,645 SCP perifoveal vascular density 0,044 0,633 DCP total vascular density -0,227* 0,012 DCP foveal vascular density -0,112 0,22 DCP parafoveal vascular density -0,192* 0,034 DCP perifoveal vascular density -0,173 0,057 Foveal avascular zone (FAZ) mm 2 0,175 0,054 Choriocapillaris flow (CCF) -0,063 0,487 Outer retina flow (ORF) 0,007 0,941 Nonflow 0,15 0,1 Spearman’s Rank Correlation Coefficient. ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed). Table 5. The correlation between OCT measurement thicknesses, Schirmer, and BUT values with FMS severity Variables r p Retinal nerve fber layer (RNFL) μm 0,146 0,109 Total retinal foveal thickness μm (TRFT) -0,129 0,155 Total retinal parafoveal thickness μm (TRPAFT) -0,001 0,989 Total retinal perifoveal thickness μm (TRPEFT) -0,013 0,885 Choroidal thickness μm 0, 211* 0,02 Schirmer test (mm) -0,017 0,853 TBUT test (sn) -,250** 0,005 r: Spearman’s Rank Correlation Coefficient. ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed). 4. Discussion The abnormal sympathetic hyperactivity playing a role in the pathogenesis of fibromyalgia syndrome (FMS) has been shown to lead to long-term disruption of blood pressure regulation, triggering endothelial dysfunction and vascular wall sclerosis, ultimately resulting in vasoconstriction and choroidal ischemia [ 12 – 14 ]. It has been suggested that this decrease in blood perfusion may be related to changes in the function of the autonomic nervous system. Numerous potential pathogenic mechanisms, such as the roles of inflammation and glial cell activation, are actively being investigated in the pathogenesis of FMS [ 15 ]. The lacrimal gland is one of the target tissues in rheumatic diseases and can become dysfunctional due to lymphocytic infiltration. This condition can adversely affect tear production and the stability of the tear film, leading to disruptions in ocular surface homeostasis. Kötter et al. have demonstrated that the lacrimal gland can be affected in patients with FMS, similar to other rheumatic diseases [ 16 ]. Enríquez et al. suggested that inflammatory cytokines playing a role in the pathophysiology of FMS may be effective in suppressing tear osmolarity [ 17 ]. In a study by Tezel et al., investigating the prevalence of dry eye in individuals with FMS, TBUT values were found to be significantly lower in the FMS group, whereas no differences were detected in Schirmer test results between groups [ 18 ]. Similarly, Schuster et al. did not find a significant difference in Schirmer test results when assessing patients with FMS compared to the control group [ 19 ]. In our study, similarly, no significant difference was found in Schirmer test results between individuals with FMS and the control group, while TBUT values were significantly lower in the FMS group, and it was observed that TBUT results significantly decreased as disease severity increased. Our findings suggest that the dysfunction of the autonomic nervous system observed in the pathogenesis of FMS affects the neural regulation of the lacrimal glands, leading to a decline in tear quality without directly impacting tear quantity. Additionally, chronic inflammation in FMS may disrupt the lipid and mucus layers of the tear film, resulting in more pronounced findings in TBUT, while not affecting the Schirmer test in the same manner. In our study, the aim was to assess the macula and choroidal structures in female patients with FMS and to investigate their relationship with disease severity. Zhang et al. demonstrated changes in the retinal microvascular network in individuals with amnestic-type mild cognitive impairment, showing significant reductions in SCP and DCP vessel densities, in addition to decreased blood flow [ 20 ]. Furthermore, Zhang et al. showed that parafoveal and peripapillary densities had a positive correlation with low scores on the Montreal Cognitive Assessment (MoCA). In a study by Bulut et al. on patients with Alzheimer's-type dementia, it was shown that retinal vascular pathologies exhibited significantly lower retinal vascular density in all regions compared to healthy controls [ 21 ]. Both studies observed a reduction in retinal vessel density and a decline in blood flow. These findings suggest that in chronic neurodegenerative diseases, vascular problems may be associated with the disruption of the blood-brain barrier and hypoperfusion. Similarly, the observation of vascular changes in chronic conditions like FMS may suggest the presence of disruptions in blood flow and decreases in vessel density, especially at the microvascular level. In our study, while no significant difference was observed in SCP in the FMS group, significant reductions were seen in DCP. Additionally, a weak negative correlation was detected between FMS severity and DCP TVD and DCP PAFVD. Bulut et al. also found, in their study on another rheumatological disease, Familial Mediterranean fever (FMF), that there was no significant change in SCP compared to the control group, while a significant reduction was observed in DCP. A weak negative correlation was found between disease duration and DCP structures [ 22 ]. We believe that the increase in inflammation in these rheumatological diseases may lead to disrupted blood pressure regulation, endothelial dysfunction, and vasoconstriction in the vascular walls, which may be linked to a decrease in capillary plexus density. Additionally, the negative correlation between disease severity and DCP density further supports this hypothesis. Changes in pro-inflammatory cytokines and chemokines playing a role in the pathogenesis of FMS have been observed [ 23 ]. In our study, an increase in choroidal thickness values was noted. We thought that the significant correlations with FMS severity could be attributed to the increase in inflammation in FMS patients and the subsequent increase in vascular permeability. Similarly, in a study conducted by Ağın et al., an increase in choroidal thickness was found in children with systemic lupus erythematosus compared to the healthy group [ 24 ]. In our study, we found that the FAZ area and non-flow parameters were higher in the FMS group compared to the healthy control group. This can be associated with the dilation of FAZ due to ischemia caused by vascular damage. In a study conducted by Temel et al., it was shown that the FAZ area was larger in diabetic patients compared to controls due to microvascular changes in the retina [ 25 ]. The autonomic dysfunction that arises in the FMS process can negatively affect the function of retinal vessels by causing endothelial damage. This process can lead to reduced blood flow and microvascular damage, thereby causing structural changes in retinal cells. Garcia-Martin et al. demonstrated that there was a reduction in RNFL thickness in patients with FMS, while the vascular density levels in the macular region were similar to those of healthy control subjects [ 3 ]. Öztürk et al. found slight differences in TRFT and TRPAFT values in patients with FMS. However, they noted that no significant vascular or neurodegenerative changes were observed compared to healthy controls [ 11 ]. In our study, no significant differences were found in RNFL, TRFT, TRPAFT, and TRPEFT values between patients with FMS and healthy individuals. The lack of significant changes in TRFT, TRPAFT, and TRPEFT values in our study can be explained by factors such as different sample characteristics, methodological approaches used, and disease severity compared to previous studies. Our study has some limitations. First, the small number of patients limits the generalizability of the results obtained. Additionally, not grouping patients according to disease stages and symptom durations may have prevented us from observing different clinical effects. Moreover, the absence of long-term follow-up limited the opportunity to more comprehensively assess the dynamics of changes and symptoms observed over time. These limitations are important factors to consider in future studies. 5. Conclusion This study presents significant findings regarding ophthalmic vascular and choroidal changes in patients with FMS. The notable decrease observed in the DCP, the increase in FAZ and non-flow areas, and the increase in choroidal thickness indicate the negative effects of autonomic dysfunction and inflammation on vascular structures in the pathogenesis of FMS. Additionally, the significant decrease in TBUT test suggests that chronic inflammation in FMS adversely affects tear quality. The use of modern imaging techniques such as OCTA and OCT enables a more detailed and precise assessment of the effects of FMS on eye health. Future studies involving larger patient groups and long-term follow-ups will be beneficial for better understanding the impact of FMS on eye health and providing important contributions to the treatment and management of this condition. Declarations Confict of interest All authors declare no funding was received and no confict of interest/competing interests Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 2013 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Clini- cal Research Ethics Committee of Health Sciences University Antalya Training and Research Hospital (decision number: 18/13, date: September 29, 2022). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent for publication Written consent was acquired by all participants. Funding No funding was received for conducting this study. Author Contribution All authors contributed to the conception and design of the study. Material preparation, data collection, and analysis were carried out by GÇ, ŞKD, MB, HB and DD. The initial draft of the manuscript was composed by GÇ, ŞKD, MB, HB and DD, while GÇ reviewed, revised, and approved the final manuscript. Acknowledgement We express our gratitude to the referees for their invaluable comments and recommendations, which greatly contrib- uted to the substantial improvement of our article. References A. P. Marques, A. de S. do E. Santo, A. A. Berssaneti, L. A. Matsutani, and S. L. K. Yuan, “Prevalence of fibromyalgia: literature review update,” Revista Brasileira de Reumatologia (English Edition), vol. 57, no. 4, pp. 356–363, Jul. 2017, doi: 10.1016/j.rbre.2017.01.005 . M.-A. Fitzcharles et al., “2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome: Executive Summary,” Pain Res Manag, vol. 18, no. 3, pp. 119–126, 2013, doi: 10.1155/2013/918216 . E. Garcia-Martin et al., “Diagnostic Ability and Capacity of Optical Coherence Tomography-Angiography to Detect Retinal and Vascular Changes in Patients with Fibromyalgia,” J Ophthalmol, vol. 2022, pp. 1–8, Aug. 2022, doi: 10.1155/2022/3946017 . B. Cordón et al., “Analysis of Retinal Layers in Fibromyalgia Patients with Premium Protocol in Optical Tomography Coherence and Quality of Life,” Curr Eye Res, vol. 47, no. 1, pp. 143–153, Jan. 2022, doi: 10.1080/02713683.2021.1951301 . A. Karakoyun, E. Yaşar, U. Gürlevik, and Y. Çalık, “Evaluation of Eye Findings in Fibromyalgia Patients,” Turkish Journal of Osteoporosis, vol. 25, no. 1, pp. 19–22, Apr. 2019, doi: 10.4274/tod.galenos.2019.55823 . J. Gallar, C. Morales, V. Freire, M. C. Acosta, C. Belmonte, and J. A. Duran, “Decreased Corneal Sensitivity and Tear Production in Fibromyalgia,” Investigative Opthalmology & Visual Science, vol. 50, no. 9, p. 4129, Sep. 2009, doi: 10.1167/iovs.08-3083 . C. F. Henrich, P. Y. Ramulu, and E. K. Akpek, “Association of Dry Eye and Inflammatory Systemic Diseases in a Tertiary Care–Based Sample,” Cornea, vol. 33, no. 8, pp. 819–825, Aug. 2014, doi: 10.1097/ICO.0000000000000173 . E. J. Price, “Dry eyes and mouth syndrome–a subgroup of patients presenting with sicca symptoms,” Rheumatology, vol. 41, no. 4, pp. 416–422, Apr. 2002, doi: 10.1093/rheumatology/41.4.416 . E. Garcia-Martin et al., “Fibromyalgia Is Correlated with Retinal Nerve Fiber Layer Thinning,” PLoS One, vol. 11, no. 9, p. e0161574, Sep. 2016, doi: 10.1371/journal.pone.0161574 . M. Ulusoy, A. Kal, S. Işik-Ulusoy, and Ö. Kal, “Choroidal thickness in patients with fibromyalgia and correlation with disease severity,” Indian J Ophthalmol, vol. 66, no. 3, p. 428, 2018, doi: 10.4103/ijo.IJO_877_17 . G. Y. Öztürk, D. T. Emekli, E. Sahutoglu, and B. F. Kocyigit, “Evaluation of ophthalmic vascular and neuroretinal alterations in fibromyalgia syndrome: a cross-sectional comparative study,” Rheumatol Int, Jul. 2024, doi: 10.1007/s00296-024-05662-w . L. J. Crofford, “The hypothalamic–pituitary–adrenal axis in the pathogenesis of rheumatic diseases,” Endocrinol Metab Clin North Am, vol. 31, no. 1, pp. 1–13, Mar. 2002, doi: 10.1016/S0889-8529(01)00004-4 . F. Petzke and D. J. Clauw, “Sympathetic nervous system function in fibromyalgia,” Curr Rheumatol Rep, vol. 2, no. 2, pp. 116–123, Mar. 2000, doi: 10.1007/s11926-000-0051-5 . D. J. Clauw and G. P. Chrousos, “Chronic Pain and Fatigue Syndromes: Overlapping Clinical and Neuroendocrine Features and Potential Pathogenic Mechanisms,” Neuroimmunomodulation, vol. 4, no. 3, pp. 134–153, 1997, doi: 10.1159/000097332 . P. Talu Erten and S. Bilgin, “Assessment of ophthalmic vascular changes in fibromyalgia patients using optical coherence tomography angiography: is there a real pathology?,” JFO Open Ophthalmology, vol. 6, p. 100057, Jun. 2024, doi: 10.1016/j.jfop.2023.100057 . I. Kötter, D. Neuscheler, I. Günaydin, D. Wernet, and R. Klein, “Is there a predisposition for the development of autoimmune diseases in patients with fibromyalgia? Retrospective analysis with long term follow-up,” Rheumatol Int, vol. 27, no. 11, pp. 1031–1039, Aug. 2007, doi: 10.1007/s00296-007-0413-7 . A. Enríquez-de-Salamanca et al., “Tear cytokine and chemokine analysis and clinical correlations in evaporative-type dry eye disease.,” Mol Vis, vol. 16, pp. 862–73, May 2010. N. TEZEL, A. ŞANAL DOGAN, E. UMAY, C. GÜRDAL, and A. ÇAKCI, “The Presence of Dry Eye Syndrome in Patients with Fibromyalgia: A Cross-sectional Controlled Study,” Muğla Sıtkı Koçman Üniversitesi Tıp Dergisi, vol. 8, no. 3, pp. 184–188, Dec. 2021, doi: 10.47572/muskutd.786962 . A. K.-G. Schuster, M. Wettstein, A. Gerhardt, W. Eich, C. Bieber, and J. Tesarz, “Eye Pain and Dry Eye in Patients with Fibromyalgia,” Pain Medicine, vol. 19, no. 12, pp. 2528–2535, Dec. 2018, doi: 10.1093/pm/pny045 . Y. S. Zhang et al., “Parafoveal vessel loss and correlation between peripapillary vessel density and cognitive performance in amnestic mild cognitive impairment and early Alzheimer’s Disease on optical coherence tomography angiography,” PLoS One, vol. 14, no. 4, p. e0214685, Apr. 2019, doi: 10.1371/journal.pone.0214685 . M. Bulut et al., “Evaluation of optical coherence tomography angiographic findings in Alzheimer’s type dementia,” British Journal of Ophthalmology, vol. 102, no. 2, pp. 233–237, Feb. 2018, doi: 10.1136/bjophthalmol-2017-310476 . M. Bulut et al., “Evaluation of retinal and optic disc vascular structures in patients with familial Mediterranean fever (FMF) via optical coherence tomography angiography,” Int Ophthalmol, vol. 43, no. 7, pp. 2171–2181, Dec. 2022, doi: 10.1007/s10792-022-02613-x . I. Rodriguez-Pintó, N. Agmon-Levin, A. Howard, and Y. Shoenfeld, “Fibromyalgia and cytokines,” Immunol Lett, vol. 161, no. 2, pp. 200–203, Oct. 2014, doi: 10.1016/j.imlet.2014.01.009 . A. Ağın et al., “Evaluation of Choroidal Thickness, Choroidal Vascularity Index and Peripapillary Retinal Nerve Fiber Layer in Patients with Juvenile Systemic Lupus Erythematosus,” Lupus, vol. 28, no. 1, pp. 44–50, Jan. 2019, doi: 10.1177/0961203318814196 . D. S. B. F. Ö. E. Temel E, “Diyabetik Olgularda Optik Koherens Tomografi Anjiyografi Bulguları ile İç Retina Kalınlığı Arasındaki İlişki.,” Turk J Ophthalmol, vol. Oct;52(5), pp. 331–337, 2022. Additional Declarations No competing interests reported. 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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-5270932","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376115781,"identity":"8536b082-140a-46ce-bd8a-90d90da11fca","order_by":0,"name":"Gülşah Çelik","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYFAC5gYGxoYDDAwSIE4FSAAogh8wIms5A9LCSIoWxjaoCD4gH5HY/OHnjjty5rObj32unFcbzd8O1PKjYhtOLYY3Etske888M5a5cyx55tltx3NnHGZsYOw5cxu3lhmJbQy8bYcTZ0jkGDM2bjuW2wDUwszYhldL88e/bYfrZ0jkf2ZsnHMsdz4hLfISiQ3SQFsSJCRymBkbG2pyNxDSYsDzsE1atu2Z4QyZY8aMDccO5G4EajmIzy/y7cmHP75tuyMvId38mLGhpi533vnDBx/8qMBjywFU/mEweQBDHbItDaj8OnyKR8EoGAWjYIQCAAKtYxFlgQ4jAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Physical Medicine and Rehabilitation, Antalya Training and Research Hospital, University of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Gülşah","middleName":"","lastName":"Çelik","suffix":""},{"id":376115782,"identity":"c20d84cc-b667-4c49-894d-2078756b5461","order_by":1,"name":"Şebnem Koldaş Doğan","email":"","orcid":"","institution":"Department of Physical Medicine and Rehabilitation, Antalya Training and Research Hospital, University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Şebnem","middleName":"Koldaş","lastName":"Doğan","suffix":""},{"id":376115783,"identity":"115cd535-d1aa-4211-a45f-0c9e0dc5db56","order_by":2,"name":"Mehmet Bulut","email":"","orcid":"","institution":"Department of Ophthalmology, Antalya Training and Research Hospital, University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Bulut","suffix":""},{"id":376115784,"identity":"419cb13d-d5a5-47e2-9b8b-1bbddb1ec09d","order_by":3,"name":"Hakan Büber","email":"","orcid":"","institution":"Department of Ophthalmology, Antalya Training and Research Hospital, University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hakan","middleName":"","lastName":"Büber","suffix":""},{"id":376115785,"identity":"d4e15928-2b3d-47b0-9521-cb17a3d6cb0f","order_by":4,"name":"Doğan Durmaz","email":"","orcid":"","institution":"Department of Ophthalmology, Antalya Training and Research Hospital, University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Doğan","middleName":"","lastName":"Durmaz","suffix":""}],"badges":[],"createdAt":"2024-10-15 19:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5270932/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5270932/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10792-025-03497-3","type":"published","date":"2025-03-25T15:57:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69888518,"identity":"e7054050-9d6a-423b-9584-ff96c49a0a72","added_by":"auto","created_at":"2024-11-26 10:06:28","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":534368,"visible":true,"origin":"","legend":"\u003cp\u003eSuperficial vascular density assessment using optical coherence tomography angiography (OCTA)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5270932/v1/fe4c6ad684da27d7242278a9.jpeg"},{"id":69889739,"identity":"4af54517-9f39-4f47-8e16-289662ed8a28","added_by":"auto","created_at":"2024-11-26 10:14:28","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1331992,"visible":true,"origin":"","legend":"\u003cp\u003eDeep vascular density assessment using optical coherence tomography angiography (OCTA)\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5270932/v1/c49a16510ee1ccfc3deb2025.jpeg"},{"id":69888520,"identity":"71fb1174-23af-4007-9eb3-677c8cc11ebf","added_by":"auto","created_at":"2024-11-26 10:06:28","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":606677,"visible":true,"origin":"","legend":"\u003cp\u003eRetinal nerve fiber layer (RNFL) thickness assessment using optical coherence tomography (OCT)\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5270932/v1/b1aeb9e2e7ff3e77db4c4ab0.jpeg"},{"id":69890128,"identity":"ce771bda-fa29-495c-b86a-7f1b56edf88f","added_by":"auto","created_at":"2024-11-26 10:22:28","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":878164,"visible":true,"origin":"","legend":"\u003cp\u003eRetinal thickness assessment using optical coherence tomography angiography (OCTA)\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5270932/v1/f1f11e630a8d9bdca980a507.jpeg"},{"id":69889740,"identity":"09d3e29c-4b9a-461b-b18c-47001db7daba","added_by":"auto","created_at":"2024-11-26 10:14:28","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":856441,"visible":true,"origin":"","legend":"\u003cp\u003eChoroidal thickness assessment using optical coherence tomography (OCT)\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5270932/v1/9f9ed246698b8613d9a4bf32.jpeg"},{"id":79604990,"identity":"6c8c3eaa-f157-45e3-93e7-01b00ecd917d","added_by":"auto","created_at":"2025-03-31 16:10:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5769867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5270932/v1/910dab8a-104b-4492-adad-3c61912394c0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Ophthalmic Vascular and Neural Structures in Female Patients with Fibromyalgia Syndrome and Their Relationship with Disease Severity","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eFibromyalgia syndrome (FMS) is a chronic condition characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive dysfunction. Its prevalence ranges from 0.2\u0026ndash;6.6%, occurring 6\u0026ndash;9 times more frequently in women than in men [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The pathophysiology of FMS involves central and peripheral sensitization, sympathetic dysfunction, neuroendocrine and autonomic system anomalies, and psychosocial factors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Central nervous system involvement in FMS may also lead to visual pathologies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Symptoms such as dry eye, photopsia, diplopia, and blurred vision are commonly reported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Dry eye in FMS may result from decreased corneal sensitivity, leading to reduced tear secretion, and suppression of tear film layer osmolarity following ocular surface inflammation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In one study, 20\u0026ndash;35% of FMS patients reported dry eye symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePerfusion anomalies in the brain, vascular changes in the thalamus and caudate nucleus, optic nerve involvement, and neuroretinal changes have been reported in FMS. Axonal loss in the retinal nerve fiber layer (RNFL) has been observed in various neurodegenerative diseases such as multiple sclerosis, Parkinson\u0026rsquo;s disease, and Alzheimer\u0026rsquo;s disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Garcia-Martin et al. observed significant thinning of the RNFL in FMS patients, suggesting the presence of neurodegenerative processes in this condition [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe choroid, with its rich vascular structure, contributes to the circulation of the outer retina, optic nerve, and the avascular fovea. Autonomic system changes can affect choroidal structure and perfusion. Ulusoy et al. demonstrated reduced choroidal thickness in FMS patients, which was associated with disease activity, suggesting that these choroidal changes might be related to alterations in autonomic nervous system function [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe imbalance between the sympathetic and parasympathetic nervous systems in FMS, along with changes in neurotransmitter and catecholamine concentrations, may affect ocular vascular perfusion [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Optical coherence tomography angiography (OCTA) plays a crucial role in evaluating neuroretinal, retinal, and choroidal vascular structures. In this study, based on potential vascular and inflammatory changes in FMS pathogenesis, we aimed to compare macular and choroidal thickness and vascular structures in female FMS patients, assessed by OCTA and optical coherence tomography (OCT), with healthy controls, and to explore the relationship between these findings and disease severity.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003ePatient Selection\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study was designed as a single-center, prospective, cross-sectional study conducted in the Department of Physical Medicine and Rehabilitation at the University of Health Sciences (UHS) Antalya Training and Research Hospital. Before starting the study, ethical approval was obtained from the Clinical Research Ethics Committee of Antalya Training and Research Hospital (approval number 2/15, dated 20.01.2022). The study was conducted in accordance with the principles of the 2013 Declaration of Helsinki. Informed consent forms were signed by the patients.\u003c/p\u003e \u003cp\u003eBetween January 2022 and October 2022, 62 newly diagnosed female patients with FMS aged 18\u0026ndash;65 years who visited the Physical Medicine and Rehabilitation outpatient clinic of UHS Antalya Training and Research Hospital were included in the patient group, along with 60 healthy female individuals of the same age group without any additional systemic diseases, who were selected as the control group. The diagnosis of FMS was made according to the 2016 revised criteria of the American College of Rheumatology (ACR). Widespread pain was defined as pain in at least 4 out of 5 body regions: the right and left sides of the body (jaw, shoulder, upper arm, forearm, hip, upper leg, lower leg) and the axial region (neck, back, lower back, chest, and abdomen), with pain lasting continuously for the past seven days. The widespread pain score (WPI) was calculated between 0 and 19. The symptom severity scale (SSS) assessed fatigue, unrefreshed sleep, and cognitive symptoms over the past week, with a score from 0 to 3 (0\u0026thinsp;=\u0026thinsp;no problem, 1\u0026thinsp;=\u0026thinsp;mild, 2\u0026thinsp;=\u0026thinsp;moderate, 3\u0026thinsp;=\u0026thinsp;severe). The presence of headaches, lower abdominal pain/cramps, and depression in the past six months was also evaluated (0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;yes). The total score was calculated. A WPI score of \u0026ge;\u0026thinsp;7 and an SSS score of \u0026ge;\u0026thinsp;5, or a WPI score of 4\u0026ndash;6 and an SSS score of \u0026ge;\u0026thinsp;9, met the FMS diagnostic criteria. The fibromyalgia severity scale was calculated by summing the WPI and SSS scores.\u003c/p\u003e \u003cp\u003eExclusion criteria included patients who had previously received or were receiving treatment for FMS; those with systemic, neurodegenerative, or rheumatologic diseases (rheumatoid arthritis, vasculitis, diabetes mellitus, hypertension, etc.); patients with spherical refractive errors outside the range of -3 to +\u0026thinsp;3 diopters or astigmatic refractive errors greater than 3 diopters; patients with retinal vascular pathologies such as diabetic retinopathy or retinal vein occlusion; patients with macular diseases such as senile macular degeneration or macular dystrophy; those with a history of uveitis, glaucoma, or optic nerve disease, or who had undergone ocular surgery or trauma; and participants with poor image quality due to movement artifacts or other factors, resulting in a signal quality score of less than 6/10.\u003c/p\u003e \u003cp\u003eAll participants underwent refraction assessment with an autorefractometer (Nidek AR600A, Nidek Co., Japan), intraocular pressure measurement with a pneumatic tonometer (Nidek NT-2000 NCT, Nidek Co. Ltd., Hiroishi Gamagori, Aichi, Japan), and visual acuity evaluation. Anterior segment and fundus structures were assessed by biomicroscopic examination.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOCTA Evaluation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOCTA is a non-invasive, rapid imaging method that provides a cross-sectional in vivo image of the dynamic microvascular system of the choroid and retina. In the OCT and OCTA imaging of the patients, the \"Spectral-domain OCTA\" (AngioVue; Optovue, Inc, Fremont, CA) device was used. OCTA measurements of the patient were performed at 6\u0026times;6 mm HD angio retina and 4.5\u0026times;4.5 mm angio disk scans. Images with poor quality due to motion artefact and other artefacts were not included in the study. Images with a signal quality greater than 8/10 were assessed. Foveal vascular density (FVD) was recorded as % of the vascular density in 1 mm diameter circle centered on fovea, parafoveal vascular density (PAFVD) was recorded as % of the vascular density in the circle from 1 to 3 mm, perifoveal vascular density (PEFVD) was recorded as % of the vascular density in the ring from 3 to 6 mm, and the total vascular density (TVD) was recorded as % of vascular density in 6 mm diameter circle centered on fovea. These areas provided the cross-sectional density measurement of the superfcial capillary area in automated mode (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.). The ratio of the vascular image in these areas (white areas) to the whole area provides the percentage of density. Foveal avascular zone (FAZ) was automatically calculated by the device; outer retinal flow (ORF) and choriocapillaris flow (CCF) automatically determined by the device were recorded as fow in mm\u0026sup2; in the area with a central radius of 1 mm and area of 3.142 mm\u0026sup2;. Retinal nerve fiber thickness (RNFL) was measured and recorded automatically by the device on 3.4 mm diameter scanning circle centered on the optic disc (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.). Retinal thickness: The retinal thickness between ILM and RPE in foveal, parafoveal and perifoveal zones was automatically measured and recorded by the device (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.). Choroidal thickness: 2 diferent observers measured the subfoveal zone at \u0026ldquo;Enhanced HD line\u0026rdquo; cross-section. The average of values measured by the 2 observers was calculated (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.). The RPE and sclerachoroidal junction was the border of subfoveal choroidal thickness.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEvaluation of Schirmer and Tear Break-Up Time Tests\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Schirmer test is a method used to measure tear quantity and aqueous production. A 5 mm wide and 35 mm long Whatman filter paper was used without local anesthesia. It was placed at the junction of the middle one-third and outer one-third of the lower eyelid. After five minutes, the amount of wetting on the filter paper was measured. When evaluated for dry eye, values between 0\u0026ndash;5 mm were considered low, between 5\u0026ndash;10 mm were suspicious, and values above 10 mm were considered normal. A wetting measurement below 5 mm was regarded as significant for aqueous tear deficiency.\u003c/p\u003e \u003cp\u003eThe Tear Break-Up Time (TBUT) test is a method used to evaluate tear stability. The patients' tears were stained using fluorescein-impregnated strips without topical anesthesia. The patient was instructed to blink once to allow the dye to spread across the ocular surface. The evaluation was performed using a wide light with a cobalt blue filter on a biomicroscope. The time between blinking and the first break in the dye on the ocular surface was measured. The test was repeated three times, and the average was taken; a time of less than 10 seconds was considered significant for dry eye.\u003c/p\u003e \u003cp\u003eAll these procedures were performed by the same ophthalmologist. Measurements were made for both eyes; however, only the data obtained from the right eye were used for statistical analysis.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDescriptive statistics were presented using frequency, percentage, mean, standard deviation, median, 25th percentile, 75th percentile, minimum, and maximum values. In the analysis of categorical data, if the percentage of cells with expected values less than 5 was greater than 20%, Fisher's Exact Test was used; otherwise, Pearson Chi-Square Test was employed. The normality assumption was checked using the Kolmogorov-Smirnov Test. For the analysis of the difference between numerical data of the two groups, if the data followed a normal distribution, the Independent Samples t-test was used; if not, the Mann-Whitney U Test was applied. Relationships between numerical data were evaluated using the non-parametric Spearman Correlation Test and the parametric Pearson Correlation Test. Analyses were performed using SPSS version 23.0, and a p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Result","content":"\u003cp\u003eA total of 62 women with fibromyalgia syndrome (FMS) had a mean age of 43.11 \u0026plusmn; 7.94 years (range: 19-59), while the healthy control group consisted of 60 women with a mean age of 40 \u0026plusmn; 12.26 years (range: 18-64). The mean duration of the disease in the FMS group was 5.08 \u0026plusmn; 3.97 years (range: 1-17). There was no statistically significant difference between the groups in terms of age and body mass index (BMI). The widespread pain index, symptom severity scale, and fibromyalgia severity scale were significantly higher in the FMS group (p \u0026lt; 0.0001). While there was no statistically significant difference between the groups in the Schirmer test, the TBUT test was significantly lower in the FMS group (p \u0026lt; 0.0001) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic and clinical characteristics of FMS patients and controls\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD (Min.-Max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (Q1-Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age, (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43,11\u0026plusmn;7,94(19-59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43(39-49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,182\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u0026plusmn;12,26(18-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40(28,5-49,5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(kg/m\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26,01+4,26(16,42-35,25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25,62 (23,53-28,91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,151\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24,95\u0026plusmn;4,49(16,42-35,25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24,53(21,64-27,99)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisease duration (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5,08\u0026plusmn;3,97 (1-17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (1-7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidespread pain\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eindex (WPI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13,5\u0026plusmn;3,01(8-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14(11-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026lt;0,0001\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,58\u0026plusmn;1,08(0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0(0-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptom Severity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eScale (SSS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9,39\u0026plusmn;1,96(5-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10(8-11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026lt;0,0001\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,53\u0026plusmn;1,08(0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0(0-0,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe fibromyalgia\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eseverity scale (FSS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22,92\u0026plusmn;4,15(15-31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23,5(20-25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026lt;0,0001\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1,12\u0026plusmn;2,03(0-6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0(0-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchirmer test (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17,19\u0026plusmn;9,65(3-35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16,5(8-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,437\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18,33\u0026plusmn;8,72(3-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17(12-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBUT test (sn)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7,76\u0026plusmn;4,28(3-19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6(5-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026lt;0,0001\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10,47\u0026plusmn;3,87(4-18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11(8-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1: Independent t test, 2: Mann Whitney U test were used. SD: Standard deviation, Q1: 25th percentile, Q3: 75th percentile\u003c/p\u003e\n\u003cp\u003eTable 2 shows the comparison between vascular densities in the superficial capillary plexus (SCP) and deep capillary plexus (DCP), as well as the foveal avascular zone (FAZ), choriocapillaris flow (CCF), outer retinal flow (ORF), and non-flow values of FMS patients and controls. In patients evaluated with OCTA, there were no statistically significant differences between the groups in the SCP TVD, SCP FVD, SCP PAFVD and SCP PEFVD parameters (p \u0026gt; 0.05). However, the DCP TVD, DCP FVD, DCP PAFVD and DCP PEFVD parameters were significantly lower in the FMS group (p \u0026lt; 0.05). While there were no statistically significant differences between the groups in CCF and ORF values (p \u0026gt; 0.05), the FAZ and non-flow parameters were found to be significantly higher in the FMS group (p \u0026lt; 0.05) (Table 2.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eComparison of OCTA findings between fibromyalgia patients and healthy controls\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetinal vasculer density(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD (Min.-Max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (Q1-Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP total vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,15\u0026plusmn;2,93(44,5-59,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,45(49,3-53,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,653\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e50,91\u0026plusmn;3,04(44,1-57,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,3(48,75-52,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP foveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e17,68\u0026plusmn;6,79(5,08-34,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e16,15(13,04-22,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,059\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e19,99\u0026plusmn;7,75(5,8-56,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18,8(15,55-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP parafoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e52,9\u0026plusmn;5,16(23,9-61,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e53,45(51,1-56,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e0,868\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e53,06\u0026plusmn;3,59(44,5-59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e53,7(50,7-55,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP perifoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,14\u0026plusmn;4,74(22,3-60,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,4(50-53,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,705\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,36\u0026plusmn;2,96(46,2-57,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,35(49,15-53,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP total vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,09\u0026plusmn;5,14(39-61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e51,3(47,2-54,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,002\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e53,87\u0026plusmn;5,23(39,1-62,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e54,8(51,15-56,95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP foveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e34,2\u0026plusmn;7,42(17,09-49,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e33,9(28,4-39,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,019\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e37,28\u0026plusmn;6,92(20,7-51,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e37,2(32,9-42,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP parafoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e55,52\u0026plusmn;3,91(44,5-61,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e56(53,6-58,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,011\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e57,09\u0026plusmn;3,94(41-62,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e57,65(55,35-59,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP perifoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e52,81\u0026plusmn;5,77(37,6-63,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e52,7(48,9-57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,009\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e55,05\u0026plusmn;6,28(32,2-63,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e56,6(52,75-58,75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFoveal avascular zone (FAZ) mm\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,34\u0026plusmn;0,13(0,08-0,77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,34(0,25-0,41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,003\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,28\u0026plusmn;0,1(0,06-0,49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,30(0,2-0,35)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChoriocapillaris flow (CCF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2,066\u0026plusmn;0,112(1,781-2,291)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2,074(2,016-2,138)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,784\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2,071\u0026plusmn;0,135(1,582-2,29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2,075(1,992-2,177)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOuter retina flow (ORF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,6\u0026plusmn;0,341(0,12-1,571)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,513(0,367-0,771)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,786\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,614\u0026plusmn;0,332(0,178-1,774)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,525(0,361-0,793)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNonflow\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,563\u0026plusmn;0,126(0,268-0,921)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,596(0,474-0,65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,042\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,515\u0026plusmn;0,132(0,19-0,916)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0,513(0,426-0,583)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1: Independent t test, 2: Mann Whitney U test were used. SD: Standard deviation, Q1: 25th percentile, Q3: 75th percentile\u003c/p\u003e\n\u003cp\u003eTable 3 presents the comparison of OCT findings between the FMS and control groups. There was no statistically significant difference between the groups in RNFL, TRFT, TRPAFT, and TRPEFT values (p\u0026gt;0.05); however, the choroidal thickness parameter was found to be significantly higher in the FMS group (p\u0026lt;0.05) (Table 3.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eComparison of OCT findings between fibromyalgia patients and healthy controls\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026plusmn;SD (Min.-Max)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (Q1-Q3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetinal nerve fber layer (RNFL) \u0026mu;m\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e117,92\u0026plusmn;11,67(85-145)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e117(112-125)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,162\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e114,97\u0026plusmn;11,51(93-139)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e113(106-124)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal retinal foveal thickness \u0026nbsp;\u0026mu;m \u0026nbsp;(TRFT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e244,34\u0026plusmn;20,88(201-304)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e243(231-257)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,0521\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e251,42\u0026plusmn;18,93(218-298)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e248(237-266)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal retinal parafoveal thickness \u0026mu;m \u0026nbsp; \u0026nbsp; (TRPAFT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e314,68\u0026plusmn;22,23(278-447)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e313(303-322)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,6652\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e314,18\u0026plusmn;12,76(289-340)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e312(305-324)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal retinal perifoveal thickness \u0026nbsp; \u0026nbsp; \u0026mu;m \u0026nbsp;(TRPEFT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e286,74\u0026plusmn;17,75(189-313)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e289,5(280-297)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,9842\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e287,78\u0026plusmn;10,73(262-309)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e288(280,5-294,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChoroidal thickness \u0026nbsp;\u0026mu;m\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFMS (n=62)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e321,55\u0026plusmn;62,12(180-569)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e316(278-352)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,004\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e287,08\u0026plusmn;46,1(180-379)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e298(253-312)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1: Independent t test, 2: Mann Whitney U test were used. SD: Standard deviation, Q1: 25th percentile, Q3: 75th percentile\u003c/p\u003e\n\u003cp\u003eIn the correlation examined between FMS severity and OCTA values, there is a statistically significant, weak negative relationship between DCP TVD and DCP PAFVD (r=-0.227, p=0.012; r=-0.192, p=0.034) (Table 4).\u003c/p\u003e\n\u003cp\u003eWhile there is a statistically significant, weak positive correlation between FMS severity and choroidal thickness (r=0.211, p=0.02), there is a weak negative correlation with the TBUT test (r=-0.250, p=0.005) (Table 5). No statistically significant relationship was found between FMS severity and other variables (p\u0026gt;0.05) (Table 4) (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eThe correlation between OCTA values measured with FMS severity\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;r\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP total vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0,04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP foveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,237\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP parafoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0,042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,645\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSCP perifoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0,044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,633\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP total vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0,227*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,012\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP foveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP parafoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0,192*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,034\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDCP perifoveal vascular density\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFoveal avascular zone (FAZ) mm\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0,175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChoriocapillaris flow (CCF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,063\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOuter retina flow (ORF)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0,007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,941\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNonflow\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;0,15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSpearman\u0026rsquo;s Rank Correlation Coefficient. ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eThe correlation between OCT measurement thicknesses, Schirmer, and BUT values with FMS severity\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;r\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetinal nerve fber layer (RNFL) \u0026mu;m\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal retinal foveal thickness \u0026mu;m (TRFT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal retinal parafoveal thickness \u0026mu;m (TRPAFT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,989\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal retinal perifoveal thickness \u0026mu;m (TRPEFT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChoroidal thickness \u0026mu;m\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0, 211*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,02\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchirmer test (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-0,017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0,853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBUT test (sn)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-,250**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e0,005\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003er: Spearman\u0026rsquo;s Rank Correlation Coefficient. ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe abnormal sympathetic hyperactivity playing a role in the pathogenesis of fibromyalgia syndrome (FMS) has been shown to lead to long-term disruption of blood pressure regulation, triggering endothelial dysfunction and vascular wall sclerosis, ultimately resulting in vasoconstriction and choroidal ischemia [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It has been suggested that this decrease in blood perfusion may be related to changes in the function of the autonomic nervous system. Numerous potential pathogenic mechanisms, such as the roles of inflammation and glial cell activation, are actively being investigated in the pathogenesis of FMS [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe lacrimal gland is one of the target tissues in rheumatic diseases and can become dysfunctional due to lymphocytic infiltration. This condition can adversely affect tear production and the stability of the tear film, leading to disruptions in ocular surface homeostasis. K\u0026ouml;tter et al. have demonstrated that the lacrimal gland can be affected in patients with FMS, similar to other rheumatic diseases [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Enr\u0026iacute;quez et al. suggested that inflammatory cytokines playing a role in the pathophysiology of FMS may be effective in suppressing tear osmolarity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a study by Tezel et al., investigating the prevalence of dry eye in individuals with FMS, TBUT values were found to be significantly lower in the FMS group, whereas no differences were detected in Schirmer test results between groups [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Similarly, Schuster et al. did not find a significant difference in Schirmer test results when assessing patients with FMS compared to the control group [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our study, similarly, no significant difference was found in Schirmer test results between individuals with FMS and the control group, while TBUT values were significantly lower in the FMS group, and it was observed that TBUT results significantly decreased as disease severity increased. Our findings suggest that the dysfunction of the autonomic nervous system observed in the pathogenesis of FMS affects the neural regulation of the lacrimal glands, leading to a decline in tear quality without directly impacting tear quantity. Additionally, chronic inflammation in FMS may disrupt the lipid and mucus layers of the tear film, resulting in more pronounced findings in TBUT, while not affecting the Schirmer test in the same manner.\u003c/p\u003e \u003cp\u003eIn our study, the aim was to assess the macula and choroidal structures in female patients with FMS and to investigate their relationship with disease severity. Zhang et al. demonstrated changes in the retinal microvascular network in individuals with amnestic-type mild cognitive impairment, showing significant reductions in SCP and DCP vessel densities, in addition to decreased blood flow [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, Zhang et al. showed that parafoveal and peripapillary densities had a positive correlation with low scores on the Montreal Cognitive Assessment (MoCA). In a study by Bulut et al. on patients with Alzheimer's-type dementia, it was shown that retinal vascular pathologies exhibited significantly lower retinal vascular density in all regions compared to healthy controls [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Both studies observed a reduction in retinal vessel density and a decline in blood flow. These findings suggest that in chronic neurodegenerative diseases, vascular problems may be associated with the disruption of the blood-brain barrier and hypoperfusion. Similarly, the observation of vascular changes in chronic conditions like FMS may suggest the presence of disruptions in blood flow and decreases in vessel density, especially at the microvascular level. In our study, while no significant difference was observed in SCP in the FMS group, significant reductions were seen in DCP. Additionally, a weak negative correlation was detected between FMS severity and DCP TVD and DCP PAFVD. Bulut et al. also found, in their study on another rheumatological disease, Familial Mediterranean fever (FMF), that there was no significant change in SCP compared to the control group, while a significant reduction was observed in DCP. A weak negative correlation was found between disease duration and DCP structures [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We believe that the increase in inflammation in these rheumatological diseases may lead to disrupted blood pressure regulation, endothelial dysfunction, and vasoconstriction in the vascular walls, which may be linked to a decrease in capillary plexus density. Additionally, the negative correlation between disease severity and DCP density further supports this hypothesis.\u003c/p\u003e \u003cp\u003eChanges in pro-inflammatory cytokines and chemokines playing a role in the pathogenesis of FMS have been observed [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In our study, an increase in choroidal thickness values was noted. We thought that the significant correlations with FMS severity could be attributed to the increase in inflammation in FMS patients and the subsequent increase in vascular permeability. Similarly, in a study conducted by Ağın et al., an increase in choroidal thickness was found in children with systemic lupus erythematosus compared to the healthy group [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, we found that the FAZ area and non-flow parameters were higher in the FMS group compared to the healthy control group. This can be associated with the dilation of FAZ due to ischemia caused by vascular damage. In a study conducted by Temel et al., it was shown that the FAZ area was larger in diabetic patients compared to controls due to microvascular changes in the retina [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe autonomic dysfunction that arises in the FMS process can negatively affect the function of retinal vessels by causing endothelial damage. This process can lead to reduced blood flow and microvascular damage, thereby causing structural changes in retinal cells. Garcia-Martin et al. demonstrated that there was a reduction in RNFL thickness in patients with FMS, while the vascular density levels in the macular region were similar to those of healthy control subjects [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. \u0026Ouml;zt\u0026uuml;rk et al. found slight differences in TRFT and TRPAFT values in patients with FMS. However, they noted that no significant vascular or neurodegenerative changes were observed compared to healthy controls [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In our study, no significant differences were found in RNFL, TRFT, TRPAFT, and TRPEFT values between patients with FMS and healthy individuals. The lack of significant changes in TRFT, TRPAFT, and TRPEFT values in our study can be explained by factors such as different sample characteristics, methodological approaches used, and disease severity compared to previous studies.\u003c/p\u003e \u003cp\u003eOur study has some limitations. First, the small number of patients limits the generalizability of the results obtained. Additionally, not grouping patients according to disease stages and symptom durations may have prevented us from observing different clinical effects. Moreover, the absence of long-term follow-up limited the opportunity to more comprehensively assess the dynamics of changes and symptoms observed over time. These limitations are important factors to consider in future studies.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study presents significant findings regarding ophthalmic vascular and choroidal changes in patients with FMS. The notable decrease observed in the DCP, the increase in FAZ and non-flow areas, and the increase in choroidal thickness indicate the negative effects of autonomic dysfunction and inflammation on vascular structures in the pathogenesis of FMS. Additionally, the significant decrease in TBUT test suggests that chronic inflammation in FMS adversely affects tear quality. The use of modern imaging techniques such as OCTA and OCT enables a more detailed and precise assessment of the effects of FMS on eye health. Future studies involving larger patient groups and long-term follow-ups will be beneficial for better understanding the impact of FMS on eye health and providing important contributions to the treatment and management of this condition.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConfict of interest\u003c/h2\u003e \u003cp\u003eAll authors declare no funding was received and no confict of interest/competing interests\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 2013 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the Clini- cal Research Ethics Committee of Health Sciences University Antalya Training and Research Hospital (decision number: 18/13, date: September 29, 2022).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Written consent was acquired by all participants.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the conception and design of the study. Material preparation, data collection, and analysis were carried out by G\u0026Ccedil;, ŞKD, MB, HB and DD. The initial draft of the manuscript was composed by G\u0026Ccedil;, ŞKD, MB, HB and DD, while G\u0026Ccedil; reviewed, revised, and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe express our gratitude to the referees for their invaluable comments and recommendations, which greatly contrib- uted to the substantial improvement of our article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eA. P. Marques, A. de S. do E. Santo, A. A. Berssaneti, L. A. Matsutani, and S. L. K. 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Oct;52(5), pp. 331\u0026ndash;337, 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Fibromyalgia, Optical coherence tomograpy, Choroidal thickness, Vascular changes, Dry eye","lastPublishedDoi":"10.21203/rs.3.rs-5270932/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5270932/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate choroidal and macular thickness, as well as vascular structures in female fibromyalgia syndrome (FMS) patients using optical coherence tomography angiography (OCTA) and optical coherence tomography (OCT), and to compare the results with healthy controls. Additionally, the relationship between these findings and disease severity was explored.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study included 62 female FMS patients and 60 healthy controls, conducted between January 2022 and October 2022 at the Antalya Training and Research Hospital. FMS patients were assessed based on American College of Rheumatology criteria. Tear production and stability were evaluated using Schirmer and Tear Break-Up Time (TBUT) tests, while OCTA and OCT were used to examine vascular and choroidal structures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean age of the FMS group was 43.11\u0026thinsp;\u0026plusmn;\u0026thinsp;7.94 years. No significant difference was found in the Schirmer test, but the TBUT was significantly lower in the FMS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). OCTA showed significantly lower deep capillary plexus (DCP) values in the FMS group, with a weak negative correlation between DCP and disease severity (r=-0.227, p\u0026thinsp;=\u0026thinsp;0.012). Foveal avascular zone (FAZ), non-flow, and choroidal thickness were significantly higher in FMS patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study demonstrated a relationship between dry eye, vascular changes, and increased choroidal thickness with disease severity in female patients with FMS. The reduction in DCP, along with increases in FAZ, non-flow, and choroidal thickness, may be linked to vascular and inflammatory processes involved in FMS pathogenesis. The decrease in tear quality may be due to autonomic nervous system dysfunction. In conclusion, we suggest that autonomic dysfunction and inflammation in FMS may negatively affect retinal vascular structures and tear function.\u003c/p\u003e","manuscriptTitle":"Evaluation of Ophthalmic Vascular and Neural Structures in Female Patients with Fibromyalgia Syndrome and Their Relationship with Disease Severity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-26 10:06:23","doi":"10.21203/rs.3.rs-5270932/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-09T18:32:43+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"156028500440493292261910911901488205428","date":"2024-10-29T13:56:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-29T07:57:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"18192974162282584368267275239032965269","date":"2024-10-27T00:20:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227737277432226313623633549557205645072","date":"2024-10-25T07:51:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162491070346120304504428529858325903385","date":"2024-10-24T15:44:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206499640530230447279623517603560334332","date":"2024-10-24T15:34:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-24T13:21:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-17T09:39:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-16T08:56:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Ophthalmology","date":"2024-10-15T18:55:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5b59ab41-d369-4d7d-990c-7701bfe85d86","owner":[],"postedDate":"November 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:05:12+00:00","versionOfRecord":{"articleIdentity":"rs-5270932","link":"https://doi.org/10.1007/s10792-025-03497-3","journal":{"identity":"international-ophthalmology","isVorOnly":false,"title":"International Ophthalmology"},"publishedOn":"2025-03-25 15:57:31","publishedOnDateReadable":"March 25th, 2025"},"versionCreatedAt":"2024-11-26 10:06:23","video":"","vorDoi":"10.1007/s10792-025-03497-3","vorDoiUrl":"https://doi.org/10.1007/s10792-025-03497-3","workflowStages":[]},"version":"v1","identity":"rs-5270932","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5270932","identity":"rs-5270932","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}