The value of retinal microvascular features in predicting risk stratification and long-term prognosis of patients with acute coronary syndrome

The value of retinal microvascular features in predicting risk stratification and long-term prognosis of patients with acute coronary syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The value of retinal microvascular features in predicting risk stratification and long-term prognosis of patients with acute coronary syndrome Yuefeng Chen, Li Chen, Huanhuan Li, Zongliang Yu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8692938/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Mar, 2026 Read the published version in BMC Ophthalmology → Version 1 posted 13 You are reading this latest preprint version Abstract Purpose This study investigates the retinal blood flow characteristics in patients with acute coronary syndrome (ACS) utilising OCTA and OCT. It aims to correlate these characteristics with Grace risk stratification and long-term major adverse cardiovascular events (MACE), while also examining the relationship between microvascular changes, risk stratification, and long-term prognosis in ACS patients. Method 122 ACS patients (122 eyes) underwent coronary angiography and PCI, with a follow-up period of 12 months. Patients were categorised into high-risk, intermediate-risk, and low-risk groups based on the Grace score. OCT was employed to assess the thickness of the full thickness, superficial layer, deep layer, outer layer, and optic nerve layer of the retina. The superficial, deep foveal, and parafoveal blood flow densities, along with the perimeter, area, and FAD-300 of the FAZ, were assessed using OCTA. Result Grace staging has a negative correlation with the macular foveal and parafoveal SCP and DCP, achieving statistical significance. In the FAZ region, statistical disparities were seen in PERIM and FD among various groups; however, no significant difference was identified in the FAZ area. The thickness of the inner retina and the nerve fibre layer correlates with Grace stage. Ordinal logistic regression analysis reveals that FD-300, foveal DCP, inner retinal thickness, and nerve fibre layer thickness are strongly correlated with Grace high-risk staging (r=-0.761, P = 0.024)(r=-0.510, P = 0.035)(r=-0.895, P = 0.029)(r=-0.371, P = 0.035). Comparative analysis of the aforementioned indicators between the 18 persons who suffered MACE episodes and the 23 high-risk individuals without MACE events revealed statistically significant differences. Conclusion OCT and OCTA serve as rapid and reproducible non-invasive biomarkers, demonstrating potential for evaluating risk characteristics and adverse outcomes in patients with ACS. This facilitates advancements in the early detection, intervention, and treatment of cardiovascular diseases. Acute coronary syndrome optical coherence tomography angiography optical coherence tomography GRACE risk stratification MACE long-term events Figures Figure 1 Figure 2 Introduction Acute coronary syndrome (ACS) represents a major health concern, contributing to morbidity and mortality globally [ 1 ] , and remains a persistent challenge within the healthcare sector [ 2 , 3 ] . It imposes significant burdens on families and society while also placing considerable strain on public healthcare systems. Despite significant advancements in diagnostic and therapeutic capabilities resulting in reduced mortality rates, challenges persist in perioperative management and prognostic prediction. The preoperative identification of high-risk patients aids in the development of personalised treatment plans, enhancing prognosis and decreasing healthcare costs. The creation of innovative, non-invasive, and reliable assessment tools for risk stratification and disease monitoring represents a critical clinical necessity [ 4 ] . The association between retinal microvascular abnormalities and systemic vascular diseases has been a topic of interest since the 19th century. Retinal vessels, due to their high similarity in size and structure to coronary arterioles and capillaries, serve as a reflection of the coronary microvascular system [ 5 ] , thereby facilitating the assessment of early cardiovascular risks [ 6 ] . Recent advancements in imaging technology, especially the extensive use of rapid and non-invasive diagnostic techniques such as Optical Coherence Tomography (OCT) and Optical Coherence Tomography Angiography (OCTA), have made the evaluation of cardiovascular disease risk a significant area of interest [ 7 , 8 ] . Retinal blood flow information has been established as an independent risk factor for adverse cardiovascular events in coronary artery disease [ 9 – 11 ] , however, its significance in the prognostic evaluation of acute coronary syndrome remains ambiguous. This study employed OCTA and OCT to assess the retinal blood flow characteristics in patients with ACS. We correlated these findings with Grace scores and MACE events to elucidate the relationship between microvascular factors, risk stratification, and long-term prognosis in ACS patients. Method Study population A total of 158 ACS patients were identified, all of whom received diagnosis and treatment at the Third Affiliated Hospital of Nanjing Medical University between January 2023 and December 2024. Gathered essential patient information, encompassing medical history, gender, age, risk factors, and family history. The diagnosis of ACS was established through the patient's clinical symptoms, signs, laboratory examination results, and angiography findings. Patients were included in the study based on the following criteria. Inclusion criteria: (1) individuals aged 18 years or older; (2) all participants successfully underwent coronary angiography and percutaneous coronary intervention（PCI） surgery; (3) all participants completed OCT and OCTA examinations. Exclusion criteria: (1) individuals with retinal conditions (including diabetic retinopathy, diabetic macular edema, vitreomacular traction, age-related macular degeneration); (2) individuals with a history of cataract surgery, previous laser interventions, intravitreal drug therapies, significant retinal surgeries, or those who have undergone treatment in the past three months; (3) individuals diagnosed with congenital heart disease, valvular heart disease, pericardial disease, or aortic dissection; (4) individuals identified with malignant tumors. This study protocol complies with the guidelines set forth by the Declaration of Helsinki and has received approval from the ethics committee (Approval No.: 2023 KY022-01). All participants completed an informed consent form following tailored explanations provided to them. The GRACE risk score for global acute coronary events was utilized to stratify risk among patients in the ACS group, categorizing them into low-risk (≤108 points), medium-risk (109-140 points), and high-risk (>140 points) groups. Postoperative Examination All subjects underwent OCT (RTVue-XR Avanti; Optovue, Fremont, CA, USA) and OCTA (RTVue-XR Avanti; Optovue, Fremont, CA, USA) examinations at the ophthalmology clinic within three days postoperatively, with all fundus examinations and procedures conducted by proficient ophthalmic technicians. OCT examines the retinal architecture with the macula as the focal point, and the program autonomously evaluates the thickness of each retinal layer of the central macular retina with a diameter of 1 mm (CRT-1 mm). The program measures the thickness of the retina's total layer, superficial layer, deep layer, outer layer, and optic nerve layer. Measure the thickness of the superior, inferior, temporal, and nasal aspects of the optic nerve layer. The whole retinal measuring range extends from the internal limiting membrane(ILM) to the outer plexiform layer(OPL)+10um. The superficial retina is delineated from ILM to the inner plexiform layer(IPL)-10um, the deep retina from IPL-10um to OPL+10um, and the outer retina from OPL+10um to the Bruch's Membrane (BM)-10um. OCTA does 6×6mm scans. The macular capillary network is examined with a focus on the fovea, assessing various regions of the whole picture, including the fovea and parafovea (superior, inferior, temporal, nasal). The program autonomously computes the vessel density (VD) of the superficial capillary plexus (SCP) and the deep capillary plexus (DCP). Concurrently, it autonomously measures the FAZ area, FAZ Perimeter (PERIM), and FD-300 (foveal vascular density within a 300µm wide zone around the FAZ) of the retinal 3×3mm macular region. The system's integrated software segments the macula into three concentric rings. The foveal region is characterized as a circular area of 1mm by 1mm, centered on the macula, whereas the parafoveal region is delineated as an annular area with an outside diameter of 3mm and an inner diameter of 1mm. The border of the SCP extends from the internal limiting membrane to the inner plexiform layer, whereas the boundary of the DCP ranges from underneath the inner plexiform layer to the outer plexiform layer. This value is computed automatically by the program. Images exhibiting a signal strength index below 40, motion artifacts, erroneous segmentation, insufficient concentration, or inadequate focus are omitted during data reading and collection. Long-term Prognosis Monitor the enrolled patients through outpatient visits and telephone calls, meticulously document the changes in patients' conditions 12 months post-surgery, note the occurrence of MACE events along with their specific timing, and categorize ACS group patients into MACE and non-MACE groups based on these events. The MACE events listed are: recurrent angina pectoris, heart failure, recurrent myocardial infarction, stroke, bleeding, repeat revascularization, stent thrombosis, in-stent restenosis, cardiac death, all-cause death. Statistical Analysis Statistical analysis was conducted with SPSS 27.0 program. Measurement results were presented as mean±standard deviation (x±s), and the means across the three groups were compared using the Spearman test. The disparities between the two groups were assessed using the two-sample t-test. Variations in qualitative variables were assessed by Fisher's exact test. Correlation was evaluated via ordinal logistic regression. P -values less than 0.05 were deemed statistically significant. Result Baseline Characteristics A total of 122 patients participated in the trial and completed all follow-ups, including 77 men (63.11%) and 45 females (36.89%). The age varied from 56 to 76 years, with a mean age of (65.03 ± 5.54) years. The axial length varied between 22.10 mm and 25.60 mm, with a mean of (23.85 ± 0.82) mm. The follow-up duration varied from 12 to 18 months, with a mean of (23.85 ± 0.82) months. Based on the Grace risk categorization, patients were categorized into three groups: the low-risk group (44 individuals, ≤108 points), the intermediate-risk group (36 individuals, 109–140 points), and the high-risk group (42 individuals, >140 points). No statistically significant variations were seen among the three groups for age, axial length, and follow-up duration (Table 1). OCT findings A total of 122 patients underwent OCT examination. The metrics of focus included: retinal thickness, inner retinal thickness, and nerve fiber layer thickness（Figure 1）. The results of the bivariate correlation analysis indicated a correlation between retinal thickness and nerve fiber layer thickness with Grace staging(Table 2). Logistic regression research indicated a strong correlation between inner retinal thickness and nerve fiber layer thickness with the Grace risk classification (r=-0.895, P =0.029) (r=-0.371, P =0.035). Subsequent examination of the nerve fiber layer thickness across several quadrants revealed that the nasal, superior, and inferior quadrants had a stronger correlation with the Grace stratification (r=-0.174, P =0.026) (r=0.267, P =0.005) (r=-0.770, P ＜0.001). OCTA findings This research assessed preoperative OCTA in 122 ACS patients, indicating characteristic ischemia alterations in the retinal SCP and DCP, along with capillary network deficiencies (Figure 2). Quantitative research revealed a statistically significant negative correlation between the Grace score and both foveal and parafoveal SCP and DCP(Table 3,4). In relation to the FAZ region, statistically significant variations were noted in PERIM and FD across various groups; however, no significant difference was detected in the FAZ area itself(Table 5). Logistic regression study revealed that only FD-300 and foveal DCP had significant correlation with the Grace risk score (r=-0.761, P =0.024) (r=-0.510, P =0.035). Follow Up Of the participants in the research, 18 developed MACEs, whereas 104 did not after 12 months postoperatively. All 18 patients who had MACEs were classified inside the high-risk category according to the GRACE risk classification. Comparing the inner retinal thickness, nerve fiber layer thickness, FD-300 and foveal DCP between 18 persons who suffered MACEs and 23 individuals in the high-risk group who did not, revealed statistically significant differences（t=5.198, P ＜0.001）（t=7.885, P ＜0.001）(t=4.626, P ＜0.001)(t=6.413, P ＜0.001). Discussion Early detection and a poor prognosis of ACS pose significant problems in the worldwide medical community. This disease's pathogenesis is characterized by the dual activity of macro and microvessels [ 12 , 13 ] . Traditional techniques used by cardiologists to directly observe cardiac microcirculation have limitations such as being highly invasive, costly, and operator-dependent, emphasizing the critical need for the development of innovative, non-invasive, and reliable risk stratification and disease monitoring methods [ 4 ] . Because of its unique position and anatomical properties, the retina, unlike the coronary arteries, may be evaluated non-invasively. In recent years, advances in retinal imaging technology, notably OCTA and OCT, have been extensively employed for accurate, objective, and highly repeatable evaluations of retinal anatomy and vascularization. McClintic originally recommended employing retinal evaluation to screen low-risk individuals for CAD, which he later proposed as a guideline indication [ 14 ] . Subsequent research has shown that retinal microvascular anomalies are directly associated with an elevated risk of cardiovascular disease (CVD) [ 15 , 16 ] . However, the use of retinal vasculature in the early diagnosis of ACS and the prediction of poor prognosis is questionable. This relatively novel non-invasive vascular imaging method has shown the ability to identify retinal vascular alterations associated with cardiovascular metabolic variables, suggesting its potential as a surrogate biomarker for cardiovascular disease. In 2018, Arnold's team discovered that SCP was markedly reduced in ACS patients compared to healthy controls [ 17 ] . The GRACE risk score is a widely used scoring system for prognostic assessment in patients with ACS. A higher score correlates with an increased probability of significant cardiovascular events, providing a crucial foundation for therapy selection and prognosis assessment. Consequently, examining the correlation between retinal microvascular features and GRACE risk scores is crucial for the early identification of ACS, prompt therapeutic management, and assessment of patient prognosis, thereby enhancing medical standards and patient quality of life. Our research revealed a negative correlation between Grace stage and macular foveal as well as parafoveal superficial and deep capillary plexus. SCP perfuses the nerve fiber layer and ganglion cell layer, while DCP perfuses portions of the inner nuclear layer and outer plexiform layer [ 18 ] , vascular anomalies in these areas often possess pathogenic significance. The retinal microvascular system has a comparable diameter (100–250µm) to that of the coronary microvascular system [ 19 ] . In individuals with coronary heart disease, retinal microcirculatory abnormalities correlate with endothelial dysfunction [ 20 ] . The results indicate shared pathways in the physiological architecture and pathological progression of retinal and coronary arteries. OCTA may also quantify the FAZ, the avascular region centrally situated in healthy human eyes, characterized by the largest concentration of cone photoreceptors and elevated oxygen demand, and around 400 micrometers [ 21 ] . Numerous studies indicate that alterations in its margins are mostly due to capillary loss and vascular remodeling [ 22 ] . FD-300 refers to the foveal vascular density within a 300 µm width around the true FAZ region, as automatically detected using OCTA. Research indicates that vascular density around the FAZ in type 2 diabetes patients exhibiting preclinical carotid atherosclerosis is markedly diminished compared to that in diabetic individuals devoid of subclinical carotid pathology [ 23 ] . Likewise, a reduced vascular density around the foveal avascular zone (FAZ) was seen in ischemic stroke patients compared to controls [ 24 ] . Our findings indicated that FD-300 was markedly reduced in high-risk ACS patients, and those experiencing MACES episodes had similarly lower levels of FD-300. In comparison to foveal DCP and SCP, FD-300 can optimize the minimization of bias arising from FAZ shape and retinal stratification in the evaluation of macular foveal microvascular density. This research represents the first use of FD-300 to assess alterations in macular foveal vascular density in ACS patients. Decreased FD-300 levels indicate heightened parafoveal capillary ischemia. Multivariate linear regression investigation indicated that FD-300 may more accurately predict risk stratification in ACS patients than other DCP and SCP markers. Consequently, the retinal microvascular system may provide additional insights into existing cardiovascular disease state and forecast the likelihood of cardiovascular-related events. Retinal microvascular imaging may function as an innovative non-invasive method for screening, diagnosing, and prognosticating cardiovascular disorders. OCT technology effectively visualizes the stratified architecture of the retina, and scholarly investigations have shown correlations between the thickness of various retinal layers and the risk of cardiovascular disease and atherosclerotic events. Research indicates that CAD patients have dramatically diminished subfoveal choroidal thickness and substantially reduced total retinal thickness [ 25 ] . Additional study has shown that the amount of retinal and choroidal thinning corresponds with the level of vascular involvement in coronary artery disease [ 26 ] . Our investigation identified a strong association between inner retinal thickness and nerve fiber layer thickness with Grace risk classification, especially in the nasal, superior, and inferior nerve fiber layers. A seven-year trial including 25,000 participants without a prior history of cardiovascular disease revealed that for each 5-micrometer decrease in RNFL thickness, the relative risk of coronary heart disease, heart failure, stroke, or mortality from these cardiovascular events escalated by 8%[27]. Recent investigations have shown a significant correlation between the superior quadrant of peripapillary RNFL and intracranial atherosclerotic stenosis (ICAS)[28]. It is theorized that ischemia and reperfusion injuries to coronary arteries expedite retinal ganglion cell death, resulting in damage and weakening of the retinal nerve fiber layer, while the advancement of vascular spasm and endothelial dysfunction may further compromise its blood supply. The thickness of distinct retinal layers is influenced by the extent of vascularization and various vascular-origin blockages and contractions, resulting in perfusion deficits in the DCP and SCP areas, eventually leading to retinal layer atrophy. Retinal and coronary microvessels exhibit coordinated reactions to shared cardiovascular risk factors, including hypertension, diabetes, hypercholesterolemia, and obesity. This reaction entails the death of endothelial cells and diminished nitric oxide generation, which accelerates inflammatory processes and results in poor angiogenesis [ 29 ] . In this study, despite our thorough efforts to exclude patients with retinal diseases, cancer, and congenital heart disease, we acknowledge that it remains impossible to entirely eliminate the potential influence of other comorbid conditions on retinal structure and blood flow function. Secondly, there are varying opinions among research teams concerning the agreement on OCTA scan quantification results. In the future, outcomes can be enhanced through multicenter studies that address measurement discrepancies among various devices and tackle challenges related to image quantification standardization. Clinical assessment of ACS prognosis remains tough, as the complexity of its pathophysiology and variety of clinical characteristics make reliable prediction presently impossible. Nonetheless, it is promising that with an enhanced comprehension of pathophysiology and ongoing advancements in diagnostic tools, multi-pathway and multi-indicator assessments provide a viable approach for improving ACS prognosis in the future. Early vascular remodeling may facilitate the prompt identification of individuals at high risk for cardiovascular disease. OCT and OCTA are quick, highly reproducible non-invasive biomarkers that have promise in evaluating risk factors and unfavorable prognoses in ACS patients. Assessing retinal microvascular condition enables non-invasive and very beneficial monitoring of systemic vascular health, facilitating early identification, intervention, and treatment of cardiovascular illnesses. Further study is necessary to confirm the clinical use of retinal microcirculation evaluation. Declarations Ethical approval All procedures performed in studies involving human participants were adhered to the Helsinki declaration and its lateral amendments. Approval was granted by the ethical review committee of Second People's Hospital of Changzhou, The Third Affiliated Hospital of Nanjing Medical University. Consent to participate Informed consent was obtained from all individual participants included in this study. Consent for publication Not Applicable. Availability of data and materials All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the article. Conflict of interest The authors have no conflicts of interest with regard to the article. Financial Support Changzhou Municipal Project of Applied Basic Research（CJ20250122） Author ’ s contributions Yuefeng Chen and Huanhuan Li : substantial contributions to the conception and design of the work; acquisition, analysis, and interpretation of data for the work; drafting and revising the work; final approval of the version to be published; and agreement to be accountable for all aspects of the work. 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Tables Table 1 Baseline characteristics of 122 eyes of 122 patients with ACS low-risk Group intermediate-risk Group high-risk Group r P patients 44 36 42 Age (years) 64.88±5.49 65.50±5.68 64.79±5.57 -0.010 0.915 Axial length of eye (mm) 23.89±0.82 24.01±0.88 23.66±0.75 -0.113 0.215 follow-up time(months） 13.84±1.27 14.44±1.80 14.33±1.78 0.104 0.253 ACS：acute coronary syndrome Table 2 Comparison of OCT measurements in 122 patients with ACS low-risk Group intermediate-risk Group high-risk Group r P Full Thickness(μm) 252.84±12.93 248.78±11.82 243.26±11.03 -0.480 0.024* Inner Thickness(μm) 51.61±3.80 48.86±2.79 44.81±4.44 -0.602 0.007** Average RNFL (μm) 109.36±7.56 98.50±7.92 86.83±10.29 -0.754 0.001** Superior RNFL (μm) 105.34±11.17 111.19±5.60 95.71±5.31 -0.432 0.031* Inferior RNFL (μm) 116.98±10.28 99.08±3.86 77.57±6.63 -0.912 0.002** Tempo RNFL (μm) 92.93±10.78 89.61±9.52 75.71±8.86 -0.096 0.047* Nasal RNFL (μm) 110.00±8.23 103.36±8.21 91.71±11.53 -0.634 0.013* OCT:Optical Coherence Tomography, ACS:acute coronary syndrome, RNFL:retina optic nerve layer Table 3 Comparison of SCP measurements in 122 patients with ACS Fovea VD(%) Tempo VD(%) Superior VD(%) Nasal VD(%) Inferior VD(%) low-risk Group 18.87±3.43 51.48±2.62 51.89±2.85 51.61±2.37 51.70±1.89 intermediate-risk Group 16.31±3.39 45.93±4.06 46.64±3.81 46.09±3.89 46.67±3.98 high-risk Group 14.18±2.64 40.15±2.71 40.22±2.87 40.00±2.71 40.14±3.30 r -0.535 -0.841 -0.846 -0.865 -0.852 P 0.022* 0.013* 0.011* 0.005** 0.009** SCP:superficial capillary plexus, ACS:acute coronary syndrome Table 4 Comparison of DCP measurements in 122 patients with ACS Fovea VD(%) Tempo VD(%) Superior VD(%) Nasal VD(%) Inferior VD(%) low-risk Group 32.58±4.19 56.21±3.29 55.55±3.79 56.72±3.56 56.71±3.76 intermediate-risk Group 30.09±3.66 50.11±3.84 50.93±3.24 51.32±3.27 52.60±2.77 high-risk Group 23.51±4.20 45.45±3.81 47.41±4.06 46.23±4.21 46.57±3.43 r -0.680 -0.784 -0.713 -0.772 -0.782 P 0.001* 0.012* 0.016* 0.014* 0.009** DCP:deep capillary plexus, ACS:acute coronary syndrome Table 5 Comparison of FAZ measurements in 122 patients with ACS low-risk Group intermediate-risk Group high-risk Group r P FAZ area(mm 2 ) 0.27±0.05 0.29±0.05 0.28±0.06 0.080 0.379 PERIM(mm) 2.06±0.24 2.11±0.25 2.16±0.17 0.380 0.015* FD(%) 51.29±3.86 46.86±3.28 43.78±3.27 -0.836 ＜0.000 ACS：acute coronary syndrome, FAZ: fovea avascular zone, PERIM FAZ perimeter, FD foveal vessel density in a 300 μm wide region around FAZ; Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Mar, 2026 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 12 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviews received at journal 30 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 27 Jan, 2026 Submission checks completed at journal 27 Jan, 2026 First submitted to journal 25 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8692938","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583480667,"identity":"58f011cf-9f0e-4ca8-b4f2-b52bb8538271","order_by":0,"name":"Yuefeng Chen","email":"","orcid":"","institution":"Changzhou No.2 People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuefeng","middleName":"","lastName":"Chen","suffix":""},{"id":583480668,"identity":"8cb24aae-ecdc-4364-bdc0-fa4511184c62","order_by":1,"name":"Li Chen","email":"","orcid":"","institution":"Yangpu Hospital of Tongji University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Chen","suffix":""},{"id":583480669,"identity":"0fe1d63a-ebce-4b98-8845-4db8cf9fd00e","order_by":2,"name":"Huanhuan Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACAyBmBjH4mBkbDiRU2PDw8zcQqYWNmbnxwYczaTKSMw4Qq4WBvdlwZtthG4OGBPxazCWSnz0ubLPLY2NnbJPmOXOex4DhAOOHjzm4tVjOSDM3ntmWXMzGDNJScZvHnLmBWXLmNjwOu5FgJs3bxpzYBtZy5jaPZcMBNmZevFrSvwG11EO08Lad4zE4kEBISw7IlsMgLSDvHyBCy5k3ZdI8546DtIACOZlHcsbBZvx+OZ6+TZqnrDqxn//4A2BU2tnz8zcf/PARjxZsgLGBNPWjYBSMglEwCjAAALeeT9olxYfpAAAAAElFTkSuQmCC","orcid":"","institution":"The First People's Hospital of Changzhou","correspondingAuthor":true,"prefix":"","firstName":"Huanhuan","middleName":"","lastName":"Li","suffix":""},{"id":583480670,"identity":"2a08cbb1-a287-4691-80cc-5c94ea020c4b","order_by":3,"name":"Zongliang Yu","email":"","orcid":"","institution":"Suzhou Medical college of Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Zongliang","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2026-01-25 14:09:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8692938/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8692938/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-026-04769-x","type":"published","date":"2026-03-30T15:58:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101786582,"identity":"9e9910a5-2984-439e-8f04-2893f2201c70","added_by":"auto","created_at":"2026-02-03 15:42:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1226482,"visible":true,"origin":"","legend":"\u003cp\u003eOCT images of the ACS patients from different GRACE risk group\u003c/p\u003e\n\u003cp\u003eOCT images of a high-risk group patient (male, 59 years old) showed the thickness of the inner retina and the nerve fiber layer significantly decreased, especially in the nasal quadrant, superior quadrant and inferior quadrant.The OCT of ACS patient from intermediate-risk group(male, 62 years old) showed a moderate decrease. However, in the low-risk group (male, 57 years old), such changes were not obvious.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8692938/v1/4d3f3100ac9503d5750f74ed.png"},{"id":101786627,"identity":"5c377bf8-f14c-44b2-a435-1d49d5b64e6c","added_by":"auto","created_at":"2026-02-03 15:42:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1604520,"visible":true,"origin":"","legend":"\u003cp\u003eOCTA images of the ACS patients from different GRACE risk group\u003c/p\u003e\n\u003cp\u003eOCTA images of a high-risk group patient (male, 63 years old) showed a typical ischemic appearance in both FD-300 (the area around the actual FAZ within 300 μm width marked yellow), SCP and DCP capillary network.The OCT scan of an ACS patient from the intermediate-risk group (male, 58 years old) showed a moderate decrease in density, while in the low-risk group (female, 65 years old), the reduction in vascular density caused by retinal ischemia was less pronounced.(acute coronary syndrome,ACS; fovea avascular zoon,FAZ; superficial capillary plexus, SCP; deep capillary plexus, DCP)\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8692938/v1/a604cc638b7097b5a9274dbf.png"},{"id":106343361,"identity":"3444db09-52ee-413b-aa17-9805cd853423","added_by":"auto","created_at":"2026-04-07 16:03:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4824388,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8692938/v1/5c2277e8-50b7-471a-81b5-c0d294850bfc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The value of retinal microvascular features in predicting risk stratification and long-term prognosis of patients with acute coronary syndrome","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute coronary syndrome (ACS) represents a major health concern, contributing to morbidity and mortality globally\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, and remains a persistent challenge within the healthcare sector\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. It imposes significant burdens on families and society while also placing considerable strain on public healthcare systems. Despite significant advancements in diagnostic and therapeutic capabilities resulting in reduced mortality rates, challenges persist in perioperative management and prognostic prediction. The preoperative identification of high-risk patients aids in the development of personalised treatment plans, enhancing prognosis and decreasing healthcare costs. The creation of innovative, non-invasive, and reliable assessment tools for risk stratification and disease monitoring represents a critical clinical necessity\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe association between retinal microvascular abnormalities and systemic vascular diseases has been a topic of interest since the 19th century. Retinal vessels, due to their high similarity in size and structure to coronary arterioles and capillaries, serve as a reflection of the coronary microvascular system\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, thereby facilitating the assessment of early cardiovascular risks\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Recent advancements in imaging technology, especially the extensive use of rapid and non-invasive diagnostic techniques such as Optical Coherence Tomography (OCT) and Optical Coherence Tomography Angiography (OCTA), have made the evaluation of cardiovascular disease risk a significant area of interest\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Retinal blood flow information has been established as an independent risk factor for adverse cardiovascular events in coronary artery disease\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, however, its significance in the prognostic evaluation of acute coronary syndrome remains ambiguous. This study employed OCTA and OCT to assess the retinal blood flow characteristics in patients with ACS. We correlated these findings with Grace scores and MACE events to elucidate the relationship between microvascular factors, risk stratification, and long-term prognosis in ACS patients.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 158 ACS patients were identified, all of whom received diagnosis and treatment at the Third Affiliated Hospital of Nanjing Medical University between January 2023 and December 2024. Gathered essential patient information, encompassing medical history, gender, age, risk factors, and family history. The diagnosis of ACS was established through the patient\u0026apos;s clinical symptoms, signs, laboratory examination results, and angiography findings. Patients were included in the study based on the following criteria. Inclusion criteria: (1) individuals aged 18 years or older; (2) all participants successfully underwent coronary angiography and percutaneous coronary intervention（PCI）\u0026nbsp;surgery; (3) all participants completed OCT and OCTA examinations. Exclusion criteria: (1) individuals with retinal conditions (including diabetic retinopathy, diabetic macular edema, vitreomacular traction, age-related macular degeneration); (2) individuals with a history of cataract surgery, previous laser interventions, intravitreal drug therapies, significant retinal surgeries, or those who have undergone treatment in the past three months; (3) individuals diagnosed with congenital heart disease, valvular heart disease, pericardial disease, or aortic dissection; (4) individuals identified with malignant tumors. This study protocol complies with the guidelines set forth by the Declaration of Helsinki and has received approval from the ethics committee (Approval No.: 2023 KY022-01). All participants completed an informed consent form following tailored explanations provided to them.\u003c/p\u003e\n\u003cp\u003eThe GRACE risk score for global acute coronary events was utilized to stratify risk among patients in the ACS group, categorizing them into low-risk (\u0026le;108 points), medium-risk (109-140 points), and high-risk (\u0026gt;140 points) groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Examination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll subjects underwent OCT (RTVue-XR Avanti; Optovue, Fremont, CA, USA) and OCTA (RTVue-XR Avanti; Optovue, Fremont, CA, USA) examinations at the ophthalmology clinic within three days postoperatively, with all fundus examinations and procedures conducted by proficient ophthalmic technicians.\u003c/p\u003e\n\u003cp\u003eOCT examines the retinal architecture with the macula as the focal point, and the program autonomously evaluates the thickness of each retinal layer of the central macular retina with a diameter of 1 mm (CRT-1 mm). The program measures the thickness of the retina\u0026apos;s total layer, superficial layer, deep layer, outer layer, and optic nerve layer. Measure the thickness of the superior, inferior, temporal, and nasal aspects of the optic nerve layer. The whole retinal measuring range extends from the internal limiting membrane(ILM)\u0026nbsp;to the outer plexiform layer(OPL)+10um. The superficial retina is delineated from ILM to the inner plexiform layer(IPL)-10um, the deep retina from IPL-10um to OPL+10um, and the outer retina from OPL+10um to the Bruch\u0026apos;s Membrane (BM)-10um.\u003c/p\u003e\n\u003cp\u003eOCTA does 6\u0026times;6mm scans. The macular capillary network is examined with a focus on the fovea, assessing various regions of the whole picture, including the fovea and parafovea (superior, inferior, temporal, nasal). The program autonomously computes the vessel density (VD) of the superficial capillary plexus (SCP) and the deep capillary plexus (DCP). Concurrently, it autonomously measures the FAZ area, FAZ Perimeter (PERIM), and FD-300 (foveal vascular density within a 300\u0026micro;m wide zone around the FAZ) of the retinal 3\u0026times;3mm macular region. The system\u0026apos;s integrated software segments the macula into three concentric rings. The foveal region is characterized as a circular area of 1mm by 1mm, centered on the macula, whereas the parafoveal region is delineated as an annular area with an outside diameter of 3mm and an inner diameter of 1mm. The border of the SCP extends from the internal limiting membrane to the inner plexiform layer, whereas the boundary of the DCP ranges from underneath the inner plexiform layer to the outer plexiform layer. This value is computed automatically by the program. Images exhibiting a signal strength index below 40, motion artifacts, erroneous segmentation, insufficient concentration, or inadequate focus are omitted during data reading and collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLong-term Prognosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Monitor the enrolled patients through outpatient visits and telephone calls, meticulously document the changes in patients\u0026apos; conditions 12 months post-surgery, note the occurrence of MACE events along with their specific timing, and categorize ACS group patients into MACE and non-MACE groups based on these events. The MACE events listed are: recurrent angina pectoris, heart failure, recurrent myocardial infarction, stroke, bleeding, repeat revascularization, stent thrombosis, in-stent restenosis, cardiac death, all-cause death.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was conducted with SPSS 27.0 program. Measurement results were presented as mean\u0026plusmn;standard deviation (x\u0026plusmn;s), and the means across the three groups were compared using the Spearman test. The disparities between the two groups were assessed using the two-sample t-test. Variations in qualitative variables were assessed by Fisher\u0026apos;s exact test. Correlation was evaluated via ordinal logistic regression. \u003cem\u003eP\u003c/em\u003e-values less than 0.05 were deemed statistically significant.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cstrong\u003eBaseline Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 122 patients participated in the trial and completed all follow-ups, including 77 men (63.11%) and 45 females (36.89%). The age varied from 56 to 76 years, with a mean age of (65.03\u0026nbsp;\u0026plusmn;\u0026nbsp;5.54) years. The axial length varied between 22.10 mm and 25.60 mm, with a mean of (23.85\u0026nbsp;\u0026plusmn;\u0026nbsp;0.82) mm. The follow-up duration varied from 12 to 18 months, with a mean of (23.85\u0026nbsp;\u0026plusmn;\u0026nbsp;0.82) months. Based on the Grace risk categorization, patients were categorized into three groups: the low-risk group (44 individuals,\u0026nbsp;\u0026le;108 points), the intermediate-risk group (36 individuals, 109\u0026ndash;140 points), and the high-risk group (42 individuals, \u0026gt;140 points). No statistically significant variations were seen among the three groups for age, axial length, and follow-up duration (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOCT findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 122 patients underwent OCT examination. The metrics of focus included: retinal thickness, inner retinal thickness, and nerve fiber layer thickness（Figure\u0026nbsp;1）. The results of the bivariate correlation analysis indicated a correlation between retinal thickness and nerve fiber layer thickness with Grace staging(Table 2). Logistic regression research indicated a strong correlation between inner retinal thickness and nerve fiber layer thickness with the Grace risk classification (r=-0.895, \u003cem\u003eP\u003c/em\u003e=0.029) (r=-0.371, \u003cem\u003eP\u003c/em\u003e=0.035). Subsequent examination of the nerve fiber layer thickness across several quadrants revealed that the nasal, superior, and inferior quadrants had a stronger correlation with the Grace stratification (r=-0.174, \u003cem\u003eP\u003c/em\u003e=0.026) (r=0.267, \u003cem\u003eP\u003c/em\u003e=0.005) (r=-0.770, \u003cem\u003eP\u003c/em\u003e＜0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOCTA findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research assessed preoperative OCTA in 122 ACS patients, indicating characteristic ischemia alterations in the retinal SCP and DCP, along with capillary network deficiencies (Figure 2). Quantitative research revealed a statistically significant negative correlation between the Grace score and both foveal and parafoveal SCP and DCP(Table 3,4). In relation to the FAZ region, statistically significant variations were noted in PERIM and FD across various groups; however, no significant difference was detected in the FAZ area itself(Table 5). Logistic regression study revealed that only FD-300 and foveal DCP had significant correlation with the Grace risk score (r=-0.761, \u003cem\u003eP\u003c/em\u003e=0.024) (r=-0.510, \u003cem\u003eP\u003c/em\u003e=0.035).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow Up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the participants in the research, 18 developed MACEs, whereas 104 did not after 12 months postoperatively. All 18 patients who had MACEs were classified inside the high-risk category according to the GRACE risk classification.\u003c/p\u003e\n\u003cp\u003eComparing the inner retinal thickness, nerve fiber layer thickness,\u0026nbsp;FD-300 and foveal DCP\u0026nbsp;between 18 persons who suffered MACEs and 23 individuals in the high-risk group who did not, revealed statistically significant differences（t=5.198, \u003cem\u003eP\u003c/em\u003e＜0.001）（t=7.885, \u003cem\u003eP\u003c/em\u003e＜0.001）(t=4.626,\u003cem\u003eP\u003c/em\u003e＜0.001)(t=6.413,\u0026nbsp;\u003cem\u003eP\u003c/em\u003e＜0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEarly detection and a poor prognosis of ACS pose significant problems in the worldwide medical community. This disease's pathogenesis is characterized by the dual activity of macro and microvessels\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Traditional techniques used by cardiologists to directly observe cardiac microcirculation have limitations such as being highly invasive, costly, and operator-dependent, emphasizing the critical need for the development of innovative, non-invasive, and reliable risk stratification and disease monitoring methods\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Because of its unique position and anatomical properties, the retina, unlike the coronary arteries, may be evaluated non-invasively. In recent years, advances in retinal imaging technology, notably OCTA and OCT, have been extensively employed for accurate, objective, and highly repeatable evaluations of retinal anatomy and vascularization. McClintic originally recommended employing retinal evaluation to screen low-risk individuals for CAD, which he later proposed as a guideline indication\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Subsequent research has shown that retinal microvascular anomalies are directly associated with an elevated risk of cardiovascular disease (CVD)\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. However, the use of retinal vasculature in the early diagnosis of ACS and the prediction of poor prognosis is questionable.\u003c/p\u003e \u003cp\u003eThis relatively novel non-invasive vascular imaging method has shown the ability to identify retinal vascular alterations associated with cardiovascular metabolic variables, suggesting its potential as a surrogate biomarker for cardiovascular disease. In 2018, Arnold's team discovered that SCP was markedly reduced in ACS patients compared to healthy controls\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The GRACE risk score is a widely used scoring system for prognostic assessment in patients with ACS. A higher score correlates with an increased probability of significant cardiovascular events, providing a crucial foundation for therapy selection and prognosis assessment. Consequently, examining the correlation between retinal microvascular features and GRACE risk scores is crucial for the early identification of ACS, prompt therapeutic management, and assessment of patient prognosis, thereby enhancing medical standards and patient quality of life. Our research revealed a negative correlation between Grace stage and macular foveal as well as parafoveal superficial and deep capillary plexus. SCP perfuses the nerve fiber layer and ganglion cell layer, while DCP perfuses portions of the inner nuclear layer and outer plexiform layer\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, vascular anomalies in these areas often possess pathogenic significance. The retinal microvascular system has a comparable diameter (100\u0026ndash;250\u0026micro;m) to that of the coronary microvascular system\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. In individuals with coronary heart disease, retinal microcirculatory abnormalities correlate with endothelial dysfunction\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. The results indicate shared pathways in the physiological architecture and pathological progression of retinal and coronary arteries.\u003c/p\u003e \u003cp\u003eOCTA may also quantify the FAZ, the avascular region centrally situated in healthy human eyes, characterized by the largest concentration of cone photoreceptors and elevated oxygen demand, and around 400 micrometers\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Numerous studies indicate that alterations in its margins are mostly due to capillary loss and vascular remodeling\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. FD-300 refers to the foveal vascular density within a 300 \u0026micro;m width around the true FAZ region, as automatically detected using OCTA. Research indicates that vascular density around the FAZ in type 2 diabetes patients exhibiting preclinical carotid atherosclerosis is markedly diminished compared to that in diabetic individuals devoid of subclinical carotid pathology\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Likewise, a reduced vascular density around the foveal avascular zone (FAZ) was seen in ischemic stroke patients compared to controls\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Our findings indicated that FD-300 was markedly reduced in high-risk ACS patients, and those experiencing MACES episodes had similarly lower levels of FD-300. In comparison to foveal DCP and SCP, FD-300 can optimize the minimization of bias arising from FAZ shape and retinal stratification in the evaluation of macular foveal microvascular density. This research represents the first use of FD-300 to assess alterations in macular foveal vascular density in ACS patients. Decreased FD-300 levels indicate heightened parafoveal capillary ischemia. Multivariate linear regression investigation indicated that FD-300 may more accurately predict risk stratification in ACS patients than other DCP and SCP markers. Consequently, the retinal microvascular system may provide additional insights into existing cardiovascular disease state and forecast the likelihood of cardiovascular-related events. Retinal microvascular imaging may function as an innovative non-invasive method for screening, diagnosing, and prognosticating cardiovascular disorders.\u003c/p\u003e \u003cp\u003eOCT technology effectively visualizes the stratified architecture of the retina, and scholarly investigations have shown correlations between the thickness of various retinal layers and the risk of cardiovascular disease and atherosclerotic events. Research indicates that CAD patients have dramatically diminished subfoveal choroidal thickness and substantially reduced total retinal thickness\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Additional study has shown that the amount of retinal and choroidal thinning corresponds with the level of vascular involvement in coronary artery disease\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Our investigation identified a strong association between inner retinal thickness and nerve fiber layer thickness with Grace risk classification, especially in the nasal, superior, and inferior nerve fiber layers. A seven-year trial including 25,000 participants without a prior history of cardiovascular disease revealed that for each 5-micrometer decrease in RNFL thickness, the relative risk of coronary heart disease, heart failure, stroke, or mortality from these cardiovascular events escalated by 8%[27]. Recent investigations have shown a significant correlation between the superior quadrant of peripapillary RNFL and intracranial atherosclerotic stenosis (ICAS)[28]. It is theorized that ischemia and reperfusion injuries to coronary arteries expedite retinal ganglion cell death, resulting in damage and weakening of the retinal nerve fiber layer, while the advancement of vascular spasm and endothelial dysfunction may further compromise its blood supply. The thickness of distinct retinal layers is influenced by the extent of vascularization and various vascular-origin blockages and contractions, resulting in perfusion deficits in the DCP and SCP areas, eventually leading to retinal layer atrophy. Retinal and coronary microvessels exhibit coordinated reactions to shared cardiovascular risk factors, including hypertension, diabetes, hypercholesterolemia, and obesity. This reaction entails the death of endothelial cells and diminished nitric oxide generation, which accelerates inflammatory processes and results in poor angiogenesis\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, despite our thorough efforts to exclude patients with retinal diseases, cancer, and congenital heart disease, we acknowledge that it remains impossible to entirely eliminate the potential influence of other comorbid conditions on retinal structure and blood flow function. Secondly, there are varying opinions among research teams concerning the agreement on OCTA scan quantification results. In the future, outcomes can be enhanced through multicenter studies that address measurement discrepancies among various devices and tackle challenges related to image quantification standardization.\u003c/p\u003e \u003cp\u003eClinical assessment of ACS prognosis remains tough, as the complexity of its pathophysiology and variety of clinical characteristics make reliable prediction presently impossible. Nonetheless, it is promising that with an enhanced comprehension of pathophysiology and ongoing advancements in diagnostic tools, multi-pathway and multi-indicator assessments provide a viable approach for improving ACS prognosis in the future. Early vascular remodeling may facilitate the prompt identification of individuals at high risk for cardiovascular disease. OCT and OCTA are quick, highly reproducible non-invasive biomarkers that have promise in evaluating risk factors and unfavorable prognoses in ACS patients. Assessing retinal microvascular condition enables non-invasive and very beneficial monitoring of systemic vascular health, facilitating early identification, intervention, and treatment of cardiovascular illnesses. Further study is necessary to confirm the clinical use of retinal microcirculation evaluation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were adhered to the Helsinki declaration and its lateral amendments. Approval was granted by the ethical review committee of Second People\u0026apos;s Hospital of Changzhou, The Third Affiliated Hospital of Nanjing Medical University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this article. Further inquiries can be directed to the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest with regard to the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChangzhou Municipal Project of Applied Basic Research（CJ20250122）\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003es contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYuefeng Chen and Huanhuan Li : substantial contributions to the conception and design of the work; acquisition, analysis, and interpretation of data for the work; drafting and revising the work; final approval of the version to be published; and agreement to be accountable for all aspects of the work. Yuefeng Chen, Li Chen, Huanhuan Li, and Zongliang Yu: revising the work; final approval of the work, and agreement to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eHeart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association\u003c/strong\u003e. \u003cem\u003eCirculation \u003c/em\u003e2023, \u003cstrong\u003e147\u003c/strong\u003e(8):e93-e621.\u003c/li\u003e\n\u003cli\u003eTajeu GS, Ruiz-Negron N, Moran AE, Zhang Z, Kolm P, Weintraub WS, Bress AP, Bellows BK: \u003cstrong\u003eCost of Cardiovascular Disease Event and Cardiovascular Disease Treatment-Related Complication Hospitalizations in the United States\u003c/strong\u003e. \u003cem\u003eCirc Cardiovasc Qual Outcomes \u003c/em\u003e2024, 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\u003cstrong\u003eRetinal nerve fiber layer thinning as a novel fingerprint for cardiovascular events: results from the prospective cohorts in UK and China\u003c/strong\u003e. \u003cem\u003eBMC Med \u003c/em\u003e2023, \u003cstrong\u003e21\u003c/strong\u003e(1):24.\u003c/li\u003e\n\u003cli\u003eGao Y, Zhang X, Wu D, Wu C, Ren C, Meng T, Ji X: \u003cstrong\u003eEvaluation of peripapillary retinal nerve fiber layer thickness in intracranial atherosclerotic stenosis\u003c/strong\u003e. \u003cem\u003eBMC Ophthalmol \u003c/em\u003e2023, \u003cstrong\u003e23\u003c/strong\u003e(1):455.\u003c/li\u003e\n\u003cli\u003eVita JA: \u003cstrong\u003eEndothelial function\u003c/strong\u003e. \u003cem\u003eCirculation \u003c/em\u003e2011, \u003cstrong\u003e124\u003c/strong\u003e(25):e906-912. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e Baseline characteristics of 122 eyes of 122 patients with ACS\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"655\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e\u003cstrong\u003elow-risk Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eintermediate-risk Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ehigh-risk Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003epatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e64.88\u0026plusmn;5.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e65.50\u0026plusmn;5.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e64.79\u0026plusmn;5.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003eAxial length of eye (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e23.89\u0026plusmn;0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e24.01\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e23.66\u0026plusmn;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.215\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003efollow-up time(months）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e13.84\u0026plusmn;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 172px;\"\u003e\n \u003cp\u003e14.44\u0026plusmn;1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 127px;\"\u003e\n \u003cp\u003e14.33\u0026plusmn;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e0.253\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eACS：acute coronary syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eComparison of OCT measurements in 122 patients with ACS\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"661\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003elow-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003eintermediate-risk Group\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ehigh-risk Group\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eFull Thickness(\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e252.84\u0026plusmn;12.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e248.78\u0026plusmn;11.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e243.26\u0026plusmn;11.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.024*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eInner Thickness(\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e51.61\u0026plusmn;3.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e48.86\u0026plusmn;2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e44.81\u0026plusmn;4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.602\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.007**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eAverage RNFL (\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e109.36\u0026plusmn;7.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e98.50\u0026plusmn;7.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e86.83\u0026plusmn;10.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eSuperior RNFL (\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e105.34\u0026plusmn;11.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e111.19\u0026plusmn;5.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e95.71\u0026plusmn;5.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.432\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.031*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eInferior RNFL (\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e116.98\u0026plusmn;10.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e99.08\u0026plusmn;3.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e77.57\u0026plusmn;6.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.912\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.002**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eTempo RNFL (\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e92.93\u0026plusmn;10.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e89.61\u0026plusmn;9.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e75.71\u0026plusmn;8.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.047*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003eNasal RNFL (\u0026mu;m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e110.00\u0026plusmn;8.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 158px;\"\u003e\n \u003cp\u003e103.36\u0026plusmn;8.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e91.71\u0026plusmn;11.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e-0.634\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOCT:Optical Coherence Tomography, ACS:acute coronary syndrome, RNFL:retina optic nerve layer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eComparison of SCP measurements in 122 patients with ACS\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"696\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eFovea VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTempo VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSuperior VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eNasal VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eInferior VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;low-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.87\u0026plusmn;3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e51.48\u0026plusmn;2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e51.89\u0026plusmn;2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e51.61\u0026plusmn;2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e51.70\u0026plusmn;1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eintermediate-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16.31\u0026plusmn;3.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e45.93\u0026plusmn;4.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e46.64\u0026plusmn;3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e46.09\u0026plusmn;3.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e46.67\u0026plusmn;3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003ehigh-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14.18\u0026plusmn;2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e40.15\u0026plusmn;2.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e40.22\u0026plusmn;2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e40.00\u0026plusmn;2.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e40.14\u0026plusmn;3.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.535\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-0.846\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e-0.852\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.022*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.013*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.005**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e0.009**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSCP:superficial capillary plexus, ACS:acute coronary syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eComparison of DCP measurements in 122 patients with ACS\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"696\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eFovea VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTempo VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSuperior VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eNasal VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eInferior VD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;low-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e32.58\u0026plusmn;4.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e56.21\u0026plusmn;3.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e55.55\u0026plusmn;3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e56.72\u0026plusmn;3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e56.71\u0026plusmn;3.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eintermediate-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e30.09\u0026plusmn;3.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e50.11\u0026plusmn;3.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e50.93\u0026plusmn;3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e51.32\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e52.60\u0026plusmn;2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003ehigh-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e23.51\u0026plusmn;4.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e45.45\u0026plusmn;3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e47.41\u0026plusmn;4.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e46.23\u0026plusmn;4.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e46.57\u0026plusmn;3.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-0.713\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.772\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e-0.782\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0.016*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.014*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e0.009**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDCP:deep capillary plexus, ACS:acute coronary syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eComparison of FAZ measurements in 122 patients with ACS\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003elow-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eintermediate-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ehigh-risk Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eFAZ area(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.27\u0026plusmn;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e0.29\u0026plusmn;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e0.28\u0026plusmn;0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003ePERIM(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2.06\u0026plusmn;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e2.11\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e2.16\u0026plusmn;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e0.015*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eFD(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e51.29\u0026plusmn;3.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;46.86\u0026plusmn;3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e43.78\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;-0.836\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e＜0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eACS：acute coronary syndrome, FAZ: fovea avascular zone, PERIM FAZ perimeter, FD foveal vessel density in a 300 \u0026mu;m wide region around FAZ;\u0026nbsp;\u003c/p\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":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acute coronary syndrome, optical coherence tomography angiography, optical coherence tomography, GRACE risk stratification, MACE long-term events","lastPublishedDoi":"10.21203/rs.3.rs-8692938/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8692938/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study investigates the retinal blood flow characteristics in patients with acute coronary syndrome (ACS) utilising OCTA and OCT. It aims to correlate these characteristics with Grace risk stratification and long-term major adverse cardiovascular events (MACE), while also examining the relationship between microvascular changes, risk stratification, and long-term prognosis in ACS patients.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003e122 ACS patients (122 eyes) underwent coronary angiography and PCI, with a follow-up period of 12 months. Patients were categorised into high-risk, intermediate-risk, and low-risk groups based on the Grace score. OCT was employed to assess the thickness of the full thickness, superficial layer, deep layer, outer layer, and optic nerve layer of the retina. The superficial, deep foveal, and parafoveal blood flow densities, along with the perimeter, area, and FAD-300 of the FAZ, were assessed using OCTA.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eGrace staging has a negative correlation with the macular foveal and parafoveal SCP and DCP, achieving statistical significance. In the FAZ region, statistical disparities were seen in PERIM and FD among various groups; however, no significant difference was identified in the FAZ area. The thickness of the inner retina and the nerve fibre layer correlates with Grace stage. Ordinal logistic regression analysis reveals that FD-300, foveal DCP, inner retinal thickness, and nerve fibre layer thickness are strongly correlated with Grace high-risk staging (r=-0.761, P\u0026thinsp;=\u0026thinsp;0.024)(r=-0.510, P\u0026thinsp;=\u0026thinsp;0.035)(r=-0.895, P\u0026thinsp;=\u0026thinsp;0.029)(r=-0.371, P\u0026thinsp;=\u0026thinsp;0.035). Comparative analysis of the aforementioned indicators between the 18 persons who suffered MACE episodes and the 23 high-risk individuals without MACE events revealed statistically significant differences.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOCT and OCTA serve as rapid and reproducible non-invasive biomarkers, demonstrating potential for evaluating risk characteristics and adverse outcomes in patients with ACS. This facilitates advancements in the early detection, intervention, and treatment of cardiovascular diseases.\u003c/p\u003e","manuscriptTitle":"The value of retinal microvascular features in predicting risk stratification and long-term prognosis of patients with acute coronary syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 15:40:34","doi":"10.21203/rs.3.rs-8692938/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-12T06:19:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T22:49:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145728652820625667489216008792049298591","date":"2026-02-04T18:12:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262293308690364252853048342088317646311","date":"2026-02-03T12:53:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330199916442156132569600227216111746930","date":"2026-01-31T10:55:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89235912017000167705320349835487147476","date":"2026-01-31T08:49:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T21:48:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306081787733336140724430663872735291641","date":"2026-01-29T20:13:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211275445172053498365441743449032849489","date":"2026-01-29T19:13:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T08:33:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T13:14:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-27T13:12:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2026-01-25T14:02:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e397273c-e209-4743-a682-000b3b575bda","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T16:01:09+00:00","versionOfRecord":{"articleIdentity":"rs-8692938","link":"https://doi.org/10.1186/s12886-026-04769-x","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2026-03-30 15:58:08","publishedOnDateReadable":"March 30th, 2026"},"versionCreatedAt":"2026-02-03 15:40:34","video":"","vorDoi":"10.1186/s12886-026-04769-x","vorDoiUrl":"https://doi.org/10.1186/s12886-026-04769-x","workflowStages":[]},"version":"v1","identity":"rs-8692938","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8692938","identity":"rs-8692938","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}