Title: Beyond Pelvic Pathology: Retinal Microvascular Rarefaction as a Systemic Marker in
Endometriosis
Version: 2 Date: 14 Jun 2025
Reviewer's report:
General Comments
This study explores the OCTA findings in patients with endometriosis, addressing a highly
interesting and novel research topic. Visualization of retinal microvasculature may offer a new
potential biomarker in this patient population. I would appreciate clarification on several points
as outlined below.
1. Participants and Methods
1.1 Severity Classification of Endometriosis
Endometriosis severity is commonly classified using internationally recognized systems such as
the ASRM classification. Could the authors clarify the distribution of disease severity among
participants? Furthermore, if possible, an analysis of OCTA findings by severity subgroup may
enhance the clinical relevance of the study.
1.2 Axial Length Measurement
Was axial length measured in this study? Axial length is a well-known factor that can influence
OCTA image scaling and may affect vascular density measurements. Clarification on whether
it was considered would be helpful.
1.3 OCTA Image Quality and Exclusion Criteria
The authors excluded cases with a signal strength index <30 dB or segmentation artifacts. It
would be beneficial to indicate the rationale or reference guidelines supporting this threshold.
2. Results
2.1 Table 1: Definition of Retinal Thickness Parameters
Please clarify the definitions of “Central Macular Thickness” and “Foveal Retinal Thickness.”
Typically, macular thickness values are higher than foveal thickness values; however, in the
present study, the opposite is shown. Additionally, please explain the definition of “Parafoveal
Retinal Thickness.” Was the ETDRS grid used for analysis? The evaluated regions are somewhat
unclear.
2.2 Table 2: Vascular Density Parameters
Similar to retinal thickness, the definitions of “Foveal” and “Parafoveal” vascular density
regions are not fully described. Could the authors specify which areas these terms refer to? Also,
the indicator “FD-300” requires further explanation—what does it represent, what region does
it cover, and how should the values be interpreted?
3. Figures
3.1 Figure 1: Region of Interest
Figure 1 appears to be a screenshot, and the evaluated areas for each OCT/OCTA parameter are
difficult to identify, particularly for readers unfamiliar with the Heidelberg Spectralis system. I
would recommend reconstructing the figure to show only the relevant parameters and regions
used in this study, which would improve clarity and understanding of the results.
4. Discussion and Conclusion
4.1 Expression in Discussion
The authors state: “In this study, women with pelvic endometriosis exhibited a significant
reduction in retinal microvascular density compared to healthy controls.” However, this may
be an overstatement, as the evaluation in this study was limited to the foveal region and did
not include the entire macula or peripheral retina. It would be more appropriate to limit this
conclusion to the evaluated area, such as “within the foveal region.”
4.2 Clarification in Conclusion
As mentioned above, the findings of this study are based on a limited area of the retina.
Therefore, the conclusion should also be revised to reflect that the results are specific to the
foveal region and not generalizable to the entire retina.