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Maduna 2,3,*, Dubravka Biuk 1,2, Zdravka Krivdi´c Dupan 2,4, Josip Bara´c 1,2, Nikolina Šilješ 4, Laura Jeluši´c 5, Tvrtka Benaši´c 1,2 and Jelena Juri Mandi´c 6,7  \nAcademic Editor: Minzhong Yu  \nReceived: 4 November 2025  \nRevised: 8 December 2025  \nAccepted: 10 December 2025  \nPublished: 1 January 2026  \nCopyright: © 2026 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license.  \n1 Department of Ophthalmology, University Hospital Center Osijek, 31000 Osijek, Croatia; [verajelusic@gmail.com](verajelusic@gmail.com) (V.J.); [dubravka.biuk@gmail.com](dubravka.biuk@gmail.com) (D.B.); [jbarac@mefos.hr](jbarac@mefos.hr) (J.B.); [tvrtka@gmail.com](tvrtka@gmail.com) (T.B.)  \n2 Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, 31000 Osijek, Croatia; [zdravka.krivdic@gmail.com](zdravka.krivdic@gmail.com)  \n3 Health Center of Osijek-Baranja County, 31000 Osijek, Croatia  \n4 Department of Radiology, University Hospital Center Osijek, 31000 Osijek, Croatia; [nikolina.grbavac91@gmail.com](nikolina.grbavac91@gmail.com)  \n5 Department of Cardiology, University Hospital Center Osijek, 31000 Osijek, Croatia; [laura.jelusic@kbco.hr](laura.jelusic@kbco.hr)  \n6 School of Medicine, University of Zagreb, 10000 Zagreb, Croatia; [jmiklau@gmail.com](jmiklau@gmail.com)  \n7 Department of Ophthalmology, University Hospital Center Zagreb, 10000 Zagreb, Croatia  \n* Correspondence: [ivankamadun@gmail.com](ivankamadun@gmail.com)  \nAbstract  \nBackground/Objectives: Thyroid eye disease (TED) can lead to structural and microvascular changes in the orbit and retina. This study aimed to investigate the associations between Clinical Activity Score (CAS), orbital magnetic resonance imaging (MRI) measurements, and retinal microvascular changes in TED patients. Methods: This cross-sectional study included 38 patients (76 eyes) with TED. Each patient underwent a comprehensive ophthalmological evaluation, CAS assessment, and a detailed medical history. Optical coherence tomography angiography (OCTA) was performed to quantify vessel density (VD) in the superficial and deep capillary plexus (SCP and DCP) . Exophthalmos, extraocular muscle thickness and orbital fat thickness were measured on MRI scans to evaluate structural changes. Laboratory analyses included thyroid hormone levels, thyrotropin receptor antibodies (TRAb), anti-thyroid peroxidase antibodies (anti-TPO), and lipid profile. Results: Active TED patients (CAS ≥ 3) had significantly higher TRAb levels (p \u003C 0.001), while anti-TPO did not differ between groups. Active eyes showed significantly higher DCP VDin the whole image (p = 0.013), parafovea (p = 0.012), and perifovea (p = 0.009) across all quadrants, with no difference in SCP or the foveal avascular zone (FAZ) . In linear mixed model regression analyses, after adjusting for previous glucocorticosteroid therapy, higher triglycerides, greater medial rectus thickness, and whole-image DCP VD independently predicted higher CAS values (R2 = 42, p \u003C 0.001) . After adjusting for age and sex, CAS remained significantly positive predictor of DCP VD in the parafovea (R2 = 0.22, p \u003C 0.001) . Conclusions: Changes in DCP VD reflect TED activity and structural orbital involvement.  \nKeywords: biomarkers; magnetic resonance imaging; optical coherence tomography angiography; thyroid eye disease  \n1. Introduction  \nThyroid eye disease (TED) represents the orbital manifestation of autoimmune thyroid disorders, most frequently associated with Graves’ hyperthyroidism (GH) [1,2] . It is  \nestimated that 30% of patients with GH develop clinically manifest TED, with a higher incidence in women, but severe forms are more common in males [3–5] . It is a heterogeneous condition with diverse clinical presentations t","cbCaiiyYHp6JoqML","https://ap.wps.com/l/cbCaiiyYHp6JoqML","pdf",635941,15,"English","# Abstract\n# 1. Introduction","[{\"question\":\"What was the study’s main aim in TED patients?\",\"answer\":\"To examine associations between Clinical Activity Score (CAS), orbital MRI metrics, and retinal microvascular changes measured by OCTA in patients with thyroid eye disease.\"},{\"question\":\"How were TED activity and retinal vessels assessed?\",\"answer\":\"TED activity was assessed using CAS, and retinal microvascular changes were quantified with OCTA vessel density in the superficial and deep capillary plexus.\"},{\"question\":\"What findings connected deep capillary plexus vessel density to TED activity?\",\"answer\":\"Active eyes (CAS ≥ 3) had significantly higher DCP vessel density in multiple retinal regions, and CAS remained a positive predictor of DCP vessel density after adjusting for age and sex.\"}]","Retinal Microvascular and Orbital Structural Alterations in Thyroid Eye Disease | PDF",1790761869,38]