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Mukkamala SK, Costa RA, Fung A, Sarraf D, Gallego-Pinazo R, Freund KB. Optical Coherence Tomographic Imaging of Sub-Retinal Pigment Epithelium Lipid. Arch Ophthalmol. 2012;130(12):1547–1553. doi:10.1001/archophthalmol.2012.2491
Author Affiliations: Vitreous Retina Macula Consultants of New York, New York (Drs Mukkamala, Fung, and Freund), LuEsther T. Mertz Retinal Research Center, New York (Drs Mukkamala, Fung, and Freund), Department of Ophthalmology, New York University, New York (Drs Mukkamala and Freund), Edward S. Harkness Eye Institute, Columbia University, New York (Drs Mukkamala and Freund), New York; Centro Brasileiro de Ciencias Visuais, Belo Horizonte, Minas Gerais, Brazil (Dr Costa); Retinal Disorders and Ophthalmic Genetics Division, Jules Stein Eye Institute, University of California, Los Angeles (Dr Sarraf), Greater Los Angeles VA Healthcare Center (Dr Sarraf), Los Angeles, California; and Department of Ophthalmology, University and Polytechnic Hospital, La Fe, Valencia, Spain (Dr Gallego-Pinazo).
Objective To describe an optical coherence tomographic finding of layered hyperreflective bands beneath the retinal pigment epithelium (RPE), the so-called onion sign believed to represent lipid within a vascularized pigment epithelial detachment.
Methods This retrospective observational case series involved reviewing clinical histories of patients with the onion sign. Imaging studies analyzed included spectral-domain optical coherence tomography, color and red-free photographs, near infrared reflectance, fundus autofluorescence, and blue-light fundus autofluorescence.
Results A total of 22 eyes of 20 patients with sub-RPE hyperreflective bands were identified. There were 15 women and 5 men with a mean patient age of 76 years (range, 60-92 years). Snellen best-corrected visual acuities ranged from 20/25 to counting fingers, with a median of 20/80. Two patients had bilateral involvement, and 3 of 17 eyes had multifocal onion signs in the same eye. All eyes had neovascular age-related macular degeneration, with type 1 (sub-RPE) neovascularization. In all patients, the onion sign correlated with areas of yellow-gray exudates seen clinically that appeared bright on red-free and near infrared reflectance imaging. No specific fundus autofluorescence or blue-light fundus autofluorescence pattern was identified.
Conclusions The onion sign refers to layered hyperreflective bands in the sub-RPE space usually associated with chronic exudation from type 1 neovascularization in patients with age-related macular degeneration. With an associated bright near infrared reflectance, these bands may correspond to lipid, collagen, or fibrin. Because the onion sign colocalizes to areas of exudation that are known to consist of lipoprotein, we propose that this finding may represent layers of precipitated lipid in the sub-RPE space. To our knowledge, this is the first report of lipid detected in the sub-RPE space on clinical examination.
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