Optical coherence tomographic imaging of sub-retinal pigment epithelium lipid

Sri Krishna Mukkamala, Rogerio A. Costa, Adrian Fung, David Sarraf, Roberto Gallego-Pinazo, K. Bailey Freund*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

25 Citations (Scopus)


Objective: To describe an optical coherence tomographic finding of layered hyperreflective bands beneath the retinal pigment epithelium (RPE), the socalled 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 redfree 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.

Original languageEnglish
Pages (from-to)1547-1553
Number of pages7
JournalArchives of Ophthalmology
Issue number12
Publication statusPublished - Dec 2012
Externally publishedYes


Dive into the research topics of 'Optical coherence tomographic imaging of sub-retinal pigment epithelium lipid'. Together they form a unique fingerprint.

Cite this