Original articleThe Onion Sign in Neovascular Age-Related Macular Degeneration Represents Cholesterol Crystals
Section snippets
Methods
The Western Institutional Review Board and the Institutional Review Board at University of Alabama at Birmingham approved the retrospective, observational cohort study and the experimental study, respectively. Research complied with the Health Insurance Portability and Accountability Act and adhered to the tenets of the Declaration of Helsinki.
Clinical Imaging and Associations
A cohort of 230 eyes of 150 consecutive patients (mean age, 84 years; 108 women and 42 men) with neovascular AMD was identified. Of these, 16 eyes of 15 patients (7.0%; mean age, 82 years; 13 women and 2 men) were found to exhibit the onion sign with SD OCT imaging. The onion sign corresponded to refractile yellow-gray exudates on color fundus photography and hyperreflective lesions on NIR SLO imaging in all 16 eyes (Fig 1).
Qualitative analysis of serial SD OCT scans revealed that the onion
Discussion
To our knowledge, this study is the first to report frequency, natural history, and histologic correlates of the onion sign in neovascular AMD. A long-lasting yet dynamic structure, the onion sign was visible in approximately 5% to 7% of neovascular AMD eyes and associated positively with intraretinal or subretinal hyperreflective foci and intraretinal fluid. A possible association between the onion sign and systemic hypercholesterolemia was suggested by a significantly higher use of
Acknowledgments
The authors thank the personnel of the Alabama Eye Bank (Doyce V. Williams, Executive Director, and Alan S. Blake, Chief Technical Officer) for timely retrieval of donor eyes and Giovanni Staurenghi, MD, for facilitating the participation of Dr. Zanzottera.
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Supplemental material is available at www.aaojournal.org.
Financial Disclosure(s): The author(s) have made the following disclosure(s):
K.B.F.: Consultant - Genentech; Optos; Heidelberg Engineering; Thrombogenics; Optovue
Supported by the Macula Foundation (New York, NY); the LuEsther T. Mertz Retinal Research Center (New York, NY); the National Institutes of Health (NIH), Bethesda, Maryland (grant no.: R01 EY06109), and the National Eye Institute, NIH (grant no.: P30 EY003039); Research to Prevent Blindness, Inc., New York, New York; EyeSight Foundation of Alabama (Birmingham AL); the International Retinal Research Foundation (Birmingham AL); and the Arnold and Mabel Beckman Initiative for Macular Research (Irvine CA). Project MACULA received additional support from the Edward N. and Della L. Thome Memorial Foundation (Boston MA), and the International Retinal Research Foundation (Birmingham AL). The funding organizations had no role in the design and conduct of this study.
Author Contributions:
Conception and design: Pang, Messinger, Freund, Curcio
Analysis and interpretation: Pang, Messinger, Zanzottera, Curcio
Data collection: Pang, Messinger, Zanzottera, Curcio
Obtained funding: Curcio
Overall responsibility: Pang, Freund, Curcio