OPHTHALMIC ULTRASOUND

Dr. Yousaf Jamal

26/05/2012
 Contents
Introduction
Instrumentation
Indications
Ultrasound Principles & physics
B-scan, UBM, A-scan & techniques
MCQs

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 Objectives
To create awareness about basics of US
To emphasize on the importance of
ophthalmic US
To create & follow standard operating
protocol while performing ophthalmic US

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 Introduction
Sound
Noise
Ultrasound
What is
Supersonic
Hypersonic
Transonic

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 Just for test of general knowledge
Who was the first one to use ultrasound?

?
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 Echolocation types

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TYPES

A SCAN

B SCAN
 Instrumentation
Pulsed-echo system
Transducer
Amplifier
Display monitor

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 Transducer function
ELECTRIC CURRENT

TRANDUCER

US WAVES

SURFACE

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 Artist: Dr. Yousaf Jamal

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 B-Scan

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 B-scan
Brightness mode scan
OPD procedure

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 Indications
To examine intraocular structures with no
direct visualization of posterior segment
Or
To confirm or differentiate between
pathologies in clear media

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 Ultrasound physics & principles
Parts of Sound wave
Amplitude
Wavelength (crest & trough)
Frequency

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 Frequency & its relations

With resolution
Image quality

With penetration
How much deep

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 Frequency versus Resolution

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 Frequency versus Penetration

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 Medical Ultrasound frequencies
Abdominal US
1-5 MHz
Ophthalmic US (B-scan)
8-10 MHz
Ultrasound Biomicroscopy (UBM)
20-50 MHz

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 Ophthalmic US
B-scan
10 MHz
40 mm
940 microns
UBM
50 MHz
5-10 mm
40 microns

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 Principles of US
Velocity
Reflectivity
Angle of incidence
Absorption

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 Velocity
Depends upon density of medium
Distance = speed x time
Thru air Thru aqueous & vitreous
330 m/s 1532 m/s
Thru water Thru cornea & lens
1500 m/s 1641 m/s
Thru metal Thru silicon oil1000 CS
5000 m/s 980 m/s
Thru blood Thru silicon oil5000 CS
1570 m/s 1040 m/s

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 Reflectivity (Echo)
Follows law of Acoustic impedance
A.I. = sound velocity x density of medium
Medium Acoustic impedance (x106) kgm-2 s-1
Fat 1.38
Human tissue 1.63
Blood 1.61
Muscle 1.70
Bone 5.6-7.8
Vitreous 1.52
Aqueous 1.50
Lens 1.84
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 Higher gain for weaker echoes
Low gain for stronger echoes

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 Angle of incidence

Transducer

Tra
n sd
ucer

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 Absorption
Dependent on density of medium
Closed lids should be therefore avoided
but in children or open wound
Shadowing occurs bcz of it

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 Probe positioning

Trans-ocular approach
Transverse
Longitudinal
Axial
Para-ocular approach

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 Trans-ocular
Transverse position

Most commonly used position

Shows about 6 clock hours
Used for basic screening
Detects lateral extent of pathology
Probe is placed opposite to the examined
meridian

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 Probe marker is tangential to limbus
Mark is at nasal side when scanning 6 and
12 oclock
For the restmarker is superior
Limbus-to-fornix approach is used to
detect from posterior pole to periphery

Nasal
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 Longitudinal positions

Detects axial (AP) extent of pathology

Useful for retinal tears detection
Shows only 1 clock hour scan

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 Probe mark is perpendicular to limbus
Pt looks towards the area of interest
Optic nerve shadow is always at bottom of
scan
Limbus-to-fornix approach can be used

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 Axial positions
Probe direct over the cornea
Pt looks in primary gaze
US waves pass thru center of lens and hit
optic nerve rather than macula
Lens density affects the quality of image

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 Positions of axial scan
Horizontal
Marker always nasal
Vertical
Marker always superior
Oblique
Marker always superior
Nasal
Bridge

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 Basic screening technique
Done for screening purpose in opaque
media
Highest gain settings are used so weaker
signals shouldnt be missed
Any pathology foundfurther scanning is
required

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 Technique
05 scans in different positions will detect
gross pathology
Transverse position with limbus-to-fornix
approach in
12, 3, 6 and 9 o'clock
Horizontal axial scanshows optic nerve
& macula in one image
Print out of each position is taken with
labels

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 If pathology found
Clock hour noted on transverse scan
Patient is asked to look in the direction of
pathology
Probe should be perpendicular
Longitudinal scan, A-scan & change of
gainsadds further info of pathology

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 Localization of macula
04 positions for macular detection
Horizontal axial
Vertical axial
Transverseprobe placed nasally
Longitudinalprobe placed nasally

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 Anterior segment evaluation

Immersion technique

High resolution technique

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 Immersion technique
Cornea, anterior chamber & lens create
noise bcz of close contact with probe
Shell or water bath is used to create
space

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 High resolution technique
Ultrasound biomicroscopy
High resolution probes are used
Scleral shell technique is used
Image quality far superior to immersion
technique

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 Common examples
Vitreoretinal disorders
Most common indication for B-scan
Vitreous hemorrhage
Retinal detachment
Intraocular tumors
Intraocular foreign bodies

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 Vitreous hemorrhage
Fresh:
Dot-likeEcholucent or low reflectivity
Old:
Membrane-likevarying reflectivity &
dense inferiorly

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 Fresh VH Old VH
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 Retinal detachment
Rhegmatogenous R/D:

Thin, continuous membrane anteriorly

separated from globe wall
Echoes are of high amplitue-100% of
scleral spike
Retinal cysts, subretinal hemorrhages may
be seen

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 Tractional R/D:

Traction membranes are seen

R/D usually doesnt extend to ora serrata
Lower mobility in contrast to Rheg. R/D

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 Exudative R/D:

Smooth elevation of retina

Shifting fluid

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 Supine position

Erect position

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 Intraocular tumors
Retinoblastoma:

Single or multiple mass lesions arising

from retina
Highly refractile calcium seeding in
vitreous +/- orbital shadowing
R/D may be found

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 Choroidal melanoma:

Solid Dome shaped or mushroom shape

High surface reflectivity with low to
medium internal reflectivity
A scan flickering spikesinternal blood
flow
Choroidal excavation
Exudative R/D may be present

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7/25/17 Dome shape 57
 Collar stud shape
Arrowhead in A scan shows bruchs membrane
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 Intraocular foreign body
Echodense signals with shadowing
Persistence of signals at low gains
Glassreverberations
Air bubblemay simulate IOFB

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 Dislocated lens
Signals depend on clarity of lens
Clear lensEcholucent globular structure
Brunescent lenshighly reflective with
shadowing

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 A-Scan

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 A - scan
Amplitude scan
10 MHz probe
Measures axial length of eye and used for
diagnostic purposes when combined with
B-scan
Follows law of acoustic impedance

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 X-axistime
Y-axisamplitude
Method
Applanation technique
Immersion technique

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 A-scan by Applanation
Cornea is anesthetized
Patients should look directly at the red
fixation light
Probe placed directly on cornea
This causes a slight indentation (0.14 -
0.28 mm)
 Measurements vary slightly from each
other due to inconsistent corneal
compression
Also, will have a shallower AC depth than
immersion
Takes (20) readings

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 At least (4) of these should be within 0.02
mm of each other, and should look like
the previous slide
This way the measurements will be made
to the center of the macula, giving the
refractive axial length, rather than
anatomical axial length
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 A- Scan facts
Average length of the eye: 23.5mm
Average A/C depth: 3.24mm (but can vary
greatly)
Average lens thickness: 4.63mm ( but can
vary with cataractous changes up to as
thick as 7.0mm in density)
Average Ks : 43.00 44.00D
 Summary
Ophthalmic UShigh frequency
A & B scans mostly used
Different pathologies can be diagnosed
easily when both scans are used
simultaneously

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 Take home message
Understanding of basic physics
Proper standardized technique should be
applied in each case
Eyes do not see what mind does not
know
So background knowledge of pathologies
and experience count the yield of US

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JazakAllah

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 MCQs / Cases

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 MCQs / Cases
1. A patient presents with bilateral granulomatous
panuveitis with hazy fundus view due to cataract. No
Hx of trauma. B scan picture is given below:

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 A. What is the probe position?
Axial
B. What do the arrow head and arrow show?
Retinal detachment
Choroidal thickening
C. Probable diagnosis?
V-K-H

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 2. A young patient with blunt ocular trauma comes to
your opd, complaining of floaters with normal visual
acuity. You order B scan which is given below

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 Describe the picture
What is your probable diagnosis?
How you differentiate it from retinal detachment?

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 3. An old patient complains of decreased vision after
trabeculectomy. There is large bleb but hypotonic
eye. B scan shows

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 Describe the picture
Your probable diagnosis?

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 4. Describe the following A-scan

Ans Immersion technique A-scan

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 5. What you say about these A-scans?

Ans Artifacts By IOL (Reverberations)

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 6. Diagnosis?

AnsHypotonic eye with choroidal thickening

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 NEXT
Lecture
Dr. Bilal corneal topography

Journal club
Dr. Maooz

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