ULTRASONOGRAPHY IN OPHTHALMOLOGY

B-SCAN

UBM

INTRODUCTION

One of the commonest non invasive imaging investigative procedures Complementary to CT & MRI Cheaper, can be done in office setting Done by Ophthalmologist with a dedicated ophthalmic US All types of USG useful Wide range of applications Particularly helpful in opaque media

HISTORY

Mundt & Hughes (1956): A scan to evaluate intraocular tumour Oksala et al : A scan for diagnosis of intraocular disorders / Data of sound velocities of various components of the eye Baum & Greenwood (1958): B scan for Ophthalmic use Jansson et al (1960): Used US to measure the distances between different structures of the eye Coleman et al (1970): 1st commercially available immersion B Scan Bronson: Contact B scan for Ophthalmic use Ossoinig (1960): Standardization of instrumentation & technique Standardized Echography / Meticulous examination techniques

ULTRASOUND

Acoustic wave of frequencies >20kHz Diagnostic US in Ophth : 8-10 MHz Higher frequency Better resolution Lower frequency Deeper penetration Velocity depends on the medium Longitudinal waves behave like light Refraction & Reflection property makes US useful for diagnostic purpose

B - SCAN

Brightness mode 2 Dimensional acoustic section where echoes are plotted as dots Brightness of dots Strength of received echo Uses focused beam from an oscillating transducer that slices through tissue Useful in evaluation of intraocular structures with opaque media & of orbital lesions Biggest advantage: Dynamic Echography

Pulse-Echo Technque:
Rapidly repeating short bursts of ultrasonic energy are beamed into ocular & orbital tissue. Multiple short pulses of ultrasound energy are produced with a brief interval between the pulses that allows for the returning echoes to be detected, processed & displayed.

ECHOES

Echoes are produced by interfaces created at junction of 2 media of different acoustic impedances Ac. Impedance = Velocity x Density Greater difference in Impedance Stronger reflection (Echo)

Medium 1

Medium 2

Medium 1

Medium 3

ACOUSTIC IMPENDANCE

Returning of Echoes

Angle of sound incidence Size, shape & smoothness of acoustic interfaces Absorption Scattering Refraction

Different Types of Acoustic Interfaces

Transducer

Schematic Diagram of Ultrasound System

Probe / Transducer (10 MHz)

The part of US system where the US is produced & through which the echoes are received When stimulated by electric energy, Piezoelectric crystal located near the face of the probe undergoes mechanical vibration producing US in pulses. The vibration of the echo produces an electric signal that is transmitted to the receiver, which is then processed.

B-Scan Transducer

Signal Processing
Electric Signal produced by returning echo is initially received as a very weak RF signal which undergoes a complex processing comprising of :
# Amplification # Compensation # Compression # Demodulation # Rejection

DISPLAY MODES:

The processed signal is desplayed on cathode ray tubes in one two modesAscan or Bscan.

Concept of B-scan interpretation:

Real time- images can be visualised at approx.32/sec,allowing motion of globe & vitrious. Gray scale-returning echoes are two dimensional images. strong echoes-bright Weak echoes- lighter shades of gray.

B - SCAN

B-Scan Exam Techniques for the Globe

Ant Segment : Contact Post Segment : Immersion SCANS:

Transverse Longitudinal Axial

Transverse Scans

Longitudinal Scans

Axial Scans

Probe face centered on the cornea with patient in primary gaze Sound attenuation & refraction from the lens hinder resolution of the posterior segment Helpful for lesions in relation to the lens & optic nerve Can be useful for evaluation of macular region

Basic B-Scan Screening Examinations

Transverse scans of 4 major quadrants Longitudinal scans along 4 major meridians Vertical & Horizontal axial scans Procedures performed both at high & low gain settings

Special Exam Techniques

Topographic
Location Extension Shape

Quantitative
Reflectivity Internal structure Sound attenuation

Kinetic

Mobility : Aftermovement Vascularity : Blood Flow

Topographic Evaluation

Transverse scan Lateral extent Longitudinal scan Radial extent Axial scan Relationship of the lesion to anatomical landmark of lens & optic nerve

Quantitative Echography

Reflectivity : signal brightness Internal Structure : echodensity Sound Attenuation : Progressive decrease in the strength of echoes, either within or posterior to a lesion

Kinetic Echography
Used to dynamically assess the motion of or within a lesion Aftermovement : motion of the lesion echoes following cessation of eye movement Vascularity : Spontaneous motion of echoes

Evaluation of Vitreous

Normal vitreous : In young, no echo. In old, scattered echoes of low reflectivity for opacities & fine thin line for PVD Asteroid Hyalosis : Diffuse or focal bright, point like echoes

Asteroid Hyalosis

Vitreous Haemorrhage
Fresh & mild : Dots & short lines Dense : Greater no. of bright dots Organization : Larger interfaces

PVD

Thin undulating irregular membrane of irregular echotexture Kinetic echography: Distinct Aftermovement Even in presence of attachment to optic disc May be focal or extensive May separate completely from post. pole or may remain attach to optic disc Challenging to differentiate from RD & CD

PVD attached to Disc

PVD with VH

Endophthalmitis

Very useful for determining the severity & extent of the infection Irregular low intensity echoes seen as diffuse fine dots on B-Scan Appreciated only on high gains in early stage Differentiation from VH : - Heterogenous (VH : Homogenous) - PVD more extensive in VH - Pseudomembrane more common in VH

Endophthalmitis

Retinal Evaluation
Retinal Tears : High reflectivity with slight aftermovement RD: Bright, Continuous Membrane of uniform echotexture : Mobility depends on type of RD & associated findings : Besides topography, B-Scan is useful in determination of configuration : Hole, tear, band should be looked for

Rheg RD

Membrane of uniform echotexture (even at low gain) Minimum aftermovement Flickering movement over the membrane : Diagnostic

Rheg RD

Exd RD

Usually Shallow RD Marked thickening of Chorio-Retinal Layer Marked Mobility

Exd RD

RD vs. PVD
RD Echotexture Aftermovement Attachment to Optic Disc Reflectivity @ low gain Peripheral Reflectivity Thick, Uniform No or Minimum Smooth Homogenous 100% PVD Thin,Undulating Free Movement Irregular Irregular or Absent Reduced

PDR

Demonstrates the nature & extent Useful in monitoring progression Helps pre-vitrectomy evaluations * Timing of surgery * Planning of Surgery * Optimal placement of instruments * Visual prognosis

PDR

Fibrovascular Membrane Subhyaloid Hemorrhage Vitreous Hemorrhage PVD TRD Combined Rheg RD with TRD

Retinoschisis

B-Scan : Smooth, thin, dome shaped membrane not inserting to optic disc Typically located inferotemporally
Differs from RD by its more focal, smooth & thin character

Choroidal Evaluation

Choroidal Thickening : * Edema Highly reflective * Diffuse inflammatory infiltration Low to medium reflective Mildly elevated, diffuse choroidal tumors can be confused with nonspecific choroidal thickening

Choroidal Detachment

B-Scan : Smooth, thick, dome shaped membrane at periphery with little aftermovement

Choroidal Detachment

Evaluation of Sclera
Posterior Scleritis : * Best imaging modality * Thickened hyperechoeic sclera * Hypoechoic rim around sclera * T sign : Diagnostic Staphyloma : Diffuse thinning Coloboma of ON : Defect in post. sclera Scleral Rupture : Break in sclera, Vitreous Thickened chorioretinal layer incarceration, Hge in Tenons space,

Intraocular Tumors

The most important noninvasive adjunct to clinical exam even in presence of clear media Standard Echography is valuable in evaluation of intraocular tumors Provides accurate measurements, therefore valuable for assessment of tumor growth or regression Helpful in detecting extrascleral extension

Detection of Tumors

At least 0.8mm elevation for ultrasonographic detection 2-3mm height required for effective quantitative evaluation Solid Tumors : No aftermovement of surface Presence of internal echoes

Choroidal Melanoma
B-Scan

Dome or Collar button shaped Uniform iso or hypoechoic texture Highly vascular : Fast flickering movement

Choroidal Melanoma

Retinoblastoma

Irregular dome shaped mass lesion with broad base over the retina Calcification when present : Diagnostic Mixed Echotexture Normal Axial Length High Irregular Reflectivity Distal Shadowing

USG in Traumatized Globe

Great value, specially in trauma by missiled FB Lid swelling : Exam through closed lids Any open wound should be repaired prior to examination Very high gain settings when examined through closed lids Knowledge of various post traumatic ocular changes is necessary

IOFB

Dense short linear echo Distal shadowing Spherical FB : Dense echogenic distal shadow Freely floating FB : No distal shadow May get masked by associated VH

Freely Floating IOFB

USG in Post Op.

Dropped Nucleus / Lens / IOL Scleral Buckle Intraocular Gas Silicon Oil Suprachoroidal Hemorrhage

USG Orbit
Orbital Soft Tissue Assessment Extraocular Muscle Evaluation Retrobulbar Optic Nerve Examination

Orbital Mass Differentiation

Topographic : Location, Shape,

Borders, Contour abnormalities

Quantitative : Internal reflectivity,

Internal structure, Sound attenuation

Kinetic : Consistency, Vascularity,

Mobility

Evaluation of EOM

Effective in subtle & early muscle size change Useful to differentiate various causes of muscle enlargement Less echo-dense than orbital soft tissue on B-Scan

Evaluation of Rectii

Medial Rectus : Primary gaze, Probe on temporal equator Lateral Rectus : 10 Temporally, Probe placed medially Inferior Rectus : 10 Inferiorly, Probe placed superiorly on the upper lid SR & LPS : Primary gaze / Slightly superiorly, Probe inferiorly

Evaluation of Obliques

SO Tendon : Horizontal transverse scan through the superior orbit SO Belly : Oblique transverse scan through the superonasal orbit IO Tendon : Oblique transverse scan through inferotemporal orbit IO Belly : Difficult to display. When thickened : Horizontal transverse scan through most ant. aspect of inf. orbit

Optic N Evaluation

B-Scan can evaluate topography & relationship of ON Usually performed in medium gain Axial, Longitudinal & Transverse scan

Optic Disc Evaluation

B-Scan can demonstrate excavation, elevation & drusen of Optic Disc Axial, Longitudinal & Vertical Transverse approaches are useful A-Scan useful in assessing reflectivity & height of certain lesions of OD

UBM

High frequency US : 35-100 MHz Provides near microscopic two dimensional gray scale images of anterior segment Extensive use in Glaucoma Also useful in ant. segment disorders including cysts & tumors with cloudy / opaque cornea, blunt trauma, canalicular imaging etc.

Principle:

There are wide range of frequencies ranging from10- 20000Hz to>10/12Hz. Resolution is related to full width of US beam at half max amplitude (FWHM)=cf/vd=wavelength C-speed of sound. F- focal length of transducer. V-frequency. D-diam of transducer. Incresed resolution is accompanied by loss of penetration.

Design of UBM

Scanner detected signals are digitalised. Transducer made up of pizoelectric polymer PVDF & copolymer PVDF.It achieves highest resolution & good depth of focus.

Instrumentation:

Front panel consists of large high resolution LCD screen. Rear panel which plugs for connection to probe,monitor & power connector. HF Probe which are light weight accept 35-50 MHz transducer & scan at 38 or 20 degree scan angles at 15 mm max scan depth. Immersion cup 35 MHz transducer offer 70 of axial resolution & 50 MHz offer 50.

Examnation Technique:

Patients:supine with eye fixated at ceiling. Topical anaesthesia-immersion cup is placed with lips of cup under the lids. Fluid coupling medium instilled. Transducer have no membrane cover& moves at the rate of 8passes/sec.It is placed opposite the area of intrest. Pt. is asked to look away from site of pathology to bring pathological area into ex. Position.

Probe orientation

Transverse Scan Longitudinal scan Axial Scan.

Measurment of ocular strucure:

Depends on speed of a sound in structure. It consists of time required for sound to traverse the tissue & return to transducer. Mainly 1550m/sec speed of sound is used which increases accuracy to measure AC depth,iris thickness,C.B.

Mesurment modes:

Vector 1550-linear measurement Callipers-pairs of linear cursor for linear measurment. Angle Measure Biometry -accurate dist. Measurement in ant .seg. Along optical axis.

Normal ocular structure:

Cornea: layers appreciated epi.-smooth surface line. Stroma-reveals internal reflectivity. B.M.s-highly reflective line. AC-Its easy if internal corneal surface& ant surface of lens is clearly apreceatd.

Angle region: probe is oriented in radial fashion above the limbus. Scleral spur is reffering pt. for measuring angle. Trabecular Iris angle:bet. Apex of iris recess & arms passing through the meshwork 500 m from scleral spur & the pt. of iris perpendicularly ,opposite is measured.N-30 +/- .

ZONULES & LENS:Ant zonules Iris:Thickness & curvature of iris is measured

highly reflective layer on post. Surface helps in differnciating intra-iris lesion from the lesion behind iris. Cilliary body: shows configurations of cilliary processes & vallies bet. them dist. Bet. Ant. Trabecular meshwork & cilliary processes is measured & ant lens surface can be seen.

Quantitative Measurments:

AOD: bet. TM & IRIS at 500m ant to scleral spur. TIA:ang of iris recess. ID1:iris thickness at 500m ant to s. spur. ID2: iris thickness at 2 mm from iris route ID3: Max iris thickness near pupillary edge TCPD;bet TM& C.P. at 500m ant to s.spur. ICPD; bet iris & CP. Along the line of TCPD.

IZD:Bet iris & zonules Along the line of TCPD. ILCD: Contact dist. Bet iris & lens Iris lens ang: ang . Near pupillary edge.

CLINICAL USES:

Cornea: conj. Mass lesion pre PK evaluation of ant seg corneal thickness

Glaucoma: evaluate post op shallow AC malignant glaucoma plateau iris PDS iridozonular contact bleb evaluation cyclodylasis cleft

Lens: zonular inttegrity PC integrity Haptic position Uvea:Parsplanitis in media opacity scleritis Vitrioretinal diseases:sclerotomy site pars plana FB Peripheral VR dis Mas lesions: iris & CB cyst, umors& lid lesions

The sclera is imaged as a highly reflective structure compared to the cornea. One can generally differentiate the sclera from overlying episclera and underlying ciliary body and retina

Scleral thinning can be imaged and the thickness of residual sclera quantified

Scleritis shows relatively low reflective regions within the sclera likely representing edema and inflammatory infiltrates.

The anterior zonule can normally be clearly imaged. Disruption will result in absent zonules, increased lens sphericity, and increased distance of the lens margin from the ciliary body.

Cyclodialysis shows complete disinsertion of the ciliary body from the scleral spur accompanied by a 360 degree supraciliary effusion

Anterior segment foreign bodies can be localized. They generally present as a reflective lesion with shadowing of structures behind the foreign body.

IRIDOCILLIARY CYST
Ciliary Body or
Iris Tumor

Accommodation and Iris Configuration