OCULAR ULTRASONOGRAPHY

(A-SCAN AND B-SCAN)

Dr. S. Rasaily
RESIDENT

INTRODUCTION
Ultrasound is defined as sound that is beyond the range of
human hearing
Ultrasonography uses high frequency sound waves to
produce echoes as they strike interfaces between acoustically
distinct structures
Non-invasive ,efficient & inexpensive diagnostic tool to detect
& differentiate various ocular & orbital pathologies
Demonstrates morphology, characterises tissues & provides
dynamic information

INTRODUCTION
Indispensible tool
- calculation of IOL power, tissue thickness measurements
- evaluation of posterior segment behind dense cataract &
vitreous haemorrhage
- diagnosis of complex vitreoretinal conditions
- differentiation of intraocular & orbital masses
- location of intraocular FB

Based on Principle of pulse echo technique and

tissue acoustic impedance mismatch.

History
1956- Mundt and Hughes (1ST use of industrial ultrasound to
examine enucleated eye with intraocular tumor)
1957- Oksala of Finland(1stclinical use of A-scan).
1958- Baum and Greenwood developed the B-scan using the
immersion method(first two dimensional), but the image
was quite poor.
Purnell and Sokallu described orbital B-Scan evaluation and
classification of orbital disease with its help.

History
1960- Jansson( Sweden) used USG to measure distance
between structures in the eye.
1970- Coleman and associates 1st commercially available
immersion B- scan.
Later Bronson introduced a contact B-scan machine.
Ossoinig( Australian Ophthalmologist) -standardized
echography.

Physics
Ophthalmic Ultrasound = 8-10 MHz( 1 MHz= 1,000,000 cycles
/sec) Short wavelength( < 0.2 mm) have small
penetration(6cm at 7.5MHz) but excellent resolution of small
structures
Propogated as longitudinal wave consisting of compressions &
rarefraction of molecules as the wave passes through the
medium, that can propagate within fluid & solid substances

Reflectivity
-When sound travels from one medium to another medium
of different acoustic impedences, part of the sound is
reflected from the interface between those media back
into the probe. This is known as an echo;

Acoustic impedence = sound velocity x density

 The greater the difference of acoustic impedence of the

two media that produce the interface, the stronger the
echo, or the higher the reflectivity
In A-scan ultrasonography the stronger the echo, the higher
the spike
In B-scan ultrasonography , the stronger the echo, the
brighter the dot


1.
2.
3.

The returning echoes are affected by many factors

Absorption and refraction
Angle of sound incidence
Size,Shape and Smoothness of acoustic interfaces

Angle of Sound incidence

When the beam strikes an interface in perpendicular
manner ,the echo is reflected back towards its origin
When oblique beam strikes some of the reflected energy is
diverted away from direction of origin, resulting in a weaker
echo.

Angle of Incidence

Acoustic interfaces
Echoes are created by acoustic interfaces
created at the junction of two media that
have different acoustic impedance
The size shape and smoothness of an
interface play roles in the character of
returning echoes

Gain
Represents relative units of the ultrasound intensity(dB)
Adjusting gain does not change the amount of energy
emitted from the transducer , it changes only the intensity
of the returning echo that is displayed on the screen.
The higher the gain level, the greater the ability of the
instrument to display weaker echoes ( e.g vitreous
opacities)
Conversely as the gain is lowered , only the stronger echoes
will continue to be displayed ( e.g retina and sclera)
Many instruments incorporates time gain compensation to
enhance weak echoes displayed from deeper tissue layer.

Pulse echo system

Emits ultrasound wave detects and processes and displays
returning echoes
The basis of pulse echo system is piezoelectric elements
made up of ceramic crystals or quartz
Piezoelectric crystals-mechanical vibration-longitudinal
ultrasound wave pause of several microseconds-allows
transducer rim to receive and process returning echoes

Signal processing

Probe

Schematic Diagram of ultrasound

system

A-Scan
One dimensional acoustic display
Echoes are represented as vertical spikes from a baseline
The distance between any two spike can be calculated by
the formula D= V (velocity) x T (Time)
Spikes represents reflectivity, location & size of anatomic
structure
The height of the spikes corresponds to the strength
(amplitude ) of the echo.
Various types of A-scans :
1. A -scan for axial length measurement
2. Vector A -scan that can occur simultaneously on B-scan
echogram
3. Standardized A-scan

Interpretation of normal A-scan

B- mode (brightness modulation)

Two dimensional acoustic section
An echo is represented as a dot rather
than a spike
Strength of the echo is shown by the
brightness of the dot
A section of tissue is examined by an
oscillating transducer that emits a
sound beam that slices through the
tissue

Interpretation of normal B-scan

At high gain reveals 2 echographic areas
separated by an echo free area
Echographic area at beginning of scanreverberations at tip of probe
If good resolution- posterior convex
structure of crystalline lens
Large echo free area vitreous cavity
Echogenic area after vitreousretina,choroid,sclera & orbital tissues
Retina seen as a concave surface proximally
Optic nerve shadow triangular shadow
within orbital fat

Indications for USG

Opaque ocular media
Anterior segment
Anterior segment
Corneal opacification
Iris lesion
Hyphema or hypopyon
Ciliary body lesions
Miosis
Posterior segment
Cataract
Tumours
Choroidal detachment: serous versus Pupillary or retrolenticular
membrane.
exudative
Retinal detachment: rhegmatogenous Posterior segment
versus exudative
Vitreous hemorrhage
Optic disc abnormalities
Endophthalmitis
Unexplained retinitis/ choroiditis
Intraocular foreign bodies: detection
and localization
Biometry
Axial length of eyeball
Anterior chamber depth
Lens thickness
Tumor measurements
Determining the extraocular muscle
thickness

Clear ocular media

Techniques
It is best to begin with maximum gain
on B scan
Patient is kept in a reclined position
rather than sitting position
Patients head and instruments are
situated close together so that probe
position and screen may be viewed
simultaneously
Methylcellulose applied to the face of
the B-scan probe as a coupling
medium

Techniques
Probe is placed directly on the eye (i.e
conjunctiva or cornea) opposite to the area
examined

Marker on the probe act as the orientation

point
Topical anaesthetic drops are applied to the
eye before examination

Contact Techniques

Immersion Techniques

Techniques used for evaluation

1. Transverse Scans

Shows lateral extent of the lesion

Sound beam oscillates back and forth across the opposite
fundus producing a circumferential slice

Techniques used for evaluation

1. Transverse Scans
Horizontal transverse: Evaluate superior and inferior fundus
and marker is oriented towards nose
Vertical transverse: Evaluate the nasal and temporal fundus
and marker is oriented superiorly
Oblique transverse: Evaluate the pathology not located at
major meridians(3,6,9,12 oclock) and marker is oriented
superiorly

Techniques used for evaluation

2. Longitudinal Scans
Sound beam sweeps along the meridian opposite the probe
rather than across the meridian.
Shows AP extent rather than a lateral extent.
Echogram- Optic disc and posterior fundus displayed on the
lower portion of the screen

Techniques used for evaluation

2. Longitudinal Scan

Techniques used for evaluation

3. Axial technique
Horizontal: marker towards the nose( macular region just below the optic disc).
Vertical: marker oriented superiorly

A systematic approach to
Echographic examination is
recommended
1. Screening for lesion detection.
2. Topographic examination ie, shape, border and location
of lesion.
3. Quantitative echography, ie reflectivity, sound,
attenuation & internal structure of lesion.
4. Kinetic echography, ie mobility, vascularity, consistency
of lesion.

1. Basic screening examination

To detect lesions in the posterior segment.
Both B-scan and A-scan can be used.
B-Scan screening technique:
Transverse and longitudinal scans of four major
meridian and axial scan
High settings to detect vitreous opacities and gross fundus lesions
low settings to detect relatively flat fundus lesions.

A-scan screening technique:

At tissue sensitivity decibel (24db) setting.
Performed in 8 meridians - limbus to fornix,

B-Scan screening

2.Topographic echography
1. Useful for shape, location,
extension
2. Performed with B-scan,
supplemented by A-scan.
3. Transverse B scan probe is
placed exactly opposite the
lesion , shift from limbus to
fornix
4. In longitudinal approach
sound beam is oriented
laterally
5. Axial approach

2.Topographic echography
Topographic differentiation in A-Scan:
Point like - Foreign body, Vitreous opacities.
Membrane like - RD, PVD, choroidal
detachment.
Mass lesion Melanoma, Retinoblastoma,
Hemangioma.

3.Quantitative echography
1. Reflectivity : is estimated according to size,
configuration,thickness ,density.
Comparision of spike height on A scan and signal
brightness in B scan
2 Internal structure : degree of variation in
histologic architecture within a masslike lesion
a.Regular- little or no variation in height and
length of spikes on A-scan whereas uniform
appearance of echoes on B-scan
b.Irregular- marked differences in echoes
appearance

3.Quantitative echography
Sound attenuation :
-Sound energy is absorbed, scattered or
reflected by a given medium
-Evaluated on both B- and A-scan
-Progressive decrease in strength of echoes
either within or posterior to a lesion

3.Kinetic echography
1.

Assess the motion of or

within a lesions

Aftermovement -non solids

lesion like vitreous membrane
or retinal detachment
Vascularity fast
spontaneous motion of
echoes on screen
Convection-slow
spontaneous motion of
echoes seen(cholesterol
debris )

BRIEFLY ULTRASOUND FINDINGS OF DIFFERENT

VITREORETINAL DISEASES

Vitreous Haemorrhage
Pattern depends upon density, location, extent &
associated fibrous changes
A-scan:
In fresh, mild with dispersed RBC -a chain of low
amplitude spikes
More dense haemorrhage- high reflectivity
If blood organizes larger interface - even higher
reflectivity(60-100%)

Vitreous Haemorrhage

B-scan:
- Appears as small white echoes

With greater density of vitreous haemorrhage - greater opacities

Fresh, diffuse & unclotted haemorrhage - very little or no echoes
- Vitreous haemorrhage may be confined- within PVD
Thick inferiorly and thin superiorly

Asteroid Hyalosis

A-scan multiple spikes of medium to high reflectivity

B-scan Appears bright point like echo sources
opacities exhibit distinct movement on
movement of the eye

Posterior Vitreous Detachment

A-scan:
Tall single spike but not as tall as in RD
Reflectivity is low(5-10%) if post. vitreous layer is thin & high(80-90%) if
thick or lined by RBC

Posteiror Vitreous Detachment

B-scan:
Appears as an undulating membrane in front of the retinochoroidal layer
May remain attached to optic disc or separated completely from the post. pole
Height of A-scan spike & brightness of B-scan of PVD reduces as gain is
reduced
Kinetic echography typically shows a very fluid ,undulating after movement of
PVD-this characteristics differentiates PVD from retinal and choroidal
detachment

A-scan :

Retinal detachment

Single, steeply rising, extremely high(100%) & moderately

thick retinal spike when sound beam is perpendicular to
retinal surface
Lower & wider spikes with 2 or more peaks - oblique beam
Long chain of low to medium high spikes -tangential beam
Distance between the retinal spikes and the ocular wall
spikes in a given beam direction is equal to the degree of
elevation.
Presence of signals between retinal & scleral spikeindicative of exudative or hemorrhagic RD

 B-scan:
- Appears as a bright, continuous, somewhat folded
membrane
Attached to optic nerve & ora serrata
Recent RD- mobile retina & translucent subretinal space

Tractional retinal detachment

Common in vascular retinopathies

Caused by strong adhesion of vitreous
membrane, bands or the post. hyaloid
face to retina & subsequent traction
Adhesion could be focal causing a tent
like, or broad-causing table top traction
of retina
Detached retina- concave configuration

Retinal tear
Large are visualized easily & smaller ones require
meticulous examination
If fresh vitreous haemorrhage due to the retinal tear
obscures the fundus view-mostly located in upper half of
retina
A-scan:
appears as a highly reflective tissue separate from the other fundus
spikes
B-scan:
breach of tissue
Giant retinal breaks with detachments appear as rolled out tissue with
clear breach of tissue

Evaluation of choroid
Retinochoroidal layer:
A-scan- tall spike
B-scan- smooth concave configuration

Choroidal detachment
A-scan:
A thick steeply rising 100% high spike just behind the
retinal spike
On lowering the gain the spike is double peaked
If choroidal haemorrhage- low to medium spikes in
subchoroidal space
If choroidal effusion- echofree space

 B-scan:
Smooth, dome-shaped, thick membranous structure not
inserted to the optic nerve
localized or involve entire fundus- kissing choroidal
detachment
little or no after movement on
kinetic scanning
Nature of Suprachoroidal fluid
In serous detachment- echolucent
Haemorrhagic - echodense

Differentiation of PVD ,RD and

Choroidal detachment
technique

PVD

RD

Choroidal
detachment

topographic

Smooth, open
funnel with or
without disc or
fundus insertion

Smooth or folded,
open or closed
funnel with disc
insertion

Smooth ,dome or
flat ,no disc
insertion

quantitative

Variable spike
height < 100%

Steeply rising 100%

high spike

Steeply rising ,
thick, double
peaked 100% high
spike

Kinetic (after
movement)

Marked to
moderate

Moderate to none

Mild to none

Endophthalmitis
A-scan:
Multiple echospikes with low to medium reflectivity(10-60%)
With organization & membrane formation reflectivity increases
Chain of low amplitude spikes
B-scan:
Opacities are seen
Membrane formation - in severe cases
Choroidal thickening,choroidal detachment, RD, retained IOFB possible associated findings

Evaluation of traumatized eye

Dislocated lens
A-scan:
- 2 smooth and high reflective surfaces spikes in front of ocular spike

B-scan:
- round or oval globular structure in the post. Vitreous
- strands of vitreous may be attached to dislocated lens
Acoustic shadowing is seen, implying that the lens could be cataractous
or calcified

Intraocular foreign body

A-scan:
Steeply rising spike with extremely high reflectivity(100%)
Reflectivity remains same with lower gain
Can also detect radiolucent FB missed on x-ray
Small spherical FB-pellet-shows high echospike followed by a long chain of
echospikes of decreasing height
Large FB has ant. & post.echospike- thickness can be measured

B-scan:
Metallic FB produce very bright signals
Shadowing artifact on the adjacent orbit
Round metallic FB-reverberation artifact behind FB

B-scan showing the intravitreal foreign body

Posterior globe rupture

Breach of sclera & choroidal tissue with associated choroidal thickening
Associated findings:
-Vitreous haemorrhage
-Retained intraocular or intraorbital FB
-RD

Optic nerve avulsion

Seen secondary to trauma and is rare
Vitreous hemorrhage may be present & actual peripapillary scleral break may
be seen; in long standing cases- proliferative tissue at optic disc

Optic disc drusen

Calcified nodules seen echographically with high reflectivity at or within the
optic nerve head
Best seen with - transverse or longitudinal B-scan approach which bypasses
the lens

Evaluation of intraocular tumors

Display different acoustic characteristic on USG due
to vast difference in histologic composition
B- scan: topographic features as shape, location, &
extension
A- scan: structure, reflectivity, vascularity,& height
Serial USG: measures height & growth of tumor over
a period of time

choroidal melanoma

Collar-button shaped choroidal melanoma indicating that tumor has

broken through bruchs membrane. A-scan pattern typical of melanoma,
with the high retinal spike on the surface of the lesion but low-to-medium
internal reflectivity within the lesion. The sclera and orbital tissues are seen
as spikes to the right of the lesion.
No after movement of spikes- solid consistency
Low reflective spikes behind the sclera.

Choroidal hemangioma

Choroidal hemangioma with an associated exudative retinal

detachment. This lesion is composed of tightly compacted blood
vessels and, therefore, demonstrates high, regular internal reflectivity
on both B-scan and diagnostic A-scan.

Metastatic choroidal lesion

Metastatic choroidal lesion from the breast. The lesion has rather irregular
borders, with medium-high, irregular internal reflectivity on both B-scan and
diagnostic A-scan(high internal reflectivity-60 to 80%)

D/D of ocular melanoma

lesion

location

shape

reflectivity

structure

vascularity

melanoma

Choroidal/
Cil. body

Collar
button

Lowmedium

regular

Metastatic
carcinoma

Post.
choroid

Diffuse/
irregular

Mediumhigh

irregular

Choroidal
hemangioma

Post.
choroid

dome

high

regular

Choroidal
nevus

choroid

dome

high

regular

Choroidal
hemorrhage

choroid

dome

variable

variable

Retinoblastoma
A-scan:
Irregular acoustic structure with high internal
reflectivity(70-100%)
Spontaneous movement of lesion spikes
evidence of vascularity
Axial length measured - normal or decreased
Depends upon size, degree of tumors, calcification
& necrosis

Retinoblastoma
B-scan:
If large- irregular echogenic mass involving vitreous, retina,
subretinal space
Area of calcification - high echogenicity- strong sound
attenuation-

Choroidal Osteoma

Very echo dense lesion

irregular surface contour
shadowing of scleral and
orbital echoes
A scan- very highly
reflective broad spike from
the lesion with mark
decrease in height of
orbital spike

Pthisis bulbi
Globe is atrophic and shrunken, intraocular contents
are disorganized & intraocular calcification may be
present
A-scan:
Irregular pattern of high & low reflective
echospikes fill the globe
High reflective echospikes may be due to ossification
Short axial length
B-scan:
Multiple echogenic vit. opacities
choroidal thickening
calcification of ocular coats
Absence of orbital echospikes

Posterior staphyloma
Shallow excavation of the posterior pole with
smooth edge in high myopia

Lateral rectus muscle

Posterior scleritis

Nodular posterior scleritis with fluid in the Tenon capsule. The

scan on the right demonstrates a positive T-sign at the insertion
of the optic nerve

Thyroid-related orbitopathy

Enlargement of the extraocular muscle belly. The tendinous insertion

of the extraocular muscle at the globe is not thickened, which is
characteristic of thyroid-related orbitopathy.

Limitations
&
pitfalls of USG

Multiple signals (Reverberations)

Occur between the probe tip and a highly reflective surface
or between two highly reflective ocular interfaces
May cause error in axial length measurements
Can be distinguished from true echoes by their position in
the echograms as well as by their more pronounce
movements
Calcified lens, intraocular implants, foreign
bodies, scleral buckles , air bubbles
common producers

Attenuation artifacts
Silicone oil disperses the
ultrasound beam difficult to
perform
The sound attenuation prevents
resolution of posterior ocular
wall and orbital contents.
The velocity of sound in silicone
oil is much less than in vitreous
this causes the echograms of
such globes to appear larger
than normal

Refraction Artefacts
The high lenticular propogation velocity can
produce apparent abnormalities of the posterior
pole that resembles tumor formation or
thickening of the choroid( Baums Bumps)

Absorption/ Shadowing effect

Blockage of sound wave transmission by a highly reflective
interface. This appears as a hypointense area behind a
bright echo.eg calcium, glass, bone, air, metal.

Low reflective spikes

Seen in front of the retinal spike when performed
at high gain
This is because the lateral portion of the ultrasound
beam reaches the concave retina earlier than the
central portion

Insufficient fluid coupling

Entrapment of air
between probe and the
eye
Display bright echoes
that represents multiple
signals between probe
and entrapped air.

Tumors
To detect the acoustic structure its thickness
should at least be 2mm
Tumors located at the orbital apex are difficult to
recognize because of the attenuation of the sound
and confluence of Optic Nerve and Muscles that
are inseparable ultrasonically.

Vitreoretinal diseases
Dispersed vitreous cells or haemorrhage may be
missed initially due to low reflectivity
Gain should be increased to improve resolution

Intra ocular foreign bodies

If IOFBs surface is less than 1mm2 OR if it is
embedded in the sclera
Wooden FB initially be highly reflective but
its decrease reflectivity makes difficult to
localise
Small air bubbles may mimic IOFB but usually
disappear within a day or two.

Common Errors In biometry

A problem should be suspected if a difference of more than
0.3mm is present between the two eyes or a difference of
more than 0.2mm in consecutive measurements occurs in
the same eye medical reason or macular pathology like
posterior staphyloma
Erroneous axial length measurements occur when the
ultrasound beam is not aligned with the visual axis of the
eye or is not perpendicular to the macula.

 If the sound beam is misaligned at an angle through the lens

and is not in the visual axis ,the posterior and or the anterior
lens spike is not of high amplitude
The posterior lens spike may be slightly shorter than anterior
lens spike because of its greater curvature however, if the
posterior lens spike is more than 10 percent shorter than the
anterior one means the sound beam is misaligned.
Corneal compression in the contact technique yields shorter
axial length.

Ultrasound biomicroscopy
New method of producing high resolution images of anterior segment
with high frequency ultrasound. Ranging from 50-100MHz
Depth penetration is in the range of 5-7mm
Imaging eye at microscopic resolution
In 1990 Pavlin and colleagues described the first high frequency
ultrasound .

Ultrasound biomicroscopy
Uses
To evaluate ant. segment anatomy in eyes with corneal scars
before penetrating keratoplasty
To delineate the extent of iris & ciliary body tumors
To understand the pathology - mechanism of various types of
glaucoma

To locate ant. segment FB

Measures anterior chamber depth.
Measures corneal thickness

Color-Doppler Ultrasonography
Use of B-scan with color Doppler
Non-invasive approach to measure and visualize blood flow
in orbital vessels and tumors.
To evaluate many ocular disorders including glaucoma,
hypertension & ocular ischemia

Colour Doppler imaging of the

ophthalmic artery

RECENT ADVANCES
Recently used Power Doppler (PD) has three times the
sensitivity of conventional Color Doppler in detecting blood
flow & very useful in imaging of vascular lesions of the globe
and orbit
Recently, Silverman and colleagues developed a highfrequency annular array transducer with higher depth of field

Other promising new developments in the field of diagnostic

ultrasound include tissue characterization and Echo contrast
agents (gas microbubbles)

 Three-dimensional (3D) ultrasound- 3-D image is constructed from a

series of ordered B-scan planes that are processed by special
software

Other promising developments in ultrasound in general include

refinement in transducer's material and technology, leading to
improvements in sensitivity and bandwidth

References
1.Ultrasound of eye and orbit- Sandra Frazier Byrne
Ronald L. Green
2.Ultrasonography of the eye and orbit D. Jackson coleman
3.American Academy of Ophthalmology- Optics- 2013-2014

Thank You