LOOK BEYOND AND BEHIND........

OPHTHALMIC B SCAN
ULTRASONOGRAPHY

DR. IRAM JOWHER

CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.

Why a class?????
History
What is it????
Principles and physics
Instrumentation
Technique
How a normal scan looks like????
Some abnormal scans
Ultrasonography in pediatric patients
Pitfalls
Reporting
Caution
Danke

 WHY

A CLASS???????

COZ.........

WHY????

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

HISTORY.....

1793: Lazzaro Spallanzani (Italy) discovered

that bats orient themselves with the help of
sound whistles while flying in darkness. This
was the basis of modern ultrasound
application

World war II: a device based on piezoelectric

effect developed by Paul Langevin (France)
,able of emitting & receiving ultrasound
under water used as sonar.

1956: first documented use of ocular USG,

Mundt and Hughes used A scan technique to
detect intraocular tumour.

1972: First use of hand held B scan by

Bronston & workers ,which was applied
directly to the closed lid without a water bath

WHAT IS IT?????

sound pressure with a frequency greater than

the upper limit of human hearing.

Although this limit varies from person to

person, it is approximately 20 kilohertz
(20,000 hertz) in healthy, young adults

It is an acoustic wave that consists of

particles within the medium

Frequencies used in diagnostic ophthalmic

ultrasound are in the range of 8-10 MHz

These high frequencies produce shorter wave

lengths which allow good resolution of
minute ocular and orbital structures

Multiple short pulses are produced with a

brief interval that allows the returning echos
to be detected, processed and displayed.

The basis of the echo system is piezoelectric

element which is a quartz or ceramic crystal
located near the face of the probe

PRINCIPLES AND PHYSICS...

Ophthalmic ultrasonography uses highfrequency sound waves,

transmitted from a probe into the eye.
As the sound waves strike intraocular
structures,
they are reflected back to the probe and
converted into an electric signal.
The signal is subsequently reconstructed as an
image on a monitor,
14

As the frequency of USG increases, the

wavelength decreases and wavelength
of an ultrasound determines its depth of
tissue penetration and resolution

Wavelength Depth of penetration of the

ultrasound

So, Larger is the frequency of US = shorter is

its wavelength = shallower is its penetration
= better is the resolution of resultant echo
graph.

Thats why USG probes used for Ocular

USG are of higher frequency(10MHz)as
it needs much less tissue penetration
(an eye is 23.5 mm long on average) &
higher resolution.

In contrast, ultrasound probes used for

purposes such as obstetrics, use lower
frequencies (1-5Hz) for deeper
penetration into the body, and, because
the structures being imaged are larger, they
do not require the same degree of resolution

VELOCITY

The velocity of the sound wave is

dependent on the density of the
medium through which the sound travels.

Sound travels faster through solids than

liquids, an important principle to understand
since the eye is composed of both.

There are known velocities of different

components of the eye, with sound traveling
through both aqueous and vitreous at a
speed of 1,532 meters/second (m/s) and
through the cornea and lens at an
25
average speed of 1,641 m/s

REFLECTIVITY

When sound travels from one medium to

another medium of different density, part of
the sound is reflected from the interface
between those media back into the probe.

This is known as an echo; the greater the

density difference at that interface, the
stronger the echo, or the higher the
reflectivity

In A-scan ultrasonography, a thin, parallel

sound beam is emitted, which passes
through the eye and images one small axis
of tissue; the echoes of which are
26
represented as spikes arising from a

In B-scan ultrasonography, an oscillating

sound beam is emitted, passing through
the eye and imaging a slice of tissue; the
echoes of which are represented as a
multitude of dots that together form an
image on the screen.
The stronger the echo, the brighter the dot.

27

For example, the dots that form the posterior

vitreous hyaloid membrane are not as bright
as the dots that form the retinal membrane.
This is very useful in differentiating a posterior
vitreous detachment (a benign condition)
from a more highly reflective retinal
detachment (a blinding condition) because
retina is more dense than vitreous.

ANGLE OF INCIDENCE

The angle of incidence of the probe is critical

for both A-scan and B-scan ultrasonography.

When the probe is held perpendicular to

the area of interest, more of the echo is
reflected directly back into the probe
tip and sent to the display screen.

29

When held oblique to the area imaged,

part of the echo is reflected away from
the probe tip and less is sent to the
display screen.

The more oblique the probe is held from the

area of interest, the weaker the returning
echo and, thus, the more compromised the
displayed image.

On A-scan, the greater the perpendicularity,

the more steeply rising the spike is from
baseline and the higher the spike.

On B-scan, the greater the perpendicularity,

the brighter the dots on the surface of the
area of interest
31

Because various parts of the eye and various

pathologies are different in size and shape,
understanding this concept and anticipating
the best possible display for that eye are
important.

Perpendicularity to the area of interest

should be maintained to achieve the
strongest echo possible for that structure

32

ABSORPTION

Ultrasound is absorbed by every medium

through which it passes.

The more dense the medium, the

greater the amount of absorption.

This means that the density of the solid

lid structure results in absorption of
part of the sound wave when B-scan is
performed through the closed eye,
thereby compromising the image of the
33
posterior segment

Therefore, B-scan should be performed on

the open eye unless the patient is a small
child or has an open wound.

Likewise, when performing an ultrasound

through a dense cataract as opposed to the
normal crystalline lens, more of the sound is
absorbed by the dense cataractous lens and
less is able to pass through to the next
medium, resulting in weaker echoes and
images on both A-scan and B-scan.
34

For this reason, the best images of the

posterior segment are obtained when
the probe is in contact with the sclera
rather than the corneal surface,
bypassing the crystalline lens or
intraocular lens implant.

PRINCIPLE OF
ULTRASOUND
USG wave has a
frequency > 20
kHz.
Wavelength
Depth of

penetration of
the ultrasound.

VELOCITY
Sound
travels
faster
through
solids than
liquids.

Velocity of
Larger d
sound wave
frequency =
is depends
short wavelength on the
= shallow
density of
penetration =
the media .
better resolution Vitreous
1532 m/s
Cornea
speed of
1,641 m/s

REFLECTIVITY
Greater the
density
difference at
interface,
stronger the
echo/higher
the
reflectivity
The stronger
the echo, the
higher the
spike
The stronger
the echo, the
brighter the
dot.

ANGLE OF
INCIDENCE

ABSORPTIO
N

Perpendicular
d probe to the
area of
interest,

More
dense the
medium,
the greater
the amount
of
absorption.

=more of the
echo is
reflected
directly back
into the probe
tip.
= brighter d
spot.

B-scan
should be
performed
on the open
eye unless
the patient
is a small
child or has
an open
wound

USE OF INCREASING GAIN

USE OF DECREASING GAIN

When the gain is high, weaker signals

are displayed, such as vitreous opacities
and posterior vitreous detachments.

When the gain is low, the weaker signals

disappear, and only the stronger
echoes, such as the retina, remain on the
screen.

Typically, all examinations begin on

highest gain so that no weak signals are
missed; then, the gain is reduced as
necessary for good resolution of the stronger
signals

40

INSTRUMENTATION....

INSTRUMENTATION

Ophthalmic ultrasound instruments use what

is known as a pulse-echo system, which
consists of a series of emitted pulses of
sound, each followed by a brief pause
(microseconds) for the receiving of echoes
and processing to the display screen.

The amplification of the display can be

altered by adjusting the gain, which is
measured in decibels (dB). Adjusting the
gain in no way changes the frequency or
velocity of the sound wave but acts to
change the sensitivity of the
instrument's display screen.

42

An USG unit is composed of four basic elements :

Pulser,
Receiver
Display

screen

Transducer

Probe

thick, with a mark

emit focussed sound beam at frequency
10mhz
mark on the B scan probe indicates
beam orientation-area towards which
mark is directed appears at the top of
the echogram on display screen

TECHNIQUE....

The patient is either

reclining on a chair or lying
on a couch. The probe can
be placed directly over the
conjunctiva or the lids.

PROBE POSITIONS

Transverse
: most common
Lateral extent, 6 clock hours

Longitudinal : radial ,1 clock hrs, AP

diameter in Retinal tumors and tears

Axial : lesion in relation to lens and

optic nerve .

TRANSVERSE SCAN
EYE anaesthetised.
EYE looking in the direction of
observers interest
PROBE parallel to limbus and placed
on the opposite conjunctival surface
PROBE MARKER superior (if
examining nasal or temporal) or
nasal(if examining superior and
inferior).
6 clock hrs examined at a time.

 The clock hour which the marker

faces is always at the top of the scan.

The area of interest in a properly

done transverse scan is always at the
centre of the right side of scan.
If examining nasal area -12 6 clock
hrs
temporal
- 6- 12 clock
hrs
superior
- 9 -3 clock
hrs

NASAL AREA

TEMPORAL AREA

SUPERIOR AREA

INFERIOR AREA

LONGITUDINAL SCAN
EYE Anaesthetised.
EYE - looking in the direction of observers

interest.
PROBE perpendicular to the limbus and
placed on the opposite conjunctival
surface.
PROBE MARKER- directed towards the
limbus or towards the area of interest
regardless of the clock hour to be
examined.
Optic nerve shadow always at the bottom
on the right side.
1 clock hour.

AXIAL SCAN

EYE anaesthetised.
EYE in primary gaze
PROBE centered on the cornea .

HOW THE SCAN LOOKS LIKE..

The probe face is usually oval in shape and

when placed on the globe is represented by
the initial white line on the left side of the
display screen.

64

NORMAL B-SCAN
Cornea, AC and the
anterior capsule-not
easily visualised
without immersion
technique
Lens oval high
reflective structure
Vitreousacoustically clear
Retina, choroid and
sclera-seen together
as a high reflective
structure

Sclera 100% reflective

Optic nerve-wedge shaped acoustic void in

retrobulbar space on axial scan

Extraocular muscles-echolucent to low

reflective fusiform orbital structures

SOME ABNORMAL B SCANS....

VITREOUS HAEMORRHAGE
To detect extent, density,
location and cause
Fresh haemorrhage shows
dots or lines
Old haemorrhage the dots
gets brighter

ASTEROID HYALOSIS
Asteroid hyalosis:
Calcium soaps
produce bright
point like echos

Differentiation between VH & asteroid

Hyalosis:

AH is highly echogenic,they are still visible

when the gain setting is reduced upto 60dB
whereas VH which usually disappears by 60
dB

70

Asteriod Hyalosis

Vitreous Haemorrhage
71

VITREOUS INFLAMMATION
USG is very helpful in assessing the severity and
extent of intraocular inflammation in a patient
suspected of having endophthalmitis.
VITRITIS appears in B-scan as scattered particle
or large aggregates.
sometimes in absence of external inflammatory
signs, it is important to differentiate between
endophthalmitis and vitreous hemorrhage.
VH is generally associated with PVD and
layering of blood in inferior portion of the
eye to produce sheet-like echoes
72

POSTERIOR VITREOUS DETACHMENT

Posterior vitreous
detachment:
The detached
posterior vitreous is
seen as
membranous lesion
with no/some
attachments to the
optic disc

POSTERIOR VITREOUS
DETACHMENT
Mobility of PVD is
more than RD.
The spike of RD is
more than PVD.
PVD becomes more
prominent in higher
gain settings

TOPOGRAPHIC
EXAMn.

KINETIC
EXAMn.

QUANTITATIVE
EXAMn.

SHAPE

MOBILITY

REFLECTIVI
TY
(SPIKE Ht. &
PEAKS)

LOCATION

AFTER
MOBILITY

TEXTURE

EXTENSION

VASCULARI
TY

SOUND
ATTENUATI
ON

PVD

RETINA
DETACHME
NT

CHOROID
DETACHME
NT

Linear

SHAPE
LOCATION
ATTCH. TO ON
OTHER
SPIKE HT.
SPIKE PEAKS
MOBILITY
AFTER MOVMT.

Variable

Yes

No

Thicker inferiorly

Folds/Breaks

Vortex Vein

40-90%

80-100%

90-100%

Single

Single

Double / M shape
peak

Marked (Hammock
like)

Moderate

Minimal

Marked

Moderate to
severe

Absent

RETINAL DETACHMENT
The detachment
produces a bright
continuous, folded
appearance with
insertion into the disc
and ora serrata.
It is to determine the
configuration of the
detachment as
shallow, flat or bullous

EXUDATIVE RETINAL DETACHMENT

RHEGMATOGENOUS RD

RHEGMATOGENOUS RETINAL
DETACHMENT

CLOSED FUNNEL RD WITH

RETINAL CYST

CLOSED FUNNEL RD WITH

RETINAL CYST

Appears as rd but it is a pvd.

Clues: non uniform thicness of membrane
Very thin attachment to the disc.

RETINAL TEAR

Retinal tear with free superior end .

The membrane is convoluted on itself.
Posterior vitreous is attached at the superior
end of the tear.

TUMOURS
Differentiation, extrascleral extension, size,
assessing tumour growth or regression.
Measurement of tumour dimensions such as
elevation and base.
Help in distinguishing solid from cystic
lesions.

RETINOBLASTOMA

Size of the tumour

Shows irregular
configuration
Calcification shows
high internal
reflectivity

IRIS MELANOMA

COLLAR BUTTON OR MUSHROOM

SHAPE.LARGE TUMOURS SHOWS
ACOUSTIC HALLOWING

TUMOURS - OSTEOMA

CHOROIDAL DETACHMENT:
KISSING CHOROIDS

Smooth, thick, dome shaped

membrane in the periphery with
very little after movement
360 degree detachment shows a
pathognomonic scalloped
appearance

CHOROIDAL DETACHMENT
KISSING CHOROIDS

CHOROIDAL DETACHMENT

INTRAOCULAR FOREIGN BODIES:

Localisation and extent of intraocular
damage
Metallic foreign bodies produce very high
bright signal
Shadow present posterior to the foreign
body
Wood, glass and organic material produce
specific echographic finding

INTRA OCULAR FOREIGN BODY

CUPPED DISC

MACULAR EDEMA

PERSISTENT HYALOIDAL VESSEL

POSTERIOR STAPHYLOMA

LACRIMAL GLAND TUMOUR

NANOPHTHALMOS

RETINOSCHISIS

Retinoschisis:
Smooth, thin dome shaped membrane that
doesnt insert on optic disc

Diabetic retinopathy:
Nature and extent of the disease
To monitor progress of the disease
Aids in pre vitrectomy evaluation

ENDOPHTHALMITIS

CYSTICERCOSIS WITH RETINAL

TEAR

COLOBOMA OF THE CHOROID

AND
DISC

PERSISTENT FETAL VASCULATURE

RETINOPATHY OF PREMATURITY

POSTERIORLY DISLOCATED LENS

INTRA OCULAR AIR / GAS

SILICON OIL FILLED VITREOUS

SCLERA

Thickening in hyperopic and

nanopthalmic eyes

Infolding in severe hypotony or a

ruptured globe

SCLERITIS

NODULAR POSTERIOR SCLERITIS WITH FLUID IN THE

TENON CAPSULE.
POSITIVE T-SIGN AT THE INSERTION OF THE OPTIC
NERVE.

EVALUATION OF EXTRAOCULAR MUSCLES

Normal muscles show less echo dense than

surrounding orbital soft tissue

Documenting the gross size and contour of a

muscle

EVALUATION OF OPTIC NERVE

General topography, relationship to

structures, optic disc anomalies and
alteration in contour of the globe

The subarachnoid space surrounding

optic nerve appears as echolucent
cresentric or circle around the nerve
called Doughnut sign

ADVANTAGES:
Non invasive
Performed in an office setting
Does not expose to radiation
High resolution echography provides
reliable and accurate assessment
Ideal for follow up of lesion

DISADVANTAGES

High frequency sounds waves have limited

penetration

LTRASONOGRAPHY IN PAEDIATRIC PATIENTS:

Useful in the following conditions:
Abnormal size of eye
Abnormal shape of eye
Congenital abnormalities
Vitreous alterations
Retinal detachments (type/ location)
Ocular and orbital tumours
Trauma

PITFALLS.....

Artefacts:

Insufficient fluid coupling ( i.e., lack of

methyl cellulose) cause entrapment
of air between the probe and eye
leading to display of bright echos
which represent multiple signals

REVERBERATION ARTEFACTS

ANGLE OF INCIDENCE ARTEFACT

Tumours:
Mass may be missed is less than 0.75 mm
False ve results in case of small lesion and
fibrotic tissue
False + ve in subretinal haemorrhage and
metastatic tumour with massive infiltration

Vitroretinal disease:

In RD unable to detect actual tear

In vitrectomised eyes vitreous

haemorrhage is diffuse leading to
echolucency

Silicon oil decrease in sound velocity

Intraocular foreign body:

Small Intraocular foreign body of < 1mm
may be missed.
Orbit:
An orbital mass can be detected or
differentiated if > 3 mm in size if anterior
and
> 5 mm in posterior orbits.

B- SCAN REPORTING

Describe the features and correlate with

clinical findings.

Dont jump to diagnosis.

Always examine both in sitting and erect

postures in case of RD.

Examine other eye also.

Try to take the best picture possible.

Four transverse scans

One horizontal axial scan to evaluate the

posterior pole are sufficient.

CAUTION

Correlation with clinical findings is essential to make a

diagnosis

 THE

END....