ULTRASONOGRAPHY PRINCIPLE,

METHODS AND INTERPRETATION

Pabita Dhungel
B.Optometry
3rd year
 PRESENTATION LAYOUT

Introduction
History
A- scan
B- scan
Methods for special purposes
Clinical pictures
Summary
 References

Clinical Procedure in Optometry

Optometry: science, techniques and Clinical
managements
Ophthalmic ultrasonography
Borish Clinical Refraction
 Introduction
Ultrasound is an acoustic wave (above audible frequency)
that consists of oscillations of particles within a medium,
frequencies greater than 20kHz(20,000 oscillations/s)
Diagnostic ophthalmic Ultrasound
Frequency 8-10 MHz (Sandra Frazer et. Al)
8-25 MHz for Posterior segment & Orbit (Jagers Duane Oph.)
50 MHz for imaging Anterior segment (Jagers Duane Oph.)
Produce short wavelength = 0.2 mm
Good resolution of ocular structures Less Penetration
 Contd
Examination of larger structures e.g
abdominal or obstetric ultrasound requires
frequencies in the range of 1 to 5 MHz
Such wavelengths produced by these lower
frequencies enable these instruments to
penetrate deeper into the body decreasing
their resolution capability
 Contd
Ultrasound is transmitted as a longitudinal wave
so its speed is dependent upon the density of the
medium it is passing through e.g air sound travels
at 340m/s whereas in water its speed is much
faster at approx 1480m/s.
Fluid contact is essential betn the transducer and
eye so normal saline is used in open eye or water
soluble gel is used if reading taken through
eyelids
 Sound Wave Velocities Through Various Media

Medium Velocity (m/sec)

Water 1,480
Aqueous/ Vitreous 1,532
Silicon Lens 1,486
Crystalline Lens 1,641
PMMA Lens 2,718
Silicon Oil 986
Soft Tissue 1,550
Bone 3,500
 History
In 1956,
First time: Mundt and Hughes, American Oph.
A-scan (Time Amplitude ) to demonstrate various ocular disease
Oksala et. Al in Finland
Ultrasound Basic Principle (Pulse-Echo Technique)
Studied reflective properties of globe
In 1958, Baum and Greenwood
Developed the first two-dimensional(immersion) (B-scan)
ultrasound instrument for ophthalmology.
In the early 1960s, Jansson and associates, in Sweden,
used ultrasound to measure the distances between structures in the
eye.
 Contd
In the 1960s, Ossoinig, an Austrian ophthalmologist
first emphasized the importance of standardizing
instrumentation and technique.
developed standardized A-scan.

In 1972, Coleman and associates made

first commercially available immersion B -scan instrument
Refined techniques for measuring Axial length, AC depth, Lens
thickness

Bronson in 1974 made contact B scan machine.

 Advantages of USG
Easy to use.
No ionizing radiation
Excellent tissue differentiation
Cost effectiveness
Primary uses in ophthalmology:
Posterior segment evaluation in Hazy media / Orbit
Structural integrity of eye but no functional integrity
Detection and differentiation of intraocular and orbital lesions
Tissue thickness measurements.
Location of Intra Ocular Foreign Body
Ocular Biometry for IOL power calculations
 Principle
Average velocity in Eye = 1500 m/sec
Takes about 33 microseconds to travel & return
back from the posterior part of eye
Principle
Pulse- Echo System
Emission of multiple short pulses of ultrasound
waves with brief interval to
Detect, process and display the turning
Echoes
 Piezoelectric crystal (Quartz & Ceramic Crystal)
Present in Probe tip
Application of Pulse of Voltage electric energy
Mechanical Vibration Rapid vibration
Generate short pulse Ultrasound energy
(Transducer)
Longitudinal ultrasound wave propagate through
medium (Eye) Echoes come back from different
Acoustic Interfaces
A pause of Several Milliseconds for receiving echoes
Creates mechanical vibration as it strikes the probe tip
and the piezoelectric crystals Produce electric energy

Transmitted to receiver and in a Cathode ray Tube to

display Ultra sonogram
 Terms
PROBE Consists of piezoelectric transducer.
A piezoelectric transducer consist of small ceramic plates
which converts electricity into sound waves and sound
waves into electric signals to be displayed on the screen.
Damping material (metal powder with plastic or epoxy)
Help to produce shorter Pulse Better for Axial
resolution
Axial resolution
The minimum distance between two interfaces
(Echo Sources) along the direction of the sound
beam
 Contd
Shape of the Crystal:
Planer crystal
Produce relatively parallel sound beam (A- Scan)
Acoustic lens Produce focused sound beam (B-
scan)
Improves lateral resolution
Minimum separation between two interfaces
perpendicular to the direction of sound beam
 Contd
RECEIVER (computer unit)
Receives returning echoes

Produces electrical signal that undergoes

complex processing
Amplification, Compensation, Compression,
Demodulation and Rejection
 Contd
RESOLUTION
Ability to discern two interfaces close to each
other.
Higher the frequency of ultrasound
Shorter the wavelength & better the
resolution.
Echoes-
Reflected portion of the wave.
 GAIN
Relative units of Ultrasound intensity
Expressed in Decibel (db)
Adjust of gain doesn't change the amount of energy
emitted by transducer
but chance in intensity of the returning echoes for
display
Electric Amplification of the echo signals received by the
transducer
Higher the gain Greater the sensitivity of the
Instrument in displaying weaker echoes (i.e Vitreous
opacities)
Lower the gain Weaker the depth of sound penetration
only stronger echoes are displayed (i.e Retina /
Sclera)
 Gain contd
Stronger echoes are located in the centre of
the returning sound wave
Lowering gain effectively narrows the sound beam
Improves both axial and lateral Resolution
When the gain is Increased
A-scan gets taller and B-scan echoes gets brighter
conversely
When the gain is turned down the echoes get
shorter and dimmer.
 Displaying the Ultrasound

1. A-Mode Display

2. B-Mode Display

3. M-Mode Display
 A - scan
A for amplitude provides one dimensional display of
returning echoes in the form of vertical spikes of
various heights and distances from the initial signal
Echoes from the structures deeper within the eye
take longer to return to the transducer for conversion
back to electric signal, so appear further along the
time baseline
 Contd
Two fundamental data obtained are
i) distance of echo source from the probe face
- forms the basis of biometry
ii) amplitude of echo signal (spike) which partly
depends on the nature of reflecting interface
- forms the basis of quantitative echography
 Standardization of A scan
Credited to Dr. Karl Ossoinig
1.Unique sound Amplification :
S-shaped amplifier with flat upper and lower
curves and a steep mid segment and a
dynamic range of 36dB
This amplification enhances the difference
between normal and abnormal signals
 A-Mode
A-ModeDisplay
Display
Sound velocity should be adjusted
Time Dimension calculated according to the speed at which
sound travels via a given medium
Phakic Eye Average Sound Velocity : 1,550 m/sec

Average Velocity Adjustment for Eye Length measurement

Ocular Media Velocity (m/sec)

Aphakia (Aqueous/ Vitreous) 1,532
Phakia 1,550
Pseudophakia
PMMA Implant 1,532 + 0.2 mm or 1,550
Silicone Implant 1,486
Silicon oil 986
Note: Average Velocity :
Average of Sound Velocities for the Aqueous + Vitreous + Lens
 Examination steps
Patient is positioned with head near
oscilloscope
Topical anaesthetic drops are placed in the eye
Probe is firmly placed on the globe without
coupling jelly as tear acts as coupling agent
Eight meridians are scanned, postero-
anteriorly, by shifting and tilting the probe in a
single, smooth arc movement from limbus to
fornix
 Contd
In cases of traumatized or infected eyes, or
soon after intraocular surgery, examination
through the closed eyelids is safer
At the end of procedure, the eye is irrigated
with sterile saline, and the probe tip is cleaned
with alcohol wipe or other suitable
disinfectant
 Orientation and labelling of scan
The labelling of sections is determined by the
projection of the beam and not the probe
location
E.g a section labelled 12 equator (12E) is
produced by placing the probe at 6 0clock and
mid distance betn limbus and fornix, a section
labelled 6 anterior (6 A) is produced by placing
the probe at 12 0clock fornix
 Macular screening

1) Axial section
easier of the two approaches
Probe is placed on cornea and directed axially
Suitable for measurement but not sensitive in
detecting early macular thickening or in
differentiation of its lesions because of strong
sound attenuation by the lens
 Contd
Posterior section
In the RE this is 9P position and in the LE the
3P position
Produced by directing the patients gaze
temporally and placing the probe at the nasal
limbus and aiming it posteriorly thus avoiding
the lensand achieving better resolution
 Examination of fundus periphery
Patients gaze is directed maximally towards
the meridian to be scanned and probe is
placed at the opposite fornix the beam being
aimed across the globe towards the opposite
periphery
Useful for detecting peripheral retinal
cysts/retino-schisis, choroidal detachments
and ciliary body lesions
 B - Scan
B for brightness produces two dimensional slice
of tissue images, composed of coalescing dots of
varying degrees of brightness , depending on the
reflectivity of the echo source
Probe emits a focused sound beam at the
frequency of 10 MHz , eye dedicated scanners
produce a sound beam whose focal zone
coincides with the posterior globe wall and
anterior orbit
 Contd
Marker at the probe tip indicates the beam
orientation and the top of the echogram as it displays
on the screen
Coupling jelly is applied to the probe tip to ensure
adequate sound transmission
Probe sterilized with alcohol, impregnating B-probe
in sterilizing soln isnt recommended as it damages
the transducer
 Fundamental objectives for high
quality B- scan
Lesions must be placed in the center of the scanning
beam
Beam must be directed perpendicularly to interfaces
at the area of interest
Lowest possible decibel gain that is consistent with
the maintenance of adequate intensity should be
used to optimize resolution of the images
 B- scan sections: orientation and
labelling
1) Axial section
Easiest to perform and interpret
Probe is placed on the cornea and directed
axially
Posterior lens surface and optic nerve head
are placed in the center of the echogram
Optic nerve head is used as an echographic
centre
 Contd
Depending on the clock hour location of the
probe marker, a vertical axial section (marker
at 12 0clock) horizontal axial scan (marker at 3
0clock RE and 9 0clock LE) and sections of all
other clock hours can be performed
Easy orientation and demonstration of
posterior pole lesions and attachments of
membranes to optic nerve head
 Contd
Because of scatter and strong sound
attenuation created by the lens higher decibel
gain levels are needed to show structures at
the posterior segment
In pseudophakia strong artefacts created by
the lens implant will hamper the adequate
visualization
 Contd
2) Transverse section
Probe is placed on the limbus and directed
posteriorly
Echograms are labelled according to clock hour at
the center of the beam and also to the beams
anteroposterior location
E.g section labelled 12 posterior (12P) is produced
by a probe located at 6 0clock limbus, a 6 0clock
(6E) by probe located at 12 0clock
 Contd
3) Longitudinal section
Section produces an antero-posterior slice of
the ocular wall along one meridian only; from
the optic nerve (lower portion of echogram) to
the ciliary body (upper portion of the echogram)
Probe is located on sclera with marker at its
limbal side
 Contd
Echograms are labelled after the clock-hour
location of the beam
E.g L-3 is a section produced by a probe at 9
0clock limbus and L-12 by a probe at 6 0 clock
limbus
 Steps for ocular screening
1) Transverse 12:
Patient directs gaze superiorly
Probe is placed at the 6 0clock limbus with
its marker nasally
Shifting and rotating the probe from limbus
to fornix scans the superior retina postero-
anteriorly
 Contd
2) Transverse 3:
The patient gazes at 3 0 clock and the probe is
placed at 9 0clock with its marker up
Probe is manoeuvred from the limbus to fornix,
scanning the nasal retina in the RE and temporal
retina in the LE
 Contd
3) Transverse 6:
The patient looks downwards and the probe is
positioned at 12 0clock with the marker nasally and
swept from limbus to fornix to scan inferior retina
4) Transverse 9:
The patient gazes at 9 0clock and the probe is
manoeuvred at 3 0clock with its marker kept up,
section scans the temporal retina in the RE and nasal
retina in the LE
 Contd
Four additional transverse scans of the oblique
quadrants i.e 1:30 , 4:30, 7:30 and 10:30 0
clock hours may be performed in a similar
fashion if abnormalities in the oblique
periphery are suspected
 Macular screening
1) horizontal axial
an axial section with the marker nasally will display
the macular area and adjcent optic nerve head
2) Vertical macula
Probe is tilted temporally without losing the posterior
lens echoes
Vertical beam is shifted from optic nerve to the
macular area, lens acts as a reference point for accurate
placement and future reference
 Contd
3) Transverse 9:00 RE and 3:00 LE
The probe is placed on the corresponding nasal
limbus with its marker up, and the patient gazes
temporally
Avoiding the lens allows better visualization of
the vertical extent of macular masses
 Contd
4) Longitudinal 9:00 RE and 3:00 LE
Patients gaze is directed temporally
Probe is placed on the nasal side of the globe
with the marker at the limbus
Macular area will appear at the centre of the
echogram with the optic nerve at the bottom
and ciliary body at the top
Lateral extension of lesion is studied in this
section
 M- Mode Display
Motion Mode & Time-Motion Mode
Used to monitor Integrity of Blood Vessels/ Lens
Accommodation Dynamic
Aka Color Doppler Imaging (CDI), the technique
provides information about the ocular vascular
supply superimposed on a B-scan image
 Contd
This modality gives approx flow velocity of the
principal vessels in the eye and orbit, by
providing a color doppler display for pulse
doppler examination (Lieb et al 1991; Giovagnorio et al 1993)
CDI scans of the eye and orbit are performed
with patient lying in supine position with their
eye closed using an ultrasound frequency > 7
MHz and a Doppler frequency >5 MHz (Tranquart et
al 2003)
 Contd
The transducer or probe is applied to closed
eyelid using a thick layer of conducting gel
Care must be taken not to exert any pressure
on the globe as this might result in a decrease
in blood flow velocity, thus increasing the RI
with no diagnostic significance
FACTOR INFLUENCING HEIGHT IN
A-SCAN AND BRIGHTNESS IN B-SCAN

1. Angle of the sound beam

1. Interface

2. Size and shape of interfaces

 1. ANGLE OF INCIDENCE

When the sound beam is

directed perpendicularly to
a structure

Maximum amount of sound

will be reflected back to the
probe.

The farther away from the

ideal angle , the lower the
amplitude.
 2. INTERFACE
Depends upon the difference
between Acoustic Impedance
Greater the diff. AI stronger the
Reflected Echoes
EG:
Anterior lens surface produce
strong echo when bordered by
Aqueous than by Blood
Interface between vitreous and
fresh blood is very slight
resulting in small echo.
The difference between a
detached retina and the
vitreous is great producing a
large echo
3. TEXTURE AND SIZE OF INTERFACE

Smooth surface like retina will give strong

reflection.

Smooth and rounded surface scatter the

beam.

Coarse surface like ciliary body or

membrane with folds tend to scatter
the beam without any single strong
reflection.

Small interface produces scattering of

reflection.
 Indications for Intraocular
Examination
Clear Ocular Media
Opaque Ocular Media
Anterior segment
Anterior Segment
Iris lesions
Corneal opacification
Hyphema /hypopyon Ciliary body lesions
Posterior segment
Cataract
Pupillary or Tumors
retrolenticular Choroidal detachment
membrane
Retinal detachment
Posterior Segment
Vitreous hemorrhage or Optic disc abnormalities
inflammation -Intraocular foreign bodies

Biometry
 Intraorbital Examination

Indications-
Signs & Symptoms-
Unilateral or Bilateral Additional Indications-
Exophthalmos
Enophthalmos Tissue Differentiation
Globe Displacement of Mass Lesions
Lid Abnormalities - Ptosis, Clarification of CT or
Retraction, Swelling, MRI Findings
Ecchymosis
Palpable or Visible Masses Assessment of blood
Chemosis flow within lesions
Motility Disturbances; Follow-up studies
Diplopia
Pain
 Examination Techniques For The Globe:
Positioning the patient

Topical anesthesia

Techniques

Contact Technique
Probe - placed directly on the globe

Immersion Technique

Methylcellulose - a coupling medium (B-Scan)

 Contact Technique
The Probe Placed
Directly on the cornea (A-Scan)
or over closed lids (B- Scan)

To evaluate the posterior

segment only (B Scan)

Small solid probe fits in

the Tonometer holder
for A-scan biometry.
Applanation Technique
Contact Technique
A Scan Phakic Eye
Contact Technique
A- Scan - Aphakia
 Contact Technique

Sources of Error
Corneal compression
(Shorter Axial length)
1mm error in Axial length
2.5 to 3.0 Ds error in IOL
Power

Misalignment of sound
beam
Fluid Miniscus Trapped
Erroneously Long AL
 A- Scan

Correct
( no compression )

No Fluid meniscus
trapped between
probe tip and cornea.
 Immersion Technique
Can use in the same
instrument
Requires Scleral Cup
Coupling Agent Methylcellulose
Probe is not directly placed on the Prager Scleral Shell
cornea immersed into the fluid

Error
Small air bubbles in the fluid
gives falsely long AL
measurement
 Scleral Shells

The Hansen scleral shells

available in 16, 18, 20, 22, and 24
mm

The Prager Shell

The Kohn shell

Immersion Technique

The cup is placed between the

lids and methylcellulose 1% is
poured into the cup.

The ultrasound probe is

immersed in the solution, keeping it 5
to 10 mm away from the cornea.
 A-Scan (Immersion Biometry)

Initial spike (IS), the anterior (C1) and posterior (C2) corneal surfaces,
the anterior (L1) and posterior (L2) lens surfaces, the retina (R), sclera
(S), and orbital tissues (O).
 Immersion Technique: Advantages

Important in patients with shorter

axial length < 22.00 mm no corneal
compression
Where small error in measurement cause
significant error in Biometry

Can examine the cornea, anterior

chamber, iris, lens & retrolental space

Ultrasound Biomicroscopy:
developed by Pavlin & colleagues
uses sound wave of 50 to 100 MHz
 Immersion Technique
Should be cautious in eyes with recent intraocular
surgery or penetrating trauma.

No corneal compression

No problem of fluid meniscus

The display of a separate corneal spike makes it easier

to determine when the sound beam is properly
aligned along the optical axis.
 Examination Techniques For The Globe-A scan
The probe should remain perpendicular to the structure studied
The probe is first adjusted to the Tissue Sensitivity gain setting.
One dimensional acoustic display-echoes-vertical spikes from
baseline

Uses
For IOL calculations
(biometry)
For differentiating and
monitoring certain ocular
conditions
Congenital glaucoma
Progressive Myopia
 Axial Eye Length Measurements

Two techniques:
The contact method
The immersion method
In both techniques, the
sound beam must be
directed along the
optical axis of the eye.
 B scan
Different types of Probe
The probe face is Oval
Shaped with the transducer
movement in the direction
of longest diameter
The probe contains
transducer that moves back
and forth near the tip

Fig of probe face

 B scan
Each probe has a
marker A dot / Line
Indicates the side of
the probe that is
represented on the
upper portion of B-Scan
Display
 Examination Techniques For The Globe:..

Basic Screening Examination

transverse scans of the four major
quadrants at a high gain setting,
from limbus to fornix
first superior portion nasal
portion inferior portion
temporal portion
 Examination Techniques For The Globe-B scan

After transverse scan

Eye should be scanned with longitudinal scan at
least in four major quadrants
Helpful in detecting lesions in peripapillary region and macula

Globe should also be evaluated with vertical

and horizontal axial scan
A-scan basic screening examination
 Special Examination Techniques
Topographic
Location
Extension
Shape
Quantitative
Reflectivity estimate: spike height
Internal structure: histologic architecture
Sound attenuation: absorption, shadowing
Kinetic
Mobility: after movement
Vascularity: blood flow
 Topographic Echography

A. point-like
e.g. fresh V.H
B. membrane-like
e.g. R.D
C. mass-like
e.g. choroidal
melanoma
 Quantitative Echography

1-Reflectivity estimate:

PVD Vs RD
PVD produces 50%
high spike
RD produces 100%
high spike
Quantitative ..internal structure

Choroidal melanoma-
homogenous histologically-
regular internal
stucture,low reflectivity
Choroidal hemangioma-
multiple vascular spaces-
regular internal structure
high reflectivity
Metastatic carcinoma-
irregular arrangement of
tumor cells,variable
reflectivity
 Kinetic Echography
Lesion mobility (after
movement)
Non-solid lesion (e.g.
vitreous membrane,
RD) displays after
movement.

Solid lesion (e.g.

tumor) does not.

Blurred appearance of spikes

 Vascularity (spontaneous
Kinetic
motion)

Vascularity is a
characteristic that is
assessed in tumors
spontaneous motion (low-
amplitude flickering of the
internal lesion spikes)
 Examination Techniques For The Orbit:

Three major portions:

orbital soft tissue assessment
extraocular muscle evaluation
retrobulbar optic nerve
examination
Two approaches:
Transocular (through the globe)
for lesions located within the posterior & mid-aspects of the orbital
cavity
Paraocular (next to the globe)
for lesions located within the lids or anterior orbit
Examination Techniques For The Orbit:

Basic Screening Examination

Mainly Transocular approach
Transverse scans of the four major meridians
using a medium-high gain setting
From limbus to fornix
First superior portion nasal portion inferior
portion temporal portion
 Clinical Examples:

Order of disappearance with gain reduction :

Vitreous Opacities Blood- Retinal Tissue Ca++
 Vitreoretinal Disease

Dense Vitreous hemorrhage

Mild and extremely dense Asteroid hyalosis
 Vitreous Haemorrhage
US showing
hemorrhagic track
through vitreous
cavity along path
of penetrating nail
injury
 Posterior Scleritis

High reflective
thickening of
retinochoroid layer
and sclera
RD Vs PVD

Choroidal Detachment
 Posterior Vitreous Detachment
Low reflective
vitreous opacities
and a posterior
vitreous
detachment as
seen with normal
aging of the eye.
 Tractional RD
US showing tent
shaped tractional
RD (Large arrow).
Small arrows show
vitreous membranes
of low reflecting
attached to apex of
detached retina.
Dislocated Lens:
 Choroidal Detachment
B-scan of eye with
kissing
Choroidal
detachment &
Haemorrhage
Subarachnoid Fluid Around the Optic Nerve

Positive crescent sign.

 Ciliary Body Detachment
(Immersion Technique)
Ciliary body
detachment as
seen on high-
resolution scan.
Note the large
cleft in the
subciliary space
Choroidal Melanoma:
 Thyroid Ophthalmopathy Vs Myositis

Thickened muscles due to

thyroid ophthalmopathy.
Orbital myositis
Thickened muscle
to be irregular and
medium-high reflective
in thyroid but regular and
low reflective in myositis.
Posterior Staphylomas
 Scleritis
.

Nodular posterior scleritis

with fluid in the Tenon capsule Positive T-sign at the insertion
of the optic nerve
 AC Hyphema
(Immersion Technique)

US showing anterior chamber hyphema.

C represents cornea, white arrow - hyphema and L - Lens.
 Metallic Foreign Body
US of eye
demonstrated a
metal F.B. (arrow)
which is highly
reflective. This can
produce a region
that may look like a
nerve shadow or
even resemble a
dehiscence in sclera.
 Metallic IOFB

Thick, very highly reflective

spike from foreign body(F)
and decreased spike height
of sclera and orbital tissue
as a result of sound
attenuation.

.
Retinoblastoma

Calcified RB Non-calcified RB
 Extrusion of Lens Material
B-scan of eye with
severe blunt trauma
showing extrusion of
lens material through
small posterior lens
rupture (arrow).
 S
A NK YOU
TH