The A-Scan Biometer

16
Maya C. Shammas and H. John Shammas

A-scan ultrasonography has been used for diag- when measuring eyes with a mature cataract or
nostic purposes since the 1960s. Biometry was other vitreoretinal pathology. A-scan biometry is
then limited to measuring eyes with deformities needed in these cases. A-scan biometry can be
affecting the axial length (AL), i.e., congenital achieved by contact or immersion techniques.
glaucoma, axial myopia, and phthisis bulbi. The contact technique applanates the probe
Around the mid-1970s, the use of intraocular against the cornea to obtain the measurements;
lenses during cataract surgery gained in popular- errors can occur with axial length measurements
ity and many intraocular lens (IOL) theoretical from excessive indentation of the probe against
formulas were published to determine the IOL the cornea. With the immersion technique, the
power. All these formulas required an AL mea- probe is immersed in a gonioscopic solution or
surement, and A-scan biometry was the only way balanced salt solution (BSS) contained within a
to accomplish the task. The original units required scleral shell; because it does not cause indenta-
manual measurement of the ultrasound travel tion of the cornea, the results are more reliable
time with a caliper from a Polaroid picture of the and therefore the preferred method whenever
A-scan and converting it to millimeters. The possible.
measurement was then entered into a calculator
to obtain the IOL power needed for emmetropia.
Through the years, the ultrasound biometer Basic Technology
evolved with the introduction of electronic gates,
automatic calibration, and computerized capa- An ultrasound unit is composed of four basic ele-
bilities. Most available A-scan biometers are now ments: the pulser, the receiver, and the display
compact, efficient, computerized, and complete screen all contained within the same chassis and
with IOL power calculation capabilities. connected to the transducer, located at the tip of
Routine use of A-scan ultrasound biometry the probe by an electrically shielded cable
has been largely replaced by the more accurate, (Fig. 16.1a). The pulser produces electrical pulses
precise, and reproducible optical biometry. at a rate of 1000 pulses/s. Each pulse will excite
However, the use of optical biometry is limited the electrodes of the piezo-electric crystal of the
transducer, generating sound waves. The return-
M. C. Shammas ing echoes are received by the transducer and
Shammas Eye Center, Lynwood, CA, USA transformed into electrical signals. These signals
H. J. Shammas (*) are processed in the receiver and demodulator
Ophthalmology, The Keck School of Medicine of and then displayed on the screen.
USC, Los Angeles, CA, USA

© The Author(s) 2024 289

J. Aramberri et al. (eds.), Intraocular Lens Calculations, Essentials in Ophthalmology,
https://doi.org/10.1007/978-3-031-50666-6_16
290 M. C. Shammas and H. J. Shammas

Fig. 16.1 (a) An a

ultrasound unit is
composed of four basic
elements: the pulser, the
receiver, and the display
screen all contained
within the same chassis
and connected to the
transducer, located at the
tip of the probe by an
electrically shielded
cable. (b) The piezo-­
electric principle:
changes in the polarity
of an electric current
passing through a quartz b
crystal will cause
changes in the shape and
size of the crystal, and
vice versa. This in turn
will transform the
electrical energy into
mechanical energy in the
form of sound waves.
When the sound waves
return to the probe, the
mechanical energy will
modify the thickness of c
the crystal and produce
electrical energy. (c) A
crystal with a flat
surface emits a
non-focused beam,
essential for biometry.
(d) A crystal with a
concave surface emits a
focused beam essential
for B-scan echography d

This process is based on the piezo-electric mechanical energy will modify the thickness
principle (Fig. 16.1b); changes in the polarity of the crystal and produce electrical energy.
of an electric current passing through a quartz The performance of the crystal depends mainly
crystal will cause changes in the shape and on its shape and thickness. A flat surface emits
size of the crystal, and vice versa. This in turn a non-focused beam (Fig. 16.1c) essential for
will transform the electrical energy into biometry; a concave surface emits a focused
mechanical energy in the form of sound waves. beam essential for B-scan echography
When the sound waves return to the probe, the (Fig. 16.1d).
16 The A-Scan Biometer 291

 hysical Principles of A-Scan

P
Ultrasound

Ultrasound refers to sound waves beyond the

range of human hearing. In order to make this
definition more precise and to explain the proper-
ties of ultrasound, we must first explain sound.
Consider knocking on a door. When the knuckles
of the hand strike the door’s surface, the mole-
cules of which the door is made are temporarily
forced closer together. The compression or
“mechanical disturbance” has thus moved or
“propagated” deeper into the “medium” which is
the material of the door. Disturbances which
propagate in this way are generally called waves;
hence, we speak of “sound waves.”
A point source of sound creates a spherical
wavefront, with sound propagating in all direc-
tions away from the source. A piston-like sound
source creates a quasi-planar wavefront, with
sound propagating mostly in a single direction, as
shown in Fig. 16.2. Fig. 16.2 Quasi-planar wavefronts created by a broad,
When the piston is moving repetitively back flat sound source (piston)
and forth at a constant frequency, we can plot a
graph of the piston’s position against time and we ited range or band of frequencies. The size of the
would obtain a curve as shown in Fig. 16.3. Such range is called the bandwidth. The midpoint of
a curve is called periodic because it repeats itself the range is called the center frequency. Both are
continuously. The smallest repeated portion is typically measured in MHz. A typical A-scan
called a cycle, and the length of time required for biometry system, for example, might have a cen-
one cycle is called the period. The study of peri- ter frequency of 10 MHz and a bandwidth of
odic sound provides the theoretical basis of oph- 4–6 MHz.
thalmic ultrasound. Frequency is measured in The amount of distance corresponding to one
cycles per second, also called Hertz (after cycle (Fig. 16.4) is called the wavelength, and it
Heinrich Hertz, a German physicist who studied depends on both the frequency of the sound and
wave phenomena at the end of the nineteenth the speed or velocity at which it propagates
century), which is abbreviated Hz. One kilohertz, through the medium, according to the formula:
abbreviated kHz, equals 1000 cycles/s. One λ =v/ f
megahertz, abbreviated MHz, equals where “λ” represents wavelength, “v” represents
1,000,000 cycles/s. The healthy human ear can velocity, and “f” represents frequency. Most ocu-
detect sound frequencies in a range of about lar ultrasound images work at frequencies of
20 Hz to as much as 20 kHz. Ultrasound is sound 8–10 MHz. The average velocity of sound in
at frequencies well above the 20 kHz. human tissue is about 1550 m/s. 10 MHz sound
Real-world ultrasound equipment generates in human tissue has a wavelength of 155 μm (mil-
sound pulses whose energy is confined to a lim- lionths of a meter).
292 M. C. Shammas and H. J. Shammas

Fig. 16.3 Piston’s

position plotted against
time

Fig. 16.4 Plot of sound

pressure vs. distance
along sound beam, at a
single instant

Major Components of a Biometer Kretztechnik 7200 MA ultrasound unit. This

probe can also be used to measure the axial length
Four different components are herein discussed through an immersion technique. The newer
including the probe and its transducer, the sensi- probe (Fig. 16.6) is thinner and designed specifi-
tivity setting, the velocity setting, and data analy- cally for biometry.
sis with IOL calculation. The transducer emits the ultrasound beam.
Ultrasound consists of high-frequency sound
waves over 20,000 cycles/s, which is the highest
The Probe and Its Transducer frequency audible to the human ear [4]. The
ultrasound beam is formed of ultrasound waves
The probe is connected to the main chassis of the that display different characteristics depending
biometry by an electronically shielded cable and on the ultrasound frequency, wavelength, veloc-
contains a transducer at its tip [1–3]: The original ity, and direction.
solid probe (Fig. 16.5) has been designed for The frequency [5] is the number of hertz (Hz)
standardized A-scan echography using the or cycles per second. Higher frequencies provide
16 The A-Scan Biometer 293

the eye, the ultrasound velocity is 1532 m/s in

aqueous and vitreous, 1640 m/s in a clear lens,
and 1550 m/s in solid tissues. During an accurate
measurement of the different eye components,
the proper sound speed must be used for each of
these entities.
The direction of the ultrasound beam [8, 9]
affects the display of the tissues under examina-
tion. During biometry, the emitted sound beam
Fig. 16.5 The Kretztechnik 7200 solid probe is used for will meet multiple interfaces. At each interface,
diagnostic standardized A-scanning and for biometry
part of the sound beam is reflected toward the
probe and the remainder of the sound beam keeps
propagating deeper into the tissues. This process
will generate echo spikes from the different inter-
faces that have been intersected, i.e., anterior sur-
face of the cornea, posterior surface of the cornea,
anterior surface of the lens, posterior surface of
the lens, anterior surface of the retina, and ante-
rior surface of the sclera. When the ultrasound
beam reaches the orbital tissues, it is attenuated
until it loses all its energy. The sound beam
returns to the transducer that also acts as a
receiver. The pulses are then processed within the
biometer to display “echo-signals” on the screen.

The Sensitivity Setting

The sensitivity setting controls the height of the

Fig. 16.6 Smaller solid probe designed for biometry echo spikes displayed on the screen.
The axial length is more accurately measured
at a lower system sensitivity that allows a better
a higher resolution while lower frequencies pro- pattern recognition of the anterior and posterior
vide better penetration but a reduction in the res- corneal surfaces, anterior and posterior lens sur-
olution. To obtain the high resolution needed for faces, and anterior retinal surface.
axial length measurement, biometry units use
ultrasound frequencies ranging between 8 and
25 MHz (1 MHz = 1 megahertz = 1 million The Velocity Setting
cycles/s).
The wavelength [6] is the distance between The velocity setting controls the speed of sound
two particles in the same phase of oscillation. propagation. The velocity, measured in meters
Within the ocular tissues, the wavelength is per second (m/s), varies according to the medium
approximately 0.19 mm if an 8 MHz probe is through which sound propagates. Most units use
used and 0.15 mm if a 10 MHz probe is used. an average velocity of 1548–1556 m/s in a cata-
The velocity [7] is the speed of sound propa- ractous eye and 1532 m/s in an aphakic eye.
gation and is expressed in meters per second Newer units measure each ocular compartment at
(m/s). The velocity varies according to the its correct velocity; the anterior chamber depth is
medium through which sound propagates; within measured with a velocity of 1532 m/s; the
294 M. C. Shammas and H. J. Shammas

c­ataractous lens is measured with an average the region of the anterior corneal spike and the
velocity of 1640 m/s; the vitreous cavity’s depth “retinal gate” placed in the region of the retinal
is measured with a velocity of 1532 m/s like the spike. Such instruments measure the travel time
aqueous. These measurements are then computed between the anterior surface of the cornea and the
within the instrument to display one axial length anterior surface of the retina and use an average
reading. sound velocity for the measurement of the axial
length.
Instruments equipped with four gates
The Electronic Gates (Fig. 16.7) allow the positioning of these gates
over the leading edges or the peaks of the
Electronic gates allow ultrasound units to provide echoes generated from the anterior surface of
an electronic read-out of the axial length in mil- the cornea, the anterior surface of the lens, pos-
limeters. The gates will measure the travel time terior surface of the cornea, the anterior surface
between the leading edges of the spikes of the lens, the posterior surface of the lens, and
(Fig. 16.7) or the peaks of the spikes (Fig. 16.8). the anterior surface of the retina. A measure-
Biometers are equipped with 2, 4, or 5 gates. The ment of the anterior chamber depth, lens thick-
two main gates are the “corneal gate” placed in ness, and the total axial length is displayed on
the screen.
Instruments equipped with five gates
(Fig. 16.8) will additionally locate the posterior
corneal surface and include a measurement of the
corneal thickness.

Data Analysis and IOL Calculation

Most biometers will analyze the measurements

and will display the axial length, anterior
chamber depth, and lens thickness. IOL power
Fig. 16.7 The four gates of this horizontal caliper lights calculations are provided using available mod-
(arrows) measure the distances between the leading edges
of the anterior corneal surface, anterior lens surface, pos-
ern formulas. Many will be able to provide a
terior lens surface, and the retina print out or connect directly to an imaging sys-
tem or Electronic Medical Record. These pro-
grams are also able to store information,
compare results, review data, and refine the
ELP constants.

Choosing the Appropriate

Ultrasound Biometer

Most biometers provide reproducible and accu-

rate measurements and are programmed with
popular formulas. However, each biometer is
characterized by specific features and compo-
Fig. 16.8 Five vertical gates (dotted lines) measure the nents that have been discussed in length in this
distances between the peaks of the anterior cornea (C1),
the posterior cornea (C2), anterior lens surface (L1), poste-
chapter. Here are some essential features to look
rior lens surface (L2), and retina (R) for in a biometer:
16 The A-Scan Biometer 295

–– A display screen that allows pattern recogni- Table 16.1 Commonly used ultrasound biometers
tion of the displayed echogram. Biometers Additional Other
shaped like a pen without a display unit are Company Product features models
not advisable. Quantel Aviso S Pachymetry Aviso
Medical/Ellex UBM Axis Nano
–– Measurement capability of the anterior cham-
B scan Compact
ber depth and of the lens thickness, in addition MEDA ODM-2200 B scan MD-1000A
to measuring the entire axial length. Newer Suoer SW-1000P Pachymetry SW-1000
formulas require these measurements. Tonometry
–– Measurement capability of aphakic and pseu- Keeler Accutome Optional
A-Scan UBM
dophakic eyes.
Plus Optional B
–– A freeze frame capability and a print out of the Connect scan
A-scan echogram for review. Nidek US-4000 Pachymetry US-500
–– Visible electronic gates. B scan
–– IOL power calculation capability. Sonomed MV4500 Optional B
Master-Vu scan
DGH Scanmate Alignment Scanmate A
Some biometers are available with diagnostic A Flex ranking
B-scan, ultrasound biomicroscopy (UBM), and/ UBM
or pachymetry within the same chassis. Practices B scan
that handle vitreoretinal pathology and/or per- Ellex/Quantel Eye Cubed UBM
B scan
form corneal surgery will enjoy the added fea-
Tomey AL-4000 Auto AL-100
tures in one compact unit. alignment
SonoStar SPA-100 Pachymetry
Micromedical PalmScan Pachymetry A2000T,
 ommonly Used Ultrasound
C AP2000 Mobile AP2000T,
Pro A2000
Biometers

There are many excellent ultrasound machines

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