A SCAN, B SCAN & BIOMETRY

A-Scan

11/08/2024 2
 A-SCAN
• A-scan is a one-dimensional display of echo
strength over time. Vertical spikes correspond
to echo intensity and are shown on the
horizontal axis as a function of time.

• Two primary types of A-scan: biometric A-

scan and standardized diagnostic A-scan.
 A-scan
1. Biometric A-scan is optimized for axial eye length
measurements.
2. It uses a probe with an operating frequency of 10
to 12 MHz and a linear amplification curve.
3. The sound velocity in ocular structures along the
visual axis at physiologic temperatures results in
highly accurate measurements.
• Used in cataract surgeries for IOL calculations.
An error in axial length measurement of 1 mm
can cause an error in IOL power of 2.5 D
(approximately)
 A-scan
2. Standardized A-scan uses a probe with an
operating frequency of 8 MHz and an S-shaped
amplification curve.
• Primary feature is the tissue sensitivity or
standardized decibel setting used for the
detection and differentiation of abnormal
intraocular tissues.
• It is designed to display an echo spike for retina
that is 100% on the echo intensity scale.
• In combination with B-scan, diagnostic A-scan is
essential in the differentiation of vitreoretinal
membranes
 • Average Axial Length of
Normal Eye
23.06 mm

•Majority 22.0 to 24.5 mm

•Accuracy of AL measurement using A-scan

ultrasound is
+ 0.1 mm
•Difference in AL measurement between both eyes
+ 0.3 mm
Instrumentation
A-Scan biometry/laser interferometry
• A-Scan ultrasound
by applanation method
by immersion method
• Laser interferometry
IOL Master (Zeiss)
Lenstar LS 900 (Haag-Streit)
• X-axis…time
• Y-axis…amplitude
• A scan: Amplitude Scan; utilizes
ultrasound waves of 10 - 12 MHz
frequency.
• 2 Principles: Piezoelectric Phenomenon
Acoustic Impedence.
• Pulsed-echo system.
• Components: Transducer
Amplifier
Display Monitor
• In A-scan, thin, parallel sound beam is emitted
from the probe tip, with an echo bouncing
back into the probe tip as the sound beam
strikes each interface.

• An interface is the junction between any two

media of different densities and velocities.
 anterior corneal surface
 aqueous/anterior lens surface
 posterior lens capsule/anterior vitreous
 posterior vitreous/retinal surface
 choroid/anterior scleral surface.
• The echoes received back into the probe from
these interfaces are converted by the
biometer to spikes arising from baseline.
• The greater the difference in the two media at
each interface, the stronger the echo and the
higher the spike.
• Spike height is affected by the difference
in density & by the angle of incidence,
which is determined by the probe
orientation to the visual axis.

• If the probe is held nonparallel, part of the

echo is diverted at an angle away from the
probe tip, and is not received by the
machine.

• A perfect high, steeply rising retinal spike

may be impossible when macular
pathology is present (eg, macular edema,
macular degeneration, epiretinal
membranes, posterior staphylomas).
• Resolution: ability to display two interfaces
that lie in close proximity, one directly behind
the other, as separate echoes or spikes.

• The more dense the cataract, the higher the

necessary gain.

• Gain setting may vary not only from patient to

patient but from one eye to the next in the
same patient, depending on cataract density.
• Gates are electronic calipers on
the display screen that measure
distance between two points.

• Proper gate placement is on the

ascending edge of each
appropriate spike.

• If the biometer does not allow for

movement of gates, scans must be
repeated until they automatically
align properly.
• Ultrasound biometry machines use the formula
Distance = Velocity x Time.

• Sound velocity through different media:

 Phakic – 1550 m/s
 Aphakic – 1532 m/s
 Pseudophakic – 1532 + Correction factor for IOL

• Velocity through PMMA is 2718 m/s, through acrylic is

2120 m/s, and through silicone is 980-1107 m/s.

• Correction factor is +0.4 mm for PMMA, +0.2 mm for

acrylic, and -0.4 mm to -0.8 mm for silicone
• Biometry of pseudophakic eye performed:
- To compare to the fellow phakic eye for accuracy
- IOL exchange
- Checking an unwanted postoperative refractive error.

• A scan of pseudophakic eye → multiple reverberation echoes in

the vitreous cavity that tend to decrease in amplitude from left
to right.

• Decreasing the gain in pseudophakic eye is helpful.

 Applanation A-scan Biometry

• A-scan biometry by applanation requires that the

ultrasound probe be placed directly on the corneal
surface. This can either be done at the slit lamp, or
by holding the ultrasound probe by hand.

• Even in the most experienced hands, some

compression of the cornea is unavoidable; this
typically being 0.14 mm - 0.28 mm.
Applanation A-scan Biometry.

• a: Initial spike (probe tip

and cornea)
b: Anterior lens capsule
c: Posterior lens capsule
d: Retina
e: Sclera
f: Orbital fat
 Applanation A-scan Biometry
• When echoes b through d are
high and steeply rising, the
ultrasound beam is most
likely on visual axis.

• If no scleral or orbital fat

echoes visible, then
ultrasound beam is most
likely aligned with optic
nerve.
The five basic limitations of applanation A-scan biometry are:

1. Variable corneal compression.

2. Broad sound beam without precise
localization
3. Limited resolution.
4. Incorrect assumptions regarding sound
velocity.
5. Potential for incorrect measurement
distance.
 Immersion A-scan Biometry
• The immersion technique is accomplished by placing
a small scleral shell between the patient's lids, filling
it with saline, and immersing the probe into the fluid,
being careful to avoid contact with the cornea.

• More accurate than contact method because corneal

compression is avoided.

• Eyes measured with the immersion method are, on

average, 0.1-0.3 mm longer. 6 spikes instead of 5.
 Immersion A-scan Biometry
• . • A: Probe tip. Echo from tip of
probe, now moved away from the
cornea and has become visible.
• B: Cornea. Double-peaked echo
will show both the anterior and
posterior surfaces.
• C: Anterior lens capsule.
• D: Posterior lens capsule.
• E: Retina. This echo needs to have
sharp 90 degree take-off from the
baseline.
• F: Sclera.
• G: Orbital fat.
Immersion A-scan Biometry
• The immersion
technique requires the
use of a
Prager Scleral Shell .

Potential Sources of Error

with Immersion Method

1. Air bubbles within fluid

2. Inappropriate eye type
 Immersion A-scan Biometry
• When the ultrasound beam is properly aligned
with the center of the macula, all five spikes will
be steeply rising and of maximum height.

• Both the peaks of corneal spike should be equal

in height ideally.

• Other advantage: Easier,

better repeatability.
Measurement Mode
 Automatic
 Semiautomatic
 Manual

Gain Setting

• Initially high gain setting should be used to assess the overall

appearance of the echogram , then gain should be reduced to a
medium level to improve resolution of spikes .
 NON CONTACT
• The Zeiss IOLMaster (1999)- non-
contact optical device that
measures the distance from corneal
vertex to the RPE by dual beam
partial coherence laser
interferometry.

• Uses 780 nm infrared light &

Michelson Interferometer.

• The IOL Master is consistently

accurate to within ±0.02 mm or
better.

• Haag-Streit launched similar device

named Lenstar LS 900 in 2009.
• IOL Master provides following measurements:
 AC depth
 Lens thickness
 Axial Length
 Keratometry
 White to white distance

• In-built IOL power calculation by diff. formula: SRK II, SRK – T,

Holladay II, Hoffer Q, Haigis L.

• This method cannot be used in significant media opacity

(eg. dense cataracts or corneal or vitreal opacity) due to
absorption of light or inability of the patient to fixate on
target.
• IOL Master produces a
primary maxima (narrow, well-
defined, centered peak
identified by a circle above it),
secondary maxima (discrete
lower peaks, sometimes
disappearing into the
baseline), and a baseline
(which is low and even, but
may become high and uneven
with decreasing signal-to-
noise ratio (SNR)).
• SNR is a measure of accuracy and decreases
with increasing cataract density.

• SNR > 2.0 is valid and good if repeatable, SNR

between 1.6-2.0 is borderline but usable if
repeatable, and SNR < 1.6 is not usable.

• However, a proper waveform is more

important than the SNR value.
 Advantages of IOLMaster
• Easy & technician independent
• Noncontact
• No water bath is needed
• Can measure through glasses
• Accurate for silicone oil filled eyes and posterior
staphyloma.
• Accurate (Holladay II)
• Haigis L formula incorporated for post-LVC pts.
• For Piggyback IOLs
• Lenstar LS 900 measures CCT, ACD, Lens
thickness, Retinal thickness, AL, Keratometry,
White to white distance, Pupillometry &
eccentricity of optical axis.

• Lenstar measures keratometry & ACD more

accurately than IOL Master.
 Accuracy of axial length by different
machine
Applanation A Immersion A- IOL Master
-scan scan
+/- 0.24mm +/- 0.12mm +/- .01mm
Do not throw away old ultrasound machine

Immersion IOL
ultrasound master
Posterior staphyloma Difficult •Yes
Silicone oil Difficult •Yes
Pseudophakia Variable •Yes
4++brunescent lens •Yes No
Central PSC plaque •Yes No
Vitreous hemorrhage • No
Yes
Central corneal scar No
•Yes
 IOL FORMULA Ist generation
• Most are based on regression formula developed
by Sander ,Retzlaff & Kraff
• Known as SRK formula.

• P = A - 2.5(L) - 0.9(K)

P=lens implant power for emetropia

L= Axial length (mm)
K=average keratometric reading (diaopters)
A= lens constant
 IOL FORMULA 2 generationnd

• SRK formula –
works well for average eyes.
less accurate for long, short eyes.
• SRK II formula
modification of SRK
works on ELP
P = A1 – 2.5L – 0.9K A1 = A + 3
A1 = A + 2
AL < 20mm
AL 20-21
A1 = A + 1 AL 21-22
A1 = A AL 22-24.5
A1 = A – 0.5 AL >24.5
 IOL FORMULA 3 generation
rd

• Third generation formulas-

• SRK/T -very long eyes >26mm

• Holladay I -long eyes 24-26 mm
• HofferQ -Short eyes<22mm
 IOL FORMULA 4 generation th

• Holladay II
• Haigis formula-
d = a0 + (a1 * ACD) + (a2 * AL)
ACD is the measured anterior chamber depth
AL is the axial length of the eye

The a0, a1 and a2 constants are set by optimizing

a set of surgeon- and IOL-specific outcomes for a wide
range of ALs and ACDs.
• SRK/T formula — uses "A-constant“

• Holladay 1 formula — uses "Surgeon Factor“

• Holladay 2 formula — uses "Anterior

Chamber Depth“

• Hoffer Q formula — uses "Anterior Chamber

Depth"
 Summary
• Use IOL master or immersion ultrasound for
most accurate axial length measurement.

• Use fourth generation IOL formulas.

• Examine and reevaluate your result

periodically.
 B-Scan

11/08/2024 42
 B-scan
• Brightness mode scan
• OPD procedure
Indications
• To examine intraocular structures with no
direct visualization of posterior segment
Or
• To confirm or differentiate between
pathologies in clear media
11/08/2024 43
 Ultrasound physics & principles
• Parts of Sound wave
– Amplitude
– Wavelength (crest & trough)
– Frequency

11/08/2024 44
 Frequency & its relations
• With resolution
• Image quality
• With penetration
• How much deep
• Ophthalmic US (B-scan)
– 8-10 MHz
• Ultrasound Biomicroscopy (UBM)
– 20-50 MHz
 Ophthalmic US
• B-scan
– 10 MHz
– 40 mm
– 940 microns
• UBM
– 50 MHz
– 5-10 mm
– 40 microns

11/08/2024 46
 Principles of US
• Velocity
• Reflectivity
• Angle of incidence
• Absorption
Velocity
• Depends upon density of medium
• Distance = speed x time

11/08/2024 47
 Reflectivity (Echo)
• Follows law of Acoustic impedance
• A.I. = sound velocity x density of medium
Angle of incidence
• TRANSDUCER
• TRANSDUCER

Absorption
Dependent on density of medium
Closed lids should be therefore avoided but in children or
open wound
Shadowing occurs bcz of it
 Probe positioning

• Trans-ocular approach
– Transverse
– Longitudinal
– Axial
• Para-ocular approach

11/08/2024 49
 Trans-ocular
Transverse position

– Most commonly used position

– Shows about 6 clock hours
– Used for basic screening
– Detects lateral extent of pathology
– Probe is placed opposite to the examined
meridian

11/08/2024 50
 Longitudinal positions

– Detects axial (AP) extent of pathology

– Useful for retinal tears detection
– Shows only 1 clock hour scan

11/08/2024 51
 Axial positions
• Probe direct over the cornea
• Pt looks in primary gaze
• US waves pass thru center of lens and hit optic
nerve rather than macula
• Lens density affects the quality of image

11/08/2024 52
 Basic screening technique
• Done for screening purpose in opaque media
• Highest gain settings are used so weaker
signals shouldn’t be missed
• Any pathology found…further scanning is
required
Anterior segment evaluation
Immersion technique
High resolution technique
11/08/2024 53
 Immersion technique
• Cornea, anterior chamber & lens create noise
bcz of close contact with probe
• Shell or water bath is used to create space

11/08/2024 54
 High resolution technique
• Ultrasound biomicroscopy
• High resolution probes are used
• Scleral shell technique is used
• Image quality far superior to immersion
technique

11/08/2024 55
11/08/2024 56
 Common examples
Vitreoretinal disorders
• Most common indication for B-scan
– Vitreous hemorrhage
– Retinal detachment
– Intraocular tumors
– Intraocular foreign bodies

11/08/2024 57
 Vitreous hemorrhage

• Fresh:
– Dot-like…Echolucent or low reflectivity
• Old:
– Membrane-like…varying reflectivity & dense
inferiorly

11/08/2024 58
 Fresh VH Old VH
11/08/2024 59
 RETINAL DETACHMENT

11/08/2024 60