B scan

Ultrasonography

D R K A L PA N A R E D D Y
 Physics
 Ultrasound is an acoustic wave that consists of
an oscillation of particles within a medium.

 Frequencies > 20 kHz – inaudible by humans

 Frequencies used in diagnostic ophthalmology
are in the range of 8 – 10 MHz .
 (Abdominal and OBG USG – 1 to 5 MHz)

 These very high frequencies used in opth

produce short wavelengths, which allow good
resolution of minute ocular and orbital
structures.
Types of frequencies

 Low frequencies(<7MHz): orbital tissues

 Medium frequencies (7-10MHz) -

retina,vitreous,optic nerve
 High frequencies (30-50MHz)-anterior chamber

up to 5mm
 velocity

 Velocity of the ultrasound wave is dependent

totally on the medium through which it passes.

 The more compressible the media, the lesser is

the velocity. ( Ex: sound travels faster through a

solid lens than does through liquid vitreous.)
 Principle
Probe / transducer

Ultrasonic energy

Longitudinal waves

tissue
Part of wave is reflected back toward
the source of the emitted
energy(probe)
This reflected wave is referred to
as ECHO

Displayed as image on screen

 Echoes are produced by the acoustic interfaces that

are created at the junction of two media that have

different acoustic impedances.

 Acoustic impedance = sound velocity x density.

 The greater the difference in the acoustic impedance

of the two media that produce the interface, the

stronger is the reflection of the ultrasound
wave( i.e., echo)
Acoustic impedance
 B-scan:

It produces 2D acoustic section by using both the

vertical and horizontal dimensions of the screen
to indicate configuration and location.

Echo is represented as a dot the screen, and the

strength of the echo is depicted by the
brightness of the dot. The coalescence of the
multiple dots on the screen forms a two-
dimensional representation of the examined
tissue section.
GAIN
 Gain

 Represents the relative units of ultrasound

intensity

 Measured in decibels(dB)

 Adjusting the gain does not change the amount

of energy emitted from the transducer, but
changes only the intensity of the returning echo
that is displayed on the screen.
 The higher the gain, the greater the sensitivity of

the instrument in displaying weaker echoes(ex:

vitreous opacities)

 Low gain:

1. only stronger echoes will remain

displayed(retina, sclera) ,
2. improves resolution and

3. decreases the depth of sound beam penetration.

 Resolution – smallest distance between two
targets necessary to register them as two
separate entities.

 Resolution capacities - approximately 0.4 mm

axially and 1 mm laterally

 Attenuation – decrease in the level of energy

when the ultrasound beam propagates within
ocular and orbital tissues.
Standardized echography:

The combined use of standardized A-scan,

contact B-scan
Display modes
 B scan
 b/a mode
 a/b mode

Image documentation mode

Static
Dynamic/Kinetic Echography : is required to
determine the tissue mobility and vascularity in
the lesion. For this, at times colour Doppler
instruments are used in conjunction with Bscan.
INDICATIONS
 Indications

Anterior segment
Opaque media: corneal opacities
hyphema or hypopyon
cataract
pupillary or retrolenticular
membrane
Clear media: iris lesions
ciliary body lesions
Posterior segment:
Opaque media:
vitreous haemorrhage or inflammation
Clear media:
Tumors
choroidal detachment: serous vs haemorrhagic
RD: rhegmatogenous vs exudative
optic disc abnormalities
IOFB:detection and localization
 Contraindications

1. Obvious or suspected globe rupture

2. Significant peri-orbital injuries

3. Suspected clinically significant retro orbital

haematoma
 Examination technique

1. The patient is either reclining on a chair or

lying on a couch
2. Coupling jelly is applied to the probe tip to

ensure adequate sound transmission

3. Probe sterilized with alcohol, impregnating B-

probe in sterilizing solution isn’t recommended

as it damages the transducer
The mark on the B scan probe indicates beam
orientation so that the area towards which the
mark is directed appears at the top of the
echogram on display screen.
The probe face is always represented by the initial
line on the left side of the echogram.
The fundus of the eye, located on the side of the
globe opposite to where the probe positioned, is
represented on the right side of the echogram.
 METHODS
Contact method
Immersion technique

1.Contact method:

Two techniques

a. B scan probe can also be put directly on the

anaesthetized globe after applying eye speculum;

b. Trans-palpebrum with slightly increased overall

gain.
 Immersion Technique

 Can use in the same instrument –

 Requires Scleral Cup and Coupling Agent –
Methylcellulose

 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.
 B

A B

C C

A-transverse scan B-longitudinal scan C-axial scan

 Axial scan

 Easiest to perform and interpret

 Patient in primary gaze.

 Probe is placed on the cornea and directed axially

 Optic nerve head is used as an echographic centre

 Easy orientation and demonstration of posterior

pole lesions and attachments of membranes to
optic nerve head
 Probe position Direction of
marker

Horizontal axial scan nasal

vertical axial scan superior

Oblique axial scan superior

 Transverse section

 Probe is placed on the limbus and directed

posteriorly
 Probe face is oriented parallel (i.e., tangential) to
the limbus.
 The sound beam sweeps across the meridian.
6 clock hours
Lateral extent of lesion

Three scans-horizontal transverse scan

vertical transverse scan
oblique transverse scan
 Probe position Direction of
marker
Horizontal transverse
nasal
scan
vertical transverse
superior
scan

Oblique transverse scan superior

So in horizontal transverse scan, the upper
part of the echogram always represent the
nasal portion of the globe.

In the vertical transverse scans, the upper

part of the echogram represents the upper
portion of the globe.
 Echograms are labelled according to clock hour at
the center of the beam.
 •E.g transverse section of 12 0’clock meridian is
produced by a probe located at 6 0’clock limbus
and a 6 0’clock is produced by probe located at 12
0’clock
 Longitudinal scans

Probe is located on sclera with marker

perpendicular to the limbus.
The sound beam sweeps along the meridian
opposite the probe.
This scan shows the anterio-posterior extent
of the lesion
 The marker is always directed toward the center of
the cornea and of the meridian that is being
examined.

 Optic disc and posterior fundus is displayed on the

lower portion of the screen and the peripheral
globe is displayed on the upper portion of the
screen.
Echograms are labeled after the clock-hour
that is being examined.

Ex: If the probe is placed on the 6 O clock

meridian, the sound beam sweeps along the
12 o clock meridian; this is designated as a
longitudinal scan of the 12 o clock meridian.
If the probe is placed in a position that it
slightly overlaps the limbus, the sound beam
sweeps more of the posterior aspect of the
eye, thus allowing better evaluation of the
peripapillary region.

When the probe is placed close to the fornix,

the sound beam extends more peripherally to
better display the peripheral fundus and
often the ciliary body.
Macula screening
 1) Horizontal axial
an axial section with the marker nasally will display
the macular area and adjacent optic nerve head

 2) Vertical axial
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
 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

 4) Longitudinal 9:00 RE and 3:00 LE

Patient’s 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
 Reflectivity categories

category Spike height , %

Extremely low 0-5

low 5-40

medium 40-60

Medium-high 60-80

high 80-100
 Vitreoretinal diseases

Asteroid hyalosis:
Bright point like echo sources from calcium
soaps.

An area of clear vitreous is normally present

between the posterior boundaries of the
opacities and the posterior hyaloid.

A-scan- medium to high reflective spikes that

move with vitreous gel.
Vitreous hemorrhage
In fresh mild haemorrhage:
dot and short lines on B-scan
chain of low amplitude spikes on A-
scan
In old and dense haemorrhage
greater the no.of opacities on B-
scan
higher reflectivity on A-scan
 Asteroid hyalosis Vs vit haem

AH is highly echogenic,they are still visible

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

 Focal or extensive
 Posterior hyaloid may separate completely from the
posterior pole or it may remain attached to the
optic disc with very thin attachment to the disc.
 Smooth
 Kinetic echography typically shows undulating
after movement of a PVD on B-scan
Low reflective vitreous opacities and a
PVD with a very thin
complete posterior vitreous
attachment at optic disc
detachment as seen with normal
aging of the eye.
In PVD with normal eye, the reflectivity is
very low, high gain(90dB) setting is required

The reflectivity disappears lowering the

sensitivity,under 70 dB.
PVD Vs RD
The image of PVD will disappear from the
screen at higher gain setting(70dB) than a
RD(40-50dB)
technique PVD RD CD
Topographic Smooth,open Smooth or Smooth,dome or
funnel with or folded,open or flat;no disc
without disc or closed funnel insertion;inserts
fundus with disc at ora or ciliary
insertion:inserts insertion:may body
at ora serrata or have associated
ciliary body cysts;inserts at
ora
quantitative <100% high Steeply rising Steeply
spike 100% high spike rising,thick,dou
ble peaked
100% high spike
Kinetic Marked to mod Mod to none Mild to none
(after
movement)
 Retinal detachment:

Bright, continuous and somewhat folded

appearance on the B-scan

Total RD-the detached retina inserts into both

optic disc and ora.
Total retinal detachment and vitreous hemorrhage. The retinal
detachment appears as a somewhat wavy membrane of high
reflectivity in an open-funnel configuration, attaching at the optic
disc and out peripherally at the ora serrata.
On A-scan :100% spike
sometimes <100%
spike(atrophy, severe folding,disruption of
retina)

RD vs PVD
RD exhibits a more tethered,restricted after
movement than does the highly mobile PVD.
PVD will have no or very thin attachment at
optic disc.
Tractional RD
Shows a tent like elevation from the retina.
There is no after movement.
A. Open funnel RD with mild PVD

B. Triangular shape with bridging

membrane indicating PVR

C.T-shape (closed funnel) indicating

PVR
 Retinoschisis:

On B-scan: smooth, thin dome shaped

membrane that does not insert into the optic
disc.

On A-scan: a 100% high spike

Retinoschisis Vs RD:
Retinoschisis differs from RD by its more focal,
smooth and thin character and does not
insert into optic disc.
A. Moderately elevated thin,
smooth,dome shaped membrane

B. Very thin 100% high

spike on A-scan
 Retinoblastoma

Retinoblastoma. Note the small, highly reflective echodensities

within the tumor, which are foci of calcium.
MACULA
MACULAR EDEMA CAUSED BY VMT
MACULAR HOLE WITH OPERCULUM
 CHOROID

Choroidal Detachment:

CD appear as smooth, convex elevations from

the posterior eye wall.

In massive CD, choroids from opposite fundus

areas may touch in the middle of the vitreous
cavity-“Kissing Choroid”
Choroidal Detachment
Choroidal haemorrhage

A. Thick smooth detached

choroid with dense opacities in
the subchoroidal space

B. A-scan shows highly

reflective, thick spikes from
detached choroid
Choroid melanoma

Can present as a fusiform mass

 Choroidal melanoma

collar-button shaped choroidal melanoma. The lesion began as a dome shape,

then broke through the Bruch membrane to form the button on the anterior
surface of the dome. Note the diagnostic 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.
 Choroidal metastasis

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.
 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.
 Choroidal osteoma

Shadowing caused from sound absorption by the calcium

within a choroidal osteoma. Calcium is so dense that no
sound can penetrate it to travel on to the next structure.
 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. The edematous distention of the sub-Tenon’s space
produces the ‘T-sign
 Endophthalmitis

 In endophthalmitis, the inflammatory cells which

are seen dotlike on Bscan, are multiple, scattered
diffusely or may be localised to the anterior, mid or
the posterior one third of the vitreous cavity. On A
scan, these dot like opacities show low to medium
reflectivity (10-60%).
 Post op Endophthalmitis vs TASS

In TASS, the severe inflammation is visible only in

the anterior segment whereas in endophthalmitis
there is severe vitritis and exudation in the vitreous
cavity.
 Miscellaneous

Posterior staphyloma
RD with retinal cyst
Nucleus drop
IOL drop
 Optic disc drusen

O
 Cysticercosis

well-defined cystic mass with a central hyperechoic area

suggestive of scolex.
Metallic IOFB
 Scleral buckle

.
Asteroid hyalosis VH
 Vitreous substitutes

silicone oil produces marked sound attenuation hindering the

visualization of posterior segment.
It also results in a larger vitreous cavity which is relatively echo-free
Perfluorocarbons on the other hand show
multiple, highly reflective liquid bubbles in
the posterior vitreous
Gas-fluid and gas-tissue interfaces were so
highly reflective that no structures within or
behind a bubble could be visualized.
Shadowing, reverberation, and reflection
artifacts were prominent, and dominated
ultrasonographic findings.
 Advantages of B scan

1. Contact B-scan ultrasound provides a convenient,

noninvasive means for the evaluation of

intraocular structures in situations where clinical
examination is not possible because of opaque
ocular media
2. It also allows a dynamic examination of the

vitreoretinal relationship.
3. 3D and digital technology expand teaching

capability and bring the clinical availability of

contact ultrasonography to a larger audience.
 DRAWBACKS OF B SCAN:
 Reverberation artefacts

 Les than 0.75 mm mass

missed.

 IOFB less than 1 mm

missed.

 Cant be used in open globe

injuries.

 Cant be used in active

ocular surface infections.