I N S T R U M E N T

P R O F I L E

Ophthalmic Ultrasound
Ultrasound has a number of uses with respect to the eye. In most cases, the transparency of healthy eyes will allow a clinician to closely examine ocular structures. However, in the following situations ultrasound imaging can be a valuable tool for enhancing patient care: pathology renders the eye translucent or opaque (eg. corneal scarring, mature cataracts or hyphaema); imaging ocular structures that are not usually visible due to anatomical location (eg. the ciliary body); additional information may be sought to assist with diagnosis and management (eg. choroidal lesions).
Figure 1: Pachmate DGH 55 Ultrasonic Pachymeter.

Function
Ultrasounds use sound waves to create images of hidden ocular structures, to obtain information on the consistency of particular structures and to collect biometric data. Increasing the frequency of the sound waves increases resolution of the target structure and concurrently decreases its ability to penetrate tissue. A typical ophthalmic ultrasound device, used to image posterior ocular structures, uses a frequency of 8-10 Mhz and the ultrasound biomicroscope (UBM), which is used for the anterior eye, uses a frequency of 30-50 Mhz. The speed of sound is also influenced by the temperature and the composition of the medium through which it passes. Ultrasound imaging occurs by transmitting and receiving high frequency sound waves through a probe/transducer, placed on the eye. Reflectance, or the echo of the sound waves, occurs at the interface between regions of different acoustic impedance. The transducer captures the echo, creating a voltage which is amplified, processed and an image is formed. The distance to the reflecting object is calculated using the speed of sound and time. The sound wave can also undergo scattering when the discontinuities in the media are smaller than the wavelength. Attenuation of the sound wave occurs due to reflection, scatter or absorption of the energy by tissue.
Figure 2: Reichert Reflex Ultrasound Biomicroscope (UBM).

Ultrasounds use sound waves to create images of hidden ocular structures

The different ultrasound technologies used to image either the anterior or posterior segments include Pachymetry (Figure 1), Biomicroscopy (Figure 2) and A-Scan / B-Scan (Figure 3).

Figure 3: Tomey UD-6000 A-scan and B-scan ultrasound.

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Ophthalmic Ultrasound of the Anterior Segment

Ultrasound Pachymetry
Measurement of corneal thickness by ultrasound utilises a transducer, made from material with piezo-electric properties, emitting high frequency sound waves through the cornea (usually in the order of 1520 MHz). The subsequent reflectance from the anterior and posterior corneal surface is received by the transducer and corneal thickness can be determined using time and speed of sound through corneal tissue. Ultrasound pachymetry is quick, easy, portable and accurate with a number of different commercially available models including the Pachmate (Figure 1), which requires a topical anaesthetic for usage. The speed of sound usually used with ultrasonic pachymeters is around 1640m/sec, giving rise to a central corneal thickness of approximately 545 35 m in a normal population4. The relevance of corneal thickness measurement in assessing intraocular pressure will be discussed in a later edition of IMAGE.
Figure 4: Slitlamp image of elevated iris in asymptomatic 20 yearold female.

Ultrasound Biomicroscopy
Ultrasound Biomicroscopys (UBM), such as the Reichert Reflex (Figure 2), are used for examining anterior segment structures, providing high resolution images of the cornea, anterior chamber angle, iris, ciliary body, sclera, lens and lens zonules. The key benefit of UBM compared with anterior Optical Coherence Tomography (OCT) imaging is the ability to image through opaque media, which would otherwise not be possible. In addition to providing qualitative images of the anterior chamber angle, for conditions such as Plateau Iris Syndrome or iris elevations (Figures 4, 5 and 6), there are also several methods of obtaining quantitative information, such as measuring the parameters of a lesion or the distance between structures. Standardised methods have also been proposed for the measurement of the anterior chamber angle and the angle area.

Figure 5: Reichert UBM results indicating the cause of the iris elevation is an irido-ciliary cyst (* in middle of cyst).

The key benefit of UBM compared with anterior OCT imaging is the ability to image through opaque media
Figure 6: Reichert UBM image of the anterior segment.

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Ophthalmic Ultrasound of the Posterior Segment

There are two forms of ophthalmic ultrasound imaging - the A-scan and B-scan. The A-scan consists of a single static point of transmission and reception, whilst the B-scan consists of a moving probe, which oscillates along a particular axis, transmitting and receiving A-scans at several points along that axis. A-Scans provide a single reflectance profile from which quantitative data can be extrapolated, and are commonly used to obtain biometric data prior to cataract surgery (including anterior chamber depth, lens thickness and total axial length). It also enables the differentiation between tissue types based on their reflectivity (amplitude of spikes) and structure (density or regularity of spikes). A-scans have, however, mostly been replaced for cataract surgery biometry by laser interferometers, such as the Lenstar, but retain their usage in cases of opaque media (advanced cataracts). The B-scan is a two-dimensional image, created from multiple A-scans, which is useful in topographic analysis of tissue, including shape and contour. It can assist in the differential diagnosis of conditions such as retinal detachment, optic disc drusen and posterior staphyloma (Figures 7, 8 and 9). A-Scans and B-Scans are typically incorporated within the same instrument, such as the Tomey UD-6000 (Figure 3).

Figure 7: B-scan of a retinal detachment (refer to arrows).

A-scan
The typical A-scan includes a double peaked spike from the cornea, followed by spikes from the anterior and posterior lens surfaces and the retina. Anterior chamber depth, lens thickness and total axial length can then be determined. A-scans through mass-like lesions also produce a spike on the reflectance profile. Characteristics of the lesion can also be determined as different lesions have different ultrasound echo characteristics. For instance, melanomas exhibit a regular structure consisting of spikes of similar height and consistent distribution. Alternatively, metastatic lesions consist of heterogeneous cell types and create spikes of varying heights and the distribution of spikes varies depending on which part of the lesion is being imaged. Blood flow may also be determined by observing the kinetic properties of the A-scan, which typically reveals a fast flickering motion in the valley of the spikes.
Figure 8: B-scan of optic nerve head drusen (refer to two bright objects in middle of oval).

A-scans and B-scans can be combined through simultaneous scanning for measurement and localisation
Figure 9: B-scan of a posterior staphyloma (refer to arrow identifying posterior part of staphyloma).

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Ophthalmic Ultrasound of the Posterior Segment cont...

B-scan
B-scan images consist of two-dimensional slices through the ocular tissue, in any direction or angle. Relevant information on the direction in which the scan was taken is also generally included. Where possible, the optic nerve head is included in scans to assist with orientation, appearing as a minimally reflective conical structure extending posterior from the retina. The gain or sensitivity of the scan can be adjusted during image acquisition to accentuate different areas of interest. Higher gain is useful for illustrating finer dispersed opacities, such as vitreous floaters, while a lower gain improves the resolution of the retina choroid and sclera. Dynamic ultrasound, utilising eye movements, is useful in determining the physical characteristics of structures by their motion. A-scans and B-scans can also be combined through simultaneous scanning to allow measurement and localisation (Figure 10).

Suitable Conditions
Some of the conditions suited for imaging by ophthalmic ultrasound include: Disc drusen Staphyloma Vitreous opacities Pigmented iris lesions Plateau Iris Syndrome Narrow anterior chamber angle Peripheral anterior synechia Retinal detachment (if ocular media translucent) Choroidal detachment Raised choroidal lesions Raised iris lesions

In some cases direct ophthalmological referral may be more appropriate than CFEH referral.

References
1. DiBernardo. C, Schachat. A.P and Fekrat. S, Ophthalmic Ultrasound A Diagnostic Atlas, New York, USA, 1998. 2. Ruben. M and Guillon. M, London, Contact Lens Practice, UK, 1994, Pages 420-424. 3. Hans C. Fledelius, Ultrasound in Ophthalmology, Ultrasound in Medicine & Biology,Volume 23, Issue 3, 1997, Pages 365-375. 4. Al-Mezaine. H.S, Al-Amro. S.A, et al. Comparison between central corneal thickness measurements by oculus pentacam and ultrasonic pachymetry. Int Ophthalmol. 2008; 28(5), Pages 333-338.

5. Silverman RH, High-Resolution Ultrasound Imaging of the Eye - A Review, Clin Experiment Ophthalmol. 2009 Jan; 37(1): 54-67, Epub 2008.
Figure 10: Simultaneous A-scan and B-scan allowing measurement and localisation (B-scan image overlaid with yellow line of A-scan axis and blue line of A-scan acoustic impedence through the axis).

Disclaimer: Although every care is taken by CFEH to ensure that this document is free from any error or inaccuracy, CFEH does not make any representation or warranty regarding the currency, accuracy or completeness of this Instrument Profile. Copyright: 2011, Centre for Eye Health Limited.
Printed: February 2011 on recycled paper.

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