Vol.18, No. 6June 1996
Ultrasonography of the Eye
*
Louisiana State UniversityOhio State University
Jamie Williams, MS, DVMDavid A. Wilkie, DVM, MS
R
outine ophthalmic examination involves direct visualization of adnexaland intraocular structures. Opacity of the transmitting medium (e.g.,cornea, aqueous humor, lens, or vitreous body) impairs ophthalmic ex-amination. In such instances, ultrasonography can be used to complete theevaluation.Ophthalmic ultrasonography was first applied by Mundt and Hughs in1956; they used amplitude (A-mode) technology.
1
In 1958, Brum and Green- wood investigated the use of brightness (B-mode) ultrasonography for exami-nation of ocular and orbital structures.
2
Since then, ultrasonography has proved to be valuable in the examination of opaque eyes (i.e., when routine biomicroscopic or indirect ophthalmoscopicexamination is impossible). B-mode scan ultrasonography presents a two-dimensional image of the tissue.
3
Indications for ultrasonographic examinationinclude ocular trauma, the need to measure axial length, intraocular or orbitalforeign bodies or masses, intraocular hemorrhage, lens luxation, retinal detach-ment, and any opacity that prevents complete ophthalmoscopic examina-tion.
1,2,4–8
Ophthalmic ultrasonography has become part of the routine presur-gical examination for intraocular and retrobulbar procedures in small and largeanimals at the Ohio State University Veterinary Teaching Hospital.
PATIENT PREPARATION
The equipment required to perform ophthalmic ultrasonography includes anultrasound machine with an appropriate transducer (7.5- or 10-MHz), sterileacoustic coupling gel, topical ophthalmic anesthetic, and some form of sterileeyewash. Images should be recorded for later reference and included in the pa-tient’s permanent record. The easiest way to preserve the images is to recordthem on thermal paper or radiographic film; however, a videotape may also beused. Images presented in this article are reproductions of images stored onradiographic film. A topical ocular anesthetic (0.5% proparacaine hydrochloride) is applied tothe cornea. Manual restraint is sufficient for ultrasonographic ophthalmic ex-amination of most small animals. Sedation should be avoided because it may
Continuing Education Article
V
FOCAL POINTKEY FACTS
#
Ultrasonography is a safe,noninvasive way to evaluate theintraocular and retrobulbar tissueof opaque eyes.
*A companion article for veterinary technicians appeared in the June 1996 (Vol. 17,No. 6) issue of
Veterinary Technician
®
.
I
Transpalpebral ultrasonographymay be the only way to examinethe eye if the eyelid is severelyswollen.
I
A stand-off pad or extra couplinggel can be used to place theimage of the anterior chamberbelow the near-field reverberationartifact.
I
Sedation may cause extensionof the nictitating membraneor rotation of the globe.
I
Some horses require sedationand an auriculopalpebral nerveblock, in addition to topicalanesthetic, for ophthalmicultrasonography.
I
Bone, metal, or large quantitiesof gas may make it difficult tovisualize ocular lesionsultrasonographically.
cause elevation of the nicti-tating membrane and ro-tation of the globe, thusinterfering with thoroughexamination.
8
Some horses,however, require sedationand an auriculopalpebralnerve block, in addition totopical anesthetic, to facili-tate examination.Sterile coupling gel facili-tates transmission of soundfrom the transducer into theoptic tissue; therefore, a lay-er of sterile coupling gel isplaced between the patientand the transducer. If thetransducer is to be appliedto the cornea instead of tothe eyelid, sterile couplinggel is applied directly to theanesthetized cornea. Cellu-lose-based gels may be abra-sive and should be avoidedto reduce the risk of cornealirritation. Applying the trans-ducer directly to the gel-coated cornea provides abetter image of the posteriorglobe and retrobulbar tissuethan does transpalpebral ul-trasonography.
9
Some equine patients,however, do not tolerate ap-plication of the probe to thecornea. Transpalpebral imag-ing is used for these pa-tients. To avoid trapping air(which is a barrier to ultra-sound) between the trans-ducer and the patient, thepalpebral hair should be re-moved or thoroughly wettedbefore the acoustic gel is ap-plied.Exposure of intraocularcontents to the coupling gelshould be avoided. Transpalpebral ultrasonography may therefore be necessary to examine eyes that havetraumatic lesions (e.g., corneal laceration or uveal pro-lapse).
10
If the eyelids are severely swollen, trans-palpebral ultrasonography may be the only possiblemeans of ophthalmic examination.
TRANSDUCER ANDSETTINGS
It is best to use a sectorscanner with a small scan-head diameter (footprint) tofacilitate optimal placementon the patient’s eye. Trans-ducers are available in a wide range of frequencies
3
;however, a 7.5- or 10-MHzprobe is recommended forophthalmic ultrasonogra-phy.Transducer frequency isinversely proportional to the wavelength of the soundbeam.
3,11
Depth of sound-beam penetration is propor-tional to wavelength.
3
Axialand lateral resolution have asignificant effect on thequality of the resulting im-age.
3
Axial resolution is afunction of pulse length.Lateral resolution dependson beam width, distancefrom the transducer, andsize of the transducer face(footprint).
3,11,12
A 10-MHztransducer provides superiorresolution but less depth of penetration than does a 7.5-MHz transducer.
3,7,8,11,12
A good rule of thumb is to usethe transducer of the high-est frequency that will allowvisualization of the deepesttissue of concern.The focal range of a 7.5-MHz transducer is 2 to 5centimeters. This transducercan produce good images of eyes of small
2,4,7,9,11
or large
4
animals. The 7.5-MHztransducer provides betterdepth of penetration thandoes the 10-MHz probe,but the anterior segment is lost in the near-field rever-beration artifact (Figure 1A).
6–8
This problem can be atleast partially overcome by the use of a tissue-equivalentstand-off pad.
6–8
However, stand-off pads may producelinear reverberations that can become superimposedover the image, thus complicating the interpretation.
3
Small Animal
The Compendium
June 1996
AURICULOPALPEBRAL NERVE BLOCK
I
TRANSPALPEBRAL IMAGING
I
TRANSDUCER
Figure 1AFigure 1BFigure 1—
Ultrasonographic images of the eye of a healthy cat. Extra coupling gel was used as a stand-off. (
A
) Imageobtained with a 7.5-MHz transducer. The cornea andmost of the anterior chamber fall within the transducer ar-tifact zone. Only the axial anterior and posterior lens cap-sules are seen in the noncataractous lens. (
B
) Imageobtained with a 10-MHz transducer. The cornea andaqueous humor are easily seen below the transducer arti-fact zone.
C
= cornea,
I
= iris,
L
= lens,
VIT
= vitreousbody, and
ON
= optic nerve.
Another option is to apply excess sterile coupling gel tothe cornea and decrease thepressure applied with thetransducer, thus allowing thegel to act as a stand-off.
13
Ei-ther method places the im-age of the cornea and anteri-or segment of the globedeeper on the screen, away from the near-field artifactzone. Transpalpebral imag-ing in horses may provide asimilar effect. A 10-MHz transducer hasa focal range of approxi-mately 3 to 4 centimeters.
14
Depth of penetration is ade-quate for thorough visual-ization of retrobulbar tissue.The 10-MHz transducerprovides better resolutionthan does the 7.5-MHztransducer. Although thecornea may be lost in thenear-field artifact zone,more of the anterior cham-ber will normally be visual-ized (Figure 1B). Visualiza-tion of the anterior segmentcan be improved with theuse of a stand-off pad or ad-ditional coupling gel. Adverse effects from oph-thalmic ultrasonography have not been reported tooccur in animals. Neverthe-less, the transducer powershould be kept at or below20% when eyes are beingimaged. Higher power set-tings unnecessarily subjectthe choroidal tissue and vas-culature to increased pulsesof ultrasound energy.Setting the time-gaincompensation too high un-necessarily amplifies weak signals. Electronic amplifi-cation of background noiseresults in a diffuse scatter-ing of hyperechoic signalsthroughout the image.
15
This amplification may cause a false impression of degeneration of the vitreousbody.
16
EXAMINATION
Each eye is imaged in ver-tical and horizontal planesthrough the visual axis for acomplete examination. Eachview is optimized throughminor adjustments in trans-ducer angle to obtain an op-timal image. Images of theright and left eye may thenbe compared for abnormali-ty or asymmetry. After ex-amination, each eye is gen-tly flushed with eyewash orsterile saline to remove thecoupling gel and associateddebris.
NORMAL FINDINGS
The cornea is representedas a curved hyperechoic in-terface immediately belowthe transducer artifact zoneif a stand-off pad or addi-tional coupling gel has beenused (Figure 2). The an-echoic anterior and poste-rior chambers are locatedbetween the cornea and the
The Compendium
June 1996Small Animal
FOCAL RANGE
I
DEPTH OF PENETRATION
I
MACHINE SETTING
Figure 2—
Correct placement of the transducer on the cornea
(left)
and the resulting ultra-sonographic image
(right)
.
Figure 3AFigure 3BFigure 3—
(
A
) Ultrasonographic image (10 MHz) and(
B
) schematic of a normal equine eye. The hyperchoic corpo-ra nigra extend from the dorsal pupillary margin of the iris.
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Ultrasonography of the Eye
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