WFUMB Course Book
OCULAR ULTRASOUND
25. Ocular Ultrasound
Jesse Schafer, Christoph F Dietrich, Beatrice Hoffmann
Keywords: technique examination, sonoanatomy, trauma, lens dislocation, retinal
detachment, vitreous detachment
25.0. Introduction
Every year in the United States, between 2 and 3 million patients present to an
emergency or urgent care centre for eye related complaints. Ocular ultrasound can
provide rapid diagnosis of a variety of traumatic and non-traumatic conditions. The
globe, as a superficial fluid filled structure, is the ideal anatomic structure when it
comes to ultrasound imaging.
25.1. Preparation
When performing an ocular ultrasound examination, you must consider machine
settings as well as patient and sonographer position.
25.1.1. Machine settings and safety
Newer ultrasound machines typically have several presets based on examination
type to optimize image and maintain patient safety, while making set up easier for
the sonographer. For ocular ultrasound, a high frequency linear transducer on an
ocular preset should be used. An ocular preset should have the mechanical index
(MI) and thermal index for soft tissue (TIS) optimized to limit any potential bioeffects
from the interaction of the sound waves with delicate tissue (Fig 25.1). The MI
refers to the potential for bioeffects on tissue from cavitation or other mechanical
changes caused by sound waves traveling through tissue. The optimal MI should be
below 0.23. TIS is the potential for bioeffects from a rise in temperature caused by
ultrasound waves through tissue. TIS should be below 1.0. While these settings limit
potential bioeffects, it is worth noting that the duration of examination or duration of
exposure to soundwaves also has the potential for bioeffects. The ALARA Principle
or “as low as reasonably achievable” should be considered when adjusting acoustic
output settings to optimize safety and still achieve diagnostically relevant results.
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25.
View enlarged image
Fig 25.1
MI and TIS will be listed on
the screen and will change
depending on presets
25.1.2. Patient and sonographer position
To perform an ocular ultrasound, the patient should be in a supine or semi-
recumbent position. A copious amount of ultrasound gel or similar sound conducting
media should be placed over the patient’s closed eye lid (Figure 25.2.). An optional
transparent dressing can be placed over the patient’s closed eye lid prior to gel
application however the sonographer should take care to minimize any air bubbles
between the eye lid and transparent dressing. During the ultrasound examination,
the transducer should rest in this gel without coming in direct contact with the
patient’s eye lid. By convention, ultrasound examinations are performed with the
sonographer on the patient’s right and facing the patient’s head (Fig 25.3a). For
ocular ultrasound, the sonographer performs the examination with the right hand,
resting a portion of the right hand on either the patient’s cheek or bridge of nose.
Alternatively, the sonographer can stand on either the patient’s right (left-handed
sonographers) or the patient’s left (right-handed sonographers) while facing the
patient’s feet (Fig 25.3b). The sonographer then rests the heel of their hand on the
patient’s forehead when examining either the right or left eye. This non-traditional
positioning allows for greater stability as the sonographer does not have to balance a
portion of their hand on the bridge of the nose when evaluating the contralateral eye.
WFUMB Course Book
View enlarged image
Fig 25.2
Apply a large amount of
ultrasound gel or similar
conducting media over the
closed eyelid
View enlarged image
Fig 25.3a
Sonographer on the
patient’s right, traditional
head of the bed facing
technique. Dominant hand
rests on the patient’s cheek
or nose
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25. OCULAR ULTRASOUND
View enlarged image
Fig 25.3b
Right handed sonographer
on patient’s left, foot of the
bed facing technique. Non-
traditional but more stable
Ocular ultrasound setup
• Linear transducer
• Ocular preset if available
• Mechanical Index (MI) less than 0.23
• Thermal Index - Soft Tissue (TIS) less than 1.0
• Large gel pillow over closed eyelid
• Visualize a layer of gel in the near field of the image to ensure minimal
pressure on delicate structures
WFUMB Course Book 25. OCULAR ULTRASOUND

25.1.3. Structured examination View enlarged image

The linear transducer should be gently suspended in a large gel pillow to avoid
excessive pressure on the eye of interest. The depth should be set to include the
globe and a few centimeters posteriorly to incorporate the retrobulbar structures.
Gain and focal zone should also be optimized.
The sonographer should systematically evaluate the eye from anterior to posterior
and in two planes: transverse and parasagittal. For the transverse plane, the
transducer indicator should be pointed to the patients right and in the parasagittal
plane, the transducer indicator should be pointed cranially. Pupillary light reflex Fig 25.4
can be evaluated by imaging the globe in the transverse plane with an oblique Pupil visualised from a
orientation. Fan the transducer until the pupil and iris can be seen in cross section slightly oblique angle. Notice
(Fig 25.4). Constriction of the pupil should be seen when shining a bright light the layer of gel in the near
field to ensure minimal
through closed eye lid of the eye under examination. Consensual light reflex can
pressure on the globe
be evaluated by shining a light in the contralateral eye. The sonographer should
also evaluate the globe with a static technique- fanning the transducer with the
globe stationary, and a dynamic technique- holding the transducer still while having The anterior chamber appears as the anterior bulge to the globe and is bordered by
the patient move the eye from left to right and up and down. During the dynamic the cornea anteriorly and iris posteriorly. It is filled with aqueous humor. The cornea
portion of the examination, the gain should be increased to highlight any potential is visualized as the thin hyperechoic convex structure the near field, just posterior
abnormalities in the vitreous and posterior elements of the eye that were not identified to the eyelid. The iris is the linear hyperechoic structure a few millimeters posterior
using standard gain settings. Take care to recognize that with the gain increased, to the cornea.
artifact will increase. Side lobe artifact as well as reverberation artifact will appear
more pronounced. You can differentiate artifact and true pathology by changing
the angle of the transducer slightly, having the patient move their eye, or rotating
the transducer 90 degrees. Artifacts will not track with the natural movement of the View enlarged image

globe. Posterior acoustic enhancement and increased gain can cause the optic
nerve to be obscured. Therefore, the optic nerve should be evaluated under normal
gain settings. Finally, color and pulse wave Doppler can be used to evaluate the Fig 25.5
vasculature. Ocular Sonoanatomy- From
anterior to posterior: Anterior
Chamber(*), Iris and Pupil,
25.2. Sono-anatomy: Normal sonographic appearance Posterior Chamber (+), Lens
(arrow), Vitreous chamber
(VC), Optic disc, Optic
25.2.1. Globe nerve (ON). A hyperechoic
stripe with posterior shadow
The eye is an ideal anatomical structure when it comes to ultrasound. It is superficial is seen to the right of the
and fluid filled, therefore easy to image. The globe is made up of three chambers: image indicating the orbital
the anterior chamber, posterior chamber, and the vitreous chamber (Fig 25.5). rim

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WFUMB Course Book 25. OCULAR ULTRASOUND

The pupil can be seen in the center of the iris. The posterior chamber is bordered by 25.3 Sonopathology
the iris and the lens. It is also filled with aqueous humor. The lens and lens capsule
are visualized as the concave structure just posterior to the iris. The lens should be Table 1 lists traumatic and non-traumatic pathology that can be identified with ocular
hypoechoic while the capsule should appear hyperechoic. The vitreous chamber is ultrasound. Many of the conditions listed can be difficult to identify. This chapter will
the largest chamber of the globe. It is bordered by the lens anteriorly and the retina focus on a few of the more common applications.
and posterior wall posteriorly. The vitreous chamber is filled with vitreous humor,
a gelatinous substance that does not regenerate. It is surrounded by the vitreous
membrane, separating the vitreous from the rest of the eye.
Traumatic and non-traumatic pathology detectable by ocular ultrasound
• Ocular foreign body detection
25.2.2. Extra-bulbar structures • Lens dislocation
• Globe rupture
Extra-bulbar structures such as the optic nerve (ON) and sheath, ocular vasculature, • Endophthalmitis
extra ocular muscles, and orbital bones can be visualized in the far field. The optic • Vitreous hemorrhage
nerve is continuous with the retina. The nerve and nerve sheath appear hypoechoic • Vitreous detachment
and radiate posteriorly from the retina (Fig 25.6). The orbital and orbital bones make • Retinal detachment
up a cone-like structure with the apex posteriorly. With ultrasound, the bones appear
• Retinal hemorrhage
hyperechoic and closely approximated to the globe. The orbital rim can be visualized
• Central retinal artery occlusion
laterally to the globe as well. The ocular vasculature can be visualized in the far field,
the ophthalmic artery (OA) can be seen entering the orbital foramen, lateral to the ON. • Papilledema
While there is a wide variety of anatomical variation in location of the OA, generally it • Optic nerve sheath dilation for detection of elevated intracranial pressure
crosses the ON anterior and tracks toward the anteromedial orbit. The central retinal • Orbital fractures
artery (CRA) and vein (CRV) run parallel in the center of the ON. • Retrobulbar hematoma
• Retrobulbar mass
• Retrobulbar abscess
View enlarged image • Retrobulbar air

25.3.1. Anterior chamber sonopathology

Fig 25.6
Anatomy of extra-bulbar
structures. Hyperechoic
bony orbit with posterior
shadow noted along with
hyperechoic retrobulbar
fat (a), optic nerve (ON),
central retinal artery and
vein (arrow), and ciliary
branches (cb)
25.3.1.1. Globe rupture
Globe rupture is a relative contraindication to ocular ultrasound however globe rupture
is not always readily apparent on initial physical exam. Ocular ultrasound can determine
if emergent surgical intervention is indicated. The sonographer must take extreme
care when performing ocular ultrasound so as not to put excessive pressure on the
globe. The sonopathology associated with globe rupture is not restricted to the anterior
chamber but it is worth mentioning that clearly imaging the anterior chamber and
making sure that there is not excessive pressure on the anterior chamber is essential.

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One way to ensure appropriate care is taken is to visualize a layer of gel in the near View enlarged image
field between the anterior chamber and the transducer footprint. Sonopathology
of globe rupture includes volume loss or deformation of the anterior chamber,
therefore visualization of the gel layer is of critical importance to make the diagnosis.
Additionally, volume loss in the posterior or vitreous chambers can be seen, along
with loss of elliptical shape, vitreous opacities, vitreous hemorrhage, and foreign
bodies (Fig 25.7).

View enlarged image

Fig 25.7
Globe Rupture with
deformed anterior chamber
(thin arrow), globe
deformation (thick arrow),
and hemorrhage (*). Note
the presence of gel layer
visualized in the near field
to ensure limited pressure is
put on the injured globe
25.3.2. Posterior chamber sonopathology
25.3.2.1. Lens dislocation
Ocular ultrasound is quite accurate at diagnosing lens dislocation. One study
reported 96.7% accuracy to diagnose traumatic lens dislocation. In addition,
comparison with the contralateral globe can assist with diagnosis. Lens dislocation
is most commonly caused by blunt trauma however there are atraumatic causes as
well. The lens can dislocate partially or completely and either anteriorly or posteriorly
(Fig 25.8). Dynamic exam, with the transducer held still while the patient moves
their globe left to right and up/down can assist at identifying subtle pathology.
Fig 25.8
Lens dislocation (arrow)
25.3.3. Vitreous chamber sonopathology
25.3.3.1. Retinal detachment and vitreous detachment
Retinal detachment (RD) and vitreous detachment (VD) can present with flashes,
floaters, and vision loss. Management of these conditions is quite different, however.
RD requires emergency ophthalmology consultation to limit vision loss, therefore it is
important to distinguish these two entities. Ocular ultrasound can differentiate these
two entities quickly and at the bedside.
As mentioned previously, to evaluate for pathology in the vitreous chamber, the
sonographer must over gain the image and have the patient move their globe to
evaluate dynamically.
RD is an ophthalmologic emergency and should be addressed as such. RD can appear
as thin, mobile, and undulating in the early stages. Later the detached membranes
become stiff and hyperechoic. Regardless of acuity, the retina will remain tethered to
the optic nerve as the retina is an extension of the nerve. A completely detached retina
can appear as a “V” with the tip anchored to the optic nerve (Fig 25.9a).
VD will appear more mobile and thinner when compared to RD. The tip of the VD will
undulate and float with dynamic evaluation because it is not attached to the optic nerve
(Fig 25.9b).

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WFUMB Course Book 25. OCULAR ULTRASOUND

View enlarged image

US features: Retinal detachment

• Hyperechoic membrane in the vitreous chamber

• Always tethered to optic nerve
• Undulating and mobile in acute phase
• Stiff and increasingly hyperechoic later

Fig 25.9a View enlarged image

Retinal detachment with
apex attached to optic nerve

Retinal hemorrhage and vitreous hemorrhage can accompany vitreous and retail
detachment. Hemorrhage will typically appear as floating hyperechoic densities
that will move with ocular movements. Older hemorrhage will layer posteriorly or
appear as hyperechoic layers while recent hemorrhage will appear as scattered
diffuse opacities (Fig 25.10).

Fig 25.10
View enlarged image Vitreous hemorrhage.
Notice layering hyperdense
material in vitreous chamber

US features: Vitreous detachment

• Hyperechoic undulating membrane in vitreous chamber

Fig 25.9b • Not tethered to optic nerve
Vitreous detachment.
Thin layer (arrow) crosses
• Thin compared to retinal detachment
over optic nerve and not • Apex will appear to float and cross midline of the globe
tethered. Multiple artifacts
can also be seen (a)

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WFUMB Course Book 16. SPLEEN AND LYMPH NODES

25.3.4. Retrobulbar sonopathology

25.3.4.1. Optic nerve and optic nerve sheath diameter evaluation
The optic nerve appears as a hypoechoic stripe, projecting posteriorly from the
globe. The nerve sheath will often appear as parallel greyscale lines on either side
of the nerve. The nerve sheath diameter can be measured by placing the calipers
perpendicular to the optic nerve at a point 3mm posterior to the optic disc (Fig 25.11).
Tips and tricks for examination
• Globe rupture is a relative contraindication to ocular ultrasound
• Direct pressure to the globe must be avoided, particularly if occult globe
rupture is suspected
o A layer of gel should be kept in view in the near field while imaging
the globe to ensure that excessive pressure is not applied

View enlarged image • Always use a low acoustic power setting or an ocular preset when imaging
the eye to avoid any potential harmful bioeffects of ultrasound

• To better visualize pathology in the vitreous chamber, increase the gain

and perform a dynamic evaluation- have the patient move the globe while
holding the transducer stationary

• A retinal detachment will always tether to the optic nerve while a vitreous
detachment will swing freely, with the apex of the detachment crossing the
central axis with dynamic examination

Fig 25.11
Optic nerve sheath diameter
measurement

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Recommended reading

• Gandhi K, Shyy W, Knight S, et al. Point-of-care ultrasound for the evaluation of

non-traumatic visual disturbances in the emergency department: The VIGMO
protocol. Am J Emerg Med 2019. DOI: 10.1016/j.ajem.2019.04.049.
• Hoffmann B, Schafer JM and Dietrich CF. Emergency Ocular Ultrasound -
Common Traumatic and Non-Traumatic Emergencies Diagnosed with Bedside
Ultrasound. Ultraschall Med 2020; 41: 618-645. 2020/12/09. DOI: 10.1055/a-
1246-5984.
• Kimberly HH, Shah S, Marill K, Noble V. Correlation of optic nerve sheath
diameter with direct measurement of intracranial pressure. Acad Emerg Med
2008;15:201-204.
• Lahham S, Shniter I, Thompson M, Le D, Chadha T, Mailhot T, Kang TL, et
al. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment,
Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department.
JAMA Netw Open 2019;2:e192162.
• McNicholas MM, Brophy DP, Power WJ, Griffin JF. Ocular sonography. AJR Am
J Roentgenol 1994;163:921-926.
• Ojaghi Haghighi SH, Morteza Begi HR, Sorkhabi R, Tarzamani MK, Kamali
Zonouz G, Mikaeilpour A, Rahmani F. Diagnostic Accuracy of Ultrasound in
Detection of Traumatic Lens Dislocation. Emerg (Tehran) 2014;2:121-124.
• Soldatos T, Chatzimichail K, Papathanasiou M, Gouliamos A. Optic nerve
sonography: a new window for the non-invasive evaluation of intracranial
pressure in brain injury. Emerg Med J 2009;26:630-634.