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USG B Scan
Principles of ultrasound:
Thats why USG probes used for Ocular USG are of higher frequency(10MHz)as
it needs much less tissue penetration (an eye is 23.5 mm long on average) & higher
resolution.
In contrast, ultrasound probes used for purposes such as obstetrics, use lower
frequencies (1-5Hz) for deeper penetration into the body, and, because the structures
being imaged are larger, they do not require the same degree of resolution.
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Ocular B-scan USG
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Ocular B-scan USG
Echoes are captured by receiver of transducer which deform the crystal to produce a
voltage .This voltage is proportional to the strength of the echo (reflections).The
resultant voltage is weak.
Amplified image is sent for display. There are two principal display modes
A scan B scan
(A is for Amplitude) (B is for Brightness)
Graphics: PPDM
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Ocular B-scan USG
Examination Technique: All B scan probe contains a marker that contains a transducer
that moves rapidly back and forth near the tip of the probe. The probe tip is often oval in
shape with the back and forth motion of the transducer corresponding to the longest
diameter of the probe tip. Each probe has a marker (dot or line) that indicates the side of
the probe that is represented on the upper portion of the B scan screen. It is very
important to know how the probe or marker is oriented during the examination
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Ocular B-scan USG
the lids. In addition, with the lids closed, the echographer can never be certain which
position of the globe is being evaluated Ryan, 4th Edition,
However, closed lid examination technique minimizes the discomfort for patient and
allows a better visualization of peripheral fundus.
In axial scan, the patient fixates in primary gaze and the probe is
placed on the centre of the cornea, thus displaying lens & ON in the centre of the
echograph.
Transverse Scans:
Shows lateral extent of lesion (2 to 4 Oclock)
Probe placed on the globe with marker parallel to the limbus in two direction either
nasally or superiorly
Designation of transverse scan is determined by the meridian that lies in the middle of the
scanning section. For example- If probe is held horizonatally with its face centered on the
6 Oclock meridian, the middle of the echogram will display the 12 Oclock meridian of
fundus, this probe position is called a transverse scan of 12 Oclock meridian.
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Ocular B-scan USG
Longitudinal Scans:
It produces an anteroposterior slice of the globe along one
meridian.
Probe placed peripheral to the limbus.
Marker is perpendicular to the limbus (directed toward the centre of the cornea,
regardless of which meridian is being examined)
The designation of longitudinal scan is simply that meridian which is being examined.
For example, if probe is placed on the 6 Oclock meridian, the sound beam sweeps along
the 12 Oclock meridian, this is designated as a longitudinal scan of 12 Oclock position.
Axial Scan:
Patient is asked to direct his / her gaze in primary position & probe tip is centered
on the cornea.
Easy to interprete because of presence of evident landmarks ( lens & ON) but
offers less resolution & more distortion because of attenuation & refraction of the sound
beam caused by the lens
Baums Bump: Not only does the lens refract light, it also refracts sound waves, which
results in distortion of the echography, particularly if some of the sound wave passes
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Ocular B-scan USG
through lens and some not. Resultant demarcation produces bulges known as Baums
Bump
In axial view of a phacic eye, post lens capsule is the first intraocular structure to appear
in the screen, followed by vitreous gel (clear, sonoluscent),by the posterior eyeball(i.e.
retina, choroids & sclera).In an axial scan, the ON is shown at the centre of the screen as
a sonoluscent structure with a few echo inside surrounded by highly reflective intra
orbital fat tissues.
For describing the clinical application of USG, we will discuss the different
posterior segment diseases in three different headings according to their topology:
Though these distinctions are arbitrary, but it gives us a good idea about the identification
and differentiation of different pathologies.
POINT STRUCTURES:
Degenerative Changes: a few low reflective high mobile point echoes can be seen
Asteroid Hyalosis: the calcium particles are highly reflective & appear on USG as strong
white point echoes. There is normally an area of clear vitreous between the post.
boundary of asteroid opacities & the post. Hyaloid, sometimes confused as PVD
Vitreous Haemorrhages:
Fresh+ mild VH= dot & short lines displayed in USG.
More dense the haemorrhages, more opacities seen in B-scan
Because of the gravity, blood may layer inferiorly resulting in highly reflective pseudo
membranes that may be confused with RD
Fresh VH/Haemorrhage in
Old Vitreous Haemorrhage
vitrectomised eye
Echoluscent or very low reflective Of varying reflectivity
Varying position More dense inferiorly due to gravity
Retrohyaloid Haemorrhages:
Blood in Retrohyaloid space tends to remain in a fluid state and does not clot, so it has a
low reflectivity, therefore a high gain (90dB) is necessary to image retrohyaloid
haemorrhage.
Vitreous Inflammation:
Clumps of vitreal inflammatory cells appear in B-scan as scattered particle or large
aggregates.Usg is very helpful in assessing the severity and extent of intraocular
inflammation in a patient suspected of having endophthalmitis..sometimes in absence of
external inflammatory signs,it is important to differentiate between endophthalmitis and
vitreous haemorrhage.VH is generally associated with PVD and layering of blood in
inferior portion of the eye to produce sheet-like echoes .
MEMBRANOUS STRUCTURE:
RD:
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
Important points:
Gain setting is reduced to better delineate the different structures of post eye wall
Probe is directed as perpendicular as possible to the tumour surface
Once the ideal position is obtained,the image is frozen.Measurement calipers are
positioned on the ant. Surface & base of the tumour. Measurement of the lateral &
posteroanterior extension of the tumour are then performed in a similar way on
transverse & longitudinal scan
While measuring the size of the tumour,it is important to evaluate the shape of the
tumour. Melanoma begin as a dome shaped solid thickening of choroids
protruding into vitreous,but when Bruchs membrane ruptures,the mass expands
toward the vitreous pushing the retina & RPE infront of it -- Collar button /
mushroom configuration pathognomic of malignanat melanoma
Next step is to focus into the intensity of initial echoes (i,e border echoes ) of the
lesion and the number & intensity of internal reflections.Generally intial echoes
are very strong in tumour lesions because of abrupt changes in the acoustic
impedence from the normal vitreous to tumour tissues.(Choroidal Osteoma=
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Ocular B-scan USG
Ocular Trauma:
Large amount of coupling gel should be used as it allows better contact with less pressure
on the globe by USG probe.
Placing the USG probe in a sterile rubber sleeve (surgical gloves) helps to reduce / avoid
contamination of eye.
IOFB:
FBs are strong reflectors because of their acoustic impedence is so different from
that of other body tissues.
Once a highly reflecting echo is identified ( suspected IOFB),the gain setting of
the instrument is gradually reduced,while the probe is held still in the same direction. If
the echo is caused by an IOFB it will be the last echo to disappear from the screen.
Mainly two acoustic artifacts are caused by IOFB & may help in their localization
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Ocular B-scan USG
FB may be small & linear and so may be missed if the probe is not perpendicular to
the flat side of the FB
BIBLIOGRAPHY:
1. Retina,4th Edition,Edited by Stephen J. Ryan
2. The Sankara Nethralaya-Atlas of Ophthalmic Ultrasound- Muna Bhende
3. Diseases of the Retina and Vitreous by Richard F. Spaid
4. Step by step Ophthalmic Ultrasound by P K Srivastava
5. B scan ocular Ultrasound by Rhonda G Waldron , Thomas M Aaberg.
http://www.emedicine.com/oph/topic757.htm#section~author_information
6. http://www.eyeubm.com
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