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Scoring an A+ on a B-Scan
Master the art of ultrasound imaging.
By Derek Urban, OD, Jennifer Ramey, OD, Ryan Bunch, OD, and
Nathan Lighthizer, OD
This patient is undergoing a transverse 3 o’clock scan. The patient looks nasally while
the probe is placed at the 9 o’clock position with the probe marker oriented at 12
o’clock.
Principles of Ultrasonography
B-scan ultrasound uses high frequency soundwaves that are transmitted from
a probe/transducer into the eye. As these soundwaves strike the intraocular
structures, an echo is reflected back to the probe and converted into an
electrical signal. This signal is then reconstructed into a two-dimensional
image on a monitor. The stronger the echo, the brighter the display. This
process is repeated 1,000 times per second to produce a real-time display. The
soundwaves used are inaudible to human ears because they have a frequency
greater than 20KHz. Ophthalmic ultrasound most commonly uses a frequency
of 10MHz. This allows for the best combination of tissue penetration and
image resolution.
Another important aspect of all ultrasound instruments is the ability to adjust
the amplification of echo signals. This is known as the gain control. The gain
control is similar to the volume control on a radio. It changes the intensity of
the returning echo displayed on the screen. It does not change the amount of
energy emitted from the probe. A higher gain level allows for the capture of
weaker echoes, such as those caused by vitreous opacities. A lower gain level
will filter the weaker echoes, leaving only the strongest echoes, such as optic
nerve drusen, the retina and the sclera. Lowering the gain effectively improves
the resolution of the display, but in turn will also decrease the depth of the
sound beam penetration.
Table 1. Indications for B-Scan Ultrasonography
When Direct
When Ocular
Visualization is
Structures are Visible
Impossible
Differentiating iris and
Lid abnormalities
ciliary body lesions
Ruling out ciliary body
Corneal opacities
detachments
Differentiating
Hyphema/hypopyon
intraocular tumors
Differentiating serous vs.
Miosis hemorrhagic choroidal
detachments
Rhegamatogenous vs.
Dense cataracts exudative retinal
detachments
Differentiating disc
Vitreous opacities
drusen vs. disc edema
In a transverse scan, the probe is oriented tangential to the limbus with the
probe marker pointing superiorly for vertical scans and oblique scans, or
nasally for horizontal scans. You designate the meridian being scanned by the
clock hour in the center of the scan. A transverse scan is used to determine the
lateral extent of a lesion.
In a longitudinal scan, the probe is oriented perpendicular to the limbus with
the probe marker pointing to the center of the cornea. The scanned meridian
is designated by the clock hour opposite of where the marker is placed. A
longitudinal scan is used to determine the length (anterior to posterior) of the
lesion, or to identify the insertion of membranes. The imaging of longitudinal
scans always displays the anterior eye superiorly and the posterior eye
inferiorly.
In an axial scan, the probe is placed on the center of the cornea with the
patient looking straight ahead. Although this results in poor resolution of
scans due to imaging through the dense media of the natural lens, axial scans
are useful for locating lesions in the posterior pole and determining where
lesions are in relation to anatomical markers such as the optic nerve and
macula. Axial scans can be done horizontally, vertically or obliquely.
Basic Screening Examination Protocol
Here is how to perform a B-scan on a patient:
Step 1. Prior to beginning, make sure to disinfect the probe according to the
manufacturer’s instructions.
Step 2. Begin by having the patient seated comfortably. The patient can be
seated upright or reclined, with the head securely resting on the headrest.
Step 3. Instill one drop of topical anesthetic in each eye. This is especially
important if you place the probe on the patient’s cornea or conjunctiva.
Step 4. Apply a coupling agent to the probe tip. Often, artificial tear gel or
2.5% methylcellulose are used; however, be sure to avoid using abdominal
ultrasound gel, as it is considered an ocular irritant.
Step 5. Scan through the different meridians: transverse, longitudinal and
axial, moving the probe tip from limbus to the conjunctiva. Make sure to
observe the image on the screen while you are recording (Table 2).
Step 6. Save images as you go (For example, a tangential scan at 12 o’clock
on the right eye can be saved as “OD-T12”). This will be beneficial when
performing topographical evaluation of the images after completeing all the
scans.
B-scan Pearls
Here are several tips on high quality scanning images:
• Be sure to direct the patient’s gaze away from the probe and toward the
meridian being scanned.
• The probe can either be placed on the patient’s closed eyelid or, for better
resolution and certain globe position, place the probe directly on the
conjunctiva.
• Remember that the top of the displayed image always correlates to the mark
on the probe.
• Try to keep the probe perpendicular to the tissue being imaged, as doing so
will improve resolution.
Table 2. Basic
Screening
Protocol Notes
1. Transverse scans:
Perform transverse
scans of the 3, 6, 9, and
12 o’clock meridians.
Maneuver the probe
into the fornix to image
more anterior regions.
2. At minimum, perform
longitudinal scans of 9
o’clock OD and/or 3
o’clock OS. These scans
provide images of the
macula. More
meridians can be done
if indicated.
3. Axial scans can be
performed vertically or
horizontally, or both.
Axial scans are good for
imaging the posterior
pole.
Above, the patient undergoes a transverse 3 o’clock scan. The patient looks nasally while
the probe is placed at the 9 o’clock position with the probe marker oriented at 12
o’clock.
The patient undergoes a longitudinal 9 o’clock scan. The patient looks temporally, the
probe is placed opposite at 3 o’clock and the probe marker is pointed toward the 9
o’clock meridian.
• Choroid. When viewing a B-scan, the choroid appears much thicker than the
retina. This is true for normal eyes or when looking at conditions such as a
choroidal detachment. A choroidal detachment will appear with a dome-
shaped contour; larger detachments may consist of multiple domes that ‘kiss’
in the middle of the vitreous. Traumatic causes of choroidal detachments are
often hemorrhagic, rather than serous. The subchoroidal space of a
hemorrhagic detachment will show a host of dots, as opposed to a hollow
area.
Differentiating between choroidal nevi and melanomas is another useful
application for B-scan. Typically, melanomas arising from the choroid appear
as smooth, dome-shaped lesions with low to medium internal reflectivity and
a regular internal structures. Internal vascularity can also be detected. A
classic collar button or mushroom-shaped lesion is evident in tumors that
have broken through Bruch’s membrane. Occasionally, choroidal evacuation
is seen at the base of the tumor, which represent the tumor invading further
into the choroid. A melanoma can progress still further and extend through
the scleral wall, known as extrascleral extension.
Disease Scans
• Optic Nerve. Without interference of media opacities, the shape of the optic
nerve, including the cup, is detectable with ultrasound. Differentiating the
cause of a swollen optic nerve is a common clinical indication for B-scan.
Papilledema, which is the result of increased intracranial pressure, will show a
slightly widened optic nerve. With more elevated pressure, a black, empty-
appearing area within the optic nerve sheath is apparent. This is known as a
crescent sign and signifies the separation of sheath from optic nerve. Optic
disc drusen, which can simulate papilledema, appear as highly reflective
entities at the base of the optic nerve head.
Ultrasound can also be used to detect and differentiate optic nerve tumors,
such as gliomas and meningiomas. An optic nerve glioma is a neoplasm that
infiltrates the optic nerve parenchyma. On ultrasound, this is a smooth,
fusiform mass with low-to-medium and regular internal reflectivity. An optic
nerve sheath meningioma is a tumor of the optic nerve sheath. In contrast to
a glioma, this tumor typically has a medium-to-high, irregular internal
reflectivity with potential areas of calcification.
Know the Norm
It is vital to have a good grasp of what a normal ultrasound looks like. Not
only are there minor differences in normal findings from patient to patient,
but variation can exist within the same eye, due to the heterogenous nature of
a normal eye. It is highly recommended that you gain as much experience as
possible examining a normal eye to better evaluate patients with suspected
eye disease. With increased experience, you will gain the confidence to
evaluate a variety of ocular conditions.
As you become more experienced, you can expand your abilities to include
more advanced techniques—such as examining the orbit and extraocular
muscles. Your practice and, most importantly, your patients will benefit.
Dr. Urban is a staff optometrist at the Veterans Health Care System of the Ozarks
in Fayetteville, AR.
Dr. Bunch is currently completing an optometry residency in ocular disease at
the Veterans Health Care System of the Ozarks in Fayetteville, AR.
Dr. Ramey is currently completing an optometry residency in ocular disease at
the Veterans Health Care System of the Ozarks in Fayetteville, AR.
Dr. Lighthizer is assistant dean for clinical care services, director of continuing
education, and chief of both the specialty care clinic and the electrodiagnostics
clinic at NSU Oklahoma College of Optometry.