Bedi et al.

Sonography of the Eye

Head and Neck Imag ing Pictorial Essay

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C E N T U R Y

O F

MEDICAL

IMAGING

Sonography of the Eye

OBJECTIVE. The purpose of this study is to show how sonography can reveal pathology of the eye and to highlight its usefulness as a simple and cost-effective tool in investigating eye symptoms. CONCLUSION. The cystic nature of the eye, its superficial location, and high-frequency transducers make it possible to clearly show normal anatomy and pathology such as tumors, retinal detachment, vitreous hemorrhage, foreign bodies, and vascular malformations. Sonography is useful as a treatment follow-up technique because it has no adverse effects. Sonography is well tolerated by patients and relatively easy to perform for those familiar with real-time sonography. he superficial location of the eye, its cystic composition, and the advent of high-frequency ultrasound make sonography ideal for imaging the eye [1]. MRI is favored by radiologists, so there are few reports on ocular sonography in the radiology literature [2, 3]. Sonography is used more commonly by ophthalmologists to evaluate the eye, particularly when direct examination by slit-lamp and funduscopy is not sufficient. Detailed cross-sectional anatomy of the entire globe is possible with conventional sonographic equipment [14]; anterior chamber visualization requires a dedicated sonographic biomicroscope [5]. Color Doppler and A-mode sonography [1, 6] are reported to be useful in characterizing masses. The sonography examination is rapid and cost-efficient, without the contraindications, such as pacemakers, that MRI has. Sonography avoids the irradiation associated with CT and the need for sedation in children [7]. Therefore, it can be used repeatedly during treatment of tumors to assess response to therapy.

Deepak G. Bedi1 Daniel S. Gombos2 Chaan S. Ng1 Sanjay Singh3

Bedi DG, Gombos DS, Ng CS, Singh S

Keywords: eye sonography, ocular imaging, ocular melanoma, ocular sonography DOI:10.2214/AJR.04.1842 Received December 3, 2004; accepted after revision August 31, 2005.
1Department

of Radiology, The University of Texas M. D. Anderson Cancer Center, Box 57, 1515 Holcombe Blvd., Houston, TX 77030. Address correspondence to D. G. Bedi (dbedi@di.mdacc.tmc.edu). of Ophthalmology (Plastic Surgery), The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030. of Radiology, Methodist Hospital, Houston,

and an 810-MHz A-mode probe (Innovative Imaging Systems), scanning through the open eye after paralyzing the blink reflex (Fig. 1B). A dedicated ocular sonographic biomicroscope, using frequencies up to 50 MHz (Fig. 1C), was available for a limited time. In the illustrations shown here, the radiology transducers were linear and the images are axial in a traditional anterior-to-posterior orientation. Ophthalmology used sector transducers, and their images are also axial but rotated in a left-to-right orientation to show the A-mode echo patterns. The term reflectivity is used in some figure legends to describe A-mode echo patterns and is similar to the term echogenicity, but in addition describes amplitude of tissue interface reflection. Normal Anatomy The cornea, conjunctiva, anterior chamber, posterior chamber. and iris (Figs. 2 and 3) rarely require sonography and are not well visualized with conventional sonography, but they are excellently detailed with newer sonographic biomicroscopes. The lens is best inspected directly, with no need for sonography. A mature cataract of the lens may obscure the retina on funduscopy, necessitating sonography. The vitreous body is gelatinous and anechoic, with loose attachments to the retina, and it stabilizes the eyeball. The choroid is part of the uveal tract, which also includes the

2Department

3Department

TX 77030. CME This article is available for 1 CME credit. See www.arrs.org for more information. AJR 2006; 187:10611072 0361803X/06/18741061 American Roentgen Ray Society

Technique Conventional gray-scale sonographic equipment (Elegra, Siemens Medical Solutions; ATL, Philips Medical Systems) and 7.515MHz transducers were used by the radiology department, scanning through the closed eyelid (Fig. 1A). The ophthalmology department used a 10-MHz B-mode probe

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Fig. 1Technique for sonography of eye. A, Radiologists use compact hockey-stick linear transducer with patients eyelid closed. Small amount of gel is sufficient for posterior eye anatomy; standoff pad or abundant gel can be used for anterior chamber. B, Ophthalmologists perform examination after paralyzing blink reflex and scan open eye. C, Ultrasound biomicroscope transducer, operating at 50 MHz, scans through water bath (arrow), incorporated into transducer, which is placed on open eye.

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Fig. 2Axial cross-section of eye and diagrammatic representation of pathology. C = cornea, A = anterior chamber, L = lens, V = vitreous body, CH = choroid, CB = ciliary body, I = iris, R = retina, S = sclera, CRA = central retinal artery, ON = optic nerve, PCA = posterior ciliary arteries. Sonographic anatomic correlation is shown in Figure 3; some vascular structures are seen only in Figures 3 and 16.

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Sonography of the Eye

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Fig. 3Normal eye anatomy. A and B, Axial sonograms show normal anterior chamber (A), lens (L), choroid (CH), ciliary body (CB), iris (I), and sclera (S) in A and V = vitreous body (V) and optic nerve (ON) in B. C, Axial color Doppler sonogram shows normal central retinal artery (CRA).

C ciliary body and iris, and is the site of many intraocular tumors. The choroid has a rich vascular supply from the long and short posterior ciliary arteries. Because the retina is pigmented, direct inspection of the choroid by funduscopy is limited,

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Fig. 434-year-old man with cystic lesion of iris (arrow), illustrated with use of standoff gel pad to visualize anterior eye anatomy. C = cornea, A = anterior chamber, P = posterior chamber, V = vitreous body.

Fig. 547-year-old man with iris melanoma. Ultrasound biomicroscopic image provides better anatomic detail of anterior portion of eye than conventional sonogram shown in Figure 4.

Fig. 652-year-old woman with choroidal melanoma. A, Typical sonographic features include hypoechoic mass, lobular in shape, with marginal retinal elevation (large arrow). Hyperechoic rim is combination of elevated retina and peripheral blood vessels. Characteristic hypoechoic echotexture is also seen in A-mode scan (graph at bottom), which shows decreased reflectivity between two small arrows corresponding to margins of mass, a feature that sometimes helps distinguish it from other types of tumor (see Figs. 1315). B, Funduscopy shows large dark melanoma (large arrows) with peripheral retinal elevation (small arrows), which appears translucent yellow because red color of underlying choroid, seen elsewhere, is lost.

and sonography plays an important role in diagnosing choroidal melanoma and meta-

static tumors. The retina and choroid are sonographically perceived as one layer in

the normal eye; the sclera is a highly reflective outer layer.

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Sonography of the Eye

Fig. 745-year-old woman with ciliary body melanoma. A, Sonogram shows tumor is large and round, which is common for melanoma. C = ciliary body, A = anterior chamber. B, Color Doppler sonogram shows blood vessels (arrows) encircling and penetrating tumor. C, Ophthalmoscopy shows dark tumor (arrows) partially obscuring normal red reflex of retinochoroidal pigmentation seen through dilated pupil.

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Fig. 862-year-old man with melanoma (arrow) arising from ciliary body (C), which is small and buttonlike. Small melanoma of ciliary body can be missed because of its small size and location if funduscopy is performed without depressing sclera externally.

The retina has a rich blood supply from the central retinal artery, which is clearly seen on color Doppler sonography, as are the adjacent posterior ciliary arteries that supply the choroid and the optic disk. The optic nerve is visible sonographically as a hypoechoic band starting at the scleral zone and extending posteriorly and medially.

Pathology Lesions of the Iris Cystic or solid lesions of the iris are difficult to show on conventional equipment (Fig. 4) but are well detailed on dedicated ultrasound biomicroscopic imaging (Fig. 5). This equipment, operating at 50 MHz or sometimes higher, has a resolution of 30 m, far in excess of CT or MRI.

Malignant Melanoma Malignant melanoma (Figs. 68) is the most common primary intraocular tumor and occurs more often in the choroid than in the iris or ciliary body. Iris melanomas can cause secondary glaucoma. Ciliary body melanomas may cause changes in accommodation from lens displacement. Choroi-

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Fig. 10Complications of melanoma in 69-yearold woman with diminished brightness of vision. Vitreous hemorrhage, seen as low-level echoes filling vitreous body (V), completely obscures direct view of tumor (arrow) by funduscopy.

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Fig. 9Complications of melanoma in 56-year-old man with blurred vision. Retinal elevation (small arrows) is caused by tumor mass (large arrow) or by possible transudation of fluid.

dal tumors present with decreased visual acuity and visual field defects. A small melanoma of the ciliary body (Fig. 8) can be missed if funduscopy is performed without depressing the sclera externally. Melanomas of the eye are usually rounded, hypoechoic, and very vascular. They can be complicated by retinal elevation and vitreous hemorrhage (Figs. 9 and 10). Vitreous Hemorrhage Vitreous hemorrhage spreads diffusely in the gelatinous vitreous, obscuring the optic disk, and does not form a fluid meniscus unless the bleeding is in the space around the vitreous. The causes of vitreous hemorrhage include vitreous detachment, diabetic retinopathy, retinal microaneurysm, trauma, and vascular tumors. The patient complains of black rain and has reduced visual acuity. The hemorrhage is absorbed slowly, and the clinical course depends on the exact cause. If choroid tumors are large or near the optic disk (Fig. 11), enucleation of the eye is sometimes necessary. However, brachytherapythat is, radiation plaques [8] placed outside the sclera adjacent to the tumoris the preferred mode of treatment (Fig. 12). Metastasis and Lymphoma Metastasis to the choroid is most common from the breast, lung, and unknown primary

Fig. 11Complications of melanoma in 42-year-old man with severe loss of vision in one eye. Location of melanoma (large arrow) on and adjacent to optic disk (small arrows) may prevent radiation treatment and could necessitate enucleation of eye.

sites (Figs. 13 and 14). Metastatic tumors are discoid in shape and hyperechoic compared with melanoma. A-mode sonography shows the difference in echogenicity (also called reflectivity in ophthalmology literature; see Figs. 6 and 13) between melanomas and metastases. Lymphoma can occur in isolation or as metastasis to the choroid or the vitreous body (Fig. 15).

Rhabdomyosarcoma Rhabdomyosarcoma is the most common primary malignancy of the orbital cavity in children, presenting with proptosis, inflammation, and loss of vision. A combination of radiation and chemotherapy makes a cure possible in many cases. Sedation for repeated CT or MRI during follow-up was

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Sonography of the Eye

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Fig. 1255-year-old man with choroidal melanoma. A, Sonogram shows melanoma (M) before brachytherapy (radiation plaque treatment). Melanoma is biconvex, with slight elevation of retina (arrow) at one margin because of serous fluid transudate. B, After radiation plaque treatment, tumor (M) shows significant decrease in volume. Apical tumor dimensions can be obtained using A-mode sonography (not shown).

avoided in the child shown in Figure 16 by using sonography. Hemangioma Hemangioma is the most common benign tumor of the orbital cavity and can be capillary (in children) or cavernous (in adults, Fig. 17). Retinoblastoma Retinoblastoma is the most common primary intraocular malignancy of childhood [9] (Fig. 18), often occurring before the age of 3 years, and presenting with a white pupil (leukocoria) and strabismus. Retinoblastoma is quite vascular and can invade the vitreous body. Microphthalmos and Coloboma Microphthalmos and coloboma are congenital anomalies caused by incomplete fusion of the optic cup in the sixth week of pregnancy. They cause a posterior eyeball defect with a posterior orbital cyst and an abnormally short eye (Fig. 19).

Fig. 1350-year-old woman with primary breast cancer metastasizing to eye. Although flat hyperechoic tumor (long arrow) is morphologically similar to lymphoma (Fig. 15) or treated melanoma (Fig. 12), its surface is more irregular, and Amode sonography (tracing at bottom) shows high reflectivity (short arrows).

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A
Fig. 1467-year-old man with metastatic adenocarcinoma from unknown primary site. A, Tumor is flat hyperechoic mass (arrows), well seen sonographically in nasal field of rotated eyeball. B, MR image shows subtle, isointense flat mass in nasal aspect of right eye (arrow), which is best seen on this T1-weighted image; T2-weighted images showed similar intensity for tumor and adjacent orbital fat.

Fig. 1538-year-old woman with lymphoma. Sonography depicts rather flat mass of moderate echogenicity (long arrow). A-mode sonographic tracing, taken through black-line axis, shows moderate reflectivity (short arrows) that iSs greater than that of melanoma (low reflectivity) but less than that of metastasis (high reflectivity).

Foreign Bodies Foreign bodies can be metallic, plastic, or wood. The bodies usually lodge in the conjunctiva or cornea, and the diagnosis is made by direct examination. Occasionally penetrating through the cornea (Fig. 20), metallic foreign bodies may lodge anywhere up to the retina and can cause severe inflammation and infection. Asteroid Hyalosis Asteroid hyalosis (Fig. 21) is characterized by the presence of minute opacities due to calcific deposits in the vitreous body, mainly in patients with diabetes and hypercholesterolemia. It is usually unilateral and rarely bothersome to the patient, but it can obscure the examiners view of the fundus. If visual acuity is affected, the deposits are removed by vitrectomy.

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Fig. 162-year-old boy with rhabdomyosarcoma of extraocular muscle. A, Hypoechoic, conical tumor (short arrows) is seen posterior to eye and slightly superior to optic nerve (long black arrow). Retinal detachment is also present (white arrow). Advantages of sonography in this infant outweigh those of MRI because sedation was avoided with minimal loss of anatomic information. B, Color Doppler sonogram shows that despite tumor infiltration around optic nerve (arrows), blood flow through central retinal artery (CRA) and posterior short ciliary arteries (PCA) is intact.

Fig. 1737-year-old man with hemangioma of orbit. A, Nasal superior location is common, as seen on this sonogram, which shows superior ophthalmic vein (black arrow) draining hemangioma (white arrows). B, IV contrast-enhanced CT scan of orbits shows prominent draining vessels (arrows) more clearly than sonogram, but repeated irradiation from CT during follow-up was avoided by using sonography, which provided satisfactory images and flow information. C, Color Doppler sonogram shows blood flow of mixed color (arrows), indicating some turbulence in larger vessels of hemangioma in medial aspect of image. Draining ophthalmic vein seen on gray-scale images and CT is not visible, presumably because of low-velocity flow.

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A
Fig. 181-year-old girl with retinoblastoma. A, Irregular shape of tumor (short arrows) is hard to outline on this sonogram, but hyperechoic calcific foci (long arrow) are characteristic of retinoblastoma. B, Large retinoblastoma is cream-colored on funduscopic image and partly overlies optic disk (arrow).

A
Fig. 1937-year-old man with microphthalmos and coloboma. A, Axial left-to-right sonogram shows abnormally short length of eye (double arrow), posterior defect or coloboma (single arrow), and cyst (C) behind eye. B, Abnormality, particularly cyst (C), is better detailed on axial MR image although coloboma is clearer on sonography.

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Fig. 2032-year-old male iron foundry worker with foreign body in eye, which appears as hyperechoic focus (arrow) in vitreous body of eye.

Fig. 2172-year-old man with asteroid hyalosis. Sonogram shows scattered hyperechoic foci (arrow) in central vitreous body.

Fig. 2258-year-old man with optic disk drusen. Sonography shows characteristically hyperechoic spots at fundus (arrow) and is particularly helpful in revealing drusen buried in optic nerve, which are otherwise invisible on funduscopy.

Fig. 2342-year-old man with retinal detachment. Sonography shows severe posterior, central detachment (arrow). See Figures 6 and 9 for other examples of detachment.

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Bedi et al. Optic Disk Drusen Optic disk drusen (Fig. 22) are calcified lobular bodies in the tissues of the optic disk and nerve that are bilateral in most cases. Usually asymptomatic, optic disk drusen can cause visual field defects if buried deep in the disk because of compressive atrophy of nerve fibers. Retinal Detachment Retinal detachment (Fig. 23) is a separation of the neurosensory retina from the underlying pigmented layer. This condition can be asymptomatic for a long time, then presents with flashes of light, floaters, black rain (if there is accompanying vitreous hemorrhage), a dark shadow, or loss of visual acuity, depending on the exact location and severity of the detachment. The three types are based on the cause: Rhegmatogenous detachmentthat is, associated with a retinal tearis the most common type and is seen with advancing age, a familial disposition, and associated myopia. Tractional detachment
F O R YO U R I N F O R M AT I O N

originates in adjacent vitreous strands. Exudative detachment is due to fluid, blood, or lipids behind the neurosensory retina and can be associated with tumors of the choroid. Conclusion Sonography of the eye shows a variety of diseases with remarkable clarity. The technique is more cost-efficient than other diagnostic techniques and is well tolerated by the patient. We have experienced no limitations and have received no complaints from patients. We do not advocate the routine use of sonography in the asymptomatic eye, but it may serve as a useful extension of the initial investigation of the symptomatic patient.

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Sonography of the eye. AJR 1991; 157:10791086 3. Coleman DJ, Woods S, Rondeau MJ, Silverman RH. Ophthalmic ultrasonography. Radiol Clin North Am 1992; 30:11051114 4. Sen KK, Parihar JKS, Saini M, Moorthy RS. Conventional B-mode ultrasonography for evaluation of retinal disorders. MJAFI 2003; 59:310312 5. Reminick LR, Finger PT, Ritch R, Weiss S, Ishikawa H. Ultrasound biomicroscopy in the diagnosis and management of anterior segment tumors. J Am Optom Assoc 1998; 69:575582 6. Erickson SJ, Hendrix LE, Massaro BM, et al. Color Doppler flow imaging of the normal and abnormal orbit. Radiology 1989; 173:511516 7. Ramji FG, Slovis TL, Baker JD. Orbital sonography in children. Pediatr Radiol 1996; 26:245258 8. Finger PT, Romero JM, Rosen RB, et al. Three-dimensional ultrasonography of choroidal melanoma: localization of radioactive eye plaques. Arch Ophthalmol 1998; 116:305312 9. Finger PT, Khoobehi A, Ponce-Contreras MR, Rocca DD, Garcia JP Jr. Three-dimensional ultrasound of retinoblastoma: initial experience. Br J Ophthalmol 2002; 86:11361138

This article is available for 1 CME credit. See www.arrs.org for more information.

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