B SCAN ULTRASONOGRAPHY

Dr. Parameshwar Rao Dr. Haridev Dr. Ashok Dr. Siva Kumar.W (PG)

INTRODUCTION
B-scan ultrasonography is an important adjuvant for the clinical assessment of various ocular and orbital diseases. This presentation is designed to describe the principles, techniques, and indications for echographic examination, as well as to provide a general understanding of echographic characteristics of various ocular pathologies.

 B-

SCAN is a two dimensional imaging system which utilises high freq sound waves ranging from 8-10 MHz. stands for bright echoes.

B - SCAN
It

was first introduced by Baum and Greenwood in 1958 First commercially available B scan is developed by Coleman et al in seventies The importance of the instrument and technique is emphasised by Karl Ossoinig

Physics:
It

is an acoustic wave that consists of particles within the medium Frequencies used in diagnostic ophthalmic ultrasound are in the range of 8-10 MHz
These

high frequencies produce shorter wave lengths which allow good resolution of minute ocular and orbital structures

 Multiple

short pulses are produced with a brief interval that allows the returning echos to be detected, processed and displayed. The basis of the echo system is piezoelectric element which is a quartz or ceramic crystal located near the face of the probe

sound waves from transmitter

Target tissue

Echoes are received by receiver

Amplification Oscilloscope screen

Types of frequency
Low frequency: orbital tissue Medium frequency : ( 7 10 mhz )
Retinal , vitreous , optic nerve

High frequency : ( 30 50 mhz) : ant chamber upto 5 mm

 IMPEDENCE

: The difference between the strength of the returning echoes from tissues with abrupt changes in acoustic properties.
: Increase in gain is associated with increase in tissue penetration and sensitivity but decrease in resolution.

GAIN

 HIGH

FREQUENCIES - LOW PENETRATION BUT GOOD RESOLUTION. (abdominal US-1-2MHz )

INCREASE IN GAIN - INCREASE IN TISSUE PENETRATION AND SENSITIVITY DECREASE IN RESOLUTION.

INCREASE IN GAIN - INCREASE IN TISSUE PENETRATION AND SENSITIVITY DECREASE IN RESOLUTION.

 DISPLAY

MODES: A SCAN/ B SCAN /

BOTH
TIME

GAIN COMPENSATION: to enhance echoes from deeper structures.

AMPLIFICATION
Three types are commonly used. 1. Linear : Can show minor differences in echos . Limited range .(A SCAN) 2. Logarithmic : Wider range. Minor differences cannot be seen.(B SCAN) 3. S Curve : Combines the benefits of both the above.(in the standardized A SCAN for tissue differentiation)

 The

probe has Damaging material which limits the vibrations of the crystal thus shortening the pulse Shape of the crystal is useful in determining the character of the sound beam The electrical signal produced by returning echos is of very weak radio frequency signal

 This

signal undergoes complex processing before displayed on the screen Adjust the amplification of the signal displayed on the screen, this is referred as gain or sensitivity of the instrument The higher the gain level the greater the sensitivity of the instrument

Instrumentation:
It

produces Two dimensional section It uses both horizontal and vertical dimensions of screen to indicate configuration and location A section of tissues is examined by an oscillating transducer

 An

echo is represented by a dot on the screen The probe is filled inside with a fluid , a crystal oscillates sending sound waves out in a fan like array called Sector scan

Image documentation modes :

They are of 2 types stationary/static moving/dynamic

The images may be saved in different methods

1.
2. 3. 4. 5.

Polaroid photographs 35 mm photo Ink prints Thermal prints Videotapes

Indications:
Anterior segment: 1. Opaque ocular media (i.e. corneal opacities) Pupillary membrane Dislocation / Subluxation lens Cataract / after cataract Posterior capsular tear Pupillary size / reaction 2. Clear ocular media Diagnosis of iris and ciliary body tumors

Posterior segment: 1. Opaque ocular media Vitreous haemorrhage Vitreous exudation Retinal detachment (type / extent) Posterior vitreous detachment (extent) Intraocular foreign body (size/ site/ type) 2. Clear ocular media Tumour (size/ site/ post treatment follow up) Retinal detachment (solid / exudative) Optic disc anomalies 3. ocular trauma

Examination technique:
The patient is either reclining on a chair or lying on a couch. The probe can be placed directly over the conjunctiva or the lids.

Probe positions
Transverse

: most common Lateral extent, 6 clock hours

Longitudinal

: radial ,1 clock hrs, AP diameter in Retinal tumors and tears : lesion in relation to lens and optic nerve .

Axial

Transverse scan
EYE anaesthetised. EYE looking in the direction of observers interest PROBE parallel to limbus and placed on the opposite conjunctival surface PROBE MARKER superior (if examining nasal or temporal) or nasal(if examining superior and inferior). 6 clock hrs examined at a time.

 The clock hour which the marker faces

is always at the top of the scan.

The area of interest in a properly done

transverse scan is always at the centre of the right side of scan. If examining nasal area temporal superior inferior -12 6 clock hrs - 6- 12 clock hrs - 9 -3 clock hrs - 3- 9 clock hrs

NASAL AREA

TEMPORAL AREA

SUPERIOR AREA

INFERIOR AREA

Longitudinal scan EYE Anaesthetised. EYE - looking in the direction of observers

interest. PROBE perpendicular to the limbus and placed on the opposite conjunctival surface. PROBE MARKER- directed towards the limbus or towards the area of interest regardless of the clock hour to be examined. Optic nerve shadow always at the bottom on the right side. 1 clock hour.

Axial scan

EYE anaesthetised. EYE in primary gaze PROBE centered on the cornea .

 LENS:

Oval highly reflective structure with intralesional echoes with none to highly reflective echoes. VITREOUS is echolucent. RETINA, CHOROID AND SCLERA: Are seen as a single reflective high structure.

 OPTIC

NERVE : Wedge shaped acoustic void in the retrobulbar region. OCULAR MUSCLES : Echolucent to low reflective fusiform structures. The SR- LPS complex is the thickest. IR is the thinnest. IO is generally not seen except in pathological conditions.

EXTRA

 ORBIT

-highly reflective due to orbital

fat. Always examine the other eye before coming to a conclusion regarding the lesion . Opacities produce dots or short lines Membranous lesions produce an echogenic line

Anterior segment evaluaton

Immersion

technique

High

resolution technique

ULTRASONOGRAPHIC CHARACTERISTICS

VITREOUS HAEMORRHAGE
To detect extent, density, location and cause

Fresh haemorrhage shows dots or lines Old haemorrhage the dots gets brighter

POSTERIOR VITREOUS DETACHMENT

Posterior vitreous detachment: The detached posterior vitreous is seen as membranous lesion with no/some attachments to the optic disc

POSTERIOR VITREOUS DETACHMENT

Mobility of PVD is more than RD. The spike of RD is more than PVD. PVD becomes more prominent in higher gain settings

RETINAL DETACHMENT
The detachment produces a bright continuous, folded appearance with insertion into the disc and ora serrata. It is to determine the configuration of the detachment as shallow, flat or bullous

EXUDATIVE RETINAL DETACHMENT

RHEGMATOGENOUS RD

RHEGMATOGENOUS RETINAL DETACHMENT

CLOSED FUNNEL RD WITH RETINAL CYST

CLOSED FUNNEL RD WITH RETINAL CYST

APPEARS AS RD BUT IT IS A PVD. CLUES: NON UNIFORM THICKNESS OF MEMBRANE VERY THIN ATTACHMENT TO THE DISC.

RETINAL TEAR

RETINAL TEAR WITH FREE SUPERIOR END . THE MEMBRANE IS CONVOLUTED ON ITSELF. POSTERIOR VITREOUS IS ATTACHED AT THE SUPERIOR END OF THE TEAR.

ASTEROID HYALOSIS
Asteroid hyalosis: Calcium soaps produce bright point like echos

TUMOURS
Differentiation,

extrascleral extension, size, assessing tumour growth or regression. Measurement of tumour dimensions such as elevation and base. Help in distinguishing solid from cystic lesions.

RETINOBLASTOMA
Size of the tumour
Shows irregular configuration Calcification shows high internal reflectivity

MELANOMA

Collar button or mushroom shape.Large tumours shows acoustic hallowing

TUMOURS - OSTEOMA

CHOROIDAL DETACHMENT KISSING CHOROIDS

Smooth, thick, dome shaped membrane in the periphery with very little after movement
360 degree detachment shows a pathognomonic scalloped appearance

CHOROIDAL DETACHMENT KISSING CHOROIDS

CHOROIDAL DETACHMENT

Intraocular foreign bodies:

Localisation

and extent of intraocular damage Metallic foreign bodies produce very high bright signal Shadow present posterior to the foreign body Wood, glass and organic material produce specific echographic finding

INTRA OCULAR FOREIGN BODY

CUPPED DISC

MACULAR EDEMA

PERSISTENT HYALOIDAL VESSEL

POSTERIOR STAPHYLOMA

LACRIMAL GLAND TUMOUR

NANOPHTHALMOS

RETINOSCHSIS

Retinoschisis: Smooth, thin dome shaped membrane that doesnt insert on optic disc
Diabetic retinopathy: Nature and extent of the disease To monitor progress of the disease Aids in pre vitrectomy evaluation

ENDOPHTHLMITIS

CYSTICERCOSIS WITH RETINAL TEAR

COLOBOMA OF THE CHOROID AND DISC

PERSISTENT FETAL VASCULATURE

RETINOPATHY OF PREMATUIRITY

POSTERIORLY DISLOCATED LENS

INTRA OCULAR AIR / GAS

SILICON OIL FILLED VITREOUS

Sclera:
Thickening

in hyperopic and nanopthalmic eyes

Infolding

in severe hypotony or a ruptured globe

SCLERITIS

Evaluation of extraocular muscles:

Normal

muscles show less echo dense than surrounding orbital soft tissue the gross size and contour of a

Documenting

muscle

Nodular posterior scleritis with fluid in the Tenon capsule.

Positive T-sign at the insertion of the optic nerve.

Evaluation of optic nerve

General

topography, relationship to structures, optic disc anomalies and alteration in contour of the globe
subarachnoid space surrounding optic nerve appears as echolucent cresentric or circle around the nerve called Doughnut sign

The

Advantages:
Non

invasive Performed in an office setting Does not expose to radiation High resolution echography provides reliable and accurate assessment Ideal for follow up of lesion

Disadvantages
High

frequency sounds waves have limited penetration

ULTRASONOGRAPHY IN PAEDIATRIC PATIENTS: Useful in the following conditions: Abnormal size of eye Abnormal shape of eye Congenital abnormalities Vitreous alterations Retinal detachments (type/ location) Ocular and orbital tumours Trauma

PITFALLS
Artefacts:
Insufficient

fluid coupling ( i.e., lack of methyl cellulose) cause entrapment of air between the probe and eye leading to display of bright echos which represent multiple signals

REVERBERATION ARTEFACTS

ANGLE OF INCIDENCE ARTEFACT

PITFALLS
Tumours: Mass may be missed is less than 0.75 mm False ve results in case of small lesion and fibrotic tissue False + ve in subretinal haemorrhage and metastatic tumour with massive infiltration

PITFALLS
Vitroretinal disease: In RD unable to detect actual tear In vitrectomsed eyes vitreous haemorrhage is diffuse leading to echolucency Silicon oil decrease in sound velocity

PITFALLS
Intraocular foreign body: Small Intraocular foreign body of < 1mm may be missed. Orbit: An orbital mass can be detected or differentiated if > 3 mm in size if anterior and > 5 mm in posterior orbits.

B- SCAN REPORTING
Describe

the features and correlate with clinical findings. Dont jump to diagnosis. Always examine both in sitting and erect postures in case of RD. Examine other eye also. Try to take the best picture possible.

FOUR TRANSVERSE SCANS ONE HORIZONTAL AXIAL SCAN TO EVALUATE THE POSTERIOR POLE ARE SUFFICIENT.

THANK YOU