Ultrasound of The Eye and Orbit-Frazier

VI trasound of the
Eye and Orbit
SANDRA FRAZIER BYRNE

Visiting Research Scholar
Mars Hill College
Mars Hill, North Carolina
RONALD l. GREEN, MD
Professor
Doheny Eye Institute
Department of Ophthalmology
University of Southern California Keele School of Medicine
Los Angeles, California
SECOND EDITION
Illustrations by Timothy G. Hengst, FAHI
An Imprint of Elsevier Science

St. Louis London Philadelphia Sydney Toronto
Contributors
PAUL T. FINGER, MD, FACS
Associate Professor of Ophthalmology
New York Eye and Ear Infirmary
New York University School of Medicine
New York, New York
Chapter 9: Three-Dimensional Imaging of the Eye
F. STUART FOSTER, PhD

Professor and Associate Chair
Department of Medical Biophysics
Faculty of Medicine
University of Toronto
Sunnybrook and Women's Health Sciences Centre
Toronto, Ontario
Kanada
Chapter 8: Ultrasound Biomicroscopy of the Eye
WOLFGANG E. L1EB, MD
Associate Professor
Julius-Maximilians-University
Wiirzburg, Germany
Chapter 14: Color Doppler Imaging of the Eye and Orbit
CHARLES J. PAVLlN, MD
Professor
Faculty of Medicine
University of Toronto
Toronto, Ontario
Canada
Chapter 8: Ultrasound Biomicroscopy of the Eye
v
Foreword
Almost 10 years have passed since the publication of the first edition of Ultrasound
of the Eye and Orbit by Sandra Frazier Byrne and Dr. Ron Green. Many new develop-
ments in ultrasonography have occurred, and the ophthalmic community looks for-
ward to the authors' updated information regarding the new techniques and available
instrumentation. In addition to their own new observations, they have included three
new chapters by guest authors. These concern ultrasound biomicroscopy, color
Doppler imaging, and three-dimensional ultrasound.
Ultrasonography has established itself as one of our most important diagnostic tools
in ophthalmology. Perhaps more than any other such tool the value of the informa-
tion obtained is highly dependent on the skill, technique, experience, interpretation,
and dedication of the ultrasonographer. When it comes to examination of difficult di-
agnostic cases, the busy practitioner doing only a few ultrasound studies a week cannot
compete with those devoting most of their time to ultrasonography.
The authors have used detailed, clearly written, and illustrated instructions on
proper ultrasonographic techniques that will be invaluable to those wishing to master
anyone or all phases of ultrasonography. They have included a comprehensive collec-
tion of ultrasound images for most of the neoplastic, hamartomatous, inflammatory,
metabolic, traumatic, and degenerative disorders of the uveal tract, macula, retina, vit-
reous, sclera, optic nerve, and orbit. This book serves as an excellent reference for stu-
dents, residents, ophthalmologists, and those who are not involved in doing ultra-
sonography. A culmination of more than 50 years of combined experience of two
world-recognized authorities, this beautifully illustrated classic provides the reader with
a clear understanding of the physics, techniques, instrumentation, and interpretation of
ultrasound.
J. Donald M. Gass, MD
Professor of Ophthalmology
Vanderbilt University Medical School
Nashville, Tennessee
vii
Foreword
This second edition of Ultrasound of the Eye and Orbit extends the collaborative voice
and experience of Sandra Frazier Byrne and Ronald Green to 50 years. Their balanced
view of the role of echography in the armamentarium of the orbital specialist is evident
throughout the book. In addition, the careful correlation of diagnostic images using
different technology allows the reader to contextualize the spectrum of orbital
processes delineated herein. The range and specificity of examples also provides a ready
reference for the student of ultrasonography and orbital disease. They have added sec-
tions on color Doppler imaging and three-dimensional ultrasound, which add to the
dynamic spectrum of techniques emphasized.
Throughout, the reader is able to incorporate the basic knowledge of ultrasound
and apply it to a range of lesions in a meaningful manner. Most people who recognize
the complex constellation of clinical signs and symptoms of orbital disease enjoy the
challenge of piecing the investigative findings to sort out the appropriate management
of their patients. The study of these patients requires the clinician to draw upon vast
clinical, investigative, pathologic, and systemic knowledge. This book, with its lucid
text and illustrations, is essential to the comprehensive investigation and management
of the orbital patient.
Jack Rootman, MO, FRCSC

Professor, Departments of Ophthalmology and Pathology
Head, Department of Ophthalmology
University ofBritish Columbia and the Vancouver General Hospital;
Associate Member, Division ofNeurosurgery
Vancouver General Hospital
Vancouver, Britisch-Kolumbien
Kanada
ix
Preface to the Second
Edition
Since the first publication of this book in 1992, numer- Chapters 11 through 17 cover examination techniques
ous advances have occurred in the field of ophthalmic ul- and disorders of the orbital soft tissue, extraocular muscles,
trasound. Many new observations have been made, and optic nerves, and periorbital region. These chapters
over the past decade, new technologies have emerged that demonstrate the use of ultrasound as an important adjunct
have greatly enhanced the practice of echography. As a re- to CT scan and MRI for the detection and diagnosis of or-
sult, a second edition was necessary to update the body of bital and periorbital disease.
knowledge in ophthalmic ultrasound and to describe new Chapter 18 has been updated to provide a more thor-
instrumentation and examination techniques. ough explanation of the artifacts that are usually'encoun-
We are grateful to our guest contributors who have writ- tered in ophthalmic ultrasound.
ten three new chapters for this book. These chapters describe We are indebted to many individuals for their assistance
the most important technologic advances in ophthalmic ul- in the preparation of this second edition.
trasound in the last ten years: ultrasound biomicroscopy We wish to thank Nilo Davila and Tracy Nichols of the
(Chapter 8), three-dimensional ultrasound (Chapter 9), Photography Department at the Doheny Eye Institute and
and color Doppler imaging (Chapter 14). Richard Stratton of the Photography Department at the
We have written new chapters on inflammatory diseases Bascom Palmer Eye Institute for their efforts in the prepa-
of the eye (Chapter 6) and glaucoma (Chapter 7). These ration of the illustrations. Thanks are additionally extended
chapters reflect our increased experience and demonstrate to Rhonda Waldron, MMSc, COMT, and Cynthia Kendall,
additional indications for ophthalmic ultrasound. BMET, RDMS, for providing us with numerous illustra-
In Chapter 2, Examination Techniques for the Eye, three- tions for the book. Furthermore, we wish to acknowledge
dimensional drawings have been created to better illustrate contributions from Barbara Blodi, MD; Diane Chialant,
the examination techniques. This chapter also includes a RN, COT; Cathy DiBernardo, RN, RDMS; Eileen
more detailed explanation of the anterior segment evaluation. Gendron, ROUB; Linda Kelley, CRA, COA; and Kathleen
Chapter 3, Vitreoretinal Disease, has been greatly ex- Meyer, RDMS, ROUB.
panded. It contains a new section on macular disease, as Special thanks go to Susan Clarke for her expertise in
well as additional illustrations of vitreoretinal disorders. editing the manuscript. In addition, we are very apprecia-
Significant new material regarding the sclera and its ab- tive of the administrative assistance provided by Sylvia Rea
normalities has also been added. Chapter 4 has been up- that greatly facilitated the preparation of this edition. Ann
dated to include additional examples of trauma and post- Dawson also provided advice and useful suggestions.
surgical findings. A number of colleagues were very helpful in reviewing
Major revisions have been made to Chapter 5, Intraocu- portions of the manuscript. Thanks are extended to Culver
lar Tumors. These include new observations and illustra- Boldt, MD; Kari Boyce, PhD; Brian Francis, MD; Warren
tions for both the diagnosis and measurement of choroidal Hill, MD; MarkJohnson, MD; Gregg Kokame, MD; Tom
melanoma. In addition, the discussion of other types of in- Prager, PhD; and Russell Read, MD.
traocular tumors has been expanded and a new section for We also wish to thank Bernie Byrne for all of his sup-
anterior segment lesions has been created. port, encouragement, and many other contributions.
With the growing interest in IOL calculations, it was
necessary to significantly enhance the explanation and il- Sandra Frazier Byrne
lustration of axial eye length measurements in Chapter 10. Ronald L. Green, MD
xi
Preface to the First
Edition
In recent years, echography has become an essential com- that we place on ultrasound for orbital diagnosis. At our in-
ponent in the clinical practice of ophthalmology, and has stitutions, echography is considered to be an important ad-
increased greatly our ability to detect and differentiate a junct to computed tomographic scanning and magnetic res-
wide variety of ocular and orbital disorders. This diagnos- onance Imagmg.
tic imaging modality, however, can be used reliably only It is important to emphasize that the techniques de-
when the echographer understands the basic principles of scribed in this book are based primarily on the pioneering
ultrasound and utilizes appropriate examination techniques. work of Dr. Karl Ossoinig. We both studied with Dr.
Our goal in writing this book is to provide a comprehensive Ossoinig at the University ofIowa, and are very grateful to
overview of ultrasound as it applies to the eye and orbit. We him for his instruction and for his major contributions to
emphasize those techniques that have been found to be of the field of ophthalmic echography.
greatest value in our own practices, and we describe and il- This book also would have not been possible without
lustrate the most. common ophthalmic disorders that one the support and vision of Dr. Edward W.D. Norton,
might expect to encounter. Chairman Emeritus of the Bascom Palmer Eye Institute,
The reader will note that the terms echography, ultra- and Dr. Stephen]. Ryan, Chairman of the Doheny Eye In-
sonography, and ultrasound are used interchangeably stitute. By establishing echography departments in their
throughout the text. All three terms are commonly used to institutions, they have recognized the importance of oph-
describe the use of diagnostic ultrasound in medicine. In thalmic ultrasound, and we are very grateful for their con-
the book, our lack of consistent use of this terminology is tinued support and encouragement.
due primarily to our different customary usages of these This book is the result of our combined experience of
terms. more than 30 years in the field of ophthalmic echography.
The first chapter reviews the physical principles of diag- Over those years we have learned that, although proper in-
nostic ultrasound and describes the instrumentation used strumentation and examination techniques are essential,
in ophthalmic echography. Chapters 2 through 6 describe nothing is more important than experience. New findings
echography of the eye. This section is an outgrowth of a and applications for ultrasound in ophthalmology continue
chapter that we co-authored in Stephen Ryan's textbook, to make echography an exciting and challenging field. We
Retina, but we have greatly expanded our description of vit- hope that this book will allow the reader to benefit from
reoretinal disorders, ocular trauma, and intraocular tumors. our experience and that this text will serve as a useful
Chapters 7 through 12 are devoted to orbital echography. reference.
. Many readers may be surprised by our extensive coverage
Sandra ·Frazier Byrne
of this subject, but these chapters reflect the importance
Ronald L. Green, MD
xii
Contents
1 Physics and Instrumentation, 1 5 Intraocular Tumors, 115
History, 1 Detection of Lesions, 115
Physics, 1 Ocular Melanoma, 115
Instrumentation, 8 Other Tumors of the Uvea, Retina, and Retinal
Pigment Epithelium, and Sclera, 142
THE GLOBE, 13 Other Lesions Simulating Melanoma, 159
Introduction, 13 Anterior Segment Tumors, 169
Indications, 13 Retinoblastoma, 180
Other Lesions Associated with Leukokoria, 184
2 Examination Techniques for the Eye, 15
Positioning the Patient, 15 6 Inflammatory Diseases of the Eye, 191
B-scan Examination Techniques, 15 Endophthalmitis, 191
Basic Screening Examination, 22 Noninfectious Uveitis and Vitritis, 194
Special Examination Techniques, 24 Scleritis, 195
Anterior Segment Evaluation: Immersion Inflammatory Conditions of the Choroid, 199
Technique, 37 Miscellaneous Conditions Associated with Inflamma-
Evaluation of the Lens, 40 tion of the Choroid, Retina, and Retinal
Evaluation of the Pupil, 43 Pigment Epithelium, 202
Pediatric Examination, 43
Documentation of Findings, 44 7 Glaucoma, 209
Optic Disc, 209
3 Vitreoretinal Disease, 45 Congenital Glaucoma, 209
Vitreous Body, 45 Angle Closure Glaucoma, 210
Retina, 51 Secondary Glaucoma, 211
Retinal Pigment Epithelium, 66 Normal-Tension Glaucoma, 215
Macula, 67 Complications of Glaucoma Surgery, 216
Choroid,74 Glaucoma-Filtering Implant Devices (Shunts), 218
Ciliary Body, 77
Sclera, 77 8 Ultrasound Biomicroscopy of the Eye, 223
Theoretical Considerations and Development of the
4 Trauma and Postsurgical Findings, 87 Ultrasound Biomicroscope, 22 3
Blunt Trauma, 87 Clinical Use of Ultrasound Biomicroscopy, 225
Penetrating Trauma, 93 Ultrasound Biomicroscopy in Ocular Disease, 229
Surgical Trauma (Complications), 104 Summary and Future Directions, 234
Postsurgical Findings, 108
xiii
xiv CONTENTS
9 Three-Dimensional Ultrasound ofthe Eye, 236 14 Color Doppler Imaging of the Eye
Instrumentation, 236 and Orbit, 367
Intraocular Tumors, 236 Physical Background and Imaging Devices, 367
Vitreoretinal Disease, 242 Clinical Applications of Color Doppler Imaging,
Advantages and Limitations of Ophthalmic 3D 369
Ultrasound, 242 Ophthalmic Examination Technique, 369
Future Directions and the Internet, 243 Vascular Topography of the Normal Eye and
Orbit, 371
10 Axial Eye Length Measurements (A-Scan Retinal, Retinal Vascular, and Other Vascular
Biometry), 244 Diseases of the Eye, 372
Standard Axial Eye Length Dimensions, 244 Intraocular Tumors, 373
Instrumentation, 244 Orbital Disorders, 373
Instrument Settings, 246 Safety Considerations, 374
Examination Procedures for A-Scan Biometry, 249
Troubleshooting, 261 Color Plates, after 378
Minimizing Errors, 268
IOL Calculations, 269 15 Extraocular Muscles, 380
Unanticipated Postoperative Refractive Examination Techniques for Rectus Muscles, 380
Errors, 270 Evaluation of Individual Muscles, 384
Diagnostic Uses of Axial Eye Length Extraocular Muscle Disorders, 396
Measurements, 270
Cleaning and Calibration of Biometry 16 Optic Nerve, 412
Instruments, 270 Retrobulbar Optic Nerve, 412
Retrobulbar Optic Nerve Disorders, 419
THE ORBIT, 273 Optic Disc, 431
Introduction, 273
Indications, 273 17 Orbital Trauma and Periorbital Disease, 439
Trauma, 439
11 Examination Techniques for the Orbit, 275 Periorbital Disease, 451
Positioning the Patient, 27 5
B-Scan Techniques, 275 18 Artifacts, 466
Basic Examination for Lesion Detection, 284 Multiple Signals (Reverberations), 466
Special Examination Techniques for Lesion Shadowing, 466
Differentiation, 289 Enhancement, 467
Perpendicular Sound Beam Incidence, 467
12 Orbital Tumors, 310 Baum's Bumps, 467
Pseudo tumor and Lymphoma (Lymphoproliferative
Diseases), 310
Primary Orbital Tumors, 310 Glossary, 469
Metastatic and Secondary Tumors, 315
Lacrimal System Disorders, 319 Appendices, 471
Cystic Lesions, 334
13 Vascular Lesions, 347

Vascular Neoplasms, 347
Vascular Malformations, 355
Physics
and Instrumentation
This chapter reviews the physical principles of diagnostic mentation and techniques so that echographers could rely
ultrasound and describes the instrumentation used to per- on the results of fellow investigators using similar instru-
form ophthalmic echography. It is important to be aware of mentation and techniques. To this end, he developed the
the variety of available instrumentation and to have an un- first standardized A-scan instrument, the Kretztechnik
derstanding of basic ultrasound physics. A general overview 7200 MA. This machine was carefully designed to allow re-
of ultrasound physics as it applies to ophthalmology is pro- liable differentiation of tissue. 24-28 Later, Ossoinig further
vided. For a more in-depth understanding of this subject, a expanded his diagnostic method by adding the use, of a con-
suggested reading list is provided at the end of this chapter. tact B-scan instrument and then devised meticulous exam-
ination techniques for use with the two instruments. This
concept eventually evolved into what is known today as
HISTORY
Standardized Echography,31,32 a method that has proved to
Ultrasound was first used in ophthalmology in 1956. by two be highly accurate for the detection and differentiation of
American ophthalmologists, Mundt and HughesY Using both intraocular and orbital disorders.
time amplitude-mode (A-scan) to evaluate an intraocular In the early 1990s, Pavlin and associates popularized the
tumor, they showed that ultrasound had potential as a di- use of high frequency ultrasound instrumentation for eval-
agnostic tool in ophthalmology. Soon afterward, Oksala and uation of the anterior segment. 34- 37 This new instrumenta-
associates, in Finland, greatly expanded the use of A-scan tion greatly enhanced the resolution of anterior segment
for the diagnosis of intraocular disorders l8 and published structures and lesions and added a better understanding of
data regarding the sound velocities of various components the pathophysiology of anterior segment disorders.
of the eye. 19 Doppler ultrasound has been used in ophthalmology
In 1958, Baum and Greenwood l co-developed the first since the early 1970s.7,1l,31 In the late 1980s, color Doppler
two-dimensional (immersion) brightness-mode (B-scan) ul- imaging (CD!) began to be used for the assessment of ocu-
trasound instrument for ophthalmology. In the early 1960s, lar and orbital disorders. 9,1O,14,15
Jansson and associates,11,12 in Sweden, used ultrasound to In recent years, the digitization of ultrasound has greatly
measure the distances between structures in the eye. enhanced its potential and clinical applications. This com-
Further pioneering work with immersion B-scan was puterization has made possible the development of three-
carried out by Purnell,38 followed later by Coleman et a1. 4 dimensional ultrasound imaging in ophthalmology.40
In the early 1970s, Coleman and associates 5-7 developed the
first commercially available immersion B-scan instrument.
PHYSICS
In 1977, Coleman and investigators first described a
method of ultrasonic tissue characterization using spectrum Ultrasound is an acoustic wave that consists of an oscilla-
analysis. 8,16 tion of particles within a medium. By definition, ultrasound
Shortly thereafter, Bronson2 introduced a contact B-scan waves have frequencies greater than 20 KHz (i.e., 20,000
machine for ophthalmology. This portable instrument al- oscillations/sec), rendering them inaudible to humans. In
lowed placement of the probe on the closed eyelids. With the contrast, frequencies of less than 20 KHz are audible to
development of this instrument, ultrasound began to be a persons with normal hearing. Frequencies used in diagnos-
useful component of the everyday practice of ophthalmology. tic ophthalmic ultrasound are in the range of 8 to 10 MHz
In the 1960s, Ossoinig20- 23 an Austrian ophthalmologist, (1 megahertz = 1,000,000 cycles/sec). These very high
first emphasized the importance of standardizing instru- frequencies produce short wavelengths (less than 0.2 mm),
1
2 PHYSICS AND INSTRUMENTATION
A Low ...JC\~v~,...6_lr-V......f-(\-+-v---+(\.........trV-"-3I."'" Distance
B High -,-Q"""v-lQ"",,,I+-v~Q_1~V+O~Vr-"--------...- Distance
Figure 1-1 Low-frequency vs. high-frequency ultrasound. Lower frequency (A) produces
longer wavelength than higher frequency (B). The wavelength (bracket) corresponds to one os-
cillation of the sound wave.
Echoes
TABL.E 1-1
Sound Wave Velocities Echoes are produced by acoustic interfaces created at the
junction of two media that have different acoustic imped-
Medium Velocity (m/sec)
ances. The acoustic impedance of a medium is determined
Water 1,480
Aqueous/vitreous 1,532 by its sound velocity and density (acoustic impedance =
Soft tissue 1,550 sound velocity X density). The greater the difference in the
Crystalline lens 1,641 acoustic impedance of the two media that produce the in-
Bone 3,500 terface, the stronger the reflection of the ultrasound wave
(i.e., echo) (Figure 1-2). For example, the anterior lens sur-
face produces a stronger echo when bordered by aqueous
media than when it is bordered by blood (i.e., hyphema) be-
cause the difference in the impedance between lens and
which allow resolution of minute ocular and orbital struc- aqueous is greater than the difference in impedance be-
tures. Conversely, abdominal and obstetric ultrasound ex- tween lens and hemorrhage (Figure 1-3).
aminations usually require frequencies in the range of 1 to The returning echoes are affected by many factors, in-
5 MHz. The wavelengths produced by these lower fre- cluding absorption and refraction, the angle of sound inci-
quencies are longer, allowing much deeper penetration of dence, and the size, shape, and smoothness of acoustic in-
tissue (Figure 1-1). Although the longer wavelengths result terfaces. An understanding of these principles is necessary
in decreased resolution, this lower resolution is not critical for the performance of accurate ultrasound examinations.
because the abdominal and pelvic structures examined are
much larger than those of the eye and orbit.
Angle of Sound Incidence
Ultrasound is propagated as a longitudinal wave that
consists of alternating compressions and rarefactions of The acoustic wave directed by an ultrasound transducer is
molecules as the wave passes through a medium. The ve- referred to as the sound beam. The angle at which the
locity of the ultrasound wave is primarily dependent on the sound beam strikes an interface is an important factor in the
medium through which it passes. Water, for example, is strength of the returning echo. It is important to note that
very compressible; sound waves are transmitted through the angle of incidence is equal to the angle of reflection.
water at a slower velocity than through more solid media, Therefore, when the beam strikes an interface in a perpen-
which are less compressible. As a result, sound travels faster dicular manner, the echo is reflected back toward the direc-
through a solid lens than it does through liquid vitreous tion from which it originated (e.g., the probe). If, however,
(Table 1-1). the incident sound beam strikes an interface at an oblique
The behavior of longitudinal waves produced by ultra- angle, some of the reflected energy is diverted away from
sonic energy is similar to that oflight rays in that these lon- the direction of its origin, resulting in a weaker echo than
gitudinal waves can be refracted and reflected predictably. It when the sound incidence is perpendicular (Figure 1-4)./
is this property that makes ultrasound useful for diagnostic
purposes. As a longitudinal wave travels through a tissue,
Acoustic Interfaces
part of the wave may be reflected back toward the source
of the emitted energy (i.e., the transducer or probe); this The size, shape, and smoothness of an interface also play
reflected wave is referred to as an echo. important roles in the character of the returning echo.
Chapter 1 PHYSICS AND INSTRUMENTATION 3
Medium 2
. " • ," 0'0',': ••••••
• •.•• :. ',",' " • '0' .' ••
',' ','
...
Medium 1 . .. '.' .....
. '., .
'
.' ..
. .'
.. " . . . '0:,' .
. ' .. • • '0'
A :. '. ·0•.. ' ..

:.' ... .
. .... ..:: .. ,' .. .
..... " '. '. :. ..., .
"," ........... 0', •• '0' .' ••
. ..
', .... ,'. . ...
. . .. "
. .. '.' .
',,',', • I. I • " •
',' '0'
Medium 3
Medium 1
Figure 1-2 Acoustic impedance. The strength of the echo produced at the interface between
the two media depicted is dependent on the acoustic impedance of the two media. In these ex-
amples, acoustic impedance is lower in A, resulting in less energy returning to the probe.
A B
--> -->
Figure 1-3 Acoustic impedance. The echo produced from the interface between aqueous and
the anterior lens capsule (A) is stronger (higher acoustic impedance) than that produced by hem-
orrhage and the anterior lens capsule (B).
A
B
-.
c
______-\ I D
/\
Figure 1-4 Perpendicular vs. oblique incidence. Oblique sound Figure 1-5 Different types of acoustic interfaces. A, When in-
incidence results in a weaker echo than perpendicular sound inci- terface is smooth and flat, most of the reflected sound returns to
dence because less energy is returned to the transducer. Note that the probe. B, At smooth, concave interface, a portion of the re-
the angle of the reflected wave always equals that of the incident flected sound is diverted away from the probe. C, When interface
wave. is coarse, a large portion of the reflected sound is diverted away-
from the probe (scattering). D, When interface is small, most of
the echo is diverted away from the source (scattering).
Assuming that sound beam incidence is perpendicular, a ing is produced by very small interfaces (e.g., clumps of
smooth, straight interface (e.g., retinal surface) reflects cells) (Figure 1-5, D). Consequently, these types of inter-
nearly all of an echo wave back to its source (e.g., the faces return only a small amount of the echo back in the di-
probe); this is referred to as specular or mirror-like reflec- rection of the transducer. This means that the echoes dis-
tion (Figure 1-5, A). If, on the other hand, the interface is played from small or coarse interfaces are less dependent
smooth but convex (e.g., a collar button-shaped melanoma), on the direction of the incident sound wave than are those
some of the echo will be reflected away from its origin, re- displayed from larger, smooth interfaces.
sulting in a weaker echo (Figure 1-5, B).
If an interface is not smooth, but has an irregular or
Absorption
coarse surface (e.g., ciliary body), part of the echo will be
scattered (Figure 1-5, C). As a result, the echo wave re- Ultrasound energy is gradually absorbed and converted to
turning to its origin will be weakened, even if sound beam heat as it passes through a medium, although the amount of
incidence is perpendicular. Even more pronounced scatter- heat generated by diagnostic ultrasound is extremely low
beam in such a way that the surfaces of the nerve or of an

extradcular muscle may be struck in a relatively perpendic-
ular manner. Also, it is refraction that allows an acoustic lens
Incident wave to focus a sound beam, as is the case with B-scan probes.
Pulse-Echo System
Clinical echography depends on technology that emits an
ultrasound wave and then detects and processes the return-
ing echoes. This technique, known as pulse-echo, requires
the production of multiple short pulses of ultrasound en-
Reflected wave ergy with a brief interval between pulses; the intervaL allows
returning echoes to be detected, processed, and displayed.
Medium 1 Medium 2 ProbelTransducer

High velocity Low velocity
The basis of the pulse-echo system is the piezoelectric ele-
Figure 1-6 Refraction of the sound wave. With oblique inci- ment, typically a quartz or ceramic crystal, which is the key
dence, the incident wave and reflected wave have the same angle.
The angle of the transmitted wave, however, varies according to component of the ultrasound transducer. The piezoelectric
the sound velocity of the second media compared with the first crystal, located near the face of the probe, undergoes a me-
media. In this example, the angle of the transmitted wave de- chanical vibration when stimulated by electrical energy (i.e.,
creases because the sound velocity of medium 1 is higher than that voltage pulse) from the instrument. This vibration causes a
of medium 2. longitudinal ultrasound wave (i.e., the sound beam) to be
propagated through the medium (e.g., ocular arrd orbital
tissues). A pause of several microseconds then occurs, which
and has no harmful effects on tissues. 13 Higher frequency allows the transducer time to receive returning echoes. Re-
sound waves are absorbed to a greater degree than are turning energy creates another mechanical vibration as it
lower frequency sound waves, which is why a wave of strikes the crystal. The vibration, in turn, produces an elec-
higher frequency cannot penetrate as deeply into a tissue trical signal that is transmitted to the receiver and the dis-
as can a wave of lower frequency. Absorption is also related play screen. This process of generating a sound wave, al-
directly to sound velocity, as well as to the thickness of the ternating with receiving an echo, is repeated a thousand or
tissue through which it passes. Consequently, higher sound more times per second to produce a "real-time" display.
velocities and greater tissue thickness rysult in greater ab- Another important component of the ultrasound probe
sorption of the sound wave. /. is the damping material that is attached to the back of the
i
crystal. This material, consisting of metal powder mixed
with plastic or epoxy, serves to limit the vibrations of the
Refraction
crystal that produce the pulses of ultrasonic energy, thus
Another important factor that affects the appearance of shortening the pulse (Figure 1-7). This factor, in addition
echoes is refraction. As with light rays, refraction can be to the frequency, relates directly to the axial resolution of an
undesirable, producing artifacts, or it may be beneficial, ultrasound system. Axial resolution is the minimum dis-
contributing to the display of desired interfaces. Refraction tance between two interfaces (echo sources) along the di-
occurs when a sound beam is directed obliquely to an in- rection of the sound beam that can be displayed. The
terface that demarcates two media of different sound ve- shorter the pulse, the better the axial resolution.
locities. Conversely, no refraction occurs when a sound The sound beam is made up of two zones: the near field
beam is directed perpendicular to an interface or when the and the far field. The near field is the portion of the sound
velocity of the two media is the same. beam located closest to the probe face. In the near field, the
~en sound beam incidence is oblique and travels from sound beam diameter generally decreases slightly with in-
a medium of lower sound velocity into another medium creasing distance from the transducer. The far field is the
with higher sound velocity, the transmitted beam is re- portion of the sound beam that is located beyond the near
fracted away from the perpendicular. Conversely, if the field. In the far field, the sound beam diameter generally
sound beam travels from a medium of higher velocity into increases with increasing distance from the transducer. Res-
a medium of lower sound velocity, the transmitted beam is olution of echoes is greatest when the echo source.is located
refracted toward the perpendicular (Figure 1-6). within the near field. The length of the near field depends
Refraction can be useful in certain situations, such as on both the diameter and the frequency of the transducer
when examining the optic nerve and the extraocular mus- crystal. Transducers with a larger diameter and/or higher
cles. In these circumstances, refraction can bend the sound frequency will have a longer near field.
. Long pulse
----....
A -.koltage PUI~
.t
•
Piezo-Electric _ _ _ _ _ _--'
•
/\'--_ _ _ _ __
crystal
Short pulse
~
B ROltage PNu",ls",e"""rv--+
~~
Damping material t • •
Piezo-Electric /\ /\
crystal - - - - ' '-_ _ _ _ _----J, '--.- - -
Figure 1-7 Damping material within probe shortens the emitted pulse and improves axial res-
olution. A, Probe without damping material emits long pulses. The two spherical objects ate
not resolved individually; thus, only one echo is produced. B, Probe with damping material emits
shorter pulses. The two spherical objects are resolved individually; hence, two echoes are pro-
duced (improved axial resolution).
-- - - -..... - - - - - - - - - - - - - - -
Parallel beam
A
•
•
-----_.. - - - - - - -• - - - - - - -
Focused beam
Figure 1-8 Parallel vs. focused sound beam. A focused sound beam improves lateral resolution.
A, WIde, parallel sound beam does not permit resolution of the, three spherical objects as sepa-
rate echoes. B, Narrow, focused sound beam allows resolution of the three spherical objects as
separate echoes.
The shape of the crystal is an important factor in deter- tance corresponds to the point where the sound beam is
mining the character of the sound beam. A planar crystal most narrow. The resolution of echo sources is greatest
results in a relatively parallel sound beam, whereas a con- within the focal zone (an area just anterior and posterior to
cave crystal or the addition of an acoustic lens can focus the the focal point). Focusing increases both axial and lateral
sound beam. The focal distance of a focused lens system resolution of an ultrasound instrument. Lateral resolution
can vary from one instrument to another. The focal dis- is the minimum separation between two echo sources
Display
Receiver
Figure 1-9 Schematic diagram of an ultrasound system.
aligned perpendicular to the direction of a scanning sound

beam (Figure 1-8).
E 50 --f
.s
Signal Processing
An ultrasound system must be able to create a pulse of ul-
trasound energy propagated from its transducer. The unit
....... Linear
also must be able to receive the returning echo and display
it as a signal on a screen. Therefore, an instrument must - S- Shaped
have four components: a pulser, a transducer, a receiver, and - - Logarithmic
a display screen (Figure 1-9).

The electrical signal produced by the returning echoes is 50
initially received by the ultrasound instrument as a very Echo amplitude (db)
weak radio frequency signal. This signal then undergoes
Figure 1-10 Amplification curves for linear, S-shaped, and log-
complex processing that can include amplification, com- arithmic amplifiers.
pensation, compression, demodulation, and rejection.
Although all of these parameters are important, amplifi-
cation plays a particularly prominent role in the methods de- in some systems to combine the wide range of the logarith-
scribed in this textbook. In ophthalmic ultrasound instru- mic amplifier and the great sensitivity of the linear amplifier
ments, one of three different types of amplification is (Figure 1-10). This special type of amplification enhances tis-
generally used: linear, logarithmic, or S-shaped. 28 The type of sue differentiation and has proved to have unique diagnostic
amplification used affects the ability of the ultrasound system capabilities in ophthalmology.29-32
to display differences in the strengths of various echo signals.
This is indicated by the range of echo intensities that can be Gain
displayed by the system (i.e., the dynamic range). The dy- All ultrasound instruments allow the examiner to adjust the
namic range is described in units of decibels, a measure of ul- amplification of the echo signals (overall gain control) dis-
trasound intensity. A small dynamic range, characteristic of played on the instrument screen. This adjustment, which is
linear amplifiers, can display minor differences in echo similar to turning the volume up or down on a radio, is re-
strength between echo sources, but the range of echo inten- ferred to as the gain or sensitivity setting of the instrument.
sities that can be displayed is very limited. In contrast, a large Gain is measured in decibels (db), which represent relative
dynamic range, characteristic of logarithmic amplifiers, can units of ultrasound intensity. It is important to realize that
display a wide range of echo intensities, but it cannot show adjusting the gain does not change the amount of energy
slight differences between echo signals. These two amplifi- emitted from the transducer; it changes only the intensity
cation curves are used in various ultrasound systems, de- of the returning echo that is displayed on the screen. The
pending on the specific requirements of the instrument. The higher the gain level, the greater the ability of the instru-
S-shaped amplification curve, developed by Ossoinig, is used ment to display weaker echoes (e.g., vitreous opacities).
Conversely, as the gain is lowered,· only the stronger echoes among the different types of ultrasound instruments. A-
will continue to be displayed (e.g., retina and sclera). Because and B-scan echography are the types of ultrasound display
the strongest echoes are located along the central axis of the systems most commonly used in ophthalmology, although
returning sound wave, lowering the gain effectively (not actu- Doppler ultrasound is sometimes also used.
ally) narrows the sound beam, and thus improves both axial
and lateral resolution. Also, lowering the gain effectively de-
A-Scan
creases the depth of sound beam penetration, because weaker
echoes originating from deeper layers of tissue are not suffi- A-scan echography is a one-dimensional acoustic display in
ciently amplified to be displayed (see Figures 2-13 and 5-16). which echoes are represented as vertical spikes from a base-
Many instruments incorporate time gain compensation line. Spacing of the spikes is dependent on the time re-
(TGC) to enhance weak echoes displayed from deeper tis- quired for the sound beam to reach a given interface and
sue layers. This process allows greater amplification of for its echo to return to the probe. The time between any
these more distant, weaker echoes than of the stronger two echo spikes can then be converted into distance by
echoes originating close to the transducer. This control has knowing the sound velocity of the medium from which the
the effect of eq~alizing echo signals from similar tissues lo- echoes are received. This is expressed by the formula, dis-
cated at varying distances from the transducer. Although tance = velocity X time (D = V X T; see Appendix A). The
most current instruments have an automatic, internal TGC height of the displayed spikes indicates the strength (i.e.,
control, some instruments offer a manual TGC mode. amplitude) of the echoes (Figure 1-11).
There are various types of A-scan displays used in oph-
thalmology. These include the A-scan that is used primarily
INSTRUMENTATION
for axial eye length measurements, the vector A-scan that can
Specific details regarding signal processing, as well as the occur simultaneously on a B-scan echogram, and the stan-
manner in which the echoes are finally displayed, vary dardized A-scan. The characteristics of these various A-scan
Figure 1-11 Normal standardized A-scan echograms. A, Probe placed on cornea with sound
beam directed through lens. I, Initial spike corresponding to probe tip (corneal spike hidden by
initial spike); A, anterior lens capsule; P, posterior lens capsule; M, multiple signal; V, vitreous cav-
ity; R, retina; S, sclera; 0, orbital soft tissue: Steeply rising spikes from lens and retina indicate
sound beam perpendicularity. Arrow, Thin artifact spike, which indicate~ perpendicularity.
B, Sound beam bypassing lens. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound,
in Ryan S] [ed]: Retina. ed 3, St Louis, Mosby, 2001, p 226.)
displays differ somewhat. The A-scan used for most axial eye formed for each probe/instrument combination with a Tis-
length measurements employs linear amplification, a focused sue Mode141 ,42 (Figure 1-12). This determines the standard
transducer, and a frequency of between 10 and 15 MHz. The decibel setting, referred to as Tissue Sensitivity, which is the
vector A-scan (see Figures 5-11 and 10-26) incorporates the setting used for both detection and differentiation oflesions.
same characteristics as the B-scan from which it is derived.
These characteristics usually include logarithmic amplifica-
B-Scan
tion, a focused transducer, and a frequency of 10 MHz.
The standardized A-scan, pioneered by Ossoinig, was de- B-scan echography produces a two-dimensional acoustic sec-
veloped as a diagnostic tool for ophthalmology.31,32 Stan- tion (similar to a photograph) by using both the vertical and
dardized A-scan instruments incorporate the previously de- the horizontal dimensions of the screen to indicate configu-
scribed S-shaped amplification curve, as well as other unique ration and location. A section of tissue is examined by an os-
characteristics designed to enhance tissue differentiation. cillating transducer that emits a sound beam that "slices"
The standardized A-scan, according to Ossoinig's criteria, through a tissue, much like the slice of a knife. Most oph~
requires the use of a nonfocused 8-MHz transducer that thalmic B-scan instruments use logarithmic amplification and
emits a parallel sound beam. External standardization is per- require a focused, narrow sound beam to display a two-
A B
Figure 1-12 Calibration of standardized A-scan probe and instrument to obtain Tissue Sensi-
tivity. A, With probe on Tissue Model, decibel dial (B) is adjusted until correct echogram is dis-
played (C). The spike chain (I) creates echo-free triangles that are of equal size above and be-
low. Arrow, Bottom of Tissue Model; spikes to right are artifacts. (From Green RL, Byrne SF:
Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 227.)
Figure 1-13 Oscillating transducer within B-scan probe creates two-dimensional acoustic sec-
tion through normal eye. I, Initial line corresponding to transducer; P, posterior lens capsule;
V, vitreous cavity; ON, optic nerve; a7"rows, orbital soft tissue. (From Green RL, Byrne SF: Di-
agnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 227.)
dimensional sector image. In addition, the majority of oph- the Doppler shift (i.e., Doppler effect),13 which is defined as
thalmic B-scan transducers operate at a frequency in the a change in the frequency of the sound wave caused by
range of 10 MHz. An echo is represented as a dot on the movement of a reflector (i.e., echo source). If reflector mo-
screen, and the strength of the echo is depicted by the bright- tion is toward the transducer, the frequency of the return-
ness of the dot. The coalescence of multiple dots on the ing echo is greater than that of the emitted frequency. Con-
screen forms a two-dimensional representation of the exam- versely, if reflector motion is away from the transducer, the
ined tissue section (Figure 1-13). Several factors in addition to frequency of the returning echo is lower than that of the
signal processing affect the B-scan image. These include the emitted sound beam. The greater the velocity of the reflec-
angle of the scanning section, the speed of the transducer os- tor (e.g., the faster the blood flow), the greater the differ-
cillation, and the gray scale. ence between the reflected and emitted frequencies. In or-
The area of the eye and orbit that can be imaged on the bital echography, Doppler ultrasound is helpful for
echo gram at anyone time is related directly to the sector an- assessing the direction of flow within orbital blood vessels
gle of the moving transducer. This angle can vary anywhere and for the detection of blood flow within orbital lesions.
from 45 to 60 degrees, depending on the instrument used. For more details, see Chapter 14.
Another important factor is the rate of transducer oscillation. Recent advances have incorporated the use of color
To obtain a real-time image, the B-scan probe must produce Doppler instruments with conventional B-scan imaging.
multiple "slices" through a tissue each second (frame rate). This allows for the two-dimensional presentation of ocular
This frame rate usually varies from 10 to 60 frames/sec. Fi- and orbital images, with simultaneous Doppler evaluation
nally, gray scale is the continuous range of brightness be- indicated by color changes in the echogram. This color-flow
tween white and black. Instruments differ in their ability to Doppler technique allows the demonstration of blood flow
display levels of gray scale, but the greater the number of through specific vessels within the eye and orbit. Frequency
gray levels an instrument can display, the greater its ability to shifts that occur from blood flow toward the probe are gen-
quantitate differences in echo intensity (see Chapter 2). erally coded in red, whereas blood flow away from the probe
Three-dimensional B-scan imaging has also been devel- is colored blue. Spectrum analysis can be used to quantitate
oped. 40 This involves obtaining multiple sections using a the velocity of the blood flow. CDI appears to be useful for
mechanically rotated probe and software that reconstructs the study of vascular disorders of the eye and orbit, as well as
two-dimensional images into a three-dimensional format. for the study of blood flow characteristics of tumors. IS
The instrumentation and clinical application of this tech- Intravenous contrast ~gents are now being used in an at-
nology are described in Chapter 9. In addition to the con- tempt to enhance Doppler signals from blood flow. 3A more
ventionallQ MHz B-scan, newer high frequency B-scan in- detailed discussion of color Doppler and its clinical appli-
strumentation has been developed. The high frequencies cations in ophthalmology is provided in Chapter 14.
used range from 20 MHz (see p 39) to greater than 50
MHz (see Chapter 8).
Standardized Echography
The combined use of standardized A-scan and contact
Doppler
B-scan (along with Doppler for the orbit) is referred to as
A Doppler instrument emits a beam of pulsed or continu- Standardized Echography.31,32 B-scan echography, with its
ous ultrasound that is used to detect blood flow by means of two-dimensional display, yields information primarily about
the topographic nature of intraocular and orbital structures 24. Ossoillig KC: Basics of clinical echo-ophthalmography. IV: Clinical stan-
and lesions. A-scan* echography provides a variety of in- dardization of equipment and techniques, in Bock], Ossoinig KC (eds):
Ultrasonographia Medica. Vienna, Wiener Med Akadetnie, 1971, P 83.
formation regarding a lesion's character, as well as its size. 25. Ossoinig KC: Basics of echo graphic tissue differentiation. II: Acoustic
The optimal echo graphic examination results from the ap- behavior of biological structures, in Bock], Ossoinig KC (eds): Ul-
propriate combination of both A- scan and B-scan. trasonographia Medica. Vienna, Wiener Med Akadetnie, 1971, P 419.
26. Ossoinig KC: Basics of echo graphic tissue differentiation. 1. Experi-
mental and clinical examinations of the influence of system parame-
REFERENCES ters on the diagnostic value of echo grams, in Bock], Ossoinig KC
1. Baum G, Greenwood I: The application of ultrasonic locating tech- (eds): UltrasonographiaMedica. Vienna, Wiener MedAkadetnie, 1972,
niques to ophthalmology. II. Ultrasonic slit lamp in the ultrasonic vi- p 155.
sualization of soft tissues. Arch OphthalmoI1958;60:263. 27. Ossoinig KC: The first standardized system for echo-ophthalmolog-
2. Bronson NR: Development of a simple B-scan ultrasonoscope. Trans raphy, in Massin M, Poujol] (eds): Diagnostica Ultrasonica in Ophthal-
Am Ophthalmol Soc 1972;70:365. mologia. Paris, Centre National d'Ophthalmologie des Quinze-Vmgts,
3. Cennamo G, Rosa N, Vallone GF, et al: First experience with a new 1973,p131. .
echographic contrast agent. Br] OphthalmoI1994;78:823. 28. Ossoinig KC: Quantitative echography-the basis of tissue differen-
4. Coleman D], Konig WF, Katz L: A hand-operated, ultrasound scan tiation.] Clin Ultrasound 1974;2:33.
system for ophthalmic evaluation. Am] OphthalmoI1969;68:256. 29. Ossoinig KC, Patel]H: A-scan instrumentation for acoustic tissue dif-
5. Coleman D]: Reliability of ocular and orbital diagnosis with B-scan ferentiation. II: Clinical significance of various technical parameters of
ultrasound. 1. Ocular diagnosis. Am] OphthalmoI1972; 73: 50 1. the 7200 MA unit of Kretztechnik, in White D, Brown RE (eds): Ul-
6. Coleman D]: Reliability of ocular tumor diagnosis with ultrasound. trasound in Medicine. New York, Plenum Press, 1977, p 3B:1949.
Trans Am Acad Ophthalmol OtolaryngoI1973;77:677. 30. Ossoinig KC, Patel]H: A-scan instrumentation for acoustic tissue dif-
7. Coleman D], Lizzi FL, Jack RL: Ultrasonography of the Eye and Orbit. ferentiation. III: Testing and calibration of the 7200 MA unit of Kret-
Philadelphia, Lea & Febiger, 1977, p 3. ztechnik, in White D, Brown RE (eds): Ultrasound in Medicine. New
8. Coleman D], Lizzi FL: Computer-processed acoustic spectral analy- York, Plenum Press, 1977, p 3B:1955.
sis. Trans Am Acad Ophthalmol OtolaryngoI1977;83:725. 31. O~so~g KC: Standardized echography: Basic principles, clinical ap-
9. Erickson S], Hendrix LE, Massaro BM, et al: Color Doppler flow plicanons, and results. Int Ophthalmol Clin 1979;19(4):127.
imaging of the normal and abnormal orbit. Radiology 1989;173:511. 32 .. Ossoinig KC: Standardized Ophthalmic Echography of the Eye, Orhit and
10. Flaharty PM, Lieb WE, Sergott RC, et al: Color Doppler imaging: A Periorbital Region. A comprehensive slide set and study guide. ed 3, Iowa
new noninvasive technique to diagnose and monitor carotid cavernous City, Goodfellow, 1985, p 1.
sinus fistulas. Arch OphthalmoI1991;109:522. 33. Patel JR, Ossoinig KC: A-scan instrumentation for acoustic tissue dif-
11. ] ansson F, Sundmark E: Determination of the velocity of ultrasound in ferentiation. I: Signal processing in the 7200 MA unit ofKretztechnik,
ocular tissues at different temperatures. Acta OphthalmoI1961;39:899. in White D, Brown RE (eds): Ultrasound in Medicine. New York,
12. ] ansson F, Kock E: Determination of the velocity of ultrasound in the Plenum Press, 1977, p 3B:1949.
human lens and vitreous. Acta OphthalmoI1962;40:420. 34. Pavlin C], Sherar MD, Foster FS: Subsurface ultrasound tnicroscopic
13. Kremkau FW: Diagnostic Ultrasoun4. Principles and Instruments. ed 5, imaging of the intact eye. Ophthalmology 1990;97:244.
Philadelphia, WE Saunders Co, 1998. 35. Pavlin C], Harasiewicz KA, Sherar MD, et al: Clinical use of ultra-
14. Lieb. WE, Flaharty PM, Sergott RC, et al: Color Doppler imaging sound biotnicroscopy. Ophthalmology 1991;98:287.
proVIdes accurate assessment of orbital blood flow in occlusive carotid 36. Pav~in C], Foster FS: Ultrasound Biomicroscopy of the Eye. New York,
artery disease. Ophthalmology 1991;98:548. Sprmger-Verlag, 1995.
15. Lieb WE: Color Doppler imaging of the eye and orbit. Radiol Clin 37. Pavlin C], Foster FS: Ultrasound Biotnicroscopy: high-frequencyul-
NorthAm 1998;36:1059. trasound imaging of the eye and tnicroscopic resolution. Radiol Clin
16. Lizzi FL, Coleman D]: Computer-processed acoustic speCtral analysis NorthAm 1998;36:1047.
in ophthalmology, in White DN (ed): RecentAdvances in Ultrasound in 38. Purnell EW: Ultrasound in ophthalmological diagnosis, in Grossman
Biomedicine. vol 1. Forest Grove, Research Studies Press, 1977, P 117. CC (ed): Diagnostic Ultrasound. New York, Plenum Press, 1965, p 95.
17. Mundt GH ]r, Hughes WF ]r: Ultrasonics in ocular diagnosis. Am] 39. Purnell EW: Intensity modulated (B-scan) ultrasonography, in Gold-
OphthalmoI1956;41:488. berg RE, Sarin LK (eds): Ultrasonics in Ophthalmology. Diagnostic and
18. Oksala A.; The clinical value of time-amplitude ultrasonography. Am Therapeutic Applications. Philadelphia, WE Saunders Co, 1967, p 102.
] OphthalmoI1964;57:453. 40. Shammas HJ, Durme S, Fisher YL: Three-Dimensional Ultrasound To-
19. Oksala A, Lehtinen A: Diagnostics of detachment of the retina by mography of the Eye. Eden Mills, Ontario, Canada, 1999.
means of ultrasound. Acta Ophthalmol19 57;35 :461. 41. Till P: Solid tissue model for the standardization of the echo-
20. Ossoinig KC, Seher K: Echographische Untersuchungen feingewe- ophthalmograph 7200 MA (Kretztechnik). Doc Ophthalmol197 6;41 :205.
blicher Strukturen zur Klarung des Echo-Ursprunges in Tumoren. 1. 42. Till P, Ossoinig KC: First experience with a new solid tissue model
Theoretische Uberlegungen. Albrecht von Graefes Arch Klin Exp Oph- for the standardization of A- and B-scan instruments used in tissue di-
thalmol1966; 171: 17. agnosis, in White D, Brown RE (eds): Ultrasound in Medicine. New
21. Ossoinig K, Steiner H: Zum Problem der Normung in der ultra- York, Plenum Press, 1977, p 3B:2167.
schalldiagnostik des auges. Albrecht von Graefes Arch Clin Exp Oph-
thalmoI1966;169:241. Suggested Reading
22. Ossoinig K, Seher K: Einige Erkenntnisse tiber das histologische Sub-
strat der Echogramme, in Oksala A, Gernet H (eds): Ultrasonics in Bioeffects considerations for the safety ~f diagnostic ultrasound. American
Ophthalmology. Basel, S. Karger, 1967, p 103. Institute of Ultrasound in Medicine. Bioeffects Comtnittee.] Ultra-
23. O~soinig K~ Seher K, Kaufmann F: Echographische Untersuchungen sound Med 1988;7(suppl.):S4.
femgeweblicher strukturen. II. tiber ein bei der Ultraschallunter- Bushong S, Archer B: Diagnostic Ultrasound Physics, Biology, and Instrumen-
suchung von Citratblut beobachtetes Phanomen. Albrecht von Graefes tation. St Louis, Mosby, 1991. .
Arch Klin Exp OphthalmoI1967;173:327. Hedrick WR, Hykes DL, Starchman D: Ultrasound Physics and Instrumen-
tation. ed 3, St Louis, Mosby, 1994. '
McDicken WN: Diagnostic Ultrasonics. Principles and Use ofInstrument. ed
*The term "A-scan" indicates standardized A-scan throughout the book. 3, Edinburgh, Churchill Livingstone, 1990.
except in Chapter 10. Zagzebski AA: Essentials of Ultrasound Physics. St Louis, Mosby, 1996.
THE GLOBE
INTRODUCTION
Echography has become the most important method for on children, often without sedation. Recent advances in
evaluating an eye with opaque ocular media. It provides an technology have vastly improved the ability of ultrasound
instantaneous "glimpse" into the eye and, in many in- to accurately display the small structures and lesions within
stances, can yield information not obtainable by any other the eye. Also, the wealth of experience and data that has
method. Echography has also proven to be indispensable been accumulated throughout the years provides the
in the differentiation and measurement of intraocular tu- echographer with a large reference base that allows accu-
mors, even in the presence of clear ocular media. It is a rate and reliable diagnoses. It is important to emphasize,
painless, noninvasive method that can be performed easily however, that in many cases accurate interpretation of
in the clinic, at the patient's bedside, or in the operating echo graphic findings is possible only when they are corre-
room. Furthermore, ultrasound can be readily performed lated with the history and clinical findings.
INDICATIONS
The indications for echographic examination of the eye the anterior or posterior segments cannot be visualized due
have become more numerous with the accumulation of ex- to opaque ocular media and is indicated also in the pres-
perience and the improvement of instrumentation and ex- ence of clear ocular media for the evaluation of ocular tu-
amination techniques. Ultrasound is indicated whenever mors and for biometry (Table I-I).
13
14 THE GLOBE
TABLE I-I
Indications for Intraocular Examination
Opaque Ocular Media
Anterior segment
Corneal opacification
Hyphema or hypopyon
Miosis
Cataract
Pupillary or retrolenticular membrane
Posterior segment
Vitreous hemorrhage or inflammation
Clear Ocular Media
Anterior segment
Iris lesions
Ciliary body lesions
Posterior segment
Tumors
Choroidal detachment: serous versus hemorrhagic
Retinal detachment: rhegmatogenous versus exudative
Optic disc abnormalities
Unexplained retinitis and/or choroditis
Intraocular Foreign Bodies
Detection
Localization
Examination Techniques
for the Globe
Specific examination techniques have been carefully de- lationship to one another and to ocular structures. The
signed to allow thorough evaluation of the anterior and two-dimensional B-scan is the primary modality for deter-
posterior segments of the globe. I - Io The type of examina- mining lesion topography (i.e., location and configuration).
tion performed is determined by the indication for exami- By obtaining echograms from a variety of probe positions
nation. The contact method, in which the probe is placed in a systematic fashion, the echographer may construct a
directly on the globe, is used to evaluate the posterior seg- mental three-dimensional picture of a lesion's topography.
ment. In those cases in which the anterior segment also
must be evaluated, an easy immersion technique has been
Characteristics of B-Scan Probes
developed that can be performed with the same instruments
used for the contact examination. In addition, new higher All B-scan probes contain a transducer that oscillates
resolution B-scan technology has been developed for the rapidly back and forth near the face (i.e., tip) of the probe.
anterior segment examination. One of these instruments, Each probe has a marker, usually a dot, line or logo, that
the ultrasound biomicroscope (UBM),9,10 is discussed in indicates the side of the probe t:hat is represented on the
Chapter 8. This chapter will address A- and B-scan exami- upper portion of the B-scan screen display. The oscillating
nation techniques for the detection and differentiation of movement of the transducer within the probe always oc-
intraocular lesions. curs away from and toward the marker (Figure 2-2).
The probe face is always represented by the initial line
that appears on the left side of the echogram. The right side
POSITIONING THE PATIENT
of the echogram indicates the region of the eye located
A- and B-scan instruments may be placed on one large or opposite the probe face. The upper part of the echogram
two separate, small carts. The patient is seated in a reclin- corresponds to the portion of the globe where the probe
able examination chair of adjustable height. While most ex- marker is directed. The center of the screen corresponds
aminations are performed with the patient reclined, it is oc- to the central portion of the probe face. Furthermore, be-
casionally helpful to examine the patient in a sitting cause the best resolution of the echo gram is in this central
position (see Figure 3-12). The echographer is seated on region, the area of interest should be centered within the
an examining stool of adjustable height, usually to the pa- echo gram whenever possible.
tient's right. A fixation light, suspended from the ceiling, is Methylcellulose is applied to the face of the B-scan probe
useful to facilitate steady gaze. The patient's head and the as a coupling medium. The probe is then placed directly on
instruments to be used are situated close together, so that the eye (i.e., conjunctiva or cornea). Examination through
the probe position and the screen may be viewed simulta- the lids is generally less desirable because of sound attenu-
neously (Figure 2-1). Topical anesthetic drops are applied ation produced by the lid tissues. In addition, with the lids
to the eye before the examination. closed, the echographer cannot be certain of which portion
of the globe is being evaluated. The particular section of
ocular tissue displayed on the screen is dependent on where
8-SCAN EXAMINATION TECHNIQUES
the probe is positioned and how the marker is directed.
An adequate evaluation of the eye depends on the ability of
the echographer to think three-dimensionally while exam-
B-Scan Probe Orientations
ining the globe with instruments that have only a one- or
two-dimensional display. Once proper examination tech- The three basic probe orientations that are used to evaluate
niques are mastered, lesions can be reliably localized in re- intraocular lesions are transverse, longitudinal, and axial.
15
16 THE GLOBE
Figure 2-1 Patient positioned properly for echographic exami-

nation. Patient is in a reclined position. Examined eye is near
screen, so that echo gram and probe position may be monitored
simultaneously.
A B
Figure 2-2 B-scan probe. A, Transducer is shown with cap removed. Transducer oscillates near
face of probe to produce a two-dimensional acoustic section. B, Cap in place after probe is filled
with distilled water. Note probe marker (i.e., insignia on this probe) that designates upper por-
tion of echogram. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S]
led]: Retina. ed 3, St Louis, Mosby, 2001, p 231.)
Chapter 2 EXAMINATION TECHNIQUES FOR THE GLOBE 17
Figure 2-3 Three primary B·scan probe orientations. Transverse (A), longitudinal (B), and
axial (C) scans.
Transverse and longitudinal scans are used most commonly cornea, thereby displ~ying lens and optic nerve in the cen-
because the probe is placed on the conjunctiva peripheral to ter of the echo gram (Figure 2-3).
the cornea. Thus, the sound beam bypasses the lens, allow- In the B-scan examination, the optic nerve is used as an
ing better sound beam penetration. Both transverse and anatomic reference for the posterior fundus. For the sake
longitudinal scans are performed with the patient's gaze di- of clarification, the optic nerve is echo graphically consid-
rected away from the probe, toward the meridian being ex- ered to be the center of the posterior fundus rather than the
amined. This allows a wide surface of globe on which to macula (the true anatomic center). Furthermore, it serves
place and shift the probe. In an axial scan, the patient fixates as a reference point for the three primary B-scan probe po-
in primary gaze and the probe is placed on the center of the sitio.ns (transverse, longitudinal, and axial) (Figure 2-4).
18 THE GLOBE
A B
Figure 2-4 Optic nerve in center of posterior fundus serves as a reference point for the three
primary B-scan probe orientations. Transverse (A), longitudinal (B), and axial (C) scans. Lines
correspond to movement of the sound beam on the fundus for each probe position.
Transverse Scans For example, if the probe is held horizontally with its face
The probe, in a transverse scan, is placed on the globe so centered on the 6-0'clock meridian, the middle of the
that the back-and-forth movement of the transducer occurs echogram displays the 12-0'clock meridian of the fundus;
parallel (i.e., tangential) to the limbus. This causes the this probe position is called a transverse scan of the 12,.
sound beam to move back and forth across the opposite o'clock meridian. If the probe is placed in a vertical orien-
fundus, producing a circumferential slice through several tation at the 3-0'clock limbus, the sound beam sweepS;-
meridians of the globe. This orientation is appropriate for across the 9-0'clock meridian of the fundus; this is called:a
showing the lateral (i.e., circumferential) extent of a lesion transverse scan of the 9-o'clock meridian. :;
(e.g., extending from 2- to 4-0'clock meridians, from 11 :30- By convention, horizontal transverse scans (i.e., trans-
to 1:30-0'clock meridians, and so forth) (Figure 2-5; see verse scans of the 12- or 6-0'clock meridians) are per-
also' Figures 2-3, A, and 2-4, A). formed with the marker oriented toward the patient's nose.
The designation of the transverse scan is determined by Therefore, the upper part of the echogram always repre-
the meridian that lies in the middle of the scanning section. sents the nasal portion of the globe. On the other hand,
12
10;30 ~\ 1;30
/
I
\I
I f
\ /
\ I
',------.//
7;30 4:30
12
10:30 1:30
f
/ ~,
/
\
\
f \
I '0 I
\ I
\ /
\
,, I
7:30
.... _-- /
/
4:30
Figure 2-5 Technique for transverse B-scan approach. A horizontal transverse scan is demon-
strated in this example. Left, The patient fixates superiorly, and the sound beam sweeps across the
12-o'clock meridian near the equator. Top, Normal globe. Bottom, Elevated lesion extending from
11:30- to 12:30-o'clock meridians. Note that the probe marker is oriented nasally. (From Green
RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby,
2001, p 232.)
TABLE 2-1
Orientation of 8-Scan Probe Marker
Probe Position Direction of Marker
Transverse and Axial Scans
Horizontal Nasal
Vertical Superior
Oblique Superior
Longitudinal Scans Toward center of cornea
and meridian being
examined
vertical transverse scans (i.e., transverse scans of the 3- or 9-

o'clock meridians) are performed with the marker directed
superiorly so the top of the echo gram represents the upper Figure 2-6 Probe marker orientation for various transverse B-
portion of the globe. Oblique transverse scans (e.g., trans- scan approaches. H, Horizontal probe positions; 0, oblique probe
verse scans of the 1:30-, 4:30-, 7:30-, or 10:30-0'clock positions; V, vertical probe positions. Note that the marker is al-
meridians) are performed with the marker directed upward ways oriented above the horizontal for vertical and oblique scans;
(Table 2-1 and Figure 2-6).
Longitudinal Scans in contrast to the transverse scan. In this way, the longitu-
For longitudinal scanning the probe face is rotated 90 de- dinal scan shows the anterior-posterior extent of a lesion
grees from the position used for the transverse scan. This rather than the lateral extent (Figure 2-7; see also Figures
means that the back and forth movement of the transducer 2-3, B, and 2-4, B). Another way to think of this orienta-
is oriented perpendicular (rather than parallel) to the lim- tion is as a radial section (like the spoke of a wheel) where
bus. The sound beam then sweeps along the single meridian the sound beam sweeps from the optic disc out toward the
located opposite the probe rather than across the meridian, periphery along a given meridian.
20 THE GLOBE
12
Figure 2-7 Technique for longitudinal B-scan approach. A longitudinal scan of the 12-o'clock
meridian is demonstrated in this example. Left, The patient fixates superiorly and the sound
beam sweeps along the 12-o'clock meridian. Top, Normal globe. Bottom, Elevated lesion. Note
that the probe marker is oriented toward the cornea as well as the 12-o'clock meridian. ON, Op-
tic nerve; P, posterior aspect of globe; A, anterior aspect of globe. (From Green RL, Byrne SF:
Diagnostic ophthalmic ultrasound, in Ryan SJ led]: Retina. ed 3, St Louis, Mosby, 2001, p 233.)
In longitudinal scans, the marker is always directed to-

ward the center of the cornea and the meridian being ex-
amined (Figure 2-8; see also Table 2-1). This produces an
echo gram that displays a section or slice through the globe
along a given meridian. The optic disc and posterior aspect
of the globe along the meridian are displayed on the lower
portion of the screen. The peripheral aspect of the globe
along the meridian is displayed on the upper aspect of the
screen. The designation of the longitudinal scan is simply
that meridian which is being examined. For example, if the
probe is placed on the 6-0' clock meridian, the sound beam
sweeps along the 12-o'clock meridian; this is designated as
a longitudinal scan of the 12-0'clock meridian.
With the probe placed for the longitudinal scan orienta-
tion, it is possible to shift the probe on the globe either
closer to the limbus or into the fornix. This provides either
a more posterior or a more anterior view of the meridian
being examined. With the probe placed so that it slightly
overlaps the limbus, the soupd beam sweeps through more
Figure 2-8 Probe marker orientation for various longitudinal
of the posterior aspect of the eye, thus allowing better eval- B-scan approaches. Note that the probe marker is always oriented
uation of the peripapillary region. Conversely, when the toward the center of the cornea as well as the meridian being
probe is placed close to the fornix, the sound beam extends scanned.
more peripherally to better display the peripheral fundus
and often the posterior ciliary body. It is of note that as the
probe is shifted closer to the fornix, the optic nerve may
move inferiorly off the screen display (Figure 2-9).
Figure 2-9 Anterior and posterior longitudinal B-scan probe positions. A, Posterior longitu-
dinal scan of 3-o'clock meridian. Probe is placed near limbus with sound beam directed along
posterior aspect of 3-o'clock meridian. Echogram shows dome-shaped lesion nasal to the optic
nerve (ON). Note that the posterior border (P) is well shown, but the anterior border 0) is not
well imaged in this view. M, Medial rectus muscle. E, Anterior longitudinal scan of 3-o'clock
meridian. Probe is shifted toward fornix to direct sound beam more anteriorly along the 3-
o'clock meridian. The anterior margin of the lesion is now well demonstrated.
The use of a longitudinal probe orientation greatly fa- macular region (see "Evaluation of the Macula" later in
cilitates three-dimensional thinking and promotes a better this chapter).
understanding of B-scan findings. It is often the best probe \Vhen a horizontal axial scan is performed, the marker
orientation for demonstrating the insertion of membranes is oriented toward the patient's nose, which places the
into the optic disc. In many cases the axial approach, due macular region just below the optic disc in the echogram.
to sound attenuation from the lens and from the angle of A vertical axial scan is obtained with the marker in the
incidence, does not clearly demonstrate the relationship of superior position. In oblique axial scans (e.g., the sound
membranes to the optic nerve. Therefore, the longitudinal beam is sweeping from the 1:30 to 7:30 or 10:30 to 4:30
approach should always be used to determine if a mem- meridians), the marker is oriented toward the upper of
brane inserts into the optic disc (see ~igure 3-24). The lon- the two meridians being scanned (Figure 2-11; see also
gitudinal approach is useful also for demonstrating the pe- Table 2-1).
ripheral insertions of a membrane.
... Para-Axial Scans
Axial Scans Para-axial scans often facilitate the evaluation of the peri-
The axial orientation is the third type of B-scan probe po- papillary region. These scans are very similar to axial
sition. The axial scan is performed with the patient fixating scans in that the probe is centered on the cornea with the
in primary gaze and with the probe face centered on the sound beam directed through the lens. The sound beam,
cornea. The sound beam is then directed through the cen- however, is slightly shifted so that the fundus adjacent to
ter of the lens, sweeping along two opposing meridians, the optic nerve is imaged. In order to obtain a para-axial
intersected by the optic nerve (Figure 2-10; see also Fig- scan, an axial view is first displayed. The probe is then
ures 2-3, C, and 2-4, C). As mentioned previously, this scan tilted slightly so that the sound beam passes through the
is the easiest to understand because it displays the lens and fundus just next to the optic disc. If the probe is oriented
optic nerve in the center of the echo gram, thus simpHfying vertically and the sound beam is shifted slightly right or
orientation while assessing the disease process. Unfortu- left of the optic nerve, the nasal or temporal peripapillary
nately, however, sound attenuation and refraction from the region will be evaluated (see p 29). On the other hand, if
lens often hinder resolution of the posterior portion of the the probe is oriented horizontally and the sound beam is
globe, thus limiting the usefulness of axial scans. This po- shifted slightly above or below the optic nerve, the supe-
sition can be helpful in some situations, however, for doc- rior or inferior peripapillary region can be imaged. Fi-
umenting lesions and membranes in relation to the lens nally, an oblique orientation can image the peripapillary
and optic nerve. It can also be useful for evaluating the region in other quadrants adjacent to the optic nerve
22 THE GLOBE
12
10:30 1:30
/- ,
/
/' "- ,
I \
I \
I \
9 I 1 3
\ /
\ I
\
, I
7:30
"-
'- - /
/
4:30
12
Figure 2-10 Technique for vertical axial B-scan. Left, Patient fixates in primary gaze, and probe
is centered on cornea. Top, Normal globe. Bottom, Elevated lesion. ON, Optic nerve. Note that
probe marker is directed toward the 12-o'clock meridian. (From Green RL, Byrne SF: Diag-
nostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 234.)
Basic B-Scan Screening Examination Technique

Transverse scans of the four major quadrants are performed
initially at a high gain setting. The superior portion of the
globe is first scanned with the patient's gaze directed superi-
orly. The probe is oriented horizontally with its face placed
next to the inferior limbus and centered on the 6-0'clock
meridian (horizontal transverse scan of the 12-0'clock merid-
ian). Remember that the marker is directed nasally for this
probe position. With the probe first positioned near the lim-
bus, the superior, posterior fundus is examined initially. The
probe is then shifted toward the lower fornix, thus screening
progressively more peripheral aspects of the superior globe
(Figure 2-12). As the probe is shifted, the echo gram is con-
Figure 2-11 Probe marker orientation for various axial B-scan tinuously monitored to detect abnormal echoes. This ma-
approaches. 0, Oblique scans; V, vertical axial scan; H, horizontal neuver thus examines the superior half of the globe. The
axial scan. Note that the marker is directed upwards for vertical nasal portion of the eye is next examined by having the pa-
and oblique axial scans and nasally for horizontal axial scans. tient look medially and by placing the probe in a vertical ori-
entation, with the probe face centered near the temporal lim-
bus (transverse scan of the 3-0'clock meridian [right eye] or
(e.g., superotemporally or inferotemporally). The probe 9-0' clock meridian [left eyeD. Again the probe is shifted from
marker is oriented in exactly the same manner as for ax- limbus to fornix, thereby scanning the entire nasal half of the
ial scans (see Table 2-1). globe. Similar maneuvers are then performed for the infe-
rior and temporal quadrants (see Appendix B).
It is also suggested that the eye be screened using longi-
BASIC SCREENING EXAMINATION
tudinal scans, along at least the four major meridians.
The basic screening examination is performed to detect le- These scans may help detect lesions located in the peripap-
sions in eyes with opaque ocular media. This examination illary region (including the macula) as well as in the far pe-
can be performed with either B- or A-scan, although most riphery of the globe.
examiners prefer to use B-scan. A systematic technique for Once the posterior segment has been thoroughly
screening the globe is used. screened with transverse and longitudinal approaches, the
12
1:30
/'
..---- "-
"/
" "-
/-----.\
Ir ,\
9 I xo I 3
\ I
\ /
\ /
"" " /
7:30 ------ /'

/
4:30
12
1:30
I~ \
\
9 xo I 3
I
I
/
/
...... _--/
12
10:30~__1:30
~ "
/
/' "-
,
/ \
/ \
I \
9 I xO I 3
\ I
\ /
\, /
,---_//
7:30 4:30
Figure 2-12 Technique for B-scan screening. In this example, the superior aspect of the globe
is examined. Horizontal transverse approach is used to examine globe from posteriorly to ante-
riorly. Note that the probe marker is oriented nasally. (From Green RL, Byrne SF: Diagnostic
ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 236.)
24 THE GLOBE
A C
B D
Figure 2-13 Transverse scans of normal globe (A and B) and choroidal tumor (C and D). A and
C, High gain setting. Band D, Reduced gain setting. Note extremely bright echoes produced from
normal retina and sclera when the sound beam is directed perpendicularly. Such artifacts can be
mistaken for a foreign body or other very highly reflective lesion. (From Green RL, Byrne SF: Di-
SPECIAL EXAMINATION TECHNIQUES

globe is evaluated with both vertical and horizontal axial
scans. For both of these positions, the patient fixates in pri- Special examination techniques (i.e., topographic, quan-
mary gaze with the contralateral eye, and the probe is cen- titative and kinetic echography) have been devised by
tered on the cornea of the examined eye. Ossoinig6- S to provide a means of differentiating lesions
The B-scan screening procedure is performed at both through the analysis of specific acoustic characteristics
high and low gain settings. The high settings are used to (Box 2-1).
detect vitreous opacities and gross fundus lesions, whereas When one is initially learning this method, it is sug-
the lower settings (which improve resolution) are helpful gested that topographic techniques be performed first, fol-
for detecting relatively flat fundus elevations and for better lowed by quantitative and then kinetic echography. How-
showing the topography oflarge lesions (Figure 2-13). ever, once sufficient experience has been gained, the various
During the screening examination, the optic disc should techniques may be combined for greater efficiency.
also be evaluated to detect any abnormalities (see p 431).
Topographic Echography: Shape, Location,
Basic A-Scan Screening Examination Technique and Extension
Although A-scan is rarely used to screen the eye for abnor- As soon as a lesion is detected, topographic echography is
malities, the maneuver of shifting the probe along the sur- performed to determine its location, general classifi-
face of the eye is a necessary technique for the A-scan eval- cation, and configuration (Figures 2-16 and 2-17). B-scan
uation of intraocular lesions. For this technique, the patient's is ideally suited for the initial topographic evaluation be-
gaze is always directed away from the probe, toward the cause the moving, focused sound beam provides a two-
meridian to be examined. The probe is placed on the globe dimensional display. It is also important, however, to ap-
at the limbus opposite to the meridian and it is slowly shifted preciate a lesion's topography with A-scan in order to
into the fornix as the screen is continuously monitored (Fig- carry out quantitative and kinetic techniques. It is essen-
ure 2-14). This maneuver is generally first performed at the tial that scanning techniques be systematically performed
Tissue Sensitivity gain setting (see Figure 1-12) although re- with both B- and A-scan if reliable results are to be
duced gain levels can also be used (Figure 2-15). achieved (see Appendix C).
Figure 2-14 Technique for A-scan screening. In this example, the 12-o'clock meridian is ex-
amined. The patient fixates superiorly, and the probe is shifted from limbus to fornix along the
6-o'clock meridian (thereby examining the 12-o'clock meridian). This limbus-to-fornix shifting is
performed in eight meridians to screen the entire posterior segment. (From Green RL, Byrne SF:
Diagnostic ophthalmic ultrasOlmd, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 229.)
26 THE GLOBE
Topographic 8-Scan Evaluation

Once a lesion is detected, topographic evaluation of the
lesion is then performed. The lesion is first assessed with
the appropriate transverse B-scan approach where the
probe is placed on the globe exactly opposite the lesion.
For example, if a lesion is detected in the superior tem-
A poral quadrant of the right eye, a transverse scan of the
10:30 meridian is performed (probe is placed at 4:30, and
marker is oriented supranasally). The probe is then
shifted from limbus to fornix, thereby sweeping the
sound beam through the lesion from posterior to ante-
rior. This displays the gross shape and dimensions of the
lesion as well as its lateral extent (i.e., the meridians that
are affected by the lesion). The longitudinal approach is
then applied, with the sound beam oriented radially, per-
pendicular to the transverse view. For a lesion located at
the 10:30 position in the right eye, the probe face is
placed on the 4:30 meridian with the marker directed to-
ward the center of the cornea. The lesion's anterior-
posterior extent (between the optic disc and ora along the
B 10:30 meridian) is assessed and its shape and gross di-
mensions are re-evaluated.
The lesion may also be displayed in axial orientation to
document its position in relationship to the .normal
anatomic landmarks of the lens and optic nerve. This is ac-
complished by placing the probe on the cornea with the
marker directed so that the sound beam slices through the
lesion and optic nerve simultaneously (see Table 2-1). For a
Figure 2-15 Normal A-scan echograms at Tissue Sensitivity (A) lesion located at the 10:30 position, the probe face is placed
and reduced gain (B). R, Retinochoroid layer; S, sclera. (From
on the cornea and is rotated so that it is aligned along the
Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan
S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 230.) 10:30 to 4:30 meridians. When the probe marker is ori-
ented toward the uppermost of the two meridians being
scanned (toward the 10:30 meridian in this example), the
lesion is displayed above the optic nerve in the echogram
(Figure 2-18). By compiling data obtained with these vari-
ous scanning approaches, a three-dimensional concept of
BOX 2-1 the lesion may be developed and its topography adequately
documented.
Differ,ential Diagnosis of Intraocular Lesions*
Topographic B-scanning is also used to show the config-
uration and shape of a membrane. For example, a funnel-
.location shaped retinal detachment (RD) typically displays a trian-
Extension gular or T -shaped configuration when an axial scan is
Shape performed. In these cases, the transverse scan provides a
Quantitative cross-section of the funnel and thus displays a circular or
Reflectivity oval configuration. By combining the transverse with the
Inte-rhalstrUdure axial approach, a three~dimensional image of a funnel-
Sound attenuation shaped retinal detachment can be formed. This topographic
evaluation can then determine if the detachment is open or
Kinetic
closed (Figure 2-19).
Aftermovement
Vascularity Topographic A-Scan Evaluation
Convection. motion
Once the involved meridians have been generally deter-
*When an intraocular lesion is detected, these properties are mined with B-scan, A-scan is then applied. Lesion topog-
assessed for differentiation. raphy is always evaluated at the Tissue Sensitivity gain set-
ting. The probe is first placed at the limbus of the meridian
located opposite the center of the lesion. It is then shifted
A B c
Figure 2-16 B- and A-scan echograms of the three major types of abnormal echo sources.
A, Pointlike (e.g., fresh vitreous hemorrhage); B, membranelike (e.g., retinal detachment);
C, masslike lesion (e.g., choroidal melanoma). R, Retina; S, sclera; T, tumor surface; arrow, in-
ternal tumor spikes. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S]
A
c
B
28 THE GLOBE
12
Figure 2-18 Topographic evaluation of tumor at 10:30 position with schematic drawing on
upper left to illustrate sound beam orientation. Top, Transverse scan showing lateral extent of tu-
mor. Center, Longitudinal scan showing radial extent of tumor. Bottom, Axial scan showing rela-
tionship of tumor to anatomic landmarks of lens and optic nerve. (From Green RL, Byrne SF:
between limbus and forillx to assess the lesion ariteroposte- There are four basic B-scan probe positions that allow
riorly (see p 24). Next, the probe is shifted from side-to- . perpendicular sound beam exposure to the macula. These
side (parallel to the limbus) to allow evaluation of the le- include the horizontal axial, vertical transverse, longitudi-
sion laterally. Another helpful A-scan technique is to nal, and vertical macula approaches. A description of how
examine the lesion from different sound beam directions to perform the first three of these approaches has been
(i.e., with the probe placed in positions that are 90 degrees given earlier in this chapter. The fourth approach, vertical
apart). These various A-scan maneuvers help to classify a macula, is a type of para-axial scan previously described on
lesion into a general category (pointlike, bandlike, mem~ p 21. This view is obtained by first displaying a vertical ax-
branelike, or masslike) and to evaluate its exact location and ial scan and by then directing the sound beam slightly tem-
extent (see Figures 2-16 and 2-17). poral to the optic nerve (Figure 2-20). When evaluating a
lesion in the macular area, it is helpful to display it from as
Evaluation of the Macula many different probe orientations as possible in order to
Because of the importance of the macular region, it is es- document its extent, configuration, and size (Figure 2-21).
sential that this area be evaluated carefully to detect any ab- In some cases, a nontraditional longitudinal probe ap-
normality. Several approaches are available for assessment proach is also used to assess the macula. This is accom-
of the macula. It is important to be familiar with these var- plished by performing a longitudinal examination of the
ious alternatives because the optimal approach may vary nasal meridian (i.e., 3:QO OD or 9:00 OS). The patient fix-
from one eye to another. ates in either primary gaze or only slightly nasally with the
A c
B o
Figure 2-19 Three-dimensional conceptualization of funnel-shaped retinal detachments (RDs)

using axial and transverse B-scan approaches. Open, triangular RD (A and B), and closed, T-
shaped RD (C and D). A, Axial scan shows triangular shape of RD inserting into optic nerve
(ON). B, Transverse scan showing cross-section of open, funnel-shaped detachment. C, Axial
scan shows T -shape of RD inserting into optic nerve (ON). D, Transverse scan showing cross-
section of closed, funnel-shaped detachment.
12
10:30 1:30
- - ,
........
" \
\
o \
9 I 3
I
/
/
/
-"
6
12
Figure 2-20 Technique for performing vertical scan through macula (vertical macula scan).
Left, Patient fixates in primary gaze with probe centered on cornea. Note that the probe marker
is directed superiorly. Sound beam is directed just temporal to optic disc. Top, Scan of normal
macula (al'"row). Bottom, Elevated lesion at macula. (From Green RL, Byrne SF: Diagnostic oph-
thalmic ultrasound, in Ryan S] [ed].: Retina. ed 3, St Louis, Mosby, 2001, p 238.)
30
A B
12 12
,,;--- ...... , .",,---.... .......

/ "- / /' ",
/ \ I \
9 I'
'
I
II:
\
,
I 3 9
,
I
/
I )
\
\
, 3
\ I \ I
\ / \ /
\
" ...... _--/' /
/ \
" ....... __ ....... , / /
/
6 6
Figure 2-21 Four B-scan probe positions for evaluation of macula. Fundus photographs (top)
indicate sound beam orientation. Photographs, schematic drawings, and echograms are of right
eye. A, Horizontal axial scan. Patient fixates in primary gaze, probe is centered on cornea, and
marker is oriented nasally. Sound beam sweeps across 3- and 9-o'clock meridians, intersected
by the optic nerve. Echogram shows RD extending temporally from optic nerve. M, Multiple sig~
nal; arrow, macula. B, Longitudinal scan of 9-o'clock meridian. Patient fixates temporally, probe
is placed nasally, and marker is directed toward center of' cornea and 9-o'clock meridian.
Echogram shows RD extending from optic nerve temporally to equator. Arrow, Macula.
c D
12 12
/
/
/'
-- -- " .....
"- /
/'
~--- .......
" "-
\ / \
/ \ / \
I \ I \
I 0 3 9 I I 3
9 I
\ I \ I
\ / \ /
\ / \ /
", ..... _/
/' ", ........ _ - ; . . . - /
/'
7:30 7:30
6 6
Figure 2-21 cont'd C, Vertical macula scan. Patient fixates in primary gaze, probe is centered
on cornea, and marker is directed superiorly. Sound beam sweeps vertically through macula.
Echogram shows RD extending from superior to inferior through macula (arrow). D, Vertical
transverse scan. Patient fixates temporally, probe is placed nasally near limbus, and marker is di-
rected superiorly. Sound beam sweeps vertically through macula. Echogram shows RD extend-
ing from superior to inferior and involving macula (arrow). Note that the lens is not present in
this transverse scan as compared with the vertical macula view.
32 THE GLOBE
Quantitative Echography: Reflectivity, Internal

probe placed so that it slightly overlaps the temporal lim-
Structure, and Sound Attenuation
bus. Using this technique, the macular region is located at
the lower aspect of the echo gram, inferior to the optic Once the topographic findings have been ascertained,
nerves (see Figure 3-50, B). This examination technique is quantitative echography is performed to determine the re-
referred to as a reverse macula approach. flectivity, internal structure, and sound attenuation of the
A-scan evaluation of the macula is performed by plac- lesion. In the globe, two types of quantitative echography
ing the probe either on the center of the cornea or at the have been described to evaluate reflectivity.6-s
nasal limbus. If the eye is phakic and the corneal ap-
Quantitative Echography Type I
proach is employed, care should be taken to direct the
sound beam through the center of the lens to avoid re- REFLECTIVITY
fraction from the edges of the curved lens. Quantitation, Quantitative echography type I is used to estimate the re-
however, should be performed with the sound beam by- flectivity of all detected lesions. Reflectivity is evaluated by
passing the lens to avoid sound attenuation. Also, if there observing the spike height on A-scan and the signal bright-
is a dense cataract or the eye is pseudophakic, it may be ness on B-scan. Before evaluating reflectivity, the sound
best to avoid the cornea and place the probe at the nasal beam must always be directed perpendicular to the lesion
limbus (Figure 2-22). being assessed. There are several different types of intraoc-
Figure 2-22 A-scan probe positions for evaluating lesion at the macula. Top, Using Tissue Sen-
sitivity, probe is placed near limbus with sound beam bypassing lens to assess quantitative prop-
erties oflesion. L, Lesion surface; S, sclera. Bottom, Using reduced gain, probe is placed on cornea
with sound beam directed through center oflens to measure height oflesion. (From Green RL,
Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby,
2001, p 238.)
ular lesions that can be assessed with quantitative echogra- ercised in judging reflectivity from a B-scan echogram be-
phy. These include membranes and bands, opacities, for- cause it does not provide a standardized gain setting, as
eign bodies, and tumors. The reflectivity of membranes, does the standardized A-scan (i.e., Tissue Sensitivity). Fur-
bands, and opacities is related to their configuration, size, thermore, the signal display characteristics of B-scan, such
thickness, and density. The reflectivity of a tumor, however, as gray scale, dynamic range, lines of resolution, and so
correlates with its histologic architecture, such as the char- forth, may vary from one instrument to another.
acter of cellular substance; the number, size, and distribu- The technique of determining a lesion's reflectivity, es-
tion of cell aggregates; and the presence of large interfaces pecially with A-scan, is of great value in differentiating
(e.g., blood vessels, connective tissue septa, calcification, many types of intraocular lesions, such as membranes and
and so forth). intraocular tumors. For a mass lesion, the determination of
On A-scan, using the Tissue Sensitivity gain setting, re- reflectivity is necessary in order to evaluate its internal
flectivity is determined by estimating the height (i.e., am- structure and degree of sound attenuation.
plitude) of a lesion's spikes in relation to the vitreous base-
line (0%) and the top of the initial spike (100%) (Figures
2-23 and 2-24 and Table 2-2). On B-scan, the assessment of
TABLE 2-2
signal brightness is only a gross estimation and is not as
precise as is determining spike height on A-scan. In order Reflectivity Categories*
to assess the significance of a lesion's signal brightness on B- Category Spike Height (%)
scan, the signal must be cOl1}pared with that of either the Extremely low 0-5
normal highly reflective (echo-dense) sclera or the very low Low 5-40
reflective (echolucent) vitreous cavity. A lesion's internal re- Medium 40-60
Medium-high 60-80
flectivity, in comparison to these known tissues, is assessed High 80-100
in different degrees of echo density. Therefore, the most
useful q:uantitative information obtained with B-scan is *The reflectivity of a lesion is classified into a particular category de-
pending on the height of the lesion spikes compared with the initial
from those lesions that are extremely echo-dense and those spike in the echogram. This quantitative technique is performed with
that are echolucent (see Figure 4-44). Caution must be ex- standardized A-scan using the Tissue Sensitivity setting.
Figure 2-23 Quantitative echography type I to estimate lesion reflectivity with A-scan. Draw-
ing shows sound beam directed perpendicular to a membrane. Echograms at Tissue Sensitivity
from PVD (top) and RD (bottom). PVD produces 50% high spike, whereas RD produces 100%
high spike (arrows). Most PVDs produce spike height ofless than 100%, whereas only extremely
dense PVDs and RD produce a spike of 100% height. (From Green RL, Byrne SF: Diagnostic
34 THE GLOBE
Figure 2-24 Typical tumor echo grams taken at Tissue Sensitivity with histopathological cor-
relation. Schematic drawing shows A-scan sound beam directed perpendicular to tumor surface.
Top, Choroidal melanoma. Homogeneous cellular histology produces regular internal structure
and low reflectivity. Center, Choroidal hemangioma. Multiple, small vascular spaces produce reg-
ular internal structure and high reflectivity. Bottom, Metastatic carcinoma. Irregular arrangement
of tumor cells and variable size of interfaces produces irregular internal structure (i.e., variable re-
flectivity). Arrows, Internal tumor spikes; T, tumor surface; S, sclera. (From Green RL, Byrne SF:
Diagnostic ophthalmic ultrasound, in Ryan S] [edJ: Retina. ed 3, St Louis, Mosby, 2001, p 240.)
INTERNAL STRUCTURE SOUND ATTENUATION

Internal structure refers to degrees of variation in histologic Sound attenuation occurs when the sound energy is scattered,
architecture within a masslike lesion. This feature is evalu- reflected, or absorbed by a given medium. It may be more
ated by noting differences in height and length of the A- pronounced when the examination is performed through
scan spikes and, to a limited extent, differences in echo den- closed (especially swollen) lids, extremely dense opacities and
sity on B-scan echograms. Such variations can occur within membranes, or a medium that produces extremely high re-
a single echogram or within different echo grams obtained flectivity (e.g., bone, calcium, or foreign material). Sound at-
from the same lesion. Regular internal structure, indicat- tenuation may be evaluated on both B- and A-scan and is in-
ing homogeneous architecture, is represented by little or dicated by a progressive decrease in the strength of echoes,
no variation in the height and length of spikes on A-scan either within or posterior to a lesion. On A-scan, this spike
and a uniform appearance of echoes on B-scan. Conversely, decrease, called angle kappa/'s is determined by drawing an
irregular internal structure, indicating heterogeneous ar- imaginary line through the peaks of the lesion spikes and es-
chitecture, is represented by marked differences in echo ap- timating the angle that is then formed with the vitreous base-
pearance (see Figure 2-24). In some cases, slight variations line. The steeper the angle, the greater is the sound attenua-
can be present and the lesion will be classified as moder- tion. On B-scan, sound attenuation is indicated by a decrease
ately irregular. in the brightness of the echoes (see Figures 5-4 and 5-7).
n M A
1 ] \"---_LT'C
B ~ 5
Figure 2-26 Quantitative echography type II to differentiate

dense PVD from RD. Horizontal line is placed across the middle
of the screen. Probe position 1, Sound beam directed perpendicular
to membrane (M). Probe position 2, Sound beam directed perpen-
dicular to sclera (S). The decibel level is decreased until the spike
from these surfaces touches but does not surpass the horizontal
line in the middle of the screen. The difference in the decibel set-
ting required to display the membrane and sclera at this specific
spike level may help differentiate retina from vitreous membrane
(6 to 15 db = retina; >20 db = vitreous membrane). (From Green
c RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] [ed]:
Retina. ed 3, St Louis, Mosby, 2001, p 241.)
reous membrane (e.g., posterior vitreous detachment).8 It

can be applied when a membranelike lesion produces a
100% high spike at the Tissue Sensitivity gain setting dur-
Figure 2-25 Strong sound attenuation produced by choroidal ing quantitative type I assessment, and the other acoustic
osteoma. Transverse (A) and longitudinal (B) B-scans through characteristics are equivocal.
macula show a thick, plaquelike lesion (arrow) producing marked Quantitative echography type II allows precise measure-
shadowing (S) of the scleral and orbital echoes. ON, Optic nerve. ment of a membrane's reflectivity in decibels as compared
A-scan echo gram (C) shows a very highly reflective, broad spike
from the lesion with marked decrease in height of orbital spikes with reflectivity of the sclera in the same eye (Figure 2-26).
secondary to sound attenuation (S). (From Green RL, Byrne SF: However, because this technique is time consuming and has
Diagnostic ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed 3, St certain limitations (i.e., is more difficult if the lids are
Louis, Mosby, p 241.) markedly swollen, if the eye has been severely injured, or the
patient has recently undergone eye surgery), it is normally re-
served for those situations where the other special examina-
Various substances, such as bone, calcium, and most for- tion techniques are unsuccessful in differentiating the lesion.
eign bodies, typically produce strong sound attenuation.
This results in decreasing signal strength or an actual void
Kinetic Echography: Mobility, Vascularity,
posterior to the lesion that is referred to as shadowing (Fig-
and Convection Movement
ure 2-25 and see p 466). However, when a dense echo
source is extremely small, sound attenuation may be subtle One of the unique abilities of conventional ultrasound in-
or altogether absent (see Figure 4-31). struments is the nearly instantaneous display of echoes.
Therefore, any movement of or within a lesion is accu-
Quantitative Echography Type /I rately depicted in the echogram (i.e., in real-time). Ki-
Quantitative type II .echography is an A-scan method for netic echography is used to dynamically assess the mo-
the differentiation of a retinal detachment from a dense vit- tion of or within a lesion. Three types of motion (i.e.,
36 THE GLOBE
aftermovement, vascularity, and convection movement) during, and immediately following an eye movement. WIth
can be detected with the appropriate instrumentation. the patient fixating a target, the lesion is imaged on the
Aftermovement, indicative of mobility, is determined by screen. The patient is then instructed to shift their gaze a
observing motion of the lesion echoes following cessation short distance away from and then quickly back to the tar-
of eye or body movement. For example, a nonsolid lesion get in the same plane as the moving sound beam. Mean-
(e.g., vitreous membrane or retinal detachment) displays af- while, the echogram is continually monitored to evaluate
termovement, whereas a solid lesion (e.g., tumor) does not. any movement of lesion echoes.
Vascularity (fast spontaneous motion of echoes on the One of the strengths of A-scan is the detection of subtle
screen) represents blood flow within vessels. Convection motion of a lesion. Spike aftermovement may be classified
movement (slow spontaneous movement of echoes on the as horizontal or vertical. Horizontal spike motion is a lat-
screen) occurs due to convection currents of fine particles eral movement of the spike along the baseline, correspond-
(e.g., cholesterol debris) within a large cavity (e.g., vitreous ing to lateral motion of the lesion. This type of motion is
cavity or large orbital cyst). seen also on B-scan (Figure 2-27). Vertical spike motion,
which is quite subtle, is a change in spike height caused by
Lesion Mobility (Aftermovement) minimal change in position of the lesion relative to the
B-scan is used to assess the gross mobility of vitreous opac- sound beam. This slight aftermovement may not be appre-
ities and membranes. Aftermovement is evaluated before, ciable with the B-scan (Figure 2-28).
Figure 2-27 A-scan and B-scan demonstration of membrane mobility (aftermovement). A and
B, A-scan echograms show vitreous hemorrhage and PVD (p) before (A) and immediately fol-
lowing (B) eye movement, using same probe position. Note change in position of PVD and
blurred appearance of spikes in B compared with A. This changed appearance indicates that the
PVD has moved closer to the surface of the retina and that there is continuing movement of the
opacified vitreous gel. C and D, Longitudinal B-scans at reduced gain setting show PVD before
(C) and immediately following (D) eye movement. PVD appears to insert into optic nerve (ON)
in C, but D shows that the PVD is actually detached from the optic nerve.
Figure 2-29 A-scan echogram of large melanoma shows inter-

nal vascularity (spontaneous motion). Vascularity is indicated by
marked blurring of internal tumor spikes (arrow). T, Tumor sur-
face; S, sclera.
beneath a tight funnel-shaped retinal detachment. Coat's

B disease is a specific type of disorder that is typically associ-
ated with subretinal cholesterol (see p 187). In the prbit, the
most common lesion associated with convection movement
is the hematic cyst (cholesterol granuloma) (see p 340). The
characteristic ultrasound finding for convection movement
is a slow, up and down motion of spikes on A-scan and a
slow, circular motion of pointlike echoes on B-scan. This
type of movement is best assessed with the probe held sta-
tionary and the eye steadily fixating on a target.
Figure 2-28 Aftermovement of RD shown with A-scan (re-
\ duced gain setting). RD before (A) and immediately following (B),
eye movement. A, RD in focus befare eye movement. B, Slight ANTERIOR SEGMENT EVALUATION:
blurring of retinal spike (arrow) after eye movement indicates IMMERSION TECHNIQUE
slight vertical aftermovement. (From Green RL, Byrne SF: Diag-
nostic ophthalmic ultrasound, in Ryan S} [ed]:.Retina. ed 3, St Contact scanning is not well suited for the anterior segment
Louis, Mosby, 2001, p 242.) evaluation because the probe is unable to display echoes
from the first few millimeters in front of the probe face (see
Figure 1-13). As a result, immersion techniques have been
Vascularity (Fast Spontaneous Motion) developed to allow a fluid separation between the probe
Vascularity is a characteristic that is assessed in tumors. Fast face and front of the eye. Although the same instruments
spontaneous motion (i.e., low-amplimde, continuous flicker- used for contact scanning can be readily employed for im-
ing of the internal lesion spikes) is best detected with stan- mersion assessment of the anterior segment, newer higher
dardized A-scan, but in many cases maybe appreciated also frequency B-scan probes have been developed that allow
with B-scan. Vascularity is assessed with the probe held sta- .better resolution of anterior segrn,ent structures and lesions.
tionary and the eye steadily fixating on a target (Figure 2-29): A-scan can also be used with the immersion technique to
evaluate the reflecti-rity and size of anterior segment lesions
--Convection Movement (Slow Spontaneous Motion) and to measure the axial eye length (see Chapter 10).
Convection movement is a characteristic type of motion that In order to perform an immersion scan, some type of
can be observed in eyes with longstanding intraocular hem- fluid bath must be used for the examination. Various types
orrhage or in certain types of orbital cystic lesions contain- of scleral shells (see Appendix D) have been developed for
ing cholesterol debris. This type of movement occurs be- use with contact instrumentation. These shells are placed
cause of convection currents that cause a continuous, slow between the eyelids and are filled with methylcellulose. The
movement of blood and/or cholesterol debris within the eye probes are then placed into or on the top of the shell (Fig-
or large orbital cysts. "Within the eye, the most common sit- ure 2-30, A and D). An alternative to the scleral shells is a
uation where this type of convection movementis seen is balloonlike device created with a detached finger from a la-
when hemorrhage, cholesterol debris, or both, accumulate tex surgical glove. The finger is filled with water and the
38 THE GLOBE
c E
Figure 2-30 Immersion technique for anterior segment evaluation. A, B-scan probe is placed
on top of small scleral shell filled with methylcellulose. B, B-scan echogram using globe screen
expansion (posterior ocular wall not shown). M, Methylcellulose within shell; C, double line
from anterior and posterior corneal surfaces; I, iris; short arrow, anterior, lens capsule (pupil is
dilated); P, posterior lens capsule. C, B-scan echogram using orbital screen expansion shows the
entire eye. D, A-scan probe within fluid-filled scleral shell. E, A-scan echogram at Tissue Sen-
sitivity gain setting. Arrows, Multiple signals along vitreous baseline; R, retina. (From Green RL,
2001, p 243.)
B c
Figure 2-31 B-scan immersion examination of anterior segment using balloonlike device.
A, Balloonlike device (created from latex glove tip) is placed directly over closed lid with probe
on its surface. B, Echogram of anterior segment obtained with balloon directly on cornea. This
was an examination of an eye with a dense cataractous lens. B, Balloon; C, cornea; A, anterior
chamber; L, dense cataractous lens. Note echolucent lens nucleus surrounded by dense cortical
lens material. V,Vitreous cavity. C, Echogram of anterior segment obtained with balloon placed
on closed eyelid (E). This was an examination of a child with a history of corneosclerallaceration.
Curved ar70W, Rupture of peripheral aspect of posterior lens capsule.
open end is closed with suture material or dental floss. This the cornea, iris, lens, and ciliary body and can demonstrate
balloonlike device can be placed over the closed eyelid or the posterior extent of anterior segment lesions (see Fig-
on the surface of the eye. The probe (with methylcellulose ures 3-62, A and D, and 5-82). The transverse approach is
on its tip) is placed directly on the device (Figure 2-31, A). then performed with the patient's gaze in the same position
as for the longitudinal scan. The probe, however, is rotated
by 90 degrees so that the sound beam oscillates parallel
B-Scan Immersion Techniques
(tangential) to the limbus. The transverse view provides a
Using the B-scan probe with an immersion scleral shell (see circumferential section of anterior segment structures and
Figure 2-30, A), three different B-scan probe orientations the lateral extent of anterior segment lesions (see Figures
(axial, longitudinal and transverse) can be used for the an- 3-62, Band E, and 5-79, C). For the various B-scan probe
terior segment examination. The axial scan is performed positions, the marker is generally orientated in the same
with the patient fixating in primary gaze and the sound manner as for contact scans of the posterior segment (see
beam directed through the center of the cornea. This al- Table 2-1 and Figures 2-6, 2-8, and 2-11).
lows for the display of the cornea, anterior chamber, iris, In recent years, instruments have been developed that
lens, and retrolental space along the visual axis (see Figure allow the use of higher frequency B-scan probes to better
2-30, Band C; see also Figure 2-32, B). The longitudinal demonstrate anterior segment structures and lesions. Al-
approach is performed with the probe in exactly the same though these higher frequencies provide better resolution,
position as for the axial scan. However, instead of moving their depth of sound beam penetration is limited. One of
the probe, the patient's gaze is shifted so as to allow pe- these instruments is the 13 SYSTEM-ABD (Innovative
ripheral structures to be centered beneath the probe. Such Imaging, Inc, Sacramento, California). This instrument
scans provide a radial section through peripheral aspects of uses a 20 MHz probe that can be used with an immersion
40 THE GLOBE
A c
Figure 2-32 Anterior chamber hyphema. A, Axial

B-scan using contact technique. Arrows, Hyphema;
I, iris; P, posterior lens capsule; V, vitreous cav-
ity. B, Axial B-scan using immersion technique.
B M, Methylcellulose within scleral shell; C, cornea; ar-
row, hyphema; I, iris; P, posterior lens capsule; V, vit-
reous cavity. C, A-scan at Tissue Sensitivity gain set-
ting. R, Retina.
shell or a small water-filled balloon (latex tonometer cover) for imaging the lens, although A-scan may provide mea-
over the probe tip. This cover eliminates the need for a surements of lens thickness and, in some cases, is useful for
scleral shell immersion system, allows the probe to be used evaluating internal reflectivity.
in a contact manner, and provides an easy method for imag- The contact B-scan technique primarily images the pos-
ing structures and lesions of the anterior segment (Figure terior aspect of the lens, including the posterior capsule (see
2-33; see also Figure 5-85). Figure 2-32, A). Using this method, the lens is generally
The UBM9,10 currently provides the highest resolution best evaluated with an axial approach (see p 21), although
for the anterior segment examination. This technique uti- longitudinal (see p 19) and transverse (see p 18) probe po-
lizes frequencies in the range of 50 to 100 MHz and an im- sitions are sometimes helpful. To obtain an adequate longi-
mersion water bath system. The instrument and examina- tudinal view of the normal lens, an instrument with a wide
tion techniques as well as anatomy and lesions of the scanning angle must generally be used, although instru-
anterior segment are described in Chapter 8. ments with less wide angles can display the lens if it is
swollen. To show the normal lens with the transverse ap-
proach, a very anterior scan must be obtained. It is gener-
A-Scan Immersion Techniques
ally best to place the probe temporally with the patient fix-
The immersion A-scan examination is initially performed ating nasally. This transverse view is most effective for
with the patient fixating in primary gaze and the probe im- demonstrating a swollen lens and/or detecting an intralen-
mersed into the methylcellulose. Spikes from the central ticular foreign body (Figure 2-34).
aspect of the cornea, anterior chamber, iris, and lens are dis- The immersion B-scan technique is used to image the
played (see Figure 2-30, B; see also Figure 2-32, C). Pe- anterior lens capsule and the relationship of the lens to
ripheral aspects of the anterior segment and lesions can be other anterior segment structures (i.e., cornea, anterior
best demonstrated by having the patient shift their gaze so chamber, iris, and ciliary body). With this technique, the
as to center the area of interest beneath the probe (see Fig- lens is best assessed with either an axial or a longitudinal
ure 3-62, C and F). approach. The axial approach can usually display both the
anterior and posterior lens capsules with a traditional 10
MHz B-scan transducer. When higher resolution B-scan
EVALUATION OF THE LENS
instruments are employed, the depth of penetration may
The lens may be evaluated using either contact or immer- not always allow display of the posterior capsule. The
sion ultrasound techniques. B-scan is the primary modality longitudinal approach is most beneficial when there is
A c
B D
Figure 2-33 Immersion examination of anterior segment using high resolution B-scan (20
MHz) probe with balloonlike tip. A, High resolution P B-scan probe with water-filled latex
tonometer tip attached. B, High resolution probe with tip placed directly on cornea. C, Axial
scan. Open mvow, Thin membrane representing probe balloon tip on cornea (G); I, iris; straight
white arrow, anterior lens capsule. D, Longitudinal scan. Straight white a170W, Anterior chamber
angle; GE, ciliary body; cul'"Ved white arrow, Anterior lens capsule; H, surface of anterior hyaloid;
S, sclera. E, Transverse scan through ciliary body. Straight white arrows, Ciliary processes. (Cour-
tesy Cynthia Kendall, BMET, RDMS, Sacramento, California.)
42 THE GLOBE
Figure 2-34 Glass foreign body within swollen, cataractous lens. Vertical transverse B-scan
through lens at low gain setting. Foreign body (arrow) is located at inferior pole of the lens (L).
Note short comet tail artifact extending from foreign body.
significant pathology involving the lens, iris or ciliary

BOX 2-2
body (see p 77). The display of zonular attachments to
the lens requires the use of very high-resolution instru- Ultrasound Evaluation of the lens
ments such as the ultrasound biomicroscope (see p 223). Cataractous lens
A-scan assessment of the lens (i.e., thickness and internal Intralenticular foreign body
reflectivity) can be performed with either the contact or the Posterior lenticonus
immersion technique (see Figure 10-1). It should be noted, Subluxation/dislocation of lens (see Figure 4-3)
though, that to display both the anterior and posterior lens Dislocated lens nucleus (see Figure 4-40)
spikes with the contact method, the anterior chamber must Liquefaction of lens (see Figure 7-3)
be of normal or greater than normal depth. Measurement of lens thickness (see p 252)
Retained lens material (see p 106)
The normal lens appears as a very well outlined, oval,
Retrolenticular (cyclitic) membrane (see Figure 3-63)
echo lucent structure on B-scan and exhibits very low inter- Rupture of anterior or posterior lens capsule (see Figure
nal reflectivity on A-scan. The anterior and posterior lens 4-5)
capsules produce distinct echoes on both B- and A-scan (see Shrunken (reabsorbed) lens (see Figure 4-15)
Figure 1-11). An axial B-scan view typically displays the Swollen (intumescent) lens (see Figure 5-78)
center of the posterior capsule as a short, echo-dense cres- Thin lens (PHPV) (see. Figure 5-100)
cent and peripheral aspects of the posterior capsule are not
usually demonstrated (see Figures 1-13 and 4-2, A). A con-
tact, longitudinal view, on the other hand, often shows the
more complete, continuous nature of the posterior capsule varying degrees of echo density on B-scan (see Figure 4-2,
(see Figure 4-6, B). The anterior capsule, which is best dis- B) and internal spikes of differing amplitude on A-scan
played with the immersion technique, appears as a smooth, (see Figures 10-11 and 10-12). In a dense nuclear cataract,
slightly convex line. It often cannot be differentiated from B-scan can often differentiate the lens nucleus from the
the iris when using a traditional 10 MHz transducer unless surrounding cortex (see Figure 7-3). Posterior subcapsular
the pupil is dilated (see Figures 2-30, B, and 4-2, A). On cataracts are best shown with an anterior transverse B-
the other hand, dilatation of the pupil is not required to scan approach where the sound beam passes through the
demonstrate the anterior lens capsule with high-resolution posterior capsule. The subcapsular cataractous changes
instruments (see Figure 2-33, C). In the normal lens, the appear as an echo-dense, roundish, plaque-like opacity in
nucleus generally cannot be differentiated from the cortex. the echogram (Figure 2-35). In some cases, irregularities
Also, the normal lens can produce artifacts such as multiple of the posterior lens capsule can be demonstrated. One
signals (see Figures 1-11 and 2-21, A) and Baum's bumps example of this abnormal shape is posterior lenticonus
(see p 467). (Figure 2-36).
A wide variety of pathological conditions involving the Ultrasound can also be used to evaluate intraocular
lens can be demonstrated with ultrasound (Box 2-2). lenses. The appearance of an intraocular lens, with both
Cataracts, however, must usually be of moderate density conventional and high resolution instrumentation, is de-
for detection by echography. The cataractous lens exhibits scribed elsewhere (see pp 109,233, and 255).
A c
Figure 2-35 Posterior subcapsular cataract demonstrated iIi

B-scan echograms. A, Axial view shows lens with subcapsular
cataract. Dotted lines indicate scanning plane of transverse
B echo grams shown in B and C. B, Transverse view obtained
through portion oflens (L) corresponding to dotted line 1.
e, Transverse view obtained through subcapsular plaque cor-
responding to dotted line 2.
EVALUATION OF THE PUPIL

Pupillary reaction may be evaluated with B-scan as the pa-
tient fixates in primary gaze. An extremely anterior trans-
verse approach normally allows display of the iris and pupil.
Pupillary response can be obserVed on the screen when a
light is directed either toward the examined or the con-
trala teral eye (Figure 2-37).
PEDIATRIC EXAMINATION
The echographic examination of small children can be ex-
tremely challenging. This is due primarily to inadequate co- Figure 2-36 Posterior lenticonus. immersion axial B-scan
operation and the frequent necessity to examine through shows characteristic protrusion of posterior lens capsule (arrow).
closed eyelids. To perform a satisfactory examination, in some C, Cornea. (Courtesy Dr. Cecelio Velasco-Barona, Mexico City,
cases it is necessary to evaluate children under anesthesia. Mexico.)
This evaluation can be carried out in the operating room un-
der general anesthesia or in an outpatient setting under local An adequate examination can be performed on most
sedation. This later situation should only be undertaken; children without sedation although various degrees of re-
however, if adequately trained personnel and appropriate de- straint may be necessary. Newborns and children up to 6
vices are available to monitor the child both during and fol- months of age can often be held by a parent with an assis-
lowing the procedure. An additional echo graphic examina- tant gently securing the head to prevent movement. Older
tion with the child awake may be helpful in some cases to children, however, often require immobilization of arms
assess the kinetic properties of certain lesions and structures and legs that cannot be achieved without some type of ex-
that cannot be evaluated while the child was sedated. ternal wrapping (Figure 2-38).
44 THE GLOBE
Figure 2-38 Young child in restraining device for ultrasound

examination.
DOCUMENTATION OF FINDINGS
Adequate documentation of significant findings observed
during an ultrasound examination is essential. Documenta-
tion serves to provide an accurate record of the examination
and facilitates comparison at follow-up visits. Echograms are
B tYPically labeled with the specific area of the eye examined
:u;1}~{~~-scan: th~ probe orientation (i.e., tr~sverse, lon-
gltucifnaI or axtal) IS also recorded. For postenor segment
'Jesions, the area of the eye examined is generally opposite
to where the probe is placed (see Appendix E). For anterior
segment lesions using an immersion technique, the area of
the eye evaluated is directly adjacent to where the probe is
placed. It should be mentioned, however, that pictorial doc-
umentation of all echographic findings may not always be
Figure 2~37 Evaluation of the pupil. The pupil can usually be
possible due to the kinetic nature of the findings, the pres-
imaged with the B-scan by using a very anterior transverse ap- ence of artifacts, or poor patient compliance.
proach. The real-time features of the B-scan allow the exapliner to •
monitor the pupillary light response on the screen. A, Dilated REFERENCES
pupil (arrow). B, Constricted pupil. (From Green RL, Byrne SF:
Diagnostic ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed 3, St 1. Byrne SF: Standardized echography of the eye and orbit, in Naidich
TB, Quencer R (eds): Clinical Neurosonography. Berlin, Springer-
Louis, Mosby, 2001, p 261.) Verlag, 1987, p 252.
2. Byrne SF: Standardized echography. I. A-scan examination proce-
dures. Int Ophthalmol Clin 1979;19(4):267.
3. Collaborative Ocular Melanoma Study Group: The procedures of
echography (ultrasound) for the Collaborative Ocular Melanoma
Study (COMS). COMS Report No. 12, part I. ] Ophthalmic Nurs
As mentioned, it is often necessary to perform the ex- TechnoI1999;18:143.
amination through closed eyelids, especially if the child is 4. Collaborative Ocular Melanoma Study Group: The procedures of
awake. This limits the ability to accurately localize lesiop.s echography (ultrasound) for the Collaborative Ocular Melanoma
Study (COMS). COMS Report No. 12, part II. ] Ophthalmic Nurs
and sometimes prevents adequate assessment of certain TechnoI1999;18:219.
portions of the eye. Nevertheless, if a systematic approach 5. Dugel PU, Smiddy WE, Byrne SF, et aI: Macular hole syndromes. Echo-
is undertaken, in most cases, a satisfactory examination can graphic findings with clinical correlation. Ophthalmology 1994; 101 :815.
6. Ossoinig KC: Standardized Ophthalmic Echography of the Eye, Orbit and
be performed. Periorbital Region. A Comprehensive Slide Set and Study Guide, ed 3, Iowa
Evaluation of the anterior segment using an immersion City, Goodfellow, 1985.
technique is usually not possible when a child is awake. It 7. Ossoinig KC: Standardized echography: Basic principles, clinical
applications, and results. Int Ophthalmol Clin 1979; 19(4):127.
has been shown, however, that the small finger-tip balloon 8. Ossoinig KC: Quantitative echography-the basis of tissue differen-
technique used with conventional instrumentation (see Fig- tiation.] Clin Ultrasound 1974;2:33.
ure 2-31) or the 20 MHz probe with the latex tonometer 9. Pavlin C], Harasiewicz K, Sherar MD, et aI: Clinical use of ultrasound
biomicroscopy. Ophthalmology 1991;98:287.
cover (see Figure 2-33) can sometimes be beneficial in these 10. Pavlin C], Foster FS: Ultrasound Biomicroscopy of the Eye. New York,
patients. Springer-Verlag, 1995.
Vitreoretinal Disease
The accurate characterization of vitreoretinal disorders is A-scan, asteroid hyalosis produces spikes of medium to high
important in the management of eyes with opaque ocular reflectivity that move with the vitreous gel.
media. 54,57 The posterior segment must be evaluated sys-
tematically so that significant abnormalities are not over-
Vitreous Hemorrhage
looked. The evaluation should include an assessment of the
vitreous body, posterior hyaloid, subvitreal space, retina, Vitreous hemorrhage, which is second only to cataract as a
choroid, sclera, and optic disc. When indicated, the ante- cause of opaque media, may be produced by or associated
rior segment may also be evaluated47 (see p 77 and Chapters with a number of conditions. The most common of these
2,4, and 8). are diabetic retinopathy, trauma, age-related macular de-
generation (AMD) , venous occlusion, and retinal tear.
Echography is a useful adjunct to the clinical examination
VITREOUS BODY
in establishing the density and location of the hemorrhage
The vitreous cavity should be assessed for the presence of and may assist in determining the etiology of a clinically
opacities, bands, and membranes. Vitreous opacities pro- unexplained hemorrhage.
duce dots or short lines on B-scan and vertical deflections In fresh, mild hemorrhage, dots and short lines are dis-
from the baseline on A-scan. Opacities may originate from played on B-scan, and a chain oflow amplitude spikes is noted
liquefied vitreous (syneresis) or clumps of cells, includ- on A-scan. The more dense the hemorrhage, the greater the
ing calcium soaps (asteroid hyalosis), blood cells (hem- number of opacities and the higher their reflectivity.
orrhage), or inflammatory (uveitis) or infectious material If organization of the blood occurs, larger interfaces are
(endophthalmitis). formed, resulting in membranous surfaces on B-scan and
even higher reflectivity on A-scan. Gravity may cause the
blood to layer inferiorly, resulting in highly reflective
Normal Vitreous
pseudomembranes that can be confused with retinal detach-
In the young person, the clear, jellylike vitreous body ment (RD) (Figure 3-4). However, these pseudomembranes
generally produces no echoes. However, scattered vitre- can often be differentiated from RD with B-scan by noting
ous opacities of very low reflectivity may be detected in a thinning of the membrane as it extends superiorly. This
the aging eye. In addition, there may be a mobile poste- thinned membrane then appears to terminate within the vit-
rior vitreous detachment (PVD) that manifests as a fine, reous gel (Figure 3-5) rather than inserting into the fundus
thin line on B-scan and as a very low reflective spike on as is characteristic of a partial RD. Also, a PVD commonly
A-scan (Figure 3-1). occurs in association with vitreous hemorrhage.
In some cases, hep:lOrrhage may be confined to syneretic
cavities within the vitreous body. In this situation, the blood is
Asteroid Hyalosis
very homogeneous and does not form membranous surfaces
The ultrasound findings in this condition are usually quite and clumplike opacities, as occurs when it diffusely infiltrates
typical, making the diagnosis straightforward. Calcium the vitreous gel. The blood within these pockets appears very
soaps produce bright, pointlike echo sources on B-scan that low reflective on A-scan and diffusely homogeneous on
may be diffuse or focal. An area of clear vitreous is normally B-scan, similar to the hemorrhage in a vitrectomized eye (see
present between the posterior boundary of the opacities Figure 4-45, C and D). It is important to appreciate thatrwhen
and the posterior hyaloid (Figure 3-2). This appearance both the solid vitreous gel and diffuse, homogeneous blood
may be confused with a PVD, especially when the hyaloid are present, the solid gel may appear echolucent on B-scan
remains adherent to the retinal surface (Figure 3-3). On and can thus mimic cystic cavities (Figure 3-6).
45
46 THE GLOBE
A B
Figure 3-1 A PVD in the normal, aging eye. The PVD appears as a fine, thin line (P) on
B-scan (A) and a low reflective spike on A-scan (B).
B D
Figure 3-2 Asteroid hyalosis. Opacities can be mild (A and B) or extremely dense (C and D).
Note the echolucent vitreous gel (straight arrows) located between asteroid opacities (czmJed ar-
rows) and retina in C and D. This appearance can simulate a PVD. (A and B from Green RL,
2001, p 245.)
Chapter 3 VITREORETINAL DISEASE 47
Figure 3-3 Dense asteroid hyalosis with PVD. Transverse B-scan demonstrates an area of clear
vitreous between the posterior boundary of the dense opacities and the detached posterior
hyaloid (P).
A c
Figure 3-4 Dense vitreous hemorrhage layered

in the lower periphery of the globe, forming pseudo-
membranes (arrows). A, Horizontal transverse
B B-scan through the inferior aspect of globe. B, Lon-
gitudinal B-scan of the 6-o'clock meridian. A, Ante-
rior; P, posterior. C, A-scan.
A B
Figure 3-5 Technique for differentiation of layered blood from RD. A, Transver~e B-scan
through the inferior aspect of the globe in an eye with vitreous hemorrhage shows dense
pseudomembrane produced by layered blood. Straight arrow indicates the 6-o'clock meridian.
B, Transverse B-scan through 4:30 meridian shows thinning of pseudomembrane as it extends
superiorly, appearing to terminate within the vitreous gel (curved arrow). The 6-o'clock merid-
ian is indicated by straight a1'rOW. .
Figure 3-6 Vitreous hemorrhage and solid vitreous gel. Para-axial B-scan view demonstrates
echolucent sections of solid vitreous gel (arrows) outlined by diffuse hemorrhage in the vitreous
cavity. ON, Optic nerve.
A B
Figure 3-7 Axial B-scan views of two eyes with PVDs. A, Extensive PVD with complete sep-
aration of posterior hyaloid from optic nerve (ON). B, Extensive PVD with persistent attachment
of posterior hyaloid to optic nerve (ON). Since this membrane may topographically simulate
RD, quantitation and kinetic techniques should be used for differentiation.
Figure 3-9 PVD with Weiss ring. Longitudinal B-scan demon-

strates two closely spaced echo-dense opacities (open arrow) on
surface of detached posterior hyaloid overlying optic nerve head.
B ON, Optic nerve.
On B-scan, in a normal eye, a PVD usually appears

smooth and thin. When blood or inflammatory debris is
layered on the surface of a PVD, the B-scan may show a
thick line, especially posteriorly and inferiorly. Kinetic
echography typically shows a very fluid, undulating after-
movement of the PVD. This characteristic fluid movement
is helpful in differentiating a PVD from retinal and
choroidal detachments, both of which are usually less mo-
bile than a PVD.
c Another B-scan finding in the normal eye where the vit-
reous is completely separated from the optic nerve is the
presence of a Weiss ring. 26 The Weiss ring represents tis-
sue that normally surrounds the optic nerve head and pro-
vides a firm attachment of the vitreous to the posterior
pole. When the vitreous detaches from the optic nerve,
i this ring of tissue also separates and often appears on B-
Figure 3-8 B-scans from different eyes showing PVDs with var- scan as two closely spaced opacities at the level of the
ied attachments to the retina. A, Horizontal transverse view near PVD. This ring can usually be seen overlying the optic
equator of eye shows area of vitreoretinal adherence. B, Hori-
zontal axial sc'an shows PVD inserting into fundus temporal to disc (Figure 3-9) but may be located elsewhere if the vitre-
macula. ON, Optic nerve. C, Vertical axial scan shows PVD in- oils body has collapsed.
serting just s~perior to optic nerve, causing mild tractional de- On A-scan, the reflectivity of a PVD can vary from ex-
tachment of retina (arrow). tremely low, as in the normal eye, to extremely high, as is
often the case in eyes with dense hemorrhage. Kinetic eval-
uation typically shows marked horizontal and vertical spike
Posterior Vitreous Detachment (PVD)'
aftermovement (Table 3-1; also see Figure 2-27).
,A PVD may occur itt the normal aging eye, or it may be as- There are situations in which the acoustic behavior of a .
sociated with vitreous hemorrhage or inflammation. The PVD is similar to th;t of an RD. Although differentiating
PVD may be focal or extensive. The posterior hyaloid may between the two may be quite challenging, several tech-
separate completely from the posterior pole, or it may re- niques have been developed to faCilitate this distinction (see
main attached to the optic disc, producing a funnel-shaped "Retinal Detachment vs. Posterior Vitreous Detachment,"
configuration (Figure 3-7). Vitreoretinal adhesions may oc- on p 56).
cur at areas of retinal neovascularization (e.g., branch vein
occlusion or diabetes) (Figure 3-8). In addition, vitreoreti-
Subvitreal Hemorrhage
nal adhesions may be detected in areas other than the optic
disc, often in association with a retinal tear or at impact site Hemorrhage may occur in the subvitreal (subhyaloid)
following penetrating trauma (see Chapter 4). space in association with vitreous hemorrhage. Subvitreal
50 THE GLOBE
A
A
B B
Figure 3-10 Subvitreal hemorrhage. A, Transverse B-scan Figure 3-11 PVD with subvitreal hemorrhage and blood in
echo gram shows extensive PVD (P) and dense subvitreal hemor- Cloquet's canal (arrows). A, Section along length of canal also
rhage. B, A-scan shows medium-high reflective spike from PVD shows PVD and dense subvitreal hemorrhage. The canal is sur-
(P) and low reflective spikes from the subvitreal fluid blood (arrow). rounded by relatively clear vitreous gel. B, Cross-section of canal
also shows PVD and subvitreal hemorrhage. (From Green RL,
Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]:
Retina. ed 3, St Louis, Mosby, 2001, p 247.)
TABLE 3-1
Differentiation of Posterior Vitreous Detachment (PVD), Retinal Detachment (RD),
and Choroidal Detachment (CD)
Technique PVD RD CD
Topographic Smooth, open funnel with or Smooth or folded, open or closed Smooth, dome or flat; no disc
without disc or fundus funnel with disc insertion; may insertion; inserts at ora or
insertion; inserts at ora or have associated cysts; inserts at ciliary body
ciliary body ora
Quantitative Variable spike height; <100% Steeply rising 100% high spike, Steeply rising, thick, double-
high at ora superiorly including at ora superiorly peaked 100% high spike
Kinetic (aftermovement) Marked to moderate Moderate to none Mild to none
hemorrhage can be seen, however, even when there is no ous gel. Occasionally, subvitreal blood may extend ante-
hemorrhage in the vitreous gel. On echography, a high riorly through Cloquet's canal (Figure 3-11).
gain setting is often needed to detect a mild subhyaloid
hemorrhage (Figure 3-10). Subvitreal blood typically
Posterior Hyphema
does not clot; therefore, it remains 10-w_teflective and mo-
bile, even in longstanding cases. This is in contrast to the The cellular component of blood in the subvitreal space
higher reflectivity of pseudomembranes and clumplike may settle and layer, similar to a hyphema in the anterior
accumulations of blood that often form within the vitre- chamber.43 The surface of this layered blood may appear as
Figure 3-12 Posterior hypheina .in subvitreal space.

A, Horizontal transverse scan just inferior to the optic nerve
shows PVD (P); subvitreal opacities; and smooth, dense
pseudomembrane from surface of hyphema (arrows).
A B, Longitudinal scan of 6-0' clock meridian shows apparent
insertion of hyphema into optic nerve (ON). C, WIth pa-
tient in sitting position, same longitudinal 6-0'clock view
shows hyphema has shifted away from the optic nerve to-
ward the lower periphery (top of echogram).
a dense, smooth membrane on B-scan and as a highly

reflective spike on A-scan, thus simulating a shallow RD.
However, if the patient moves the eye back and forth, the
hyphema normally slides across the fundus surface (Fig-
ure 3-12). If the patient sits upright or turns his or her
head, the hyphema will shift its position.
When attempting to diagnose a hyphema in this way, it
is important to use the same probe position before and af-
ter the head or body is moved. Use of this technique is rec-
ommended, even when the diagnosis of hyphema is obvi-
ous, to exclude underlying retinochoroid layer thickening
or a shallow RD. Hyphemas can also be demonstrated in
the presence of subretinal or suprachoroidal hemorrhage Figure 3-13 Congenital vitreous cyst. Longitudinal B-scan dis-
(see p 56 and Figure 5-70). plays a large, round, echolucent lesion (arrow) that was freely
floating in vitreous cavity (V). ON, Optic nerve.
Vitreous Inflammation
(Endophthalmitis/Uveitis)
See Chapter 6 for a review of Vitreous inflammation (en-
dophthalmitis/uveitis).
Cystic lesions of the vitreous can be associated with in-
traocular cysticercosis (see p 203) and have been described
Vitreous Cysts
in eyes with medulloepithelioma (see p 187), as well as
Vitreous cysts may be congenital or may be related to a dis- retinoblastoma (see p 180).
ease process. 60 The congenital cysts are remnants of the
hyaloid system. They are usually free floating, but in some
RETINA
cases remain attached to the surface of the optic disc. On B-
scan they appear well outlined and either lobulated or One of the most important roles of echography is to evalu-
round (Figure 3-13). ate the status of the retina in the presence of opaque media.
52 THE GLOBE
Retinal tears, RD, retinoschisis, and many other disorders

can be accurately characterized.
Retinal Tears
A retinal tear is a type of retinal break that is readily de-
tected with ultrasound and, therefore, should always be
considered when screening an eye with opaque media. Fo-
cal retinal tears, a common cause of unexplamed vitreous A
hemorrhage, are located most often· in the superior periph-
eral fundus. The examiner should first search for a PVD
and then for specific areas where the vitreous remains at-
tached to the retinal surface. A retinal tear appears as a
small, focal, echo-dense membrane extending from the sur.-
face of the fundus to which the posterior hyaloid is attached
(Figure 3-14). Kinetic echography is important in confirm-
ing the area of vitreoretinal adherence and the presence of
a retinal tear.
Other lesions that can simulate a retinal tear echograph-
ically include stalklike areas of neovascularization; as in di-
abetic retinopathy or branch vein occlusion, as well as small
traction RDs. A focal accumulation of blood at an area of
vitreoretinal adherence may also mimic a small retinal tear.
In these situations, consideration of the history, location,
and kinetic behavior of the lesion will generally allow dif- B
ferentiation from a true retinal tear. In addition, the pres-
ence . 0£ a shallow, focal RD surrounding the tear may be
helpful in securing the diagnosis (Figure 3-15). It should
also be noted that the echo graphic findings for treated and
untreated retinal tears are similar. .
Ultrasound has been incorporated into the treatment of
retinal tears in some eyes with vitreous hemorrhage. 12 ,36 In
these cases, B-scan is used instead of ophthalmoscopy to lo-
calize the tear and to monitor it during cryotherapy (Figure
3-16).
In most cases of extensive, rhegmatogenous RD, small c
tears usually cannot be detected with ultrasound. On the
other hand, retinal folds can sometimes simulate small
tears. One study has shown, however, that a retinal tear is
usually located within 2 clock hours of the area of greatest
retinal elevation. 6 Echography may thus indirectly aid in
the localization of a tear by determining where the detach-
ment is most elevated. Figure 3-14 Peripheral retinal tears. A, Schematic drawing
Giant retinal tears are often difficult to diagnose because shows peripheral retinal tear with the posterior hyaloid remaining
attached to its surface. Longitudinal B-scan echograms (B and C)
they produce varied and unusual echo graphic findings 2o,32 from two different patients show adherence of posterior hyaloid to
and because they are most often present in severely injured peripheral retinal tears (arrows). Both eyes contain dense vitreous
eyes. Whenever the insertion of a membrane appears to be hemorrhage.
unusual, the possibility of a giant tear should be considered
(Figure 3-17). In some cases the detached retina may be
folded over on itself, giving the false impression of two sep-
arate membranes (Figure 3-18). In addition, because of the breaks can occur spontaneously, they are most often seen
large tear, the detached retina may show greater mobility following blunt trauma. The most common locations for
than normal. peripheral retinal dialyses include the supranasal and infe-
Another type of retinal break that may be encountered is rotemporal quadrants. These types of retinal breaks usually
a peripheral retinal dialysis. A retinal dialysis is a disinser- are associated with shallow rather than bullous RDs (see
tion of the retina from the ora serrata. Although these Figure 4-6).
A B
Figure 3-15 Peripheral retinal tear with shallow RD. Transverse B-scan echograms from two
different patients show retinal tears (arrows) and associated RD. Detachment in A is more local-
ized than detachment in B.
A c
Figure 3-16 Ultrasound localization of retinal tear during

cryotherapy. A, Transverse B-scan at reduced gain shows small
peripheral tear in superior aspect of globe (straight arrow).
B, Photograph shows ultrasound guided localization of tear
B during cryotherapy. C, Transverse B-scan shows indentation
of globe wall by cryoprobe (arrow) and shadowing (S) of or-
bital tissue. (C from DiBernardo C, Blodi B, Byrne SF: Echo-
graphic evaluation of retinal tears in patients with spontaneous
vitreous hemorrhage. Arch Ophthalmol1992; 11 0:513.)
54 THE GLOBE
Retinal Detachment (RD)

RD can have a number of etiologies, including tear (i.e.,
rhegmatogenous), exudate (e.g., uveal effusion, inflamma-
tion, central serous retinopa.thy, and intraocular tumors),
hemorrhage (e.g., disciform lesions, trauma, and melano-
mas), and traction (e.g., diabetic retinopathy and trauma).
The ultrasound findings differ somewhat according to the
A cause of the detachment.
The echo graphic features of RD are typically quite char-
acteristic (see Table 3-1), thus making the differentiation
from other membranes relatively straightforward. An RD
(except those secondary to traction) generally appears as a
bright, continuous, somewhat folded membrane on B-scan
and as a highly reflective spike on A-scan 37 (Figure 3-19).
There are certain situations, however, in which the retinal
spike may be less than 100% high (e.g., atrophy, severe
folding, or disruption of the retina).
In assessing an RD, it is always important to identify its
insertions. An extensive or total RD can usually be shown
to insert into the optic disc posteriorly and the ora serrata
in the periphery. When the retina is only partially de-
B tached, it may not extend to the optic disc or the ora ser-
rata but may appear to insert into the fundus in areas
where it remains attached. Unusual situations in which the
insertions may be atypical include peripheral retinal dialy-
sis (see Figure 4-6), giant retinal tear (see p 52), and very
rarely, complete avulsion of the retina from the optic disc
due to severe trauma.
Peripheral rhegmatogenous RDs typically extend posteri-
orly as they extend laterally. This may not be true, however,
Figure 3-17 Giant retinal tear. Transverse (A) and longitudinal following vitrectomy and 360-degree peripheral panretinal
(B) views show extensive, folded RD with marked retraction of
photocoagulation. 3o In this case, the photocoagulation creates
the retina and obvious disinsertion from the periphery (arrows).
(From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in retinal adhesions that prevent posterior extension of a pe-
Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 249.) ripheral rhegmatogenous detachment. This can lead to an un-
usual annular configuration of the detached retina that can
simulate a choroidal detachment (see p 77 and Figure 7-8).
RD typically exhibits a tethered, restricted aftermove-
ment that contrasts with the highly mobile, undulating
movement of a PVD. However, certain factors can affect
the mobility of the retina. For example, fresh, bullous de-
tachments and those with large tears may be very mobile,
whereas longstanding detachments with proliferative vitre-
oretinopathy (PVR) may be quite stiff. Additionally, exuda-
tive detachments show greater shifting of the subretinal
fluid than do rhegmatogenous detachments. It should al-
so be noted that atrophic retina, as may occur in endoph-
thalmitis, may exhibit marked mobility, similar to that of
aPVD.
An RD with underlying hemorrhage shows echoes in the
subretinal space (Figure 3-20). The detection of mild hem-
orrhage generally necessitates the use of a high gain setting.
Figure 3-18 Giant retinal tear. Longitudinal B-scan demon- As in subvitreal hemorrhage, subretinal blood typically does
strates detached retina due to giant retinal tear. Note that retinal not clot and may produce a posterior hyphema (see p 50
leaves are folded upon each other (straight arrows), thus creating
the impression of two separate membranes. ON, Optic nerve; and Figure 3-21). This is in contrast to suprachoroidal
curved arrow, shallow peripheral choroidal detachment. blood, which often produces solid clots (see p 106).
Chapter 3 VITREORETINAl DISEASE 55
A c
B D
Figure 3-19 Smooth (A and B) and folded (C and D)RDs (R). A-scans show characteristic
100% high, single-peaked spike at Tissue Sensitivity. Note mild vitreous opacities and PVD in
A and B (arrows). In A and C, note that the smooth surface of the fundus underlying the detached
retina represents the inner surface of the retinal pigment epithelium. This surface is highly re-
flective on A-scan, similar to the retina. .
Figure 3-20 Hemorrhagic RD in an eye with choroidal melanoma. A, B-scan echogram shows
mildly folded RD with dense subretinal hemorrhage (arrow, edge of melanoma). B, A-scan shows
100% high spike from retina (R) and low reflective echoes from subretinal hemorrhage (H).
(From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3,
St Louis, Mosby, 2001, p 250.)
56 THE GLOBE
A
A
B
B
c
c
Figure 3-21 Posterior hyphema in subretinal space. Horizontal Figure 3-22 Axial B-scan echograms showing funnel-shaped
axial B-scan echo grams from same patient with head turned to- RDs. A, Open funnel shape and mild PVD. B, Triangular shape
ward nasal side (A), with head straight (B), and with head turned with bridging membrane indicating PVR. C, T-shape (closed fun-
toward temporal side (C). Echograms show shifting of hyphema nel) indicating PVR. (From Green RL, Byrne SF: Diagnostic oph-
(arrows) as head is moved from side to side. Note that the funnel- thalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby,
shaped RD appears echolucent when surrounded by dense opaci- 2001, p 250.)
ties. (From Green RL, Byrne SF: Diagnostic ophthalmic ultra-
sound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 248.)
The configuration of an RD may vary from shallow, flat, ripheral retinal dialysis. The possible presence of a periph-
and smooth to bullous and highly folded. In addition, an eral retinal dialysis should be considered when examining
extensive RD often takes the form of a funnel-shaped mem- an eye with a diffuse, shallow RD (see Figure 4-6).
brane. The funnel-shaped detachment may be open or Longstanding RDs may also develop retinal cysts and
closed (see Figure 2-19) and may be concave, triangular, or become partially calcified. Cholesterol debris may accumu-
T-shaped. Detachments that are triangular or T-shaped, or late in the subretinal space (see p 37 and Figure 3-25).
that have fixed retinal folds, indicate PVR19 (Figures 3-22
and 3-2 3). As mentioned in Chapter 2 (see p 21), an axial B-
Retinal Detachment vs. Posterior Vitreous
scan view may not always demonstrate the insertion of an
Detachment
RD into the optic nerve. Therefore, a longitudinal ap-
proach should always be used to assess the relationship of a In some situations, the mobility of a PVD or an RD may be
membrane to the optic nerve (Figure 3-24). Shallow, ex- atypical, thus hindering differentiation of these two mem-
tensive detachment of the retina is often secondary to a pe- branes. An incomplete PVD that is still attached to the op-
A B
Figure 3-23 RD with fixed folds (PVR). A, Transverse B-scan echo gram shows Vitreous opac-
itiesand PVD (arrow) attached to eXtensive, folded RD (R). B, A-scan shows low chain of spikes
from vitreous opacities and 100% high spike from RD (R); Note low reflective spike at left base
ofRD (arrow) corresponding to PVD that is adherent to the RD.
A c
B D
Figure 3-24 Axial vs.longitudinal B-scan approach for displaying posterior insertion of funnel-
shaped RDs. Axial B-scan echograms from two different eyes with RD (A and C) do not demon-
strate their insertion into the optic nerve (ON). Longitudinal scans (B an~ D) from these same
patients, however, clearly show the insertion of the detachments into the optic nerve.
58 THE GLOBE
A c
B D
Figure 3-25 Various findings in three different longstanding RDs. A, Immersion B-scan
echogram from aphakic eye shows closed funnel-shaped RD with dense vitreous hemorrhage
(V) anteriorly and dense subretinal cholesterol (C) posteriorly. Note that funnel-shaped RD ap-
pears echolucent (black arrows) when surrounded on both sides by dense opacities. B, Corre-
sponding A-scan echogram shows dense vitreous hemorrhage anteriorly (V) and the highly re-
flective RD (R). Medium reflective, blurred spikes are displayed from the moving subretinal
cholesterol (C) debris. C, Longitudinal B-scan shows calcified, funnel-shaped RD inserting into
optic nerve (ON). D, Transverse B-scan shows extensive RD with two retinal cysts (arrows).
(From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed3,
tic disc may be less mobile than normal (e.g., trauma, dia- an RD remains highly reflective, a PVD often becomes
betic retinopathy, or uveitis) and, therefore, may be con- less reflective as it inserts into the peripheral fundus 45
fused with a funnel-shaped RD. Conversely, a detached (Figures 3-27 and 3-28). The exception to this rule is
retina can sometimes be more mobile than normal (e.g., en- in the inferior periphery, where the posterior hyaloid
dophthalmitis), thus simulating a PVD. In these situations, tends to remain higher reflective, similar to retina. B-scan
the echo graphic findings that are traditionally used (see can also be used in some instances to demonstrate the dif-
Table 3-1) may be insufficient for differentiation, therefore ference in reflectivity between a PVD and an RD in the
necessitating the use of additional techniques. periphery.
In these atypical cases, the posterior insertion of the mem-
brane in question should be reassessed with B-scan. It may be
Traction Retinal Detachment
possible to rule out an RD merely by noting that the mem-
brane inserts into the peripapillary region rather than into Vitreous membranes or bands that adhere to the fundus may
the optic disc (see Figure 3-7). Furthermore, the detection exert traction on the retina. Traction is typically seen in di-
of a second membrane, located either anterior or posterior to abetic retinopathy or trauma (see p 97) but can also occur in
the membrane in question, may be helpful in differentiating other conditions. Some of these include endophthalmitis
a PVD from an RD. If the etiology of the second membrane (see p 191), uveitis, toxocariasis (see p 203), retinopathy of
can be established, then the diagnosis of the membrane in prematurity (see p 184), and persistent hyperplastic primary
question may often be clarified (Figure 3-26). vitreous (see p 185).
In extremely difficult cases, an A-scan technique has
proved useful for differentiating PVD from RD.18 This Diabetic Retinopathy
technique is based on the finding that the reflectivity of Echography effectively demonstrates the nature and extent
PVD and that of RD differ in the periphery. Whereas of abnormalities in patients with diabetic vitreous hemor-
A c
B D
Figure 3-26 PVD and RD. It can sometimes be helpful to confirm that a membrane represents
detached retina by identifying another membrane to be a PVD. A dense PVD (P) and RD (ar-
rows) are shown in axial (A), transverse (B), and longitudinal (C) B-scan echograms. Note in-
sertion of RD into optic nerve (ON) in A and C. D, A-scan shows medium reflective PVD and
highly reflective RD.
Figure 3-27 A-scan technique for differentiating dense PVD from RD in the superior por-
tion of the globe. A 100% high spike is first displayed from the membrane posteriorly (1). The
probe is then shifted so as to trace the membrane to its insertion in the periphery (2, 3, and 4).
Typically, a PVD becomes low reflective in the periphery, whereas retina remains highly reflec-
tive, as in this example. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan
S] led]: Retina.ed 3, St Louis, Mosby, 2001, p 251.)
60 THE GLOBE
A D
B E
c F
Figure 3-28 Funnel-shaped RD (A to C) and dense PVD (D to F). This example shows that
evaluating the reflectivity of a membrane in the periphery can be helpful in differentiating retina
from vitreous. Note the similar appearance of the RD (R) and PVD (P) on B-scan (A and D).
Also, both membranes are highly reflective posteriorly (B and E). In the periphery, however, the
retina (C) remains highly reflective, whereas the PVD (F) decreases in reflectivity.
rhage. 41 It is also used to monitor the progression of the tion RD) or frank traction RD may be observed at the sites
disease. In previtrectomy evaluations, echography helps de- of adherence (Figure 3-30).
termine the timing of surgery and the optimal placement Splitting of the posterior cortical vitreous (posterior vit-
of instruments, as well as the visual prognosis. reoschisis)9,50,51 may be present in eyes with proliferative di-
Vitreous hemorrhage commonly occurs secondary to diabetic retinopathy and vitreous hemorrhage. Such splitting
abetic retinopathy. In these eyes, the blood may be located produces schisis cavities that often contain fluid blood. The
within the vitreous gel and/or the subvitreal space. Poste- inner wall of the schisis cavity may be echographically con-
rior hyphemas, which typically occur in the subvitreal fused with a PVD if the posterior hyaloid remains attached
space, can simulate RD (see Figure 3-12). to the retinal surface (Figure 3-31). Serial examinations may
In the early stages of diabetic retinopathy, PVDs are typ- clarify the situation, however, by showing detachment of
ically shallow. They often begin in the temporal periphery the true posterior hyaloid. It is of interest that posterior vit-
and then extend posteriorly; the nasal posterior hyaloid reoschisis can also be seen in other conditions such as
tends to detach as the disease progresses. Vitreoretinal ad- trauma and posterior uveitis (see Figure 6-5).
hesions often occur in areas of proliferative preretinal Using the B-scan examination techniques described in
membranes and stalks, which are usually located in the re- Chapter 2, the location of the PVD and retinal traction can
gion of the optic nerve (Figure 3-29) or along the vascular be mapped out. Moreover, detachment or thickening of the
arcades. Mild retinal elevation (i.e., very shallow, focal trac- macula (macular edema, see p 68) can usually be detected.
Figure 3-29 Proliferative, stalklike membrane in diabetic retinopathy. Longitudinal B-scan

shows short, echo-dense membrane extending from optic disc. ON, Optic nerve. (Courtesy
Dr. Barbara Blodi, Madison, Wisconsin, and Kathleen Meyer, RDMS, ROUB, Ann Arbor,
Michigan.)
Figure 3-30 Diabetic retinal traction in the eyes of two different patients. A, Transverse B-
scan echo gram shows extensive PVD with vitreoretinal adherence producing slight elevation of
retina (arrow). B, Longitudinal B-scan shows PVD producing a frank, focal RD (arrow). (From
Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis,
Mosby, 2001, p 253.)
62 THE GLOBE
A
c
Figure 3-31 Posterior vitreoschisis in diabetic retinopathy. Transverse (A) and longitudinal
(B) B-scans show splitting of posterior cortical vitreous that has produced schisis cavities (S).
The inner wall of the cavity (arrows) has a similar appearance to the detached posterior hyaloid
(P) and may actually simulate a PVD in eyes in which the posterior hyaloid remains attached.
Note hemorrhage present both in schisis cavity and subhyaloid space. C, A-scan displays spikes
of medium reflectivity corresponding to the inner wall of the schisis cavity (arrow) and the pos-
terior hyaloid (P). (From Chu TG, Lopez PF, Cano MR, et al: Posterior vitreoschisis-An echo-
graphic finding in proliferative diabetic retinopathy. Ophthalmology 1996;103 :317 -318.)
In diabetic retinopathy, traction RDs are found most eyes and are characterized by a ringlike or annular configu-
commonly in the peripapillary region and along the vascu- ration28 (Figures 3-33 and 3-34).
lar arcades. Traction may present as mild elevation of the In some cases the posterior hyaloid may form a bridge
retina, a shallow or highly elevated detachment, or in ex- between closely spaced, tentlike traction detachments (i.e.,
treme cases, an extensive or complete funnel-shaped de- hammock appearance). This bridging membrane can be
tachment. These detachments must be examined using dif- confused with a table-top traction RD. "\Nhen occurring
ferent probe positions to accurately delineate their over the macula, this hammock-shaped membrane may be
appearance and extent. confused with a macular RD. A bridging membrane should
The most common configurations of traction detach- be suspected when a vertical scan through the macula (see
ments are tentlike and tabletop (i.e., plateau). A tentlike de- p 28) demonstrates a smooth membrane extending between
tachment is produced by a pointlike vitreoretinal adherence, the temporal arcades (Figure 3-35). It should be stressed,
whereas a table-top detachment is the result of a broader vit- however, that whenever examining the macular region, a
reoretinal adherence, thus the table-top detachment is usu- combination of transverse, longitudinal, and axial scans
ally more extensive (Figure 3-32). In some cases, although a should be used (see Chapter 2).
traction detachment may appear to be tentlike from one The peripapillary region is a common location for dia-
sound beam direction, it may actually be table-top. This can betic traction RDs (Figure 3-36). Particular attention
be determined by examining the lesion with a combination of should always be given to the peripapillary region when ex-
transverse and longitudinal approaches (see Chapter 2). amining patients with diabetic retinopathy.
A third type of traction RD that may occur in diabetic Complex patterns of traction RD, secondary to poste-
retinopathy is peripheral traction secondary to anterior rior vitreoschisis (see p 60), can be caused by traction ex-
hyaloidal fibrovascular proliferation. These peripheral de- erted by the inner wall of the schisis cavity and the posterior
tachments typically occur following vitrectomy in phakic hyaloid (see Figure 3-37).
Chapter 3 VITREORETINAl DISEASE 63
A B
Figure 3-32 Diabetic traction RD. A, Small area ofvitreoretinai adherence produces tentlike
detachment. B, Broad area of vitreoretinal adherence in another patient produces tabletop de-
tachment. (A from Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] [ed]:
Retina. ed 3, St Louis, Mosby, 2001, p 254.) .
A c
B D
Figure 3-33 B-scans showing peripheral traction RD. Initial examination (A, transverse;
B, longitudinal) shows shallow, peripheral traction RD (arrows). V, Residual peripheral vitreous
skirt; ve, vitreous cavity. Follow-up examination with corresponding transverse (C) and longi-
tudinal (D) views shows increasing elevation and extent of traction RD.
64 THE GLOBE
Figure 3-34 Retrolenticular traction in diabetic patient following vitrectomy (immersion tech-
nique). M, Retrolenticular membrane; R, retina. (From Green RL, Byrne SF: Diagnostic oph-
thalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 254.)
A B
Figure 3-35 Traction RDs with bridging membrane in diabetic patients. Vertical transverse
sections through macula show bridging membrane (white a1"rows) overlying the macula (M). This
bridging membrane is posterior hyaloid, which extends from one traction detachment to an-
other. In these two cases, detachments are located at the superior and inferior temporal vascular
arcades (black al"rows). The hammock-shaped appearance of these bridging membranes may be
confused with a simple tabletop traction RD. (From Green RL, Byrne SF: Diagnostic oph-
thalmic ultrasound,in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001; p 254.)
Figure 3-36 Peripapillary traction RD in a patient with diabetic retinopathy. Para-axial B-scan
view demonstrates traction RDs (arrows) on either side of optic nerve (ON). Note that vitreous
is detached in the periphery but remains attached to the retina in the peripapillary region. P,
Posterior hyaloid.
A B
Figure 3-37 Complex traction RDs secondary to posterior vitreoschisis. Longitudinal B-scan
echograms from two different patients with diabetic retinopathy show traction detachment pro-
duced by inner wall of schisis cavity (A) and posterior hyaloid (B). P, Detached posterior hyaloid;
S, schisis cavity; straight arrows, inner wall of schisis cavity; curved arrows, membranous attach-
ment producing traction; ON, optic nerve.
A thorough echographic examination should be carried echographic appearance of residual vitreous gel and the char-
out just prior to vitrectomy surgery. * Echography may of- acteristics of hemorrhage in the vitrectomized eye (see p 109).
ten demonstrate the best area to insert the vitrectomy in-
struments and the safest regions to break through the pos- Pitfalls in the Differentiation of Retinal
terior hyaloid. The findings also allow the surgeon to
Detachment
anticipate areas of vitreoretinaladherence and traction. Fi-
nally, a thorough examination may provide a reasonable as- Although the diagnosis of an RD is generally straightfor-
sessment of the expected visual prognosis. ward (see p 54), a number of other lesions can simulate RD,
After vitrectomy, the examiner needs to be aware of the and certain types of RDs can be quite challenging to diag-
nose. The examiner must be aware of both situations to
*References 5, 10, 11,44,48,57. avoid a misdiagnosis (Box 3-1).
66 THE GLOBE
A
A
B
B
Figure 3-38 Retinoschisis. A, Transverse B-scan echogram

shows moderately elevated, thin, smooth, dome-shaped mem-
brane located in the inferotemporal periphery. B, Very thin 100%
high spike is shown on A-scan. (From Green RL, Byrne SF: Di-
agnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3,
c
Retinoschisis
Retinoschisis, most often involving the inferotemporal pe-
ripheral fundus, is usually bilateral. On B-scan, retinoschisis
appears as a smooth, thin, sharply demarcated, dome-shaped,
non-mobile membrane. On A-scan, retinoschisis produces a
100% high, single-peaked spike, which may demonstrate
Figure 3-39 Scleral indentation for differentiating retinoschisis
slight vertical aftermovement (Figure 3-38). from peripheral RD. Example of peripheral RD. Longitudinal B-
Retinoschisis differs from RD in its more focal, smooth, scan echo grams show localized inferotemporal RD prior to depres-
and thin character and its lack of mobility. Although a sion (A), shallowing of subretinal space with slight depression (B),
choroidal detachment is also dome-shaped and is located in and complete flattening of subretinal space with full depression (C).
the periphery, it is thicker than retinoschisis and, on careful
inspection, may show a double-peaked spike. Because
RETINAL PIGMENT EPITHELIUM
retinoschisis is often bilateral, examination of the fellow eye
may be helpful in establishing the diagnosis. The retinal pigment epithelium (RPE) cannot generally be
The use of scleral indentation in conjunction with B- echo graphically differentiated from the overlying retina or
scan7 can differentiate retinoschisis from localized rheg- underlying choroid. The inner surface of the RPE becomes
matogenous RD. After the membrane is localized with B- exposed and echographically apparent when the overlying
scan, scleral depression is simultaneously performed over retina detaches. In this situation, the inner surface of the
the affected area. If the membrane in question represents RPE appears smooth and echo-dense on B-scan and highly
an RD, the space between the sclera and the retina flattens reflective on A-scan (see Figure 3-19).
as the subretinal fluid is forced through the break into the The outer surface of the RPE and the sub-RPE space
vitreous cavity (Figure 3-39). Conversely, if the membrane can be demonstrated echo graphically in the presence of an
represents retinoschisis, the space between the sclera and RPE detachment. These detachments are usually due to
the inner wall of the retinoschisis narrows but does not macular degeneration, most commonly AMD. RPE de-
completely flatten (Figure 3-40). tachments may be focal (either serous, see p 70 and Figure
Chapter 3 VITREORETfNAl DISEASE 67
Figure 3-40 Scleral indentation for differentiating retinoschisis

from peripheral RD. Longitudinal B-scan echograms show
retinoschisis cavity in temporal periphery prior to depression (A)
and with full depression (B). Note that schisis cavity shallows but
does not collapse with full depression. ON, Optic nerve; arrow,
chain of multiple signals produced by depressor tip. (From Boldt
He, Brown DM, McGeorge AJ: Echographic diagnosis of de-
generative retinoschisis facilitated by scleral indentation [letter].
Am J OphthalmoI1994;118:124.)
3-41, or hemorrhagic, see p 161) or massive, secondary to c

diffuse, dense sub-RPE hemorrhage (see Figure 5-65). In
addition, certain intraocular tumors can occur beneath the
pigment epithelium (see Figure 5-54).
MACULA
Macular edema, AMD, macular holes, and other disorders
affecting the macula can be evaluated with ultrasound (Box Figure 3-41 Serous detachment of the RPE in AMD. A, Fundus
photograph demonstrates well circumscribed, nonpigmented le-
3-2). The macular region should always be assessed during sion at inferior edge of macular region. B, Vertical macula B-scan
an echographic screening examination of the eye. Tech- shows smooth, dome-shaped, blisterlike, echolucent lesion (ar-
niques for examining the macular region have been de- row). P, Posterior lens capsule. C, A-scan demonstrates very low
scribed previously in Chapter 2 (see p 28). internal reflectivity oflesion. S, Sclera.
Macular Edema
Macular edema is caused by leakage of fluid into the retina
in the macular region. Causes of this disorder include apha-
68 THE GLOBE
Figure 3-43 Cystoid macular edema. Longitudinal B-scan

echogram demonstrates mildly elevated dome-shaped lesion (arrow)
temporal to optic nerve (ON). Note small cystic space within lesion.
8
P 71), inflammatory lesions of the retina (e.g., tuberculous

granuloma [see p 205] and toxoplasmosis [see p 205]), as
well as small tumors involving the macular region. These
tumors include choroidal hemangioma (see p 147), metasta-
tic carcinoma (see p 143), choroidal nevus (see p 151), and
Figure 3-42 Macular edema. A, Longitudinal B-scan through choroidal melanoma (see p 115).
the macula shows moderately elevated dome-shaped lesion (ar-
row) just temporal to the optic nerve (ON). B, Lesion exhibits high
internal reflectivity on A-scan. R, Retina; C, choroid; S, sclera. Age-Related Macular Degeneration (AMD)
(From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in
Ryan S] red]: Retina. ed 3, St Louis, Mosby, 2001, p 256.) AMD is a chronic, degenerative disease, primarily involving
the choriocapillaris, Bruch's membrane, and RPE in the
macular region. Occasionally, however, this lesion can oc-
BOX 3-2 cur in an eccentric location. Other causes of macular de-
generation that can simulate AMD, both clinically and
Macular lesions echo graphically, include presumed ocular histoplasmosis
I\IICl~ularedema (POR) and myopic degeneration.
Age"rel~~e~macUlardegelleration(AMD) There are two primary forms of AMD: wet and dry. The
RPEdetachment dry form produces degeneration and atrophy of the RPE
Macularhole and overlying retina. Although this disorder may be associ-
RDofthe macula ated with slight thickening of the tissues in the macular re-
Hypotonymaculopathy (see p 72)
gion, ultrasound generally provides little assistance in its
Prert;lacular.hemol'rhaQe
detection and evaluation. In longstanding cases, however,
Staphyloma inlJollJipgthe macula
ultrasound can frequently detect small foci of calcification
underlying the flat or minimally elevated retina (probably at
the level of Bruch's membrane) (Figure 3-44).
kiclpseudophakic cystoid macular edema (CME) , diabetic In the wet form of AMD, choroidal neovascularization
retinopathy, uveitis, and retinal vein occlusions. produces sub-RPE and subretinal exudate and/or hemor-
Macular edema is characterized echo graphically by an rhage. In the more chronic stages of this form of the dis-
elevated, usually dome-shaped, lesion just temporal to the ease, fibrosis, scarring, and calcification can occur. Clini-
optic nerve. In many cases, these lesions are only very cally, the wet form of AMD is referred to as senile disciform
mildly elevated and show a somewhat irregular surface con- macular degeneration. The ultrasound features of senile dis-
tour. Their small size usually precludes an accurate assess- ciform macular degeneration vary according to the stage of
ment of their internal reflectivity. When moderately ele- the disease and the extent of exudate and/or hemorrhage
vated, however, they generally exhibit medium to high present.
internal reflectivity on A-scan (Figure 3-42) and may show A disciform lesion generally appears as a mildly to
small cystic spaces on B-scan (Figure 3-43). moderately elevated, dome-shaped, heterogeneous lesion
The echographic differential diagnosis of macular edema on B-scan and as two or three highly reflective spikes on
includes AMD, epiretinal membranes, macular holes (see A-scanS (Figure 3-45). The internal structure of these le-
A B
Figure 3-44 Dry form of AMD with calcification. A, LongitUdinal B-scan througtrthe maCula
shows a mildly elevated lesion containing echo-dense signal corresponding to calcific degener- <
ation (straight arrow). Note shadowing produced by the calcium (curved arrow). B, A-scan demon- .• ~.
strates very high reflectivity of calcified lesion (arrow). S, Sclera.
A c
Figure 3-45 Disciform macular lesion. Horizontal axial

(A) and vertical transverse (B) B-scan echo grams show
mildly elevated lesion in the macular region (arrows). C, A-
B scan displays the two highly reflective spikes (D) that are
suggestive of a disciform lesion. S, Sclera. (From Green RL,
Byrne SF: Diagnostic ophthalniic ultrasound, in Ryan S]
led]: Retina. ed 3, St. Louis, Mosby, 2001, p 282.)
70 THE GLOBE
Figure 3-47 Fundus photograph showing full-thickness macu-

lar hole. (Courtesy Dr. MarkJohnson, Ann Arbor, Michigan.)
B
hemorrhage is substantial, the echo graphic features of the
lesion differ significantly from those described earlier and
need to be differentiated from intraocular tumors. These
hemorrhagic disciform lesions and their differential diag-
noses are described in Chapter 5 (see p 160).
Another manifestation of AMD is the presence of serous
Figure 3-46 Longstanding disciform lesion with calcification. RPE detachments. These lesions may occur in combina-
A, Longitudinal B-scan through macula at high gain shows mod- tion with, or instead of, the disciform lesion previously de-
erately elevated lesion (curved al'"'row). B, Same longitudinal B-scan scribed. Clinically, RPE detachments appear as sharply de-
view as in A at reduced gain shows two echo-dense nodules (closed marcated, mildly elevated lesions, either in the macular
m"'rows) representing foci of calcification within lesion. Open ar- region or in an eccentric location. These smooth, dome-
rows indicate thin lines of shadowing produced by calcium.
shaped lesions appear blisterlike and echolucent on B-scan
and very low reflective on A-scan (see Figure 3-41).
These blisterlike RPE detachments are often hemor-
sions can vary, depending on the degree and the extent of rhagic and, as such, may masquerade as choroidal mela-
exudate and hemorrhage in the sub-RPE and/or subreti- nomas clinically. The echo graphic appearance of these le-
nal spaces. Lesions that are only mildly elevated may sions is described in Chapter 5 (see p 161 and Figure 5-68).
demonstrate somewhat irregular surface contour. Because
these findings are only suggestive of, rather than specific
Macular Holes
for, a disciform lesion, the diagnosis can be substantiated
echo graphically only by observing a decrease in elevation Macular holes (Figure 3-47) can lead to significant central
with serial examinations. Another helpful sign is the pres- visual loss. The cause of macular hole formation is contro-
ence of calcification that can occur in longstanding cases versial, but the most widely \lccepted theory is that macular
(Figure 3-46). holes are a result of vitreous traction in the macular re-
The echo graphic differential diagnosis of a disciform le- gion. 21 ,35 Various stages of macular holes have been
sion includes metastatic carcinoma to the choroid, identified, ranging from impending holes to full-thickness
choroidal hemangioma, choroidal nevus, and macular holes. Until recently, there has been no effective treatment
edema. These lesions may all be highly reflective and, for this condition. Vitreoretinal procedures have now been
therefore, can be difficult to differentiate from disciform developed, however; for the treatment of full-thickness
lesions. As previously mentioned, demonstrating a regres- macular holes. 52
sion in size over time may be the only way to establish the Ultrasound and ocular coherence tomography (OCT)
diagnosis of a disciform lesion with echography. Further- are the two methods currently available for imaging the vit-
more, it should be noted that a mildly elevated disciform reoretinal relationship in the macular region. 29 OCT has
lesion can be difficult to differentiate from a small choroidal been shown to provide high-resolution images of vitreous
melanoma. Serial examinations may be helpful because traction on the macula and full-thickness macular holes
choroidal melanomas typically show growth, whereas dis- (Figure 3-48). The primary limitation of OCT is its inabil-
ciform lesions usually regress. ity to provide a broad perspective of the vitreous body and
As previously mentioned, disciform lesions can be asso- its relationship to the macula. Echography, on the other
ciated with sub-RPE and subretinal hemorrhage. "When the hand, can, in most cases, evaluate the overall status of the
Figure 3-48 OCT showing full-thickness macular hole (arrow).

(Courtesy Dr. Gregg Kokame, Honolulu, Hawaii.)
Figure 3-50 Two cases of full thickness macular holes resolved

with B-scan. A, Longitudinal B-scan at reduced gain demonstrates
elevated lesion in macular region with imaging of actual macular
hole (arrow). ON, Optic nerve. B, Reverse longitudinal B-scan of
another case at reduced gain also displays macular hole (arrow).
Figure 3-49 Full-thickness macular hole. Longitudinal B-scan (B courtesy Dr. Gregg Kokame, Honolulu, Hawaii.)
at reduced gain demonstrates mild elevation in macular region
with slight central depression corresponding to macular hole.
Small opacity directly over depression (arrow) represents retinal
operculum. ON, Optic nerve.
vitreous in relation to the macula and can provide addi-

tional information to that given by OCT. Echography can
also assess kinetic properties of the vitreous that can help
clarify vitreoretinal attachments in the peripapillary region
and macula.I 3,16,17
With macular holes, the echographic findings are very
subtle. Several studies have shown, however, that these
findings correlate well with th~ various stages of macular
hole development. 13 ,34,58,59 Ultrasound demonstrates the re-
lationship of the vitreous to the macula, as well as changes
in the topography of the macular region.
As previously described, there are specific methods for Figure 3-51 Relationship ofPVD to macular hole (same case as
examining the macular region (see p 28). It is suggested that in Figure 3-48). Para-axial B-scan at high gain displays shallow
the macula be examined with several different probe orien- detachment of posterior hyaloid (P) overlying macular hole rep-
resented by mild elevation in macular region (arrow). ON, Optic
tations to most accurately define the vitreomacular rela- nerve. (Courtesy Dr. Gregg Kokame, Honolulu, Hawaii.)
tionships.34,38 A recent report emphasizes the importance
of directing the sound beam perpendicular to the macular
region. These investigators found that placing the probe on
the cornea with the sound beam directed through the lens pression cprresponding to the hole (Figure 3-49). In some
(horizontal axial and vertical macula scans) were the opti- cases, B-scan can resolve the full thickness macular hole
mal probe positions for imaging the posterior hyaloid in (Figure 3-50). A shallow PVD can often be demonstrated
the macula. 34 directly over the macular region, either still adherent to
In a fully developed macular hole, ultrasound typically (stage 3) or completely separated from (stage 4) the optic
shows an elevation in the macular region with a central de- disc (Figure 3_51).13,59 In both instances, ultrasound often
72 THE GLOBE
known macular hole. It has been shown that the presence of

a PVD in the fellow eye significantly lowers the risk for
hole formation. Biomicroscopy can only determine if a
PVD is present when a pseudo-operculum is detected over-
lying the macula. 58 A pseudo-operculum is thought to rep-
resent a focal condensation of the vitreous cortex suspended
on the detached hyaloid in front of the macula. 22 ,25 In eyes
in which a pseudo-operculum cannot be seen with biomi-
croscopy, ultrasound may be the only means of demon-
strating the presence of a shallow PVD overlying the mac-
ula (Figure 3-53).
Retinal Detachment of the Macula

Retinal detachment involving the macula can be secondary
to traction (e.g., diabetic retinopathy), exudate (e.g., cen-
tral serous retinopathy), hemorrhage (e.g., AMD), and tears
Figure 3-52 Stage 2 macular hole. Longitudinal B-scan shows or holes. They can also occur in association with optic pits
shallow, partial detachment of the posterior hyaloid (P) adherent (see Figure 16-29). The determination of whether an RD
to surface of elevated macula (arrow). ON, Optic nerve. (Courtesy
involves the macular region is essential in the management
Dr. MarkJohnson, Ann Arbor, Michigan.)
and prognosis of the disorder; therefore, precise echo-
graphic localization is essential (see p 28). When the ocular
media are opaque, ultrasound can help determine the ex-
tent and cause of a macular RD. Ultrasound can even be
useful in clear ocular media, especially in a large staphy-
lomatous eye in which a shallow detachment of the macula
may not be clinically apparent (see p 73).
As discussed in the section on diabetic retinopathy,
bridging membranes overlying the macular region can sim-
ulate tractional detachment of the macula (see p 62). In ad-
dition, certain conditions can exhibit traction retinal folds
through the macula. These include retinopathy of prema-
turity (see p 184) and toxocariasis (see p 203).
Hypotony Macuiopathy
Figure 3-53 Pseudo-operculum. Vertical macula B-scan shows
small echo-dense opacity (arrow) on surface of detached posterior In chronic hypotony, diffuse thickening of the retino-
hyaloid (P) overlying macula. Note absence of macular elevation. choroid layer in the macular region results from thicken-
ing and shrinkage of the posterior sclera. This may lead to
significant irreversible visual loss if the pressure is not re-
identifies a small opacity on the posterior surface of the stored to normal (see Figure 7-11).
hyaloid directly over the macula. This opacity has been The thickened retinochoroid layer and thickening of the
shown to correspond to an operculum attached to the pos- posterior sclera can be demonstrated on B-scan examina-
terior hyaloid (see Figure 3-49). In addition to the retinal tion. Focal detachment of the retina, RPE, and/or choroid
operculum, ultrasound may identify opacities correspond- at the macula can occasionally be detected (see Figure
ing to the Weiss ring26 (see Figure 3-9) when the vitreous is 7-1 0). This disorder is described in more detail in Chapter
completely detached from the optic disc (see p 49). Rarely, 7onp216. .
the Weiss ring may be present (indicating detachment from
the optic nerve) even though the vitreous is still attached
Premacular Hemorrhage
in the macular region. 39 ,4o
In early stages of macular hole development (stages 1 and Certain disorders produce hemorrhage in the premacular
2), ultrasound often reveals partial detachment of the pos- region. This premacular hemorrhage, located either in the
terior hyaloid, with persistent attachment to the macula. A subhyaloid space or beneath the internal limiting mem-
slight elevation of the macula may be apparent, suggesting brane, may be associated with a vitreous hemorrhage that
vitreous traction on the developing hole (Figure 3-52).34 precludes visualization of the posterior pole. Disorders that
Ultrasound may be a useful adjunct to biomicroscopy in may cause premacular hemorrhage include Terson's syn-
the detection of a PVD in the fellow eyes of patients with a drome,61 hypertensive retinopathy, retinal artery micro-
fj
A
A
B B
Figure 3-54 Premacular hemorrhage due to Terson's syndrome. Figure 3-55 Premacular hemorrhage. A, Fundus photograph
Echograms show shallow retina-like membrane resulting from shows layering of premacular hemorrhage. B, Longitudinal B-
dense preretinal hemorrhage. A, Horizontal axial B-scan at re- scan through macula demonstrates smooth, dome-shaped mem-
duced gain shows shallow, smooth, echo-dense, dome-shaped brane overlying macula (white a170W) and layering of submem-
membrane (straight arrow) overlying macula and inserting into op- branous blood (black arrow). ON, Optic nerve. (Courtesy Dr.
tic nerve (ON). Note mild hemorrhage in posterior vitreous over- Barbara Blodi, Madison, Wisconsin, and Kathleen Meyer,
lying membrane (curved arrow). B, A-scan obtained with probe on RDMS, ROUB, Ann Arbor, Michigan.)
cornea shows high reflectivity of membrane (a17ow) compared to
retina (R) and sclera (S). A, Anterior lens capsule; P, posterior lens
capsule. (A courtesy Dr. Barbara Blodi, Madison, Wisconsin, and
Kathleen Meyer, RDMS, ROUB, Ann Arbor, Michigan.)
aneurysm, leukemia, shaken-baby syndrome, and Valsalva they may be secondary to congenital disorders and colobo-
maculopathy. mas that involve the macula. Ultrasound can easily demon-
On ultrasound, premacular hemorrhage appears as a strate the bowing out of the posterior scleral wall (see Fig-
dome-shaped, smooth, mildly elevated, nonmobile mem- ure 10-25). As previously mentioned, shallow RDs in the
brane overlying the macula. 46 This membrane, which rep- macular area in the presence of a posterior staphyloma can
resents the posterior hyaloid or internal limiting membrane, sometimes be appreciated better with ultrasound than with
is usually highly reflective due to the submembranous blood ophthalmoscopy (Figure 3-56).
adherent to its posterior surface (Figures 3-54 and 3-55). The echo graphic localization of a posterior staphyloma is
Consequently, it may mimic a localized detachment of the very important in obtaining accurate axial eye length mea-
macula. Differentiation from RD can usually be made by surements for intraocular lens calculations (see Chapter 10).
considering the history and other clinical findings. Serial
echographic examinations will also often show resolution of
Trauma Involving the Macula
the hemorrhage and flattening of the overlying membrane.
Trauma can cause several different types of macular lesions,
including Berlin's edema (commotio retinae, see p 90),
Staphyloma Involving the Macula
choroidal ruptures (see Figure 4-7), and traction detach-
Staphylomas involving the macular region are most comments (see p 58), as well as intraretinal and preretinal hem-
monly associated with elongated, highly myopic globes, or orrhage (see above).
74 THE GLOBE
Choroidal Inflammation
Choroidal thickening can also be produced by diffuse inflam-
matory infiltration, such as Vogt-Koyanagi-Harada syn-
drome (see p 200), sympathetic ophthalmia (see p 201), and
lymphoid hyperplasia of the uvea (see p 153). In these con-
ditions, the homogeneous nature of the choroidal inflamma-
tory infiltration contrasts with the highly reflective retinal
and scleral borders, facilitating detection with ultrasound.
On B-scan the thickened choroid appears as an echolucent
band, whereas on A-scan, the infiltration exhibits low to
medium internal reflectivity. The ability of ultrasound to im-
age the choroid in these conditions has gready enhanced
their detection and diagnosis. In addition, ultrasound is often
Figure 3-56 Staphyloma of macula with shallow RD. Horizon- more reliable than CT scan and MRI in differentiating
tal axial B-scan shows staphyloma temporal to the optic nerve choroidal from scleral thickening (see Figures 5-55 and 6-8).
(ON) involving macula. White arrows, shallow RD involving mac-
ula; black arrow, macula. Choroidal Tumors
Choroidal thickening may also be caused by either primary
or metastatic tumors (see Chapter 5). Mildly elevated, dif-
fuse choroidal tumors may be difficult to differentiate echo-
CHOROID
graphically and, therefore, can be confused with choroidal
Although the choroid and suprachoroidal space can be ex- thickening of other etiologies. These choroidal tumors in-
amined indirecdy with ophthahnoscopy and fluorescein an- clude diffuse melanomas, metastatic carcinomas, lym-
giography, ultrasound has gready enhanced the examina- phomas, and diffuse hemangiomas (as in Sturge-Weber
tion of this region of the eye. In the normal eye, ultrasound syndrome) (see Figures 5-46 and 5-47).
is generally unable to differentiate the thin layer of choroid
from the overlying retina and underlying sclera. This com- Choroidal Folds
plex of surfaces (i.e., posterior ocular coats) appears as an Choroidal folds can produce diffuse thickening of the pos-
echo-dense band on B-scan and as a small group of highly terior choroid. This thickening appears related to diffuse
reflective spikes on A-scan. However, when the choroid thickening of the posterior sclera; together, these produce
and/or suprachoroidal space are expanded by fluid or distinct echographic findings (see p 80).
infiltration, ultrasound is then able to image this region to
provide topographic, quantitative, and kinetic information
Choroidal Detachment
not obtainable by other means.
Choroidal detachment occurs when serous fluid, blood, or
inflammatory debris accumulates in the suprachoroidal
Choroidal Thickening
space. Choroidal detachments usually occur in peripheral
Choroidal thickening, either focal or diffuse, may be asso- aspects of the eye, but they may extend to the posterior
ciated with many conditions. The causes of choroidal thick- pole. Peripheral choroidal detachments usually also involve
ening include edema, inflammatory infiltration, tumor, and the ciliary body (ciliochoroidal detachments). Choroidal
. idiopathic choroidal folds. detachments may be shallow or bullous in nature. They can
be associated with a number of conditions and can develop
Choroidal Edema following surgery or trauma49 (Box 3-3).
Choroidal edema can be produced by inflammation, vas- The characteristic echo graphic features of choroidal de-
cular congestion, and hypotony. In the presence of tachments generally facilitate differentiation from other
choroidal edema, the posterior ocular coats appear thicker conditions (see Table 3-1).
than normal, and in some cases, the retinochoroid layer is A choroidal detachment typically presents as a smooth,
distinguishable from the sclera. In this situation, two bands thick, dome-shaped membrane on B-scan and as a thick,
can be identified on B-scan: one representing the retino- steeply rising, 100% high spike on A-scan (Figure 3-57).
choroid layer, the other the sclera. On A-scan, the group On careful inspection at low gain, a double-peaked spike
of highly reflective spikes representing the posterior ocular may be observed. The kinetic evaluation typically shows lit-
coats is thicker and the individual spikes are more distinct de or no aftermovement with either A- or B-scan.
(see Figure 7-10). In most cases, the retina cannot be dis- Choroidal detachments that extend for 360 degrees pro-
tinguished from the edematous choroid unless the retina is duce a typical scalloped appearance when scanned with a
detached. transverse approach (Figure 3-58, A). Highly elevated de-
A c
Figure 3-57 Peripheral serous choroidal detachment.

A, Transverse view through peripheral aspect of globe
shows typical dome-shaped configuration of choroidal de-
tachment (C). B, Peripheral longitudinal B-scan echogram
B
again shows dome-shaped configuration of choroidal de-
tachment. Note sharp insertion of posterior margin (arrow).
C, A-scan shows 100% high, thick, double-peaked spike
from choroidal detachment.
vated, a thin band stretching from the inner aspect of the

BOX. 3-3
detached choroid to the sclera may be noted. This band is
Causes of Choroidal (Ciliochor6idal) postulated to represent a vortex vein or a ciliary blood ves-
Detachment sel and/or nerve (Figures 3-58, C and 3-59).
Idiopathic Choroidal detachments very often extend anteriorly to
Uveal.effusion syndrome (see p 82) involve the ciliary body and, in such cases, are more appro-
Nanpphthalmos(see p 82) priately referred to as ciliochoroidal detachments. Shallow
Inflammatory peripheral choroidal detachments typically appear flat and
Uv,eitis(infectious or noninfectiQus,see p 194) smooth on B-scan, as opposed to the scalloped appearance
Scleritis (see p 195) described earlier. When an annular ciliochoroidal detach-
Hypotony (see p 214) ment extends a full 360 degrees, it can be easily confused
lntradcular surgery (see pp 109 and 216) with a shallow, peripheral RD. It should be noted, however,
Trauma
that it is very rare for a non tractional RD to be so extensive
Intraocular tumor (see p 144)
and yet confined only to the periphery30 (see p 54).
ArteriovenouSfistula (see p 355)
Renal disease The accumulation of hemorrhage and/or cellular debris
Toxic reactions to systemic medications (see p 216) in the suprachoroidal space produces echoes in this region
(Figure 3-60). Dense hemorrhage may produce solid clots
that can be detected and monitored with ultrasound (see
p 106). A focal (especially hemorrhagic) choroidal detach-
ment may initially simulate a melanoma, but it can usually
tachments are more likely to extend to the posterior pole be differentiated by noting mobility of the fluid supra-
and may insert adjacent to but not directly into the optic choroidal blood and/or by changes observed with follow-
disc (Figure 3-58, B and C). up examinations (see p 106 and Figure 5-71). It is also of
In some cases of 360 degree, highly elevated choroidal interest that choroidal detachments can be associated with
detachments, apposition of the temporal and nasal detach- uveal tumors (see Chapter 5 and Figure 5-43), as well as ve-
ments may occur in the central aspect of the vitreous cavity nous congestion (see p 355).
(kissing or appositional choroidal detachments) (Figure Choroidal detachments can usually be differentiated
3-58, B and C). When the detachment is sufficiently ele- from RDs. However, when choroidal detachments decrease
76 THE GLOBE
A c
Figure 3-58 Topographic characteristics of bullous,

choroidal detachments at reduced gain setting. A, Ex-
tremely peripheral transverse section through 360 degree
choroidal detachments show classic scalloped shape. Kiss-
ing choroidal detachments are shown in B (axial view) and
B C (longitudinal view). Note broad central adherence (ar-
rows) and insertion next to optic nerve (ON). Suprachoroidal
band (B) is shown in C. (From Green RL, Byrne SF: Diag-
nostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3,
A B
Figure 3-59 Bullous choroidal detachments with band in suprachoroidal space. A, Peripheral
transverse section through choroidal detachments shows typical scalloped appearance and supra-
choroidal band (arrow). B, Longitudinal view displays cross-section of band (arrow).
peciallynasally. Whenever an abnormality is suspected,

comparison with the same region of the contralateral eye
is recommended. Ciliochoroidal detachments can be
demonstrated with both B-and A-scan (Figure 3-61). The
contact technique can also show posterior ciliary body tu-
mors or peripheral choroidal tumors that extend into the
pars plana (see p 173).
A An immersion technique is often more effective for eval-
uating the ciliary body31,42 (see p F and Chapter 8). De-
tachments of the ciliary body (Figure 3-62), cyclitic mem-
branes (Figure 3-63), and in some cases, cyclodialysis clefts
are best shown using-this technique. These findings are
shown even better with the newer high resolution B-scan
instrumentation (Figure 3-64; see also Figure 8-19). The
position of intraocular lenses and their haptics can also be
shown with this equipmenr47,53 (see Figure 8..,,18).
SCLERA
Many disorders affectthe sclera. However, clinical evalua-
tion of the sclera, especially posteriorly, is o£!:endifficult be-
cause the sclera cannot bedirecdy visualized. As a result,
B scleral disorders oftert go undetected or misdiagnosed. The
imaging capabilities of ultrasound make it an ideal tool to
assist in the evaluation of the sclera and its various disor-
ders (Box 3-4).
Examination Techniques for the Sclera '.

Examination of the sclerais best achieved using'B-scan.
Figure 3-60 H~inorrhagic choroidal detachment. A, Transverse Certain probe positions can facilitate the assessment of
B-scan echogram demonstrates moderately elevated, thick, dome- scleral topography and thickness, as well as the relationship
shaped membrane with dense suprachoroidal hemorrhage. B, of the sclera to other ocular and orbital structures. Immer-
A-scan shows thick, 100% high choroidal spike (C) and blurred,
low-to-medium reflective spikes (arrows) from the mobile supra-
sion techniques can be helpful for evaluating the anterior
choroidal blood. (From Green RL, Byrne SF: Diagnostic oph- sclera, especially with the use of high resolution B-scan (see
thalmic Ultrasound, in Ryan S] [ed]: Retina. ed 3, St Louis, Mosby, Chapter 8). A-scan can be used as well to evaluate the quan-
2001, p 258.) titative features of thickened sclera.
A relatively high gain setting is used initially to image
the sclera with B-scan. Once the sclera is displayed, the gain
in elevation,' they may exhibit more pronounced after- is reduced to better distinguish the scleral borders from the
movemen.t and a more folded appearance, similar to that of surrounding tissues. The posterior sclera is best evaluated
anRD.: with a combination of axial, para-axial, and longitudinal
probe positions, whereas transverse and longitudinal ap-
proaches are primarily used for the peripheral sclera (see
CILIARY BODY
Chapter 2).
The ciliary body can be difficult to assess using conven-
tional ultrasound because of its extreme anterior location
Normal Sclera
and its irregular surface contour. Abnormalities of the cil-
iary body that can be detected with ultrasound include The appearance of normal sclera varies with the size of the
thickening due to edema or infiltration, detachment, or tu- globe being examined. Scleral thickness increases as eye size
mors (see p 173). In addition, cyclitic membranes and in decreases (i.e., hyperopia) and decreases as eye size in-
some cases, cyclodialysis clefts can be demonstrated. creases (i.e., myopia). In all cases, however, the.normal
The contact method of ultrasound can assess the more sclera is thickest posteriorly, measuring approximately 1.0
posterior aspects of the ciliary body (i.e., pars plana) and mm in an eye of average size. In the anterior aspects of the
sometimes the anterior ciliary body (i.e., pars plicata), es- globe, the sclera thins, measuring 0.6 mm at the equator
78 THE GLOBE
Figure 3-61 Normal ciliary body and ciliochoroidal detachment (contact technique). Normal
ciliary body (CB) is shown in A and Band ciliochoroidal detachment (arrows) is shown in C to
E. A, Peripheral longitudinal B-scan of normal ciliary body shows slight elevation. B, A-scan
shows thick, irregular spike from coarse surface of normal ciliary body. Extremely peripheral
transverse (C) and longitudinal (D) B-scans show detachment of ciliary body and peripheral
choroid. E, A-scan demonstrates 100% high spike from detachment. (C to E from Green RL,
Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan 5] led]: Retina. ed 3, St Louis, Mosby,
2001, p 259.)
A D
B E
c F
Figure 3-62 Normal and ciliary body detachment (immersion technique). Normal ciliary body
(straight arrows) is shown in A to C and ciliary body detachment (curved arrows) is shown in D to
F. A and D, Longitudinal B-scans. Band E, Transverse B-scans. C and F, A-scan echograms.
C, Cornea; I, iris; M, methylcellulose within scleral shell; S, sclera; V, vitreous cavity.
80 THE GLOBE
BOX 3-4
Disorders of the Sclera
Thickening of sclera
Hyperopia
- Choroidal folds
Nanophthalmos
Uveal effusion syndrome
Anterior ischemic optic neuropathy (AION)
Scleritis
Hypotony
Thinning of sclera
Myopia
Figure 3-63 Cyclitic membrane. Immersion B-scan shows shal-
low anterior chamber, cataractous lens, and dense cyclitic mem- Staphyloma
brane (arrows). Membrane inserts into the ciliary body at edges of Necrotizing scleritis
echogram. M, Methylcellulose within scleral shell; S, side of scler- Plaque radiotherapy
al shell; V, vitreous cavity. (From Green RL, Byrne SF: Diagnos- Scleral rupture (see pp 90 and 95)
tic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Scleral infolding (see p 97)
Mosby, 2001, p 260.) Scleral calcification (see pp 114, 148, and 151)
Scleral tumor (see p 155)
cause transverse scans are used for screening the globe (see
p 22), overall scleral thickness is usually evaluated with this
probe orientation. To confirm the presence of scleral ab-
normalities, however, longitudinal scans should also be uti-
lized. The extraocular muscle insertions are important
landmarks that can aid in the evaluation of peripheral scler-
al thickness because the insertion of the muscle highlights
the outer surface of the sclera (see Chapter 15).
Disorders of the Sclera

In most cases, scleral abnormalities include thickening,
Figure 3-64 Cyclodialysis cleft. High resolution B-scan (20 thinning, deformity, or infiltration. These findings may be
MHz) (longitudinal view) is through peripheral aspect of anterior either diffuse or focal.
chamber and ciliary body. Arrow indicates cyclodialysis cleft be-
tween the anterior chamber and supraciliary space (curved arrow) Thickening of the Sclera
created by the detachment of the ciliary body. (Courtesy Rhonda HYPEROPIA
Waldron, MMSc, COMT, Atlanta, Georgia.)
Hyperopia is generally associated with a shorter than nor-
mal eye and thicker than normal sclera (Figure 3-66). Al-
though thickened sclera in the hyperopic globe is a normal
and only 0.3 mm directly beneath the insertions of the rec- finding, these eyes, as well as those of normal size with
tus muscles. 55 atypically thickened sclera, are predisposed to certain dis-
Echographically, the outer scleral surface can be distin- orders, including choroidal folds, uveal effusion syndrome,
guished from the adjacent highly reflective Tenon's capsule and anterior ischemic optic neuropathy (AlON).
by reducing the gain. The relationship of the sclera to the
optic nerve is best evaluated using axial and/or longitudi- CHOROIDAL FOLDS (CHORIORETINAL FOLDS)
nal scans. However, the inner scleral surface may be Although choroidal folds represent folding or wrinkling of
difficult to distinguish from the adjacent retinochoroid the choroid and retina, the underlying cause appears to be
layer unless there is thickening or infiltration of the choroid scleral thickening. 22 A number of conditions cause sec-
and/or retina. Consequently, the very thin retinochoroid ondary choroidal folds, including indentation of the sclera
layer may have to be included in the assessment of scleral by a retrobulbar mass, a foreign body, or a scleral buckle.
thickness (Figure 3-65). In these conditions, it is postulated that the folds are due to
As previously mentioned, the peripheral sclera is best as- thickening and indentation of the sclera. Scleritis may also
sessed using both transverse and longitudinal scans. Be- cause thickening of the sclera and secondary choroidal
A B
Figure 3-65 B-scan imaging of sclera in eye of normal size. Horizontal axial (A) and longitu-
dinal (B) scans show band corresponding to normal sclera combined with thin retinochoroid
layer (arrows). ON, Optic nerve.
A B
Figure 3-66 Short hyperopic globe with thick sclera. A, Horizontal axial B-scan demonstrates
the thick nature of posterior sclera. Thickness of sclera temporal to optic nerve (ON) measures
1.5 6 mm. B, Contact A-scan measurement of axial length = 21.07 mm. A, Anterior lens capsule;
P, posterior lens capsule; R, retina; S, sclera.
82 THE GLOBE
A C
B 0
Figure 3-67 Choroidal folds associated with flattening of posterior ocular wall. A, Fundus
photograph shows choroidal folds radiating horizontally from the optic disc. B, Corresponding
horizontal axial B-scan echogram shows typical flattening of posterior ocular wall (arrows).
ON, Optic nerve. C, Fundus photograph of normal fellow eye. D, Corresponding horizontal
axial B-scan echo gram of fellow eye shows normal concave appearance of posterior ocular wall.
folds (see p 195). Choroidal folds have also been associated least 2 mm! and axial eye lengths can range from 14.0 to
with choroidal tumors (e.g., melanoma and metastatic car- 20.5 mm. 33 Other findings include a shallow anterior cham-
cinoma) and infiltrative disorders such as VKH (see p 200). ber and diffuse thickening of the retinochoroid layer. Al-
Hypotony caused by uveitis or trauma, or occurring as a though the lens in these very short eyes is of normal size, it
result of glaucoma surgery, may also cause choroidal folds occupies a proportionately greater than normal volume
because of shrinkage of the globe and subsequent scleral (Figure 3-68). Nanophthalmic eyes are predisposed to an-
thickening. However, the majority of choroidal folds are gle closure glaucoma (see p 214), as well as to postopera-
idiopathic. They are often found as an incidental finding, tive or spontaneous serous ciliochoroidal and retinal de-
usually in patients who are hyperopic. tachments (i.e., uveal effusion syndrome).
The most striking echo graphic feature of idiopathic
choroidal folds is flattening of the posterior ocular wall UVEAL EFFUSION SYNDROME
caused by diffuse thickening of the posterior sclera and Uveal effusion syndrome, which produces spontaneous,
retinochoroid layer (Figure 3-67). These eyes frequently serous ciliochoroidal and retinal detachments, appears to
have a shorter than normal axial length (see p 244), and be caused by diffuse thickening of the sclera. It is hypothe-
there may be echographic evidence of increased fluid sur- sized that the thickened sclera leads to obstruction of the
rounding the retrobulbar optic nerve 2 (see p 419). vortex veins and subsequent accumulation of proteinaceous
fluid in the suprachoroidal and, in some cases, the subreti-
NANOPHTHALMOS
nal space. 22 In addition to demonstrating the ciliochoroidal
This bilateral condition is characterized by diffuse, marked and retinal detachments, ultrasound can show thickening
thickening of the sclera and very short axial eye lengths. of the sclera and retinochoroid layer (Figure 3-69). These
Scleral thickness in these eyes has been reported to be at eyes are usually shorter than normal and may be very short
83
Figure 3-68 Nanophthalmos. A, Horizontal axial B-scan at reduced gain shows thickening of
posterior retinochoroid layer and sclera (arrow). ON, Optic nerve. B, A-scan at reduced gain
shows contact axial length measurement of 19.3 mm. A, Anterior lens capsule; P, posterior lens
capsule; R, retina.
Figure 3-69 Choroidal detachment (A) and choroidal and retinal detachment (B) in uveal ef-
fusion syndrome. A, Anterior longitudinal B-scan displays peripheral dome-shaped, serous
choroidal detachment (C) as well as diffuse thickening of retinochoroid layer (black straight arrow)
and sclera (black curved aT7ow). B, Anterior transverse B-scan shows shallow choroidal detach-
ment (C), RD (R), and PVD (P).
84 THE GLOBE
sclera in these patients produces long, narrow scleral canals

and the clinical finding of a crowded discl 5,23 (see p 434).
These findings may be implicated in the pathogenesis of
AlON.3,14 Ultrasound in these eyes demonstrates thickened
sclera and long scleral canals (Figure 3-70). The axial
length measurement is usually normal or moderately
A short. 15 These findings are similar to those of patients with
idiopathic chorioretinal folds that can sometimes be clini-
cally identified in eyes with AlON.
SCLERITIS
Ultrasound can be used to evaluate both anterior and poste-

rior scleritis and is, in fact, the best imaging modality for di-
agnosing posterior scleritis.4,23,27 The scleral thickening in pos-
terior scleritis can vary from mild to marked and can be either
diffuse or localized (i.e., nodular; see p 196). Along with the
thickened sclera, there is generally thickening of the choroid,
as well as edema or inflammatory infiltration in sub-Tenon's
space. Scleritis is discussed in detail in Chapter 6 (see p 195).
B
HYPOTONY
Longstanding hypotony following glaucoma surgery or sec-

ondary to uveitis, ruptured globe or a cyclodialysis cleft
usually leads to shrinkage of the globe and diffuse thicken-
ing of the sclera. This condition is also often associated
with diffuse thickening of the retinochoroid layer, and
choroidal detachments may develop. Hypotony maculopa-
thy can also occur (see p 72).22 The ultrasound findings for
hypotony are described in detail in Chapter 7 on p 216.
Thinning of the Sclera
MYOPIA
c Large myopic globes have thinner than normal sclera. Be-
cause it is much more difficult to distinguish the sclera from
the adjacent ocular coats using ultrasound, it is often nec-
essary to include the retina and choroid when evaluating
the scleral thickness. As in eyes of normal axial length, the
sclera tends to be thinner in the periphery than posteriorly
in the myopic eye.
Figure 3-70 Crowded optic disc. A, Fundus photograph shows
blurring of the disc margins (pseudopapilledema) due to crowded STAPHYLOMA
optic disc. Longitudinal B-scans from two different patients show
eye of average length (B) and short hyperopic eye (C). Note mild Focal or localized thinning of the sclera can produce a
elevation of optic disc (curved white arrows), long scleral optic staphyloma. These lesions may be congenital, or they may
canals (black straight arrows), and thickened posterior sclera develop following chronic inflammation or intraocular
(straight white arrows). surgery. Anterior staphylomas can be confused with in-
traocular tumors, whereas posterior staphylomas can com-
plicate the biometrY examination (see p 263). Large, broad
as occurs in nanophthalmos (see p 82).56 In some cases, ul- staphylomas in the posterior pole are often_associated with
trasound can detect increased subarachnoid fluid around high axial myopia. However, staphylomas may be eccentric,
the optic nerve (see p 419 in Chapter 16). These patients located near the equator. When these eccentric staphylo-
may also present with secondary angle closure glaucoma mas are large, they have been observed to be associated
(seep 214). with significant corneal astigmatism. 24
ANTERIOR ISCHEMIC OPTIC NEUROPATHY NECROTIZING SCLERITIS
Anterior ischemic optic neuropathy (AlON) may be caused, Thinning of the sclera can develop secondary to necrotiz-
in part, by thickening of the posterior sclera. The thickened ing scleritis. When the scleral thinning presents anteriorly,
the underlying choroid may sometimes be visible through 10. Coleman DJ, Franzen LA: Vitreous surgery: preoperative evaluation
the thin sclera, thus producing a dark or pigmented ap- and prognostic value of ultrasonic display of vitreous hemorrhage.
Arch OphfhalmoI1974;92:375.
pearance that may clinically simulate a tumor. In these sit- 11. Coleman DJ: Preoperative evaluation of the vitreous with ultrasound,
uations, ultrasound can be used to identify the thin sclera in McPherson A (ed): New and Controversial Aspects of Vitreoretinal
and exclude the presence of an intraocular tumor (see p 196 Surgery. St Louis, Mosby, 1977, P 95.
12. DiBernardo C, Blodi BA, Byrne SF: Echographic evaluation of retinal
and Figure 6-12). _tears in patients with spont:aneous vitreous hemorrhage. Arch Oph-
thalmoI1992;110:51L
PLAQUE RADIOTHERAPY (BRACHYTHERAPY) 13. Dugel PU, Smiddy WE, Byrne SF, et al:Macular hole syndromes.
Echographic findings with clinical correlation. Ophthalmology
Radioactive plaques are often used to treat choroidal 1994;101:815.
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treatment. pathogenesis of ischemic optic neuropathy. Am J Oph-thalmol
1984;98:105.
15 .. Feldon SE, Sadun AA, DuBois LG, et al: Echographic features pre-
Scleral Deformity and post-optic nerve sheath fenestration for progressive aion. Invest
The normal shape of the globe can be altered in a number Ophthalmol Vis Sci 1991;32:951.
16. Fisher YL;Slakter JS, Friedman RA, et al: Kinetic ultrasound evalua-
of ways, including flattening and indentation by external tion of the posterior vitreoretinal interface. Ophthalmology 1991;
sources, folds secondary to hypotony (see pp 82 and 214), 98:1135.
ruptures and perforations due to trauma (see Chapter 4), 17. Fisher YL, Slakter JS, Yannuzzi LA, et al: A prospective natural his-
tory study and kinetic ultrasound evaluation of idiopathic macular
longstanding degeneration as in phthisis bulbi (see p 114), holes. Ophthalmology 1994;101:5.
and changes in contour due to choroidal tumors. 18. Freyler H, Egerer I: Echography and histological studies in various
Indentation or flattening of the globe may present on eye conditions. Arch OphthalmoI1977;95:1387.
19. Fuller DG, Laqua H, Machemer R: Ultrasonographic diagnosis of
clinical examination with choroidal folds and elevation of massive periretinal proliferation in eyes with opaque media (triangu-
the fundus. Ultrasound can usually identify the cause of the lar retinal detachment). Am J Ophthalmol1977 ;83 :460.
scleral abnormality. Possible causes include pressure from 20. Fuller DG, Hutton WL: Presurgical Evaluation of Eyes With Opaque
Media. New York, Grone & Stratton, 1982, p 109.
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43. Ossoinig KC: Echographic detection and classification of posterior drome. Ophthalmology 2000;107:902.
hyphemas. Ophthalmologica 1984;189:2. 54. Till P, Ossoinig KC: Ten-year study on clinical echography in in-
44. Ossoinig KC, Frazier SL, Watzke RC, et al: Combined A-scan and traocular disease. Bibl Ophthalmol197 5;83 :49.
B-scan echography as a diagnostic aid for vitreoretinal surgery, in 55. Torczinski E: Sclera, in Duane TD, Jaeger EA (eds): Biomedical Foun-
McPherson A (ed): New and Controversial Aspects of Vitreoretinal dations of Ophthalmology. vol 1. Philadelphia, JB Lippincott, 1988, p 3.
Surgery. St Louis, Mosby, 1977, P 106. 56. Uyama M, Takahashi K, Kozaki J, et al: Uveal effusion syndrome.
45. Ossoinig KC, Islas G, Tamayo GE, et aI: Detached retina versus dense Clinical features, surgical treatroent, and pathophysiology. Ophthal-
fibrovascular membrane: standardized A-scan and B- scan criteria, in mology 2000;107:441.
Ossoinig KC (ed): Ophthalmic Echography. Dordrecht, Germany, Dr 57. van Heuven WAJ, Ossoinig KC: Ultrasonography before vitrectomy,
WJunk, 1987, p 275. in Symposium on Retinal Diseases. St Louis, Mosby, 1977, P 11.
46. Ossoinig KC, Reshef DS, Weingeist TA, et al: Echographic findings 58. Van Newkirk MR, Gass JDM, Callanan D, et al: Follow-up and ul-
in Terson's syndrome, in Ossoinig KC (ed): Ophthalmic Echography. trasonographic examination of patients with macular pseudo-opercu-
Dordrecht, Dr WJunk, 1987, p 247. lum. Am J Ophthalmol1994; 117: 13.
47. Pavlin CJ, Foster FS: Ultrasound Biomicroscopy of the Eye. New York, 59. Van Newkirk MR, Johnson MW, Hughes JR, et al: B-scan ultrasono-
Springer-Verlag, 1995. graphic findings in the stages of idiopathic macular hole. Trans Am
48. Purnell EW, Frank KE, Cappaert WE: Preoperative ultrasonographic Ophthalmol Soc 2000;98:163.
evaluation of vitrectomy candidates with diabetic retinopathy, in 60. Yanoff M, Fine BS: Ocular Pathology. ed 4, London, Mosby-Wolfe,
McPherson A (ed): New and Controversial Aspects of Vitreoretinal 1996, p 444.
Surgery. St Louis, Mosby, 1977, P 84. 61. Weingeist TA, Goldman EJ, FolkJC, et al: Terson's syndrome. Clin-
49. Sabti K, Lindley SK, Mansour M, et al: Uveal effusion after cataract icopathologic correlations. Ophthalmology 1986;93: 143 5.
surgery: an echographic study. Ophthalmology 2001;108:100.
Trauma and Postsurgical
Findings
One of the most difficult clinical examinations for the oph- may be clinically apparent. Blunt trauma injuries include
thalmologist is that of the traumatized globe. The patient those caused by blows from fists or elbows, inflating
may be unable or unwilling to open the lids because of se- airbags, tennis balls or racquetballs, and paint balls. Specific
vere pain. Opacification of the anterior chamber, lens, or injuries to both the anterior and posterior segments of the
vitreous cavity may further hinder the clinical examination. eye should be considered (Box 4-1).
In these cases, ultrasound can provide valuable information
that may be unobtainable by other means.*
Anterior Segment
In a severely injured eye, marked lid swelling and patient
discomfort often necessitate examination through closed lids. Ultrasound can be used to assess the anterior segment in
Nevertheless, with a systematic approach, sufficient informa- the presence of corneal opacification or anterior chamber
tion can usually be obtained to allow a reasonable assessment hyphema. If a hyphema is present, ultrasound can demon-
of the extent of intraocular injuries. Whenever possible, open strate both the presence of the clot and the depth of the an-
wounds should be repaired prior to the echo graphic exami- terior chamber. The status of the lens may also be readily
nation. In those few cases, however, in which the intraocular assessed by ultrasound (Figure 4-1).
contents must be assessed before initial wound closure, it is If the trauma is such that traditional immersion tech-
possible to perform an examination without further injuring niques using a scleral shell cannot be used, the anterior seg-
the globe. This can be achieved by placing the probe gently ment can be examined through closed lids (see p 39). One
on the closed lids, using copious amounts of sterile methyl- of the newer high resolution B-scan probes utilizes a soft,
cellulose. WIth this method, virtually no pressure need be ex- water-filled, balloon-like tip that can be very useful in these
erted to obtain useful echograms. When examining through circumstances (see p 37 and Figure 2-33).
closed lids, however, relatively high gain settings must be used Blunt trauma can also affect the lens. Although mild
to help overcome the effects of sound attenuation by the lids. cataractous changes may not be obvious with ultrasound,
For anterior segment examinations through the lids, a soft moderately dense cataracts can usually be detected. On
stand-off technique may be used (see p 39). B-scan, a cataractous lens exhibits varying degrees of echo
Because examination of the traumatized eye may be lim- density, whereas the normal lens is echolucent (Figure
ited and because only a brief examination may be possible, . 4-2). Subluxation or dislocation of the lens may also be eas-
it is important that the echographer be aware of the various ily detected. A subluxated lens may lie in the anterior
types of pathologic changes that are most likely to occur chamber, or it may be displaced laterally or posteriorly
with different types of injuries. The three main categories (Figure 4-3). A dislocated lens can usually be detected float-
of intraocular trauma are blunt injuries, penetrating ining within the vitreous cavity; or sometimes it can be ob-
juries, and surgical complications. served sliding along the surface of the retina (see Figure
In addition to ocular trauma, this chapter will also ad- 5-77). Vitreous membranes or strands are occasionally at-
dress typical echographic findings in the post-surgical eye. tached to the dislocated lens (Figure 4-4).
Severe blunt trauma can also result in rupture of the lens
capsule, either anteriorly or posteriorly. Echographic de-
BLUNT TRAUMA
tection of a lens rupture is useful for determining the best
Blunt trauma to the eye can produce marked, sudden dis- surgical approach for cataract extraction (Figure 4-5).
tortion of the globe, resulting in more severe damage than Blunt trauma to the anterior segment may cause dehis-
cence of a corneal or limbal surgical wound. These cases
*References 6,7,11,12,16,18,21,23,26. are often associated with anterior chamber hyphemas.
87
88 THE GLOBE
BOX4~1
SeCJu~lae of Blunt Trauma

A:nt~Ji:o~ Segment Posterior Segment
. Hyphema Vitreous hemorrhage
Cataract Posterior vitreous detachment
(Sub)luxation otlens or iOL Retinal tear
Lenscapsule rupture Retinal dialysis
Corneoscleral rupture Retinal detachment
Cyclodialysis cleft Edema of retinochoroid layer
Hemorrhagic choroidal detachment·
I'osterior scleral rupture
Avulsion of optic nerve
A B
Figure 4-1 Anterior chamber hyphema. A, External photograph showing diffuse corneal blood
staining. B, Immersion axial B-scan shows anterior chamber hyphema (aT7ow). C, Cornea; I, iris;
L, lens. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina.
ed 3, St Louis, Mosby, 2001, p 263.)
A B
Figure 4-2 Normal lens and traumatic cataract due to blunt trauma. Immersion axial B-scans
are at reduced gain setting. A, Normal lens (arrow) with typical echolucent appearance.
C, Cornea; M, methylcellulose within scleral shell. B, Cataractous lens.
Chapter 4 TRAUMA AND POSTSURGICAL FINDINGS 89
A B
Figure 4-3 Subluxated and dislocated lenses following blunt trauma. A, Immersion B-scan
echo gram shows subluxated lens (L). B, Contact B-scan shows cataractous, dislocated lens (ar-
row) lying on surface of retina.
Figure 4-4 Dislocated lens following blunt trauma injury. Transverse B-scan shows oval-
shaped lens (arrow) on surface of retina. Vitreous opacities and membranes are attached to lens.
V,Vitreous cavity.
A B
Figure 4-5 Two exa~ples of ruptured len~es from severe blunt trauma. A, Para-axial B-scan
shows extrusion of lens material through small rupture at periphery of posterior lens capsule
(arrow). B, Immersion axial B-scan shows irregular contour of posterior lens capsule (open arrow)
due to lens rupture. C, Cornea; M, methylcellulose within scleral shell; V, vitreous cavity. (From
Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis,
Mosby, 2001, p 263.)
90 THE GLOBE
Ultrasound is useful for determining the status of the ante-

rior chamber and the crystalline lens or intraocular lens
(IOL) implant. Ultrasound is often needed to determine
whether the lens has been extruded from the eye.
A cyclodialysis cleft following blunt trauma to the ante- A
rior segment may sometimes occur. This can lead to per-
sistent hypotony and should be considered whenever there
is hypotony of unknown etiology. Clinically, these clefts
may be difficult to detect if the anterior chamber is shallow
and/or the cornea is opacified. High resolution B-scan in-
strumentation is usually necessary to image these lesions
(see Figures 3-64 and 8-19).
Posterior Segment
Vitreoretinallnjuries
B
A wide variety of posterior segment abnormalities can oc-
cur secondary to blunt trauma. These include vitreous he-
morrhage, posterior vitreous detachment (PVD), periph-
eral retinal tears, sub retinal hemorrhage, and macular
holes. The typical echographic findings for these posterior
segment abnormalities have already been described in
Chapter 3. When the ocular media are opaque, the eye
should be carefully evaluated to detect the presence of any
of these conditions.
Additional findings that should be considered in patients
with blunt ocular trauma include peripheral retinal dialy-
sis, Berlin's edema (commotio retinae), and choroidal rup- c
ture. A retinal dialysis, a disinsertion of the peripheral
retina from the-ora serrata, is best detected with B-scan us-
ing a longitudinal approach (Figure 4-6). Although a retinal
dialysis may be located in any quadrant, common locations
are supranasally and inferotemporally. 8 When a retinal de-
tachment (RD) results from a peripheral retinal dialysis, it
Figure 4-6 Peripheral retinal dialysis following blunt trauma.
is usually shallow rather than bullous, and, when long- A, Schematic drawing showing retinal dialysis. B, Anterior longi-
standing, it may develop multiple intraretinal cysts. 8 tudinal B-scan shows RD with peripheral dialysis (arrow). L, Lens.
Berlin's edema is often associated with acute visual loss. C, Posterior longitudinal view shows the peripheral dialysis and
On ultrasound, this condition appears as diffuse thickening RD inserting into the optic nerve (ON). (From Green RL, Byme
of the retinochoroid layer, usually in the posterior pole SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina.
(Figure 4-7).
A choroidal rupture consists of a tear in the retinal pig-
ment epithelium (RPE), Bruch's membrane, and choroid.
Acutely, a choroidal rupture may be associated with Berlin's
edema, intraretinal, or subretinal hemorrhage and gener- an irregular contour, thickening, and decreased reflectiv-
ally cannot be differentiated from these conditions with ul- ity.!5 An actual split in the scleral fibers may, however, not
trasound. However, once the hemorrhage and/or edema be detectable.
have partially resolved, the choroidal rupture can in some Other findings associated with scleral rupture include (1)
cases be imaged echographically (see Figure 4-7). vitreous incarceration associated with vitreous hemorrhage
and PVD, (2) thickening or detachment of the surround-
Posterior Scleral Rupture ing retina and/or choroid, and (3) hemorrhage in the im-
Severe blunt trauma can result in rupture of the posterior mediate episcleral space (Figure 4-8).!5 Additionally, the in-
sclera. These eyes usually present clinically with marked carcerated vitreous may produce traction folds or bands
hemorrhagic chemosis as well as vitreous hemorrhage.!7 In extending across the vitreous cavity toward the site of in-
most cases, these ruptures are occult with no external signs carceration. Retinal incarceration can also occur. In one
of rupture, and the intraocular pressure may be normal. On case, nearly the entire retina was extruded through a large
ultrasound, the sclera in the area of the rupture may show scleral defect into the orbit (Figure 4-9).
A B
Figure 4-7 Choroidal rupture following blunt trauma. A, Fundus photograph demonstrates
choroidal rupture at temporal edge of macular region. B, Longitudinal B-scan shows thin
echolucent line representing choroidal rupture (black arrows) and associated irregular thickening
of retinochoroid layer in macular region (white arrow). ON, Optic nerve.
A c
Figure 4-8 Scleral rupture following blunt trauma. A, Ex-

ternal photograph showing anterior chamber hyphema and
hemorrhagic chemosis. B, Longitudinal B-scan displays vit~
B reous hemorrhage (1/), incarceration of vitreous into scleral
rupture (arrow), and inferior RD (R). C, Transverse B-scan
view through area of scleral rupture shows vitreous incarcer-
ated into scleral wound and RD (R). H, Orbital hemorrhage.
92 THE GLOBE
A
A
:
II
:1
Figure 4-9 Large posterior scleral rupture following severe

blunt trauma. A, Transverse B-scan shows large defect in posterior
sclera (arrow) and adjacent extraocular cavity containing extruded c
retina. B, Gross pathology specimen demonstrates scleral rupture
and extruded retinal tissue. .
Hemorrhagic Choroidal Detachment

Hemorrhagic choroidal detachments commonly occur fol-
lowing a posterior scleral rupture. Moreover, experience has
shown that the presence of a hemorrhagic choroidal detach- Figure 4-10 Acute avulsion of the left optic nerve following se-
vere blunt trauma. Patient experienced immediate total loss of vi-
ment indicates that there has been a rupture of the globe.
sion. A, Fundus photograph of left eye shows vitreous hemor-
Traumatic hemorrhagic choroidal detachments may be rhage overlying optic disc and area of bare sclera (arrows) at edge
localized or quite extensive, even reaching the edge of the of optic disc (not shown). B, Axial B-scan echogram shows vitre-
optic disc. Focal detachments are mildly dome-shaped, ous hemorrhage emanating from optic disc and extending inferi-
whereas those that are more extensive have a relatively flat orly (arrows). ON, Optic nerve. C, Longitudinal B-scan along
temporal fundus shows vitreous hemorrhage (large straight arrow),
configuration similar to those seen in penetrating injuries
thin scleral rupture at edge of optic disc (small arrow), and small
(see p 97). The exception to this rule is in aphakic eyes in area of orbital hemorrhage (curved arrow).
which blunt trauma caused a corneal or limbal wound rup-
ture or in pseudophakic eyes in which the IOL was extruded
through a wound dehiscence. In these cases, the hemorrhagic
choroidal detachments may be highly elevated and dome- Avulsion of the Optic Nerve
shaped and may adhere centrally (kissing or appositional Avulsion of the optic nerve is a rare sequela ofbhmt trauma.
choroidal detachments) (see the section, "Expulsive Hemor- B-scan may show an actual break in the sclera near the op-
rhage," on p 104). The presence of choroidal detachments tic disc (Figure 4-10). There can also be enlargement of the
can alter the timing of surgical intervention as well as the retrobulbar optic nerve (see p 429). In longstanding cases,
surgical approach. 3,4,16,25 proliferative membranes develop at the optic disc, and the
Figure 4-11 Longstanding avulsion of the optic nerve

following football injury. A, FUndus photo (11 years after
injury) shows pale optic disc with glial tissue on surface.
Longitudinal B-scans show ayulsed optic nerve (B) and
A
normal fellow optic nerve (C). B, Proliferative tissue~d
herent to optic nerve (arrow) and abnormal appearing
retrobulbar optic nerve (ON). C, Normal fellow optic
nerve.
c
B
insertion of the optic nerve into the globe may appear atyp-
icaPO,13 (Figure 4-11).
PENETRATING TRAUMA
Penetrating ocular injuries can cause marked disruption and
distortion of normal anatomical structures. Nevertheless, a
systematic ultrasound examination will often yield useful
information (Box 4-2).
Anterior Segment
Marked. disruption of the anterior segment can occur fol-
lowing a penetrating injury. This can produce hyphema, iri-
dodialysis, and disruption of the lens. Ultrasound can
demonstrate many of these lesions and is ideal for deter-
mining the status of the anterior chamber, iris, and lens.
Lens abnormalities that can be shown include cataractous
changes (see Figure 4-2), subluxation/dislocation (Figure
4-12), lens capsule rupture (Figures 4-13 and 4-14), and re-
absorption oflens material (Figure 4-15). Dislocation of an
IOL can be determined as well (Figure 4-16).-Cyclitic
membranes may also be demonstrated posterior to the
94
Figure 4-12 Hyphema, iridodialysis, and subluxation oflens following penetrating injury. Im-
mersion axial B-scan echo gram. C, Cornea; H, anterior chamber hyphema; I, iris; L, lens;
M, methylcellulose within scleral shell; V, vitreous hemorrhage; arrow, iridodialysis.
Figure 4-13 Posterior lens capsule rupture secondary to penetrating injury. Para-axial B-scan
demonstrates rupture of posterior capsule (arrow) with incarceration of anterior vitreous. Note
vitreous traction bands extending toward site of incarceration. V, Vitreous cavity.
A c
Figure 4-.14 Hemorrhagic track through vitreous cavity

from penetrating nail injury. A, Vertical macula B-scan
echo gram shows thick, hemorrhagic track coursing through
the vitreous cavity along path of penetrating nail. Anteriorly,
track extends from large rupture of posterior lens capsule (P).
B B, Transverse B-scan shows cross-section of track surrounded
by clear vitreous. C, B-scan at reduced gain shows shallow
traction RD (arrow) near posterior impact site. (From Green
RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S]
Figure 4-15 Marked disruption of lens following penetrating injury. Immersion axial B-scan
echogram demonstrates residual lens material (arrow). C, Cornea; M, methylcellulose within
scleral shell; V, vitreous cavity.
A B
Figure 4-16 Dislocated IOL. A, Fundus photograph shows dislocated IOL on posterior
retina. B, Transverse B-scan displays echodense dislocated lens (straight arrow) on posterior reti-
nal surface. S, Shadowing from IOL; curved arrow, lens haptic. (Courtesy Dr. Barbara Blodi,
Madison, Wisconsin, and Kathleen Meyer, RDMS, ROUB, Ann Arbor, Michigan.)
crystalline lens (see Figure 3-63), an IOL, or the iris (in body, a hemorrhagic track through the vitreous cavity is
aphakic eyes). usually present. The track appears as a bandlike structure
Ciliary body or ciliochoroidal detachments, either sec- that occurs along the path of the foreign object. The
ondary to hypotony or the result of traction from cyclitic track may terminate in the vitreous or at an impact site
membranes, may be present (see Figure 3-61). Epithelial in the fundus. In some cases, the track may lead to an in-
downgrowth is a rare complication of penetrating trauma. traocular foreign body (Figure 4-17), a posterior exit
In this condition, a sheet of epithelial cells extends onto the wound (posterior scleral rupture) (Figure 4-18), or a for-
surface of anterior segment structures. Occasionally, this eign body outside ofthe globe (Figure 4-19; see also Fig-
downgrowth proliferates to form a cyst or solid mass that ure 17-9). Thickening or detachment of the retina and/or
can be demonstrated by ultrasound (see p 177). choroid is typically present near an impact site (see Fig-
ures 4-14 and 4-18).
Posterior Segment Unless the sound beam is properly aligned with the
track, it may not be displayed in its entirety and, therefore,
Vitreoretinallnjuries/Posterior Scleral Rupture may not be appreciated. ffi.enever there has been a pene-
Penetrating injuries to the posterior segment frequently trating injury, a careful search should be made for a hem-
produce vitreuus hemorrhage (see p 45). ffi.en a pene- orrhagic track. It is usually beneficial to know the location
trating injury is caused by a sharp object (e.g., needle, of the anterior entrance wound and the direction from
nail, screwdriver, or pencil) or a projectile-type of foreign which the foreign body entered the eye to determine its
96 THE GLOBE
Figure 4-17 Hemorrhagic track produced by intraocular foreign body. Para-axial B-scan shows
thick hemorrhagic track (straight arrow) extending from region of lens (L) and terminating at
foreign body (curved arrow) located in front of posterior retina. Note foreign body shadow (S),
which simulates optic nerve.
A
c
Figure 4-18 Posterior scleral rupture and hemorrhagic

B track extending through orbit following perforating ocular
injury. A, Transverse B-scan echogram at medium-high
gain setting shows vitreous track (arrow) inserting into pos-
terior s~leral rupture. Note shallow RD (R) and thickened
sclera (S) adjacent to rupture. B, Longitudinal B-scan at
lower gain better demonstrates scleral rupture (black arrow).
Note that the hemorrhagic track (Ii) behind globe along
the path of the foreign body is also better shown. C, Fun-
dus photograph following vitrectomy shows stalk of vitre-
ous still attached to fundus in area of impact site.
A 8
Figure 4-19 Perforating foreign body injury demonstrating vitreous incarceration. A, Exter-
nal photograph showing repaired corneoscleral wound and opacified anterior vitreous. B, Lon-
gitudinal B-scan demonstrates vitreous incarceration into posterior exit wound (curved black ar-
row) located adjacent to optic nerve (ON). Note vitreous traction bands (white arrow) extending
toward exit site. Straight black arrow, Extraocular foreign body; S, shadowing produced by foreign
body.
Traumatic Retinal Detachment

Anterior penetrating injuries that lead to significant vit-
reous loss often result in traction on the posterior retina.
Traction RDs can occur immediately following the injury,
or they may develop subsequently (Figure 4-20). Fre-
quent echographic follow-up is therefore very useful for
detecting the onset of traction RD in eyes with Vitreous
incarceration. i8
RhegmatogenousRDs may develop at the site of pene-
tration, and RDs with subretinal blood are a common find-
ing following penetrating injury (see p 54).1 8 Incarceration
of the retina into a scleral wound can sometimes be demon-
strated as well (Figure 4-21).
Figure 4-20 Traction RD following perforating foreign body Hemorrhagic Choroidal Detachment
injury (same case as in Figure 4-19). Axial B-scan echogram shows Hemorrhagic choroidal detachments can occur after a pen-
traction RD (arrows) adjacent to optic nerve (ON) produced by etrating or perforating injury. In fact, the majority of globes
vitreous incarceration anteriorly. L, Lens; P, posterior hyaloid;
V, vitreous hemorrhage. with a scleral laceration develop an associated hemorrhagic
choroidal detachment.
As described for scleral ruptures secondary to blunt
trauma, hemorrhagic choroidal detachments occurring af-
path within the globe. This information can help determine ter penetrating trauma are usually only mildly to moder-
proper probe positioning. ately elevated and have a slightly dome-shaped or flat
U1trasound can often show vitreous incarceration at the configuration (Figure 4-22). They may be localized to the
site of a penetrating injury. When, however, there has been area of rupture, or they can be quite diffuse, extending pos-
a perforating injury (both entrance and exit wounds), interior to the equator.
carceration may be observed at both wound sites. As has
been described for ruptured globes secondary to blunt Scleral Folds
trauma (see Blunt Trauma on p 87), the vitreous incarcera- Sudden decompression of the globe, from a penetrating
tion, regardless of location, usually forms traction bands injury or a perforated corneal ulcer, may result in a col~
that can be easily demonstrated echo graphically (see Fig- lapse of the scleral wall. This collapse can produce scleral
ure 4-19). Once the origin of such traction bands has been infolding that may be easily detected with echography.1 9
determined, the opposite side of the globe should be eval- Scleral folds are typically dome-shaped on B-scan, and
uated to rule out traction RD. the apex of the dome may be very highly reflective. In
98
Figure 4-21 Retinal incarceration following penetrating injury (knife wound). A, Axial B-scan
shows funnel-shaped RD inserting into optic nerve (ON). B, Transverse B-scan view through in-
ferior aspect of eye shows incarceration of retina (white arrow) into sclera (black arrows).
Figure 4-22 Shallow hemorrhagic choroidal detachment following penetrating injury. A, Pe-
ripheral transverse B-scan at reduced gain shows smooth, concave appearance of choroidal de-
tachment (C) and opacities in suprachoroidal space (arrow). B, Corresponding A-scan displays
spikes beneath choroid (arrow) due to suprachoroidal hemorrhage. S, Sclera.
Foreign Bodies
Intraocular Foreign Bodies
Various types of intraocular foreign bodies are, in most in-
stances, readily detectable with echography (Box 4-3).*
B Even when a foreign body has been previously localized by
means of computed tomography (CT), ultrasound exami-
nation should be performed for more precise localization
and for determination of the extent of intraocular damage.
Moreover, if a foreign body is located next to the scleral
wall, CT scanning may be unable to indicate whether it lies
just within or just outside of the globe.
METALLIC FOREIGN BODIES
Although no two foreign bodies are exacdy alike, the echo-
graphic findings for metallic foreign bodies (or other very
hard substances) are generally similar. On B-scan, these for-
eign bodies produce a very echo-dense signal that persists at
c low gain settings. In addition, there is usually marked shad-
oWing of the ocular and orbital structures just posterior to
the foreign body (Figure 4-24). As mentioned previously
(see p 95), the echo graphic detection of a foreign body can
be facilitated if it has produced a hemorrhagic track within
the eye (see Figure 4-17).
The examiner should be aware of two situations in which
an intraocular foreign body may be overlooked during the
Figure 4-23 Scleral fold in patient with ruptured cataract
ultrasound examination. First, shadowing from a foreign
wound (open eye at time of examination). A, Scleral infolding pro-
duces localized convex-shaped appearance (arrow). The irregu- body located posteriorly can be confused with the optic
larly shaped sclera is highly reflective and produces shadowing (S). nerve void,causing the foreign body to go undetected. To
This appearance may simulate an intraocular foreign body. avoid this situation, it is important always to identify the
B, Schematic drawing showing scleral fold. C, Same area of globe optic nerve in relationship to the foreign body. Second,
3 days after wound repair shows resolution of fold. (A and C from small foreign b6dies.(less than 0.5 mm in diameter or thin
Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan
S] [ed]: Retina. ed 3, St Louis, Mosby, 2001, P 262.) . pieces of wire) may not produce obvious shadowing even
though they can be quite echo-dense. In this case, other
imaging studies may be important to help confirm the pres-
ence of a foreign body.
addition, the folded sclera may produce shadowing pos- of Metallic foreign bodies produce very high reflectivity on
terior orbital tissues (Figure 4-23; also see p 466). Scleral A-scan, regardless of the sound beam direction. In these
folds can be mistaken for choroidal detachments, foreign cases, .examination WIth the A-scan, using oblique sound
bodies, or scleral buckles. The presence of a scleral fold beam incidence, can be helpful in confirming the presence
should be anticipated in an eye with very low intraocular of a foreign body.
pressure, (either from sudden decompression or secondary
to severe inflammation). -References 1,2, 16,22,24,27.
100 THE GLOBE
! I
A
A
B
B
c c
Figure 4-24 Metallic intraocular foreign body several years fol- Figure 4-25 Intralenticular foreign body. A, External photo-
lowing injury. A, B-scan echo gram shows foreign body on surface graph showing perforation of iris. B, Vertical axial B-scan
of retina and marked shadowing (S). B, A-scan at Tissue Sensitiv- echogram at reduced gain shows small, echo-dense lesion (arrow)
ity shows thick, very highly reflective spike from foreign body (F) within lens. P, Posterior lens capsule. C, Horizontal axial B-scan
and decreased spike height of sclera (S) and orbital tissue (arrows) shows long section of sliverlike foreign body protruding through
as a result of sound attenuation. C, Foreign body spike persists at posterior lens capsule.
a very low gain setting. (From Green RL, Byrne SF: Diagnostic
ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed 3, St Louis,
Mosby, 2001, p 267.)
Foreign bodies in the anterior segment, especially those mation through the lids with a soft stand-off technique (see
in the lens, can often be detected with a contact technique p 40) may also be necessary if the standard immersion
(Figure 4-25; see also Figure 2-34). However, if the foreign method cannot be performed.
body is small and is situated adjacent to the lens capsule, in
the plane of the iris, or in the pars plicata, an immersion SPHERICAL FOREIGN BODIES
technique (see p 37) may be necessary for detection and lo- Spherical foreign bodies (e.g., BBs or gunshot pellets)
calization. This technique, however, should be used only if produce unique and specific echographic signals. 22 ,27
the entrance wound has been sutured or has healed. Exam- When sound waves pass through a spherical, metallic for-
Emitted Pulse Transmitted Pulse
Probe
Figure 4-26 Schematic drawing shows reverbera-

tions from BB pellet. (Redrawn from Ossoinig KC:
l> Standardized Ophthalmic Echography of the Eye, Orbit
and Periorbital Region. A Comprehensive Slide Set and
l> Study Guide. ed 3, Iowa City, Goodfellow, 1985, p 12.)
o ~
I
()
LU « c:::::;;==
A B
Figure 4-27 Intraocular BB. A, Transverse B-scan echo gram shows BB (B) in center of vitreous
cavity followed by characteristic chain of multiple signals (comet tail artifact) (small white al"rows).
Note mild shadowing of sclera and orbital signals (black amri1Js). B, Corresponding A-scan echogram.
Note decreased height of sclera (S) and orbital spikes (large a1"row) due to sound attenuation.
GLASS AND ORGANIC MATERIAL

eign body, a portion of the sound wave reverberates
within the object. Each time a reverberation occurs, some Glass foreign bodies exhibit certain unique echographic
of the sound energy passes back to the transducer, pro- characteristics. In most cases, glass enters the eye as a
ducing a series of echo signals of decreasing amplitude sliver. When the sound beam strikes the long, smooth
that appear to the right of the foreign body echo (i.e., surface of a glass sliver with an oblique incidence, most of
reduplication or multiple signals) (Figure 4-26). On B- the sound is reflected away from the' probe, resulting in
scan, this chain of multiple signals is referred to as a the display of only a weak echo. For this reason, a rela-
comet tail artifact. As the sound beam strikes the foreign tively large piece of glass may be completely missed or
body, this chain of multiple signals appears instantly on mistaken for a small foreign body. Only when the sound
the screen, thus allowing very easy detection and local- beam is directed perpendicular to the long, flat surface of
ization of this specific type of foreign body (Figures 4-27 the glass sliver is a very echo-dense signal displayed that
and 4-28). accurately indicates the foreign body's density and size
102 THE GLOBE
A C
Figure 4-28 Intraocular subretinal BB (gunshot). A, Ax-

ial B-scan view at high gain shows dense vitreous hemor-
rhage (V) and large, echo-dense signal from BB (large black
arrow). Note the characteristic chain of multiple signals
B (comet tail artifact) produced by BB (small black arrows).
B, Transverse B-scan at reduced gain shows RD (straight
white arrow) and underlying BB (curved white a77ow). C, Ax-
ial CT scan shows spherical foreign body (straight white ar-
row) in vicinity of posterior ocular wall.
Figure 4-30 Intraocular thorn (from brambleberry bush). Lon-

gitudinal B-scan shows thorn as echo-dense line (closed arrow) in
anterior aspect of vitreous cavity (V). Open arrows indicate shad-
owing produced by thorn. (Courtesy Dr. Barbara Blodi, Madison,
Wisconsin, and Kathleen Meyer, RDMS, ROUB, Ann Arbor,
Michigan.)
(Figure 4-29). Therefore, when a glass foreign body is

suspected, it is eisential that a very thorough screening
examination be performed to ensure accurate detection
and localization.
Wood or other types of vegetable matter can produce
Figure 4-29 Intraocular glass splinter. A, Sound beam aligned various echographic findings, depending on their size and
with length of splinter (arrow). B, Cross-section through splinter.
density (Figure 4-30). Initially, these foreign bodies may be
Note multiple signals (M) produced by the glass foreign body and
shadowing of sclera and orbital tissue (S). (From Green RL, Byrne highly reflective, but their reflectivity may decrease over
SF: Diagnostic ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed time, thus making detection extremely difficult.
3, St Louis, Mosby, 2001, p 268.) Penetrating ocular injuries may introduce eyelashes (cilia)
A A
B B
Figure 4-32 Intraocular air following penetrating InJury.

A, Transverse B-scan view through superior globe immediately
following repair of penetrating injury shows highly reflective for-
eign bodylike signal (arrow) produced by intraocular air bubble.
c Open arrows, Multiple signals. B, Transverse B-scan echo gram
through same section of globe 2 days later shows complete reso-
lution of bubble. (From Green RL, Byrne SF: Diagnostic oph-
thalmic ultrasound, in Ryan S] [ed]: Retina. ed 3, St Louis, Mosby,
2001, p 269.)
Figure 4-31 Intraocular cilia following penetrating injury. A, An-
terior longitudinal B-scan echograrn along 6-0'clock meridian shows
thin, foreign body-like echo (arrrnv) corresponding to cilia. B, Trans- of more than one foreign bodylike echo when the history
verse B-scan view shows cross-section of cilia. C, Photograph show-
ing encapsulated cilia that was removed during vitrectomy. indicates that only one foreign body should be present (Fig-
ure 4- 33, B). In addition, there are some differences between
the acoustic properties of air bubbles and those of true in-
traocular foreign bodies. The majority of true foreign bod-
into the eye. These foreign bodies typically show a thin, elon- ies are irregularly shaped; consequently, their echoes may
gated shape on B-scan. They do not produce shadowing but differ slightly in appearance when examined from different
appear relatively echo-dense (Figure 4- 31). The possibility of sound beam directions. Moreover, true foreign bodies gen-
an eyelash foreign body should always be considered when erally do not move, even when the patient's head or body
examining an eye following a penetrating injury. position is changed. Conversely, air bubbles, because of their
spherical and smooth nature, produce echoes of similar ap-
AIR BUBBLES pearance when evaluated from different sound beam orien-
Small air bubbles may enter the globe as a result of a tations. And since they are normally found in the vitreous
penetrating ocular injury. These focal, point-like echo cavity and are lighter than vitreous, they tend to move op-
sources are extremely high reflective, resulting in echo- posite to the direction of head tilt. If the diagnosis is uncer-
grams that are similar to those of true intraocular foreign tain, a follow-up examination, performed a day or two later,
bodies. Like spherical foreign bodies, they can produce may be of great help because small air bubbles usually dis-
multiple signals (Figure 4-32) as well as shadowing (Fig- appear within this time period (see Figure 4-32).
ure 4-33, A).
Orbital Foreign Bodies
Certain findings may help to differentiate air bubbles
from true foreign bodies. The first clue may be the display See p 439 in Chapter 17 for a review of orbital foreign bodies.
104 THE GLOBE
A B
Figure 4-33 Two examples of intraocular air following recent penetrating injury. A, Single
bright echo corresponding to intra-vitreal air bubble (arrow). Note shadowing (S) produced by
air bubble. V, Vitreous cavity. B, Axial B-scan echogram (through closed lids at reduced gain)
shows numerous bright echo signals (arrows) from small air bubbles. These echoes moved freely
as the patient shifted body position.
hemorrhagic choroidal detachment may involve only one

or two quadrants of the eye (Figure 4-34). In more severe
cases, however, 360 degree choroidal detachments may ad-
here in the central aspect of the vitreous cavity, producing
an appositional (kissing) configuration.
On B-scan, these large, dome-shaped membranes can be
seen to adhere to one another in the central portion of the
eye. These detachments may extend to the posterior pole, in-
serting next to rather than into the optic disc (Figure 4-35).
Massive hemorrhagic choroidal detachments also can
occur on a delayed basis following intraocular surgery in
aphakic or pseudophakic eyes. These are most likely to oc-
cur following glaucoma procedures (see p 218) or corneal
transplant surgery. Expulsive hemorrhagic choroidal de-
tachments also may be observed following rupture of the
SURGICAL TRAUMA (COMPLICATIONS)
globe, in either aphakic or pseudophakic eyes.
Ultrasound is an important adjunct for evaluating some of In some cases, the hemorrhagic choroidal detachments
the complications that follow intraocular surgery. Many of are so massive and the hemorrhage so dense that it may be
the possible findings (e.g., vitreous hemorrhage or RD) extremely difficult to detect them with B-scan.The echo-
have already been described in Chapter 3. Other compli- graphic findings in these cases are sometimes confused with
cations (Box 4-4) will be described in this chapter and else- very dense vitreous hemorrhage. A B-scan sign that is oc~
where. in the book. casionally helpful in detecting hemorrhagic choroidal de-
tachments is the presence of spontaneous motion from
blood vessels on the surface of the choroidals. In some
Endophthalmitis/Uveitis
cases, reducing the gain level may allow better resolution
See Chapter 6 for a review of endophthalmitis and uveitis. of the closely adherent choroidal surfaces (Figure 4-36).
Echography can be used to follow the course of hemor-
rhagic choroidal detachments and to help determine
Expulsive Hemorrhage
whether intervention is indicated and, if so, when it should
One of the most devastating complications of intraocular be undertaken. 3,4 Studies have shown that many ofthese
surgery is an expulsive hemorrhage. In this condition, mas- detachments separate after a few weeks, although shallow
sive suprachoroidal hemorrhagic detachments can partially detachments may persist for months. 3,4,25 It is of note that
or totally fill the vitreous cavity. In some cases, a massive shallow RDs may occur at the posterior aspect of highly el-
A c
B D
Figure 4-34 Large hemorrhagic choroidal detachment resulting from expulsive hemorrhage at
the time of cataract surgery. A, Horizontal axial B-scan echogram shows highly elevated, hem-
orrhagic choroidal detachment (arrows) extending from temporal aspect of globe and overlying
optic nerve (ON). J, Iris. B, Longitudinal B-scan view along temporal meridian shows large hem-
orrhagic choroidal detachment. C, Transverse B-scan view through temporal periphery of eye
shows large, dome-shaped choroidal detachment. D, A-scan of choroidal detachment (C) in area
of greatest elevation from the sclera (S). Note medium-high internal reflectivity and decreasing
spike height (due to sound attenuation) produced by clotted blood in suprachoroidal space
(arrows).
Figure 4-35 Appositional (kissing) hemorrhagic choroidal de- Figure 4-36 Appositional (kissing) hemorrhagic choroidal de-
tachments. Longitudinal B-scan of 3-0' clock meridian in right eye tachments. Peripheral transverse B-scan at reduced gain shows
demonstrates highly elevated nasal (N) and temporal (I) choroidal 360-degree massive choroidals with temporal (I), superior (S),
detachments adhering in central aspect of vitreous cavity (arrows). nasal (N), and inferior (J) detachments meeting in the central vit-
ON, Optic nerve. Note dense hemorrhage in suprachoroidal reous cavity and almost completely obliterating the vitreous space.
space. This example shows that typical configuration in which the nasal
and temporal detachments adhere to one another in the central
aspect of the vitreous cavity.
o
Figure 4-37 Massive appositional (kissing) hemorrhagic choroidal detachments immediately

following expulsive hemorrhage (A to C) and at follow-up examination (D to F). A, Transverse
B-scan. Note that surfaces of choroidal detachments cannot be identified because of their marked
adherence centrally. B, Longitudinal B-scan view shows central adherence of choroidals (white
arrow). Note sharp posterior insertion of choroidals near optic nerve (ON) and shallow RD (black
arrow). C, A-scan of hemorrhagic choroidal (C) shows medium-high internal reflectivity (ar-
rows) of clotted suprachoroidal blood. S, Sclera. D, Transverse B-scan corresponding to A shows
marked reduction and concave appearance of choroidal detachment. E, Longitudinal B-scan
corresponding to B also shows marked decrease in choroidal detachment. Note that very shal-
low RD is still present at posterior edge of choroidal detachment (curved white arrow). F, A-scan
corresponding to C shows decreased elevation of detachment and very low reflectivity of fluid
blood in suprachoroidal space.
eva ted hemorrhagic choroidal detachments. In some cases, orrhages, in which RDs are often present after the
these detachments may be caused by the mass effect of the choroidal detachments have begun to resolve. 3,4
choroidal detachments. As the choroidals resolve, these
RDs tend to decrease and/or resolve (Figure 4-37).
Retained Lens Material
In most cases of large, hemorrhagic choroidal detach-
ments, highly reflective solid blood clots are initially present When rupture of the posterior capsule occurs during
in the suprachoroidal space. Over time, however, these clots cataract surgery, cortical lens material, lens nucleus frag-
diminish in size and become lower reflective (Figure 4-38). ments, or the entire lens nucleus may fall back into the vit-
The echographic documentation of clot appearance and reous gel. The cortical material and nuclear fragments typi-
size may be useful in determining the optimal timing for cally appear echo graphically as irregularly shaped, medium
drainage. Also, as these choroidal detachments decrease in to high reflective opacities of varying size in the vitreous cav-
size, RDs may become echographically apparent. Delayed ity (Figure 4-39). The lens nucleus is usually oval in shape.
hemorrhagic choroidal detachments often flatten out com- Inflammatory vitreous opacities and/or membranes are nor-
pletely, with residual retinal traction only in the periphery. mally associated with retained lens material (Figure 4-40). A
This is in contrast to surgical or traumatic expulsive hem- dislocated lens nucleus may adhere to the retina, and, thus,
A D
c F
Figure 4-38 Massive appositional (kissing) hemorrhagic choroidal detachments demonstrating

clot lysis. Longitudinal B-scan and corresponding A-scan echograms are from three different
patients showing various stages of clot lysis. A, B-scan 2 days after hemorrhage shows large,
dense, solid clot (arrow) surrounded by fluid blood (FE) in suprachoroidal space. ON, Optic
nerve. B, B-scan of second patient 7 days after hemorrhage also shows solid clot surrounded by
fluid blood in the suprachoroidal space. Note that this older clot appears echolucent, whereas the
fresher clot in A is more echo-dense. C, B-scan from third patient obtained 2 weeks after
choroidal hemorrhage shows complete resolution of solid clot, with fluid blood completely fill-
ing suprachoroidal space. D, A-scan corresponding to A shows choroidal detachment (C) and
medium-high reflectivity of suprachoroidal solid clot (arrows). E, A-scan corresponding to B
shows low reflectivity of both fluid blood (FE) and solid clot (SC). Arrows, Borders of SC. F, A-
scan corresponding to C shows low reflectivity of fluid blood. (From Green RL, Byrne SF: Di-
108 THE GLOBE
Figure 4-41 Inadvertent injection of steroid into the vitreous

cavity. Longitudinal B-Scan shows echo-dense, well-circum-
scribed appearance of Depo-Medrol (arrow). ON, Optic nerve.
Macular Edema
See p 67 in Chapter 3 for a review of macular edema.
B
Penetrating Needle Injuries
of the Eye
Inadvertent penetration of the eye can occur during
retrobulbar or sub-Tenon's injections. A variety of echo-
graphic findings may be present following this event. 9 ,14
Figure 4-39 Retained lens fragments following cataract surgery In some cases, because of the sharp needles used, only
and anterior vitrectomy. A, Transversf;; B-scan displays relatively minimal findings, such as mild vitreous hemorrhage and
large, echo-dense, irregularly shaped lens fragment (straight ar- localized PVD, may be observed. In other cases, how-
row) within residual vitreous gel (V). Curved arrow, inner surface ever, vitreous incarceration, retinal and choroidal de-
of remaining vitreous skirt. VG, Vitrectomy cavity created by re-
moval of anterior vitreous gel. B, Lens fragment produces tachments, and scleral thickening maybe detected. The
medium-high reflective, multi-peaked spike on A-scan. inadvertent injection of steroids into the vitreous cavity
has also been shown with echography (Figure 4-41).
Sympathetic Ophthalmia
See Chapter 6 for a review of sympathetic ophthalmia.
Epithelial Downgrowth and Inclusion

(implantation) Cyst
Epithelial downgrowth or implantation of epithelial cells
may occur following intraocular surgery or penetrating
trauma. This can result in the formation of masslike lesions
(see p 177) or the development of epithelial inclusion cysts
Figure 4-40 Dislocated lens nucleus following cataract surgery.
involving the iris or ciliary body (see p 170).
Transverse B-scaiJ. shows oval-shaped echolucent lens nucleus on
surface of retina (arrow). Note attachment of posterior hyaloid (P)
to nucleus.
POSTSURGICAL FINDINGS
Certain echo graphic findings may be present after intraoc-
unlike a dislocated intact lens (see Figure 5-77), it may not ular surgery. These findings are due to changes in the
move during kinetic echography. anatomy of the globe as a result of the surgical procedure
and to various types of implants or devices that may be in-
serted in or around the eye (Box 4-5). Familiarity with these
Dislocated Intraocular Lens
findings and the related artifacts that may occur is neces-
An IOL may sometimes dislocate posteriorly, and in these sary to avoid misdiagnosis. In addition, the ultrasound ex-
cases, it appears as a large, foreign body-like structure amination may help to clarify a vague or inadequate clinical
within the vitreous cavity (see Figure 4-16). history.
BOX 4-5
PostsurgicC!1 Findings
IOL
Scleral buckle
Vitreous skirt/vitreous hemorrhage
Intraocular gas/air A
Perfluorocarbon
Intraocular silicone
Glaucoma-filtering implant devices (shunts) (see p218)
Gandclovir implant (see Figure 6-23)
Intraocular lens Implants

IOLs can create strong artifacts that may complicate the
echo graphic examination of the posterior segment. The
smooth, highly reflective surface of the lens implant pro-
duces numerous multiple signals that can hinder visualiza-
tion of the vitreous cavity and posterior fundus when an ax- B
ial A- or B-scan approach is used (Figure 4-42). To evaluate
the posterior segment of these eyes reliably, the probe must
be placed peripheral to the limbus.
Scleral Buckle
Scleral buckling procedures produce indentation of the oc-
Figure 4-42 IOL producing multiple signals. A, Axial B-scan
ular wall. Reflectivity of the buckle varies, depending on the echogram shows bright anterior echo from an IOL implant (1).
type of scleral buckle used. A solid silicone buckle produces Note multiple signals (arrows) produced by reverberations be-
a very highly reflective surface that is indistinguishable tween the lens implant and probe face. E, A-scan shows highly re-
from the sclera. The interior of the silicone buckle, how- flective spike from IOL implant (L) and spikes of decreasing
ever, is echolucent on B-scan and low reflective on A-scan. height from the multiple signals (111). (From Green RL, Byrne SF:
Diagnostic ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed 3,
A scleral sponge, on the other hand, produces highly reflec- St Louis, Mosby, 2001, p 300.)
tive surface signals, and the sponge material is echo-dense
and highly reflective. Both types of buckle produce strong
sound attenuation and orbital shadowing (Figures mains attached at the vitreous base, with its posterior sur-
4-43 and 4-44). A silicone encircling band indents the globe face moving freely in the vitreous cavity (Figure 4-45, A
only minimally and extends around the globe circumferen- and B). The internal reflectivity of the remaining vitreous
tially. These thin bands usually cause only mild sound at- gel is very low, appearing echolucent on B-scan.
tenuation. Longitudinal views are usually the best means of In a vitrectomized eye, a diffuse hemorrhage in the vit-
demonstrating the presence of an RD extending posteriorly reous cavity usually produces very weak echoes because the
from the buckle margin (see Figure 6-14). blood remains in a liquefied state and does not become
clumped as it does in the vitreous gel. Therefore, when ex-
amining a vitrectomized eye, it is important to use high
Vitreous Skirt/Vitreous Hemorrhage
gain settings to assess the vitreous cavity for the presence of
Residual vitreous gel may remain in the periphery of the hemorrhage (Figure 4-45, C and D).
eye following a vitrectomy. This remnant of the vitreous
body (i.e., vitreous skirt) can easily be missed on an ultra-
Intraocular Gas/Air
sound examination if the far periphery of the eye is not ad-
equately evaluated. In addition, if the residual vitreous gel is Large gas or air bubbles located in the vitreous cavity may
detected but is not correctly identified, it can be confused hinder or prevent echo graphic examination of the poste-
with a peripheral RD. rior segment. This occurs because gas or air strongly
The unique topography of a vitreous skirt usually facili- reflects the sound waves and thus precludes imaging of
tates its recognition. A transverse B-scan section through any structures located posterior to the bubble (shadow-
the far periphery of the globe typically shows the circum- ing). Multiple signals, produced by reverberations be-
ferential configuration of the vitreous skirt. A longitudinal tween the probe and bubble, are also typically present. In
B-scan section, on the other hand, shows that the gel re- some cases, the bubble may be small enough to allow a
110 THE GLOBE
A D
B E
c F
Figure 4-43 Circumferential solid scleral buckle (A to C) and radial scleral sponge (D to F).
A, Peripheral transverse B-scan echogram shows echolucent area corresponding to scleral buckle
as it surrounds the globe (black arrows). B, Anterior longitudinal B-scan view shows cross section
of buckle (white arrow) near the equator. The buckle is indenting the globe and produces shad-
owing (SR) of the orbital tissue. ON, Optic nerve. C, Corresponding A-scan shows low internal
reflectivity of solid silicone buckle. B, Buckle surfaces; S, sclera. D, Peripheral transverse B-scan
at very low gain shows cross-section of radial sponge that is markedly indenting globe (white ar-
row). The solid scleral buckle (B) lies adjacent to the sponge. SR, Shadowing. E, Longitudinal
B-scan demonstrates the anterior (A) and posterior (P) extent of the echo-dense sponge. F, Cor-
responding A-scan shows highly reflective sponge (arrow) adjacent to sclera (S).
Figure 4-44 Circumferential scleral sponge and solid scleral buckle. Transverse B-scan at equa-
tor shows sponge (open arrows) adjacent to solid buckle (closed arrows).
A c
B D
Figure 4-45 Recurrent hemorrhage and residual vitreous gel following vitrectomy for diabetic
retinopathy. A, Peripheral transverse B-scan shows core of remaining vitreous gel (vitreous skirt).
P, Detached posterior hyaloid; V, vitreous gel; arrows, inner surface of peripheral vitreous skirt.
B, Anterior longitudinal B-scan echogram shows cross-section of vitreous skirt attached to vit-
reous base. Note diffuse vitreous opacities from recurrent vitreous hemorrhage detected at this
high gain setting. C and D are from a different patient. C, Transverse B-scan at a very high gain
shows diffuse opacities from the fluid blood within the vitreous cavity. D, Corresponding
A-scan (also at very high gain setting) shows a chain of low reflective spikes corresponding to the
fluid vitreous blood.
112 THE GLOBE
Figure 4-46 Intraocular gas bubble (G) after vitrectomy. The gas bubble is producing multiple
signals (arrows) as well as total shadowing and obscuration of the adjacent ocular and orbital tis-
sues (S). The sound beam, however, partially bypasses the large anterior bubble and penetrates
a small portion of the posterior globe (P). An Ol;bital foreign body (FE) is located just posterior
to the globe inferiorly. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan
S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 300.)
Figure 4-47 Retained intraocular perfluorocarbon bubble following vitrectomy surgery.

B-scan shows two chains of multiple signals (small a170WS) emanating from bubbles on surface of
retina (large arrows).
Intraocular Silicone
portion of the fundus to be imaged. However, it is often
necessary to have the patient either sit upright or tilt their The sound velocity of silicone oil is much slower than
head so as to move the bubble away from the central axis that of normal ocular tissue and the majority of intra-
of the eye. This frequently allows at least the posterior as- ocular lesions (see Table 10_2).5,28 Consequently, echograms
pect of the vitreous cavity, fundus, and optic disc to be of silicone-filled eyes typically appear much larger than nor-
evaluated (Figure 4-46). A follow-up examination is often mal. Silicone may also produce significant sound attenua-
helpful in these eyes since gas and air bubbles dissipate tion, thus hindering reliable evaluation of the posterior seg-
over time. Mirror-image artifacts 29 may occasionally be ment (Figure 4-48). Although techniques for detecting RDs
encountered in these eyes. in eyes with silicone oil have been reported,28 experience in-
dicates that ultrasound is generally not reliable for detecting
detachments in these eyes. See p 265 for a discussion of sil-
Perfluorocarbon
icone oil and the measurement of axial eye length.
Residual perfluorocarbon bubbles may remain in the eye
following vitrectomy surgery. These bubbles have a ten-
Glaucoma-Filtering Implant Devices (Shunts)
dency to adhere to the surface of the fundus. On B-scan,
they appear as small, bright echoes followed by a promi- See p 218 in Chapter 7 for a review of glaucoma-filtering
nent chain of multiple signals20 (Figure 4-47). shunts.
A c
B D
Figure 4-48 A- and B-scan echograms of globe filled with silicone oil (A and B) and normal
fellow eye (C and D) at same screen expansion. Silicone oil produces marked sound attenuation,
preventing resolution of the posterior ocular wall and orbital contents. The sound velocity in the
silicone oil is significandy slower than that of aqueous and vitreous, which causes echograms to
appear larger than normal. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in
Ryan S] [ed]: Retina. ed 3, St Louis, Mosby, 2001, p 301.)
114 THE GLOBE
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may be partially calcified (Figure 4-49). The subretinal Ultrasound. St Louis, Mosby, 1969, p 311.
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either hemorrhage or cholesterol debris (see Figure 3-25, A orrhage. Clinical features and results of secondary surgical manage-
ment. Ophthalmology 1993;100:460.
and B). In phthisis bulbi, the globe may be so shrunken and 26. Rubsamen PE, Cousins SW,Winward KE, et al: Diagnostic ultra-
calcified that the normal ocular structures cannot be rec- sound and pars plana vitrectomy in penetrating ocular trauma. Oph-
ognized: In such cases, it may be impossible to completely thalnzology 1994;101:809.
27. Sawada A, Frazier SL, Ossoinig KC: The role of ultrasound in the
rule out the presence of an intraocular tumor. management of ocular foreign bodies, in White D, Brown RE (eds):
Ultmsound in Medicine. New York, Plenum Press, 1977, 3A:I003.
28. Shu gar JK, de Juan E Jr, McCuen BW II, et al: U1trasonic examina-
REFERENCES tion of the silicone-filled eye. Theoretical and practical considerations.
1. Awschalom L, Meyers SM: Ultrasonography of vitreal foreign bodies Graefes A7'ch Clin Exp OphthalnzoI1986;224:361.
in eyes obtained at autopsy. Arch Ophthalnzol1982; 100:979. 29. YVhitacre MM: B-scan ultrasonography of eyes containing intravit-
real gas. Anz J OphthalnzoI1991;112:272.
Intraocular Tumors
Ultrasound has become increasingly important in the eval- solid (e.g., serous or hemorrhagic detachment of the
uation of eyes with intraocular tumors.* Aside from its ob- choroid, retina, or pigment epithelium). This is accom-
vious benefits for eyes with opaque ocular media, it has now plished by observing the lesion's surface to detect the pres-
become the most useful, noninvasive adjunct to the clinical ence of aftermovement (see p 36). Another indication that
examination for the differentiation of intraocular tumors in the lesion may not be solid is the lack of internal echoes
the presence of clear ocular media. In addition, ultrasound when an extremely high gain setting is used. It should be
can provide accurate measurements of tumor size and is pointed out, however, that these criteria may be difficult to
therefore valuable for the assessment of growth or regres- evaluate when a lesion is only mildly elevated. Conse-
sion. Both anterior segment and posterior segment tumors quently, the determination of whether a slightly elevated
can be evaluated. Standardized Echography,34,60,61 three- lesion is solid or nonsolid cannot always be made.
dimensional B-scan imaging 81 (see Chapter 9), spectrum
analysis,20,21,47 ultrasound biomicroscopy (UBM)72 (see
OCULAR MELANOMA
Chapter 8), and color Doppler imaging (CDI) (see Chapter
14) are useful for evaluating intraocular tumors. The evaluation and measurement of ocular melanomas is
one of the most important functions of ophthalmic ultra-
sound.l 6,17,52 Ultrasound has proved to be a useful diagnos-
DETECTION OF LESIONS
tic imaging modality for determining the presence of a
An intraocular tumor must be of a minimum thickness (i.e., melanoma in opaque ocular media,51 but it also offers a re-
elevation) before it can be resolved by ultrasound. In most liable, independent diagnosis in clear ocular media. In sev-
cases, a lesion arising within the choroid must be more el- eral large studies, it has been shown that Standardized
evated than the surrounding retinochoroid layer to be de- Echography, in particular, is highly accurate for the diag-
tected. Experience has shown60 that a lesion usually must nosis of ocular melanoma. 28 ,56,59,98 Echography has proved
be elevated by approximately 0.75 mm before it can be dis- to be useful also for the detection of extraocular tumor
tinguished from surrounding tissue. Lesions involving the growth, and it is a reliable method of obtaining accurate
ciliary body normally need to have an even greater eleva- measurements of tumor dimensions. 56
tion to be detected because of the irregular nature of the
normal ciliary body and its anterior location. It should be
Typical Acoustic Properties of Ocular Melanoma
noted, however, that very small ciliary body lesions can be
detected with the new high resolution B-scan instrumenta- Specific criteria are used to diagnose an ocular melanoma
tion (see pp 39 and 173 and also Chapter 8). with Standardized Echography.60-62 The cardinal features
Although a choroidal lesion may be large enough to be include (1) solid consistency, (2) collar button (i.e., mush-
detected by ultrasound, effective quantitation may require room) shape, (3) low to medium internal reflectivity, (4)
even more elevation. This height is usually 2 mm or regular internal structure, and (5) internal blood flow (i.e.,
greater, but the size required for differentiation in many vascularity) (Figure 5-1). Additional factors, including the
cases depends on the location and internal reflectivity of the presence of sound attenuation, the extent of associated ex-
lesion. In general, anterior segment lesions need to be udative retinal detachment, and the status of tlle adjacent
thicker than choroidal lesions to be differentiated. Addi- scleral/orbital interface are also important considerations.
tionally, low reflective lesions require less elevation than do Echographically, most melanomas are dome shaped, but
highly reflective lesions to be diagnosed with echography. some may be lobulated or have an irregular surface contour
In determining whether an elevated fundus lesion is a (Figure 5-2). The classic configuration of a melanoma,
tumor, it is important to assess whether it is solid or non- however, is the collar button shape. In addition, melanomas
may have a diffuse configuration with a relatively flat but
*References 7,17,58,62-64,67. irregular surface. The collar button shape, indicating that
115
116
Figure 5-1 Choroidal melanoma. A, Transverse B-scan echogram shows typical collar button
(i.e., mushroom) configuration. I, Initial line corresponding to probe face. B, A-scan echogram
shows low to medium internal reflectivity that is typical of choroidal melanoma. I, Initial spike cor-
responding to probe tip; T, tumor surface; arrow, internal tumor spikes; S, sclera.
Figure 5-2 Choroidal melanomas. Transverse B-scans demonstrate dome (A) and lobulated
(B) configurations. Arrows, Tumor.
Chapter 5 INTRAOCULAR TUMORS 117
Other Findings in Ocular Melanoma

the tumor has broken through Bruch's membrane, gives the
tumor a distinct, nearly pathognomonic appearance on There are several other findings that may be encountered in
B-scan. The break usually occurs near the center of the the ultrasound examination of an ocular melanoma. These
tumor, but it sometimes occurs in an eccentric area of the include sound attenuation, choroidal excavation, posterior
lesion. The collar button shape is most often noted in larger scleral bowing, and retinal detachment, as well as vitreous
tumors, but it can be present in smaller lesions as well (Fig- and subretinal hemorrhage. In addition, certain melanomas
ure 5-3). This finding is usually easy to detect, although in may exhibit an atypical irregular internal structure, cystic
some cases, it is discovered only through careful topo- spaces, signs of inflammation, and/or calcification.
graphic evaluation. It should be noted that rarely the collar
button shape can be seen in tumors other than melanoma Sound Attenuation
(see p 144). Large ocular melanomas often produce significant internal
The internal reflectivity of an ocular melanoma is an im- sound attenuation. 32 ,53 As previously described (see p 34),
portant criterion for diagnosis. Because of their cellular, ho- sound attenuation, represented by a decrease in echo
mogeneous histologic architecture, these tumors typically strength, occurring from left to right in the echogram, re-
demonstrate low to medium reflectivity. For the same rea- sults in the display of lower reflectivity at the base of the
son, their internal structure is, in most cases, quite regu- tumor. On B-scan, this decreased reflectivity at the tumor
lar42 ,44,62 (see Figures 2-24 and 5-1). base has been described by some authors as acoustic hol-
Internal blood flow (i.e., vascularity) is another impor- lowing.1 8,43 The lower reflectivity on A-scan and acoustic
tant acoustic property that can be observed in nearly all oc- hollowing on B-scan at the base of a large melanoma may
ular melanomas. Vascularity, on A-scan, is indicated by the also be due in part to the more homogeneous nature of the
presence of a fast, spontaneous, low-amplitude flickering tumor in this region (Figure 5-4). Occasionally, melanomas
motion occurring within the internal tumor spikes (see Fig- produce very strong sound attenuation that causes de-
ure 2-29). Internal blood flow can also be detected with creased reflectivity of the orbital echoes behind the tumor
B-scan,34 as well as with CDI (see p 373). (i.e., shadowing).
A c
B o
Figure 5-3 Four different collar button-shaped choroidal melanomas (transverse B-scan
echograms). A, Large collar button, centered over the tumor base. B, Large collar button, lo-
cated eccentrically. C, Very small collar button (arrow), centered over the tumor base. D, Small
collar button (arrow), located eccentrically.
118 THE GLOBE
Figure 5-5 Scleral bowing. Axial B-scan showing dome-shaped

B melanoma adjacent to optic nerve (ON) with bowing of sclera pos-
terior to the tumor (arrows).
ing posterior to the tumor. 9 This bowing is caused by

increased concavity of the sclera underlying the tumor (Fig-
ure 5-5) and can be associated with scleral infiltration (see
p 131). Posterior scleral bowing can be confused with
choroidal excavation but can be differentiated by noting the
Figure 5-4 Collar button-shaped melanoma demonstrating increased concavity of the sclera. It should also be noted
strongintenial sound attenuation and "choroidal excavation."
A, Transverse B-scan echo gram shows echolucent area at base of that posterior scleral bowing is not specific for choroidal
tumor produced by sound attenuation. This echolucency (acoustic melanoma and has been reported in other tumors occur-
hollowing) can also be due, in part, to a more homogeneous cel- ring in younger individuals (see p 154).
lular architecture at the base of the tumor. Arrow, apparent
choroidal excavation due to curving of tumor base at its margin. Retinal Detachment
B, A-scan echogram shows moderately steep angle kappa, indica-
tive of internal sound attenuation and/or a change in the cellular Serous retinal detachments are commonly associated with
architecture at the tumor base. T, Tumor surface; arrow, internal choroidal melanomas. These exudative detachments often
tumor spikes; S, sclera. extend from the margins of the. tumor and are also fre-
quently present in the lower periphery of the globe, away
from the tumor mass. In rare cases, the retina may be de-
Choroidal Excavation tached over the apex of the tumor (see p 123).
A B-scanfinding that has been described in melanomas is
choroidal excavation. 16 ,18 This B-scan characteristic, noted Hemorrhage
at the tumor base, is thought to be caused by homogeneous Vitreous hemorrhage and/or subretinal hemorrhage may
tumor infiltration of the normal choroid (see Figure 5-4). occur secondary to an ocular melanoma (Figure 5-6).
The normal choroid, however, is of microscopic thickness, When such hemorrhage is extremely dense, it can mask an
and therefore, tumor infiltration does not adequately ex- underlying tumor. Therefore, whenever a dense hemor-
plain this phenomenon. Another explanation is that the rhage is present, the eye should be carefully screened to
finding of choroidal excavation is merely an illusion created rule out a solid mass. If a lesion of questionable solidity is
by the curved appearance of the tumor base at its margins. found, serial examinations may be necessary to rule out a
It should also be noted that choroidal excavation has been melanoma.
demonstrated in a variety of other choroidal lesions and is
therefore not specific for melanoma.2 8 Irregular Internal Structure
Some melanomas have been shown to exhibit atypical
Posterior Scleral Bowing features such as irregular structure and higher internal
Another finding that has recently been described in reflectivity.32 These features are most commonly noted
melanomas occurring in younger individuals is scleral bow- in very large melanomas that contain hemorrhage and
A B
Figure 5-6 Large collar button-shaped melanoma with vitreal and subretinal hemorrhage.
A, Transverse B-scan echo gram shows posterior vitreous detachment (P), tumor (I), and sub-
retinal hemorrhage (black arrows). B, Photograph of gross pathologic specimen shows large
choroidal melanoma (mixed cell type) and subretinal hemorrhage.
A B
Figure 5-7 Large ciliochoroidal melanoma with irregular internal structure. A, Transverse
B-scan shows large dome-shaped melanoma with relatively echolucent base due to sound atten-
uation. B, A-scan shows somewhat irregular internal structure, although there is a moderately
steep angle kappa. T, Tumor surface; arrows, internal tumor spikes; S, sclera. Note the higher
internal reflectivity within the anterior portion of the tumor.
necrosis, as well as dilated blood vessels, especially in button appearance on B-scan. In these cases, spikes may
more anterior portions of the lesion. This can result in a be produced by both the tumor surface and the edges of
higher, more irregular internal reflectivity in these por- Bruch's membrane, resulting in an irregular internal struc-
tions of the tumor. Additionally, these lesions may pro- ture on A-scan. However, with slight movement of the
duce moderate sound attenuation (Figure 5_7).53,62 A-scan probe, directing the sound beam completely through the
echograms may also be more irregular when a tumor has break, the A-scan pattern often becomes lower reflective
broken through Bruch's membrane and shows a collar and more regular (Figure 5-8). Lesions with a very bumpy
120 THE GLOBE
A C
B D
Figure 5-8 Collar button-shaped melanoma with irregular internal structure due to rupture in
Bruch's membrane. A, Transverse B-scan echogram through periphery of tumor in area where
Bruch's membrane is intact (closed arrow). B, Transverse B-scan view through center of tumor
shows breakin Bruch's membrane (open arrow). C, A-scan corresponding to B-scan in A displays
irregular internal structure owing to a highly reflective spike produced by Bruch's membrane
(arrow). T, Tumor surface; S, sclera. D, A-scan corresponding to B-scan in B shows more regu-
lar internal structure as sound beam passes through break in Bruch's membrane.
surface contour also may produce a slightly irregular pat- demonstrated microscopic extraocular extension in one
tern on A-scan examination. case. 107 Another report described three cases of choroidal
melanoma with clinical signs of inflammation that under-
Cystic Spaces went partial spontaneous regression. 89 One of these tumors
B-scan may demonstrate tiny cystlike spaces within ocular was found to be highly necrotic on histopathologic exami-
melanomas. This finding is not specific for melanoma, nation. A more recent histopathologic study from the
however, and may occur in other types of intraocular tu- Armed Forces Institute of Pathology (AFIP)55 reported on
mors. On the other hand, very large cystic cavities are more the association of scleritis and episcleritis with choroidal
characteristic of ciliochoroidal melanomas 5o (see p 173). and ciliary body melanoma. This investigation showed that
scleritis and episcleritis were significantly associated with
Inflammation tumor necrosis. It is important to note that the echographic
Scleritis, sub-Tenon's edema or inflammatory infiltration, findings of scleritis and episcleritis can mimic extraocular
and orbital inflammation can sometimes be detected echo- extension. Follow-up examination is, therefore, essential
graphically in association with ocular melanomas. 3,89 In two whenever there is a question of inflammation vs. extraocu-
such cases, the inflammation resolved and the size of the lar extension (see p 131).
choroidal melanoma decreased following treatment with
corticosteroids (Figure 5-9). The etiology of this inflam- Calcification
matory reaction was not entirely clear. Neither case Another rare finding in ocular melanoma is the presence of
showed any histopathologic evidence of scleral or ex- calcification. Calcium usually appears as a solitary focus on
trascleral invasion, although one tumor showed partial the surface of the tumor, in most cases, underlying an area
necrosis. In a report of three similar cases, histopathology of localized retinal detachment (Figure 5-10). One case
A c
B D
Figure 5-9 Choroidal melanoma with associated scleritis and orbital inflammation. Echograms
show initial evaluation (A and B) and following corticosteroid therapy (C and D). A, Transverse
B-scan demonstrates dome-shaped intraocular mass with shallow overlying serous retinal de-
tachment (straight arrow) and diffuse sub-Tenon's lesion adjacent to intraocular tumor (curved
arrow). S, Sclera. B, Corresponding A-scan shows low reflectivity of choroidal mass as well as
shallow retinal detachment and medium reflectivity of lesion posterior to sclera. T, Tumor sur-
face; S, sclera. C and D show significant decrease in elevation of intraocular tumor and nearly
complete resolution of orbital mass. Note retinal detachment is no longer present.
E, Histopathology shows partially necrotic melanoma (mixed cell type) without evidence of ex-
trascleral extension.
122 THE GLOBE
A
A
B
B
Figure 5-10 Dome-shaped melanoma showing calcified nodule Figure 5-11 Measurement of tumor elevation using simultane-
(arrow) on peripheral surface of tumor. Transverse B-scan ous vector A-scan. A, Transverse B-scan with vector A-scan
echograms are at medium gain (A) and low gain setting (B). through center of dome-shaped tumor. B, Vector A-scan dis-
played without B-scan shows cursors positioned on tumor surface
and inner sclera. Height of tumor = 2.2 mm.
report describes a large plaque of calcified bone within a

choroidal melanoma. 10 prognOSIS and management of patients with ocular
melanoma.
Spectrum Analysis of Ocular Melanoma
Tumor Biometry
Coleman and associates have developed a technique using
spectrum analysis for tissue characterization of intraocular One of the more important functions of echography in the
tumors. 19 ,47,48 This technique uses computer analysis of cer- evaluation of melanomas is the measurement of tumor di-
tain ultrasound parameters to provide acoustic signatures mensions. 56 Accurate measurements are important for plan-
of intraocular tumors. Spectrum analysis has been success- ning tumor management (e.g., observation vs. treatment
ful in differentiating ocular melanoma from other intraoc- and radiation dosimetry) and for monitoring tumor growth
ular tumors and has shown the potential to identify differ- or regressIOn.
ent cell types of melanoma (e.g., spindle B and mixed
epithelioid).20 More recently, this technique has been used Tumor Height Measurements
to demonstrate microcirculatory patterns in uveal The measurement of apical tumor height (i.e., maximum el-
melanomas. It has been shown that the histologic presence evation) should first be performed using B-scan. WIth some
of microvascular networks in ocular melanoma is associated B-scan instruments, measurements can be obtained directly
with increased mortality.91 The microcirculatory networks from the screen using electronic cursors; in others, it may
appear to provide a specific acoustic signature with spec- be necessary to measure a photograph of the echogram (see
trum analysis. This method may prove beneficial for the Appendix F). The measurement of tumor height can also be
performed in some instruments by using a vector A-scan scleral spike. Measurements are obtained from the screen
placed on the B-scan echogram (Figure 5-11). by means of electronic cursors positioned on the same
For B-scan measurements, either a transverse or a lon- phase or region of the tumor surface spike and the inner
gitudinal view can be employed; but ideally, measure- scleral spike (Figure 5-14). Some instruments lack elec-
ments should be obtained using both views. There are sit- tronic cursors and thus require that measurements be made
uations, however, in which one approach may be more from photographs using calipers and conversion tables 59
reliable than the other, depending on the location and (see Appendix A).
shape of the lesion. Peripheral lesions are frequently bet- The examiner should strive to obtain several consistent
ter assessed with a longitudinal view. With a transverse measurements from the best-quality echograms that can be
scan through a peripheral tumor, the sound beam may be obtained. There should be a close correlation between
unknowingly directed obliquely, resulting in a falsely high measurements obtained with B-scan and standardized
tumor elevation. Furthermore, it should be stressed that A-scan techniques. The measurements obtained with these
it is not possible to obtain an accurate height measure- two methods should generally be within 0.2 to 0.3 mm for
ment of a tumor located in the periphery using the vector small tumors and 0.5 mm for large tumors. When greater
A-scan technique. differences are encountered, the quality of the echo grams
For most tumors, the initial step in obtaining an apical should be re-evaluated and those considered suboptimal re-
height measurement with B-scan is to examine the tumor peated. The echo grams should also be assessed to ensure
with a transverse probe position. Using a medium gain set- that the correct surfaces were measured.
ting, the tumor is centered in the echogram and the probe Correct identification of A-scan spikes originating from
is angled back and forth, thus sweeping the acoustic section the tumor surface and the inner sclera is critical for accurate
across the lesion. As this maneuver is carried out, the measurements. In cases in which the retina is attached to
echogram is monitored in an attempt to direct the sound the apex ofthe tumor, the tumor surface spike includes
beam perpendicular to both the apex of the tumor and the both retina and tumor surface. This results in the tumor
inner sclera at the tumor base. The inner sclera can be surface spike appearing relatively thick at Tissue Sensitivity
identified as the first distinct line at the base of the tumor and sometimes double peaked at reduced gain. In these
that is continuous with the surrounding fundus (Figure cases, measurements should always be obtained from the
5-12). Once optimal display of both the apex and the inner retinal portion of the surface spike. Conversely, if B-scan
sclera has been achieved, the apical height of the tumor can examination shows that the retina is detached from the tu-
be measured from the B-scan echo gram. A similar maneu- mor apex, measurements should be taken from the actual
ver, using a longitudinal scan, is then performed to obtain a tumor surface spike rather than from the retinal spike (Fig-
second apical height measurement. ure 5-15). In some tumors, it may be impossible to display
Axial and para-axial B-scan probe approaches (e.g., ver- the surface spike at 100% height. This can occur in tumors
tical macular scan, see p 2S) are usually best suited for mea- with a very convex surface configuration, steep elevation,
suring lesions in the peripapillary region (see Figure 2-20). or an irregular, bumpy surface. In such cases, the highest
These approaches are not appropriate, however, for mea- amplitude tumor surface spike that can be displayed should
suring more peripheral tumors. be used for the measurement.
Once a preliminary measurement of tumor elevation has The spike produced by the inner sclera may sometimes
been obtained with B-scan, this value is confirmed with be difficult to identify correctly. The most common error in
standardized A-scan. The A-scan is first set at Tissue Sen- this regard is measuring to the outer sclera/Tenon's capsule
sitivity and the probe is placed on the area of the globe op- interface and thus obtaining a falsely large measurement.
posite the tumor. The probe is then shifted as needed to di- This can occur because the outer sclera/Tenon's interface
rect the sound beam toward the tumor apex. Localization of is often more highly reflective than the inner scleral sur-
the tumor apex can be further accomplished by shifting the face; therefore, it is easier to display for measurement. This
sound beam back and forth across the tumor. The sound error can be avoided, however, by recognizing that the in-
beam should be shifted until it is simultaneously aligned ner sclera produces the first distinct spike at the base of the
perpendicular to both the surface of the tumor at its apex tumor when using both Tissue Sensitivity and reduced gain
and the inner sclera. Perpendicularity is achieved once (Figure 5-16). The use of a medium or slightly higher gain
steeply rising spikes of maximum height are displayed from setting can facilitate identification of the inner scleral spike.
both surfaces (Figure 5-13). In addition, A-scan measurements should always be corre-
When both the tumor surface spike and the scleral spike lated with those obtained from B-scan to help assure accu-
have been adequately displayed at Tissue Sensitivity, a mea- ra te readings (Figure 5-17).
surement of the elevation is obtained. For further refine- It is important to point out that the steepness and
ment of the measurement, the gain is reduced slightly (as height of the inner scleral spike may diminish due to scler-
the screen is continuously monitored) to display distinct al tumor infiltration or associated scleritis (Figure 5-IS),
peaks from both the tumor surface spike and the inner or as a result of plaque radiotherapy (see p 13 7). In these
Text continued on p 129
124 THE GLOBE
Figure 5-12 Dynamic B-scan technique to localize tumor apex (maximum elevation).
Schematic drawing shows probe placement for transverse scanning. Probe is first placed near
the limbus on the meridian opposite the tumor and is shifted toward the fornix. This provides
multiple sections of the tumor from its posterior (1) to its anterior border (4). The maximum tu-
mor height is displayed with probe position 2. Note exudative retinal detachment overlying and
adjacent to tumor. A170WS, Inner sclera.
Figure 5-13 Dynamic A-scan technique to localize tumor apex (maximum elevation).
Schematic drawing shows probe shifted from limbus to fornix. This displays the lesion from its
posterior margin (1) to its anterior matgin (4). Note that maximum tumor height is displayed
with probe position 2. In the corresponding echo gram (2), the steeply rising, high spikes from
the retina and sclera indicate that the sound beam is directed perpendicular to these surfaces.
T, Tumor surface; S, sclera.
126 THE GLOBE
Figure 5-14 A-scan measurement of choroidal melanoma. A, A-scan echogram at Tissue Sen-
sitivity gain setting to examine and measure tumor with relatively wide portion of sound beam.
T, Tumor surface; I, inner sclera. Elevation = 5.7 mm. B, A-scan at reduced gain setting. At
lower gain, the sound beam is effectively narrowed (only center of beam is used), thus improv-·
ing axial resolution and providing more accurate measurements. Maximum elevation = 5.7 mm.
A c
B o
Figure 5-15 Choroidal mdanoma with overlying retinal detachment. Measurement of tumor
height must be obtained from actual tumor surface rather than from detached retina. Transverse
(A) and longitudinal (B) B-scans show retinal detachment (arrow) overlying apex of tumor. A-
scan views at Tissue Sensitivity (C) and reduced gain setting (D) show separate spikes from de-
tached retina (arrow) and tumor surface (1).
128
I
I
I
I
II II
II I II
LJ
II I II
'k
II I II
'! . T!, A
, . \JII \ I
I
II
II
I
:
::0
I
I I'
T' B
Figure 5-16 Schematic drawing showing A-scan technique for measuring tumor height. Probe
is placed on globe opposite tumor with sound beam directed perpendicular'to apex of tumor and
sclera. Measurement is obtained at both Tissue Sensitivity (A) and moderately reduced gain (B).
To obtain an accurate measurement, the sound beam must be directed perpendicular to both the
tumor surface (I) and the inner sclera (I). Note that an erroneously large measurement can be ob-
tained if the tumor is measured. to the outer sclera (0). This can be avoided by maintaining the
display of the inner scleral spike as' the gain is reduced for measurement.
A c
B D
Figure 5-17 Erroneous measurement of intraocular tumor height. Apical height is first mea-
sured from transverse (A) and longitudinal (B) B-scans with electronic cursors (black crosses)
placed on tumor surface and inner sclera. The apical height measures 3.2 0 rnm. ON, Optic nerve.
The tumor is then measured with A-scan, first at Tissue Sensitivity (C) and then at reduced gain
(D). C, With cursors placed on surface of tumor (I) and inner sclera (I), apical height measures
3.19 rnm. 0, Outer scleral spike. D, .At reduced gain, the weaker inner scleral spike is no longer
displayed and an erroneous measurement (3.87 rnm) is obtained to the outer scleral spike (0).
This error can be avoided by correctly identifying the inner scleral spike at the higher gain level
(Tissue Sensitivity) and then maintaining its display as the gain is reduced. This example demon-
strates the importance of always correlating A- and B-scan measurements.
A
A
D
Figure 5-18 Choroidal melanoma with scleritis resulting in de-
creased reflectivity of sclera. A, Longitudinal B-scan view at re-
duced gain setting shows irregular, indistinct scleral surface (small
arrows) and edema in sub-Tenon's space (large arrow) due to scler-
itis. ON, Optic nerve. B, A-scan echogram shows reduced height
of scleral spike (S) due to inflammation. CU'f7Jed a1TOW, Surface of
tumor; vertical arrow, edema in sub-Tenon's space; T, Tenon's cap- Figure 5-19 B-scan monitoring for growth of small choroidal
sule. C, Corresponding A-scan at reduced gain again shows melanoma treated with laser. Transverse B-scan echo grams show
Tenon's capsule (I) to be more highly reflective than the inflamed tumor prior to laser therapy (A), during ongoing treatment
sclera (S). Vertical arrow, Inflammation in sub-Tenon's space. (B and C) and following treatment CD). Note that tumor is al-
most completely flat in C after last laser treatment, but shows mild
increase in height 3 months after completion of treatment (D).
more difficult cases, identification of the scleral spike can
be aided by correlating A- and B-scan echograms.
The A-scan measurement of small tumors « 1.5 mm) Tumor Base Measurements
can be quite challenging. This is due to the difficulty of si- Ultrasound can be utilized to measure the basal diameter
multaneously directing the sound beam perpendicular to of a tumor by examining it with both transverse and longi-
both the tumor apex and the inner sclera. It is therefore tudinal approaches. The transverse approach measures the
recommended that B-scan measurements be used to mon- circumferential (lateral) diameter, whereas the longitudinal
itor the apical height of small tumors (Figure 5-19). approach measures the radial (anteroposterior) diameter.
130
12
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A \
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\
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"-
' ................. _--_ ....... /
B E
c F
Figure 5-20 Basal diameter measurements of choroidal tumor using transverse and longitudi-
nal B-scan approaches. Three-dimensional schematic drawings show choroidal tumor (A) with
transverse (B) and longitudinal (C) sound beam approaches. Schematic drawing (D) shows path
of sound beam through tumor for the transverse (I) and longitudinal (L) scans. Transverse (£)
. and longitudinal (F) echo grams show dome-shaped tumor with correct placement of cursors at
tumor margins. The transverse approach provides the lateral (i.e., circumferential) extent
whereas the longitudinal approach displays the anteroposterior (i.e., radial) extent of the tumor.
In this example, the tumor base measures 8.65 mm circumferentially and 7.40 mm radially. ON,
Optic nerve.
Figure 5-21 Choroidal melanoma with extrasclerafex-

tension. A, Longitudinal B-scan shows dome-shaped tumor
B with extrascleral nodule (large arrows) located hear the op-
tic nerve (ON). Note communication of nodule with in-
traocular tumor through small vessel in sclera (snzallarrows).
B, Transverse B-scan obtained through posterior aspect of
tumor also shows extrascleral tumor nodule (arrows).
C, Gross pathologic specimen shows choroidal melanoma
(mixed cell tuIllor) with extrascleral extension (arrow).
These measurements can be performed from the screen forms of ultras~und. This combination is used to evaluate
with electronic cursors or from photographs, using calipers tumor size and to establish whether growth or regression
(Figure 5-20; see also Appendix F). has occurred. The one measurement that eludes this
In some cases, the longitudinal arid transverse views may method, however, is an accurate determination of tumor
not demonstrate the largest basal diameter of the tumor. volume. Many investigators believe that an assessment of
This can sometimes be appreciated, however, by simply ro- tumor volume is the most effective and reliable means of
tating the probe while performing either a transverse or a measuring and following choroidal melanomas. The devel-
longitudinal scan. opment of new three-dimensional (3-D) ultrasoUnd tech-
Measurements from B-scan are most accurate and useful nologyH now provides a more effective and reliable means
when the tumor has very distinct margins that can be easily of measuring tumor volume (see Chapter 9).
identified echo graphically. B-scan measurements are less
reliable in areas of the tumor that have tapered, indistinct
Extrascleral Extension
margins. In cases in which the tumor margins are clinically
visible, B-scan measurements should be compared with the B-scan can be very useful in detecting extrascleral- exten-
clinical estimate. If the tumor is to be plaqued, a general sion of an intraocular melanomap,52,78,79 Extrascleral tu-
rule of thumb is that the greater of the clinical and echo- mor extension typically appears as one or more nodules lo-
graphic measurements should be used. Also, it should be cated near the sclera, adjacent to the base of the tumor
realized that when a choroidal tumor extends into the cil- (Figure 5-21). The thickness of the nodule must be ap-
iary body, the anterior border may not be clearly imaged proximately 1.5 mm before it can be reliably detected.
(see p 174). As a result, measurement of the radial basal di- When the lesion is of sufficient thickness, standardized A-
ameter for such tumors may be inaccurate. scan can also be used to assess internal reflectivity (Figure
5-22) and blood flow within the nodule. .
Tumor Volume Measurements/ Small areas of suspected tumor extension may be
Three-Dimensional Imaging identified, but in many cases, the small size precludes
As previously described (see p 122), traditional methQds of confident diagnosis at the initial examination. When a suspi-
measuring intraocular tumors utilize a combination of the cious area is detected, follow-up examinations can be useful
one-dimensional (A-scan) and two-dimensional (B-scan) to look for an increase in size or changes in configuration
132 THE GLOBE
A
c
Figure 5-22 Choroidal melanoma with extrascleral ex-

tension. A, Transverse B-scan echogram shows dome-
shaped intraocular tumor with retinal detachment at margin
B (white arrow). Large extrascleral tumor nodule is shown at
lower edge of choroidal mass (black arrow). B, A-scan shows
low reflectivity of both intraocular (open arrow) and ex-
traocular (straight arrow) portions of tumor. T, Tumor sur-
face; S, sclera; curved arrow, Tenon's capsule. C, Gross
pathologic specimen shows choroidal melanoma (mixed cell
tumor) and extrascleral tumor nodule (arrows).
A B
Figure 5-23 Choroidal melanoma with extrascleral extension. Transverse B-scan echograms
show growth of suspicious area of extraocular extension. A, At initial examination, there is a
small area of echolucency in the episcleral region adjacent to tumor (arrow). B, At follow-up ex-
amination 1 year later, there is growth of both intraocular tumor and extraocular lesion (arrow).
Note that the extrasclerallesion now has a nodular appearance.
that may indicate true extraocular growth (Figure 5-23). It traocular extension, can be demonstrated echographically
should also be emphasized that small choroidal melanomas (Figure 5 -2 5). In addition, extension through the sclera
can be associated with significant extraocular tumor growth within small blood vessels may sometimes be detected; and
(Figure 5-24). As a result, small tumors should be monitored occasionally, the vessel may be shown to communicate with
with ultrasound, even when there is no clinically apparent an extraocular nodule (see Figure 5-21). In one instance,
change in the size of the intraocular lesion. the extension of a melanoma into the orbit by way of a vor-
In some cases, scleral infiltration, with or without ex- tex vein was observed 34 (Figure 5-26; see also Figure 9-3).
A B
Figure 5-24 Small intraocular melanoma with large extrascleral tumor extension. A, Trans-
verse B-scan echogram (at reduced gain setting) shows relatively small, lobulated intraocular
melanoma (curved arrow) and large melanoma in orbit (NT). V, Vitreous cavity; straight arrow,
sclera; B, orbital bone. B, A-scan shows small, medium reflective intraocular melanoma (arrow),
and large, low reflective portion in orbit. T, Tumor surface; S, sclera.
A B
Figure 5-25 Small choroidal melanoma showing infiltration and bowing of posterior sclera.
A, Transverse B-scan demonstrates dome-shaped tumor with diffuse infiltration and bowing of
sclera (arrows). B, Histopathologic specimen of the melanoma (spindle cell type) shows scleral in-
filtration (arTows) and bowing of sclera.
134 THE GLOBE
Figure 5-26 Large, irregularly shaped melanoma with extension into orbit via vortex vein (ar-
row). (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed
3, St Louis, Mosby, 2001, p 274.)
Figure 5-27 Choroidal melanoma located temporally

overlies insertions of lateral and inferior oblique muscles.
A, Fundus photograph shows large choroidal tumor located
temporally in the left eye. B, Vertical transverse B-scan
through anterior portion of lesion at 3-o'clock shows thin
A
echolucency adjacent to sclera (arrow) produced by inser-
tion oflateral rectus muscle. C, Oblique transverse B-scan
through more posterior aspect of tumor shows inser'tion of
inferior oblique muscle (curved arrow) and slightly more
posterior section of lateral rectus muscle (straight arrow).
B c
Pseudoextrascleral Extension (Figure 5-27). This mlsmterpretation can usually be

Certain findings can simulate extraocular growth of a avoided, however, if the examiner is aware of the location
melanoma. These include congested blood vessels, ex- and normal appearance of the extraocular muscles (see
traocular muscles, and inflammation in sub-Tenon's Chapter 15 and Figure 15-2). It should be pointed out,
space. 24 ,80 A dilated episcleral blood vessel adjacent to an however, that the presence of a muscle adjacent to an in-
intraocular tumor may be difficult to distinguish from extraocular tumor can mask small areas of extrascleral exten-
traocular extension but should not change in size on fol- sion. If, in such cases, the pattern in the region of the ex-
low-up examination. traocular muscle has a somewhat nodular or irregular
The insertion of an extraocular muscle, especially the in- configuration, then extraocular tumor extension should be
ferior oblique, can be mistaken for extrascleral extension strongly suspected (Figure 5-28).
A c
B D
Figure 5-28 Choroidal melanoma with extrascleral extension. Patient with painful eye was re~
ferred for echography with suspected scleritis. Although view of the fundus was hazy, an amel-
anotic lesion was visible in the lower temporal periphery beneath a bullous retinal detachment.
Echograms were typical for melanoma. In addition, there was an extraocular lesion in the region
of the inferior oblique muscle adjacent to the tumor. On initial examination, it could not be de-
termined whether this represented thickening of the muscle or actual extraocular tumor growth.
A, Transverse B-scan echogram from initial examination shows large, irregularly shaped in-
traocular tumor with adjacent echo lucent lesion in orbit (curved arrow). Straight arrow, RD.
E, Transverse B-scan 4 weeks later shows increased thickness and slight change in shape of ex-
traocular lesion (curved al''Tow). Definite extrascleral extension was diagnosed by echography at
this visit. Sagittal MRI scans (C and D) obtained at time of second echography examination
failed to disclose extrascleral portion of tumor. Intraocular tumor, arrows. C, Tl-weighted scan.
D, Scan with fat suppression. E, Gross pathologic specimen shows melanoma (mixed cell tu-
mor) and extraocular tumor nodule (arrow).
136 THE GLOBE
Diffuse Melanoma
Episcleral inflammation adjacent to a choroidal mela-
noma can also mimic extraocular extension. As mentioned Diffuse melanomas can be difficult to diagnose, both clini-
earlier (see p 120), some choroidal melanomas have been cally and echo graphically. Although these tumors are usu-
associated with scleritis and episcleritis. In all of these cases, ally flat and diffuse, they may have a slightly irregular,
the inflammation resolved following corticosteroid therapy, bumpy surface with indistinct margins. When the tumor is
thereby eliminating the echo graphic suspicion of extraocu- sufficiently elevated, the internal reflectivity is typically low
lar extension. However, subsequent histopathologic exam- to medium (Figure 5-29). Internal vascularity is often
ination of some of these eyes indicated the presence of mi- difficult to assess because of the shallow nature of these tu-
croscopic extrascleral and/or scleral extension. 107 Changes mors. Additionally, diffuse melanomas are associated with a
involving the sclera, episclera, and extraocular muscle in- high incidence of extrascleral extension. 25 The echographic
sertions following plaque radiotherapy can also mimic ex- differential diagnosis of diffuse melanoma includes metasta-
traocular extension (see p 137). tic carcinoma to the choroid (see p 143), diffuse choroidal
B D
E
c
Figure 5-29 Diffuse choroidal melanoma. A, Fundus photograph shows extensive, pigmented
choroidal melanoma (arrows). B, Transverse B-scan echo gram shows mildly elevated lesion with
flat surface contour (a17ows). C, Longitudinal B-scan shows much larger base of tumor in this
view (an-ows). D, A-scan at Tissue Sensitivity shows very low reflective, thin lesion. T, Tumor sur-
face; S, sclera. E, A-scan at reduced gain setting.
nevus (see p 151), Vogt-Koyanagi-Harada syndrome26 (see ment and to ensure proper placement of radioactive
p 200), uveal lymphoid hyperplasia (see p 153), diffuse plaques. 22, 70, 71
choroidal hemangioma (see p 147), and disciform lesion
(see p 160). Postradiation Findings
Typical echographic findings have been observed following
radiation treatment bf ocular melanoma. These lesions tend
Radiation Therapy
to become more irregular in structure and higher reflective
Radiation therapy, either by plaque or external beam, has as they decrease in size (Figure 5-30). Such changes in in-
become a common alternative modality for treating eyes ternal characteristics appear to be due largely to necrosis
with choroidal melanomas. 68 ,94 Echography is used to fol- within the lesion,79,80 Loss of internal vascularity is also usu-
low these tumors in order to assess the effectiveness of treat- ally noted following effective treatment. Although treated
A D
B E
c F
Figure 5-30 Dome-shaped choroidal melanoma before plaque radiotherapy (A and D), at
4 months (B and E), and at 8 months (C and F) after treatment. Transverse B~scan (A) shows
shallow overlying retinal detachment and corresponding A-scan (D) shows low internal reflec-
tivity. At 4 months, transverse B-scan (B) shows marked decrease in tumor elevation and flat-
tened surface; corresponding A-scan (E) shows increased reflectivity and lower elevation. At 8
months, transverse B-scan (C), demonstrates further decrease in elevation and complete resolu-
tion of serous retinal detachment; corresponding A-scan (F) also shows decrease in tumor ele-
vation. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina.
ed 3, St Louis, Mosby, 2001, p 276.) .
138 THE GLOBE
A D
B E
c F
Figure 5-31 Dome-shaped choroidal melanoma overlying insertion of lateral rectus muscle
before treatment (A to C) and 8 months after plaque radiation therapy (D to F). Transverse
(A), longitudinal (B)B- scans and A-scan (C) show dome-shaped, medium-reflective melanoma
adjacent to insertion of lateral rectus muscle (closed arrows). T, Tumor surface; open arrow, inter-
nal tumor spikes; S, sclera. Corresponding echograms at follow-up examination after treatment
(D to F) show decreased height of tumor, increased internal reflectivity and thickened insertion
of muscle. Note how the thickened muscle can simulate extraocular tumor extension.
melanomas typically become smaller over time, some tu- Although treated melanomas usually become gradually
mors may enlarge shortly after radiotherapy. In the major- smaller, long-term follow up should be performed. This is
ity of these cases, however, the tumors eventually decrease because tumors can show signs of growth after significant
in size. This initial enlargement appears to be due to edema regression (Figure 5-33).
of the tumor after irradiation. Continued enlargement of
the tumor may indicate true tumor growth. Plaque and External Beam Localization Techniques
Other possible associated findings include thickening of Ultrasound examination can be a useful adjunct to transil-
an adjacent extraocular muscle insertion (Figure 5-31) and lumination for verifying the position of a radioactive
decreased reflectivity of the sclera. In addition, inflamma- plaque adjacent to an ocular melanoma.* Ultrasound is es-
tory changes may appear in sub-Tenon's space behind the pecially useful for localization of a plaque behind a poste-
tumor in the area where the plaque had been placed. It is rior tumor that lies close to the optic nerve, where transil-
important to recognize these post-treatment changes be- lumination may not adequately indicate the tumor
cause they may affect the appearance of the posterior scleral margins. Echography can also be of value in cases in which
spike when measuring the tumor after treatment (Figure the entire tumor base cannot be visualized with ophthal-
5-32). As previously mentioned, changes in the sclera, epi- moscopy (e.g., collar button tumors with overhang) (see
sclera, and thickening of extraocular muscles can be mistaken Figure 5-34, A and B).
for extraocular tumor growth. Consequently, such findings The technique for plaque localization incorporates the
should be closely observed to ensure that there is no increase use of B-scan, either in the operating room under sterile
in size over time. Any enlargement on follow-up examina-
tion suggests the possibility of extraocular extension. *References 22, 41, 68, 70, 71, 96,103.
139
A D
B E
c F
Figure 5-32 Small choroidal melanoma before treatment (A to C) and 6 months following ra-
dioactive plaque therapy CD to F) show diffuse episcleral inflammation after treatment. A, Trans-
verse B-scan echo gram shows dome-shaped tumor. B, A-scan at Tissue Sensitivity shows low
internal reflectivity. T, tumor surface; S, sclera. C, A-scan at reduced gain shows maximum height
of tumor. D, Extensive echolucent lesion in episcleral space (arrow) adjacent to tumor following
treatment. E, A-scan echogram at Tissue Sensitivity shows mild increase in reflectivity of tumor
and thin lesion in episcleral space (arrow). F, A-scan view at reduced gain shows maximum height
of tumor and lesion in episcleral space. Note reduced height of scleral spike due to inflammation
following therapy.
A B c
Figure 5-33 Choroidal melanoma at initial examination (A), at 1 year (B) and 3 years (C) af-
ter plaque radiation therapy. A, Large collar button-shaped tumor demonstrates low to medium
reflectivity. T, Tumor surface; S, sclera. B, Tumor shows marked decrease in height as well as in-
crease in internal reflectivity. The internal vascularity was also markedly diminished compared to
the initial examination. C, Tumor is much larger, and reflectivity has decreased. Also, the inter-
nal vascularity had increased markedly compared to the first follow-up examination.
140
Figure 5-34 Gold shield (left) and 1-125 plaque containing radioactive seeds (right).
Figure 5-35 B-scan probe placed in sterile rubber sleeve. (Roper Hall, model 2606-P-6078,
Kieler.)
B
A T
/
/ "
/
,
/
-A0
5'
L p- o
Ii
\
\
\
\
\
Figure 5-36 B-scan technique for localizing radioactive plaque behind choroidal melanoma.
A, Schematic drawing shows tumor temporal to the optic disc and path of transverse (T) and
longitudinal (L) scans through tumor. S, superior tumor margin; P, posterior tumor margin; 1, in-
ferior tumor margin; A, anterior tumor margin. E, Transverse B-scan echo gram through
choroidal melanoma and plaque (open arrow) shows superior (S) and inferior (1) margins of
plaque. C, Longitudinal B-scan through tumor and plaque shows anterior (A) and posterior (P)
margins of plaque. Note that plaque margins extend beyond tumor borders, indicating proper
placement.
A B
Figure 5-37 Longitudinal B-scan echograms demonstrate repositioning of 1-125 plaque.

A, Initial examination after plaque placement shows that the plaque does not properly extend be-
yond the posterior tumor margin (arrow). ON, Optic nerve. B, Examination after repositioning
of plaque shows that plaque is now correctly positioned.
A B
Figure 5-38 B-scan echo grams of choroidal melanoma following external beam irradiation.
A, Transverse view shows choroidal tumor adjacent to enlarged medial rectus muscle (!'VI).
B, Transverse scan just adjacent to tumor shows two small, highly reflective echoes from tanta-
lum rings (arrows) placed next to tumor prior to treatment. S, Shadowing from tantalum rings.
conditions or postoperatively, where strict sterility is un- tilted, it can be moved and the echogram repeated to en-
necessary. The iodine-12 5 (1-125) plaques typically consist sure that adequate coverage has been accomplished (Figure
of a gold shield with a plastic insert containing the ra- 5-37). As previously mentioned, this technique is more use-
dioactive seeds 46 (Figure 5-34). On B-scan, these plaques ful for tumors located posteriorly, near the optic nerve.
produce a distinct, echolucent pattern in the orbit adja- Also, this method is most suitable for tumors that have very
cent to the sclera, with marked shadowing of the orbital distinct, steeply rising margins, where the true edges of the
tissues. tumor can be identified with ultrasound. Echography is less
When the plaque is to be localized under sterile condi- reliable for localizing the plaque behind tumors with slop-
tions, the B-scan probe can be placed into a sterile rubber ing, indistinct borders (see Figure 5-29).
sleeve (Figure 5-35). Sterile methylcellulose is placed into For external beam irradiation, tantalum rings are sutured
the rubber sleeve before inserting the probe and is also ap- to the globe to help localize the tumor for treatment.
plied to the surface of the globe just prior to the examina- Echography can often demonstrate these rings adjacent to
tion. The probe is then placed on the eye, opposite the tu- the tumor (Figure 5-38).
mor. The base of the tumor is imaged in both transverse
and longitudinal orientations to display the relationship of
Ciliary Body and Iris Melanomas
the plaque to the tumor margins (Figure 5-36). If the
plaque is shown to be improperly positioned or appears See p 169 for a review of ciliary body and iris melanomas.
142 THE GLOBE
BOK·5-1
*These lesions call simulate an ocular melanoma clinically and/or echographically.
Figure 5-39 Fundus photograph showing metastatic carcinoma to choroid.
OTHER TUMORS OF THE UVEA, RETINA,

Differential Diagnosis of Ocular Melanoma RETINAL PIGMENT EPITHELIUM, AND
SCLERA
Many pigmented and nonpigmented lesions can clinically
simulate a melanoma 28 ;58 (Box 5-1). The most common le- Metastatic Carcinoma
sions include choroidal nevi, metastatic neoplasms, Metastatic carcinoma to the choroid presents clinically as a
choroidal hemangiomas, disciform lesions, and choroidal yellowish, mildly elevated, diffuse lesion with irregular bor-
hemorrhages (Table 5-1). There are, however, a large va- ders (Figure 5-39) that may occur in one or both eyes. 87 ,88
riety of less common conditions that also can simulate a These tumors are often located in the posterior aspect of
melanoma, including posterior nodular scleritis, the fundus and can be focal or multifocal. They are fre-
melanocytoma, and even dislocated lenses. Echography quently associated with a serous retinal detachment.
can be used to differentiate and diagnose many of these Echographically, metastatic carcinomas are usually
disorders. \Vhenever a suspicious lesion is detected, a sys- mildly to moderately elevated, although they can occasion-
tematic echographic examination should be performed us- ally become quite elevated. These tumors typically have an
ing topographic, quantitative, and kinetic techniques (see irregular, bumpy surface contour, often with central exca-
Chapter 2). vation. 6,34 They are frequently diffuse and are sometimes
TABLE 5-1
Differential Diagnosis of Ocular Melanoma*
Lesion Location Sha~e Reflectivity Structure Vascularity
Melanoma Choroid/ciliary Dome/collar button Low-medium Regular +
body
Metastatic carcinoma Posterior choroid Diffuse/irregular Medium to high Irregular
High Regular
Choroidal hemangioma Posterior choroid Dome
Choroidal nevus Choroid Dome High Regular

Disciform lesion Macula Dome/irregular High Variable
Choroidal hemorrhage Choroid Dome Variable Variable
*This table lists the main echographic findings for the most common intraocular lesions that clinically simulate a melanoma.
A c
B D
Figure 5-40 Two cases of metastatic carcinoma to the choroid. A and B, Mildly elevated tu-
mor; C and D, highly elevated tumor. B-scans (A and C) show both lesions to have an irregular,
bumpy or lobulated surface (arrows). The A-scans (B and D) of both patients show relatively
high reflectivity but also variability of the internal tumor spikes (arrows), indicating irregular
structure. T, Tumor surface; S, sclera. (From Green RL, Byrne SF: Diagnostic ophthalmic ul-
trasound, in Ryan 5] led]: Retina. ed 3, St Louis, Mosby, 2001, p 281.)
found by echography to be more extensive than is clinically tachments associated with metastatic carcinomas tend to be
appreciable. The internal reflectivity of metastatic carcino- more elevated and extensive than are those occurring with
mas is generally medium to high, but the internal structure melanomas of similar size s7 (Figure 5-41). In some cases,
can be somewhat irregular (Figure 5-40). These findings re- metastatic tumors present with simultaneous intraocular
sult from the varied histologic architecture produced by the and orbital lesions (Figure 5-42). Vitreous and subretinal
growth pattern of metastatic carcinomas to the choroid (see hemorrhage is rarely associated with metastatic carcinoma.
Figure 2-24). Additionally, internal vascularity is typically Echographically, metastatic carcinomas to the choroid
minimal or absent in these lesions. The serous retinal de- can be confused with diffuse choroidal melanomas (see
144 THE GLOBE
A C
B D
Figure 5-41 Choroidal melanoma (A and B) and metastatic carcinoma to the choroid (C and
D) of similar size. B-scans (A and C) show dome-shaped tumors with associated retinal detach-
ments (arrows). Note that detachment is much more extensive in C, as is typical for metastatic tu-
mors. A-scan of melanomalB) is also much lower reflective than metastatic tumor (D). T, Tu-
mor surface; arrows, internal tumor spikes; S, sclera.
Figure 5-42 Metastatic carcinoma to choroid and orbit. Longitudinal B-scan shows dome-
shaped intraocular mass and smaller extrascleral mass (large arrow) adjacent to optic nerve (ON).
Note possible communication between intraocular and extraocular lesions through scleral canal
(small arrow).
P 136), uveal lymphoid hyperplasia (see p 153), disciform fore confused echo graphically with choroidal melanomas.
lesions (see p 159), choroidal hemangiomas (see p 147), The most common type of metastatic tumor to produce
posterior nodular scleritis (see p 196), choroidal nevi (see these echo graphic findings is the small cell (oat cell) carci-
p 151), and Vogt-Koyanagi-Harada syndrome (see p 200). noma of the lung. 101 Another unusual finding that may be
In some cases, metastatic choroidal tumors present with observed is the presence of bullous choroidal detachments 93
atypical findings. Some tumors may exhibit low internal (Figure 5-43). An additional rare finding in metastatic car-
reflectivity as well as internal vascularity and may be there- cinoma to the choroid is a collar button shape. 102 One case
B o
c E
Figure 5-43 Metastatic carcinoma to the choroid with associated retinal and choroidal de-
tachments. A, Fundus photograph shows bullous choroidal detachments. B, Longitudinal
B-scan echo gram of 3-o'clock meridian shows peripheral dome-shaped choroidal detachments
(C) and funnel-shaped retinal detachment (an-ow) inserting into optic nerve (ON). C, Corre-
sponding A-scan echo gram shows thick, highly reflective, double-peaked spikes from choroidal
detachments (C) and lower spike frOInretinal detachment (an-ow) as a result of oblique sound
beam incidence. D, Transverse B-scan through lower periphery of globe shows diffuse tumor
mass (an-ow) with irregular surface contour. Note peripheral choroidal detachments (C) and
overlying retinal detachment (R). E, A-scan shows irregular internal structure and high reflec-
tivity of metastatic tumor (an-ow). C, Choroidal detachment; R; retinal detachment overlying tu-
mor; T, tumor surface; an-ow, internal tumor spikes; S, sclera. (From Sneed RS, Byrne SF, Meiler
WF, et al: Choroidal detachments associated with malignant choroidal tumors. Ophthalmology
1991; 98:968.)
146 THE GLOBE
A 8
Figure 5-44 Metastatic carcinoma with collar button configuration. A, Longitudinal B-scan
shows choroidal mass with eccentric collar button (arrows) located adjacent to optic nerve (ON).
Total, closed funnel-shaped retinal detachment (R) and subretinal hemorrhage (If) are also pres-
ent. B, A-scan shows medium to low internal reflectivity of tumor. T, Tumor surface; S, sclera,
H, hemorrhage in subretinal space; R, retina. Low height and double-peaked nature of retinal
spike are due to closed funnel shape and oblique sound beam incidence. This eye was enucleated
due to uncontrollable intraocular pressure. Histopathologic examination showed metastatic car-
cinoma from the lung and confirmed that the tumor had broken through Bruch's membrane.
(From Read RW, Green RL, Rao NA: Metastatic adenocarcinoma with rupture through the
Bruch membrane simulating a choroid melanoma. Am J OphthalmoI2002;132:994.)
A c
8 D
Figure 5-45 Choroidal hemangioma located adjacent to optic nerve. Axial (A) and transverse
(B) B-scan echograms show dome-shaped lesion (arrows). ON, Optic nerve. C, A-scan at Tissue
Sensitivity shows regular internal structure and high reflectivity typical of a choroidal heman-
gioma. T, Tumor surface; S, sclera. D, A-scan of tumor at reduced gain.
A c
B D
Figure 5-46 Diffuse choroidal hemangioma in child with Sturge-Weber syndrome. A, Exter-
nal photograph shows port wine stain typical of Sturge-Weber syndrome. B, Axial B-scan
echo gram shows diffuse, mildly elevated lesion (arrows) surrounding the optic nerve (ON).
C, Longitudinal B-scan shows diffuse lesion extending from ON to the periphery. D, A-scan
shows mildly elevated lesion with medium-high internal reflectivity. T, Tumor surface; arrow,
internal tumor spikes; S, sclera.
of metastatic carcinoma from lung presented with a collar Sturge-Weber syndrome is associated with a more diffuse
button configuration and a massive subretinal hemorrhage. type of choroidal hemangiomaJ5 These tumors are often
The internal structure of the tumor was slightly irregular less elevated than the focal, dome-shaped lesions described
and the reflectivity was medium to low (Figure 5-44). This earlier (Figure 5-46). In some cases, these hemangiomas are
patient developed severe secondary glaucoma. so diffuse that they can be mistaken for nonspecific
retinochoroid layer thickening (see p 74).Therefore, in cases
of Sturge-Weber syndrome, retinochoroid layer thickness
Choroidal Hemangioma
should be carefully compared between the two eyes. Occa-
This tumor often presents as an orange-red, mildly ele- sionally, these diffuse tumors can be moderately elevated and
vated lesion in the posterior fundus, temporal to the optic partially dome shaped. Serous retinal detachments may de-
nerve. 29 These dome-shaped lesions typically exhibit high velop, and associated thickening of adjacent extraocular mus-
internal reflectivity and regular internal structure (Figure cles may be present (Figure 5-47).
5-45). Although hemangiomas are classified as vascular le-
sions, significant internal blood flow is usually not observed Choroidal Osteoma and other Calcific Lesions
echographically. Serous retinal detachments can be present
of the Eye
at the tumor margins and cystic degeneration of the over-
lying retina can occur. Calcification occasionally can be Certain intraocular tumors are associated with calcification.
seen on the surface of a choroidal hemangioma. lo5 Echo- In addition, there are numerous other lesions that demon-
graphically, hemangiomas can be confused with other strate signs of calcification on the ultrasound examination
highly reflective lesions such as metastatic carcinomas, dis- (Box 5-2).
ciform lesions, choroidal nevi, and occasionally, posterior A choroidal osteoma usually presents as a yellow-white
nodular scleritis. to orange-red lesion in the peripapillary region, most com-
148 THE GLOBE
A c
Figure 5-47 Diffuse choroidal hemangioma in Sturge-Weber syn-

drome with an area of dome-shaped elevation. A, Horizontal axial
B-scan shows diffuse, mildly elevated nature of hemangioma nasally
(a1'"row) and more elevated, dome-shaped area temporally (curved ar-
B row). ON, Optic nerve. B, Longitudinal B-scan demonstrates pe-
ripheral extent of dome-shaped portion of tumor with associated reti-
nal detachment (R). Note inferior oblique muscle (straight black
arrow) and thickening oflateral rectus muscle (lvI). C, Tumor exhibits
high internal reflectivity on A-scan. T, Tumor surface; S, sclera.
BOX 5-2
Conditions Associated with Calcification
Choroidal osteoma (see p 147) Granuloma (e.g., toxocariasis) (see p 203)
Sclerochoroidal calcification (see below) Cysticercosis (see p 203)
Retinoblastoma (see p 180) Mature cataracts (see p 265)
Retinal angioma (see p 155) Trauma
Retrnal astrocytic hamartoma (see p 155) Calcification underlying longstanding retinal
Choroidal melanoma (see p 120) detachment
Choroidal hemangioma (see p 147) Phthisis bulbi (see p 114)
Optic nerve head drusen (see p 434) Cogan's plaques (see p 149)
Disciform lesions (see p 68)
monly in young women. 4 Osteomas are typically unilateral, peripheral fundus, often supra temporally. Echographically,
focal, and only mildly elevated. 29 Because these lesions con- these lesions are usually flat or only mildly elevated. They
sist of bone, they produce extremely high internal reflectiv- produce extremely high reflectivity and marked shadowing
ity and marked shadowing of the scleral and orbital signals of the orbital tissues posterior to the lesion 76 ,92 (Figure
posterior to the lesion (see Figure 2-25). Although many os- 5-49). It has been shown that echography may detect bilat-
teomas have a relatively smooth, flat appearance, theyocca- erallesions, although clinically they may only be visible
sionally show an irregular surface contour 29 (Figure 5-48). in one eye. 40 Similar types of lesions have been described
Idiopathic sclerochoroidal calcification is a disorder that in patients with hyperparathyroidism and other metabolic
can simulate choroidal osteoma.4D,49,73,88 This condition, which disorders.40
is usually bilateral, is charactt;rized by multiple, discrete, yel- Other intraocular tumors can also show signs of calcifi-
lowish plaquelike lesions. They are typically found in the mid- cation. The tumor most often associated with calcification
B c.
Figure 5-48 Choroidal osteoma. A, Fundus photograph shows extensive hypopigmented lesion
superiorly (arrows). B, Transverse B-scan echogram shows very echo-dense lesion with irregular
surface contour (arrows). Note wide area of shadowing (S) behind lesion. C, A-scan shows very high
reflectivity of osteoma (arrow). Orbital spikes are absent because of very strong shadowing (S).
Figure 5-49 Idiopathic sclerocalcification. Transverse B-scan displays slightly irregular, echo-
dense plaque at level of retinochoroid layer and sclera (arrow). S, Shadowing produced by calci-
fied lesion.
is retinoblastoma (see p 180). Retinal angiomas and retinal clude optic nerve head drusen (see p 434), degenerative
astrocytic hamartomas (see p 155) are also knoWn to changes of the eye, and Cogan's plaques. is Examples of de-
demonstrate calcific deposits. Calcified nodules have also generative lesions associated with calcification include long-
been observed in choroidal melanomas (see p 120 and Fig- standing disciform lesions, granulomas from toxocariasis, cys-
ure 5-10) and choroidal hemangiomas, usually on the tu- ticercosis, and lesions caused by trauma. Dense, mature
mor surface. cataracts can also demonstrate extensive calcification. Plaque-
Nontumorous causes of calcification within the eye in- like calcification of the choroid and!or sclera may be seen in
150 THE GLOBE
A B
Figure 5-50 Cogan's plaque. A, Axial CT scan (bone window) shows plaquelike calcifications
of nasal and temporal peripheral sclera. B, Anterior longitudinal B-scan demonstrates small,
echo-dense lesion involving peripheral sclera (arrow). M, Lateral rectus muscle.
B c
Figure 5-51 Choroidal nevus. A, Fundus photograph shows pigmented lesion. B, Transverse
B-scan echogram shows mildly elevated lesion (arrow). C, A-scan shows mild elevation and high
internal reflectivity of lesion. T, Tumor surface; S, sclera.
eyes with longstanding retinal detachment. Finally, dense

calcification of the posterior ocular coats and other structures
including the detached retina and lens, occurs secondary to
phthisis bulbi (see p 114).
Cogan's plaques are focal areas of scleral calcification
that are located anterior to the insertion of the horizontal
rectus muscles. They are frequendy bilateral and are often
detected during routine ultrasound screening examina-
tions. These small lesions are nodular and echo dense (Fig- .
ure 5-50). A
Choroidal Nevus
Choroidal nevi are usually minimally elevated and, in many
cases, are too flat even to be detected by echography. Al-
though there is scant pathologic correlation with echographic
findings, most elevated choroidal nevi appear to be highly
reflective and nonvascular66 (Figures 5-51 and 5-52). Their
small size, however, often prevents effective differentiation,
and therefore, echography frequendy cannot distinguish nevi
from small melanomas. As a result, suspected nevi should be
observed closely to detect any changes in size or internal
reflectivity. Nevi usually show lime orJ;1O growth, whereas
melanomas tend to increase in size. In addition, as small
melanomas grow, their internal reflectivity tends to decrease.
It should be noted, however, that choroidal nevi can develop 8
subneovascular membranes with subretinal fluid, thus mim-
icking growth. 8
Choroidal nevi also can be echographic;ally confused
with other highly reflective lesions, such as choroidal he-
mangiomas, metastatic carcinomas, and disciform lesions.
Melanocytoma (Magnocellular Nevus)

This darkly pigmented, benign tumor, most often situated.
at the optic nerve head, can be clinically confused with a
melanoma. Melanocytomas are usually only mildly elevated
and have a smooth, dome shape. They are typically highly
reflective, with regular internal structure and no internal c
vascularity (Figure 5-53). These tumors sometimes involve
the choroid or ciliary body (see p 177). Rarely melanocy-
tomas undergo malignant transformation 88 ; therefore, they
should be monitored for growth.
Intraocular 8-Cell Lymphoma

(Reticulum Cell Sarcoma)
Figure 5-52 Choroidal nevus that was clinically suspicious for
These lesions have a yellow-white appearance, are often bi- choroidal melanoma. A, Fundus photograph shows pigmented le-
lateral, and may be associated with a diffuse cellular infiltra- sion inferotemporal to optic nerve. B, Oblique axial B-scan shows
tion of the vitreous, presenting clinically as a uveitis. 12 The slighdy irregular, dome-shaped mass adjacent to optic nerve (ON).
fundus lesions usually represent neoplastic infiltrati'on in C, Lesion exhibits high internal reflectivity with slighdy irregular
the sub-retinal pigment epithelium (sub-RPE) space. In internal structure on A-scan. T, Tumor surface; S, sclera. Needle
biopsy confirmed benign nature of the tumor. .
most cases, they are only mildly elevated, with a bumpy,
irregular surface contour. The few lesions examined have
demonstrated irregular internal structure without evidence
of internal vascularity (Figure 5-54). The echographic
152
Figure 5-53 Melanocytoma. A, Fundus photograph shows darkly

pigmented tumor overlying optic disc. B, Axial B-scan echogram shows
A mildly elevated lesion (arrow) overlying surface of optic nerve (ON).
C, A-scan shows regular internal structure and high reflectivity of le-
sion. T, Tumor surface; 0, surface of optic disc.
B c
A c
B D
Figure 5-54 B-celllymphoma (reticulum cell sarcoma). A, Transverse B-scan echogram shows
opacification of vitreous and extensive PVD (P). B, A-scan echogram shows low to medium re-
flectivity ofPVD (P). C, Vertical macula B-scan echogram shows mildly elevated lesion with ir-
regular surface contour (arrow). D, Corresponding A-scan shows high internal reflectivity ofle-
sion. T, Tumor surface; S, sclera.
A c
B D
Figure 5-55 Uveal lymphoid hyperplasia involving the choroid of the right eye. A, Transverse
B-scan echogram shows diffuse, echolucent thickening of choroid (black arrows) with focal, very
shallow retinal detachment at inferior aspect of lesion (white arrow). B, A-scan shows low re-
flective choroidal thickening (arrow).S, Sclera. Axial (C) and coronal (D) MRI scans show dif-
fuse thickening of ocular wall in the right eye (arrows).
appearance of these tumors can be very similar to that of Oft ultrasound, uveal lymphoid hyperplasia appears as a
metastatic carcinoma to the choroid. Unlike metastatic car- diffuse lesion with a smooth or somewhat bumpy surface con-
cinomas, however, B-celllymphomas are not usually asso- tour. This lesion exhibits low to medium internal reflectivity,
ciated with extensive serous retinal detachments. 63 and internal vascularity has been reported (Figure 5-5 5).11 Ex-
traocular nodules are frequently demonstrated in the peri-
papillary region (Figure 5-56). These nodules appear to ex-
Uveal lymphoid Hyperplasia
tend through emissary canals from the intraocular lesion. II ,36
Lymphoid hyperplasia is an uncommon, often unilateral, More extensive orbital lesions can also occur.
lymphoproliferative disorder that involves primarily the The primary differential diagnoses for uveal lymphoid
uveal tract. This condition has been referred to as inflam- hyperplasia, both clinically and echo graphically, include dif-
matory pseudotumor,29,74 benign reactive lymphoid hyper- fuse melanoma (see p 136), metastatic carcinoma (see p
plasia,11,74 and more recently, uveal lymphoid infiltration. 36 142), posterior scleritis (see p 196), uveal effusion syndrome
Recent investigations have shown that most of these lesions (see p 82), Vogt-Koyqn~gi-Harada syndrome (see p 200),
are actually a type of low-grade lymphoma. 14 sympathetic ophthalmia (see p 201), and leukemia (see
Clinically, lymphoid hyperplasia presents as a diffuse or .p 154). The majority of these conditions can be differenti-
nodular amelanotic choroidal lesion. 11 One investigator has ated by combining the clinical and echo graphic findings. 26
described the appearance as multifocal, creamy choroidal The most challenging diagnosis to exclude, however, is dif-
infiltrates. 45 Serous retinal detachments have also been re- fuse amelanotic melanoma. This difficulty arises from the
ported. The uveal infiltration may involve the ciliary body, fact that both disorders may exhibit low to medium reflec-
causing shallowing of the anterior chamber and, in some tive choroidal thickening, as well as extrascleral nodules.
cases, secondary angle-closure glaucoma. 11 These patients Differentiation can be made in some cases by noting a
may also present with salmon-colored conjunctival lesions. prompt response to steroid therapy, thus favoring the diag-
Iris lesions have also been described. nosis of lymphoid hyperplasia. It is of interest, however,
154 THE GLOBE
A c
Figure 5-56 Uveal lymphoid hyperplasia. A, Longitu-

dinal B-scan shows diffuse choroidal thickening (straight
. white arrows) and total, closed retinal detachment (curved
arrow) inserting into the optic nerve (ON). Note the
small nodule in the orbit (black arrow). B, Longitudinal
B-scan along another meridian shows diffuse choroidal
B thickening (white arrow) and an extrasclerallesion con-
forming to the globe (black arrow). C, A-scan corre-
sponding to B shows low reflectivity of both thickened
choroid (straight arrow) and extrasclerallesion (curved ar-
row). T, Tumor surface; S, sclera; R, retina. Low height
of retinal spike is due to oblique sound beam incidence.
(From Chang TS, Byrne SF, Gass JDM, et al: Echo-
graphic findings in benign reactive lymphoid hyperpla-
sia of the choroid. Arch OphthalmoI1996;114:672.)
that choroidal melanomas can be associated with inflam-

matory episcleral lesions, which also may respond to anti-
inflammatory therapy (see p 120).
leukemia
A
Leukemia can affect the eye by diffusely infiltrating the
choroid. Echographically, leukemic infiltrates exhibit low
to medium reflectivity, similar to other highly cellular
choroidal lesions (Figure 5-57).
leiomyoma
This rare tumor, occurring most often in young women, is
typically located in the peripheral choroid and/or ciliary
body.83 Leiomyomas may be difficult to differentiate from
melanomas both clinically and echographically.83 The few tu-
mors that have been examined showed a smooth, domed
B
configuration and internal vascularity. They exhibited regular
or slightly irregular internal structure and predominantly low
to medium internal reflectivity (Figure 5-58). It is interest-
ing, however, that leiomyomas are known to transilluminate
very well. 83 ,88
Figure 5-57 Diffuse leukemic infiltration of choroid. Uveal Schwannoma (Neurilemoma)

A, Transverse B-scan demonstrates diffuse thickening of choroid Schwannoma of the choroid is a benign tumor that arises
(straight white arrow) and sclera (S). Curved arrows show diffuse in-
filtration of sub-Tenon's space. B, A-scan displays low internal re- from peripheral nerve sheaths. 29,85,88 These lesions may be
flectivity of thickened choroid (straight arrow) and widening of amelanotic or pigmented and may simulate a choroidal
sub-Tenon's space (curved arrow). T, Tumor surface; S, sclera. melanoma both clinically and echographically.88 A rare
A c
B D
Figure 5-58 Leiomyoma in teenage girl. A, Fundus photograph shows elevated lesion in pe-
riphery of eye. The pigment clumping adjacent to the lesion is secondary to a previous retinal
detachment. Transverse (B) and longitudinal (C) B-scan echograms show smooth, dome-shaped
lesion in periphery (arrows). A-scan (D) shows low to medium internal reflectivity with moderately
irregular internal structure. T, Tumor surface; S, sclera. Histopathology confirmed the diagnosis
ofleiomyoma 12 years later, when the eye was enucleated due to significant growth of the lesion.
form of this tumor, occurring in younger individuals, is dif- sociated with von Hippel-Lindau syndrome arepredomi-
fuse uveal melanocytic schwannoma, also referred to by one nantly medium reflective (Figure 5-60) and show some de-
author29 as diffuse choroidal melanocytic nevus. On B-scan, gree of internal vascularity. Two cases of retinal astrocytic
these lesions are diffuse and typically involve the posterior hamartoma have been seen, both of which were associated
choroid. They exhibit regular internal structure and low in- with tuberous sclerosis. The lesion in one patient was heav-
ternal reflectivity on A-scan. In addition, they demonstrate ily calcified, exhibiting very high reflectivity and marked
significant internal vascularity. An unusual echographic shadowing (Figure 5-61). The second patient had bilateral
finding in these cases, similar to that seen in younger indi- tumors, one of which showed medium internal reflectivity
viduals with choroidal melanoma (see p 118), is thickening without calcification. The tumor in the other eye demon-
and bowing of the posterior sclera in the region of the tu- strated a small focus of calcification but otherwise exhib-
mor (Figure 5-59). Histopathology has demonstrated scler- ited low reflectivity (Figure 5-62).
al infiltration in these tumors. 29
Scleral Tumors
Neurofibroma
Tumors primarily involving the sclera are extremely rare.
Neurofibromas of the uveal tract are usually associated with These unusual lesions, however, can mimic choroidal
neurofibromatosis. They appear as a diffuse, either pig- melanoma both clinically and echographically. Two types
mented or nonpigmented lesion, that may involve the en- of scleral tumors are scleral cysts and focal fibrosclerosis
tire uveal tract. Serous retinal detachments may also be (scleral pseudotumor). Scleral cysts present as nonpig-
present. The echo graphic features of these tumors include mented, well-circumscribed, dome-shaped fundus lesions.
a diffuse lesion that demonstrates regular internal structure On B-scan, these very well-circumscribed lesions are dome
and low to medium internal reflectivity. shaped and echolucent. In addition, they appear to cause
an outward bowing of the posterior scleral surface. On
Hamartomas of the Retina (Capillary, Combined A-scan, these lesions produce low internal reflectivity. The
histopathology of one case is shown in Figure 5-63.
Retinal/Retinal Pigment Epithelium, Astrocytic)
The systemic disorder of multifocal fibrosclerosis (most
Retinal hamartomas, usually located at the optic disc or in commonly associated with retroperitoneal fibrosis) can pro-
the peripheral fundus, are typically mildly elevated with a duce focal lesions of the sclera. 3s These tumors may either
domed configuration. Peripheral capillary hemangiomas as- be unilateral or bilateral and may occur as a solitary mass or
156 THE GLOBE
Figure 5-59 Uveal schwannoma (neurilemoma) in

a child. A, Fundus photograph demonstrates diffuse,
pigmented lesion in the temporal posterior pole.
B, Horizontal axial B-scan shows moderately ele-
vated, diffuse choroidal mass with shallow, overlying
A retinal detachment (white arrow). Note posterior
bowing of sclera behind tumor (black arrow). ON, Op-
tic nerve. C, Tumor exhibits medium to low internal
reflectivity on A-scan. Arrow, Retinal detachment;
T, tumor surface; 5, sclera.
B c
A c
Figure 5-60 Retinal angioma associated with von

Hippel-Lindau syndrome. Transverse (A) and lon-
gihldinal (B) B-scan echo grams show dome-shaped
B lesion (arrows) in periphery of eye. C, A-scan shows
medium internal reflectivity of tumor. T, Tumor
surface; 5, sclera.
A 8
Figure 5-61 Astrocytic hamartoma. A, Fundus photograph shows well-outlined, nonpig-

mented lesion supratemporal to optic disc. B, Transverse B-scan demonstrates highly echo-
dense, mildly elevated lesion. Marked shadowing (S) indicates calcified nature of lesion.
Figure 5-62 Astrocytic hamartoma. A, Transverse B-scan displays smooth, dome-shaped le- .
sion (arrow). Note echo-dense nodule at base oflesion representing small focus of calcification.
B, A-scan shows low internal reflectivity of lesion and high reflectivity of calcified nodule (C).
T, Tumor surface; S, sclera.
158 THE GLOBE
B D
Figure 5-63 Intrascleral cyst. A, Fundus photograph demonstrates well-outlined, nonpig-

mented lesion superior to optic disc. Transverse (B) and longitudinal (C) B-scans at reduced
gain display well-outlined, echolucent lesion within the sclera (S). Internal echoes were present
at higher gain settings. Note slight bowing of both the inner and outer scleral walls. Arrow, sur-
face of retina. D, A-scan shows low internal reflectivity of lesion. R, Retina; I, inner scleral wall;
0, outer scleral wall. E, Pathology shows epithelial-lined scleral cyst containing mucin.
as multiple lesions within one eye. Clinically, they appear as lesions can mimic choroidal lesions, choroidal involvement
a nonpigmented, elevated fundus lesion, usually with a in some of the reported cases may have actually represented
dome shape. In addition, outer scleral fibrous plaques have primarily scleral involvement. 35
been identified adjacent to the intraocular lesion. On B-
scan, this lesion appears as a solid, elevated, dome-shaped
mass with a thick surface. The outer scleral surface appears OTHER LESIONS SIMULATING MELANOMA
to be slightly bowed outward, and the tapered lateral mar-
_Disciform Macular Degeneration
gins of the lesion can be shown to be contiguous with the· - (Disciform Lesion) .
episcleral space rather than with the choroid. This latter
finding is important in helping to differentiate these pri- Disciform macular degeneration is the wet form of age-
marily scleral lesions from choroidal masses which they can related macular degeneration (AMD). It is caused by
easily mimic. On A-scan, these lesions exhibit low internal choroidal neQvascularization, producing sub-RPE and sub-
reflectivity and regular internal structure (Figure 5-64). No retinal exudate and/or hemorrhage~ In the more chronic
internal vascularity has been identified. They have been stages of this form of the disease, fibrosis and scarring can
shown to decrease in size with anti-inflammatory therapy. occur, as can calcification.
Although lesions with similar histopathology have been Disciform lesions can usually be differentiated clinically
previously described as pseudotumors in the orbit, theit oc- from choroidal melanomas by the ,presence of drusen and
currence in the sclera is extremely rare. In addition, several exudate,· and by their location in the macular region. The
authors have reported cases of fibrosclerotic lesions involv- fellow eye may have similar changes of discif()rm mac-
ing both the uvea and the sclera. 54,77,99 Because these scleral ular degeneration. In some cases, however, these associated
A c
B D
Figure 5-64 Scleral lesion secondary ~o multifocal fibrosclerosis. A, Fundus photograph shows
well-outlined, elevated mass lesion. Transverse (B) and longitudinal (C) B-scan echograms show
an elevated dome-shaped lesion with a thick inner surface representing indentation of the retina
and choroid (straight white arrow). Straight black arrows show slight bowing of outer surface where
lesion contacts Tenon's capsule. Note how lesion merges with the episclera (curved arrows) at
its margins. D, Lesion exhibits .low internal reflectivity on A-scan. R, Retinochoroid layer;
T, Tenon's capsule. ....
16(} THE GLOBE
A C
8 D
Figure 5-65 Large hemorrhagic disciform lesion. A, Horizontal axial B-scan echogram at re-
duced gain setting shows extensive peripapillary disciform lesion (straight arrows) surrounding
optic nerve (ON) with greatest elevation at macula Gust below optic nerve in echogram). V, Vit-- .
reous hemorrhage; curved arrow, PVD. B, Corresponding A-scan through macula shows typical
high internal reflectivity of lesion. V, Vitreous hemorrhage; D, surface of disciform lesion;
S, sclera. C, Transverse B-scan through inferotemporal quadrant shows peripheral extension of
hemorrhagic lesion (black arrows). V,Vitreous hemorrhage; curved arrow, PVD. D, Correspond-
ing A-scan shows low internal reflectivity of lesion in this region.
findings may not be present, thus obscuring the clinical di- ular region and progressinferotemporally. Hemorrhagic
agnosis. Disciform lesions can also occur in eccentric areas disciform lesions usually exhibit a bumpy, lobulated surface,
of the fundus. The clinical differentiation from a small and may have very indistinct margins. Their internal struc-
melanoma in these circumstances may not be straight- ture is often quite irregular with areas of both high and low
forward. Ultrasound may be of assistance in distinguishing internal reflectivity. This heterogeneous appearance is due
these lesions. The echographic features of nonhemor- to the presence of sub-RPE hemorrhage (clotted and un-
rhagic disciform lesions are described in detail in Chapter 3 clotted), as well as to fibrovascular proliferation. These le-
(see p 68). sions do not show internal vascularity. The retinal detach-
ments with subretinal hemorrhage that occur in these eyes
Hemorrhagic Disciform Lesion are usually very shallow, although they can be quite exten-
Hemorrhagic disciform lesions are primarily the result of sive and elevated (Figure 5-65; see also Figure 7-7).
hemorrhage and fibrovascular proliferation in the sub-RPE Plaquelike foci of calcification are observed in some
space. They may be associated with subretinal hemorrhage. hemorrhagic disciform lesions, presumably at the level of
The blood in the sub-RPE space may be partially clotted. Bruch's membrane. IOO In addition, shallow suprachoroidal
The echo graphic features of hemorrhagic disciform lesions hemorrhages can underlie a disciform lesion (Figure 5-66). It.
differ significantly from the nonhemorrhagic form de- has been observed that these patients are often on anticoagu-'·
scribed in Chapter 3 (see p 68). They may be quite well lant therapy at the time they develop the hemorrhagic disci-
localized or diffuse and extensive, involving the entire pos- form lesions.
terior fundus and, in some cases, extending into the periph- Vitreous hemorrhage can be associated with hemor-
ery.6,IOO These hemorrhagic lesions often begin in the mac'" rhagic disciform lesions. In fact, disciform lesions have been
Figure 5-66 Hemorrhagic discifdrm lesion. A, Transverse B-scan demonstrates hemorrhage

beneath retina (white arrow),. retinal pigment epithelium (P), and choroid (black arrow).
B, A-scan shows highly irregular structure of lesion. White arrow, Retina; P, retinal pigment ep-
ithelium; C, choroid; curoed arrow, suprachoroidal space.
shown to be one of the most common causes of dense vit- regular surface contour and medium to high internal reflec-
reous hemorrhage in older patients. 33 When vitreous hem- tivity) but the clinical differentiation is usually not difficult.
orrhage occurs in these eyes, the posterior hyaloid usually As a rule, metastatic carcinomas are only mildly elevated
separates from the posterior fundus and the underlying le- and it is rare for them to be associated with vitreous hem-
sion (see Figure 5-65). orrhage or extensive subretinal hemorrhage.
The echographic differential diagnosis of a hemorrhagic
disciform lesion includes large choroidal melanoma and Hemorrhagic Retinal Pigment Epithelial Detachment
metastatic carcinoma. Generally, choroidal melanomas are Hemorrhagic retinal pigment epithelial detachments
more regularly structured and demonstrate low to medium (HRPED) and hemorrhagic disciform lesions comprise a
reflectivity, although very large tumors can demonstrate in- clinical and histopathologic continuum. lOO The HRPED rep-
creased heterogeneity as a result of hemorrhage and necrosis resents a limited sub:-RPE hemorrhage resulting in a dark,
within the tumor (see p 118). In addition, these tumors may be smooth, dome-shaped lesion that can clinically simulate a
associated with vitreous hemorrhage, which can also occur choroidal melanoma .. They may occur in the macular region
secondary to a hemorrhagic disciform lesion. Distinguishing or in eccentric locations, often in the temporal periphery.
between these two entities can sometimes be difficult, but the This limited hemorrhage is in contrast to the more exten-
detection of internal vascularity favors the diagnosis of sive, diffuse hemorrhage that produces the more highly ele-
melanoma. Otherwise, serial examinations can be performed vated, irregularly shaped disciform lesion.
for differentiation. Hemorrhagic disciform lesions tend'to de- Echographically, HRPED produces a smooth, domed
crease in size (Figure 5-67), whereas melanomas remain the configuration on B-scan, often with very sharp, distinct
same or become more elevated. In rare instances, spontaneous margins (Figure 5-68). This blister-like appearance is more
regression of choroidal melanoma can occur89 (see p 120). suggestive of a pigment epithelial detachment than a solid
Choroidal metastases may share some of the echo- tumor. 34 On A-scan, the reflectivity varies according to the
graphic features of hemorrhagic disciform lesions.(e.g., ir- size and consistency of the blood (clotted vs. liquefied) in
162 THE GLOBE
A C
B D
Figure 5-67 Large hemorrhagic disciform lesion (A and B) with follow-up examination 1
month later (C and D) showing regression. A, Vertical macula B-scan echogram shows a very ir-
regular, bumpy surface (a17ows). B, A-scan shows irregular internal structure with areas of both
high and low internal reflectivity. D, Lesion surface; S, sclera. Vertical macula B-scan (C) shows
marked decrease in size oflesion. Also, note vitreous hemorrhage and PVD (V). D, A-scan shows
more regular internal structure and higher reflectivity. (From Green RL, Byrne SF: Diagnostic
the sub-RPE space. These lesions do not demonstrate in- show aftermovement of the surface spike and/or mobility
ternal vascularity. Echographically, the diagnosis of of the blood echoes. In rare cases, a suprachoroidal hy-
HRPED is confirmed only when the lesion is observed to phema may be present (Figure 5-70; see also p 51).
decrease on follow-up examination (Figure 5-69). How- Whenever a patient presents with an intraocular mass
ever, in some cases HRPED may persist for weeks or postoperatively, the possibility of a choroidal hemorrhage
months. should be considered. In these cases, a follow-up examination
performed after 2 to 3 weeks typically shows a decrease in the
size of the lesion, as well as a change in the internal reflectiv-
Choroidal Hemorrhage
ity resulting from liquefaction of the blood (Figure 5-71).
Focal choroidal hemorrhages occurring after intraocular
surgery or for other reasons 95 have been confused clinically
Hemorrhage into Retinal Cyst/Retinoschisis
with melanomas. Echographically these lesions have a
domed configuration and can be mildly to highly elevated. Two cases of hemorrhage into a large retinal cyst have been
The internal reflectivity and structure of choroidal hemor- evaluated. In both patients, the initial clinical impression was
rhages can vary due to the consistency of the blood (i.e., that of a solid tumor. In one case, an oval-shaped cyst was
clotted vs. liquefied) (see p 106 and Figure 4-38). When associated with a shallow retinal detachment. The other
they initially develop, the suprachoroidal blood is usually lesion was round and was attached to the leaf of a funnel-
clotted. As the blood liquefies, however, echography may shaped retinal detachment (Figure 5-72). In both cases,
A c
Figure 5-68 Hemorrhagic pigment epithelial detach-

ment (HRPED). Transverse (A) and longitudinal (B)
B-scan echo grams show smooth dome-shaped peripheral
. lesion. Note steep insertions (arrows), characteristic of
RPE detachments. A-scan (C) shows a relatively thin,
highly reflective surface spike (P) and very low internal re-
flectivity. S, Sclera. <
A c
B D
Figure 5-69 Peripheral eccentric HRPED at initial visit (A to D) and at follow-up examination
2 months later (E to II) showing regression. A, Fundus photograph at initial examination shows
hazy vitreous with lesion temporal to the macula. Transverse (B) and longitudinal (C) B-scan
echograms show smooth, dome-shaped lesion located in temporal aspect of peripheral fundus.
Note mild opacities from vitreous hemorrhage overlying lesion in C. A-scan (D) shows high
internal reflectivity of lesion. D, Surface of disciform lesion; S, sclera.
Continued
164 THE GLOBE
E G
F H
Figure 5-69, cont'd E, Fundus photograph at follow-up examination shows clearing vitreous
hemorrhage with exudation surrounding slightly elevated choroidal lesion. Corresponding
echograms in F, G, and H show lesion regression.
Figure 5-70 Hemorrhagic choroidal detachment with suprachoroidal hyphema. B-scan

echograms using same probe position were obtained with patient in reclined (A) and upright
(B) positions. Echograms demonstrate dome-shaped choroidal detachment with liquefied blood
in the suprachoroidal space. Note shifting ofhyphema (arrows) as body position is changed.
A c
B D
Figure 5-71 Large hemorrhagic choroidal detachment at initial presentation (A and B) and at
follow-up examination 10 days later (C and D). A, Peripheral transverse B-scan echogram shows
thick, smooth, detached choroid (C) with dense opacities in the suprachoroidal space. B, A-scan
shows highly reflective, thick, spike from detached choroid (C) and low reflective spikes from fluid
suprachoroidal blood (arr071J). C, B-scan corresponding to A shows significant decrease in eleva-
tion of the choroidal detachment. D, A-scan corresponding to B also shows decreased elevation.
A B
Figure 5-72 Two examples of hemorrhagic retinal cysts. A, Longitudinal B-scan demonstrates
large retinal cyst (C) within shallow retinal detachment. Note layering, of blood within cyst.
B, Eccentric horizontal axial B-scan echogram shows large cyst (C) attached to temporal leaf of
funnel shaped retinal detachment. Arrow, Insertion of retina into optic disc. Note dense opaci-
ties within retinal cyst.
166 THE GLOBE
A C
Figure 5-73 Retinoschisis with hemorrhage. Peripheral

transverse (A) and longitudinal (B) B-scan echo grams show
smooth, dome-shaped membrane with moderately dense
B opacities within schisis cavity (arrows). V, Vitreous hemor-
rhage. C, A-scan shows thin, highly reflective spike from
surface of retinoschisis (R) and very low reflective spikes
from hemorrhage in schisis cavity (arrow). S, Sclera.
mobile, liquefied blood was identified within the cyst and diffuse, mildly elevated metastatic carcinoma of the choroid
aftermovement of the surface spike was observed. Hemor- (see p 143) should be considered in the differential diagnosis.
rhage into a peripheral retinoschisis (see p 66) can also be
confused with an intraocular tumor (Figure 5-73).
Ampulla of Vortex Vein
Dilated vortex vein ampullae are darkish appearing,
Posterior Nodular Scleritis
smoothly contoured, mildly elevated lesions. They are
See p 196 in Chapter 6 for a review of posterior nodular typically found where the vortex veins exit the globe, near
scleritis. the equator. 5.57 Echographically, these lesions demonstrate
a dome shape, low to medium internal reflectivity, and no
vascularity. These dilated veins are generally not present
Bilateral Diffuse Uveal Melanocytic
when the patient is fixating in primary gaze; they become
Proliferation (BDUMP)
apparent only when gaze is directed toward the involved
Bilateral diffuse uveal melanocytic proliferation (BDUMP), vortex vein. Mild pressure exerted on the globe by the ul-
an unusual paraneoplastic syndrome, is an ocular disorder trasound probe may cause the lesion to collapse (Figure
that is associated with systemic carcinoma (e.g., small cell 5-74).
carcinoma of the lung and ovarian cancer).2,30,31 This dis-
order is characterized by diffuse thickening of the uveal
Posterior Coloboma
tract with multiple, slightly elevated, pigmented and non-
pigmented melanocytic tumors. In addition, these eyes de- Colobomas of the posterior fundus associated with staphy-
velop exudative retinal detachments and cataracts. The eti- lomas of the sclera have been misinterpreted as an elevated
ology of the ocular findings is unknown, and treatment lesion by ophthalmoscopy. It is possible for the sharp mar-
(e.g., corticosteroids or irradiation) is ineffective. gin of a coloboma to be mistaken for the edge of a mass le-
Echographically, there is diffuse, mild, irregular thicken- sion. Alternatively, the edge of a coloboma may be mistaken
ing of the retinochoroid layer that is usually too minimal for for the apex of a tumor with the bottom of the staphyloma
any reliable assessment of internal reflectivity. Shallow ex- simulating the tumor base. B-scan can easily demonstrate
udative retinal detachments may be demonstrated. The the staphylomatous nature of the lesion, thus ruling out an
echographic findings are generally nonspecific, although a intraocular tumor (Figure 5-75).
B c
Figure 5-74 Ampulla of vortex vein. A, Fundus photograph shows dark, mildly elevated le-
sion (arrows) located in the supranasal aspect of the eye near the equator. B, Transverse B-scan
echo gram shows mildly elevated, dome-shaped lesion (arrow) as patient fixates supranasally,
C, Transverse B-scan view through same region with slight pressure of probe against globe
causes collapse and disappearance of lesion.
A B
Figure 5-75 Posterior coloboma. A, Fundus photograph shows well-circumscribed posterior

coloboma. B, Transverse B-scan demonstrates staphylomatous nature of the lesion.
168 THE GLOBE
A B
Figure 5-76 Dislocated lens nucleus. A, Transverse B-scan echogram through inferior aspect
of globe shows oval-shaped lens nucleus lying on surface of the retina (arrow). B, A-scan shows
highly reflective spikes from the anterior and posterior surfaces of the nucleus. S, Sclera.
A c
B D
Figure 5-77 Dislocated, cataractous lens. A, Horizontal transverse B-scan echogram through
inferior posterior globe (at reduced gain setting) shows round, swollen, partially calcified dislo-
cated lens (arrow) lying near surface of retina. Note marked shadowing (S) of posterior ocular and
orbital structures produced by the calcified lens. B, Corresponding A-scan view of the lens shows
very high reflectivity (arrows). S, Decreased spike height of orbital tissues due to strong sound at-
tenuation. C, Vertical axial B-scan obtained with patient in normal reclined position shows dis-
located lens (arrow) just inferior to optic nerve (ON). D, Vertical axial B-scan obtained with pa-
tient in sitting position shows lens has moved more inferiorly and anteriorly (arrow).
Dislocated lens
Lenses and lens nuclei that dislocate into the posterior seg-
ment, usually following blunt trauma or during intraocular
surgery (see p 106), have been confused with intraocular tu-
mors clinically.l \Vhen the lens is adherent to the posterior
fundus, it can simulate a tumor, but in most cases, these
A
lesions are mobile and can be observed to move during eye
movement.
Echographically, dislocated lenses and lens nuclei typi-
cally appear oval and their internal reflectivity varies, de-
pending on the degree of cataract formation (Figure
5-76). WIth eye movement, B-scan may show mobility of
the lens within the vitreous cavity or sliding of the lens
along the retinal surface (Figure 5-77). Another common
finding is the adherence of vitreous membranes or strands
to the surface of the lens or lens nucleus (see Figure 4-40).
A dislocated lens should always be considered in the differ-
ential diagnosis of an intraocular mass. In many cases, a tu-
B
mor can be easily ruled out by noting that the lens is not
located in its normal position.
Intumescent lens
A swollen, cataractous lens located in its normal position
may be mistaken for a peripheral tumor. This confusion re-
sults from the appearance of the lens when it is displayed Figure 5-78 Intumescent, cataractous lens masquerading as in-
in cross-section on a very anterior transverse scan. In this traocular tumor. A, Very anterior transverse B-scan echogram
displays cross-section of swollen lens (arrow). Note that in this
probe position, the lens may appear as a mass emanating view the lens appears very similar to a large ciliary body tumor.
from the ciliary body or peripheral choroid. This lesion B, Axial B-scan of same eye shows cataractous lens in its normal
usually can be identified as a lens, however, by performing position. ON, Optic nerve.
an axial or longitudinal scan and noting that the lens is
swollen and is located in its normal position (Figure 5-78).
are greater than 2.0 mm in thickness. A-scan can evaluate

ANTERIOR SEGMENT TUMORS
the internal reflectivity of these lesions and can help
Many of the different types of lesions (tumors, inflamma- determine whether they are vascuiarized. This acoustic
tory lesions, and cysts) that can affect the posterior segment information can be of value in differentiating certain
of the eye can also occur in the anterior segment (i.e., iris lesions.
and ciliary body) (see Box 5-1). This section will address the use of conventional B- and
Until recently, the only echo graphic method for evalu- A-scan instrumentation for the evaluation of anterior seg-
ating the anterior segment was through the use of conven- ment pathology. This technology is still the most widely
tional contact B- and A-scan instrumentation. An immer- available throughout the world and is routinely used in
sion technique was adapted to allow imaging of anterior clinical settings. In most cases, conventional ultrasound is
segment structures (see p 37). As a rule, iris lesions must be adequate for documenting the size and extent of anterior
at least 1.0 mm thick and ciliary body lesions must be at segment lesions and for monitoring their growth. Exam-
least 1.5 mm for reliable detection with this method. Newer ples of anterior segment pathology, utilizing one of the
instrumentation, however, using higher frequency trans- new high resolution B-scan (20 MHz) probes (see p 39),
ducers, now provides greater resolution of both normal will also be shown.
anatomic structures and lesions of the anterior segment. As
a result, lesions of smaller size can be detected and more
Iris lesions
information can be obtained. A complete discussion and il-
lustration of anterior segment pathology, with UBM, is An iris lesion can present as either a pigmented or anamel-
provided in Chapter 8. anotic lesion on slit-lamp examination, or it can present as
Because anterior segment lesions are relatively small, an elevation (bulging) of the iris. The main role for echog-
the use of the standardized A-scan for tissue differentia- raphy in these cases is to differentiate a solid from a cystic
tion is generally limited to the assessment of lesions that lesion, and to document its size and extent.
110 THE GLOBE
A c
B o
Figure 5-79 Posterior iris cyst (immersion technique). A, External photograph showing
bulging of iris. B, Longitudinal B-scan echogram shows small, well-outlined, oval, echolucent le-
sion at posterior aspect of peripheral iris (.1t7~aight arrow). Lesion is bowed forward, causing nar-
rowing of anterior chamber near angle (curved arrow). M, Methylcellulose within scleral shell;
C, cornea; P, posterior lens capsule; V, vitreous cavity. C, Transverse B-scan (with sound beam di-
rected through limbus) shows the lateral extent of the lesion. D, Vector A-scan tl1fough lesion
displays thickness of 2.2 mm. S, Sclera; arrow, posterior wall of cyst. (A courtesy Rosario Bate,
CRA, Ottawa, Canada.)
Iris Cyst the posterior iris, usually near the wound site. They are typ-
Cystic lesions may be developmental or acquired. The most ically well outlined and echo lucent, often with an irregular
common developmental cysts are primary cysts of the iris shape (Figure 5-80).
pigment epithelium. These lesions usually present clinically
as a bulging of the peripheral iris. Generally, they cannot Iris Melanoma and Nevus
be visualized with slit-lamp or ophthalmoscopic examina- Iris melanomas can be either pigmented or amelanotic.
tion. Echographically, they are well circumscribed, round They may be "located at the pupil or may involve the iris
or oval, and echolucent. They are located in the peripheral near the angle. B-scan shows a solid lesion that may vary in
iris at the junction of the anterior ciliary body (Figure 5- shape (Figure 5-81). In addition, B-scan is useful for de-
79). One study of 52 eyes 90 showed these cystic lesions to termining whether a peripheral iris melanoma extends
have a mean sagittal thickness of 1.6 mm. In this study, the posteriorly into the ciliary body (Figure 5-82). If the le-
sagittal thickness was defined as the distance from the an- sion is sufficiently thick, A-scan shows medium inter-
terior surface of the iris to the inner surface of the posterior nal reflectivity and may demonstrate internal vascularity
cyst wall. (Figure 5-83).
Acquired cysts, which occur most commonly following Clinically, iris nevi may appear very similar to iris
surgery or trauma, result from the implantation of surface melanomas. Criteria for differentiating these lesions with
epithelium. These lesions can be located on the anterior or echography have not been established.
A c
Figure 5-80 Two examples of epithelial implan-

tation cysts following corneoscleral laceration.
Immersion axial B-scan (A) and 'contact B-scan
(B) show well-outlined, lobulated, echolucent le-
sion (arrows) located in ciliary body region. M,
B Methylcellulose within scleral shell; C, cornea;
I, iris. C, Axial immersion B-scan from second pa-
tient shows irregularly shaped, echo lucent lesion
(horizontal arrows) in the angle of the anterior cham-
ber. P, Posterior lens capsule.
Figure 5-81 Iris melanoma examined with high resolution B-scan (20 MHz). Arrow, Dome-
shaped iris mass; C, cornea. (Courtesy Rhonda Waldron, MMSc, COMT, Atlanta, Georgia.)
172 THE GLOBE
B C
Figure 5-82 Peripheral iris melanoma with extension into ciliary body (immersion technique).
A, External photograph shows pigmented tumor involving peripheral aspect of iris in right eye.
B, Horizontal axial B-scan demonstrates irregularly shaped mass lesion extending from the an-
terior chamber (straight arrow) posteriorly into ciliary body (curved arrow). Lesion is in contact
with lens. M, Methylcellulose within scleral shell; C, cornea; P, posterior lens capsule;
V, vitreous cavity. C, Longitudinal scan with posterior aspect of ciliary body mass centered be-
neath probe. Patient gaze is such that cornea and other anterior segment structures are not vis-
ible. This view clearly delineates the posterior tumor margin (curved arrow).
A B
Figure 5-83 Iris melanoma (immersion technique). A, Vertical axial B-scan echogram shows
iris mass filling inferior aspect of anterior chamber (arrow), including the angle. M, Methylcel-
lulose within scleral shell; C, cornea; I, iris; P, posterior lens capsule; V, vitreous cavity. B, A-scan
shows medium internal reflectivity of lesion (arrow).
Figure 5-84 Metastatic carcinoma to the iris (immersion

technique). A, External photograph shows nonpigmented le-
sion involving inferior iris. B, Vertical axial B-scan shows
mass lesion extending both anterior (straight arrow) and pos-
A terior (curved arrow) to iris. Lesion appears to be in contact
with lens. M, Methylcellulose within scleral shell; C, cornea;
P, posterior lens capsule; V, vitreous cavity. C, A-scan shows
high internal reflectivity of lesion. C, Cornea; straight arrow,
anterior tumor surface; curved arrow, posterior tumor surface.
B c
Iris Metastasis On B-scan, ciliary body melanomas exhibit a smooth,

Clinically, metastatic lesions appear as pink or yellow nod- dome shape (Figure 5-85); larger lesions may develop a col-
ules involving the iris stroma. 88 B-scan shows a solid lesion lar button shape (see Figure 5-6). They may be confined to
with a somewhat irregular shape that may extend into the the anterior ciliary body or may extend posteriorly into the
ciliary body. A-scan demonstrates an irregular internal struc- pars plana and peripheral choroid. The contact method, us-
ture with predominantly medium to high internal reflectiv- ing a longitudinal B-scan approach, is usually best suited
ity (Figure 5-84). Vascularity is typically not detected. for demonstrating the extent of peripheral choroidal in-
volvement (Figure 5-86). B-scan may also show extension
into the anterior chamber and impingement on the lens
Ciliary Body Lesions
(Figure 5-87; see also Figure 5-86), and A-scan may
Lesions of the ciliary body are often masked by their pe- demonstrate "the characteristic low to medium internal
ripherallocation and can sometimes become quite large be- reflectivity, as well as internal vascularity.
fore manifesting clinically. The immersion technique is of- Another interesting echographic feature of some cil-
ten the best method for documenting the topography and iary body melanomas is the presence of one or more
measuring the thickness of a ciliary body tumor. N everthe- cystic cavities (i.e., cavitary melanoma)50 (Figure 5-88).
less, the contact method can sometimes be of value in as- In some cases, the cystic cavities occupy nearly the
sessing these lesions. entire volume of the tumor and may simulate a benign
cyst of the ciliary body. Two features of these melanomas
Ciliary Body Melanoma that may help differentiate them from benign cysts
Although ciliary body melanomas Cannot be easily visual- are (1) a solid mass at the base of the lesion and (2)
ized ophthalmoscopically, they are frequently associated a thick wall surrounding the cavities within the tumor
with clinical findings that may indicate the diagnosis. 88 (Figure 5-89).
These findings include dilated episcleral blood vessels, ex- When large choroidal melanomas extend anteriorly,
trascleral extension, a dome-shaped mass behind the pupil, . contact techniques may be unable to display the anterior
cataract and subluxation of lens, and extension into the iris border of the lesion. Immersion B-scan is then recom-
and anterior chamber. These patients may also develop sec- mended to document the anterior extent of the lesion and
ondary glaucoma. the degree of ciliary body involvement (see Figure 5-87).
174 THE GLOBE
A B
Figure 5-85 Ciliary body melanoma examined with high resolution B-scan (20 MHz). A, Lon-
gitudinal scan demonstrates well-outlined, oval tumor (1). e, Cornea; S, sclera; I, iris; curve4 ar-
row, anterior lens surface. B, Transverse B-scan shows circumferential slice through tumor.
(Courtesy Cynthia Kendall, BMET, RDMS,Sacramento, California.)
A c
B D
Figure 5-86 Large ciliary body melanoma displayed with contact technique. A, Oblique axial
B-scan view shows large, peripheral melanoma (M) displacing lens inferiorly. P, Posterior lens
capsule. B, Oblique transverse B-scan through superior aspect of ciliary body shows very large,
dome-shaped tumor. Note that the tumor and sclera are not well shown because of difficulty in
maintaining perpendicularity in the periphery of the globe. C, Anterior longitudinal B-scan
shows extreme peripheral location of tumor. Note that in this view the entire radial extent of
tumor cannot be displayed. eB, Ciliary body; arrow, posterior aspect of tumor. D, A-scan at Tis-
sue Sensitivity shows very low reflectivity of melanoma (M). T, Tumor surface; S, sclera.
Figure 5-87 Large ciliochoroidal melanoma (immersion teclmique, same tumor as in Figure 5-
86). A, Large ciliary body mass located supra temporally is visible through pupil on external pho-
tograph. B, Axial B-scan view shows large melanoma (l'v1) displacing the lens (L). ME, Methyl-
cellulose within scleral shell; arrows, small air bubbles; C, cornea; S, sclera; A, anterior chamber.
C, Transverse B-scan with tumor centered beneath probe (patient fixating inferonasally) shows
melanoma (M).
176 THE GLOBE
A C
Figure 5-88 Two examples of ciliochoroidal melanoma with cystic degeneration (cavitary
melanoma). A, Transverse B-scan demonstrates large dome-shaped tumor with area of cystic
degeneration (arrow). B, Gross pathologic specimen shows large ciliochoroidal melanoma (mixed
cell tumor) with hemorrhagic degeneration (arrow). C, Transverse B-scan of second case shows
large mass with eccentric collar button (arrows) containing multiple cystic spaces. D, A-scan cor-
responding to C shows moderately irregular structure with areas of low reflectivity due to cys-
tic cavities (arrows). T, Tumor surface; S, sclera.
Figure 5-89 Ciliochoroidal melanoma with cystic degen-

B eration (cavitary melanoma). A, Transverse B-scan displays
highly elevated lesion with multiple, large cystic cavities.
Only small areas of solid tissue remain. E, Lesion exhibits
very irregular internal structure due to the highly reflective
surfaces dividing the various cavities within the tumor com-
bined with the very low reflective nature of the cystic cavi-
ties (arrows). T, Tumor surface; S, sclera. C, Gross patho-
logic specimen shows ciliochoroidal melanoma (mixed cell
type) containing large cystic spaces. (Courtesy Dr. Richard
Green and Dr. Andrew Schachat, Baltimore, Maryland.)
Other Lesions of the Ciliary Body tioned earlier, cavitary melanomas can simulate these lesions
A number of other lesions can involve the ciliary body and and must be considered in the differential diagnosis (see
may mimic a melanoma clinically. Some of these include p 173 and Figure 5-89).
melanocytoma, adenoma, leiomyoma, medulloepithelioma Epithelial down growth can present as a masslike lesion
(see p 187), benign cysts, and epithelial downgrowth. On involving the ciliary body. This lesion may demonstrate an
B-scan, most of these lesions are well outlined and dome irregular shape on B-scan and high internal reflectivity on
shaped. A-scan (Figure 5-92). Epithelial down growth should be
Melanocytomas and adenomas usually demonstrate reg- suspected if there has been previous penetrating trauma or
ular internal structure and high internal reflectivity on A- complicated intraocular surgery.
scan (Figure 5-90). In contrast, leiomyomas exhibit low to Conjunctival (limbal) dermoid tumors usually present
medium internal reflectivity. These tumors are also highly in childhood. In many cases, they extend onto the cornea.
vascularized (see p 154 and Figure 5-58). These lesions can often be assessed with ultrasound using
Benign cysts involving the ciliary body are usually round or the immersion technique previously described for eval-
oval and appear echolucent on B-scan (Figure 5-91). As men- uation of the anterior segment (see p 37). Typically,
178 THE GLOBE
Figure 5-90 Adenoma of ciliary body (immersion technique). A, Photograph shows nonpig-
mented ciliary body mass behind iris. B, Longitudinal B-scan shows roundish ciliary body mass
(curved arrow). M, Methylcellulose within scleral shell; straight arrow, air bubble; S, sclera; open ar-
row, posterior extent of lesion along ciliary body; V, vitreous cavity. Patient gaze is such that cornea
and iris are not visible. C, A-scan indicates high internal reflectivity of tumor. (A courtesy James
Gilman, CRA; Band C courtesy Rhonda Waldron, MMSc, COMT, Atlanta, Georgia.)
Figure 5-91 Ciliary body cyst examined with high resolution B-scan (MHz). Longitudinal
scan. Arrow, Ciliary body cyst; C, cornea; I, iris; S, sclera. (Courtesy Rhonda Waldron, MMSc,
COMT, Atlanta, Georgia.)
A
c
Figure 5-92 Epithelial downgrowth following cataract

surgery. A, Immersion axial B-scan echogram shows large,
round ciliary body mass (curved arrow). M, Methylcellulose
B within scleral shell; C, cornea, I, iris; V, vitreous cavity.
B, Contact A-scan with probe on sclera overlying lesion
shows high internal reflectivity (straight arrows). Curved ar-
row, Tumor surface. C, Gross pathologic specimen show-
ing large mass lesion secondary to epithelial downgrowth.
180 THE GLOBE
A B
Figure 5-93 Limbal dermoid (immersion technique). A, External photograph from child
shows limbal dermoid. B, Longitudinal B-scan shows dome-shaped mass (curved arrow) in peri-
limbal region with extension onto cornea (straight arrow). Lesion is relatively echo-dense and
cannot be differentiated from underlying sclera. M, Methylcellulose within scleral shell; V, vit-
reous cavity. (A courtesy Dr. Jonathon Dutton, Carey, North Carolina.)
ultrasound demonstrates a smooth, dome-shaped lesion on agnosing a retinoblastoma, these eyes should be examined
the surface of the globe at the limbus. They exhibit high very carefully. Internal vascularity mayor may not be de-
internal reflectivity and often appear to infiltrate the un-·· tected in these lesions. It should also be mentioned that these
derlying sclera (Figure 5-93). eyes are usually of normal size or larger. 97 Consequently, ax-
iaLeye length measurements can often be helpful in differ-
entiating a retinoblastoma from other causes of leukokoria
RETINOBLASTOMA
that present with small globes (Table 5-2). It should also be
Echography is useful for the detection and differentiation mentioned that orbital inflammation can occur in associa-
of intraocular tumors in children and is particularly valu- tion with retinoblastomay,84
able in the diagnosis of retinoblastoma. 58,65 Retinoblas- In some cases, a retinoblastoma can present as a mildly
tomas can be unilateral or bilateral, focal or multifocal, and elevated, diffuse lesion at the level of the retina, with a
frequently have a creamy, yellow-white appearance. These bumpy, irregular contour. These diffuse tumors, which usu-
tumors can grow either anteriorly from the inner surface ally occur in older children, may contain little or no cal-
of the retina toward the vitreous (endophytic) or posteri- cium (Figure 5-97). In these eyes, tumor cells may accu-
orly from the outer aspect of the retina toward the choroid mulate in the anterior chamber as a pseudohypopyon or in
(exophytic).108 Retinoblastomas commonly contain calcium. the vitreous, simulating a vitritis. 84,97 They may also pro-
Echographically, retinoblastomas may have a smooth, duce cysts within the vitreous cavity.l06 Because the clinical
dome shape, but more typically, they have a very irregular presentation can mimic an inflammatory disorder and be-
configuration. The internal reflectivity can vary according to cause calcification may not be present on ultrasound, the
the degree of calcification within the lesion. Noncalcified tu- diagnosis of retinoblastoma may not be readily apparent.
mors demonstrate low to medium reflectivity, whereas cal- Therefore, whenever a diffuse, bumpy, noncalcified lesion
cium produces extremely high internal reflectivity. The cal- is detected in a child, the diagnosis of retinoblastoma
cium may be quite dense and located throughout the lesion, should be considered.
or it may be limited to a few small foci (Figure 5-94). VVhen Retinoblastomas can infiltrate the optic nerve or extend
these deposits are numerous and/or large, shadowing of the into the orbit. This may be difficult to detect with ultra-
adjacent sclera and orbit may occur (Figures 5-9 5 and 5-96). sound because of shadowing from intraocular calcification.
Because the demonstration of calcium is so important in di- Consequently, computed tomography (CT) or magnetic
A c
Figure 5-94 Large exophytic retinoblastoma showing only mild calcification. A, Longitudinal
B-scan echogram displays large, roundish, echo-dense lesion (straight arrow) in peripheral as-
pect of eye. Retinal detachment (curved arrow) is noted extending from lesion to optic nerve
(ON). B, Same view as A (at reduced gain setting) shows persistent, echo-dense signals from cal-
cium deposits within tumor (arrows). C, A-scan through tumor shows highly reflective spike
from focus of calcium (arrow). T, Tumor surface; S, sclera. D, Gross pathologic specimen shows
total retinal detachment with large exophytic tumor.
\.
/
182 THE GLOBE
A D
B E
Figure 5-95 Two cases of retinoblastoma showing calci-

fication. B-scan echogram at high gain setting (A) shows
a large, bright mass (arrow) within the vitreous cavity.
B, B-scan view at lower gain setting shows multiple, bright
echoes corresponding to calcium within the lesion.
C, A-scan shows very high reflectivity of tumor (arrows)
with decreased reflectivity posteriorly, due to shadowing of
c the sclera and orbital soft tissue (0). D, Another large,
heavily calcified retinoblastoma (arrow) shadows the orbital
signals (S). E, B-scan from another portion of the eye
demonstrates tumor seeding along the posterior hyaloid
(arrows). (From Green RL, Byrne SF: Diagnostic oph-
thalmic ultrasound, in Ryan S] [edJ: Retina. ed 3, St Louis,
Mosby, 2001, p 287.)
Figure 5-96 Highly calcified endophytic retinoblastoma. A, External photograph shows

whitish mass posterior to lens. B, Axial B-scanechogram shows calcified retinoblastoma within
funnel-shaped retinal detachment (arrows). ON, Optic nerve. C, Transverse B-scan view at re-
duced gain setting shows large focus of calcium within tumor (arrow) and shadowing of orbital
soft tissue (S). D, A-scan shows very high reflectivity of calcified tumor (aT·rows). S, Strong sound
attenuation prevents display of orbital soft tissue.
~[:A.BlE 5-2
Conditions Associated with leukokoria*
Condition Main Echographic Finding Axial Eye Length Unilateral/Bilateral
Reti noblastoma Calcified mass Normal Un i lateral/bUatera I
Retinopathy of prematurity Total retinal detachment with Short Bilateral
(ROP) (stage V) retinal loops
Persistent hyperplastic Vitreous band from lens to Short Unilateral
primary vitreous (PHPV) optic nerve
Coats' disease Exudative retinal detachment Normal Unilateral
Toxocariasis Peripheral glaucoma; retinal Normal Unilateral
folds and posterior traction
retinal detachment
Endophthalmitis Vitreous opacities Normal Unilateral
Cysticercosis Cyst with scolex Normal Unilateral
Medulloepithelioma Ciliary body mass with cystic Normal Unilateral
(diktyoma) cavities
*This table lists the main echographic findings for the most common conditions associated with leukokoria.
184 THE GLOBE
Figure 5-98 Stage V ROP. Longitudinal B-scan echo gram of

total funnel-shaped retinal detachment demonstrates large, pe-
8 ripheral retinal loop (arrow). Note dense opacities within moder-
ately open funnel. ON, Optic nerve. (From Pulido ]S, Byrne SF,
Clarkson ]G, et al: Evaluation of eyes with advanced stage Vof
retinopathy of prematurity using standardized echography. Oph-
thalmology 1991 ;98: 11 00.)
typically occurs within the retina or choroid and therefore

has a plaquelike configuration 34 (see Figure 4-49). This is in
Figure 5-97 Diffuse, noncalcified retinoblastoma. A, B-scan
echogram shows diffuse lesion with irregular, bumpy contour (ar- contrast to the clumplike calcification that is usually ob-
rows). B, A-scan shows medium internal reflectivity with no evi- served in retinoblastomas.
dence of calcium. T, Tumor surface; S, sclera. (From Green RL, A number of rare or unusual conditions that were clini-
Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: cally suggestive of retinoblastoma have been evaluated.
Retina. ed 3, StLouis, Mosby, 2001, p 288.) These included a large, collar button-shaped melanoma in
a 6-year-old child and a rhabdomyosarcoma of the ciliary
body, also in a 6-year-old child. Other unusual lesions that
resonance imaging (MRI) are better modalities for the de- have been evaluated with echography include combined
tection of optic nerve or orbital involvement. hamartoma of the retinal pigment epithelium and
Echography is also important for monitoring the size of neurofibroma of the choroid (see p 155). It should also be
retinoblastomas that have been treated with radiation or al- mentioned that astrocytomas of the retina can also be
ternative methods of therapy. In most instances, tu~~rs calcified (see p 155) and thus may simulate retinoblastoma.
that recur or continue to grow after treatment tend to ex-
hibit low to medium internal reflectivity and usually do not
show calcification. OTHER LESIONS ASSOCIATED
WITH LEUKOKORIA
Differential Diagnosis of Retinoblastoma Retinopathy of Prematurity
There are several intraocular conditions associated with Retinopathy of prematurity (ROP) is typically a bilateral
leukokoria that must be considered in the differential diag- condition that affects mainly the vitreous and peripheral
nosis of retinoblastoma (see Table 5-2). The primary con- retina. 69 In advanced cases (i.e., stage V), the retina is ex-
ditions are (1) retinopathy of prematurity (ROP), (2) per- tensively detached, often in a funnel-like configuration.
sistent hyperplastic primary vitreous (PHPV), (3) Coats' The peripheral retina frequently has a loop or troughlike
disease, (4) toxocariasis, (5) cysticercosis, (6) medulloep- appearance as a result of traction by dense retrolental mem-
ithelioma, and (7) endophthalmitis (see p 191). Unlike branes. Echography can show the presence of these pe-
retinoblastomas, these lesions do not usually contain cal- ripheralloops, as well as the extent and configuration of the
cium unless the eye has undergone chronic degeneration. retinal detachment (Figure 5_98).13,34,73,82 It should be men-
The calcification that is detected in degenerative conditions tioned that these retinal loops can appear echographi-
A c
B D
Figure 5-99 Stage V ROP. Longitudinal B-scan echograms (A and B) show dense, membra-
nous opacities anteriorly and tightly closed funnel-shaped retinal detachment posteriorly in-
serting into optic nerve (ON). A large retinal loop (a770W) is present anteriorly. A-scan echo grams
(C and D) show hemorrhage and cholesterol (C) in subretinal space. C, A-scan at Tissue Sensi-
tivity setting. D, A-scan at slightly increased gain. At this higher setting, movement of the sub-
retinal opacities results in blurred spikes. (From Green RL, Byrne SF: Diagnostic ophthalmic ul-
trasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 289.)
cally similar to peripheral retinal cysts. Hemorrhage and/or (persistent hyaloid vessel) may' be seen extending from the
cholesterol debris sometimes may be detected in the sub- posterior lens capsule to the optic disc (see Table 5-2). Very
retinal space (Figure 5-99).1 3,73 Many eyes with severe stage often, this band is extremely thin and difficult to identify
V ROP are shorter than normaF3 (see Table 5-2). along its entire course (Figure 5-1 0 1); in other situations, it
can be extremely thick and easy to demonstrate (Figure
5-1 02). In addition, vascularity can sometimes be identified
Persistent Hyperplastic Primary Vitreous
within the patent blood vessels that may be present within
Persistent hype~plastic primary vitreous (PHPV) has a this band.
characteristic clinical appearance consisting of a small In PHPV; the band can produce a traction retinal de-
cornea and prominent ciliary processes. In most cases, tachment in the peripapillary region (Figure 5-103); in
PHPV is a unilateral condition. 69 Echography usually more advanced cases, a total retinal detachment may occur.
shows a shorter than normal globe, although it may be nor- A thick band secondary to persistent hyaloid structures can
mal in some patients. The lens is often thin, and there may sometimes be confused with a tightly closed, funnel-shaped
be irregularity of the posterior capsule (Figure 5-100). A retinal detachment. The identification of a small area of
retrolental membrane can sometimes be demonstrated on traction posteriorly, however, can often help rule out the
the posterior surface of the lens. In PHPV; a vitreous band presence of a total retinal detachment.
186 THE GLOBE
Figure 5-100 PHPV: B-scan echo gram shows small globe and thin lens (arrow). There is also
a thin membrane adherent to the posterior lens capsule that cannot be distinguished from lens
in this echogram. (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S]
Figure 5-101 PHPV with thin band. Longitudinal B-scan shows thin band (arrow) extending
from optic disc into vitreous cavity.
A 8
Figure 5-102 PHPV with thick band. A, Longitudinal B-scan shows thick echo-dense band
(arrow) extending from anterior aspect of eye to optic nerve (ON). B, Transverse B-scan shows
cross-section of thick band.
Figure 5-103 PHPV with focal traction retinal detachment. Longitudinal B-scan demon-
strates attachment of thick band at optic nerve and shallow peripapillary traction retinal de-
tachment (black arrow). ON, Optic nerve. Entire length of band could not be displayed in one
section.
A B
Figure 5-104 Early Coats' disease. A, Vertical macula B-scan echogram shows localized dome-
shaped exudative retinal detachment at the macula (arrow). B, A-scan shows multipeaked spike
from thickened retina (arrow) and medium reflective spikes from subretinal cholesterol (C).
(From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina. ed 3,
Coats' Disease Cysticercosis

Coats' disease is typically a unilateral condition character- See Table 5-2 and p 203 in Chapter 6 for a review of cys-
ized by an exudative retinal detachment. 39 In the early ticercosis.
stages, multiple, localized, shallow retinal detachments may
be detected (Figure 5-104). In more severe cases, total de-
Medulloepithelioma (Diktyoma)
tachment of the retina can occur. In these eyes, areas of
marked retinal thickening can sometimes be demonstrated. This rare tumor, which has been described mainly in chil-
Also characteristic of this condition is the presence of cho- dren,104 often appears as a whitish mass within the ciliary
lesterol in the subretinal space 38 ,61 (Figure 5-105; see also bodyP Echographically, these lesions are most often dome-
Table 5-2 and Figure 3-25). shaped, highly reflective, and moderately vascular. The
internal structure is generally somewhat irregular and
multiple cystic spaces can often be demonstrated 27 (Figure
Toxocariasis
5-106; see also Table 5-2). Certain forms of medulloep-
See Table 5-2 and p 203 in Chapter 6 for a review of toxo- ithelioma also contain cartilage, producing echoes of ex-
cariasis. tremely high reflectivity. It has also been reported that
A c
Figure 5-105 Advanced Coats' disease. A, Longitudinal

B-scan echogram shows funnel-shaped retinal detachment
(arrows) and opacities from subretinal cholesterol (C).
ON, Optic nerve. B, Transverse B-scan view through tem-
poral globe shows marked thickening of detached retina (ar-
rows). C, A-scan shows marked thickening of detached
B retina (aT7ows) and low reflective echoes from cholesterol in
the subretinal space (C). A-scan at increased gain level
(echogram not shown) displayed typical medium-reflective
spikes from the subretinal cholesterol. (From Green RL,
Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S]
red]: Retina. ed 3, St Louis, Mosby, 2001, p 291.)
A c
B o
Figure 5-106 Medulloepithelioma of ciliary body (immersion technique). A, External photo-

graph shows vascularized mass behind the lens. B, Axial B-scan echo gram shows rounded ciliary
body mass (curved aTTow) containing large cystic space adjacent to lens (L). M, Methylcellulose;
open arrows, surface of scleral shell; C, cornea; V, vitreous cavity. C, Longitudinal B-scan view
with patient's eye rotated so that ciliary body is centered beneath probe shows mass (curved
arrow). Posterior margin of mass is noted by small a770W. Note cystic cavities within lesion.
S, Sclera; open a770WS, surface of scleral shell. D, A-scan of ciliary body lesion (curved a77ow) dis-
plays mainly high internal reflectivity with medium spike height from cystic area (C). S, Sclera.
these tumors can shed cells into the vitreous, developing 29. GassJDM: Stereoscopic Atlas ofMacular Diseases-Diagnosis and Treat-
into cystS. 106 ntent, vol 1, ed4, StLouis, Mosby, 1997.
30. Gass JDM, Geiser RG, Wilkinson CP, et al: Bilateral diffuse uveal
melanocytic proliferation in patients with occult carcinoma. Arcb
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Inflammatory Diseases
of the Eye
Ultrasound can play an important role in the evaluation of a high gain setting on both B- and A-scan. On B-scan, these
a wide variety of inflammatory conditions affecting the eye opacities and membranes appear as fine dots and lines of
(Box 6-1). It may be used to identify specific sites of in- varying density. On A-scan, moderately severe endoph-
traocular inflammation or to help establish the etiology of thalmitis normally produces a chain oflow amplitude spikes
inflammation. It is especially important when the inflam- from within the vitreous cavity (Figure 6-1). If the opacities
matory response precludes visualization of the posterior are secondary to an anterior locus of infection, they tend to
segment. Echography also has been shown to aid in the be denser anteriorly than posteriorly. As the infection
management and follow-up of patients with inflammatory spreads, however, the opacities usually become more evenly
disease. distributed throughout the vitreous cavity. In eyes with pos-
Inflammatory disease can have an infectious or nonin- terior vitreous detachment (PVD), the subvitreal space
fectious etiology and may affect the eye in a variety of ways. should be carefully inspected using a high gain setting on
The inflammation may be diffuse, involving multiple ocu- B-scan since the presence of opacities in the subvitreal
lar structures, as in endophthalmitis or panophthalmitis. Al- space suggests active inflammation (Figure 6-2, A). If the
ternatively, the inflammation may be more localized, as posterior hyaloid has not detached prior to the infection, it
seen in scleritis or in certain inflammatory conditions that usually remains attached, presumably because of an inflam-
involve the choroid. Some of these include Vogt-Koyanagi- matory adhesion between the hyaloid and the retina.
Harada syndrome, sympathetic ophthalmia, uveal lymphoid In eyes with endophthalmitis, ultrasound may also de-
hyperplasia, and Lyme disease. tect thickening of the retinochoroid layer as well as exuda-
Unique ultrasound findings may be observed in certain tive and traction retinal detachment (RD). Other findings
types of ocular infections (e.g., toxocariasis and cysticerco- can include swelling of the optic nerve head and choroidal
sis). In addition, ultrasound has been used to visualize the detachment (Figure 6-2, B, C, and D). One study has shown
inflammation that occurs in association with some intraoc- that the presence of choroidal detachment on the initial
ular tumors (e.g., retinoblastoma or melanoma) and may be evaluation correlates with a poor visual outcome. 6 In some
useful in the evaluation and treatment of inflammation re- cases of endogenous endophthalmitis, associated choroidal
lated to human immunodeficiency virus (HIV) infection abscesses and/or granulomas have been identified (Figure
(acquired immunodeficiency syndrome [AIDS]). 6-3). Furthermore, endogenous endophthalmitis in chil-
dren may present clinically with leukokoria and may be
caused not only by bacterial infection but also by other eti-
ENDOPHTHALMITIS
ologies such as toxocariasis (see p 203) or intraocular cys-
Infectious endophthalmitis is a potentially devastating con- ticercosis (see p 203).
dition that may occur following intraocular surgery or oc- Ultrasound may also be useful in the treatment of en-
ular trauma, or it may develop from an endogenous source dophthalmitis since the echographic findings may help de-
elsewhere in the body. Endophthalmitis is clinically sus- termine the best diagnostic and/or therapeutic approach.
pected when there are signs of inflammation, both exter- For example, the detection of a choroidal detachment may
nally and within the eye. influence the length of the infusion cannula for diagnostic
Echography is very useful for determining the severity vitrectomy or the depth of needle penetration necessary for
and extent of the infection in eyes with endophthalmitis diagnostic vitreous aspiration. Furthermore, the discovery
(Box 6-2). The first step in the evaluation is to assess the of RD may indicate the need for more extensive vitreoreti-
vitreous cavity for the presence of inflammatory opacities nal surgery than would be necessary for diagnosis and treat-
and membranes. This assessment is facilitated by the use of ment alone.
191
192 THE GLOBE
BOX6c1 BOX 6-2

Inflantmatory Conditions Echographic Findings in Enclopht~almitis*
Enddpf"tthalmitis Vitreous opacities/membranes
Uveitisandvitritis PosteriOr vitreous detachment
Sder'itis Subvitreal opaciti.es
Vogt-Kbyanagi-Harada syndrome Macular edema
S~mpatheticophthalmia Retinochoroidal thickening (diffuse)
uveal lymphoid hyperplasia Reti na Itraction
Lyme disease Retinal detachment
Toxocariasis Subretinalopacities
Cysti(er~Osis Choroidal detachment
Acq u ired immunodeficiencysynd rome (AI DS) Suprachoroidal opacities
Inflammation associated with intraocular tumors Choroidal abscess or granuloma
Optic nerve head swelling
Scleral thickening
Episcleral edema
Orbital inflammation
*50me or all of the above findings may be detected in patients

with endophthalmitis.
B c
Figure 6-1 Endophthalmitis. A, External photograph shows large hypopyon. B, Transverse B-

scan demonstrates diffuse vitreous opacities with some membrane formation. C, A-scan shows
low reflective spikes from inflammatory debris in vitreous cavity.
Chapter 6 INFLAMMATORY DISEASES OF THE EYE 193
A c
B D
Figure 6-2 Various B-scan findings in endophthalmitis. A, Transverse view shows diffuse, mild
opacities in subhyaloidal space in association with diffuse vitreous opacities and shallow PVD
(P). B, Longitudinal scan demonstrates organized vitreous membranes extending to posterior as-
pect of eye. ON, Optic nerve. C, Transverse scan demonstrates shallow retinal detachment (ar-
rows) with overlying vitreous opacities and membranes. D, Longitudinal view along the tempo-
ral meridian shows opacities and PVD producing focal, tentlike traction RD at the macula
(arrows). Note bullous, nonserous choroidal detachment (C).
A. B
Figure 6-3 Choroidal abscess associated with endogenous endophthalmitis. A, Transverse

B-scan through peripheral fundus demonstrates dome-shaped lesion (white arrow). Note thick-
ening of adjacent sclera (S) and edema of sub-Tenon's space (black arrows). B, A-scan shows some-
what irregular internal reflectivity of lesion.
194 THE GLOBE
Figure 6-4 Panophthalmitis. Longitudinal B-scan demonstrates Figure 6-5 Posterior vitreoschisis in eye with uveitis. Longitu-
dense vitreous opacities and membranes (arrows), nonserous dinal B-scan. shows multiple layers of membranes representing
choroidal detachment (C), and diffusely thickened sclera (S). Note splits in the posterior cortical vitreous. ON, Optic nerve.
also inflammation and thickening of sub-Tenon's space (T) and
thickening oflateral rectus muscle (M). ON, Op,tic nerve.
In some cases, the diagnosis of endophthalmitis may be in duce posterior vitreoschisis,28,29 which can simulate inflam-
question because the clinical presentation is not straightfor- matory vitreous membranes (Figure 6-5).4
ward. The echographic detection of vitreous opacities in these In some cases, an external infection may produce a ster-
eyes may be misleading because vitreous hemorrhage may ap- ile vitritis, which can be confused with an infectious en-
pear echo graphically similar to inflammatory vitreous debris. dophthalmitis. For example, a sterile vitritis may occur in
However, there are two findings that may be useful in differ- the presence of an infectious corneal ulcer with sterile hy-
entiating inflammation from hemorrhage: first, PVDs tend popyon. This vitritis appears to be due to a spillover of
to be more extensive when resulting from hemorrhage than inflammatory cells from the hypopyon into the vitreous
from endophthalmitis; and second, pseudomembrane forma- cavity, especially in aphakic or pseudophakic eyes. Sterile
tion in the inferior portion of the globe (secondary to blood vitreous opacities also may be associated with either infec-
layered by gravity) more commonly occurs with vitreous tious or noninfectious scleritis or with orbital inflammation.
hemorrhage (see p 45 and Figure 3-4). In these instances, the echographic findings can mimic an
The intraocular infection occurring in panophthalmitis, infectious panophthalmitis (see Figure 6-4).
a more advanced form of endophthalmitis, mayaddition- Another cause of intraocular inflammation is lens-in-
ally involve the sclera, episclera, and sometimes the orbital duced uveitis. This condition occurs when lens material
tissues (Figure 6-4). leaks from a hypermature cataractous lens or is lost in the
vitreous cavity during cataract surgery. When the inflam-
mation is secondary to a hypermature cataract, a diffuse vit-
NONINfECTIOUS UVEITIS AND VITRITIS
ritis commonly occurs. In some cases, a hypermature lens
Uveitis is an inflammatory condition that may be idiopathic may leak into the anterior chamber. This may result in
or may be associated with a specific autoimmune disease opacification of the anterior chamber and a secondary glau-
(e.g., collagen vascular disorders, sarcoidosis, or ankylosing coma. In such cases, immersion ultrasound may demon-
spondylitis). It may affect the anterior and/or the posterior strate the hypermature nature of the lens (see Figure 7-3).
segment of the eye, or both, but ultrasound is gem;rally Cortical lens material, lens nucleus fragments, or the en-
more useful for the evaluation of posterior uveitis. The tire lens nucleus may fall back into the vitreous gel during
echographic findings most commonly seen in posterior cataract surgery (see p 106). Inflammatory vitreous opaci-
uveitis include vitritis, PVD, subvitreal opacities, retino- ties and/or membranes are normally associated with re-
choroid layer thickening, macular edema, and choroidal de- tained lens material (see Figures 4-39 and 4-40).
tachments. Peripheral vitreous opacities and preretinal Longstanding uveitis can lead to the formation of
membranes can be detected in certain peripheral types of cataract and cyclitic membrane (Figure 6-6). In addition,
posterior uveitis (i.e., pars planitis). chronic uveitis can cause hypotony, either by shutting down
The noninfectious (sterile) vitritis associated with pos- the production of aqueous or by detachment of the ciliary
terior uveitis produces echographic findings similar to those body due to traction from the cyclitic membrane (see p 77).
of infectious endophthalmitis, although there appears to be Hypotony produces specific echo graphic findings such as
less vitreous membrane formation in eyes with sterile vitri- diffuse thickening of the retinochoroid layer (including the
tis. It should be noted, however, that this condition can pro- macula), scleral thickening, choroidal detachments, scleral
Chapter 6 INFLAMMATORV DISEASES OF THE EVE 195
Figure 6-6 Cataract and cyclitic membrane in eye with uveitis (immersion technique). Axial
(A) and longitudinal (B) B-scans show deep anterior chamber (A) and dense, swollen cataractous
lens (open arrows). Note dense lens nucleus within cataract in A. Curved arrows indicate
cyclitic membrane extending between lens and ciliary body, possibly on surface of zonules.
M, Methylcellulose within scleral shell.
folds, and shortened axial eye length measurements (see sion. However, the ability of ultrasound to image the sclera
p 216). now provides a more reliable means to evaluate and diag-
Treatment for posterior uveitis often includes the injec- nose scleritis, especially in the posterior segment.
tion of steroids in sub-Tenon's space. Ultrasound can be
used in these eyes to localize the injected steroid material,
Posterior Scleritis
thus ensuring proper needle placement. 13 There have been
cases in which steroids were inadvertently injected into the The clinical presentation of posterior scleritis often in-
vitreous cavity (see Figure 4-41). cludes severe pain, periocular inflammation, and visual loss.
Signs of this condition may include choroidal folds, serous
retinal detachment, swollen optic disc, and orbital inflam-
SCLERITIS
mation (e.g., proptosis and lid swelling).23 Occasionally, a
Scleritis is an inflammatory condition that can affect either subretinal mass may also be visible. It should be mentioned,
the anterior or posterior aspect of the eye or both. This dis- however, that a certain number of patients present with
order can be idiopathic; it may be secondary to systemic minimal clinical findings.
diseases (e.g., rheumatoid arthritis), or it can have an infec- The most important ultrasound finding in this condition
tious etiology.26 Scleritis usually results in thickening of the is thickening of the sclera. The scleral thickening can vary
sclera, although thinning can occur in more chronic stages. in degree and can be either diffuse or localized (i.e., nodu-
Patients with scleritis often present with severe ocular pain, lar).1,9,17 The thickened sclera is usually highly reflective,
usually with other associated inflammatory signs and symp- with regular internal structure, and in most cases,there is
toms. Clinically, the diagnosis of anterior scleritis is usually an associated inflammatory reaction in the episcleral region,
straightforward, whereas the assessment of posterior scleral resulting in distention and swelling of sub-Tenon's space.
inflammation can be quite challenging. In fact, posterior Frequently, thickening of the retinochoroid layer can also
scleritis has generally been considered a diagnosis of exclu- be identified.
196 THE GLOBE
Figure 6-7 Diffuse posterior scleritis. A, Transverse B-scan echogram shows diffuse thicken-
ing of retinochoroid layer and sclera (S). Arrow indicates diffuse infiltration in sub-Tenon's space.
B, A-scan shows highly reflective thickening of retinochoroid layer (R) and sclera (S). Arrow
shows medium reflectivity from infiltration in sub-Tenon's space. (From Green RL, Byrne SF:
Diffuse Posterior Scleritis This lesion causes focal expansion of the ocular wall, ex-
Diffuse posterior scleritis presents as a diffuse thickening tending both within and outside of the normal confines of
of the posterior sclera that is usually most prominent in the the globe. The thickened sclera in these nodular lesions ex-
temporal aspect of the eye. It is typically associated with hibits predominantly high reflectivity with regular internal
diffuse retinochoroid layer thickening, as well as episcleral structure. As in the diffuse form, there may also be thick-
infiltration and/or edema (Figures 6-7 and 6-8). When it ening of the retinochoroid layer, as well as edema or inflam-
occurs in the peripapillary region, the episcleral inflamma- matory infiltration in sub-Tenon's space adjacent to the le-
tion causes distention of sub-Tenon's space, producing the sion (Figure 6-10). Echographically, nodular scleritis is
"T -sign"l9 on B-scan (Figure 6-9). Choroidal and ciliary easily differentiated from melanoma, although sometimes
body detachments may also occur,which may result in an- it may be confused with a highly reflective choroidal tumor
gle closure and secondary glaucoma. Serous retinal detach- (e.g., hemangioma or metastatic carcinoma)P
ments have also been identified. Associated orbital findings
may include myositis (see Chapter 15), optic neuritis (see
Anterior Scleritis
Chapter 16), and diffuse soft tissue inflammation (see
Chapter 17). The diagnosis of anterior scleritis can typically be made by
the clinical signs of conjunctival injection, intense redness
Nodular Posterior Scleritis of the sclera, and tenderness to touch. Anterior scleritis is
Nodular posterior scleritis may present" clinically as an ele- similar to posterior scleritis in that it can present in a diffuse
vated choroidal mass, thus mimicking an intraocular tu- or nodular manner. Ultrasound plays less of a role in this
mor. 9 In addition, these patients may present with little or group of patients since the diagnosis can usually be made
no pain, further obscuring the clinical diagnosis of scleritis.l on a clinical basis. Ultrasound, however, can show diffuse
197
B c
Figure 6-8 Diffuse posterior scleritis. A, Axial CT scan demonstrates diffuse thickening of
posterior ocular wall in the right eye (white arrows). B, Transverse B-scan of right eye shows dif-
fuse thickening ofretinochoroid layer and sclera (S) and edema ofsub-Tenon's space (black ar-
rows). C, Transverse B-scan of left eye displays normal thickness ofretinochoroid layer and
sclera.
Figure 6-9 Axial B-scans demonstrating "T-sign" in two different patients with diffuse poste-
rior scleritis. The T-sign is formed by distension of sub-Tenon's space (arrows) occurring around
the optic nerve (ON).
198 THE GLOBE
A C
B D
Figure 6-10 Posterior nodular scleritis. B- and A-scan echo grams show marked, localized
thickening of sclera that clinically presented as an intraocular mass. Transverse B-scans at high
gain (A) and reduced gain (B) show the markedly thickened retinochoroid layer (white arrows)
and sclera (black arrows) expanding both within and outside of the globe. Note moderately
echolucent area adjacent to the sclera (E) corresponding to inflammation in sub-Tenon's space.
A-scan at Tissue Sensitivity (C) shows high reflectivity of thickened retinochoroid layer (R) and
sclera (arrows), as well as medium reflectivity of the infiltrated sub-Tenon's space (E). T, Tenon's
capsule. D, A-scan at reduced gain shows thickness of lesion between retina (R) and Tenon's cap-
sule (T). (From Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan S] led]: Retina.
thickening of the anterior sclera, as well as the presence of

shallow ciliochoroidal detachments (Figure 6-11). In some
cases, these findings can be better documented using high-
resolution ultrasound (see p 233).
In the chronic or necrotizing form of this disease, scleral
thinning may occur, leading to scleral bulging (i.e., staphy-
loma). The underlying darkly pigmented uveal tissue can
sometimes be seen and may simulate a pigmented tumor
such as a melanoma. Therefore, in chronic scleritis, ultra-
sound can be useful for identifying these staphylomas and
ruling out an intraocular tumor (Figure 6-12).
Scleritis Associated with Intraocular Tumors

Figure 6-11 Anterior scleritis. Transverse B-scan view through
peripheral aspect of eye shows diffuse thickening of sclera and
Scleritis has been known to occur in association with in-
mild edema of sub-Tenon'sspace (curved black arrows), as well as traocular tumors, including choroidal melanoma (see Fig-
shallow ciliochoroidal detachment (straight white arrows). ures 5-9 and 5-18) and metastatic carcinoma. Scleral
A A
B B
Figure 6-12 Anterior staphyloma in an eye with necrotizing Figure 6-13 Infectious scleritis. A, External photograph
scleritis. A, External photograph shows large, dark lesion inferior demonstrates abscess formation superior to limbus. B, Transverse
to limbus (arrows). B, Immersion B-scan obtained with balloonlike B-scan view through the superior anterior aspect of the eye shows
device (B) placed over closed eyelid (E). Echogram shows large intrascleral abscess (straight black arrows). Curved white arrow dis-
staphyloma (black arrows) inferior to anterior chamber (A) and lens plays diffuse thickening of underlying choroid. Open arrows indi-
(L). V, Vitreous cavity. cate diffuse episcleral inflammation. V, Vitreous cavity.
inflammation is most likely secondary to tumor necrosis. (e.g., scleral buckle or glaucoma-filtering shunt) in that the
Episcleral andlor orbital involvement may also be present sound attenuation from these materials may prevent imag-
in these cases. ing of the affected sclera. Whenever there is the possibility
of an infected buckle, the ultrasound examination should
focus on areas adjacent to the buckle to look for inflamma-
Infectious Scleritis
tory changes that are not masked by the foreign material
Infectious scleritis occurs less frequently than the idiopathic (Figure 6-14).
or autoimmune forms of the disorder. Anterior infectious
scleritis has been associated with corneal ulcers and the ex-
INFLAMMATORY CONDITIONS
cision of pterygia, as well as with infected scleral buckles
OF THE CHOROID
and glaucoma-filtering shunts (see p 221). Infectious pos-
terior scleritis can occur as an extension of anterior scleri- Diffuse choroidal thickening secondary to inflammatory
tis, or more rarely, it may develop from an endogenous infiltration may be observed in a number of conditions such
source. as Vogt-Koyanagi-Harada syndrome (VKH), sympathetic
The echographic findings of infectious scleritis are sim- ophthalmia, and uveallyrnphoid infiltration.* Some of these
ilar to those of noninfectious forms of scleritis, although disorders may also be associated with thickening of the
the intraocular and orbital inflammation may be more se- sclera, serous RD, and vitritis, as well as with episcleral and
vere. Abscesses can be present within the sclera 31 (Figure orbital lesions.
6-13), the choroid (see Figure 6-3), and even the orbit. The
ability of ultrasound to aid in the diagnosis, however, can
be limited in the presence of implanted foreign material *References 3, 5, 7, 11, 12, 18,21.
200 THE GLOBE
Figure 6-14 Infectious scleritis associated with scleral buckle. Figure 6-15 Vogt-Koyanagi-Harada syndrome. A, Vertical
Transverse (A) and longitudinal (B) B-scans show curved echo- macula B-scan view demonstrates diffuse thickening of posterior
dense scleral buckle (B) indenting the globe and producing shad- choroid (curved arrow) and shallow serous RD (straight arrow) ex-
owing (Sh). Inflammation and thickening of episclera are seen ad- tending from superior margin of the lesion. B, Corresponding
jacent to the buckle (arrows). Note thickening of sclera (S) A-scan demonstrates low internal reflectivity of thickened choroid
overlying and adjacent to the buclde. Detached retina (R) extends (C). R, Retina; S, sclera.
posteriorly from the buckle. V,Vitreous cavity.
BOX 6-3
Vogt-Koyanagi-Harada Syndrome
Clinical and Echographic Differential Vogt-Koyanagi-Harada (VKH) syndrome is a systemic dis-

Diagnosis of VKHSyndrome order that often includes ocular involvement. This condi-
tion is usually bilateral, although the findings may be asym-
Posterior scleritis metric. The primary ophthalmologic features of VKH
Sympathetic ophthalmia*
include anterior and posterior uveitis, serous detachment
Idiopathic posterior uveitis
of the retina, changes in the retinal pigment epithelium,
Lymedisease*
REllapsil1gpblychondritis* and hyperemia of the optic disc.27
Uveal lymphoid hyperplasia (see p 153)* Several conditions can mimic VKH clinically (Box 6-3).
Lymphoma (seep 151)* In addition, VKH may have an atypical presentation, and in
Leukemia (seep 154)"f some cases, opaque ocular media may preclude adequate vi-
Diffuse malignant melanoma of the choroid (see sualization of the fundus. In all of these instances, ultra-
p136)* sound can be helpful for either confirming or ruling out the
Metastatic carcinoma (see p 143) diagnosis ofVKH. Moreover, ultrasound may be able to
Uveal effusion syndrome (see p 82) detect abnormalities in an eye with a normal fundus ap-
pearance. These findings can be important for confirming
*Inflammatory conditions that exhibit diffuse, low to medium
reflective choroidal thickening, similar to VKH.
bilateral involvement in patients who clinically appear to
have only unilateral disease.12
The most important echographic finding in VKH is dif-
fuse, low to medium reflective thickening of the choroid.
This thickening is generally most pronounced in the peri-
Chapter 6 INFLAMMATORV DISEASES OF THE EVE 201
A c
B D
Figure 6-16 Vogt-Koyanagi-Harada syndrome before (A and B) and after (C and D) corti-
costeroid therapy. A, Vertical macula B-scan section shows diffuse thickening of posterior
choroid (black arrows) and focal overlying serous retinal detachment (white arrow). B, Corre- .
sponding A-scan shows low internal reflectivity of thickened choroid. R, Retina; S, sclera.
Vertical macula B-scan (C) and corresponding A-scan CD) demonstrate nearly complete resolu-
tion of choroidal thickening and retinal detachment following treatment.
papillary region (Figure 6-15). From there, it usually ex- decrease in choroidal thickening and/or serous detachment
tends to the equator, where the choroid becomes progres- of the retina (Figure 6-16). Also, when the ocular media are
sively thinner. In some patients, the infiltration may also in- clear, the presence of residual choroidal thickening may not
volve the ciliary body. Other echo graphic features of this be clinically apparent, despite the resolution of other signs
disease may include serous RD, mild vitreous opacities, and and symptoms. Therefore, ultrasound can be used as an-
thickening of the sclera and/or episclera. other clinical marker for determining the response to ther-
The echographic differential diagnosis ofVKH includes apy and as a gauge for tapering the steroid treatment.
a number of conditions (see Box 6-3). Although many of
these disorders can demonstrate low to medium internal
Sympathetic Ophthalmia
reflectivity, other clinical and echographic findings will usu-
ally allow accurate differentiation. Sympathetic ophthalmia is a rare condition that can occur
U1trasound can also be incorporated into the manage- after penetrating injury or intraocular surgery. Although
ment of patients with VKH. The usual clinical method for sympathetic ophthalmia is a bilateral condition, the symp-
monitoring the response to corticosteroid therapy is the toms are often most evident in the noninjured (sympathiz-
documentation of an improvement in signs and symp- ing) eye. The primary echographic finding is diffuse,low
toms.ll However, if a cataract or other media opacity limits to medium reflective thickening of the choroid (Figure
visualization of the fundus, then these clinical findings may 6-17). Choroidal thickening can also be detected in the
not be an accurate means of assessing resolution of the traumatized eye if it is not too disorganized. Other associ-
inflammation. In these cases, ultrasound can document a ated findings can include vitreous opacities, serous RD, and
202 THE GLOBE
A C
B D
Figure 6-17 Sympathetic ophthalmia following penetrating foreign body injury. A, External
photograph of injured eye demonstrating dense opacification of anterior vitreous. B, Transverse
B-scan from eye shown in A demonstrates large intraocular foreign body (arrow) surrounded
by dense vitreous opacities.Sh, Shadowing from foreign body. C, Horizontal axial
B-scan of fellow eye demonstrates diffuse thickening of posterior choroid (black arrows) and shal-
low retinal detachment overlying macula (white arrow). ON, optic nerve. D, Corresponding
A-scan through macula shows retinal detachment (large white arrow) and low to medium reflec-
tive choroidal thickening (small white arrow). C, Surface of choroid; S, sclera.
scleral thickening. Ultrasound can also be used to monitor medium internal reflectivity on echography. The clinical
choroidal thickness to determine the response to therapy. and echo graphic features of this disorder are described in
The clinical and echo graphic findings for sympathetic detail in Chapter 5 (see p 153).
ophthalmia are similar to those of other disorders, although
they most closely resemble the features of VKH. Sympa- MISCELLANEOUS CONDITIONS ASSOCIATED
thetic ophthalmia, however, occurs almost exclusively fol- WITH INFLAMMATION OF THE CHOROID,
lowing· penetrating ocular trauma or previous ocular
RETINA, AND RETINAL PIGMENT
surgery.11 .
EPITHELIUM (RPE)
An unusual form of sympathetic ophthalmia has recently
been described. The patient presented with a bilateral, dif- There are some isolated reports of inflammatory conditions
fuse,granulomatous infiltration involving primarily the retina associated with significant choroidal thickening. One
and retinal pigment epithelium and a history of scleral buckle of these conditions is Lyme disease, one report of which
surgery in one eye. 33 On B-scan, there was pronounced, dif- described diffuse, bilateral, low to medium reflective
fuse thickening of the retina and retinal pigment epithelium, choroidal thickening, 8 similar to that ofVKH. Another dis-
especially in the peripapillary region, giving the false impres- order that has been associated with diffuse choroidal thick-
sion of an enlarged optic cup (Figure 6-18). No serous retinal ening is relapsing polychondritis. In one case, the patient
detachment was detected. The internal reflectivity of the presented with bilateral medium to high reflective cho-
thickened tissue was primarily medium-high. roidal thickening. In the more severely affected eye, there
was also an associated scleral thickening (Figure 6-19), as
well as a serous retinal detachment. 2
Uveal Lymphoid Hyperplasia
Mild choroidal thickening can occur secondary to other
This unilaterallymphoproliferative disorder presents as a inflammatory conditions, including endopthalmitis (see
diffuse or nodular amelanotic choroidal lesion with low to p 191), uveitis (see p 194), and scleritis (see p 195).
Figure 6-18 Granulomatous infiltration of retina and

retinal pigment epithelium in eye with history of scleral
B buckle surgery. Fundus photograph (A) shows diffuse le-
sion in posterior pole surrounding optic disc. Note normal
size of optic cup. B, Axial B-scan (with sound beam bypass-
ing lens) demonstrates diffuse thickening of the fundus in
the posterior pole (curved arrows). Note the pseudo-optic
cup (straight arrow) created by the thickened peripapillary
tissue. ON, Optic nerve. C, Gross pathology specimen
shows diffuse band of tissue representing granulomatous in-
filtration that primarily involves retina and pigment epithe-
lium. Open arrow, Scleral buckle. (A and C from Wang RC,
Zamir E, Dugel PU, et al: Progressive subretinal fibrosis
and blindness associated with multifocal granulomatous
chorioretinitis-a variant of sympathetic ophthalmia'. Oph-
thalmology. In press.)
Toxocariasis
Toxocariasis may present clinically as a whitish lesion in
the posterior or peripheral fundus, or as a leukokoria (see
Table 5-2) secondary to diffuse inflammation of the vit-
reous. Although there are no pathognomonic echo-
graphic criteria for toxocariasis, three characteristics that
are common to these infections have been identified in
eyes with clear media, as well as in eyes with endoph-
thalmitis that had opaque media. 32 These echographic
findings are (1) mildly to moderately elevated granulo-
matous lesions that may be calcified, (2) vitreous mem-
branes extending from the granulomatous lesion to the Figure 6-19 Relapsing polychondritis. Longitudinal B-scan
posterior pole, and (3) posterior traction RD or retinal demonstrates diffuse thickening of choroid (arrows) and sclera (S).
fold (Figures 6-20 and 6-21). V,Vitreous cavity.
Cysticercosis
more well-outlined, oval-shaped cysts located within the
Cysticercosis may present as a whitish mass in the poste- vitreous cavity and/or the subretinal space. 1O ,24 The scolex
rior aspect of the eye, with secondary inflammation of the of the parasite appears as a very highly reflective, echo-
vitreous. When the vitreous inflammation is severe, the pa- dense nodule attached to the inner wall of the cyst (Figure
tient may present with leukokoria (see Table 5 -2). The 6-22). Some investigators have reported movement of the
echographic appearance is quite characteristic, with one or cyst during kinetic evaluation. 24
204 THE GLOBE
Figure 6-20 Toxocariasis. A, Fundus photograph montage shows a retinal fold extending from
the optic disc to a peripheral granuloma. B, Longitudinal B-scan demonstrates the dense nodu-
lar peripheral granuloma (alrrow) shown in A. A thin membrane (!vI) and retinal fold (F) extend
from the granuloma back to the optic nerve (ON). C, More anterior longitudinal B-scan better
shows the granuloma and adjacent retinal fold. (From Green RL, Byrne SF: Diagnostic oph-
thalmic ultrasound, in Ryan S] led]: Retina. ed 3, St Louis, Mosby, 2001, p 291.)
A B
Figure 6-21 Toxocariasis. A, Longitudinal B-scan shows an elevated peripheral granuloma (ar-
row). A thick membrane (!vI) extends from the peripheral granuloma to the posterior aspect of a
radial traction retinal fold (F). B, Transverse B-scan shows cross-section of open traction retinal
fold with inflammatory membrane attached to apex.
Figure 6-23 Gancyclovir implant in a patient with CMV retini-

tis. Very anterior transverse B-scan shows echo-dense implant
(white arrow) followed by chain of multiple signals (black arrows)
and shadowing (Sh). V, Vitreous cavity.
tuberculosis, herpes simplex, and herpes zoster. Fortu-

B nately, however, recent improvements in medical therapy
have significantly lessened the incidence and severity of
these opportunistic infections.
Although there are no specific echo graphic findings in
the patient with AIDS, different infections present in
unique forms, and ultrasound can be useful in the diagno-
sis and management of these patients.
CMV retinitis usually presents with flat, creamy lesions
in the posterior pole. In some cases, these lesions are
treated with a gancyclovir implant. Although ultrasound is
not helpful in diagnosing CMY, the implant does exhibit a
rather specific echographic appearance (Figure 6-23).
c Herpes infections are associated with certain forms of
retinal necrosis. Herpes simplex is most commonly associ-
ated with acute retinal necrosis (ARN). Herpes zoster, how-
ever, is the primary etiologic agent of progressive outer
retinal necrosis (PORN), the form of retinal necrosis usu-
ally seen in patients with AIDS. In both of these conditions,
mild to moderately dense vitreous opacities may be pres-
ent, and retinal detachments frequently occur (Figure
Figure 6-22 Intraocular cysticercosis. A, Fundus photograph 6-24). Swelling of the retrobulbar optic nerve can be seen
shows elevated, nonpigmented lesion in inferior aspect of eye.
E, Transverse B-scan echo gram shows subretinal cyst containing
in some patients.
dense nodule (arrow) corresponding to scolex of the organism that Tuberculosis and syphilis, typically rare ocular disor-
typically attaches to the inner cyst wall. C, A-scan echo gram ders, are now being seen more frequently because of
shows highly reflective spike from anterior cyst wall (C) and thick, AIDS. Clinically, they usually present with an anterior
high spike from the scolex (arrow). S, Sclera. and/or posterior uveitis. There may also be a choroiditis
in the case of tuberculosis, or a chorioretinitis in syphilis.
These disorders may produce diffuse thickening of the
retinochoroid layer and/or focally elevated fundus le-
Acquired Immunodeficiency Syndrome (AIDS)
sions 2o (Figure 6-25). The echographic findings are sim-
In recent years, AIDS has created multiple new clinical ilar to the inflammatory changes seen in posterior uveitis
problems affecting the eye. Many different opportunistic (see p 194). In one case of tertiary syphilis, a markedly
infections can occur that may lead to a devastating visual thickened optic nerve was demonstrated 22 (Figure 6-26).
outcome. The various infections can include cytomegalo- Ocular toxoplasmosis in the immunocompromised pa-
virus (CMV), toxoplasmosis, Pneumocystis carin ii, syphilis, tient may present with a focal retinitis, although it may be
206 THE GLOBE
B
Figure 6-24 . Acute retinal necrosis. A, Anterior longitu-
dinal B-scan view shows necrotic retinal hole (arrow) in shal-
low retinal detachment. B, Axial B-scan displays vitreous
opacities (V), PVD (P), and shallow, diffuse posterior reti-
nal detachment (curved arrows). L, Lens; ON, optic nerve.
C, Gross pathology specimen demonstrates organized vit-
reousand shallow, diffuse retinal detachment.
Figure 6-25 Miliary tuberculosis. A, Fundus

photograph shows multiple cream colored, mildly
A elevated lesions in the posterior pole. B, B-scan
echogram demonstrates mildly elevated lesion with
slightly irregular surface contour (arrow). C, Cor-
responding A-scan displays mildly elevated lesion
with low internal reflectivity. R, Retina; S, sclera.
B c
Inflammation Associated with Ocular Tumors

Certain intraocular tumors can be associated with inflam-
mation, whereas others may mimic an inflammation by
their clinical presentation (pseudoinflammation). In both
instances, the confusing clinical and echo graphic findings
may lead to misdiagnosis. Some systemic malignancies
A can also produce a secondary intraocular inflammatory
response that is unrelated to a metastatic intraocular
tumor.
Tumors that sometimes develop inflammation include
choroidal melanoma, metastatic carcinoma, and retinoblas-
toma. Melanomas have been associated with ciliochoroidal
detachments, scleritis, episcleritis and orbital inflammation
(see Figures 5-9 and 5-18). These findings can occur with or
without extraocular extension of the tumor (see p 120). In
metastatic carcinoma, ciliochoroidal detachments have been
described when the tumor involves the peripheral choroid
and ciliary bodi o (see Figure 5-43). Scleritis may also occur
B when the tumor simultaneously involves the choroid and
adjacent episclera or the orbital tissues. Furthermore,
retinoblastoma may produce an orbital cellulitis that may
not be related to extraocular extension (see p 180).
Pseudoinflammation occurring secondary to tumor
infiltration of the vitreous or the anterior chamber can be
seen in retinoblastoma, as well as in intraocular B-celllym-
phoma (reticulum cell sarcoma, see p 151). In retinoblas-
toma, this usually occurs in older children with a diffuse
tumor. The clinical presentation may include hypopyon
and/or vitritis. Intraocular B-cell lymphoma may also
mimic a vitritis secondary to tumor cells within the vitre-
c ous cavity.
Certain systemic malignancies (e.g., ovarian and small
cell carcinoma) can produce a bilateral diffuse inflamma-
tory infiltration of the choroid that is unrelated to choroidal
metastasis. This rare condition, known as bilateral diffuse
uveal melanocytic proliferation (BDUMP),14,16 is typically
associated with a low-grade inflammation and cataract (see
Figure 6-26 Syphilitic optic neuritis in a patient with AIDS. p 166). Echographically, this condition appears as mild, dif-
A, Axial CT scan demonstrates proptosis of right eye and marked fuse thickening of the retinochoroid layer with slightly ir-
thickening of retrobulbar optic nerve. B, Axial B-scan shows marked, regular surface contour.
irregular thickening of the optic nerve (ON). C, A-scan shows
marked thickening of optic nerve with low to medium internal re-
flectivity. Arrows, Perineural sheath. (A from Kronish]w, Johnson REFERENCES
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2. Bhagat N, Green RL, Feldon SE, et al: Exudative retinal detachment
in relapsing polychondritis-case report and literature review. Oph-
thalmology 2001;108:1156.
a diffuse process in patients with AIDS.25 Vitreous opaci- 3. Chang TS, Byrne SF, Gass JDM, et al: Echographic findings in be-
nign reactive lymphoid hyperplasia of the choroid. Arch Ophthal'l7zo1
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Ultrasound may demonstrate mild to moderately ele- graphic finding in proliferative diabetic retinopathy. Ophthal'l7zology
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vated fundus lesions. Echographic findings can also include 5. Cockerham GC, Hidayat AA, Bijwaard KE, et al: Re-evaluation of
vitreous opacities and strands, as well as PVD. Elevation of "reactive lymphoid hyperplasia of the uvea"-an immunohistochem-
the optic disc has been demonstrated, as well as orbital ical and molecular analysis of 10 cases. Ophthalmology 2000;107:151.
6. Dacey MP, Valencia M, Lee MR, et al: Echographic findings in infec-
inflammation, including myositis (see p 396) and enlarge- tious endophthalmitis. Arch Ophthal'l7zo11994; 112: 1325.
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208 THE GLOBE·
8. DiBernardo C, Schachat A, Fekrat S: Ophthalmic Ultrasound-A Di- 21. ]akobiec FA, Sacks E, Kronish]W, et al: Multifocal static creamy
agnostic Atlas. New York, Thieme, 1998, p 68. choroidal infiltrates: An early sign of lymphoid neoplasia. Ophthal-
9. Finger PT, Perry HD, Packer, et al: Posterior scleritis as an intraocu- mology 1987;94:397.
lar tumor. Br J OphthalmoI1986;74:12 1. 22. Kronish]w,]ohnson TE, Gilberg SN, et al: Orbital infections in pa-
10. Fishman M, Kerman B, Foxman S: Intraocular cysticercosis: Migra- tients with human immunodeficiency virus infection. Ophthalmology
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Junk, 1987, p 285. 23. McCluskey P], Watson PG, Lightman S, et al: Posterior scleritis-
11. Forster D], Cano MR, Green RL, et al: Echographic features of the clinical features, systemic associations, and outcome in a large series of
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12. Forster D], Green RL, Rao NA: Unilateral manifestation ofVogt- 24. Moragrega E: Ultrasonic diagnosis of intraocular cysticercus, in Hill-
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1991;111:380. Dr. W]unk, 1984, p 191.
13. Freeman WR, Green RL, Smith RE: Echographic localization of cor- 25. Nussenblatt RB, Whitcup SM, Palestine AG: Uveitis-Fundamentals
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14. Gass ]DM: Ste1-eoscopic Atlas ofMacular Diseases, ed 4, St Louis, Mosby, 26. Riono WP, Hidayat M, Rao NA: Scleritis-a clinicopathologic study
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16. Gass ]DM, Glatzer R]: Acquired pigmentation simulating Peutz- 28. Schwartz SD, Alexander R, Hiscott P, et al: Recognition of vitreoschisis
]eghers syndrome-initial manifestation of diffuse uveal melanocytic in proliferative diabetic retinopathy. A useful landmark in vitrectomy for
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17. Green RL: Echographic diagnosis of posterior scleritis, in Ossoinig, 29. Seabag]: Diabetic vitreopathy (editorial). Ophthalmology 1996;103:205.
KC (ed): Ophthalmic Echography. Dordrecht, Dr. W]unk, 1987, p 515. 30. Sneed RS, Byrne SF, Meiler WF, et al: Choroidal effusions associated
18. Grossniklaus HE, Martin DF, Avery R, et al: Uveal lymphoid infiltra- with malignant choroidal tumors. Ophthalmology 1991;98:968.
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19. Harr DL, Quencer RM, Abrams GW: Computed tomography and 32. Wan WL, Cano MR, Pince K], et al: Echographic characteristics of
ultrasound in the evaluation of orbital infection and pseudotumor. Ra- ocular toxocariasis. Ophthalmology 1987;94(Oct Suppl):135.
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20. Illingsworth RS, Wright T: Tubercles of the choroids. Br Med J and blindness associated with multifocal granulomatous chorioretini-
1948;2:365. tis-a variant of sympathetic ophthalmia_ Ophthalmology. In press.
Glaucoma
As a result of improvements in ultrasound instrumenta- large cup can be considered a reliable finding; but if not de-
tion, as well as significant advances in the treatment of tected, the diagnosis cannot be excluded.
glaucoma, the role of echography has become increasingly When a large cup is detected, the possibility of a deep,
important in the evaluation of glaucoma patients. In addi- congenital physiologic cup should be considered. Compar-
tion, the indications for echography in this field are con- ison with the fellow eye, provided the cup can be visualized
tinuallyexpanding. with ophthalmoscopy, can usually help determine whether
The assessment of optic nerve cupping in the presence the echographic findings repres~nt glaucomatous changes.
of opaque ocular media was one of the initial indications Pseudocupping of the optic disc can occur. This can be
for the use of ultrasound in glaucoma. 9 Ultrasound subse- seen in eyes with marked, diffuse thickening of the retina
quently has proved to be helpful in the differentiation and and/or choroid surrounding the optic disc. The result is a
diagnosis of angle closure glaucoma, secondary glaucoma, cavity or depression overlying the optic nerve head that can
and congenital (infantile) glaucoma. It is now commonly mimic a large optic cup on B-scan (see Figure 6-18). Dif-
employed for the management of patients with glaucoma ferentiation can usually be made, however, by comparing
shunt surgery,23 and it has become indispensable for the the thickness of the retinochoroid layer in the peripapillary
evaluation and management of complications following all region to other areas of the fundus and/or the fellow eye.
types of glaucoma surgery.
New ultrasound technologies have emerged in recent
CONGENITAL GLAUCOMA
years, including ultrasound biomicroscopy (UBM)27,28 and
color Doppler imaging.2l,22 These techniques now provide The clinical diagnosis of congenital glaucoma is generally
a better understanding of the pathophysiology of certain established by the assessment of intraocular pressure, eval-
types of glaucoma and, in some cases, can aid in the diag- uation of the optic nerve, the measurement of corneal di-
nosis and management of these disorders (see Chapter 8 ameter, and gonioscopy (Figure 7-2). Diagnostic challenges
and Chapter 14). arise because early optic disc cupping may be difficult to
detect, corneal diameter and gonioscopy may be normal,
and visual fields analysis is not possible. Also, the intraocu-
OPTIC DISC
lar pressure may be normal at the time of examination un-
B-scan can provide a useful and reliable estimation of optic der anesthesia, and the intraocular pressure may be
cup size in eyes with opaque ocular media. The technique influenced by the anesthetic agent.
for optic nerve head evaluation, as described on p 431 in Ultrasound biometry can be helpful for establishing the
Chapter 16, emphasizes the importance of positioning the diagnosis of glaucoma in borderline cases and for monitor-
probe so that the sound beam bypasses the lens, thereby ing the condition during treatment. Studies have shown a
maximizing resolution of the optic rim. close correlation between longstanding changes in intraoc-
Although the assessment of cup size is somewhat unreli- ular pressure and the axial eye length measurement. 3 ,24,30
able for small and medium-sized cups, the detection of Therefore changes in axial length may be the best indicator
large cups has been shown to be relatively accurate 9 (Figure of the success or failure of glaucoma therapy.
7-1). In certain cases, however, the estimation of cup size The immersion technique is generally preferable to the
may be especially challenging, such as when a large cup has contact method for detecting subtle changes in the length
a shallow, saucer-like shape. In these eyes, the resolution of of the smaller eyes characteristic of the pediatric population
the ultrasound system may be insufficient to resolve the (see p 259 and Table 10-1). In addition, B-scan examination
borders of the optic rim, and therefore the enlarged cup can help evaluate and monitor the contour of the posterior
may not be recognized. Additionally, membranes inserting ocular wall to determine if a posterior staphyloma is develop-
into or overlying the optic disc may prevent echo graphic ing. It should be noted that as eyes with congenital glau-
imaging of the optic cup. Consequently, the detection of a coma enlarge, the anterior chamber depth increases and lens
209
210 THE GLOBE
A c
B D
Figure 7-1 Large optic cup displayed in various B-scan views. A, Fundus photograph showing
large optic cup. B, Optic cup is rather indistinct in vertical axial B-scan orientation. Cup is shown
better in vertical transverse (C) and longitudinal 12-o'clock (D) views. Arrows, Optic cup.
thickness decreases. This observation is helpful in differenti-

ating congenital glaucoma from normal growth of the my-
opic eye. More recently, UBM has been used to evaluate the
anterior segment of eyes with congenital glaucoma (see
Chapter 8).27,28
Congenital glaucoma may also occur in Sturge-Weber
syndrome. In addition to measuring axial eye length, ultra-
sound can demonstrate the diffuse choroidal hemangiomas
that are often present in these eyes (see p 147).
ANGLE CLOSURE GLAUCOMA

Clinical findings of angle closure glaucoma include increased
intraocular pressure, pain, redness, corneal edema, blurred vi-
sion, and a mid-dilated pupil. In these patients, gonioscopy
typically shows a very narrow or closed anterior chamber an-
gle. Corneal edema and, in some cases, cataract formation
may prevent adequate visualization of the fundus.
In eyes with primary acute angle closure glaucoma, ul-
trasound can be used to document certain anatomic char-
acteristics. These include a relatively shallow anterior
chamber and short axial eye length, as well as diffuse thick-
ening of the retinochoroid layer and sclera. In addition,
these eyes often have somewhat thickened lenses, especially
in the presence of cataractous changes. The echo graphic
findings may also be valuable for identifying eyes with po-
tentially occludable anterior chamber angles.
Ultrasound can also be helpful in identifying the many
Figure 7-2 Congenital glaucoma. External photograph shows causes of secondary angle closure glaucoma, including in-
markedly enlarged cornea. traocular tumors (see p 212), phacomorphic glaucoma (see
GLAUCOMA 211
below), malignant glaucoma (see p 216), ciliochoroidal ef-

fusion (see p 216), intraocular hemorrhage (see p213), iris
bombe (see p 213), retinopathy of prematurity (see p 184),
and persistent hyperplastic primary vitreous (see p 185).
Newer ultrasound technology, using higher frequency
probes, allows a more detailed examination of anterior seg-
ment structures (see Figure 2-33 and Chapter 8). As a re-
B
sult, the mechanisms of angle closure glaucoma are now
better understood. These newer techniques can also aid in
the diagnosis of certain types of angle closure glaucoma,
such as plateau iris (see p 229).
SECONDARY GLAUCOMA
There are many causes of secondary glaucoma in which ul- Figure 7.3'Phacolytic glaucoma in eye with hypermature
trasound can be useful for both diagnosis and management cataractous lens. A, Slit-lamp photograph shows complete opaci-
(Box 7-1). fication of anterior chamber secondary to, leakage of proteinaceous
lens material. B, Immersion vertical axial B-scan of anterior s.eg-
ment demonstrates deep, clear anterior chamber (A) and a thin,
Lens Abnormalities cataractous lens with inferior displacement of the lens nucleus
Phacolytic Glaucoma (curved arrow) within the otherwise liquefied cortical material.
M, Methylcellulose within scleral shell. P, Posterior lens capsule.
Phacolytic glaucoma is a form of open angle glaucoma as-
sociated with a hypermature cataractous lens .. Clinically,
these patients present with an acute onset of monocular pain block. An immersion, ultrasound examination can detect
and redness. Slit-lamp examination of the anterior chamber ·shallowing of the anterior chamber and thickening of the
shows a heavy flare and the presence of small crystals in the cataractous lens (Figures 7-4 and 7-5).
aqueous. In some cases, however, complete opacification of
the anterior chamber occurs. It has been suggested that the Dislocated Lens
material in the anterior chamber is a macrophagic response Dislocation of the lens anteriorly into the pupil or anterior
to extruded lens protein. 32 An immersion ultrasound exam- chamber may result ill. acute narrow angle glaucoma sec-
ination usually demonstrates a thinner than normal lens and ondary to pupillary block. If the G~ornea becomes opacified
may also show displacement of the nucleus within the oth- as a result of corneal edema, ultrasound can demonstrate
erwise liquefied cortical material (Figure 7-3). the anterior displacement of the lens and rule out any pos-
A less common variation of phacolytic glaucoma occurs teriorsegment abnormalities (see Figure 7-5).
when the lens has dislocated posteriorly into the vitreous
and has undergone phacolysis. Vitreous reaction may pre-
Pigmentary Glaucoma
vent adequate visualization, and ultrasound can dem,on-
strate the hypermauire nature of the dislocated lens (see Pigmentary glauccitna appears to occur secondary to pig-
Figure 5-77). mentary dispersion, presumably caused by mechanical rub-
bing of the lens zonules against the posterior iris pigment
Pha,comorphic Glaucoma (Intumescent Lens) epithelium. 32 UBM has gready contributed to the under-
Swelling of a cataractous lens produces phacomorphic glau- standing of the pathophysiology of this disorder and its
coma, a type of angle closure glaucoma with pupillary managem.ent (see p 230).
212 THE GLOBE
A B
Figure 7-4 Phacomorphic glaucoma. Axial immersion B-scan (A) and immersion A-scan axial
eye-length measurement (B) demonstrate thickened cataractous lens (L) and shallowing of the
anterior chamber (A). M, Methylcellulose within scleral shell; a170W, cornea; P, posterior lens
capsule; R, retina.
A B
Figure 7-5 Anterior dislocation of intumescent lens. A, Immersion axial B-scan shows
markedly thickened, densely cataractous lens dislocated anteriorly with complete flattening of the
anterior chamber. Large, serous ciliochoroidal detachments (C) are also shown. M, Methylcel-
lulose within scleral shell; arrow, cornea; P, posterior lens capsule, ON, optic nerve. B, Contact
axial B-scan better demonstrates large ciliochoroidal detachments that caused the anterior dis-
location of the intumescent lens.
Intraocular Tumors Anterior Segment Tumors

Glaucoma is associated with a variety of intraocular tu- Benign and malignant tumors of the anterior segment may
mors, the most common of which is uveal melanoma. The cause a secondary glaucoma. Primary cysts of the iris pig-
mechanism of glaucoma depends on whether the tumor in- ment epithelium, although rarely associated with secondary
volves the anterior or posterior segment. Glaucoma caused angle closure glaucoma, can be detected and differentiated
by anterior segment tumors may be secondary to direct in- from solid tumors with ultrasound (see pp 170 and 232).
vasion of the tumor into the anterior chamber angle or to Secondary cysts (epithelial implantation cysts) may occur
angle closure. Posterior segment tumors, on the other after surgery or trauma and are more likely than are pri-
hand, usually produce a form of angle closure glaucoma mary cysts to cause glaucoma (see p 170). Solid benign tu-
when they become very large and displace the lens/iris di- mors of the anterior segment that can be associated with
aphragm anteriorly. glaucoma include iris nevi, melanocytomas, benign adeno-
Chapter 7 GLAUCOMA 213
mas, and uveallyrnphoid hyperplasia (with iris and/or cil-

iary"body involvement) (see Chapter 5). Uveal melanoma
is the most common malignant tumor of the anterior seg-
ment, although metastatic carcinoma and lymphoma can
occur as well. A unique form of ciliary body melanoma, in
which the tumor invades the ciliary body in a circumferen-
tial manner, has been referred to as ring melanoma.
Posterior Segment Tumors
Large choroidal melanoma is the most common type of
posterior segment tumor that results in glaucoma. Ultra-
sound can often show a very large tumor pressing against
the lens (see Figure 5-87). In rare cases, metastatic tumors
to the choroid are associated with secondary glaucoma (see
Figure 5-44).
Intraocular Tumors of Childhood
RETINOBLASTOMA Figure 7-6 Anterior chamber hyphema and iris bombe. High-
resolution axial B-scan (20 MHz) shows shallow hyphema (H) and
When a child presents with glaucoma in the presence of forward bowing of iris (J). Note adhesion of iris at pupillary
opaque ocular media, the diagnosis of retinoblastoma should margins (straight arrows) to anterior lens capsule (curved arrows).
be considered. The causes of glaucoma in patients with C, Cornea; open arrow, surface of probe balloon tip on cornea.
(Courtesy Rhonda Waldron, MMSc, COMT, Adanta, Georgia.)
retinoblastoma include neovascularization of the iris, angle
closure caused by massive retinal detachment, and obstruc-
tion of the anterior chamber angle by inflammatory cells or
necrotic tumor tissue. 32 Ultrasound has proved to be very ous hemorrhage, as well as from massive subvitreal, sub-
reliable in the diagnosis of retinoblastoma, largely because retinal,l1 or suprachoroidal hemorrhage.
of the presence of calcium within the tumor (see
p 180). In addition, ultrasound can differentiate retinoblas- Hyphema
toma from other causes ofleukokoria that may be associated A large blood clot in the anterior chamber can mechani-
with glaucoma, including Coats' disease (see p 187), persis- cally occlude the trabecular meshwork, producing sec-
tent hyperplastic primary vitreous (PHPV) (see p 185), and ondary open angle glaucoma. Ultrasound can be especially
retinopathy of prematurity (ROP) (see p 184). The most helpful when corneal blood staining prevents visualization
common cause of glaucoma in these cases is secondary angle of the anterior and posterior segments (Figure 7-6; see also
closure. In Coats' disease, the angle closure may be sec- Figure 4-1).
ondary to a massive exudative retinal detachment that causes
shallowing of the anterior chamber. In both ROP and Vitreous Hemorrhage
PHPV; shallowing of the anterior chamber may be caused In longstanding vitreous hemorrhage, red blood cells de-
by contracture of retrolental fibrous membranes. 32 generate and become less pliable (ghost cells). In addition,
macrophages can ingest the contents of the red blood cells.
MIEDULLOEPITHELIOMA When the anterior hyaloid is disrupted, these ghost cells
Medulloepitheliomas are primary tumors of childhood that and macro phages can enter the anterior chamber and ac-
arise from the nonpigmented ciliary epithelium. A large num- cumulate in the trabecular meshwork, causing elevation of
ber of these cases are associated with glaucoma. Ultrasound the intraocular pressure (hemolytic/ghost cell glaucoma).
usually shows a well-defined ciliary body mass (see p 187). Ultrasound can be useful for the diagnosis of this disorder
by demonstrating diffuse opacities in the vitreous cavity. It
NEUROFIBROMATOSIS should be noted that in the vitrectomized eye, a very high
Glaucoma can be associated with neurofibromatosis, espe- gain setting may be needed to detect diffuse, mild hemor-
cially the peripheral form that includes not only intraocular rhage in the vitreous cavity (see Figure 4-45, C and D).
tumors but also plexiform lesions of the lid (see p 315). In-
traocular lesions can involve the iris, ciliary body, and Subvitreal Hemorrhage
choroid (see p 155). Occasionally, a massive subvitreal hemorrhage can push the
vitreous body forward, causing shallowing of the anterior
chamber and secondary angle closure glaucoma. Ultra-
Intraocular Hemorrhage
sound can demonstrate the very dense nature of the subvit-
Intraocular hemorrhage can cause glaucoma in a variety of real hemorrhage and forward displacement of the posterior
ways. This can occur from hyphema or longstanding vitre- hyaloid (see Figure 3-10).
214 THE GLOBE
number of conditions.!2 These include uveal effu~on syn-

drome, nanophthalmos, toxic reaction to systemic medica-
tions, arteriovenous fistulae (see below), and certain inflam-
matory disorders (see p 198). Angle closure secondary to
ciliochoroidal effusion has also been shown to occur after
scleral buckling procedures (see p 109), glaucoma surgery
A (see p 216), and panretinal photocoagulation.
Uveal Effusion Syndrome
Uveal effusion syndrome is characterized by spontaneous
uveal effusions that produce thickening and detachment of
the choroid and ciliary body, as well as· serous retinal de-
tachment. Glaucoma can occur if angle closure is present.
In these cases, ultrasound typically shows a moderately
short eye, diffusely thickened sclera, and detachment of the
choroid and retina (see Figure 3-69).
Nanophthalmos
B Nanophthalmos may present with ciliochoroidal detach-
ments, similar to those seen in uveal effusion syndrome.
N anophthalmos is characterized by a very small eye with a
shallow anterior chamber and unusually thick sclera. These
eyes have a tendency to develop postoperative or sponta-
neous uveal effusions, which may cause a pupillary block
and subsequent angle closure glaucoma. Ultrasound of a
Figure 7-7 Massive subretinal hemorrhage secondary to age- nanophthalmic eye typically demonstrates a short axial
related macular degeneration producing angle closure glaucoma. length and thickened sclera (see p 82).
Axial (A) and longitudinal (B), B-scans show a total, closed,
funnel-shaped retinal detachment (arrows) extending between pos-
terior surface of the lens and the optic nerve (ON). Note dense Toxic Reaction to Systemic Medications
subretinal opacities.
A number of cases have been reported in which a toxic re-
action to systemic medications produced bilateral, shallow
Subretinal and Suprachoroidal Hemorrhage ciliochoroidal detachments (Figure 7-8). This resulted in
Massive subretinal and/or suprachoroidal hemorrhage can shallowing of the anterior chamber, increased myopia, and
displace the iris-lens diaphragm anteriorly, producing a sec- in some cases, angle closure glaucoma. Ultrasound was es-
ondary angle closure glaucoma. Ultrasound can demon- sential for documenting the etiology of the clinical findings
strate these detachments and the underlying hemorrhage. in these unusual cases.34
The most common cause of massive subretinal hemorrhage
is age-related macular degeneration (Figure 7-7; see also
Elevated Episcleral Venous Pressure
p 159). Other causes include subretinal hemorrhage associ-
ated with intraocular tumors, the most common of which is A rise in episcleral venous pressure can produce an in-
choroidal melanoma. Although rare, massive subretinal crease in intraocular pressure, resulting in glaucoma. 29
hemorrhage secondary to a metastatic lung carcinoma to Conditions known to produce this phenomenon include
the choroid can also occur (see Figure 5-44). arteriovenous fistulae and malformations (see pp 355 and
Massive suprachoroidal hemorrhage usually develops ei- 365), thyroid ophthalmopathy (see p 396), and Sturge-
ther at the time of intraocular surgery (expulsive hemor- Weber syndrome (see p147).
rhage) or after severe penetrating trauma. Delayed supra-
choroidal hemorrhage can also occur following intraocular Arteriovenous Fistulae and Malformations
surgery, most often after glaucoma surgery. The ultrasound Arteriovenous fistulae and malformations include carotid-
characteristics of suprachoroidal hemorrhages are explained cavernous and dural-cavernous sinus fistulae and arteriove-
later in this chapter, as well as in Chapters 3 and 4. nous malformations of the orbit. These conditions produce
increased arterial blood flow in the orbit, resulting in orbital
soft tissue congestion and venous stasis. 1,29 Clinically, these
Ciliochoroidal Effusion
patients may present with proptosis, characteristic dilatation
Ciliochoroidal detachment can cause a forward rotation of of episcleral blood vessels, and frequently, increased in-
the lens-iris diaphragm and angle closure glaucoma in a traocular pressure. Choroidal effusions with secondary angle
synechiae, resulting in increased intraocular pressure.

Posterior synechiae can produce iris bombe and sec-
ondary angle closure glaucoma. Angle closure can also be
caused by ciliochoroidal detachments associated with
posterior scleritis or by inflammatory infiltration of the
ciliary body in disorders such as Vogt-Koyanagi-Harada
A syndrome (VKH) (see p 200) and sympathetic ophthalmia
(see p 201).
Anterior Uveitis
Anterior uveitis can produce anterior synechiae that may
lead to secondary angle closure. These anterior synechiae
are best demonstrated with high resolution B-scan (see
p 230). Posterior synechiae can also develop, producing
adhesions of the iris to the crystalline or pseudophakic
lens. This can result in iris bombe and angle closure glau-
coma, secondary to pupillary block. Ultrasound can
demonstrate the anterior bowing of the iris and can rule
B
out an underlying cyst or solid mass (see Figure 7-6 and
Chapter 8).
Posterior Scleritis
Posterior scleritis can produce choroidal effusions, resulting
in angle closure glaucoma. Ultrasound can show the dif-
fusely thickened sclera typically seen in this disorder, as well
Figure 7-8 Annular ciliochoroidal detachments secondary to as the anterior effusions (see p 195 and Figure 6-11).
toxic reaction from systemic medication. Transverse (A) and lon-
gitudinal (B) B-scans demonstrate shallow, annular, peripheral cil- Vogt-Koyanagi-Harada Syndrome/
iochoroidal detachments (arrows). The patient also had shallow
anterior chambers, increased myopia, and secondary angle closure Sympathetic Ophthalmia
glaucoma. Both VKH and sympathetic ophthalmia are characterized
by diffuse inflammatory infiltration of the choroid. When
the uveal inflammation involves the periphery of the eye,
closuJ;"e can also occur in these patients. Ultrasound can be thickening of the peripheral choroid and ciliary body can
useful both for diagnosing these disorders and for demon- cause anterior rotation of the ciliary body and iris. This can
strating the presence of choroidal effusions. lead to shallowing of the anterior chamber and secondary
angle closure glaucoma. Ultrasound is an ideal method of
Thyroid Ophthalmopathy showing the diffuse thickening of the choroid (see Figure
Increased intraocular pressure can develop as a result of el- 6-15) and ciliary body (see p 77).
evated episcleral venous pressure in patients with thyroid
ophthalmopathy. This increased venous pressure is caused
NORMAL-TENSION GLAUCOMA
by the obstruction of venous outflow produced by orbital
congestion. Inflammation and fibrosis of the extraocular Although the pathogenesis of glaucomatous damage in
muscles can also contribute to increased intraocular pressure normal-tension glaucoma is unknown, in recent years,
in patients with thyroid ophthalmopathy, leading to a me- color Doppler ultrasound has provided an increased un-
chanical restriction of ocular motility and a rise in intraocu- derstanding of this disorder. 17 ,19 The use of color Doppler
lar pressure when eye movement is attempted (especially imaging to measure blood flow velocities in the ophthalmic
with upgaze).29 Ultrasound has proved to be very effective artery, central retinal artery, and posterior ciliary arteries
for evaluating this disorder, particularly when the patient has shown that eyes with normal-tension glaucoma have
does not present with the typical signs of thyroid ophthal- an increased vascular resistance distal to the ophthalmic
mopathy. The findings usually include bilateral extraocular artery. This implies that the glaucomatous damage in these
muscle thickening and orbital soft tissue swelling (see p 396). patients may have a vasogenic etiology resulting in reduced
blood flow to the optic nerve. Ongoing studies utilizing
color Doppler imaging may further clarify the pathogene-
Inflammatory Diseases
sis of normal-tension glaucoma and may assist in the
Inflammatory diseases can produce secondary glaucoma development of new treatments for this disorder (see
in a number of ways. Anterior uveitis can lead to anterior Chapter 14).
216 THE GLOBE
COMPLICATIONS OF GLAU(:OMA SURGERY

Certain surgical complications that are unique to or that
occur more commonly after glaucoma/surgery include
malignant glaucoma, hypotony, and choroidal hemor-
rhage. Endophthalmitis secondary to infected filtering
blebs can also occur. 5,20 Ultrasound has become an indis-
pensable tool for the evaluation and management of these
complications.
Malignant Glaucoma
Shallowing of the anterior chamber associated with nor-
mal or high intraocular pressure sometimes presents as a .
complication following glaucoma surgery. Traditionally
the diagnosis of malignant glaucoma has been made once
Figure 7-9 Ciliary body detachment. High resolution B-scan
other possible causes of these findings have been excluded (20 MHz) (longitudinal view) through ciliary body and peripheral
(i.e., suprachoroidal hemorrhage and pupillary block). This . aspect of anterior chamber shows significant ciliary body detach-
complication is generally believed to be a result of misdi- ment (CD). Note the presence of echoes within the supraciliary
rection of aqueous into the vitreous cavity. The misdi- space indicatinghemonhage and/or inflammation. C, Cornea; ar-
rected aqueous is thought to produce pockets of fluid be-· row, anterior chamber angle; I, iris; P, pars plicata; S, sclera. (Cour-
tesy Rhonda Waldron, MMSc, COMT, Atlanta, Georgia.)
hind the vitreous body, displacing the vitreous forward and
resulting in shallowing of the anterior chamber and in-
creased intraocular pressure. No imaging technique, in-
Hypotony
cluding ultrasound, has been able to demonstrate this phe-
nomenon. One echographic study, however, of patients Although low intraocular pressure commonly Occurs after
with a clinical diagnosis of malignant glaucoma showed glaucoma surgery, persistent hypotony can lead to serious
that all of the patients demonstrated peripheral annular cil- ocular sequelae. Low pressure is often associated with a
iochoroidal detachments. lO The investigators concluded shallow anterior chamber that, in most cases, is due to
that these p~ripheral detachments may simulate aqueous overfiltration of aqueous. This shallowing of the chamber,
misdirection. however, can also be secondary to serous choroidal detach-
ments resulting from the low intraocular pressure. Chronic
hypotony can lead to macular abnormalities, including
Annular Ciliochoroidal Detachment
edema, striae and folds ("hypotony maculopathy").13,18
Annular ciliochoroidal detachments have been found as a In patients with hypotony and opaque ocular media, ul-
postoperative complication of glaucoma surgery. They are trasound can docUment the presence of choroidal detach-
associated with a shallow anterior chamber and normal to ments (see p 74). In addition, chronic hypotony has been
high intraocular pressure, apparently caused by anterior ro- shown to cause a decrease in axial eye length measurements
tation of the ciliary body-iris diaphragm. The clinical pre- (see Chapter 10). Other echographic findings in these
sentation of these detachments is similar to that of malig- eyes include diffuse thickening of the retinochoroid layer
nant glaucoma (aqueous misdirection) and cap be difficult and sclera. Ultrasound examination of the macula may,
or impossible to detect with ophthalmoscopy. Ultrasound is however, show more pronounced thickening of the
the key tool for confirming the diagnosis of annular pe- retinochoroid layer and/or shallow focal detachment of the
ripheral ciliochoroidal detachments (although concurrent retina, retinal pigment epithelium or choroid (Figure 7-10).
aqueous misdirection cannot be excluded).lo These periph- Maculopathy following hypotony may persist even after
eral detachments can usually be imaged using contact tech- normal intraocular pressure has been restored. Anecdotal
niques by directing the sound beam to the far peripheral experience with ultrasound, in patients with chronic hy-
aspect of the eye (see Figure 7-8 and Figure 3-61). Immer- potony, has shown that the scleral thickening remains even
sion techniques, however, using both conventional and after the pressure increases 15 (Figure 7-11). Further stud-
UBM instrumentation, may more elegantly demonstrate ies may help determin~ the period of time that an eye can
the ciliary body detachment (see p 230 and Figure 3-62). A tolerate low intraocular pressure before scleral thickening
recently introduced high resolution B-scan (20 MHz) and maculopathy become irreversible.
probe, using a contact stand-off technique; also appears to Chronic hypotony, if not reversed, will ultimately lead to .
be an easy, safe, and effective method of demonstrating the marked shrinkage of the eye. This, in turn, can produce atro-
ciliary body detachments in these cases (Figure 7-9). The phy and degeneration of intraocular structures with
medical or surgical management of these detachments can calcification of the posterior ocular coats. The ultrasound
be readily monitored with ultrasound. findings for this process, phthisis bulbi, can be found on p 114.
217
Figure 7-10 Hypotony maculopathy in two different patients. Vertical transverse (A) and hor-
izontal axial (B) B-scans through macula show diffuse thickening of retinochoroid layer and
sclera (S) with a focal, dome-shaped membrane (a/70W). These membranes may represent focal
detachment of the retina, pigment epithelium, or choroid. ON, optic nerve.
Figure 7-11 Irreversible hypotony maculopathy. A patient with bilateral high myopia had
chronic hypotony in the right eye for approximately one year. In spite of normalization of in-
traocular pressure, hypotony maculopathy persisted. A, Axial B-scan of right eye obtained at time
of normalization of pressure, demonstrates diffuse thickening of retinochoroid layer and sclera in
peripapillary region (straight a/70WS) including the macula (curved a77ow). B, Axial B-scan of fellow
left eye shows significantly longer globe and no appreciable thickening of the retinochoroid layer
and sclera. Axial length measurements were 25 mm in the right eye and 28 mm in the left eye.
218 THE GLOBE
extended into the posterior segment. 4,35 In such situations,

ultrasound can be used to evaluate the posterior segment
for concurrent signs of inflammation (e.g., vitreous opaci-
ties and membranes, retinal, and choroidal detachments,
see Chapters 3 and 6).
Potential Error in Intraocular Lens Calculations

Successful glaucoma filtering surgery often results in a short-
ened axial eye length measurement due to the lower in-
traocular pressure. This can lead to challenges in determin-
ing the intraocular lens (IOL) power if subsequent cataract
surgery with IOL placement is planned. The problem in
these situations is that if the pressure in the eye increases fol-
lowing the cataract procedure, the axial length may also in-
Figure 7-12 External photograph of infected filtering bleb. crease, resulting in an unanticipated postoperative myopia.
(Courtesy Dr. Don Minckler, Los Angeles, California.) One study compared axial length measurements pre- and
post-trabeculectomy as well as following cataract surgery.6
This small series of patients showed that the axial length de-
Choroidal Hemorrhage
creased after successful trabeculectomy surgery but then in-
Although massive suprachoroidal hemorrhage (i.e., expul- creased back toward pre-trabeculectomy values following
sive hemorrhage) can be an intraoperative complication of the cataract surgery. There are no studies to date, however,
any type of intraocular surgery (see Figure 4-34), delayed that address the changes in axial length that occur in eyes
hemorrhagic choroidal detachments most commonly de- with chronic hypotony following cataract surgery.
velop following glaucoma filtering procedures. 16 These de- As previously noted, selection of the IOL power can be
layed lesions usually present within the first few postoper- quite challenging in patients who have undergone a tra-
ative days but can occur significantly later. The frequency beculectomy or other types of glaucoma filtering surgery. A
of these hemorrhages appears to increase in eyes that have determination needs to be made in these patients as to the
undergone previous intraocular surgical procedures such as likelihood that the axial length will increase following
cataract extraction and/or vitrectomy. They are usually ac- cataract surgery. In patients with very low intraocular pres-
companied by the onset of severe ocular pain, redness, and sure that has persisted for a long period of time, the axial
in some cases, increased intraocular pressure. The echo- length may not change significantly following cataract
graphic findings for choroidal hemorrhages have been pre- surgery. On the other hand, eyes with moderate lowering of
viously described (see p 75). Massive hemorrhagic choroidal pressure following trabeculectomy may revert back to pre-
detachments may demonstrate apposition (kissing) in the trabeculectomy axial length values following cataract
central vitreous cavity (see p 104). surgery. As a result of these possible scenarios, adjustments
Serial ultrasound examinations can be performed to in the IOL power to be used may be necessary.
monitor for regression of the choroidal detachments and
status of the retina when the patient is managed conserva-
GLAUCOMA-FILTERING IMPLANT DEVICES
tively. When surgical intervention is contemplated, how-
(SHUNTS)
ever, the ultrasound documentation of suprachoroidal
blood clot lysis (see p 106 and Figure 4-38) can be useful The surgical implantation of drainage devices has been
for timing the surgical procedure. Studies have shown that used increasingly in recent years in the management of
the average time required for clot lysis is 14 days.? complicated glaucomas. Several somewhat similar devices
are currently used. Each consists of a tube that extends
from the anterior chamber (or in some cases the vitreous
Endophthalmitis
cavity) to a plate located on the sclera, beneath the con-
Endophthalmitis can occur after any type of intraocular junctiva and Tenon's capsule. These devices differ in size
surgery. However, patients who have undergone tra- and shape, as well as in the materials from which they are
beculectomy have a higher incidence of endophthalmitis af- constructed. They either have an open, unobstructed
ter the immediate postoperative period because of subse- drainage tube or a pressure-regulating valve. When a de-
quent infection of the filtering bleb. Inflammation of the vice does not include a pressure valve, an absorbable suture
filtering bleb (blebitis)4 (Figure 7-12) and signs of anterior is typically placed around the drainage tube at the time of
segment inflammation may suggest but do not necessarily surgery. Absorption of the suture over time allows a gradual
indicate the presence of endophthalmitis. 2,5 Conservative lowering of the intraocular pressure to prevent complica-
management can be undertaken if the inflammation has not tions that can occur from a sudden drop in pressure.
A
c
Figure 7-13 Molteno implant with bleb. B- and

A-scan echograms of fluid bleb surrounding Molteno
implant. Transverse B-scan (A) shows lateral extent of
implant with fluid (F) located both above and beneath
the plate (arrow). S, Sclera. Longitudinal B-scan (B)
B shows anteroposterior extent of implant. ON, Optic
nerve. Note flattening of the ocular wall by bleb in
A and B. A-scan echo gram (C) demonstrates low re-
flectivity of fluid (F) surrounding highly reflective plate
(arrow).
After the plate is inserted, a capsule forms around it, thus

providing a potential space in which a fluid bleb can be con-
tained. Because the plate is often placed in a relatively pos-
terior position on the globe, the bleb can be difficult to ob-
serve clinically. In such situations, ultrasound can be used to
image the plate and determine if a bleb has been created.23
On B-scan, the bleb appears as an echolucent region
adjacent to (underlying and/or overlying) the plate. 14 ,23
Flattening or indentation of the adjacent sclera is some-
times noted. B-scan localization of the bleb and plate is
best achieved with the use of both transverse and longitu-
dinal scans (see Chapter 2). The transverse view shows the
lateral extent of the plate (for example, from the 12:30 to Figure 7-14 Molteno plate without bleb. Transverse B-scan
2:30 clock positions), whereas the longitudinal view shows highly reflective plate (black arrow) adjacent to sclera (S).
Note thin areas of shadowing (white arrows) produced by edges of
demonstrates the posterior extent relative to the optic plate. (From Lloyd MA, Minckler DS, Heuer DK: Echographic
nerve. On A-scan, the plate is represented as a highly evaluation of glaucoma shunts. Ophthalmology 1993;100:921.)
reflective spike just posterior to the scleral spike. The fluid
bleb exhibits very low (cystlike) internal reflectivity in con-
trast to the highly reflective spike from the plate (Figure 7- The echographic detection of a bleb correlates well with
13). Localization of the plate can be challenging if no bleb . the patency of a drainage tube, although bleb size has not
is present because the highly reflective plate (e.g., Molteno been shown to correlate with intraocular pressure. 23 In some
implant) may be difficult to distinguish from the normal cases, very large blebs are associated with high intraocular
highly reflective sclera and orbital soft tissues. For the pressure, and conversely, shallow blebs maybe present when
Molteno implant, plate location is best identified by not- the pressure is low. Nevertheless, the echographic findings
ing shadowing produced by the thick edges of the plate are very important for the postoperative management of
(Figure 7-14). these patients. For example, if the intraocular pressure is
220 THE GLOBE
Figure 7-16 Ahmed implant without bleb. Transverse B-scan

shows lateral extent of silicone plate (black arrows). Note dense
echo in center of plate (curved arrow) representing implant valve.
Tif7hite arrows, Thin regions of shadowing produced by edges of
plate.
3
vice developed. 25 ,26 This device was subsequently re-

designed with two plates to increase the surface area of the
bleb. With the double-plate Molteno implant, ultrasound
can demonstrate a plate and bleb adjacent to the globe both
supratemporally and supranasally.
Figure 7-15 Baerveldt implant wjth bleb. A, Transverse B-scan Another drainage device currently in use is the Baerveldt
demonstrates thick, circumferential band representing silicone
implant. 33 In this implant, the plate is made of silicone (see
Baerveldt plate (white arrow). Echolucent region on either side of
band indicates fluid bleb. Note the scalloped appearance of the p 112); therefore it appears significantly thicker and less
bleb due to fibrous tissue growth through fenestration holes in reflective on ultrasound than the Molteno implant. As a re-
plate (black arrows). S, Sclera. B, Longitudinal B-scan shows plate sult, the plate is sometimes difficult to distinguish from the
(white arrow) and bleb extending posteriorly toward optic nerve surrounding bleb. The initial Baerveldt implants produced
(ON). On B-scan, the silicone Baerveldt plate normally appears very large blebs, often causing marked flattening of the
relatively echolucent as in B. The more echodense appearance in
A is due to a slightly oblique section to emphasize the scalloped globe. More recent versions of the Baerveldt implant have
nature of the bleb. been designed with multiple perforations of the plate.
These perforations allow fibrous bands to grow between
the bleb walls, thus limiting the size of the bleb. On B-scan,
the bleb created by these perforated plates has a scalloped
high and ultrasound detects no bleb, this may indicate that appearance (Figure 7-15).
the ligature has not absorbed or the drainage tube is The Ahmed implant, also made of silicone, has a pressure-
plugged or kinked. On the other hand, high pressure in the sensitive valve that eliminates the need for a slow releasing
presence of a bleb may indicate that the eye is in a hyper- ligature around the tube. s On B-scan, the Ahmed plate ap-
tensive, encapsulated bleb phase. This is a period of time, pears similar to the Baerveldt plate, although the contour of
usually 1 to 3 months postoperatively, when high pressure its anterior surface is somewhat irregular. The valve within
can occur in the presence of a functioning tube. However, the plate can also be demonstrated (Figure 7-16).
this could also mean that further medical or surgical treat- The Schocket tube shunt is a drainage device that uses a
ment is indicated. tube extending from the anterior chamber to a silicone
The absence of a bleb in the presence oflow intraocular band that completely encircles the globe. 3l In many cases,
pressure may indicate insufficient aqueous production, ex- the encircling band is already present from previous retinal
cessive flow around the tube, or detachment of the choroid detachment surgery (i.e., a scleral buckle; see p 109). Ul-
or retina. Alternatively, if the pressure is low and a bleb is trasound is generally not very effective in assessing the
present, there is likely to be excessive flow through the bleb function of the Schocket device because sound attenuation
walls. from the encircling band prevents adequate imaging of the
Several different drainage devices are currently being filtering bleb.
used in the treatment of complicated glaucomas. The single Anterior chamber hyphemas and/or hypopyons can pro-
plate Molteno implant was the first glaucoma filtering de- duce drainage of blood or inflammatory cells into a filtering
Tubes are sometimes inserted into the anterior vitreous

cavity through the pars plana rather than into the anterior
chamber. When this occurs, contact B-scan can often
demonstrate the anterior aspect of the tube (Figure 7-18).
REFERENCES
1. Atta HR, Dick AD, Byrne SF, et a1: Venous stasis orbitopathy-a clin-
iCal and echographic study. Br J OphthalmoI1996;80:129.
2. Ayyala RS, Bellows AR, Thomas:TY, et al: Bleb infections. Clinically
different courses of "blebitis" and endophthalmitis. Ophthalmic Surgery
and Lasers 1997;28:452. .
3. Bluth K: Ultrasonic biometry in congeriital glaucoma, in Hillman JS,
LeMay MM (eds): Ophthalmic Ultrasonography. D"ordrecht, Dr W
Junk, 1984, P 191.
Figure 7-17 Molteno implant with hemorrhagic bleb. Trans- 4. Brown RH, Yang LH, Walker SD, et al: Treatment of bleb infection
verse B-scan displays Molteno plate (black arrow) and blood within after glaucoma surgery. Arch OphthcilmoI1994;112:57.
the bleb (B). Note also diffuse hemorrhage within vitre.ous cavity 5. Ciulla TA, Beck AD, Topping TM et al: Blebitis, early endoph-
(V). (From Lloyd MA, Minckler DS, Heuer DK: Echographic thalmitis, and late endophthalmitis after glaucoma-filtering surgery.
evaluation of glaucoma shunts. Ophthalmology 1993;100:924.) Ophthalmology 1997;104:986.
6. Cashwell FL, Martin CA: Axial length decrease accompanying suc-
cessful glaucoma filtration surgery. Ophthalmology 1999;106:2308.
7. Chu TG, Cano MR, Green RL: Massive suprachoroidal hemor-
rhage with retinal apposition. Arch OphthalmoI1991;109:1575.
8. Coleman AL, Hill R, Wilson MR, et al: Initial clinical experience with
the Ahmed glaucoma valve implant. Am J OphthalmoI1995;102:894.
9. Darnley-Fisch DA, Byrne SF, Hughes JR, et al: Contact B-scan
echography in the assessment of optic nerve cupping. Am J Ophthal-
mol 1990;109:59.
10. Dugel PU, Heuer DK, Thach AB: Anmilar peripheral choroidal de-
tachment simulating aqueous misdirection after glaucoma surgery.
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11. EI Baba F, Jarrett WH, Harbin TS, et al: Massive hemorrhage com-
plicating age-related macular degeneration. Ophthalmology 1986;
93:1581.
12. Fourman S: Angle-closure glaucoma complicating ciliochoroidal de-
tachment. Ophthalmology 1989;96:646.
13. GassJDM: Hypotonymaculopathy, in BellowsJC (ed): Contemporary
Ophthalmology honoring Sir Stewart Duke-Elder. Baltimore, Williams
& WIlkins, 1972, p 343.
14. Green RL, Lloyd MA, Minckler DS, et al: Echographic evaluation of
Molteno implants. ARVO Abstracts. Invest Ophthalmol Vis Sci
Figure 7-18 Molteno tube through pars plana. Axial B-scan of 1991;2:746.
aphakic eye shows tube (straight arrow) extending from pars plana 15. Green RL: Chronic hypotony. Personal communication, 2001.
into anterior vitreous cavity. Multiple signals (curved arrow) ex- 16. Gressel MG, Parrish RK, Heuer DK: Delayed nonexpulsive supra-
tend posterior to tube. ON, Optic nerve. (From Lloyd MA, choroidal hemorrhage. Arch Ophthalmol1984; 102: 1757.
Minckler DS, Heuer DK: Echographic evaluation of glaucoma 17. Harris A, Sergott RC, Spaeth, et al: Color Doppler analysis of ocular
shunts. Ophthalmology 1993;100:924.) vessel blood velocity in normal-tension glaucoma. Am J Ophthalmol
1994;118:642.
18. Jampe! HD, Pasquale LR, DiBernardo CL: Hypotony macclopathy
following trabeculectomy with mitomycin C. Arch Ophthalmol
1992;110:1049.
bleb. When this occurs, B-scan can detect opacities within 19. Kaiser HJ, Schoetzau A, Stumpfig D, et al: Blood-flow velocities of
the extraocular vessels in patients with high-tension and. normal-
the bleb (Figure 7-17). tension primary open-angle glaucoma. Am J Ophthalmol 1997;
In some situations, clinical signs may suggest infection of 123:320.
the sclera adjacent to the filtering device. The ability of ul- 20. Kangas TA, Greenfield DS, Flynn HW; et al: Delayed-onset endoph- .
thalmitis associated with conjunctival filtering blebs. Ophthalmology
trasound to evaluate the sclera in this region is, however, 1997;104:746.
somewhat limited because of sound attenuation from the 21. Lieb WE, Flaharty PM, Sergott RC, et al: Color Doppler imaging
plate. However, the existence of an occult infection may be provides accurate assessment of orbital blood flow in occlusive carotid
artery disease. Ophthalmology 1991;98:548.
suggested by the demonstration of scleral and/or episcleral 22. Lieb WE: Color Doppler imaging of the eye and orbit. RBdiol Clin
thickening adjacent to the plate and bleb (see p 199 and NorthAm 1998;36:1059.
Figure 6-14). 23. Lloyd MA, Minckler DS, Heuer DK: Echographic evaluation of glau-
coma shunts. Ophthalmology 1993;100:919.
The tube placed in the anterior chamber with glaucoma 24. Massin M, Pellat B: Ultrasonic biometry in congenital glaucoma-
filtering devices usually cannot be imaged with traditional a clinical study, in HillmanJS, LeMay MM (eds): Ophthalmic Ultra-
contact B-scan instrumentation. High resolution B-scan in- sonography. Dordrecht, Dr WJunk, 1984, P 191.
25. Minckler DS, Heuer DK, Hasty B, et al: Clinical experience with the
struments, on the other hand, can often localize these tubes single-plate Molteno implant in complicated glaucomas. Ophthalmol-
and, in some cases, can determine whether they are patent. ogy 1988;95:1181.
222 THE GLOBE
26. Molteno ACB: New implant for drainaage in glaucoma: clinical triaL 32. Shields, B: Textbook of Glaucoma. ed 4, Baltimore, Williams & Wilkins,
Br J Ophthalmoll969;53 :606. 1998.
27. Pavlin C], Foster FS: Ultrasound Biomic7'osCOpy of the Eye. New York, 33. Sidoti PA, Dunphy TR, Baerveldt G, et al: Experience with the
Springer-Verlag, 1995. Baerveldt glaucoma implant in treating neovascular glaucoma. Opb-
28. Pavlin C], Foster FS: Ultrasound Biomicroscopy: high-frequency ul- thalmology 1995;102:32.
trasound imaging of the eye and microscopic resolution. Radiol Clin 34. Soylev MF, Green RL, Feldon SE: Choroidal effusion as a mecha-
NorthAm 1998;36:1059. nism for transient myopia induced by hydrochlorothiazide and tri-
29. Phelps CD, Thompson HS, Ossoinig KC: The diagnosis and prog- amterene. Am J OpbthalnzoI1995;120:395.
nosis of atypical carotid-cavernous fistula (red-eyed shunt syndrome). 35. Wolner B, Leibmann ]B, Sassan]W, et al: Late bleb-related endoph-
Am J OphthalmoI1982;93:423. thalmitis after trabeculectomy with adjunctive 5-fluorouraciL Opb-
30. Sampaolesi R, Caruso R: Ocular echometry in the diagnosis of con- tbalnzology 1991;98:1053.
genital glaucoma. Arch OphthalmolI982;100:574.
31. Schockett SS, Lakjanpal V; Richards RD: Anterior chamber tube
shunt to an encircling band in the treatment of neovascular glauco-
mas. Ophthalmology 1982;89:1188.
Charles J. Pavlin, F. Stuart Foster
Ultrasound Biomicroscopy
of the Eye
The use of ultrasound frequencies in the 40 to 100 MHz tern, the lateral resolution can be related via diffrac-
range is a relatively new development in ultrasound imag- tion theory to the full width of the ultrasound beam at
ing of the eye. This technique has been developed in the half maximum ampli~de (FWHM) and is given by the
authors' laboratories over the past several years,19,23,29 pro- equation:
gressing from the theoretical description of the basic sci-
FWHM = cf/(lJ d) = A (f-number) (1)
ence required, past the first in vitro experiments in eye bank
eyes, to the construction of an instrument capable of clini- where c is the speed of sound, f is the focal length of the
cal use. Investigators have established a broad clinical ex- transducer, lJ is the frequency of ultrasound, d is the diam-
perience with this instrument in normal patients and pa- eter of the focused transducer, A is the wave length, and
tients with ocular disease. The term ultrasound biomicroscopy f-number is the ratio of the focal length to the diameter of
(UBM) is applied to this technique because of its similarities the transducer. Figure 8-1 represents a plot of resolution as
to optical biomicroscopy, i.e., the observation of living tis- defined by equation 1 for transducers with f-numbers of
sue at microscopic resolution. This chapter will summarize 1.0,2.0, and 4.0. A typical ophthalmic transducer with a
the theoretical basis of the technology and illustrate the ap- frequency of 10 MHz and an f-number of 4.0 would have
plication of this tool in clinical ophthalmology and oph- lateral resolution of 600 /-Lm at the focus (Figure 8-1, point
thalmic research. a). Equation 1 allows the examiner almost unlimited free-
dom in achieving arbitrarily high resolution by simply se-
THEORETICAL CONSIDERATIONS AND lecting the appropriate frequency. For example, to achieve
a 60 /-Lm resolution, an operating frequency of 60 MHz
DEVELOPMENT OF THE ULTRASOUND
and an f-number of 2.0 could be chosen, as shown in Fig-
BIOMICROSCOPE
ure 8-1, point b. This is approximately 10 times the resolu-
Mechanical waves and vibrations occur over a wide range of tion obtained with conventional ophthalmic ultrasound
frequencies called the acoustic spectrum. This spectrum ex- instrumentation.
tends from the familiar audible range (10 to 20,000 Hz) to The trade-off for this increase in resolution is a loss of
the range of phonons (> 10 12 Hz), which comprise the vi- penetration. All human tissues exhibit ultrasound attenua-
brational states of matter. This chapter considers the de- tion coefficients that increase with frequency. Assuming an
velopment and application of a new class of ultrasound attenuation coefficient of 0.5 dB/mm MHz, which is con-
imaging systems that use very high frequency ultrasotmd in sistent with typical soft tissues,8 the maximum penetration
the range from 40 to 100 MHz. Such systems have pro- that could be achieved for a 10 MHz system is approxi-
vided subsurface detail with resolution that approaches that mately 50 mm for an 80 dB dynamic range. For the 60
of optical microscopy and is not available using any other MHz system, penetration is only 5 mm (Figure 8-2). This
imaging means. reinforces the need to optimize transducer sensitivity and
performance in UBM systems development.
Resolution
Scanner Design
The current limits of clinical imaging result from
the need to provide maximum resolution versus the need In an ultrasound biomicroscope, essential component
for the ultrasound beam to penetrate the eye and, to a blocks are identical to those of a conventional B-mode
certain extent, the orbit. In an ultrasound imaging sys- imaging system except that the operating frequency is
223
224 THE GLOBE
10000
(ij' 1000
c:
...u
0
g
til
c:
0
:;::l
::I
'0
til
Q)
a:
100
Frequency (MHz)
Figure 8-1 Plot of resolution vs. frequency for transducers with various f-numbers. (From
Pavlin C], Foster FS: Ultrasound Biomicroscopy of the Eye. New York, Springer Verlag, 1994, p 14.)
1000
100
E
.sc:
0
:;::l
......
ttl
Q)
c:
Q)
a..
10
.............. -: ......... .
1 L -_ _-L~~_L~~~_ _~-L~~~~____
1 10 100
Frequency (MHz)
Figure 8-2 Plot of depth of penetration vs. frequency for a system with a dynamic range of 80
dB. (From Pavlin C], Foster FS: Ultrasound Biomicroscopy of the Eye. New York, Springer Verlag,
1994, p 14.)
Chapter 8 ULTRASOUND BIOMICROSCOPV OF THE EVE 225
Transducers
~ 5mm -1 SMA barrel

The development of high-frequency transducers has been
central to the progress achieved in ultrasound biomicroscopy.
The piezoelectric polymer polyvinylidene diflouride (PVDF)
connector
and copolymer polyvinylidene diflouride/triflouroethylene
materials are used for external imaging applications such as
the eye (Figure 8-3). Such transducers produce short, wide
bandwidth pulses with good sensitivity. Note that the high-
est resolution, defined as FWHM in equation 1, is only
achieved at the focus. The depth of field (DOF), defined as
the range of depth over which the beam remains well fo-
cused, must also be considered. In general the DOF increases
with the square of the f-number. F-numbers ranging from
Center pin 2 to 4 represent a good compromise between DOF and res-
olution. Typical UBM transducers have f-numbers of 2.0
to 3.0. The choice of transducer parameters will clearly have
a significant impact on image quality; therefore it is necessary
Conductive or
Spurr's epoxy to optimize transducer characteristics for each applica-
tion to obtain the best compromise for resolution, contrast,
andDOF.
-1----- 0 ring ground

CLINICAL USE OF ULTRASOUND
T Smm 10 J.Lm PVDF
BIOMICROSCOPY
3 mm diameter High-resolution ultrasound scans used in this chapter have

been performed with the original instrument constructed
*
active area
in the authors' laboratories and the commercial instrument
based on this design (paradigm, Salt Lake City, Utah). The
laboratory instruments have frequencies between 40 and
100 MHz. The commercial instrument uses a 50 MHz
transducer that provides a good compromise between res-
olution and penetration.
Figure 8-3 A high frequency PVDF transducer. The width of
the beam at the focus is given in equation 1. Technique
The technique of eye examination using UBM is similar to
approximately an order of magnitude higher. A 40 to 100 conventional B-scari examination of the anterior segment (see
MHz transducer is moved linearly over the imaging field p 37). A fluid immersion technique is required to provide all
(typically 4 to 8 mm), collecting radiofrequency (rf) data at adequate standoff from the structures being examined. This is
each position. A monocycle high voltage 40 to 100 MHz necessary to avoid distortion of the image close to the trans-
pulse is used to excite the transducer. The rf signal is re- ducer and to prevent contact of the transducer and the eye. A
ceived and amplified in proportion to the depth from series of eye cups (see Appendix D) are used to hold the eye-
which it originated, using a time-gain circuit. This com- lids open and allow more rapid patient preparation. These
pensates for the attenuation of the ultrasound beam in the eye cups resemble those used in conventional ophthalmic ul-
tissue. After the signal is processed to enhance the low- trasound (see Figure 2-30), with a lip that slides under the
level signals, a section of the detected signal correspond- eyelids and holds the cup in place. They differ from biometry
ing to the focal zone is digitized by a special high-speed eye cups in that they are shallower and have a distinct flair
scan converter, stored, and displayed as brightness on a that allows a good view of precisely where the scanning head
video monitor. The servo motion system and electronics is being placed. Figure 8-4 shows an examination being per-
are controlled and synchronized by a computer. More deformed with one of these eye cups. 1% methylcellulose is an
tailed quantitative analysis of rf signals can be perf~rmed excellent coupling medium with sufficient viscosity to prevent
using a digitizing oscilloscope interfaced to the computer. fluid loss during the examination. Air bubbles have to be care-
B-mode imaging is currently performed at 5 to 10 frames/ fully avoided, both in the fluid and on the concave sUrface of
second. Additional details on the scanner design are pro- the transducer. Air bubbles can be removed by immersing the
vided in the literature: 6,29,B transducer in water and wiping the surface gently with a swab.
226 THE GLOBE
that through conjunctiva because of the attenuation

caused by keratinized epithelium. Examination of struc-
tures such as the posterior pole of the eye is not possible at
the present time.
Measuring Ocular Structures

Ultrasound biomicroscopy improves the ability to accu-
rately measure ocular structures. Measurement accuracy
is improved by UBM, which has an axial resolution 5 to
10 times that of conventional 10 MHz ultrasound. Mea-
surements are performed on the screen during the exami-
nation using electronic calipers. Stored images can be
transferred to a computer via an image capture board and
measured using imaging software. Measuring a structure
accurately with ultrasound requires knowledge of the speed
of sound in the structure being examined. Little is known
of the true speed of sound in these structures, particularly
at these frequencies. A speed of sound of 1,540 m/sec has
been used to make the majority of measurements. This
speed is used in conventional ultrasound scanning to mea-
sure distances in most tissue. A speed of 1,640 m/sec is gen-
erally used for the cornea, and can be used for the sclera as
well since it is similar in structure. Greater precision will
require studies to determine the true speed of sound in oc-
ular tissue at high frequencies.
Conventional ultrasound is capable of measuring rela-
tively large distances such as anterior chamber depth (see
Chapter 10). However, UBM increases the measurement
Figure 8-4 An examination with UBM using a flared eye cup. accuracy of such structures because the shorter wavelength
allows a finer positioning of end points and the exact mea-
surement position can be defined more precisely. A number
of ocular structures, such as the ciliary body, sclera, and iris,
Unlike conventional 10 MHz B-scan, high frequency cannot be measured as precisely by other techniques be-
transducers are generally not covered by a membrane. A cause of inadequate resolution and the inability to differ-
membrane would provide excessive sound attenuation and entiate these structures from adjacent tissue. UBM allows
defeat the purpose of doing examinations at this fre- clarification of borders and, thus, allows accurate measure-
quency. Since the transducer is constantly moving, con- ment. For example, UBM presents the unique ability to
tact with the eye and resulting corneal abrasion must be measure iris thickness at various positions in living human
carefully avoided. The presence of an articulated arm is eyes. Current imaging techniques are inadequate for this
invaluable in improving control of the scanning head. A purpose because of lower axial resolution and difficulty in
technique that involves resting part of the examiner's hand differentiating the posterior iris from the anterior lens
on the patient's forehead is also valuable in this regard. surface.
Careful attention must be paid to the screen image to pre-
vent the scanning head from getting too close to the eye.
Normal Ocular Structures
In practice, contact with the eye has been an extremely
rare occurrence. Because a large number of structures that can be imaged
Any part of the eye that can be approached directly have not previously been imaged in the living eye, it is use-
over the surface can be examined. The cornea and ante- ful to define a number of measurement parameters that can
rior segment structures are easily examined in any merid- be used for future comparison between normal and patho-
ian. The conjunctiva, underlying sclera, and peripheral logic eyes. 21 Modifications and additions have been made
retina can be evaluated by rotating the eye as far as possi- as this method has been brought to bear on various ocular
ble away from the region being examined. This allows problems. Some of these measurement sites are shown di~
imaging posterior to the muscle insertions with somewhat agrammatically in Figure 8-5. Measurement sites are
greater range temporally because of anatomic considera- defined in terms of fixed anatomic landmarks such as the
tions. Any adnexal structures with exposed surfaces can be scleral spur, tip of the ciliary processes, etc., to allow re-
examined. Penetration through the skin is not as good as producibility in the future.
Chapter 8 ULTRASOUND BIOMICROSCOPV OF THE EVE 227
Figure 8-5 UBM measuring positions shown on a diagrammatic

cross-section of the eye. The scleral spur is used for a fixed refer-
ence point. Trabecular-ciliary process distance (TCPD) is mea-
sured on a line extending from a point 500 fLm from the scleral
spur perpendicularly through the iris to the ciliary process. Iris
thickness (IDl-3) can be measured at any position. Iris-zonule dis-
tance (IZD) is measured at a point just clearing the ciliary process.
Length of iris-lens contact (ILCD) can be measured. Various an-
gles can also be measured as shown in the diagram. ICPD, Iris-
ciliary process distance. (From Pavlin CJ, Harasiewicz K, Foster
FS: Ultrasound biomicroscopy of anterior segment structures in
normal and glaucomatous eyes. Am J OphthalmoI1992;113:384.)
B
Figure 8-7 A, Typical UBM radial cross-section section

through the angle region. The image is taken through a ciliary
process. The scleral spur (arrow) is an important landmark.
B, UBM cross-section image through the angle. The anterior
zonule is clearly displayed (arrow). (From Pavlin CJ, Foster FS:
Ultrasound Biomicroscopy of the Eye. New York, Springer Verlag,
1994, p 49.)
Figure 8-6 UBM image of the central anterior chamber. The dothelium cannot be differentiated from Descemet's mem-
cornea displays reflections from the epithelial surface, Bowman's brane, but together they form a single highly reflective line
membrane, and Descemet's membrane. The anterior chamber at the posterior corneal margin. Greater definition of
depth can be measured from the inner corneal surface (arrow) to
the anterior lens capsule (double arrow). (From Pavlin CJ, Ha- corneal structure can be achieved using higher frequency
rasiewicz K, Foster FS: Ultrasound biomicroscopy of anterior seg- transducers.
ment structures in normal and glaucomatous eyes. Am J Ophthal-
mol 1992;113:384.) Anterior Chamber
Anterior chamber depth (ACD) is easily measured using ul-
trasound biomicroscopy (see Figure 8-6). Measuring the ax-
Cornea ial distance from the internal corneal surface to the lens sur-
A typical corneal cross-section is shown in Figure 8-6, face is facilitated by the ease of distinguishing the iris from
which shows the central anterior chamber. The corneal lay- the lens surface. This can be difficult in eyes with very small
ers can be differentiated. The epithelium forms a smooth pupils using conventional ultrasound. Measurement of an-
surface line that is thickened in the presence of edema. The terior chamber depth is not confined to the axial position; it
epithelium can be differentiated from Bowman's mem- can be taken from any point on the endothelial surface to
brane, which forms a highly reflective line just below that of either the iris or lens surface. This provides an improved
the epithelium. The corneal stroma reveals an internal ability to define the profile of the entire anterior chamber.
reflectivity that is lower than that found in the more irreg-
ular collagen distribution of the sclera. This difference al- Angle .Region
lows definition of the corneoscleral junction. The en- Figure 8-7 represents cross-sections through the angle re-
228 THE GLOBE
gion. These scans were made along the temporal meridian,

through a typical ciliary pro~ess, and as ve~cally as possi-
ble, as determined by observmg the scr~en Image. The cor-
neosc1eral junction and scleral spur can be distinguished
consistently with UBM. These structures are important in
maintaining orientation in the angle region. The scleral
spur, in particular, is a very useful landmark, presenting a
constant reference point for measurement in the angle
region.
Angle Opening
Previous methods of measuring the angle opening have
been largely qualitative in nature. One suggested technique
for quantifying angle measurements is based on ultrasound
biotnicroscopy.21,34 A poiot 500 /-Lm from the scleral spur Figure 8-8 UBM image demonstrating the ciliary processes
would correspond to the anterior aspect of the trabecular (perpendicular to image shown in Figure 8-7). The variability of
meshwork. A line perpendicular to the plane of the trabec- the ciliary processes is displayed.
ular meshwork Is extended from this point to the opposing
iris. The length of this line is then measured. This mea-
surement is the "angle opening distance" (AOD). Angular profile on a computer and calculating the area of the iris.
measurements in degrees are easily made but difficult to This can then be projected to a full 360 degrees. Iris curva-
define because of anatOlnic variations in angle configura- ture can be measured by extending a line from the iris root
tion. The angle formed with the apex at the iris recess and to the iris tip and measuring the deviation of the iris ep-
the arms passing through the point on the meshwork 500 ithelium from this line. 3D
/-Lm from the scleral spur and the point on the iris perpen-
dicularly opposite is termed the trabecular-iris angle (01). Ciliary Body
Ultrasound methods have been used in the past to attempt The ciliary body is well defined by UBM. The ciliary
a quantitative measure of the angle of iris opening. 14. Con- processes can be quite variable in configuration and length.
ventional ultrasound, however, lacks theresolution required The appearance of the ciliary booy will va:ty dependil).g on
to define the subtle variations in curvature found in the pe- whether the sound beam is passing through a process or a
ripheral angle and these methods provide a gross estimate valley between processes. During the examination, either
at best. The ability of ultrasound biomicroscopy to image a of these views can be produced, as desired. Figure 8-8
cross-section of the angle structures with sufficient resolu- shows an image at right angles to the view shown in Figure
tion. to appreciate these variations allows the first truly 8-7 and displays the variable configuration of the ciliary
quantitative method of angle assessment. This method is processes and the valleys between them.
not restricted by corneal clarity or iris configuration. The The distance between the anterior trabecular meshwork
ability to observe the angle opening in the context of its and the ciliary process is an important measurement. This
surrounding structures aids in clarifying the reason for an- distance is defined as the length of a line starting 500 /-Lm
gle closure. from the scleral spur on the trabecular meshwork and ex-
tending perpendicularly through the iris to the ciliary
Iris process. This distance defines the port through which the
The iris normally shows variations in thickness. Histo:lggic iris must traverse and has implications as to the potential
;tudies show that it is generally thinnest at the iris root and maximum angle opening. The ciliary sulcus is defined as
ruckest near the pupillary margin. In addition, there are the space between the anterior surface of the ciliary
'ariations in thickness depending on the presence of crypts, processes and the posterior iris surface.
Ind the state of dilation or constriction of the pupil. The
mpil size is constantly variable within a small range in the Zonule
hsence of pharmacologic agents. The position of iris mea~ The entire posterior chamber cannot always be defined
urement can be defined with reference to the scleral spur. with UBM. The posterior zonule and vitreous face can be
~he iris epithelium forms a constant highly reflective layer resolved in some shallow chambered eyes but not consis-
n the posterior iris surface. This highly reflective line tently in eyes with chambers of average or greater depth.
efines the posterior iris border and can be quite useful The anterior zonule and lens surface, however, can be con-
,hen differentiating intra-iris lesions from lesions behind sistently visualized in all eyes (see Figure 8-7, B). The
le iris. The zone of iris-lens contact can be measured. Vol- zonule inserts smoothly into the surface of the lens but is
metric measurements are possible by tracing the iris occasionally more irregular, which may indicate the degree
of zonular tension.
Chapter 8 ULTRASOUND BIOMICROSCOPY OF THE EYE 229
ULTRASOUND BIOMICROSCOPY IN OCULAR
DISEASE
Since UBM is a new nonspecific imaging tool, it is suitable
for examination of a large range of diseases that fall within
the penetration limits of this technique. It is particularly
useful in those conditions in which structural abnormalities
are present, i.e., those conditions that produce rearrange-
ment of normal anatomy. Glaucoma and intraocular tumors
are two areas in which UBM provides particularly useful
information. The use of conventional ultrasound for glau-
coma is described in Chapter 7 and for intraocular tumors
in Chapter 5.
Glaucoma
Several types of glaucoma are caused by structural ab-
normalities of the anterior segment of the globe. This is
particularly true cif angle closure glaucoma and infantile
glaucoma. The ability of UBM to image structural abnor-
malities on a much finer scale than has previously been pos- Figure 8-9 UBM image in a case of pupillary block. The iris is
sible provides us with a quantitative new tool for research bowed forward. The angle is narrow but open. The iris-lens con-
tact is minimal (arrow).
and clinical assessment of glaucomatous disease. Examples
of use in glaucoma are provided.
Pupillary Block
In pupillary block the iris assumes a convex profile due to
the pressure differential between the posterior and anterior
chambers. The convex contour of the iris in a case of pupil-
lary block is noted in Figure 8-9. Following iridotomy, the
profile changes to a much straighter configuration. Previ:..
ous studies have been done to define the iris profile. Tiede-
man provided a theoretical analysis to predict the iris
profile. 35 An optical technique (Scheimpflug technique) has
been described to define the iris profile.! UBM presents a
relatively easy method of accomplishing this task and al-
lows definition of the entire iris profile to the iris root. In-
terestingly, the degree of iris-lens contact is relatively small
in pupillary block, as the iris is lifted off the lens. Thus, the
block is not related to the area of contact. The area of iris-
lens contact becomes even smaller when the pupil dilates.
Anatomic angle closure in the dark, resulting in pupillary
block, occurs rapidly and relates to increased iris thickness
and increased anterior bowing as the iris tip moves towards
the iris root. 37 A dark room provocative test can be done
Figure 8-10 UBM image in a case of plateau iris syndrome. The
utilizing UBM to detect whether anatomic angle closure ciliary processes (ep) are forward, closing the ciliary sulcus and
occurs in the dark.!O,22 supporting the peripheral iris (1). The iris profile is straight, but
the peripheral angle is narrow (arrow).
Plateau Iris Syndrome
UBM has been used to eJucidate the etiology of plateau iris
syndrome. 26 In plateau iris syndrome, the ciliary processes
are anatomically anterior, closing the ciliary sulcus and pro- iary processes and the trabecular meshwork form a port
viding structural support behind the peripheral iris (Figure through which the iris thickness must pass. The smaller this
8-10). This prevents this portion of the iris from falling port and/or the thicker the iris in this region, the greater
away from the trabecular meshwork following iridectomy. the degree of angle closure. In studies of this disease, ante-
A good way of looking at this phenomenon is that the cil- rior chamber depth, trabecular-ciliary process distance, and
230 THE GLOBE
Figure 8-11 UBM image showing a closed angle due to ante- Figure 8-12 UBM image in a case of malignant glaucoma. A
rior synechiae. The iris has an angled appearance (arrow). supraciliary effusion (E) is present. The ciliary processes (CP) and -
iris (I) are rotated forward closing the angle. The lens margin (L)
is just medial to the ciliary process.
iris-zonule distance were all significantly smaller than that
found in normals. In studies of plateau iris in the dark and
after pilocarpine administration, it was demonstrated that tated ciliary processes!2,36 (Figure 8-12). It is likely that
the distance between the ciliary processes and trabecular effusions playa major role in the clinical manifestation of
meshwork remained constant with iris thickness being the this condition (see p 216).
only variable contributing to angle narrowing. 20
Pigmentary Dispersion
Anterior Synechiae Pigmentary dispersion syndrome is characterized by loss of
Total angle closure by synechiae is illustrated in Figure pigment from the pigment epithelial layer of the iris and
8-11. The iris takes an angular form as opposed to the subsequent pigment deposition in the trabecular meshwork,
smooth curve of pupillary block. The state of the angle be- leading to glaucoma. The concept of reverse pupillary
hind synechia can be defined by UBM. This may improve blocpo implies temporary reversal of the pressure differen-
the ability to assess the prognosis in these cases. It is difficult tial in the anterior and posterior chambers, producing pos-
to differentiate complete appositional closure from synechial terior bowing of the iris and leading to iris-zonule contact
closure, but UBM is capable of defining an extremely small with mechanical pigment loss. UBMhas shown that ac-
split between the iris and the trabecular meshwork. commodation produces posterior iris bowing, which is re-
versed by iridotomy.24 Other factors, including blinking and
Iris Rotation exercise, have also been considered possible causes.!! Ex-
In patients with extremely shallow anterior chambers such amination of patients with this condition should include
as those seen in spherophakia, the iris can be rotated for- observation of the effects of accommodation on iris profile.
ward, directly narrowing the angle in the absence of pupil- This can be accomplished by having the patient change
lary block. fixation from a target on the ceiling to a near target, using
the eye not being examined (Figure 8-13).
Supraciliary Effusions and Malignant Glaucoma
Supraciliary effusions that cannot be detected by conven- Filtering Surgery
tional ultrasound can be imaged by UBMY These effu- Figure 8-14 illustrates the ability of UBM to analyze the
sions occur in a variety of conditions including inflamma- state of filtering procedures. This figure shows a patent
tory disease and vein occlusions, and following retinal opening continuous with a distinct scleral split and a func-
detachment surgery.28,39 Supraciliary effusions produce ro- tioning bleb. The internal surgical opening can be consis-
tation of the ciliary processes and iris around the scleral tently visualized and the state of the filtering bleb as-
spur. This can result in angle closure, particularly if the sessed. 38 Filtering blebs show variable internal reflectivity,
angle is narrow to begin with. Most cases of malignant most likely dependent on the distribution of fluid in the
glaucoma have supraciliary effusions and anteriorly ro- episcleral tissue.
ChapterS ULTRASOUND BIOMICROSCOPY OF THE EYE 231
A B
Figure 8-13 UBM images of pigmentary glaucoma. With distance fixation (A) the iris is
slightly bowed posteriorly (arrow). With accommodation (B), bowing of the posterior iris in-
creases markedly (aT70w). (From Pavlin C], Foster FS: Ultrasound Biomicroscopy of the Eye. New
York, Springer Verlag, 1994, p 19.)
Figure 8-14 UBM image following filtering surgery. The internal ostium and trans-scleral
pathway are imaged (arrow). The bleb shows diffuse reflectivity from edematous episcleral tissue ..
(From Pavlin C], Harasiewicz K, Foster FS: Ultrasound biomicroscopy of anterior segment
structures in normal and glaucomatous eyes. Am J OphthalmoI1992;1l3:387.)
Anterior Segment Tumors

may be followed with greater precision. Where surgical in-
UBM is a very useful adjunct in the management of ante- tervention is indicated, information gained is helpful in
rior segment tumors. 25 UBM provides a clear image of even planning the approach.
the smallest anterior segment lesions. The ability to mea-
sure these lesions accurately adds the dimension of depth Iris Tumors
to the criteria for demonstrating growth. The ability to de- The presence of a typical morphologic appearance on
termine the underlying structure of the tumor allows im- UBM may be helpful as a diagnostic sign. Several small,
proved classification and the ability to determine ciliary minimally elevated lesions involving the peripheral iris and
body involvement. When observation is elected, lesions clinically considered nevi have a similar appearance on
232 THE GLOBE
Figure 8-15 UBM image demonstrating iris nevus at the pupil- Figure 8-16 UBM image showing ciliary body tumor (T) with
lary margin. A low reflective surface plaque is present (arrow). regular, medium reflectivity. The peripheral iris is involved.
UBM. They share the ultrasound biomicroscopic appear- because of sound attenuation. Small lesions that cannot
ance of a small moderately thickened iris lesion, not ex- be detected by conventional ultrasound can be defined by
tending past the iris root. There is frequently a hypoechoic UBM. Larger ciliary body lesions are detectable by con-
layer on the surface of these lesions, possibly indicating that ventional ultrasound (see Chapter 5), but UBM shows
the superficial layer is involved with the closely spaced cells improved internal detail of the superficial part of the tu-
of a surface plaque (Figure 8-15). mor and frequently allows a more precise localization of
It is difficult to be too specific as to histologic diagnosis the posterior and lateral boundaries (Figure 8-16). This
with ultrasound, even with the added detail presented by information is important if iridocyclectomy is considered
UBM. Resolution is not at the level that can differentiate as a possible treatment. Extrascleral extension can be lo-
individual cells. Malignant melanomas of the iris can be calized in relation to the tumor and frequently a trans-
quite variable in their clinical and ultrasonic presentation. scleral connection imaged.
UBM can be helpful in a number of ways. Internal reflec-
tivity varies considerably, depending on the degree of vas- Cysts
cularity and the patterns of internal cellular structure. Some Cysts are clearly imaged by UBM.2,25 The usual clinical
melanomas show a linear internal pattern, others show a presentation of an iridociliary cyst is an elevation of the pe-
uniform reflectivity, still others show a large degree of in- ripheral iris without iris involvement. The typical ultra-
ternal vascularity. Margins can be defined, which is espe- sound biomicroscopic appearance of a thin-walled cyst with
cially important for assessing ciliary body involvement. His- no internal reflectivity (Figure 8-17) is diagnostic and es-
tology has shown good correlation between the ultrasound s·entially eliminates any question of whether a lesion is a
margin and the histologic margin. The posterior pigment cyst or a solid tumor. Small cysts are also found occasion-
epithelial layer can be assessed for evidence of break- ally, either as an isolated finding on examination for some
through. Serial measurements are invaluable for assessing other clinical indication, or in association with solid lesions
growth. A change in shape of the lesion can also be imaged. of the iris or ciliary body. 5
Evidence of internal seeding can be defined. Some iris
melanomas have a component that is under the iris and can Peripheral Choroidal Tumors
be hidden from view. UBM can image these regions. If iri- The anterior aspect of anteriorly located choroidal tumors
docyclectomy is performed, UBM provides an additional can be imaged by UBM.13 Although it is often impossible
method of assessing the iridocyclectomy bed for evidence to measure these tumors through their greatest thickness,
of recurrence. valuable information can be gained regarding the anterior
extent of the lesion and the involvement of anterior seg-
Ciliary Body Tumors ment structures. This is particularly important if radioac-
Ciliary body tumors can be assessed easily, although large tive plaque treatment is contemplated, as it provides a
tumors « 4 mm in depth) cannot be completely imaged guide for placement of the anterior margin of the plaque.
..
Figure 8-17 UBM image showing iridociliary cyst (C). Note the Figure 8-18 UBM image showing IOL haptic (arrow). Note
cyst wall and lack of internal echoes indicating fluid. Local angle that the haptic is displaced over the pars plana.
closure is present.
Imaging the internal structure of the anterior aspect of the

tumor can also provide helpful differential diagnostic in-
formation. In cases of extrascleral extension, the relation-
ship of the tumor to the extrascleral component can be
defined, and frequently the trans-scleral co"nnection is
imaged.
Corneal and Scleral Disease

UBM can be helpful in patients with opaque corneas prior
to transplantation. 15 Anterior segment details, such as the
depth of the anterior chamber, state of the angle, presence
of anterior synechiae, and intraocular lens positioning, can
be determined preoperatively. Intracorneal abnormalities
can also be imaged. Corneal edema can be assessed and
measured. An arc scanner recently developed uses a trans-
ducer path that follows the corneal curvature, allowing
imaging of the entire cornea in one sweep. This instru-
mentation has allowed construction of three-dimensional
depth maps of corneal thickness, epithelial thickness, and Figure 8-19 UBM image demonstrating cyclodialysis cleft (ar-
row). The cleft is open in this image.
depth of intracorneal incisions. 31 It is likely to be helpful in
assessing results and complications of refractive surgery.
Hypotony and Trauma
UBM is also useful in scleritis, allowing differentiation be-
tween extrascleral and intrascleral disease and allowing as- UBM can image cyclodialysis clefts even when the anterior
sessment of the degree of scleral thinning. IS chamber is shallow and the cyclodialysis cleft is not obvious
with gonioscopy.7 There is always 360 degrees of supraciliary
fluid present in these cases. The region of the cleft is usually
Intraocular Lens Complications
obvious from the displacement of the iris root from the scle-
UBM can easily evaluate the position of intraocular lens ral spur (Figure 8-19). Other causes of hypotony in which
haptics. This is very useful in assessing malpositioned UBM can provide useful information include occult wound
lenses 27 (Figure 8-18) and the source of intraocular bleed- leaks and ciliary body membranes. In other trauma problems,
ing and in determining haptic freedom if removal or repo- UBM can image the state of the anterior chamber under
sitioning is requited. 32 traumatic opacities3 and detect small foreign bodies that are
234 THE GLOBE
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3. Berinstein DM, Gentile RC, Sidoti PA, et al: Ultrasound biomi-
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4. Deramo VA, Shah GK, Baumal CR, et al: illtrasound biomicroscopy
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8. Hill C: Physical hinciples ofMedical Ult1'asonics. London, Ellis Howood
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9. HurwitzlJ, Pavlin CJ, Hassan A: Proximal canalicular imaging utiliz-
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Figure 8-20 UBM image showing foreign body in the angle anterior chamber angle width. Jpn J OphthalmoI1999;43:526.
(black arrow). Note high reflectivity and shadowing of posterior 11. Liebmann JM, Tello C, Chew SJ, et al: Prevention of blinking alters
structures (white arrow). iris configuration in pigment dispersion syndrome and in normal eyes
[see comments]. Ophthalmology 1995;102:446.
12. LiebmannJM, Weinreb RN, Ritch R: Angle-closure glaucoma asso-
difficult to image using conventional techniques 4 (Figure ciated with occult annular ciliary body detachment. Arch Ophthalmol
1998;116:731.
8-20). For the use of conventional ultrasound in hypotony, 13. Maberly DA, Pavlin CJ, McGowan HD, et al: Ultrasound biomicro-
see p 216 and for anterior segment trauma, see pp 87 and 93. scopic imaging of the anterior aspect of peripheral choroidal
melanomas. Am J OphthahnoI1997;123:506.
14. Makabe R: Comparative studies of the width of the anterior chamber
Conjunctival and Adnexal Disease angle using echography and gonioscopy. Klin Montasbl Augenheilkd
1989; 194:6.
UBM can provide valuable information in the differential 15. Milner MS, LiebmannJM, Tello C, et al: High-resolution ultrasound
biomicroscopy of the anterior segment in patients with dense corneal
diagnoses of tumors, judging the depth of conjunctival and scars. Ophthalntic Surg 1994;25:284.
limballesions and imaging canalicular conditions. 9 16. Pavlin C], Christopher DA, Burns PN, et al: High-frequency Doppler
ultrasound examination of blood flow in the anterior segment of the
eye. Am J OphthalnzoI1998;126:597.
SUMMARY AND FUTURE DIRECTIONS 17. Pavlin CJ, Easterbrook M, Harasiewicz K, et al: An ultrasound bio-
microscopic analysis of angle-closure glaucoma secondary to cilio-
UBM presents a new method of imaging the anterior seg- choroidal effusion in IgA nephropathy. Ant J Ophthalmol 1993;
116:341.
ment of the eye at high resolution. Its strengths lie in its abil- 18. Pavlin CJ, Easterbrook M, Hurwitz lJ, et al: illtrasound biomi-
ity to produce cross-sections of the living eye at microscopic croscopy in the assessment of anterior scleral disease. Am J Ophthal-
resolution without violating the integrity of the globe. Al- mol 1993;116:628.
19. Pavlin C], Foster FS: illtrasound biomicroscopy. High-frequency ul-
though histologic assessment of various disease types is trasound imaging of the eye at microscopic resolution. Radiol Clin
sometimes available from pathology specimens, this usually NorthAm 1998;36:1047.
occurs at a late stage in the disease and is susceptible to the 20. Pavlin CJ, Foster FS: Plateau iris syndrome: changes in angle opening
associated with dark, light, and pilocarpine administration. Am J Oph-
inevitable distortions of the preparation process. UBM, al- thalmol1999; 128:288.
though lacking the resolution of optical microscopy, provides 21. Pavlin CJ, Harasiewicz K, Foster FS: Ultrasound biomicroscopy of
images in living eyes without affecting the internal relation- anterior segment structures in normal and glaucomatous eyes [see
comments]. Am J Ophthabnol1992; 113:3 81.
ships of the structures imaged. This method has proven valu- 22. Pavlin CJ, Harasiewicz K, Foster FS: An ultrasound biomicroscopic
able in both clinical practice and ophthalmic research. New dark-room provocative test. Ophthalmic Surg 1995;26:253.
methods of using high frequency ultrasound are in develop- 23. Pavlin CJ, Harasiewicz K, Sherar MD, et al: Clinical use of ultrasound
biomicroscopy. Ophthalmology 1991;98:287.
ment including three-dimensional imaging, Doppler,16 and 24. Pavlin CJ, Macken P, Trope GE, et al: Accommodation and iridotomy
the use of contrast agents. These developments should ex- in the pigment dispersion syndrome. Ophthalmic Surg Lam's
tend the use of this technique to new areas. 1996;27:113.
25. Pavlin CJ, McWhae JA, McGowan HD, e.t al: Ultrasound biomi-
croscopy of anterior segment tumors. Ophthalmology 1992;99: 1220.
26. Pavlin CJ, Ritch R, Foster FS: illtrasound biomicroscopy in plateau
ACKNOWLEDGMENTS iris syndrome. Ant J OphthalmoI1992;113:390.
27. Pavlin CJ, Rootman D, Arshinoff S, et al: Determination of haptic
The authors would like to acknowledge the contribution of position of transsclerally fixated posterior chamber intraocular lenses
Michael Sherar, Brian Starkoski, and Kasia Harasiewicz to by ultrasound biomicroscopy [see comments]. J Cataract Refract Surg
the development of this imaging system. 1993;19:573.
28. Pavlin C], Rutnin SS, Devenyi R, et al: Supraciliary effusions and cil- 34. Tello C, Liebmann], Potash SD, et al: Measurement of ultrasound
iary body thickening after scleral buckling procedures. Ophthahnology biomicroscopy images: intraobserver and interobserver reliability. In-
1997;104:433. vest Ophthalnzol Vis Sci 1994;35 :3549.
29. Pavlin C], Sherar MD, Foster FS: Subsurface ultrasound microscopic 35. Tiedeman S: A physical analysis of factors that determine the contour
imaging of the intact eye. Ophthalmology 1990;97:244. of the iris. Ant J OphthalmoI1991;111:338. .
30. Potash SD, Tello C, Liebmann], et al: Ultrasound biomicroscopy in 36. Trope GE, Pavlin C], Bau A, et al: Malignant glaucoma. Clinical and
pigment dispersion syndrome [see comments]. Ophthalnzology ultrasound biomicroscopic features. Ophthalnzology 1994; 101: 103 O.
1994;101:332. 37. Woo EK, Pavlin C], Slomovic A, et al: Ultrasound biomicroscopic
31. Reinstein DZ, Silverman RH, Raevsky T, et al: Arc-scanning very quantitative analysis of light-dark changes associated with pupillary
high-frequency digital ultrasound for 3D pachymetric mapping of the block. Am J Ophtbalmol 1999; 127 :43.
corneal epithelium and stroma in laser in situ keratomileusis.J Refract 38. Yamamoto T, Sakuma T, Kitazawa Y: An ultrasound biomicroscopic
Surg 2000;16:414. study of filtering blebs after mitomycin C trabeculectomy. Ophthal-
32. Rutnin SS, Pavlin C], Slomovic AR, et al: Preoperative ultrasound mology 1995;102:1770.
biomicroscopy to assess ease of haptic removal before penetrating ker- 39. Yuki T, Kimura Y, Nanbu S, et al: Ciliary body and choroidal detach-
atoplasty combined with lens exchange. J Cataract Refract Surg ment after laser photocoagulation for diabetic retinopathy. A high-
1997;23:239. frequency ultrasound study. Opbthalmology 1997; 104: 12 59.
33. Sherar M, Starkoski B, Taylor WE, et al: A 100 MHz B-scan ultra-
sound backscatter microscope. Ultraso7Z Imaging 1989; 11 :95.
Paul T. Finger
Three-Dimensional
Ultrasound of the Eye
Three-dimensional ultrasonography (3 DUS) combines se- a pathologist slices into a paraffin block. But, unlike the
quential two-dimensional (2D) digital image acquisition pathologist, the observer can reform the block or slice it
(tomograms) with computerized reconstruction software. from two or more directions at the same time. For example,
Computer-assisted image processing allows ocular pathol- Romero et al retrospectively obtained an oblique ultra-
ogy to be viewed in 3D. Three-dimensional reconstruction sound image of extrascleral extension (of a uveal melanoma)
can allow the entire surface of an intraocular tumor to be in an effort to match its corresponding histopathologic sec-
visualized, its topographic anatomy rendered, and its vol- tion (Figure 9-3).1 9
ume calculated. Interactive analysis (sectioning) of the It is important to note that 3DUS probes operate at 10
scanned 3D volume image block allows for examination of MHz and offer an axial resolution of 0.1 mm, as in conven-
unique oblique and coronal views (Table 9_1).2,6,12 These tional B-scan ultrasound. 1The acquisition time for obtain-
capabilities have already been found helpful for evaluating ing serial B-scan images is currently 5 to 7.5 seconds per
episcleral plaque placement and extrascleral extension of scan sequence. Sound velocities used to perform measure-
choroidal melanoma. ll ,19 ments with the OTI machine are 1,550 mis, ± 3%.
Future prospects for ophthalmic 3D imaging include the
potential for new and unique findings in ocular and orbital
INTRAOCULAR TUMORS
oncology, as well as in vitreoretinal diseases. In addition,
3D imaging should play an important role in telemedicine. 3DUS can be particularly helpful in the diagnosis and man-
agement of intraocular tumors. This technique has been
used for the diagnosis of extrascleral extension,19 for imag-
INSTRUMENTATION
ing radioactive plaques during implantation,l1 and for clin-
The one commercially available ophthalmic 3D ultrasound icopathologic correlation in retinoblastoma. 21 The accuracy
system (3D i-scan, [OTI] Ophthalmic Technologies Inc, and reproducibility of 3DUS for measurements (especially
Toronto, Ontario) utilizes a conventional 10 MHz B-scan volume) of choroidal melanomas have been studied,18
transducer combined with a motorized, rotating holder and
computerized image processing (Figure 9-1). The data
Topography and Volumetric Analysis
from 60,90, or 180 serial B-scan images are acquired while
the transducer rotates (in angular increments of 3,2, or 1 Ocular oncologists have traditionally used conventional A-
degrees, respectively). These images are imported into a and B-scan ultrasound to assess a tumor's apical height,
computer for processing to form a 3D volume image (Fig- considered the most reliable indicator of growth or post-
ure 9-2). treatment shrinkage. In addition, 2D B-scan has been used
Three-dimensional volume image blocks are displayed indirectly to assess a tumor's topography and volume. 13 The
on the computer screen. The polyhedral display format development of 3DUS now allows for an easier and more
used by OTI has been used for other 3DUS applications in accurate method of evaluating both tumor topography and
radiology,15 The initial 3D volume image block is 41 mm volume, and can enhance the measurement of apical height.
deep by 37.5 mm high by 37.5 mm wide. The polyhedron The procedures used to measure tumor volume and to
consists of six fixed planes, which define the boundaries of perform topographic mapping are essentially the same, but
the scanned volume image block, plus movable planes cre- the information is processed differently by the computer
ated by the operator. By moving two or more planes, the software. The procedure involves outlining multiple, suc-
observer slices into the 3D volume image block, much like cessive, parallel cross-sectional slices of the tumor volume
236
Chapter 9 THREE-DIMENSIONAL ULTRASOUND OF THE EVE 237
20 vs. 3D Ultrasound*
Characteristics 2D Ultrasound 3D Ultrasound
Axial resolution 0.1 0.1
Lateral resolution 0.3 0.3
Linear analysis Yes Yes
Spatial analysis No Yes
Initial image 2D real-time 2D real-time
Dynamic examination Yes No
Acquisition time 5 to 15 minutes 5 to 7.5 seconds
Images acquired 5 to 10 60 to 180
Static record 2D files/2D slices 3D files/2D slices
Replay possible No Yes
3D reconstruction No Yes
Image rotation No Yes
Coronal/oblique sections No Yes
Volumetric analysis No Yes
Topographic mapping No Yes
*Both 2D and 3D ultrasound instruments use a 1D MHz probe.
Figure 9-1 Photograph of the aTr B-scan probe. The probe is contained within a motorized,
rotating holder and is rotated to acquire multiple sequential 2D images.
238
B-probe
of2D;m,/
Captured se~~~n/
..
3D reconstruction
3D volume image
Figure 9-2 Schematic drawing shows rotation of the B-scan probe to acquire multiple, se-
quential2Dimages for computer storage. Software is used to construct a polyhedral volume im-
age (volume image block) that appears on the computer screen for interactive analysis. (Courtesy
Ophthalmic Technologies, Inc, Toronto, Canada.)
A B
Figure 9-3 3DUS echogram and histopathology of choroidal melanoma with extrascleral ex-
tension. A, 3DUS echo gram shows an "oblique" slice through the volume image block that cor-
responds to the histopathologic section (B). Note the path of the tumor through the sclera (ar-
row).B, Histopathologic section of tumor showing extrascleral extension and tumor extension
through sclera.
Chapter 9 THREE-DIMENSIONAL ULTRASOUND OF THE EYE 239
Figure 9-4 3DUS topographic mapping of a choroidal melanoma. The retinal and scleral sur-
faces of a tumor slice obtained from the volume image block are manually outlined. This proce-
dureis performed on multiple serial slices to calculate tumor volume. This process will be auto-
mated in the future.
image block. The number of slices to be analyzed ranges umes may be found to be better predictors of a change in
from 60 to 180. Currently, each slice presented on the tumor size, as well as of metastatic potential. There are cur-
screen must be outlined manually (Figure 9-4). For tissue rently no comparative or prospective clinical studies that
volume, a single numeric value is provided; for topography, have examined these potentials.
the results are presented in a graphic three-dimensional An experienced observer performing topographic and
form. volumetric analysis typically takes from 1 to 2 hours to out-
Topographic renderings of intraocular tumors, using line 60 to 180 2D slices. This procedure of outlining the
3DUS, provide the ability to view the entire surface of the retinal/tumor surfaces and defining the sclera is subjective
tumor, thereby enhancing the detection of subtle changes (see Figure 9-4); but this process will become less subjective
along the tumor's surface. 20 This is because each 3D ren- with the use of a computer software process called autoseg-
dering provides thousands of measurements of lesion mentation. By this method, a computer will be pro-
thickness and cross-sectional extent (Figure 9-5). This can grammed to identify the retinal and scleral sUrfaces, thus
be especially helpful for measuring the apical height of in- increasing the speed and accuracy of outlining the two-
traocular tumors. Traditionally, the apical height mea- dimensional slices. .
surement has been obtained with A-scan or an interpo-
lated 2DUS B-scan image. 4 ,5 These approaches, however,
Choroidal Melanoma
require the examiner to identify the apex of the tumor by
dynamically scanning across the tumor surface. With In addition to topographic and volumetric analysis, there
3DUS, on the other hand, 60 to 180 2DUS image slices . are a number of other ways in ~hich 3DUS may prove
are individually outlined and a multitude of points near useful in the .evaluation of choroidal melanomas. Coronal
the tumor surface are obtained. Because the tumor apex and oblique sections through the tissue block are uniquely
is accurately localized on the topographic map (see Fig- helpful in the diagnosis and management of these tumors.
ure 9-5), the apical height measurement becomes more An example is when a subretinal hemorrhage obscures an
objective and less dependent on examiner skill. This tech- underlying melanoma both clinically and with conven-
nique for localizing the tumor apex is also helpful when tional ultrasound. In such cases, repeated analysis of
the location of the apex changes because of growth or re- oblique and coronal views obtained with 3DUS can help
gression. "With 3DUS, future software refinements will al- differentiate blood from tumor. The examiner can also
Iowa computer algorithm to search the topographic use 3DUS to detect an eccentric or occult collar button
thickness map to identify the original tumor apex location by scrolling back and forth through serial sections of the
in relation to the margins of the lesion, thus minirn'izing tumor.
errors. The diagnosis of extrascleraI'extension is another area
Despite clinical reliance on apical height measurements, in which 3DUS is particularly beneficiaJ.19 In these cases,
most tumors grow volumetrically.1 1,15 As previously de- coronal and oblique reconstructions allow evaluation of
scribed, a volumetric measurement can simply be a single the presence, degree, and relative location of extraocular
number in cubic measure. "With further study, tumor vol- extension. The reliability of 3DUS in this regard has
240 THE GLOBE
A B
-1.0
-6.0
-5.0
-4.0
-3.0
-2.0
a "1,0
-S
0.0
~
3 1.0
2.0
3.0
4.0
5.0
6.0
7.0
M7.0 -6,0 ~S,O -4.0 -3.0 -2.0 -f,O 0.0 1 0 2.0 3.0 4.0 S.O is.O 7.0 -7J)-6.0-5.0~4JJ-3.0-2.0-1D 0.0 1.02.0' 3.0 4.0 $,0 6.0 7.0
\)floth(mm) \1id1h(mm)
1.0 1.5 2.0 25 1.0 1,5 2.0 2.5

Thicko)?ss (rom) Tbi.;krws$ (mm)
La 1.5 2.0 2.5

Th1ckMss (mm)
Figure 9-5 Topographic surface rendering of a choroidal melanoma from 3DUS images. The
tumor is imaged before (A) and 7 months after (B) palladium-103 ophthalmic plaque radiation
therapy. (Courtesy Dr. Ray Iezzi, Detroit, Michigan.)
Retinoblastoma
been confirmed by sonopathologic correlation. This was
achieved by interactively analyzing the stored volume 3DUS may playa particularly important role in the evalua-
image block to recreate the same plane of section used by tion of retinoblastoma. Because children are typicallyexam-
the pathologist (see Figure 9-3). As a result, 3DUS can in- ined under sedation or general anesthesia, the ability to ac-
crease confidence in the diagnosis of extraocular tumor ex- quire and subsequently analyze the stored volume image
tension and may affect the management. 8 block is invaluable. In addition, 3DUS vividly reveals intratu-
3DUS may also aid in the assessment of choroidal moral calcification and the associated 3D orbital shadows pro-
melanomas by quantifying areas of cystic or necrotic tumor duced by the calcium. The demonstration of calcification is a
and by evaluating internal reflectivity. These capabilities major diagnostic finding in retinoblastoma (Figure 9-6).
may become even more useful as morphology is linked to Known risk factors for metastasis of retinoblastoma in-
tumor behavior. 3,l? clude optic nerve invasion, choroidal infiltration, and or-
Chapter 9 THREE-DIMENSIONAL ULTRASOUND OF THE EVE 241
Figure 9-6 3DUS volume image block of retinoblastoma with

calcification. Simultaneous sections in the plane of the optic nerve
(arrow) and tumor show their relative location. T, Temporal; S,
superior; P, posterior.
bital extension. 16 Coronal sectioning of the optic nerve with

3DUS offers a new perspective for evaluation of this struc-
ture. Topographic mapping offers the potential to quantify
choroidal invasion. Furthermore, the ability to examine B
suspicious areas of sclera with repetitive interactive analysis
using coronal and oblique sectioning, should enhance the
detection of extrascleral·extension.
3DUS for Ophthalmic Plaque Radiation Therapy

Ultrasound is helpful for ophthalmic plaque localization in
the treatment of intraocular tumors. 14 While a standard B-
scan probe can be rotated by hand to evaluate all of the
plaque walls and their proximity to the sclera, 3DUS auto-
mates that process and allows the surgeon to replay the en- Figure 9-7 3DUS evaluation of choroidal melanoma with ra-
tire rotation. Interactive analysis of the stored volume im- dioactive plaque. A, Interactive analysis of plaque position beneath
age block has allowed "quartering" of the plaque. This tumor simultaneously reveals the temporal and inferior margins.
The plaque is "quartered" with simultaneous nasal-temporal and
quartering technique provides for the simultaneous assess- inferior-superior cuts. S, Superior; N, nasal; P, posterior.
ment of two perpendicular tumor-plaque margins (Figure B, Unique coronal section demonstrates the back of the plaque
9-7, A). In addition, coronal sections can be useful for judg': (P) adjacent tothe optic, nerve (arrow).
ing proximity of the plaque to the optic nerve (Figure 9-7,
B). 10,11
3DUS has also been used to image radioactive seeds
within eye plaques. ll In current practice, determining seed- actual dose to the tumor and normal ocular structures using
to-tumor apex distance requires calculations with a Iium- 3DUS may help define the actual dose thresholds for radi-
ber of assumptions (plaque position on the sclera, thickness ation complications. 9 Finally, the time needed to obtain a
of the sclera, and constancy of tumor thickness during 3D volume image block is much less than that required by
treatment).8 In vivo measurements, both prior to and after conventional B-scan using dynamic scanning. With 3DUS,
ophthalmic plaque radiation therapy, will help define the interactive analysis of the volume image block can be per-
dose delivered to the tumor. In addition, calculation of the formed at a safe distance from the radioactive plaque.
242 THE GLOBE
Figure 9-9 3DUS analysis of funnel-shaped retinal detach-

ment. Coronal section shows cross-section of the open funnel.
Scrolling anterior or posterior along the retina allows the funnel
to be visualized.
Figure 9-8 Dislocated crystalline lens imaged by 3DUS. Inter- cause the retinal detachment is both visible on the screen
active analysis allowed a cut at the lens equator and a perpendic- and available for analysis. These capabilities become more
ular slice creating a lens quarter. This quartering technique allows
the nucleus and cortex to be shown in two separate planes (arrow). important when there is no ophthalmoscopic view of the
fundus.7
VITREORETINAl DISEASE Choroidal Detachment

Vitreous opacities (hemorrhage, asteroid hyalosis, floaters, Evaluation of choroidal detachments can be aided by 3DUS
and inflammatory debris) are best evaluated during the dy- reconstructions. Combinations of standard, coronal and
namic, conventional B-scan examination. With this oblique sections can be used to reveal the multifaceted
method, the mobility of the opacities can be readily as- shapes of choroidal detachment that are seen beneath a
sessed. 3DUS, on the other hand, can create a unique vol- retinal detachment (Figure 9-10).
umetric recording of the quantity and position of the opac-
ities. This capability can be particularly helpful for the
ADVANTAGES AND LIMITATIONS
follow up of these eyes.
OF OPHTHALMIC 3DUS
Similarly, the mobility of a dislocated crystalline lens is
best demonstrated using conventional B-scan. However, in- With conventional 2D ultrasound, the ultrasonographer
teractive sectioning of the 3D volume image block of the typically takes from 5 to 15 minutes to evaluate the eye dy-
lens allows quartering to create a unique and diagnostic namically while performing a mental 3D reconstruction
perspective (Figure 9-8). (see Table 9-1).4,5 In contrast, after dynamic examination,
3DUS involves acquiring 60 to 180 sequential 2D images
that are stored with each transducer rotation. Computer
Retinal Detachment
software then uses this information to reconstruct a 3D vol-
3DUS is particularly helpful for evaluating retinal detach- ume image block (see Figure 9-2). Without further contact
ment. In one case, a 3D volume image block was sliced to with the patient, the entire examination can either be
demonstrate a coronal view of an open funnel retinal de- played back repeatedly (with the same perspective) or ro-
tachment (Figure 9-9). Retinal surgeons can use 3DUS to tated and viewed from any orientation. This is quite differ-
evaluate the shape of the funnel and document any sub- ent from conventiona12D ultrasound that typically involves
retinal elements of traction prior to surgery. The ultra- the acquisition and storage of five or more representative
sonographer need not mentally construct a 3D image, be- 2D images. 1,4,5
Chapter 9 THREE-DIMENSIONAL ULTRASOUND OF THE EYE
243
telemedicine will make the unique talents of ultrasound

specialists available to more patients around the world.
At this time, 3DUS should beviewed as an emerging
technology that offers unique capabilities for improving
ophthalmic practice and patient care.
REFERENCES
1. Byrne SF, Green RL: Ultrasound of the Eye and Orbit. St. Louis, Mosby,
1992.
2. Coleman DJ, Katz L, Lizzi FL: Isometric, three-dimensional viewing
of ultrasonograms. Arch Ophthalmol197 5;93: 13 62.
3. Coleman DJ, Rondeau MJ, Silverman RH, et al: Correlation of mi-
crocirculation architecture with ultrasound backscatter parameters of
uveal melanoma. Eur J OphthalmoI1995;5:96.
4. COMS Study Group: Echography (Ultrasound) Procedures fOf the
Collaborative Ocular Melanoma Study (COMS), Report No. 12, Part
I.J Ophthalmic Nurs TechnoI1999;18:143. .
5. COMS Study Group: Echography (Ultrasound) Procedures for the
Collaborative Ocular Melanoma Study (COMS), Report No. 12, Part
II.J Ophthalmic Nyrs TechnoI1999;18:219. .
6. Downey DB, Nicolle DA, Levin MF, et al: Three-dimensional wtra-
Figure 9-10 Hemorrhagic choroidal detachment imaged with sound imaging of the eye. Eye 1996; 10: 75.
3DUS. Coronal and oblique sections reveal scalloped shape of 7. Endo K, Kato S, Fukushima H, et al: Usefulness of three-dimensional
choroidal detachments. Dotted lines, Surface of choroidal detach- ultrasonography for invisible fundus [letter]. Br J Ophthalmol
ments; A, anterior; T, temporal; S, superior. (Courtesy Dr. Julian 2000;84:1080.
Garcia, New York, New York.) 8. Finger PT: Radiation therapy for choroidal melanoma. Surv Qphthal-
mol, 1997;42(3):215.
9. Finger PT: Tumour location affects the incidence of cataract ·and
retinopathy after ophthalmic plaque radiation therapy. Br J Ophthal-
mol 2000;84:1068.
10. Finger PT, Iezzi R, Esteveo ML, et al: Diode-light transillumination
The interactive ability to rotate and slice a 3D volume for ophthalmic plaque localization around juxtapapillary choroidal
image block allows for the analysis of unique coronal and melanomas. Int J Radiat Oncol Bioi Phys 1999; 44:887.
11. Finger PT, Romero JM, Rosen RE, et al: Three-dimensional ultra-
oblique perspectives. These views were not previously ob- sonography of choroidal melanoma: localization of radioactive eye
tainable with 2D ultrasound because oflimitations in probe plaques. Arch OphthalmoI1998;116:305.
placement due to the orbital bone and other anatomlc 12. Fisher Y, Hanutsaha P, Tong S, et al: Three-dimensional ophthalmic
contact B-scan ultrasonography of the posterior segment. Retina
structures (see Table 9-1). As with evaluation of the static 1998;18:251.
2D images, retrospective evaluation of the 3D volume im- 13. Gosbell AD, Barry WR, Favilla I: Computer-aided volume measure-
.age block does not reproduce the dynamic nature of the ment of choroidal melanomas. Aust N ZJ OphthalmoI1987;15:349 .
14. Harbour Jw, Murray TG, Byrne SF, et al: Intraoperative echographic
original ultrasound examination. In fact, the quality of the localization of iodine 125 episcleral radioactive plaques for posterior
reconstructed 3D volume image block is exquisitely sensi- uveal melanoma. Retina 1996;16:129.
tive to movement of either the patient's eye or the ultra- 15. Iezzi R, Rosen RE, Tello C, et al: Personal computer-based 3-dimen-
sional ultrasound biomicroscopy of the anterior segment. Arch Oph-
sonographer's hand during the S- to 7.S-second image ac- thalmoI1996;114:520.
quisition cycle. In practice, multiple 3D data sets are usually 16. KopelmanJE, McLean Iw, Rosenberg SH: Multivariate analysis of
acquired and reviewed until the reconstructed volume is risk factors for metastasis in retinoblastoma treated by enucleation.
Ophthalmology 1987;94:371. .
free of motion artifacts. 17. Pe' er J, Rummelt V, Mawn L, et al: Mean of the ten largest nucleoli,
microcirculation architecture, and prognosis of ciliochoroidal
melanpmas. Ophthalmology 1994;101:1227.
FUTURE DIRECTIONS AND THE INTERNET 18. Romero JM, Finger PT, Rosen RE, et al: Three-dimensional ultra-
sound for measurement of choroidal melanomas. Arch Ophthalmol
The Internet has revolutionized everyday life, and telemed- 2001;119:1275.
icine is rapidly becoming a reality. Teleradiology has led the 19. Romero JM, Finger PT, Iezzi R, et al: Three-dimensional ultra-
sonography of choroidal melanoma: Extrascleral extension. Am J Oph-
way because radiographic images lend themselves to being thalmoI1998;126:842.
transmitted from a remote facility to the radiologist. In 20. Rosen RE, Iezzi R, Romero J, Finger P: Topography Mapping. In
these cases, the ability to replay the 3DUS, as well as the Shammas JH, Dunne S, Fisher Y: Three-Dimensional Ultrasound Topog-
raphy of the Eye. Eden Mills, Ontario, NovaCoast, 1998, p 197.
ability of the observer to evaluate the scanned tissues inter- 21. Shammas JH, Dunne S, Fisher Y: Three-Dimensional Ultrasound. To-
actively, are likely to make this format invaluable. Clearly, mography of the Eye. Eden Mills, Ontario, NovaCoast, 1998.
Axial Eye Length
Measurements
(A-Scan Biometry)
The measurement of axial eye length (AEL) is the most In children, A-scan biometry has become increasingly
common ultrasound procedure performed in ophthalmol- important, both for IOL calculations,and for management
ogy and is the primary component of intraocular lens (IOL) of congenital glaucoma. Various studies have been per-
power calculations. 8,18,31,43 This chapter will describe the formed to establish standard axial length values in the pe-
contact and immersion examination techniques for mea- diatric population (Table 10-1 ).11,13,16,46
suring eye length2 ,12,37 (Figure 10-1). It will also cover dif-
ferent types of instrumentation and the use of appropriate
INSTRUMENTATION
instrument settings. Solutions to various problems and the
avoidance of pitfalls will also be addressed. This chapter A variety of A-scan equipment is available for AEL mea-
will also discuss the use of A-scan biometry in the diagno- surements. Some instruments are specifically dedicated to
sis and management of certain ocular conditions (e.g., con- AEL measurements (i.e., biometers), whereas others have
genital glaucoma and nanophthalmos). capabilities for both diagnostic and biometric examinations
(Figure 10-2). Most available biometers provide accurate
STANDARD AXIAL EYE LENGTH measurements as long as proper technique is used.
Certain features are recommended when choosing
DIMENSIONS
among the instrumentation that is currently available (Box
The accuracy of AEL measurements, using A-scan ultra- 10-1). Most importantly, an instrument should have a
sound, is generally accepted to be within 0.1 mm. 1,3 Standard screen display that can be continually monitored. In addi-
values for the AEL and the various ocular components (i.e., tion to the echogram, the display should ideally include a
cornea, anterior chamber, and lens) have been established. A numerical reading of the AEL measurement, as well as val-
review of several studies using different measurement tech- ues for the anterior chamber depth, lens thickness, and vit-
niques shows that the axial length of the normal eye is ap- reous length. Certain instruments additionally provide val-
proximately 23.6 mm.* It has also been shown that the ma- ues for the average and/or standard deviation of multiple
jority of axial lengths range from 22.0 mm to 24.5 mm22 and measurements obtained from a given eye. Contact and im-
that in most individuals, the difference in AEL measurement mersion capabilities are beneficial, as are manual and auto-
between right and left eyes is within OJ mm. 8,24,40 matic measurement modes.
Average values have also been determined for corneal In addition, some instruments provide the ability to
thickness, anterior chamber depth, and thickness of the change the sound velocity setting from preset values,
crystalline lens. 19 ,21 The established value for average which can be helpful in certain situations (see pp 246 and
corneal thickness is 0.55 mm. The anterior chamber depth 266). Also, most newer machines allow the storage of mul-
in phakic eyes has been found to measure 3.24 mm (±0.44 tiple echograms for subsequent review and critiquing, so
mm),21 and the thickness of the cataractous lens is 4.63 that scans of poor quality can be deleted and repeated, if
mm. 19 It has also been shown that the thickness of the necessary.
cataractous lens increases and the anterior chamber depth The majority of biometric A-scan instruments are digi-
decreases with age. 19 tized, which allows individual echograms to be frozen and,
in some instruments, one or more echograms to be stored.
*References 1, 3,19,21,22,36,41,42. Most of these machines have a foot pedal that is depressed to
244
Chapter 10 AXIAL EYE LENGTH MEASUREMENTS (A-SCAN BIOMETRY) 245
I
I
I
I
A I
I I
I I I II
I I I II
If1Ar'PI R!\~
,ul~\
I --------------
,
I C
: I(A_=_~~~_=_~~~~~_=_
B I
I
II
II
p
---------
I II
I II
I::
I II
II
I II I
I II I R
: II I I--~~~-
I II I liS
~JI'\IL'~
I ~ \
Figure 10-1 Techniques for contact (A) and immersion (B) A-scan AEL measurements. In both
methods, the sound beam is directed along the visual axis, through the center of the lens, perpen-
dicular to the macula. A, Probe is placed directly on cornea. I, Initial spike corresponding to probe
tip on cornea; A, anterior lens capsule; P, posterior lens capsule; R, retina; S, sclera. B, Probe is
placed in fluid within immersion shell (not touching cornea). I, Initial spike corresponding to tip of
probe in fluid; C, cornea; A, anterior lens capsule; P, posterior lens capsule; R, retina; S, sclera.
freeze a given scan. The foot pedal is beneficial because it

TABLE 10-1
frees the examiner's hands to perform other functions.
Documentation of measurements is important and can Normal Axial length Values
be accomplished with a photograph of the echogram. Many Age Axial Length (in mm)
of the newer biometers also offer the option of a printer, Newborn 17.02
which can provide less expensive documentation of findings. 10-45 days 17.22
Also, many of these biometers are programmed with a vari- 46-75 days 18.77
76-120 days 19.43
ety of formulas to facilitate calculation of the IOL power.
5-9 months 20.09
10-18 months 20.14
Probes 19-36 months 22.01
4-5 years 22.78
The first generation of contact biometers used water-filled 6-7 years 22.56
probes with a soft membranous tip. The purpose of the soft 8-10 years 23.12
tip was to minimize corneal indentation. Water-filled
Modifed from Grignolo A, Rivara A: Biometry of the human eye from
probes, however, must be filled with distilled water, and in the sixth month of pregnancy to the tenth year of life, in J Vanysek
the process, small air bubbles can become trapped in the (ed): Diagnostica Ultrasonica in Ophthalmologia, Brno, Czechoslova-
kia, Universita J.E. Purkynje, 1968, p 251.
246 THE GLOBE
A B
Figure 10-2 Instruments used for A-scan biometry. A, BVI Axis (BV International, Clermont-
Ferrand, France) is primarily used for AEL measurements. B, P ABD-X (Innovative Imaging,
Inc, Sacramento, California) can be used for both AEL measurements and diagnostic echography.
ular instrument is important so the proper adjustments can

BOX 10-1
be made. 5,s
Recommended Features of Biometry
Instrumentation
Measurement Mode (Automatic vs. Manual)
Screen display
Contact and immersion capabilities Most of the newer biometry instruments provide a choice
Choice of average or individual sound velocity settings of automatic or manual measuring modes. In the automatic
Adjustable sound velocity settings mode, the instrument (rather than the examiner) selects the
Four or more measuring gates (which are moveable on scan to be measured. The automatic acquisition of an
frozen echogram) echo gram is often accompanied by an audible tone. These
Numeric values displayed for anterior chamber depth, automated features can allow the examiner to concentrate
lens thickness, vitreous length, average and standard
on the mechanics of technique while relying on the instru-
deviation of the AEL measurements
ment to indicate when proper sound beam alignment has
From Byrne SF: A-scan Axial Length Measurements-A Hand- been achieved. Furthermore, the automatic mode can be
book for IOL Calculations. Mars Hill, NC, Grove Park Publishers, beneficial for performing more rapid measurements in an
1995, p 10. otherwise normal cataractous eye. Although these auto-
matic features require minimal technical skill, it is impor-
tant that the examiner be able to interpret the echograms
water chamber. These bubbles can result in erroneous AEL selected by the instrument.
readings. Some biometers also provide a semiautomatic or dense
Newer biometers use a solid probe that requires less cataract mode that can be used when the examiner is having
maintenance and avoids many of the problems inherent in difficulty in displaying a distinct, high spike from the pos-
water-filled probes (Figure 10-3). The solid tip probe, how- terior lens capsule or retina. In this mode, the instrument
ever, can more easily indent the cornea, resulting in a short- parameters for spike height and smoothness are somewhat
ened AEL reading. Nevertheless, in most cases, the probe relaxed compared to those used for the fully automatic
can be applied with minimal pressure, thereby minimizing mode.
corneal compression. A manual scanning mode can also be used. For this
Most biometry probes function at an operating fre- mode, the examiner determines when a scan is to be mea-
quency of 10 to 12 MHz, providing adequate resolution for sured, depresses a foot pedal to freeze the image, and posi-
obtaining accurate measurements. Some of these probes tions the gates at the desired spikes. It should be noted,
emit a focused sound beam, whereas others emit a nonfo- though, that in some instruments, it is necessary to prepo-
cused beam (see p 6). sition the gates prior to freezing the echogram. The man-
ual mode may be helpful for examining aphakic and
pseudophakic eyes, as well as phakic eyes in which mea-
INSTRUMENT SETTINGS
surements are difficult to obtain using the automatic mode.
The settings on most instruments include (1) measurement With the manual mode, more time can be taken to align
mode, (2) eye type, (3) position of electronic gates or cur- the sound beam along the visual axis to select the best scan
sors, and (4) gain. Familiarity with the settings on a partic- for measurement.
Figure 10-3 Solid and water-filled probes mounted in spring-loaded sleeve for applanation
technique. A, Solid-tip probe has fixation light in center of probe (arrow). B, Water-filled probe
with rubber membrane on surface.
the instrument should always be checked prior to begin-

TABLE 10-2
ning the examination.
Sound Velocities for Eye Length When measuring a phakic eye, some instruments use an
Measurements average sound velocity setting of 1,550 m/sec, which takes
INDIVIDUAL OCULAR MEDIA into account the faster sound speed in lens (1,641 m/sec), as
Medium Velocity (m/sec) comparedto aqueous and vitreous (1,532 llIsec). This av-
Cornea 1,641 erage sound velocity assumes a constant relationship be-
Aqueous/vitreous 1,532 tween the lens thickness and the depth of the anterior
Crystalline lens 1,641* chamber. Although this method is sufficient for measuring
Solid tissue 1,550 the normal phakic eye (see p 252), slight errors may occur
IOL Implants See Table 10-3
Silicone oil 980-1,040
when ~e lens is inordinately thin or thick or when the eye
EYE TYPES is very short or very long. 3,2o In these cases, more accurate
Eye Type Velocity (m/sec) measurements can be obtained with instruments that mea-
Aphakia 1,532 sure the components separately at their appropriate sound
Phakia (average) 1,550 velocities and then add'these individual values together for
Pseudophakia 1,532 (see p 255) the final reading.
If an incorrect eye type (sound velocity setting) is used,
*This value may decrease with age (see p 253).
an erroneous measurement will occur. The correct value
can be determined, however, without remeasuring the eye
Eye Type (Sound Velocity)
by using the velocity conversion equation8 ,20 (see p 262).
As discussed in Chapter 1, ultrasound measurements are
calculated according to the speed at which the sound wave
Gates
travels through a given medium. The use of appropriate
sound velocity settings is essential for obtaining accurate Gates are electronic markers or cursors on the screen dis-
AEL measurements(Table 10-2). The velocity setting on play that provide measurements of the distance between
248 THE GLOBE
A D
B E
C F
Figure 10-4 Normal contact axial A-scans shows proper positioning of gates. Echograms were
obtained from six different phakic eyes using instruments with varying types and number of
gates. A, Mini A-scan (4 gates). Small arrow, Ascending limb or leading edge of spike; large ar-
row, descending limb of spike; 1, corneal gate (initial spike); 2, anterior lens capsule gate; 3, pos-
terior lens capsule gate; 4, retinal gate. B, Sonomed A-2500 biometer (2 gates). C, Paxial biom-
eter (4 gates). D, Ophthascan S, BfA-scan (4 gates). M, Multiple signal. E, Ocuscan biometer
(4 gates). F, P ABD-X, BfA-scan (4 gates). Note that gates are positioned on either the ascend-
ing limb or peak of each spike but are never placed on the descending limb of a spike. (From
Byrne SF: A-scan Axial Length Measurements-A Handbook for IOL Calculations. Mars Hill, NC,
Grove Park Publishers, 1995, p 20.)
Chapter 10 AxiAL EVE LENGTH MEASUREMENTS (A-SCAN BIOMETRV) 249
A B
Figure 10-5 Contact axial A-scans from phakic eye at high gain (A) and reduced gain (B).
I, Initial spike; A, anterior lens capsule; P, posterior lens capsule; M, multiple signals; R, retina;
S, sclera; 0, orbital fat; arrows, gates. (From Byrne SF: A-scan Axial Lengtl; Measurements-A
Handbook for 10L Calculations. Mars Hill, NC, Grove Park Publishers, 1995, p 22.)
two or more anatomic interfaces; In the automatic mode Errors can occur when the gain is set too high or too
(see p 246), gate position is usually determined by the in- low. WIth a very high gain setting, instruments that mea-
strument, whereas in the manual mode, it is selected by the sure between the peaks of the spikes may yield a slightly
examiner. short reading. Conversely, at a very low gain setting, the
An ultrasound instrument can have two to four gates. amplitude of the retinal spike may decrease to the point
Aphakic and pseudophakic eyes are measured with either that the adjacent scleral spike may be mistaken forthe reti-
two or three gates, depending on the instrument (see p nal spike, resulting in a long reading. Occasionally, how-
255), and the phakic eye can be measured with as few as two ever, the use of a higher or lower gain setting may be nec-
or as many as four gates (Figure 10-4; see also p 252). essary (see pp 256 and 265). .
Significant measurement errors can result from incor-
rect gate placement. incorrect placement can occur when EXAMINATION PROCEDURES
either automatic or manual measurement modes are em-
FOR A-SCAN BIOMETRY
ployed and when using either the contact or the immersion
technique (see pp 253 and 260). Constant monitoring of Accurate AEL measurements can be facilitated by using a .
the echogram for proper gate placement is essential. systematic approach for each examination. Many errors can
Instruments that employ only two gates and do not al- be attributed to a breakdown of procedures or shortcuts
low changes in the preset sound velocity settings cannot taken during the examination. All examinations should be-
provide a separate value for the lens thickness. However, gin with the examiner taking a history and explaining the
there are circumstances in which this. measurement is nec- examination to the patient. The patient should be posi-
essary. For instance, some formulas require a lens thickness . tioned for the particular type of examination (i.e., contact
measurement for accurate calculation of the IOL power. 28 or immersion) and instruinent settings. should be adjusted
In such situations, the two gates can be placed on the ante- appropriately. The examination is then performed. When-
rior and posterior lens capsule spikes and the velocity con- ever possible, both eyes should be measured for compari-
version equation can be used to derive the lens thickness son. At the conclusion of the examination, the eye is
(see p 262). cleansed and the results are double-checked for accuracy.
Because there are advantages and disadvantages to both
Gain Setting the contact and the immersion methods, one may be more
The gain is defined as the degree of echo amplification in appropriate than the other in certain situations. Although
an ultrasound system. The adjustable gain setting controls both methods can yield accurate results, it is generally be-
the effective sound beam width, sensitivity, resolution, and lieved that the immersion technique produces the most pre-
depth of penetration (see p 8). . cise measurements. This is due to the potential error of
At the beginning of an examination, the gain should be corneal compression inherent in the contact technique.
placed at a relatively high level. A high gain setting should Four investigations comparing AEL using both contact and
be used initially to align grossly the sound beam with struc- immersion techniques in the same patients have reported
tures along the visual axis and to assess the overall appear- mean values ranging from 0.14 to 0.36 mm longer with the
ance of the echo gram. Ideally, the gain should then be re- immersion technique than with the contact method. 1,36,41,42
duced to a medium levelto improve resolution of the spikes These two methods will be discussed in detail later in this
(Figure 10-5). . chapter.
250 THE GLOBE
Keratometry phakic or contains silicone oil since these conditions re-

The keratometer is used to measure the radius of curva- quire the use of specific sound velocities and examination
ture of the anterior corneal surface. These measurements techniques (see pp 255 and 265). A history of diabetes or
(k-readings) are usually performed in conjunction with A- age-related macular degeneration raises the possibility of
scan biometry to calculate the IOL power for cataract detachment or thickening of the macula that may result in
surgery. Keratometry readings should always be obtained a short AEL measurement. Furthermore, a history that in-
prior to the AEL measurement. This is because A-scan bio- cludes a scleral buckling procedure indicates that the eye
metry may cause mild distortion of the corneal mires, re- may measure significantly longer than the fellow eye.
sulting in inaccurate k-readings. It is important that the
keratometry instrument be calibrated frequently to help as-
Patient Preparation
sure accurate readings.
After the biometry procedure is explained to the patient
and the patient is questioned about any allergies to eye
History-Taking
drops, anesthetic drops are instilled. The patient is posi-
A history should be taken prior to any biometry examina- tioned according to the measurement method to be used
tion. Information to be obtained includes any previous oc- (see pp 259 and 260). The main instrument settings (mea-
ular surgery, as well as known intraocular abnormalities. surement mode, eye type, gate position, and gain) should
For example, it is important to know if the eye is pseudo- be checked just before the examination (see p 246).
Figure 10-6 Correct (no compression) and incorrect (compression) placement of probe on
cornea. A, Schematic drawing and echogram show correct measurement when probe just touches
but does not indent cornea. The anterior chamber depth = 4.1 mm and the AEL = 24.0 mm.
A, Anterior lens capsule; P, posterior lens capsule; R, retina. B, schematic drawing and echogram
of same eye with corneal indentation. The anterior chamber depth and the axial length are both
decreased by 0.5 mm.
Prior to each use, the probe should be cleaned appro- tained. During each reading, the anterior chamber depth
priatelyand the probe tip inspected to ensure that it is dry should be evaluated since the chamber shallows when the
with no fluid adherent to the surface. After the probe and cornea is indented (Figure 10-6; see alsop 269). The use of
instrument settings have been assessed, the patient is in- intermittent probe contact also lessens the likelihood of a
structed to fixate in primary gaze, preferably at the light corneal abrasion. Damage to the corneal epithelium can re-
within the probe. Whenever possible, both eyes should be sult from excessive pressure or manipulation of the probe
measured to help avoid errors. on the corneal surface. '
Prior to each measurement, it is important to make cer-
tain that no ointment or excess fluid (e.g., anesthetic drops
Contact Technique
or tears) is present on the cornea. This is because even
Using the contact technique, the AEL is measured with the small amounts of fluid on the cornea may lead to an erro-
probe placed gently on the center of the cornea and the neously long AEL reading (Figure 10-7; see also p 256).
sound beam directed toward the macula. This technique
can be performed either by placing the probe in a chin rest Applanation Method
device (applanation method) or by holding the probe by For the applanation method, a chin rest apparatus is used,
hand (hand-held method). with the probe secured within a holder or sleeve. If avail-
Steps should always be taken to minimize both corneal able, a pressure-sensitive probe holder can be used to help
compression and corneal abrasion. This can be achieved by minimize corneal compression. The patient is seated up-
obtaining a measurement as soon as the probe touches the right, with the chin positioned firmly in the chin rest and
center of the cornea. The probe is then removed from the the forehead pressed against the headrest (Figure 10-8). The
eye, and the patient is asked to blink to keep the cornea patient is instructed to fixate in primary gaze at the tiny fixa-
moist. This on-and-off procedure is repeated several times tion light located within the center of the probe tip (see Fig-
until at least three high-quality readings have been ob- ure 10-3). Initially, the joystick is retracted as far away from
Figure 10-7 Fluid meniscus between probe tip and cornea (arrow). The presence of such fluid
will result in an abnormally long AEL measurement.
A B
Figure 10-8 Applanation technique. A, Joystick is fully retracted, with probe away from eye
prior to measurement. B, Joystick is advanced, just until probe touches corneal surface.
252 THE GLOBE
Figure 10-10 Patient positioned for contact, hand-held tech-

nique. Patient is reclined and eye being measured is positioned
near the screen.
the cataract is extremely dense, sound attenuation (see

B p 265) may cause weakening of the retinal and scleral
spikes, resulting in a more difficult, prolonged examination.
In this situation, the use of a manual mode or a semiauto-
matic (dense cataract) mode (see p 246) is preferable to the
use of a fully automatic mode.
The first spike in the echogram, the initial spike, repre-
sents the probe tip on the cornea and is always present in the
echbgram. In addition to the initial spike, four additional pri-
Figure 10-9 Contact, hand-held method using solid probe in
mary spikes are displayed from the phakic eye: anterior lens
pressure-sensitive sleeve. A, Probe in gentle contact with cornea.
B, Corneal compression. Note partial obscuration of numbers (ar- capsule, posterior lens capsule, retina, and sclera. The scleral
row) as probe retracts into sleeve. (From Byrne SF: A-scan Axial spike is then followed by a chain of spikes that originate from
Eye Length Measurements-A Handbook for IOL Calculations. Mars the orbital fat behind the eye (see Figures 10-1 and 10-5).
Hill, NC, Grove Park Publishers, 1995, p 29.) All four primary spikes should be as smooth, steeply rising,
and as high as possible. If one or more spikes are indistinct or
of much lower amplitude than the others, the sound beam
the eye as possible. The joystick is then advanced until the may not be properly aligned along the visual axis.
probe gently touches the center of the cornea. Either a manual or an automatic measurement mode can
be used to measure the normal, phakic eye (see p 246).
Hand-Held Method However, it is always best to use a manual mode for difficult
Extra caution must be exercised when a hand-held tech- examinations or whenever an abnormality is suspected or
nique is employed because the cornea is more easily com- is known to be present. The phakic eye type setting is em-
pressed with this technique than with the applanation ployed for the examination.
method. For hand-held measurements, the patient is either A-scan biometers generally measure the phakic eye in
seated upright or reclined. Some examiners prefer to use a one of two ways. Some use a preset, average sound velocity
probe mounted in a pressure-sensitive sleeve (similar to that setting (1,550 m/sec)1,26,27 and two gates; others use indi-
used for the applanation method) to help lessen corneal vidual sound velocity settings and four gates to measure
compression (Figure 10-9). For the pressure-sensitive each component of the eye 'separately.30,31 When two gates
sleeve to function as intended, the patient must be exam- are employed, the anterior gate is placed at the initial spike
ined in an upright or semireclined position. When a pres- and the posterior gate is positioned at the retinal spike. For
sure sensitive sleeve is not employed, the patient should be the four-gate method, gates are placed at the initial spike,
reclined. This facilitates placement of the examined eye the anterior lens capsule spike, the posterior lens capsule
near the screen for optimum hand/eye coordination (Figure spike, and the retinal spike (see Figure 10-4, A). With the
10-10) and provides better support for the probe. four-gate method, the anterior chamber depth is measured
using 1,532 m/sec, the lens is measured using 1,641 m/sec,
Measurement of the Phakic Eye (Contact Technique) and the vitreous is measured using 1,532 m/sec. The biom-
Accurate AEL measurements can usually be obtained from eter then automatically combines these individual mea-
a normal cataractous eye within a few minutes. However, if surements to determine the AEL measurement. The use of
Figure 10-11 Contact axial A-scan showing dense cataract. Figure 10-12 Contact axial A-scans from two different patients
Note the presence of abnormal spikes (vertical arrows) between showing multiple signals produced by the lens. A, Low reflective
anterior (A) and posterior (P) lens capsule spikes. Arrows, Gates; multiple signals (m·rows). A, Anterior lens capsule; P, posterior lens
I, initial spike; M, multiple signal; R, retina; S, sclera. capsule; R, retina. B, Multiple signals (arrows) are more irregu-
larly spaced and numerous due to the very dense nature of the
cataract.
individual sound velocity settings and four gates may pro- cataract is extremely dense. In some cases, multiple signals
vide more consistent and accurate AEL readings than use of produce low reflective spikes similar in appearance to those
a two-gate method with an average sound velocity. of vitreous opacities (Figure 10-12). In the phakic eye, these
Another method has been developed for measuring the weakly reflective echoes usually occur just to the right of the
phakic eye. 26 -28 This method uses two gates, as just de- posterior lens capsule spike. To distinguish such artifactual
scribed, and the aphakic sound velocity setting (1,532 m/sec) spikes from those produced by actual vitreous opacities, the
in lieu of the average phakic sound velocity setting (1,550 probe can be placed on the conjunctiva, with the sound
m/sec). Once the AEL measurement is obtained, a corrected beam directed anteriorly across the vitreous cavity, avoiding
axial length factor (CALF)23,28 is then added to account for the lens. With the sound beam bypassing the lens in this way,
the crystalline lens. This factor is based on changes in lens the multiple signals will no longer be present (see Figure
thickness and sound velocity that occur with age. The aver- 1-11). When, however, the spikes originate from vitreous
age CALF value for most cataract patients is 0.32 mm. 28 opacities, they will continue to be displayed. Should reposi-
When a phakic eye is measured, spikes may be displayed tioning the probe fail to determine the nature of these low
in the echo gram in addition to those used for the measure- reflective echoes, a B-scan examination can be employed to
ment. These additional spikes, which may occur between evaluate the posterior segment of the eye more thoroughly.
the anterior and posterior lens capsule spikes, are due to in- Abnormal vitreous spikes can occur from a number of
terfaces within a cataractous lens (Figure 10-11). Spikes conditions. The two most common conditions encountered
may also appear along the vitreous baseline, caused either during biometry are asteroid hyalosis (Figure 10-13) and
by artifacts (multiple signals [see p 466]) or by actual ab- vitreous hemorrhag~ (see p 45).
normalities in the vitreous cavity. When abnormal spikes are present, either within the
In biometry of the phakic eye, the majority of multiple lens or along the vitreous baseline, caution should be exer-
signals encountered are due to reverberations between the cised in using the automatic mode since the instrument may
probe and the crystalline lens. Multiple signals are usually place one or more gates on the wrong spikes, resulting in an
highly reflective and evenly spaced along the vitreous base- erroneous measurement (Figure 10-14; see also p 247).
line, declining in height from left to right. These signals dis-
appear at reduced gain levels (see Figure 10-5) and typically Measurement of the Aphakic Eye
produce more motion than spikes originating from tme in- (Contact Technique)
traocular interfaces. Multiple signals are usually few in num- The aphakic eye is generally easy to measure because of the
ber when the lens is clear or there is a cataract of only mod- absence of the lens. For this same reason, however, the
erate density. However, they may be more numerous when a sound beam can more easily be misdirected in the aphakic
254 THE GLOBE
Fig u re 10-13 Asteroid hyalosis. A, Contact axial A-scan showing medium-low reflective spikes
(arrows) from asteroid bodies. A, Anterior lens capsule; P, posterior lens capsule. B, Axial B-scan
of same eye showing dense opacities within vitreous cavity (arrows). ON, Optic nerve.
Figure 10-14 Erroneous AEL measurement using automatic measurement mode (contact
technique). The gates appear as bars beneath the spikes (1, initial spike; 2, anterior lens capsule;
3, posterior lens capsule; 4, retina). A, Erroneous automatic measurement. Gate 2 is properly po-
sitioned beneath the anterior lens capsule spike (A), but gate 3 is incorrectly placed beneath a
high spike from within the cataractous lens (arrow). Note that the lens thickness measures only
1.08 mm and the AEL measurement = 24.16 mm. I, Initial spike; P, posterior lens capsule;
R, retina. B, Correct measurement using manual mode. Gate 3 has been repositioned beneath
the true posterior lens capsule spike. The correct lens thickness = 3.83 mm, and the AEL mea-
surement = 24.34 IDID.
Chapter 10 AxiAL EYE LENGTH MEASUREMENTS (A-SCAN BIOMETRY) 255
eye than in the phakic eye, in which the lens spikes help to Measurement of the Pseudophakic Eye
guide the sound beam along the visual axis .. (Contact Technique)
In the aphakic echo gram, the two lens spikes are re- . Measurement of the pseudophakic eye requires knowledge
placed by a single spike representing the iris, the poste- of the IOL composition and awareness of the artifactual
rior lens capsule, or the anterior vitreous face. The apha- signals in the echo gram produced by the IOL. Although
kic echo gram thus consists of the initial spike, a spike most IOLs were initially made of polymethylmethacrylate
from the iris/posterior lens capsule/anterior vitreous face (PMMA), silicone or acrylic lenses are primarily used to-
spike, and spikes from the retina and sclera (Figure 10- .day. Because the sound velocity of these materials varies
15). In these eyes, it is suggested that the manual mea- significantly, it is important to identify the composition of
surement mode be used to help ensure alignment of the the IOL to facilitate the use of an appropriate correction
sound beam along the visual axis. The aphakic eye type factor for the AEL measurement.
(1,532 m/sec) is used for the measurement. Using two Holladay has described two methods for determining
gates, the anterior gate is placed at the initial spike and the correctiOIi factors to be used for the measurement of
the posterior gate at the retinal spike. Some instruments pseudophakic eyes. 26,27 One method employs simple cor-
provide three gates, with the second gate placed at the rection factors and can. be used for eyes of average length
iris/posterior lens capsule/anterior vitreous face spike to (Table 10-3). The other method, for longer and shorter
measure anterior chamber depth. . eyes, requires knowing the thickness of the IOL.
Measurement of the pseudophakic eye is performed with
the manual mode using the aphakic eye type setting (1,532
m/sec). The pseudophakic echo gram consists of the initial
spike and avery high reflective spike from the IOL, as well
as spikes from the retina and sclera. In addition, the implant
spike is followed by a chain of highly reflective artifactual
spikes (multiple signals) along the vitreous baseline. These
signals are caused by reverberations occurring between the
probe tip and the surface of the implanted lens. Using a two-
gate system, the anterior gate is placed at the initial spike
and the posterior gate is placed at the retinal spike (Figure
10-16). Some instruments provide three gates, with the sec-
ond gate positioned at the lens implant spike to measure an-
terior chamber depth. The true AEL is determined by
adding the appropriate correction factor for the IOL com-
position (e.g., PMMA, silicone, or acrylic) to the measured
value (Figure 10-17; see also Table 10_3).8,26-28
The presence of multiple signals in the pseudophakic
echogram is a potential source of error because one of these
signals may be mistaken for the retinal spike, resulting in a
falsely short measurement. If the automatic mode is used
for these measurements, the instrument may be unable to
identify the true retinal spike; therefore, the manual mode
is recommended. The position of the retinal gate should be
observed closely to. ensure proper placement. Mistakes are
TABLE 10-3
Average Correction Factors
for PseudophakiC Eyes
Implant Sound Velocity Correction Factor
Composition .(m/sec) (mm)
PMMA 2,720 +0.4 mm
Silicone 980 -0.8 mm
1,090 -0.6 mm
Figure 10-15 Contact axial A-scan of aphakic eye. A single spike Acrylic 1,900 +0.3 rrim
is produced from the posterior lens capsule (P) in this example. 2,120 +0.2 mm
J, Initial spike; R, retina; S, sclera; G, gates. (From Byrne SF: A-
scan Axial Length Measurements-A Handbook for JOL Calculations. Modified from Byrne SF: A-scan Axial Length Measurements-A Hand-
Mars Hill, NC, Grove Park Publishers, 1995, P 33.) . book for IOL Calculations. Mars Hill, NC, Grove Park Publishers, 1995, p 68.
256 THE GLOBE
Figure 10-16 Contact axial A-scan of pseudophakic eye. The IOL (L) produces a very highly
reflective spike. Note highly reflective multiple signals (vertical arrows) from reverberations oc-
curring between IOL and probe tip. 1, Initial spike; horizontal arrows, gates; R, retina; S, sclera.
(Echo gram from Byrne SF: A-scan Axial Length Measurements-A Handbook for 10L Calculations.
Mars Hill, NC, Grove Park Publishers, 1995, P 34.)
most easily made in short eyes, in which the multiple sig- pression, a fluid meniscus between probe and cornea, and
nals may be superimposed on the retinal spike. In such misalignment of the sound beam.
cases, the retina can be localized by observing the screen as The most common potential error with the contact
the gain is decreased. This results in disappearance of the technique is corneal compression that results in a shortened
multiple signals and persistence of the higher reflective AEL measurement. To minimize this error, a gentle on-
retinal spike (Figure 10,..18). and-off technique is recommended. Experience has shown
The average correction factors listed in Table 10-3 can that it is more difficult to control compression of the cornea
be used to determine the true axial length ofa pseudophakic when using the hand-held technique than when using the
eye when composition of the IOL is known. 26,27 The AEL is applanation method. Some ~xaminers, however, prefer the
measured using the aphakic sound velocity setting (1,532 hand-held method. To minimize compression with this
m/sec), and the appropriate factor is then added or sub- technique, it may be helpful to view the cornea from the
tracted. These values are intended for use in eyes of aver- side. Significant compression can usually be detected by
age length. Very short or very long eyes necessitate the use monitoring the anterior chamber depth. When the cornea
of a formula requiring knowledge of the IOL thickness. 28 is indented, anterior chamber depth decreases, indicating
that compression is occurring (see Figure 10-6).
Potential Sources of Error with the Contact Method A fluid meniscus trapped between the tip of the probe
It is important to understand the potential sources of error and the cornea may result in a falsely long reading. 8,37 This
with thecontact technique. These include corneal com- can occur if a small drop of fluid is retained on the probe
A c
B D
Figure 10-17 Contact axial A-scans from two pseudophakic patients with different types of
IOLs. Both patients are pseudophakic in only one eye and phakic in the fellow eye. Patient 1:
PMMA implant (A) and normal, phakic fellow eye (B). Patient 2: Silicone implant (C) and nor-
mal, phakic fellow eye (D). Both pseudophakic eyes were measured using a sound velocity of
1,532 rn/sec with the addition of an appropriate correction factor. The phakic eyes were mea-
sured using an average sound velocity of 1,550 rn/sec. A, Patient 1. Measurement of eye with
PMMA IOL = 22.61 mm. The correction factor for PMMA (+0.4 mm) is added: 22.61 + 0.4
= 23.01 mm. I, Initial spike; L, lens implant; arrows, multiple signals; R, retina; G, gates. B, Pa-
tient 1. Measurement of phakic fellow eye = 23.14 mID. Note that the actual difference in AEL
between the two eyes is only 0.13 mm. I, Initial spike; A, anterior lens capsule; P, posterior lens
capsule; arrows, multiple signals; R, retina; S, sclera; G, gates. C, Patient 2. Measurement of eye
with silicone IOL = 25.17 mID. The correction factor for silicone IOL at 980 rn/sec (0.8 mID) is
subtracted: 25.17 mm - 0.8 mID = 24.37 mID. D, Patient 2. Measurement of phakic fellow eye
= 24.49 mID. Note that the actual difference in the AEL of the two eyes in C and D is only 0.12
mm. (From Byrne SF: A-scan Axial Length Measurements-A Handbook for IOL Calculations. Mars
Hill, NC, Grove Park Publishers, 1995, P 36.)
tip, if there is an unusually thick tear film, or if ointment is As previously mentioned, other important sources of
present in the eye (see Figure 10-7). Therefore, just prior to error include improper gate position (most often associ-
the measurement, the examiner should check to make cer- ated with the use of the automatic measurement mode,
tain that the probe tip is dry, that excess tears have been see pp 253 and 260) and incorrect eye type settings (see
wiped from the eye, and that no ointment has been previ- p 247).
ously applied.
In some cases, misalignment of the sound beam can oc-
Immersion Technique
cur with the use of the contact method, resulting in a
significant error. Proper alignment of the sound beam can The immersion technique is becoming increasingly popu-
be facilitated, however, by first localizing the optic disc and lar as demands for greater accuracy in postoperative visual
then shifting the sound beam temporally toward the mac- acuity increase and as its advantages become better known.
ula (Figure 10-19). This method employs a small water bath to avoid placing
Figure 10-18 Contact axial A-scans of pseudophakic eye
(PMMA implant) at high (A), medium (B), and very low
(C) gain settings. A, Multiple signals (arrows) nearly reach
the retinal spike (R). 1, Initial spike; L, lens implant. B, At
lower gain, multiple signals decrease in height. Spikes from
A the retina and sclera (S) are clearly displayed. C, At very low
gain, multiple signals begin to disappear whereas retinal and
scleral spikes persist. (From Byrne SF: A-scan Axial Length
Measurements-A Handbook for 101 Calculations. Mars Hill,
NC, Grove Park Publishers, 1995, P 38.)
B c
I
I
, I
I
I '~\,\ I I
I ~ I I
I
I : I
I I I I
I I I I
A
'~ B
'ILJU~\
rlTI RrS
Figure 10-19 Localization of macula technique. Contact AEL measurement to optic nerve
(A) and to macula (B) in same eye. A, Sound beam directed perpendicular to optic disc. Note
that low reflective spikes appear behind the globe as the sOlmd beam passes along the optic nerve
(N). Arrow, Initial spike; A, anterior lens capsule; P, posterior lens capsule; 0, optic disc;
G, gates. B, Sound beam is now properly directed perpendicular to retina (R) at the macula.
Note that spikes from the orbital tissues are higher reflective as compared with the lower re-
flectivity obtained from the optic nerve in A. Also note that the scleral spike (S) is now displayed.
Figure 10-21 Immersion axial A-scans from same eye. A, High

gain (Tissue Sensitivity) setting. Curved arrow, Initial spike corre-
sponding to probe tip within fluid; straight arrow, small air bubble
within fluid; C, cornea; A, anterior lens capsule; P, posterior lens
capsule; R, retina; S, sclera. B, Reduced gain setting with gates
Figure 10-20 Immersion examination technique. Patient is re- properly positioned on spikes. Corneal thickness = 0.49 mm; an-
clined with head positioned near the screen. The A-scan probe is terior chamber depth = 2.45 mm; lens thickness = 5.05 mm; AEL
immersed within the fluid overlying the cornea. measurement = 21.81 mm. Note that this instrument provides
five gates: two for cornea, two for lens, and one for retina.
the probe directly on the cornea. 8,37 The obvious advan- examiner immerses the probe into the fluid just until an
tage of this technique is that the cornea cannot be com- echogram is displayed. With the patient fixating on a target
pressed. In addition, the display of a separate corneal spike in primary gaze, the sound beam is directed perpendicular
(not present in the contact method) may facilitate align- to the center of the cornea along the visual axis. This re-
ment of the sound beam along the visual axis. The avail- sults in the display of a double-peaked corneal spike and
ability of both contact and immersion methods allows the single-peaked spikes from the anterior and posterior lens
examiner to choose the most suitable technique for a given surfaces, retina, and sclera. Once steeply rising, highly
situation. reflective spikes are displayed from these interfaces at high
The immersion technique is generally performed with gain, the decibel level is reduced slightly for improved res-
the patient reclined and the eye to be measured positioned olution (Figure 10-21). As the gain is turned down, the dis-
close to the screen. After topical anesthetic drops are in- played spikes decrease in height, necessitating close obser-
stilled, a small plastic cylinder (i.e., scleral shell; see Ap- vation of the screen to ensure that all spikes remain as high
pendix D) is inserted between the lids and filled about two- and distinct as possible. It may be necessary to adjust the
thirds full of methylcellulose (Figure 10-20; see also Figure position of the probe during this procedure to maintain
10-1). Air bubbles within the methylcellulose should be perpendicular sound beam incidence.
avoided as this can lead to erroneous measurements (see A measurement is taken when peaks of the displayed
Potential Sources of Error on p 260). spikes are at their maximum height, although in some cases,
For measurement of the phakic eye, the phakic eye type the height of the spikes may decrease slightly from left to
setting and either the automatic or manual measurement right. At least three high-quality echo grams should be ob-
mode can be used. Using a high gain setting initially, the tained from the examined eye. Measurements are usually
260 THE GLOBE
made electronically, using gates (see p 247).As for the con-

tact method, measurements can be obtained using two gates
and an average sound velocity setting or by using four gates
and discrete sound 'velocities for the aqueous, lens, and vit-
reous (seeTable 10-2). "With any immersion technique, the
first gate is positioned at the corneal spike rather than the
initial spike (which reptesentsthe tip of the probe). A
As previously described for the contact method, another
way to measure the phakic eye is to use the aphakic eye type
setting and add a CALF to the measured axial length
value 23 ,28 (see p' 253). .
Measurement of the aphakic,ot pseudophakic eye with
the immersion technique employs many of the same priri,.
ciples as the contact method (see p 255). It should be re-
emphasized thaLthe manual me.asurement mode and apha-
kic eye type setting should be used for measurement of both
the aphakic and pseudophakic eye.
Another type of scleral shell (prager shell; see Appendix
D) that has become available in recent years may simplify
the performance of the immersion technique for some ex-
aminers. 8 This shell is designed so that the probe can be se- B
cured by a set screw, allowing the probe and shell to func-
tion as one unit. The probe is inserted into the shell and
secured with its tip located approximately %inch from the
bottom of the shell. The shell (with probe attached) is
placed over the cornea, and balanced salt solution is in-
jected through a port on the side of the shell (Figure 10-
22). As the patient gazes at the light within the fixed probe,
Figure 10-22 Prager shell for immersion A-scan AEL measure-
the sound beam is easily aligned along the visual axis. An ment. A, Prager shell, butterfly cannula, and syringe. Note the
advantage of this shell is that it allows the immersion ex- white set screw near top of the shell that secures the probe. B, Pa-
amination to be performed with the patient sitting upright tient is examined in slightly reclined position. Balanced salt solu-
rather than reclined. Such positioning can be desirable tion is injected into the cannula to fill the shell. (From Byrne SF:
when a patient is confined to.a wheelchair, is otherwise un- A-scan Axial Length Measurements-A Handbook for IOL Calcula-
tions. Mars Hill, NC, Grove Park Publishers, 1995, P 44.)
able to tolerate a reclined position, or their eye contains sil-
icone oil (see p 265).
Potential Sources of Error
with the Immersion Technique Concluding the Examination
The primary source of error with the immersion technique The examination may be concluded once multiple, consis-
is the presence of small air bubbles within the fluid between tent readings have been obtained. Generally, an average of
the probe and cornea. These bubbles can result in the dis- three or more high-quality echograms are used to deter-
play of additional spikes in the echo gram to the left of the mine the final AEL reading. Ideally, the AEL readings from
corneal spike (Figure 10-23). Misinterpretation of one of multiple echograms should be within 0.2 mm. Additional
these spikes as the corneal spike can result in a falsely long echograms should be obtained if greater variability is noted.
measurement. This potential error can be avoided, how- Both the echograms and the accompanying numerical
ever, by identifying the double-peaked corneal spike to en- data should be evaluateq for accuracy. If errors are detected
sure proper gate placement. If too many bubbles are pres- (e.g., incorrect gate position or sound velocity settings, see
ent or if a bubble persistently adheres to the surface of the p 247), the examination may have to be repeated. In addi-
cornea, it may be necessary to remove and reapply the scle- tion, if discrepancies in measurements larger than 0.3 mm
ral shell and then to add fresh methylcellulose. are found between the two eyes, further testing (e.g., B-scan
As previously mentioned, the other primary potential examination, see p 263) should be considered. Repeat ex-
source of error includes improper gate position, most of- amination by a second examiner may also be helpful when
ten associated with use of the automatic measurement measurements are inconsistent.
mode (Figure 10-24; see also Figure 10-14). Errors can also After the examination, the eye should be cleansed of ex-
occur due to the selection of an inappropriate eye type cess fluid or irrigated to remove methylcellulose used for
(sound velocity) setting (see p 246). the immersion technique.
A B
Figure 10-23 Immersion axial A-scans from same eye showing proper (A) and improper (B)
gate placement. A, Correct gate placement yields an AEL measurement of 24. 33 mm. C, Cornea;
A, anterior lens capsule; P, posterior lens capsule; R, retina. A170WS, Gates. B, First corneal gate
is placed on peak of small air bubble (B) within fluid, causing incorrect AEL reading of 26.98
mm. Note that this instrument provides five gates: two for cornea, two for lens, and one for
retina. The initial spike was shifted to the left and is not visible.
A B
Figure 10-24 Immersion axial A-scans from the same eye demonstrating incorrect gate place-
ment with use of automatic mode. A, Incorrect gate placement with automatic mode. B, Correct
gate placement with manual mode. Measurements were performed using four gates. A, The in-
strument misinterpreted a spike originating from the lens nucleus (large arrow) for the posterior
lens capsule (P). The AEL = 22.92 mm. I, Initial spike representing probe tip in fluid (F);
C, cornea; A, anterior lens capsule; M, multiple signals; R, retina; S, sclera; snzall arrows, gates.
B, With manual mode, gate for posterior lens capsule is properly positioned and correct AEL
measurement = 23.00 mm. (From Byrne SF: A-scan Axial Length Measurenzents-A Handbook for
IOL Calculations. Mars Hill, NC, Grove Park Publishers, 1995, p 44.)
TROUBLESHOOTING Inadequate patient fixation can be related to poor visual

acuity in one or both eyes. If the cataract in the examined
Inadequate Patient Fixation
eye is extremely dense, the patient may be unable to clearly
One challenge that may occur during the biometry exami- visualize the fixation light within the probe. In this event, it
nation is a patient's inability to maintain steady fixation. In may be helpful to patch the fellow eye to eliminate distrac-
such situations, the first step is to ask the patient if he or tions. A patient who is still unable to visualize the light caIi
she can be made more comfortable. In many cases, merely be asked to gaze at another target with the fellow eye. If
modifying the head or body position is all that is needed to necessary, an assistant can hold a fixation target, such as a
solve the problem. penlight, at close range to be viewed by the fellow eye. If
262 THE GLOBE
the patient has poor visual acuity bilaterally and adequate the measurement (Vm) and then multiply by the incorrect
fixation cannot be attained, proper sound beam alignment (apparent) axial length reading (AAL)20:
will be difficult to achieve.
TAL = VcNm X AAL
Other techniques may be required if the patient has
strabismus, nystagmus or marked blepharospasm. When For example, an aphakic eye was measured using an in-
the examined eye is strabismic, the gaze of the fellow eye correct sound velocity of 1,550 rn/sec rather than the cor-
should be adjusted to bring the examined eye as close rect aphakic velocity of 1,532 rn/sec. The erroneous (ap-
as possible to primary gaze. In the unlikely event that parent) axial length reading obtained was 25.0 mm. To
fixation near primary gaze cannot be achieved, it may be determine the correct (true) axial length measurement:
necessary to examine the eye from an unconventional
1,53211,550 rn/sec X 25.0 mm = 24.71 mm
position (e.g., from the side). When a patient has nystag-
mus or blepharospasm, additional contact readings may To determine the true lens thickness (TLT) using a two-
be required to ensure accuracy, although an immersion gate system with unadjustable sound velocity settings, divide
technique (see p 259) is generally recommended in these the correct sound velocity (Vc) by the incorrect sound veloc-
cases to help prevent corneal abrasion. In fact, the im- ity that had been used for the measurement (Vm) and then
mersion technique should always be considered whenever multiply by the incorrect (apparent) measurement (AM):
a patient has difficulty maintaining fixation, since this
TLT = VcNm X AM
procedure often proves easiest and most accurate in such
circumstances. For example, lens thickness was measured with a two-
gate instrument with nonadjustable sound velocity settings
using the aphakic eye type (1,532 m/sec) rather than the
Incorrect Sound Velocity Settings
correct lens velocity (1,641 rn/sec). The erroneous (appar-
As previously mentioned (see p 247), accurate measure- ent) lens reading was 4.5 mm. To determine the correct
ments can only be obtained if the correct sound velocity (true) lens thickness measurement:
setting is used. This may apply to the entire AEL mea-
surement or to the measurement of individual ocular 1,64111,532 rn/sec X 4.5mm = 4.8 mm
components.
Errors in AEL measurements can occur if the wrong eye
Intraocular lesions
type (sound velocity setting) is chosen for the examination.
For example, if the phakic eye type setting is mistakenly Intraocular lesions (e.g., dense cataracts, asteroid hyalosis,
used to measure an aphakic eye, an erroneously long AEL retinal detachment, macular lesions, and posterior staphy-
measurement will result. Problems in measurement can lomas) can interfere with the ability to obtain accurate AEL
also occur if an instrument does not allow changes in the measurements. 33 Certain findings in the patient's history
sound velocity from preset values. This can be especially may suggest particular intraocular pathology that may be
problematic when measuring eyes containing silicone oil encountered during the examination. These include a his-
since the sound velocity of the oil is much slower than that tory of high myopia, previous cataract or vitreoretinal
of the vitreous (see Table 10-2). Furthermore, instruments surgery, diabetic retinopathy, and macular degeneration.
that employ only two gates and do not allow changes in the There are also certain clues that may be noted during the
preset sound velocity settings cannot provide a separate biometry examination that may suggest the presence of an
value for lens thickness. In all of these circumstances, the intraocular lesion (Box 10-2).
velocity conversion equation can be used to derive the cor-
rect values.
BOX 10·2
Velocity Conversion Equation
The velocity conversion equation 8 ,20 (VCE) is useful for A':$car1.FIndings'$\J~ij~$~iY~
obtaining a correct measurement when an inappropriate
of ani ntraocu lartesion
sound velocity is used during the examination. The cor- Unexpla i,nedspikes alongthevitreous Raseli rle
rect measurement is obtained by dividing the correct Irlf.!bJlitytodisplflydistim;t,!"lignretinaI ·~,~ik,e·.
sound velocity (Vc) by the incorrect sound velocity used Abnormal•• separationofrf;l.ti~alspi~efrorvsderfll.spikf;l
for the measurement (Vm), multiplied by the measurement In<;onsistentAJ:Lmf;lasurements in examined eye
obtained: . (>O.2mrn)
VariafionirtAELmeasuremeilt cOl1lparedtOfellOweye
correct value = VcNm X measurement (:>O.:3mm)
To determine the true axial length measurement (TAL) From Byrne SF: A-scan Axial Length Measurements-A Hand-
using the VCE, divide the correct sound velocity (Vc) by book for IOL Calculations. Mars Hill, NC, Grove Park Publishers,
the incorrect sound velocity setting that had been used for 1995, p 68.)
Whenever intraocular pathology is suspected, a B-scan addition; the macula may be located on the slope of the
examination should be performed to detect any abnormal- staphyloma, thereby resulting in oblique sound beam inci-
ities that may affect the AEL measurement. In many cases, dence to the macula (Figure 10-25). Localization of the
B-scan may assist in obtaining the measurements. A good macula and the display of a distinct, high retinal spike can
rule of thumb is whenever the posterior segment cannot be be very difficult in these eyes. 6,s
visualized with ophthalmoscopy, the eye should be screened A posterior staphyloma is suggested whenever a distinct,
with B-scan prior to biometry. high retinal spike is difficult to display and AEL readings
are long and inconsistent in the eye being measured (i.e.,
Posterior Staphyloma differing by more than 0.2 mm). In addition, if a distinct
The presence of a posterior staphyloma may complicate the retinal spike and consistent measurements are obtained but
biometry examination, and it should be considered whenever the probe appears to be directed eccentric to the macula
there is a history of high myopia. Posterior staphylomas of- (e.g., nasally), the possibility of a posterior staphyloma
ten cause an irregular shape of the ocular wall, resulting in an should be considered. Since staphylomas are typically bilat-
inability to display a distinct, high retinal spike, and thus po- eral and asymmetric in depth, the fellow eye will usually also
a
tentially leading to significant error in the A-scan measure- measure longer than normal with readings between the two
ment. These staphylomas are often located in the peripapillary eyes generally varying by more than 0.3 mm (see p 268).
region, adjacent to but not centered on the macula. In an eye with a suspected posterior staphyloma, immer-
Because the deepest portion of the staphyloma may be sion A-scan may allow for a more accurate measurement.
located eccentric to the macula, the measurement may be The presence of a separate corneal spike in the echogram
longer than the true axial length along the visual axis. In may assist in better aligning the sound beam along the visual
axis (see p 259). However, even with the immersion tech-
nique, a distinct, high retinal spike may not be obtainable.
When this occurs, it may be necessary to be satisfied with a
retinal spike that is less distinct and of lower amplitude for
the measurement than is generally acceptable.
B-scan can be of great assistance in the measurement of
eyes with posterior staphylomas. It can be used to demon-
A strate the shape of the posterior ocular wall and the rela-
tionship of the macula to the staphyloma. The AEL mea-
surement can also be obtained from the B-scan echogram
(using an immersion technique).7 Measurements are made
with either electronic gates (cursors) or by superimposing a
vector A-scan on the B-scan echogram6- S (Figure 10-26;
see also p 122).
In some severely staphylomatous eyes, it can be helpful to
use a combination of A- and B-scan techniques for the AEL
measurement. The anterior chamber depth and lens thick-
ness are first measured with either contact or immersion A-
scan techniques. Although these measurements are most
easily obtained using an instrument with four gates, a two-
B gate system can still be used by incorporating the use of the
I velocity conversion equation (seep 262). Once these values
I
I
I
I
I
are obtained, B-scan is then used to measure the length of
I A P' the vitreous cavity. A horizontal axial B-scan echogram (see
p 21) is obtained. One electronic cursor is placed at the pos-
terior lens capsule echo and a second cursor is positioned at
the surface of the macula. The A-scan measurements for
lens and anterior chamber and the B-scan measurement for
Figure 10-25 Posterior staphyloma located eccentric to the
macula. A, Horizontal axial B-scan demonstrates posterior staphy- the vitreous cavity are then added together to determine the
loma with deepest portion (black arrow) nasal to optic nerve (ON). final axial length reading (Figure 10-27).
Note that the globe is angulated in region of macula (white arrow).
B, Schematic drawing shows posterior staphyloma located eccen- Macular Lesions
tric to macula and contact A-scan echogram. Because of angula- The presence of an elevated macular lesion can complicate
tion of the globe wall temporal to the nerve, a portion of the
sound beam is refracted away from the probe. This results in a the biometry examination. These lesions may prevent the
poorly defined retinal spike (R). J, Initial spike; A, anterior lens display of a distinct retinal spike and often cause a short-
capsule; P, posterior lens capsule. ened AEL measurement. Lesions of the macula that may
264 THE GLOBE
A B
Figure 10-26 AEL measurement of an eye with a posterior staphyloma using immersion
B-scan and corresponding vector A-scan. Macula is located on slope of staphyloma. A, Hori-
zontal axial B-scan shows deep staphyloma with its base at optic nerve (ON). Line from vector
A-scan is positioned along visual axis to macula. f, Initial line representing probe tip in fluid;
B, bubbles in fluid; C, cornea; P, posterior lens capsule. B, Vector A-scan (from A) indicates AEL
measurement of 25.9 mm. f, Initial spike; B, bubbles in fluid; C, cornea; A, anterior lens cap-
sule; arrows, spikes within lens corresponding to dense nuclear sclerosis; P, posterior lens capsule;
R, retina; S, sclera. (From Byrne SF: A-scan Axial Length Measurements-A Handbook for fOL Cal-
culations. Mars Hill, NC, Grove Park Publishers, 1995, P 66.)
A
c
Figure 10-27 AEL measurement of an eye with posterior

staphyloma eccentric to the macula using a combination
of immersion A-scan (A and B) and contact B-scan (C).
A, Immersion A-scan measurement of anterior chamber
depth = 3.39 mm. I, Initial spike; white an'ows, gates;
C, cornea; A, anterior lens capsule; P, posterior lens capsule;
R, retina; S, sclera. B, Immersion A-scan measurement of
B anterior chamber depth = 4.76 mm. C, Horizontal axial
B-scan shows posterior staphyloma with deepest portion
(black arrow) nasal to optic nerve (ON). Note angulation of
globe in region of macula (M) and placement of electronic
cursors (black crosses) at posterior lens capsule and macula
for measurement of vitreous length. The AEL measure-
ment = 25.49 mm (3.39 + 4.76 + 17.34 mm).
Vitreous Lesions
Dense opacities and membranes in the vitreous cavity, espe-
cially when located near the retina, can potentially be mis-
taken for the retinal spike, resulting in erroneous measure-
ments. The two most common vitreous conditions that may
be encountered during the biometry examination are aster-
A oid hyalosis 18 (see Figure 10-13) and vitreous hemorrhage
(see p 45). Asteroid hyalosis can be especially problematic
because of the medium to high spikes that are produced by
the calcium particles in this condition. These spikes can eas-
ily be mistaken for theretinal spike, particularly when the
'automatic measurement· mode is used. Asteroid hyalosis
should always be suspected when' one or more· abnormal
spikes appear along thevitreous baseline and artifactual
spikes (i.e., multiple signals) have been exduded;
Intraocular air or gas bubbles from previous ocular
surgery can lead to a measurement error, in some cases
preventing the AEL measurement altogether. A small to
B
medium-sized bubble situated along the path of the visual
axis can produce a spike of extremely high reflectivity and
may cause shadowing (see pp 109 and 466). In some cases,
it may be possible to dislodge the bubble from the visual
axis by having the patient change his or her head or body
position.
Figure 10-28 Shortened AEL measurement due to retinal de-
tachment involving the macula. A, A-scan shows retinal spike (ar- Dense Cataract
row) separated from sclera (S). G, Gates. AEL = 22.06 mm (1.0
mm shorter than normal fellow eye). B, Horizontal axial B-scan . Strong sound attenuation, produced by very dense cataracts;
shows retinal detachment in macular region (arrow). ON, Optic can significantly impair the'ability to displayspikes from the
nerve.
various interfaces along the visual axis. In this circumstance, a
maximum gain setting may be required to obtain spikes of
sufficient height from the posterior lens capsule and retina.
affect AEL measurements include macular edema (see Extremely strong sound attenuation may occur when
p 67), disciform lesions secondary to AMD, and tumors there is dense calcification of the crystalline lens. This may
(see Chapter 5). A macular lesion should be suspected if result in shadowing of the posterior ocular strucmres (see
there is difficulty in displaying a steeply rising, high retinal p 466), thus preventing rneasurement of the AEL (Figure
spike or if the AEL in the measured eye is shorter than the 10-29). In such circumstances, it may be necessary to use
fellow eye by 0.3 mm or more. In addition, the distance readings obtained from the fellow eye for the IOL power
between the retinal and scleral spikes may appear greater calculations. It is important to remember, however, that the
than normal. AELmeasurement used should always be considered in the
The B-scan examination can be helpful for demonstrat- context of the patient's refractive history.
ing the presence of a macular lesion (see p 28) and, in some
cases, can establish its etiology. If it is determined that the Silicone Oil
macular lesion is only temporary (e.g., macular edema), it In recent years, silicone oil has become increasingly useful
may be necessary to add a correction factor to the mea- as a tamponade in the vitreous cavity for complicated reti-
surement to account for eventual flattening of the lesion. nal det~chment surgery.l0,34,44 The lower sound velocity of
Measurement of the fellow eye can be useful in 'choosing silicone oil must be taken into account if AEL measure-
the correction value for these eyes. 6 ments are performed for subsequent cataract surgery.34,35
This low sound velocity can result in pronounced sound at-
Retinal Detachment tenuation and difficulty in identifying the retinal spike. In
Retinal detachment involving the macula produces short- addition, if proper sound velocities are not used, erro-
ening of the AEL compared with the fellow eye. Retinal neously long AEL fI.1easurements will be obtained. The
detachment should be suspected when a wider than normal sound velocity of silicone oil that is most eommonly used in
distance between the retinal and scleral spikes is encoun- the United States today is 1,040mlsec (5,000 centistokes).
tered. If a retinal detachment is suspected, a B-scan exami- The velocity may vary, however, depending on the particu-
nation is indicated (Figure 10-28). lar silicone oil used (e.g., 980 mlsec [1,000 centistokes]).
266 THE GLOBE
In order to facilitate measurement of a silicone-filled

eye, it is recommended that the patient be seated upright.
This is because the silicone oil placed at the time of surgery
may not completely fill the vitreous cavity. If the AEL mea-
surement is carried out with the patient recumbent, the sil-
icone oil, which is usually lighter than vitreous, may move
tqward the front of the eye, thus creating a fluid-filled space
between the bubble of silicone oil and the retina in the pos-
A terior pole. When this occurs, it becomes difficult to dif-
ferentiate a spike produced by the posterior surface of the
silicone bubble from that produced by the retina. This may
then result in a falsely short AEL reading. With the patient
in an upright position, however, the silicone oil bubble typ-
ically remains in contact with the posterior retina, which
facilitates correct localization of the retinal spike.
For accurate AEL measurements in eyes containing sili-
cone oil, it is recommended that the various ocular compo-
nents (e.g., anterior chamber, lens and vitreous cavity) be
measured separately using four gates and appropriate sound
velocities (Figure 10-30; see also Table 10-2). This method of
measurement requires that the instrument used allow the
sound velocity settings to be changed from preset values.
If the biometer provides only preset sound velocities, an
AEL measurement can still be obtained using the velocity
B conversion equation (VCE)8,20 (see p 262). If the instrument
has four gates, the VCE is used to correct the vitreous
length measurement. If, on the other hand, the instrument
has only two gates, the VCE is used to correct measure-
ments for both the lens and vitreous length. In the example
of a two-gate machine, the anterior chamber depth, lens
thickness, and vitreous length are first measured individu-
ally using the aphakic eye type setting (1,532 mlsec). The
VCE is then applied to obtain correct measurements for
the lens and vitreous cavity. Finally, the individual values
are combined to determine the AEL measurement. Because
of these limitations, it is important to obtain the refractive
history and the AEL of the fellow eye whenever possible.
To use the VCE as just described, measure the AEL with
a sound velocity of 1,532 mlsec as follows:
1. Measure the anterior chamber depth. Place the first gate
c at the initial spike (contact method) or the separate
corneal spike (immersion method) and the second gate
at the anterior lens capsule spike. Record the anterior
chamber depth.
2. Measure the apparent lens thickness. Place the first gate
at the anterior lens capsule spike and the second gate at
the posterior lens capsule spike. Record the apparent
lens thickness.
3. Measure the apparent vitreous length. Place the first
Figure 10-29 Totally calcified, cataractous lens (contact tech- gate at the posterior lens capsule spike and the second
nique). A, Axial B-scan shows echo-dense, oval lens (arrows). Note gate at the retinal spike. Record the apparent vitreous
wide shadow posterior to lens (S) and absence of echoes from pos- length.
terior ocular wall. B, Axial A-scan at high gain shows very highly 4. Apply the velocity conversion equation:
reflective spikes from anterior (A) and posterior (P) lens capsules.
Note multiple signals of decreasing height (arrows) following a. True lens thickness = 1,64111,532 mlsec X measured
lens spikes, as well as lack of echoes from posterior ocular wall. lens thickness
C, A-scan at lower gain setting. Only spikes from anterior and b. True vitreous length = 1,04011,532 mlsec X mea-
posterior lens surfaces can be displayed. sured vitreous length
A c
B D
Figure 10-30 Erroneous AEL measurement of eye containing silicone oil. Contact and immer-
sion axial B-scan and A-scan echo grams from patient with phakic, silicone oil-filled eye (A and B)
and phakic fellow eye (C and D). Both eyes were measured using two gates and sound velocity of
1,550 m/sec. Note differing appearance and length of echograms from the two eyes. A, Horizon-
tal axial B-scan echogram at high gain. Silicone oil produces long, attenuated echogram due to slow
sound velocity of oil. Attenuation is apparent by decreased number and brightness of echoes from
posterior ocular wall (arrows) and orbital fat (0). I, Initial line; P, posterior lens capsule; M, multi-
ple signals; ON, optic nerve. B, Immersion A-scan axial length measurement (with compressed
screen expansion) = 33.82 mm. I, Initial spike representing probe tip in fluid; F, fluid; C, cornea;
A, anterior lens capsule; P, posterior lens capsule; M, multiple signals; R, retina; S, sclera; 0, orbital
fat. C, Horizontal axial B-scan echo gram at medium gain. I, Initial spike; P, posterior lens capsule;
a170WS, posterior ocular wall; 0, orbital fat; ON, optic nerve. D, Contact A-scan axial length mea-
surement (with compressed screen expansion) = 24.24 mm. I, Initial spike; A, anterior lens capsule;
P, posterior lens capsule; R, retina; S, sclera; 0, orbital fat. The eye containing silicone oil erro-
neously measures 9.58 mm longer than normal fellow eye due to use of an incorrect sound veloc-
ity setting. (From Byrne SF: A-scan Axial Length Measurements-A Handbook far IOL Calculations.
Mars Hill, NC, Grove Park Publishers, 1995, p 48.)
c. Add the true values for lens thickness and vitreous ing lengths. 20 His investigation has shown that the aver-
length to that of the measured anterior chamber age sound velocity for an eye of average length (23.5 mm)
depth is 1,139 m/sec in a phakic eye and 1,052 m/sec in an apha-
The following example utilizes the VeE in calculating kic eye.
the AEL measurement in an eye with silicone oil (four gate To determine the IOL power to be implanted in an eye
system with preset sound velocities). The anterior chamber with silicone oil, one must also consider the refractive in-
depth = 3.5 mm (using 1,532 m/sec), the lens thickness = dex of the oil compared to that of normal vitreous. The re-
4.7 mm (using 1,641 m/sec) and the apparent vitreous fractive index of silicone oil varies according to the manu-
length = 24.3 mm (using 1,532 m/sec). Therefore, the true facturer and is different from that of the normal vitreous.
axial length = 3.5 mm + 4.7 mm + (1,040/1,532 X 24.3 This difference necessitates a correction to determine the
mm) = 24.7 mm. power of posterior chamber implant to be used when sili-
The least preferred method of measuring an eye filled cone oil replaces normal vitreous. A formula has been de-
with silicone oil is to use only two gates and an average vised to correct for this change in refractive index that indi-
sound velocity setting. Hoffer has published a range of cates how much power needs to be added to the IOL power
average sound velocities (based on silicone oil with a calculation. 39 It has been shown that approximately 3.5
sound velocity of980 m/sec) to be used for eyes of vary- diopters should be added to the calculated IOL power when
268 THE GLOBE
a posterior chamber convexplano PMMAlens is used in an

eye of average length. This assumes, however, that the re-
fractive index of the silicone oil in the eye is 1.4034. Addi-
tional correction factors may be necessary if IOL implants
with a configuration other than convexplano are used.
However, if removal of the silicone oil is planned, it is not
necessary to use these correction factors.
An AEL measurement often cannot be obtained from an
eye.containing emulsified silicone oil. Emulsification results
in the production of small droplets of silicone that can com-
pletely fill the vitreous cavity. 8 These small droplets can
produce such highly reflective echoes and strong sound at-
tenuation that it may be impossible to display a spike from
the retina. In these situations, or whenever there is
difficulty in obtaining a measurement from an eye contain-
ing silicone oil, measurements from the fellow eye, if pos-
sible, can be used. However, the patient's refractive history
should be taken into account.·
Due to the obvious difficulty of obtaining accurate AEL
measurements of an eye containing silicone oil, it is rec-
ommended that biometry be obtained prior to insertion of
the oil whenever possible.
MINIMIZING ERRORS Modified after Byrne SF: A-scan Axial Length Measurements-
There are many potential sources of error in performing A Handbook for IOL Calculations. Mars Hill, NC, Grove Park
A-scan biometry that. can lead to a short or long measure- Publishers, 1995, p 24.
ment (Box 10-3). To minimize such errors, one must be con-

stantly vigilant, and the examination must be performed in a
systematic fashion (i.e., taking a thorough history, position- eliminated and replaced as needed (Figures 10-31 and
ing the patient properly, verifying the instrument settings, 10-32). If the quality of the scans does not explain the cause
and using appropriate examination techniques). Certain of the variability, then further investigation including diag-
findings observed during the biometry examination may also nostic B-scan may be necessary.
suggest a potential error in measurement (see Box 10-2). As previously mentioned, in most patients, the difference
A useful method for minimizing errors is to routinely in AEL between fellow eyes is generally within 0.3 mm.
compare the AEL measurement with the patient's refraction. Since greater differences may indicate an error in measure-
In myopic eyes, a relatively long AEL is usually observed ment, it is suggested that both eyes be measured whenever
whereas in hyperopic eyes, the AEL is relatively short (see possible. If a difference between the two eyes is found, the
p 244). It is noteworthy, however, that increased cataract for- history should be reviewed. In some cases, a difference in
mation can cause lenticular, as opposed to axial myopia. eye length can be explained by a variation in refraction that
In addition to the refraction, the AEL should be corre- existed prior to development of the cataract (ani-
lated with the corneal curvature (k-readings). For example, sometropia). A longer AEL may also be related to previous
long eyes generally have relatively flat k.:.readings, whereas ocular surgery, such as a scleral buckling procedure.4,17 A
shorter eyes are typically associated with relatively steep shorter axial length reading, on the other hand, may occur
k-readings. because of a macular lesion such as cystoid macular edema
Consistent measurements of the examined eye are one or age-related macular degeneration (see p 68).
indication that accurate measurements are most likely being Another situation that may produce a shorter AEL read-
achieved. A rule of thumb is that the measurements ob- ing in one eye than in the other is when the eye being mea-
tained from a given eye should not vary by more than 0.2 sured has a lower intraocular pressure. This can be due to
mm. Variability greater than 0.2 mm may indicate a prob- trabeculectomy surgery or to inflammation resulting in hy-
lem with alignment of the sound beam or the presence of a potony. In these eyes, a decrease in globe size may occur
lesion located along the visual axis. One way of monitoring secondary to lowered intraocular pressure9 (see p 216).
for variability is to store multiple scans and evaluate their When measurements between the two eyes are disparate
quality while comparing the anterior chamber depth and and yet scans are easily obtained and of high quality, a phys-
lens thickness, and observing the standard deviation. With iologic difference in eye length is more likely present than
this procedure, undesirable scans and measurements can be is an intraocular abnormality. Nevertheless, if the differ-
Chapter 10 AXIAL EVE LENGTH MEASUREMENTS (A-SCAN BIOMETRV) 269
B Figure 10-32 Contact axial A-scans (from same patient) shows

correct (A) and incorrect (B) sound beam alignment. A, High-
quality scan with sound beam perpendicular to both anterior (A)
and posterior (P) lens capsules as well as retina (R). S, Sclera;
G, gates. Note that the lens and retinal spikes are steeply rising and
maximally high. The AEL = 23.07 mm. B, Sound beam is directed
obliquely to posterior lens capsule and retina. Note that the AEL
erroneously = 23.45 mm (0.38 mm longer than the correct mea-
surement in A).
Figure 10-31 Immersion axial A-scans (from same patient)
shows correct (A) and incorrect (B) sound beam alignment. very reproducible yet inaccurate. For example, if corneal
A, Correct sound beam alignment is indicated by double-peaked
corneal spike (C), and regular decrease in height of spikes from compression occurs during each scan, a consistently short
lens and retina. 1, Initial spike representing probe tip in fluid; AEL measurement may be obtained in spite of normal-
F, fluid; A, anterior lens capsule; P, posterior lens capsule; M, mul- appearing echo grams. This potential problem can be avoided
tiple signals; R, retina; S, sclera; aTTOWS, gates. B, Incorrect sound by removing the probe from the cornea between scans and
beam alignment. Nonperpendicular sound beam incidence is in- carefully monitoring anterior chamber depth (see p 251). An-
dicated by single-peaked rather than double-peaked corneal spike,
disproportionately high anterior lens capsule spike, and indistinct other situation where consistent yet inaccurate readings may
retinal spike. Note that the properly aligned A-scan (A) is 0.54 be obtained is when an eye with a posterior staphyloma lo-
mm shorter than the improperly aligned A-scan (B). (From Byrne cated eccentric to the macula is measured (see p 263).
SF: A-scan Axial Length Measurements-Handbook for 10L Calcula-
tions. Mars Hill, NC, Grove Park Publishers, 1995, p 45.)
BOl CALCULATIONS
IOL power calculation formulas require the measurement
ence is not clearly explained by the ocular history, it is sug- of AEL and corneal power, as well as an IOL constant. 22 ,25,27
gested that the readings be checked by another examiner Some formulas also require measurement of the anterior
or an immersion technique be used. In some situations, a chamber depth, lens thickness, and corneal diameter. 25 ,27
diagnostic B-scan examination may be necessary to explain Errors in any of these measurements can lead to an unan-
the disparity in measurements. Furthermore, in the case of ticipated postoperative refractive error (Box 10-4). In addi-
a shorter AEL occurring due to low intraocular pressure tion to meticulous measurements, optimum postoperative
following trabeculectomy or uveitis, it may be necessary to results require personalization of the IOL constantP
adjust the axial length value used for IOL calculations. This One of the most common, yet preventable, sources of error
adjustment is based on whether the intraocular pressure is a problem in recording and transferring data (i.e., trans-
and, therefore, the axial length are expected to increase fol- position errors). Such errors can be avoided by routinely
lowing cataract surgery (see p 216). rechecking the values that are obtained, recorded, and used
It is important to re-emphasize that AEL readings can be for the IOL power calculation. In addition, documentation
270 THE GLOBE
eyes with small corneas may be clinically suspected of being

microphthalmic when the axial length actually may be nor-
Vl1a.~tiGi~at~qP:"ostqperative Refractive mal or long. The use of biometry for congenital glaucoma
Errors"" " has also become increasingly important (see p 209). Other
conditions for which AEL measurements may be necessary
~o:teritiaI5"9urceso"f Error include phthisis bulbi (see p 114), pseudoexophthalmos (see
"AEl.tmHa~Jr~rJ!eritincbfrect p 284), or pseudoenophthalmos. In patients with leukoko-
AI')t.erlot:chamber""d(?ptb .notasamkipated ria, AEL measurements can help identify or rule out
K.er~tor:T1l~th/"rJ!easllrement incorrect """ specific disorders (see Chapter 5). In addition, biometry can
"lOt powercalsuJatiQn incorrect help differentiate axial from lenticular myopia. 29 In all of
MislabeledlOL"
the above situations, ultrasound can be used to monitor for
'[ra riS pgsit ion ofdata
further increase in axial eye length. 14,15
B-scan examination can help detect the presence and lo-
cation of posterior staphylomas (see p 263) and can be used
of all measurements should be retained in the patients to measure the vertical and horizontal dimensions of an eye.
record. In some situations, the axial length may be normal, but
other dimensions of the globe may be large or small, indi-
UNANTICIPATED POSTOPERATIVE cating an abnormal shape. The detection of a globe with ir-
regular contour can be particularly important prior to
REFRACTIVE ERRORS
cataract or strabismus surgery.
When the desired refractive goal is not attained, a complete
investigation should be implemented (see Box 10-4). This
CLEANING AND CALIBRATION
assessment should generally include re-evaluation of the
OF BIOMETRY INSTRUMENTS
biometry and keratometry readings, postoperative position
of the IOL (e.g., in-the-bag or ciliary sulcus), and the for- Probes should be cleaned with a disinfecting solution be-
mula used for the original IOL power calculations. tween each patient examination. It is important, however,
Calibration of both the biometer and the keratometer that the probe tip be thoroughly rinsed with water or saline
can be checked. The AEL can be remeasured and the ante- prior to the next examination to avoid corneal injury. Addi-
rior chamber depth measured to determine if the postop- tionally, ultrasound probes should never be subjected to
erative depth corresponds with the estimated lens position heat, which can damage the sensitive piezoelectric crystal
(ELP).8,28,45 The postoperative k-readings can also be com- located near the probe tip. Calibration of the instrument
pared to preoperative values. Finally, the IOL power calcu- should be checked periodically according to the manufac-
lations can be recomputed to ensure that the correct lens turer's specifications.
constant was used and that the planned postoperative re-
fraction was included in the computations. REFERENCES
One of the first steps when investigating an unexpected 1. Artaria LG: Messung der bulbeslange mit verschiednen ultraschall-
postoperative refractive error is to remeasure the AEL. An geraten. Klin MonatsblAugenheilkd 1986;188:492.
error of only 0.1 mm in the measurement of an eye of av- 2. Binkhorst RD: The accuracy of ultrasonic measurement of the axial
length of the eye. Ophthalmic Surg 1981;12:363.
erage length results in approximately 0.25 diopters of post- 3. Binkhorst RD: Intraocular Lens Power Calculation Manual for IBM and
operative refractive error. This same degree of error has an Compatible Personal Computers, ed. 4, New York, RD Binkhorst, 1987.
even greater impact on the postoperative refraction in a 4. Burton TC, Herron BE, Ossoinig KC: Axial length changes after reti-
nal detachment surgery. Am J Ophthalmol1977 ;83 :83.
very short eye and is of less significance in a very long eye. 5. Byrne SF: A-scan Biometry (video tape). COVE series. San Francisco,
When possible, remeasurement should be performed by American Academy of Ophthalmology, 1988.
the same examiner using the same equipment and exami- 6. Byrne SF, Green RL: Ultrasound of the Eye and Orbit. St Louis, Mosby,
1992,p215.
nation techniques employed for the preoperative examina- 7. Byrne SF: Improving A-scans. Ocular Surgery News 1994;12:86.
tion. Also, it must be remembered that the sound velocity 8. Byrne SF: A-scan Axial Eye Length Measurements-A Handbook for IOL
of the implant in the pseudophakic eye must be considered Calculations. Mars Hill, NC, Grove Park Publishers, 1995.
9. Cashwell FL, Martin CA: Axial length decrease accompanying
when remeasuring the AEL after surgery (see p 255). successful glaucoma filtration surgery. Ophthalmology 1999;
106:2307.
10. Clemens S, Kroll P, Rochels R: Ultrasonic findings after treatment of
DIAGNOSTIC USES OF AXIAL retinal detachment by intravitreal silicone instillation. Am J Ophthal-
EYE LENGTH MEASUREMENTS mol 1984;98:369.
11. Coleman DJ, Lizzi FL, Franzen LA, et al: A determination of the ve-
In addition to its use for IOL calculations, AEL measure- locity of ultrasound in cataractous lenses, in Gitter KA, Keeney AH,
Sarin LK, Meyer D (eds): Ophthalmic Ultrasound. St Louis, Mosby,
ments can be helpful in the diagnosis and monitoring of 1969, p 246.
certain conditions. These include congenital disorders such 12. Coleman DJ, Lizzi FL, Jack RL: Ultrasono[51'aphy of the Eye and 01'bit.
as nanophthalmos (see p 82) and microphthalmos. Some Philadelphia, Lea & Febiger, 1977, p 91.
13. Fledelius HC: The growth of the eye from the age of 10 to 18 years. 30. Jansson F, Kock E: Determination of the velocity of ultrasound in the
A longitudinal study including ultrasound oculometry, in Thijssen JM, human lens and vitreous. Acta OphthalmoI1962;40:420.
Verbeek AM (eds): Ultrasonography in Ophthalmology. Dordrecht, Dr 31. Jansson F, Sundmark E: Determination of the velocity of ultrasound in
WJunk, 1981, P 211. ocular tissues at different temperatures. Acta OphthalmoI1961;39:899.
14. Francois J, Goes F: Comparative study of ultrasonic biometry of em- 32. Kendall CJ: Ophthalmic &hography. Thorofare, NJ, Slack, 1990, p 102.
metropes and myopes with special regard to the heredity of myopia, in 33. Martin RG, Safir A: Asteroid hyalosis affecting the choice of intraoc-
Gitter KA, Keeney AH, Sarin LK, et al (eds): Ophthalmic Ultrasound. ular lens implant. ] Cataract Refract Surg 1987; 13 :62.
StLouis, Mosby, 1969,p 165. 34. Meldrum ML, Aaberg TM, Patel A, Davis J: Cataract extraction after
15. FrancoisJ, Goes F: Oculometry of progressive myopia. BiblOphthal- silicone oil repair of retinal detachments due to necrotizing retinitis.
mol 1975;83:277. Arch OphthalmoI1996;114:885.
16. Grignolo A, Rivara A: Biometry of the human eye from the sixth 35. Milauskas AT, Marney S: Pseudo axial length increase after silicone
month of pregnancy to the tenth year of life, in VanysekJ (ed): Diag- lens implantation as determined by ultrasonic scans.] Cataract Refract
nostica Ultrasonica in Ophthalmologia. Brno, Universita J.E. Purkyne, . Surg 1988;14:400.
1968, p 251. 36. Olsen T, Nielsen PJ: Immersion versus contact in the measurement of
17. Harris MJ, BlumenkranzMS, WittpennJ, et al: Geometric alterations axial length by ultrasound. Acta Ophthalmologica 1989;67: 101.
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18. Hoffer KJ: Preoperative cataract evaluation, in Caldwell DR (ed): 38. Ossoinig KC: Standardized Ophthalmic Echography ofthe Eye, Orbit and
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Raven Press, 1988, p 24. City, Goodfellow, 1985, p 12.
19. Hoffer KJ: Axial dimension of the human cataractous lens. Arch Oph- 39. Patel AS: IOL power selection for eyes with silicone oil used as vitre-
thalmoI1993;111:914. ous replacement (abstract #163, p 41). Symposium on Cataract and Re-
20. Hoffer KJ: Ultrasound velocities for axial length measurement. fractive Surgery, April 1-5, 1995, San Diego.
] Cataract Refract Surg 1994;20:554. 40. RetzlaffJA, Sanders DR, Kraff MC: Lens PlYWer Calculations-a Man-
21. Hoffer KJ: Biometry of 7500 cataractous eyes. Am] Ophthalmol ual of Ophthalmologists and Biometrists, ed 3, Thorofare, NJ, Slack,
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22. Hoffer KJ: The Hoffer Q formula: A comparison of theoretic and re- 41. SchlenzJ, KammannJ: Comparison of contact and immersion tech-
gression formulas.] Cataract Refract Surg 1993;18:118. niques for axial length measurement and implant power calculation.
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25. Holladay JT, Prager TC, Chandler TY, et al: Improving the pre- News Circle Publishing, 1996.
dictability of IOL power calculations. Arch Ophthalmol1998; 104:5 39 44. Shugar JK, de Juan E Jr, McCuen BW IT, et al: Ultrasonic examina-
26. Holladay JT, Prager TC: Accurate ultrasonic biometry in tion of the silicone-filled eye: Theoretical and practical considerations.
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27. Holladay JT, Prager TC: Accurate ultrasonic biometry in 45. Sorenson AL, Holladay JT, Kim T, et al: Ultrasonographic measure-
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1955;36:81.
THE ORBIT
INTRODUCTION
Standardized Echography of the orbit is a highly sophisti- larly, echography is ideal for the follow-up of lesions where
cated and accurate method for detecting and differentiat- serial examinations may be necessary. Another advantage is
ing orbital lesions. This method, developed and described that ultrasound is typically performed or supervised by an
by Dr. Karl Ossoinig, uses the standardized A-scan and ophthalmologist; this can be beneficial in settings where the
contact B-scan to evaluate mass lesions of the orbit, as well radiologist does not have a great deal of experience in eval-
as disorders of the extraocular muscles and optic nerve. Ad- uating orbital disorders.
ditionally, Doppler ultrasound is used to assess blood flow Although ultrasound has many advantages, it does have
within certain orbital lesions. Although computed tomog- limitations and should be viewed as only one of several tests
raphy (CT) and magnetic resonance imaging (MRI) have that may contribute to the diagnosis and management of
greatly advanced imaging of the orbit and periorbital re- orbital disorders. One disadvantage is that lesions located
gions, ultrasound continues to provide important informa- near the orbital apex may not be reliably evaluated. This is
tion to aid in the diagnosis and management of orbital because the high frequency sound waves necessary for ade-
disorders. quate resolution of ocular and orbital structures have lim-
U1trasound is noninvasive, can be performed readily in ited penetration into the posterior orbit. CT and MRI may
the office setting, and is ideal for screening the orbits to de- provide a better overall view of the orbit and periorbital
termine when other procedures are indicated. The unique cavities and can show these areas simultaneously. Further-
features of ultrasound that make it so useful for intraocular more, it is easier for most ophthalmologists to interpret CT
examinations play an equally important role in the orbit. or MRI scans. For these reasons, it is suggested that orbital
The high resolution of echography provides reliable and ultrasound be used in conjunction with other imaging tech-
accurate assessment of orbital structures. The small, easily niques, bearing in mind the advantages and disadvantages
maneuverable ultrasound probes allow the evaluation. of or- of each, so that the best results can be achieved.
bitallesions with unusual configurations and locations. Ad-
ditionally, echography continues to be the best method for
INDICATIONS
determining the histologic architecture of lesions in vivo.
One of the important advances of echography is its abil- The indications for orbital echography have continually
ity to assess the kinetic properties of orbital lesions. Ultra- grown as the accuracy and capabilities of the instrumenta-
sound is also an important adjunct in the examination of tion and examination techniques have improved. Ultra-
small children, since it can often be performed without se- sound is indicated whenever signs or symptoms of orbital
dation and does not expose the patient to radiation. Simi- disease are present (Table II-I).
273
274 THE ORBIT
TABLE 11-1
Indications for Orbital Examination
Signs and Symptoms
Unilateral or bilateral exophthalmos
Enophthalmos
Globe displacement
Lid abnormalities
Ptosis
Retraction
Swelling
Ecchymosis
Palpable or visible masses
Chemosis
Motility disturbances; diplopia
Pain
Optic disc edema
Optic atrophy
Chorioretinal folds
Additional Indications
Tissue differentiation of mass lesions
Clarification of CT or MRI findings
Assessment of blood flow within lesions
Follow-up studies
Examination Techniques
for the Orbit
POSITIONING THE PATIENT
The orbital examination is divided into three major por-
tiop.s: (1) orbital soft tissue assessment; (2) extraocular mus- To begin the examination, the patient is reclined, with his
cle evaluation; and (3) retrobulbar optic nerve examination. or her head positioned close to the screen of the instrument
In this chapter, the techniques that are used to detect, dif- (see Figure 2-1). Topical anesthetic drops are instilled bi-
ferentiate, and measure mass lesions of the orbital soft tis- laterally, as it is best to routinely examine both orbits. This
sue and periorbital regions are addressed. 1-7 Techniques for is important because confirmation of whether an echogram
evaluating the extraocular muscles and optic nerves are de- is normal or abnormal can sometimes be made only by
scribed in Chapters 15 and 16. comparing with the uninvolved (normal) orbit. Further-
The marked heterogeneity of the orbital soft tissue, more, orbital disease sometimes may clinically appear to be
comprised of fat, connective tissue septa, nerves, and blood unilateral when, in fact, it is bilateral.
vessels, results in echograms that are very high reflective
(A-scan) and echo-dense (B-scan) (Figure 11-1). Two ap-
B-SCAN TECHNIQUES
proaches are used to evaluate the orbit: (1) trans ocular (i.e.,
examination through the globe), and (2) paraocular (i.e., ex- Specific techniques using both trans ocular and paraocular
amination next to the globe). The trans ocular route is used approaches have been developed to facilitate three-dimen-
to detect lesions located within the posterior and mid-as- sional thinking. These techniques include the use of trans-
pects of the orbital cavity, whereas the paraocular technique verse, longitudinal, and axial views.
is most helpful for lesions located within the lids or anterior
orbit (Figure 11-2, A and B). Since most orbital lesions have
Transocular Approach
a more homogeneous composition than the normal soft tis-
sue, they usually produce an easily recognizable defect in Transocular B-scantechniques are most useful to aemon-
the echogram (Figure 11-3, A and B). strate mid- and posterior orbital lesions. A combination of
A systematic approach using both standardized A-scan transverse, longitudinal, and axial views are used for trans-
. and contact B-scan should be employed to detect an orbital ocular scanning.
mass lesion quickly and reliably. Lesions that are large
enough to produce signs qr symptoms of orbital disease are Transverse Scans (Transocular Approach)
normally easily detected with echography. The exception The probe is placed on the globe with the longest diameter
to this is when a lesion is confined to the posterior orbit, of the oval-shaped probe face positioned parallel (i.e., tan-
where detection is always more difficult. gential) to the limbus. In this way, the back-and-forth
The importance of being familiar with echo graphic find- movement of the transducer is parallel to the limbus. The
ings in the normal orbit cannot be overemphasized. The sound beam then oscillates across the opposite fundus and
heterogeneous nature of the normal orbit can cause slight orbit, producing a circumferential slice (i.e., cross-section).
variations in a given echo gram. Also, minor differences in This orientation is appropriate for showing the lateral ex-
normal findings can occur from one patient to another. tent of a lesion (e.g., extending from 1- to 3-0'clockmerid-
Therefore, it is recommended that the echographer gain as ians, from 8- to 10:30-0'clock meridians, and so forth) (Fig-
much experience as possible in examining the normal orbit ure 11-4).
before attempting to evaluate patients with suspected or- As in the globe, the designation of the transverse
bital disease. Initially the orbital examination may be quite scan is determined by the meridian that lies in the cen-
lengthy, but as experience is gained, the examination can be ter of the scanned section. For example, if the probe is
performed within a few minutes. held vertically with its face centered on the 9-0'clock
275
276 THE ORBIT
A C
8 D
Figure 11-1 B- and A-scan echograms of normal eye and orbit. Horizontal screen expansion
for globe (A and B) and orbit (C and D). I, Initial line (B-scan) and initial spike (A-scan); V, vit-
requs cavity; S, sclera; 0, orbital soft tissue; a1"rOWS, orbital bone. The normal orbital tissue is
extremely high reflective on A-scan and echo-dense on B-scan. In orbital examinations, the
screen expansion for orbit is always used for A-scan, but either the globe or orbital screen ex-
pansion may be used for B-scan. Note that there are two multiple signals (lVI) shown in echogram
D. The first signal is due to reverberations between the sclera and the orbital bone. The second
multiple signal is caused by reverberations occurring between the probe and the sclera. Such ar-
tifacts are commonly seen when the orbital screen expansion on the A-scan is used.
Chapter 11 EXAMINATION TECHNIQUES FOR THE ORBIT 277
Figure 11-2 Transocular and paraocular A-scan (A) and B-scan (B, p 278) examination of a
normal orbit. A, A-scan echograms taken at Tissue Sensitivity. Top, Transocular approach. I, Ini-
tial spike; V, vitreous cavity; S, sclera, arrow, normal soft: tissue; B, orbital bone. Bottom, paraocu-
lar approach with probe placed on closed lid and sound beam directed into anterior orbit. I, Ini-
tial spike followed by chain of highly reflective spikes (arrows) from normal orbit. Spike chain
decreases in height at steep angle due to strong sound attenuation caused by normal tissue.
Continued
278 THE ORBIT
Figure 11-2, cont'd B; B-scan echograms obtained with mediuin~high gain setting. Top,
Transocular approach. I, initialline; V, vitreous cavity; 0, orbital soft tissue; arrows, orbital bone.
Bottom, Paraocular approach. I, Initial line; 0, orbital soft tissue.
Figure 11-3 Transocular and paraocular A-scan (A) and B-scan (B) examination of orbital
mass. A, A-scan echo grams taken at Tissue Sensitivity. 1, Transocular approach. I, Initial spike;
V, vitreous cavity; S, sclera; arrow, internal lesion spikes; B, orbital bone. 2, Paraocular approach.
I, Initial spike corresponding to probe tip on lid; A, anterior surface spike of lesion; arrows, in-
ternallesion spikes; P, posterior surface spike oflesion. The transocular approach is used to mea-
sure a lesion's maximal thickness, and the paraocular approach is used to measure its maximal
depth into the orbit. B, B-scan echo grams obtained using medium gain setting. 1, Transocular
approach. I, Initial line; V, vitreous cavity; L, lesion; arrows, bone. 2, Paraocular approach. I, Ini-
tialline corresponding to probe face on lid; arrows, posterior surface of lesion.
280 THE ORBIT
Figure 11-4 Vertical transverse B-scan examination (trans ocular approach) of3-o'clock merid-
ian. A, The patient fixates toward the examined meridian. The probe marker is directed superi-
orly. B, Normal orbit. C, Extraconal tumor. V, Vitreous cavity; M, medial rectus muscle; L, le-
sion; arrows, orbital bone. Note that the medial rectus muscle is compressed by the mass in the
bottom echo gram.
meridian, the 3-0'clock meridian is displayed in the cen- the nasal portion of the orbit. Vertical transverse scans
ter of the echogram; this probe position is called a trans- (i.e., transverse scans of the 3- or 9-0'clock meridians) are
verse scan of the 3-0'clock meridian. If the probe is performed with the marker directed superiorly, so the
placed in a horizontal manner at the 6-0'clock limbus, the top of the echo gram represents the upper portion of the
sound beam sweeps perpendicularly across the 12-0'clock orbit.
meridian; this is called a transverse scan of the 12-0'clock Oblique transverse scans (e.g., transverse scans of the
meridian. 1:30-,4:30-, 7:30-, or 10:30-0'clock meridians) are per-
By convention, horizontal transverse scans (i.e., trans- formed with the marker directed toward the upper portion
verse scans of the 12- or 6-0'clock meridians) are per- of the orbit (see Figure 2-6 and Table 2-1). An oblique scan
formed with the probe marker oriented toward the pa- is the designation for a transverse view of any meridian
tient's nose, so the upper part of the echogram represents other than 12:00, 3:00, 6:00, and 9 o'clock.
9 3
Figure 11-5 Longitudinal B-scan examination (transocular approach) of 3-0'clock meridian.

Top, The patient fixates toward the examined meridian. The probe marker is directed toward
the center of the cornea and the 3-0' clock meridian. Center, Normal orbit. Bottom, Extraconal tu-
mor (same lesion as in Figure 11-4). V, Vitreous cavity; A, anterior aspect of globe; P, posterior
aspect of globe; ON, optic nerve; M, medial rectus muscle; L, lesion; arrow, orbital bone.
Longitudinal Scans (Transocular Approach) the screen and the anterior orbit being displayed on the up-
A three-dimensional conception of the orbit is greatly en- per portion of the screen. The designation of the longi-
hanced with the use of longitudinal B-scan echograms. tudinal scan is simply by the meridian that is being exam-
Longitudinal scans are performed with the probe rotated ined. For example, if the probe is placed on the 4-0'clock
90 degrees from the position used for the transverse scan. meridian of the globe, the sound beam sweeps along the
This means that the longest diameter of the oval-shaped 10-0'clock meridian; this is called a longitudinal scan of the
probe face is placed perpendicular (rather than parallel) to 10-0' clock meridian.
the limbus. The sound beam then sweeps along the merid-
ian that is located opposite to the probe, rather than across Axial Scans (Transocular Approach)
the meridian, as in the transverse scan. Consequently, the The axial orientation is the third type of probe position. An
longitudinal scan provides an anteroposterior view of the axial scan is performed with the patient fixating in primary
orbit and of a lesion (Figure 11-5). gaze and with the probe face centered on the cornea. The
In a longitudinal scan, the marker is always directed to- sound beam is then directed through the center of the lens
ward the center of the cornea and the meridian that is be- and the optic nerve. As mentioned previously, this scan is
ing examined (see Figure 2-8 and Table 2-1). This results in often the easiest to interpret because it displays a lesion in
the posterior orbit being displayed on the lower portion of relationship to the globe and optic nerve.
282 THE ORBIT
Figure 11-6 Horizontal axial B-scan examination. A, The patient fixates in primary gaze. The
probe marker is directed nasally. B, Normal orbit. C, Intraconal orbital mass. Note that the le-
sion (L) is located temporal to the optic nerve (ON).
When a horizontal axial scan is performed, the sound both transverse and longitudinal probe orientations.
beam sweeps through the 3- and 9-0' clock meridians, and Methylcellulose should be applied to the lids as a coupling
the marker is oriented toward the patient's nose (Figure medium whenever the para ocular approach is used.
11-6). In a vertical axial scan, the sound beam sweeps
through the 12- and 6-0'clock meridians, and the marker is Transverse Scans (Paraocular Approach)
oriented superiorly. With an oblique axial scan (e.g., the The probe is placed on the patient's closed eyelid, between
sound beam sweeps through the 1:30- to 7:30- or the 10:30 the globe and orbital rim, with the longest diameter of the
to 4:3 O-meridians) , the marker is always oriented toward the oval-shaped probe face oriented parallel to the orbital wall.
upper of the two meridians being examined (see Table 2-1). The sound beam then sweeps back and forth across the lid
and anterior orbit (i.e., tangential to the globe and parallel
to the orbital rim). The echographer shifts the probe back
Paraocular Approach
and forth between globe and bone to evaluate fully the re-
Paraocular B-scan techniques may be helpful to demon- gion beneath the probe. With the transverse scan, the lat-
strate anterior lesions in relationship to the globe and or- eral extent and posterior border of an anterior lesion can
bital wall. The paraocular approach can be employed with be demonstrated (Figure 11-7).
9 B
9 c
Figure 11-7 IJorizontal transverse B-scan examination (paraocular approach) of orbit at

12-o'clock. A, The probe is positioned on the upper lid. The probe marker is directed nasally.
B, Normal orbit (0). C, Superior orbital mass lesion (L). Arrow, Posterior surface of lesion.
The designation of the transverse scan is determined by from the transverse position, so that the longest diameter of
the meridian that lies in the center of the echo gram (just the oval-shaped probe face is now orientated perpendicular
beneath the probe). For example, if the probe is held hori- to the orbital rim. The sound beam thus sweeps back and
zontally with its face centered on the lid at the 12-0'clock forth (i.e., perpendicularly) between the globe and orbital
position, the echo gram is called a paraocular transverse scan wall. This scanning view may allow simultaneous display of
of the 12-0'clock meridian. Vertical and oblique transverse the peripheral globe and an anterior lesion, depending on
scans are also designated by where the probe is positioned. probe position (Figure 11-9).
The marker is oriented as previously described. WIth hor- Designation of the longitudinal scan is according to the
izontal scans (i.e., probe at the 12- or 6-0'clock positions), meridian being examined. For example, if the probe is
the marker is directed nasally; with vertical (i.e., probe at placed at the 1:30 position, the echogram is called a paraoc-
3- or 9-0'clock positions) and oblique scans, the marker is ular longitudinal scan of the 1:30-0'clock meridian.
directed superiorly (Figure 11-8, A). When performed along any meridian between the 3- and
9-0'clock meridians (i.e., superiorly), the probe marker should
Longitudinal Scans (Paraocular Approach) be directed to the bony wall (away from the globe) in the
As in the transverse paraocular approach, the probe face is meridian scanned. However, when this technique is per-
placed on the patient's closed eyelid between the globe and formed on any inferior meridian, the probe marker should be
orbital rim. The probe face, however, is rotated 90 degrees oriented toward the center of the globe (Figure 11-8, B).
284 THE ORBIT
A B
v 1~,--_......J
Figure 11-8· Various paraocular B-scan probe positions showing marker orientation. A, Trans-
verse positions. Horizontal (H), marker nasal; vertical (V), marker superior; oblique (0), marker
superior (e.g., marker directed toward 10:30- or 1:30-o'clock meridians). B, Longitudinal posi-
tions. The marker is directed toward the orbital rim in positions 1-5 and toward the globe in po-
sitions 6-8. This system ensures that all lesions are displayed in proper anatomic position in the
echogram (e.g., above globe if located superiorly, and below globe iflocated inferiorly).
BASIC EXAMINATION FOR LESION

DETECTION orbit or the 9-0' clock meridian of the left orbit). Again, the
probe is shifted from limbus to fornix, thereby scanning
8-Scan Screening
the entire nasal half of the orbit. Similar maneuvers are
The orbital screening examination can be performed with then performed for the inferior and temporal aspects of
B- as well as with A-scan. The transocular and, in some the orbit.
cases, the paraocular approach is used for B-scan screening. Longitudinal scans (transocular approach) also can be
Systematic examination techniques are used for B-scan performed to evaluate the soft tissue and are useful for as-
screening of the orbit. The examination is performed ini- sessing the lacrimal gland region. The axial approach
tially with transverse scans (trans ocular approach) of the should also be used to evaluate the retrobulbar space. This
four major meridians, with the examiner using a medium- position is especially helpful for the detection of lesions that
high gain setting. Methylcellulose is applied to the probe are located near the posterior ocular wall, the optic nerve,
or eye surface, and the probe is placed directly on the or elsewhere in the muscle cone. Vertical and horizontal ax-
globe. ial scans (with the lens and the nerve centered) are per-
The superior portion of the orbit is scanned first, with formed first.
the patient's gaze directed toward the 12-0'clock meridian. When the axial approach is employed, the retrobulbar
The probe is oriented horizontally, with its face placed next space can be more completely evaluated by tilting the probe
to the inferior limbus and centered on the 6-0' clock merid- slightly so that the sound beam just bypasses the optic nerve
ian (i.e., horizontal transverse scan of the 12-0'clock merid- (i.e., para-axial). With a horizontal axial scan the probe is
ian), with the marker directed nasally. With the probe posi- tilted slightly up and then down, and with a vertical axial
tioned near the limbus, the posterior aspect of the superior scan the probe is tilted nasally and temporally (Figure
orbit is examined initially. The probe is then shifted toward 11-11). Careful comparison should always be made be-
the lower fornix, thereby screening progressively more an- tween the two orbits.
terior aspects of the superior orbit (Figure 11-10). As the If the examination is normal, the echographer may wish
probe is being shifted, the echographer continuously mon- to measure the axial lengths to determine if a large or small
itors the echogram to detect any abnormalities. eye is producing pseudoexophthalmos or pseudoenoph-
After the superior orbit has been examined with this thalmos. Additionally, a Valsalva maneuver may be per-
procedure, the nasal orbit is examined by having the pa- formed to look for an orbital varix that may be visible only
tient look medially. The probe is placed in a vertical ori- when filled (see p 359, Figure 13-18, and Color Plate 10).
entation, with its face centered near the temporal limbus Compressibility of the soft tissues should also be assessed
(i.e., transverse scan of the 3-0'clock meridian of the right during the screening procedure. This is accomplished by
9 B
Figure 11-9 Longitudinal B-scan examination (paraocular approach) of superior orbit at

12-o'clock. A, The probe is positioned on the upper lid. The probe marker is directed toward
12-o'clock. B, Normal orbit (0). C, Superior orbital mass lesion (L) (same lesion as in Fig~
ure 7-7). Note that paraocular longitudinal scans are obtained with the sound beam directed
simultaneously through peripheral globe and paraocular tissue. V, Vitreous cavity; black arrow,
posterior surface of lesion; white arrows, area of globe surface not imaged due to oblique
sound beam incidence.
pressing the probe lightly on the globe. Normal orbital soft screen expansion for orbit is selected (see Figure 11-1).
tissue is easily compressible, which results in appreciable Both transocular and paraocular approaches are used for
narrowing of the orbital echogram. A-scan screening.
Because of the large size of most B-scan probes, paraoc-
ular screening with B-scan is not as reliable as with the Transocular Approach
smaller A-scan probe. Therefore, paraocular B-scan screen- The transocular approach is used first. Probe placement
ing is performed routinely only if A-scan is unavailable. and movement for this technique are very similar to
that utilized for the globe. As in the globe examination,
the 12-0'clock meridian is examined initially. The patient
A-Scan Screening
fixates toward 12-0'clock, and the probe is placed at the
The standardized Tissue Sensitivity gain setting is used 6-0'clock limbus, with the sound beam directed toward the
throughout the orbital examination (see Figure 1-12); the posterior orbit; The probe is then shifted along this
286 THE ORBIT
Figure 11-10 Transocular B-scan screening of superior orbit from posterior (1) to anterior
(4) using horizontal transverse probe orientation. Note that the probe marker is oriented nasally.
Arrows, Orbital bone.
Figure 11-11 Axial and para-axial B-scan echograms of retrobulbar orbitwith probe on cornea
(fixation in primary gaze). A, Axial view shows optic nerve (ON) and surrounding orbital soft
tissue. A770W, Posterior lens capsule. B, Para-axial scan with sound beam shifted slightly to ex-
amine orbit just adjacent to optic nerve.
meridian into the fornix as the display is continuously temporally and with the sound beam directed toward the
monitored for the appearance of any abnormalities (Figure nasal aspect of the anterior orbit (see Figure 12-26). The
11-12). During this procedure, small "defects" originating normal lacrimal sac may be more easily detected when the
from the normal orbital fissures, extraocular muscles, op- globe is proptotic than when it is in normal position or is
tic nerve, and so forth, may be detected. To ensure that enophthalmic.
these normal findings are not mistaken for an actualle- Careful attention should be given to the posterior orbit,
sion, it is helpful to anticipate where they may occur and because the detection of lesions in this area can be more
to compare them immediately with the same area of the difficult. It may be helpful to shift the probe additionally in
fellow orbit. The same limbus-to-fornix shifting proce- an arc-like manner along the limbus and to compare care-
dure is repeated in seven additional meridians, moving fully with the fellow orbit. The superior orbital fissure is
temporally around the globe (as in the intraocular exami- best displayed with the probe placed near the inferonasal
nation), until the entire orbital cavity has been examined limbus, whereas the inferior orbital fissure is shown with
(see Figure 2-14). the probe positioned supranasally (Figure 11-13).
Unless markedly enlarged, the extraocular muscles and
optic nerves are not well displayed during the basic A-scan Para ocular Approach
screening examination. This is because of oblique sound A-scan screening with the paraocular approach is used to
beam incidence to the sheaths as the patient fixates away evaluate the lids and the anterior orbit. It is also useful for
from the probe. Instead, these structures are examined sep- evaluating the lacrimal system and the periorbital sinuses.
arately with the patient fixating in primary gaze, as de- Methylcellulose is applied to the closed lids as a coupling
scribed in Chapters 15 and 16. medium to ensure sufficient sound penetration. Using
The normal lacrimal sac may produce a small defect in slight but firm pressure, the probe is placed first on the up-
the echogram when the probe is placed near the fornix per lid at the 12-0'clock position, with the sound beam
288
Figure 11-12 Transocular A-scan screening of superior orbit. As patient fixates superiorly, the
probe is shifted along the 6-o'clock meridian (thereby examining the 12-o'clock meridian). With
probe at limbus (1), the sound beam is aimed toward the orbital apex. As probe is shifted toward
lower fornix (5), orbital echo gram narrows and bone spike becomes higher. V, Vitreous cavity;
S, sclera; arrows, orbital soft tissue spikes decrease in amplitude due to sound attenuation;
B, orbital bone. This limbus to fornix shifting is performed in eight meridians to screen the en-
tire orbital cavity.
Figure 11-13 A-scan examination of superior and inferior orbital fissures. A, Superior orbital
fissure displayed with probe placed inferonasally. B, Inferior orbital fissure displayed with probe
placed supranasally. V, Vitreous cavity; S, sclera; 0, orbital soft tissue; arrow, fissure.
directed through the globe (toward the 6-0'clock merid- Topographic echography determines location, shape,
ian). The probe is then slowly redirected away from the size, and border character of a lesion. It is also used to mon-
globe and toward the adjacent orbit and proximal bony or- itor contour of the globe and bony orbital walls. Quantita-
bital wall. Finally, the sound beam is aimed posteriorly to- tive echography reveals data relating to histologic compo-
ward the orbital apex (Figure 11-14). This same globe-to- sition and is used to evaluate internal structure, reflectivity,
bone maneuvering is repeated in seven more meridians, and sound attenuation. Kinetic echography evaluates prop-
moving temporally around the orbit. erties of motion such as consistency, internal blood flow,
The sinuses (maxillary, ethmoid, and frontal sinuses) are and mobility.
specifically evaluated during the paraocular screening exam-
ination. The probe is directed perpendicular to the bony wall
Topographic Echography: Location,
that overlies the sinus cavity. No echoes are produced from
Shape, Size, and Borders
the normal air-filled sinus, as air totally reflects the sound
waves. However, when there is mucosal swelling, the sinus The evaluation of topographic properties is the first step
is filled with fluid, or solid tissue is present, abnormal echoes in the differentiation of an orbital mass. Topography is
appear to the right of the paraocular pattern (Figure 11-15). assessed with a combination of B- and A-scan techniques
The lacrimal system can also be examined with the and the use of trans ocular and/or paraocular approaches,
paraocular approach. The lacrimal sac is evaluated with the depending on lesion location. Masses that are confined
probe placed in the medial canthal region (3-0'clock posi- to the lids or the extreme anterior orbit may be assess-
tion for the right eye, 9-0'clock position for the left eye), able only by a paraocular route, whereas those confined
as described in Figure 12-26. The lacrimal gland can be to the muscle cone usually must be evaluated with a
evaluated using the paraocular approach, with the probe transocular approach. Conversely, large lesions that ex-
placed supratemporally (see Figure 12-17). tend both anteriorly and posteriorly can normally be
evaluated with a combination of the two approaches. B-
SPECIAL EXAMINATION TECHNIQUES scan assessment is essential for evaluating and document-
ing lesion topography, and A-scan examination can be an
FOR LESION DIFFERENTIATION
important adjunct.
As in the globe, topographic, quantitative, and kinetic tech-
niques have been developed to localize, differentiate, and Location, Size, and Shape
measure orbital mass lesions. 1- 3 All techniques should be The accurate localization of a mass is essential because its
performed systematically for best results (Box 11-1). position (e.g., lacrimal fossa, muscle cone, subperiosteal
290 THE ORBIT
Figure 11-14 Paraocular A-scan screening of superior orbit. Probe is shifted between globe
(1) and orbital wall (5) along the 12-o'clock meridian. 1, Sound beam directed through globe,
. perpendicular to sclera (S). V,Vitreous cavity. 2, Sound beam angled through peripheral globe
(oblique incidence to sclera, S). 3-5, Normal paraocular echograms.
B c
Figure 11-15 Examination of the frontal sinus with paraocular A-scan approach. A, The
A-scan probe is directed toward the frontal sinus. B, Normal sinus. No echoes are received from
the normally air filled sinus. C, Abnormal sinus echoes (S), indicating the presence of fluid, mu-
cosal swelling, or other abnormal tissue.
BOX 11·1
Differentiation of Orbital Mass lesions*
Topographic Quantitative
Location: Position, meridians Internal reflectivity: Spike height
Shape Internal structure: Histologic architecture
Borders Sound attenuation: Absorption or shadowing
Contour abnormalities
Kinetic
Bone: Excavation, defects, or hyperostosis
Globe: Indentation or flattening Consistency: Soft VS. hard
Vascularity: Blood flow
Mobility: Of lesion or its contents
*When an orbital mass is detected, these properties are assessed for lesion differentiation.
292 THE ORBIT
space) may be an important factor in differentiation. Addi- posterior extension into the orbit. As in the transverse scan,
tionally, the position of the lesion may influence the clinical the patient fixates toward the lesion, and the probe is placed
management (e.g., surgical approach). Location, size, and on the globe opposite the lesion. The probe is initially po-
shape are first evaluated with the two-dimensional B-scan. sitioned close to the limbus and is then shifted toward the
A transocular, transverse probe orientation is used ini- fornix as needed to best display the lesion in maximal ex-
tially to assess a lesion's lateral extent, shape, and thickness. tent (see Figure 11-5).
The patient fixates toward the lesion, and the probe is The final step in the topographic B-scan assessment is
placed on the globe at the limbus opposite the lesion. The the use of an axial scan. This orientation is helpful to doc-
probe is shifted between limbus and fornix until the center ument the relationship of a lesion to the globe wall, optic
of the lesion is displayed (see Figure 11-4). nerve, extraocular muscles, and orbital bone. The informa-
The longitudinal approach is then applied to add more tion derived from the transverse, longitudinal, and axial ap-
information by displaying the lesion in long section. This proaches is then combined for a complete topographic
position also displays the shape of the lesion as well as its overview (Figure 11-16).
Figure 11-16 Topographic evaluation oflarge supratemporal mass lesion using transocular
approach. T, Transverse scan shows lateral extent of lesion (L). La, Longitudinal scan shows ra-
dial extent of lesion. ON, Optic nerve. Ax, Axial scan shows relationship of lesion to globe and
optic nerve. Drawing shows sound beam orientation through lesion.
When a lesion is very large, it may not be possible to the echographer can mentally construct a three-dimen-
display its entire extent in one transverse or longitudinal sional image of a lesion and can usually classify its shape as
view. In such cases, it may be helpful to move the probe so round, oval, spindle, or irregular.
as to image both central and peripheral aspects of the le-
sion (Figure 11-17). Borders
For very anterior lesions, it may be advantageous to use Echographically, a lesion's borders are characterized as well
the paraocular B-scan approach, rather than trans ocular, for outlined (i.e., well circumscribed) or poorly outlined (i.e.,
the evaluation of topography. Again, a combined approach, indistinct or diffuse). Lesions that are very well outlined
utilizing both transverse and longitudinal views, provides (e.g., with a capsule or pseudocapsule) usually demonstrate
the most information (Figure 11-18). a smooth, regular contour and rounded shape on B-scan
A-scan complements B-scan in the assessment of a le- and a distinct, high posterior surface spike on A-scan. This
sion's location, size, and shape. In addition, A-scan can pro- posterior surface spike can be either single- or double-
vide measurements of a lesion's maximal thickness and pos- peaked (Figure 11-20).
terior extent into the orbit (Figure 11-19; see also Figure In contrast, poorly outlined lesions usually have an in-
11-3, A). By using these various A- and B-scan techniques, distinct, irregular contour on B-scan and produce a less
A
12:00
3:00 C
Figure 11-17 Transverse B-scan montage (transocular approach) oflarge supratemporal mass
(left orbit) to document entire lateral extent. A, Horizontal scan of 12-0'clock meridian shows
upper edge (arrow) oflesion (L). B, Oblique scan of 1: 30-0' clock meridian shows central portion
of lesion. C, Vertical scan of 3-0'clock meridian shows inferior edge of lesion (straight arrow).
Curved arrow, Cross-section oflateral rectus muscle. Note that the smooth, rounded borders of
the lesion are shown as the tumor margins are centered in echo grams A and C.
294 THE ORBIT
Figure 11-18 Topographic evaluation of supratemporal mass lesion using paraocular B-scan
approach. Transverse approach (T) shows cross-section oflesion (L). I, Initial line. Longitudinal
approach (La) shows long section oflesion (L). V,Vitreous cavity; arrow, area of globe surface not
imaged due to oblique sound beam incidence. Drawing shows sound beam orientation through
lesion.
Figure 11-19 Topographic A-scan evaluation of retrobulbar (A) and anterior (B) mass lesions.
A, Transocular evaluation of retrobulbar mass. Probe is shifted to localize lesion, assess posterior
border character, and determine maximal thickness. 1, With probe at limbus, sound beam is
aimed posteriorly, bypassing lesion; S, sclera; 0, orbital soft tissue. 2, Sound beam encounters le-
sion and is directed perpendicular to posterior border (P) in area not adjacent to bone. 3, Sound
beam is shifted more anteriorly, relatively perpendicular to orbital bone (B). 4, Sound beam is an-
gled through anterior aspect oflesion, perpendicular to bone. S, Sound beam is directed anterior
to mass, perpendicular to bone. Continued
296 THE ORBIT
Figure 11-19, cont'd B, Paraocular evaluation of anterior mass. Probe is angled between globe
and bone to localize lesion, assess posterior border spike, and determine maximal depth into or-
bit. 1, Sound beam is first directed through globe; S, sclera; B, orbital bone. 2, Sound beam is
shifted toward lesion but is now oblique to sclera (S). 3, Sound beam is now perpendicular to pos-
terior border (P) of lesion (L) in area of maximal depth in orbit. 4, Probe is angled through le-
sion anteriorly, more perpendicular to bone (B). 5, Beam is directed anterior to lesion, toward
bone.
Figure 11-20 Paraocular echograms of

very well-outlined, encapsulated benign
mixed tumor of the lacrimal gland. A, B-
scan echogram shows well-circumscribed
lesion (L) with smooth, round posterior
A border (P). B, A-scan at Tissue Sensitivity
shows highly reflective internal lesion
spikes and steeply rising, high posterior
surface spike (P). C, A-scan at decreased
gain shows double-peaked posterior sur- .
face spike from capsule.
B c
Immersion Technique
distinct, lower reflective posterior surface spike on A-scan
(Figure 11-21). Occasionally, sound attenuation can limit Small lesions that are located superficially on the con-
the assessment of a lesion's border characteristics. If a mass junctiva, within the lid, or within the anterior orbit can be
produces strong sound attenuation, the amplitude of its examined by means of an immersion technique. In such
posterior border echoes are likely to be significantly re- anterior lesions, the immersion method may provide the
duced and thus more difficult to evaluate. only reliable means of evaluating acoustic properties as
When assessing the borders of a lesion on A-scan, the well as thickness. A scleral shell, placed directly over the
surface being evaluated should not be situated adjacent to lesion, is filled with methylcellulose (see Appendix D).
the bony orbital wall. Therefore, anterior lesions or those Both A- and B-scan examinations can be performed, with
located more posteriorly, close to the orbital bone, must be techniques that are similar to those used for immersion
evaluated with a paraocular approach. This directs the examination of the globe (~igure 11-23; see also p 37 and
sound beam through the mass perpendicular to its poste- Figure 2-30).
rior surface and parallel to the orbital wall. If, however, a
lesion is confined to the muscle cone, it is usually necessary Quantitative Echography: Reflectivity,
to use the trans ocular approach to evaluate its borders (see Internal Structure, and Sound
Figures 11-3, A, and 11-19,A).
Attenuation
Contour Changes in Globe and Bone Once the topographic characteristics of a lesion have
When pressure is exerted on the globe by a large mass, been assessed, quantitative echography is performed to
B-scan may show flattening or indentation of the ocular determine reflectivity, i.e., the strength of a lesion's in-
wall. Chorioretinal folds in the same area also may be visi- ternal echoes. This information correlates with the le-
ble by ophthalmoscopy. Globe indentation can be associ- sion's histologic architecture such as the character of cel-
ated with a variety of orbital conditions such as tumors, lular substance; the number, size, and distribution of cell
cysts, enlarged muscles, or optic nerve, as well as hemor- aggregates; and the presence of large interfaces such as
rhage or abscess. Changes in contour of the bony orbital blood vessels, connective tissue septa, calcification, and
walls also may be detected (Figure 11-22). so forth.
298 THE ORBIT
A C
B D
Figure 11-21 Paraocular longitudinal B-scans and paraocular A-scans from very well-outlined
inclusion cyst (A and B) and poorly outlined pseudotumor (C and D) located in anterior orbit.
L, Lesion; curved a1'TOWS, posterior surface of mass; straight aTTOWS, area of globe wall not shown
well due to oblique sound beam incidence; V, vitreous cavity.
A c
B D
Figure 11-22 B-scan montage showing alteration in contour of globe and orbital bone.
A, Concave shape of normal globe and orbital bone (arrow). B, Hyperostotic bone due to fi-
brous dysplasia is convex (a7~row). C, Large benign mixed tumor of lacrimal gland is indenting
globe (open arrow) and excavating bony orbital bone (closed anrows). D, Carcinoma has broken
through .medial wall of orbit causing bone defect (straight arrow). Curved arrow, Echoes from tu-
mor msmus.
~IT
298 TH~
Figure 11-23 Immersion technique through closed lid with B-scan (A and B) and A-scan
(C and D) for evaluation of an anterior lesion. A small plastic cylinder (i.e., scleral shell) is firmly
placed on the lid and is filled with methylcellulose. B, B-scan echogram shows well-outlined,
anterior lesion (curved arrow) adjacent to lid surface (L). I, Initial line corresponding to probe
face; F, fluid (methylcellulose) in scleral shell; small arrows, air bubbles. D, Corresponding im-
mersion A-scan of lesion. I, Initial spike corresponding to probe tip; F, fluid within scleral shell;
small arrows, air bubbles; L, lid; large arrow, lesion; P, posterior surface spike.
Reflectivity play characteristics, such as gray scale, dynamic range, lines

Reflectivity is evaluated by observing the spike height on of resolution, etc., may vary from one B-scan instrument to
A-scan and the signal brightness on B-scan. On A-scan, us- another. In order to assess the significance of a lesion's sig-
ing the Tissue Sensitivity gain setting, reflectivity is judged nal brightness on B-scan, it is necessary to compare it with
by estimating the height or amplitude of the internal lesion the normal highly reflective (echo-dense) orbital soft tissue
spikes in relation to the vitreous baseline (0%) and the top and the very low reflective (echolucent) vitreous cavity. A
of the initial spike (100%). Lesions may be classified into lesion's internal reflectivity, in comparison to these known
one of several reflectivity groups (Figure 11-24; see also tissues, is assessed in terms of different degrees of echo den-
Table 2-3). If a lesion is very large, reflectivity should be as- sity. The most useful quantitative information obtained
sessed more anteriorly, usually within the first 10 to 15 mi- with B-scan is in those lesions that are extremely echo-
croseconds of the internal lesion spikes. This is necessary dense (Figure 11-25) and those that are echolucent (see
to judge accurately a lesion's reflectivity because sound at- Figure 12-34).
tenuation causes a progressive reduction in the amplitude of
more posterior spikes. Internal Structure
Reflectivity may be more precisely determined by mea- Internal structure refers to degrees of variation in histologic
suring spike height on A-scan than by estimating signal architecture within a lesion. This is evaluated by noting dif-
brightness on B-scan. The echographer should be cautious ferences in the height and length of the A-scan spikes and,
in judging reflectivity from B-scan because it does not pro- to a limited extent, differences in echo density on B-scan.
vide a standardized gain setting as does the standardized Such variations can occur within a single echogram or
A-scan with Tissue Sensitivity. Furthermore, the signal dis- within different echo grams from the same lesion. Regular
301
Figure 11-24 Standardized A-scan e~hograms and histopathology of normal orbit and four
different orbital tumors (all at X 100 magnification). Echograms were obtained with a transocu-
lar approach and perpendicular sound beam incidence to sclera (S) and orbital bone (B).
A, Normal orbital soft tissue. Heterogeneous tissue (comprised of fat, connective tissue septa,
and so forth) produces extremely high reflectivity. B, Cavernous hemangioma. Multiple, large,
blood-filled spaces produce high reflectivity. C, Benign mixed tumor. Multiple, small cystic cav-
ities filled with mucinous material produce medium-high reflectivity. D, Hemangiopericytoma.
Moderately heterogeneous histologiearchitecture produces medium reflectivity. E, Lymphoma.
'Homogeneous, densely cellular lesion produces low reflectivity.
302 THE ORBIT
A c
Figure 11-25 Two examples of orbital shadowing.

A, Transverse B-scan echo gram at reduced gain shows small
focus of calcium (arrow) within cavernous hemangioma pro-
ducing narrow area of shadowing (S) through tumor.
. B, Corresponding A-scan at slightly reduced gain shows
highly reflective, foreign bodylike spike from calcium
B (arrow), followed by marked decrease in spike height
(S) due to shadowing. Note that height of orbital bone spike
(B) is also reduced. C, Axial B-scan echogram from another
patient with large retrobulbar glass sliver (arrow) demon-
strating broad area of shadowing (S) adjacent to optic nerve
(ON). M, Multiple signal.
internal structure, indicating homogeneous architecture, is When evaluating a lesion's angle kappa on A-scan, its
represented by little or no variation in the height and reflectivity at Tissue Sensitivity must be considered. Since
length of spikes on A-scan and a uniform appearance of the ideal spike height for assessing a lesion's angle kappa is
echoes on B-scan. Conversely, irregular internal structure, a medium level, the gain may need to be changed accord-
indicating heterogeneous architecture, is represented by ingly. Consequently, if a lesion has high internal reflectivity,
marked differences in echo appearance (Figure 11-26). In the gain may need to be decreased, whereas if a lesion is
some cases, slight variations can be present and the lesion low reflective, it may need to be increased (Figure 11-28).
will be classified as moderately irregular. Various substances, such as bone, calcium, and most for-
eign bodies, typically produce very strong sound attenua-
Sound Attenuation tion (i.e., shadowing). On B-scan, this can result in a
Sound attenuation occurs when the sound energy is scat- marked decrease in signal strength or an actual void poste-
tered, reflected, and/or absorbed by a given medium. It may rior to the lesion. On A-scan, shadowing is indicated by a
be more pronounced when examining through swollen lids, steep angle of sound attenuation (see Figure 11-25). How-
dense opacities and membranes, or extremely high reflec- ever, when a dense echo source is extremely small, sound
tive media such as bone, calcium, or foreign material (e.g., attenuation may be subtle or altogether absent.
scleral buckle, see p 109).
Sound attenuation is indicated by a decrease in spike
Kinetic Echography: Consistency, Vascularity,
height on A-scan and echo density on B-scan. This may oc-
and Mobility
cur either within or posterior to a lesion (from leftto right
in the echo gram). On the A-scan, an angle is formed by an Kinetic echography is used for the dynamic assessment of
imaginary line drawn through the peaks of the internal le- the motion of or within a lesion. Kinetic characteristics may
sion spikes and the horizontal baseline of the echogram. be evaluated with A-scan, B-scan, and Doppler techniques,
This is referred to as "angle kappa" by Ossoinig. 5- 7 The depending on the given situation.
steeper the angle, the greater the sound attenuation. On
B-scan, sound attenuation is indicated by decreasing bright- Consistency
ness of the echoes, either within or posterior to a lesion The firmness (i.e., consistency) of a lesion is assessed by
(Figure 11-27). compressibility testing, performed with either A- or B-scan.
A D
B E
c F
Figure 11-26 Transocular echograms and histopathology from two tumors with regular vs. ir-
regular internal structure. Lymphoma (regular internal structure) demonstrates uniform ap-
pearance of internal echoes on both B-scan (A) and A-scan (B). V, Vitreous cavity; S, sclera;
L, lesion; B, bone. Corresponding histopathology of lymphoma (C) shows dense cellular com-
position of tumor (x 100 magnification). Lymphangioma (irregular internal structure) shows
marked variation in appearance of internal echoes on both B-scan (D) and A-scan (E). AI'rows,
Surfaces of lymphatic spaces. Corresponding histopathology of lymphangioma (F) shows irreg-
ular nature of tumor architecture (X 100 magnification).
304 THE ORBIT
A C
8 D
Figure 11-27 Transocular echograms from lymphoma (A and B) and cavernous hemangioma
(C and D) demonstrate different degrees of sound attenuation. Lymphoma (weak sound atten-
uation) shows minimal decrease in echo brightness on B-scan (A) and consistent spike height on
A-scan (B). V,Vitreous cavity; S, sclera; arrows, internal tumor echoes; P, posterior tumor surface.
Cavernous hemangioma (moderate sound attenuation) shows decreasing brightness of echoes
on B-scan (C) and decreasing height of internal tumor spikes (a77ows) on A-scan (D). B, Bone.
A c
B D
Figure 11-28 Transocular A-scan echo grams of two low reflective tumors demonstrate angle
kappa by using gain setting that is a few decibels higher than Tissue Sensitivity. Lymphoma at
Tissue Sensitivity (A) and higher gain (B) shows no significant angle kappa with increased gain
(note horizontal line). Sarcoma at Tissue Sensitivity (C) and higher gain (D) shows medium an-
gle kappa with increased gain (note declining line). S, Sclera; B, orbital bones.
306 THE ORBIT
When possible, the transocular approach should be used for If a lesion is confined to the lid or very anterior orbit,
this procedure. First, with the examiner using minimal pres- the paraocular approach may be necessary to evaluate con-
sure on the globe, the sound beam is directed perpendicu- sistency (Figure 11-30). When this approach is used, a le-
lar to the borders of the lesion through its thickest portion. sion may be displaced posteriorly and not compressed, thus
Mild pressure is then exerted against the eye with the probe giving a false impression of firm consistency. In these cases,
in an attempt to compress the lesion. As pressure is applied, B-scan examination can be more helpful because it may
the screen is monitored to determine whether the lesion de- show changes in the lesion's shape and/or internal character
creases in size or shows a change in shape or internal archi- rather than changes in size.
tecture (Figure 11-29). During this maneuver, sound beam
orientation may need to be adjusted somewhat to ensure Vascularity
that the probe has not shifted away from the thickest por- A-scan and B-scan techniques may be useful to determine
tion of the lesion (which could give a false impression of the presence of blood flow within a lesion. The patient
compressibility). For an anterior lesion, it may be helpful to fixates on a target and the lesion is displayed in its maximal
place a finger firmly on the lid over the lesion to prevent thickness. As the probe and eye are held stationary, the in-
forward displacement during compression testing. ternallesion echoes are observed for the presence of a fast,
Figure 11-29 Transocular compression test of soft orbital inclusion cyst. Schematic drawings
and echograms show cyst prior to (left) and during (right) compression. Note decrease in size and
change in shape oflesion (arrows) indicating soft consistency.
Figure 11-30 Paraocular compression test of large anterior serous orbital cyst with A-scan
(A) and B-scan (B). Echograms (beneath photographs) were taken prior to (left) and during
(r·ight) compression. Note decrease in size oflesion on A-scan and change in contour on B-scan
during compression, indicating soft consistency. C, Cyst; arrows, posterior surface of lesion.
308 THE ORBIT
Figure 11-31 Patient being examined with small, nondirectional Doppler instrument.
spontaneous flickering motion. This flickering motion is the lesion. In some cases, nonvascular lesions may push
the result of rapid blood flow through vessels. Such vascu- normal orbital vessels forward, resulting in a directional re-
larity is commonly present in many orbital lesions and may sponse that may be somewhat louder than that detected
be a key factor in their correct differentiation (see p 37 and from the same area of the contralateral normal orbit.
Figures 13-14 and 13-20). The lesion is first localized with a paraocular A-scan ap-
proach to determine its proximity to the globe and bone as
DOPPLER ULTRASOUND EVALUATION
well as the meridians that it involves. The Doppler probe is
Audio Doppler instrumentation generates a continuous then placed on the closed lid overlying the lesion (Figure
beam of ultrasound, is also used to assess blood flow. 6 11-31). The examiner listens for a response that indicates
Doppler ultrasound detects a shift in the frequency of blood, blood flow. The probe is then shifted back and forth so as to
which is flowing either toward or away from the sound direct the sound beam throughout the lesion. This maneu-
beam. The audio Doppler instrument is best suited for eval- ver is necessary to determine if the response is diffuse or
uating blood flow within those tumors that are located ante- directional. A pulsatile sound indicates arterial flow,
riorly next to the globe by using a paraocular approach. The whereas a continuous sound indicates venous flow. If both
Doppler response is more difficult to interpret when the types of flow are present, a mixed response is obtained.
transocular approach is used because of competing blood Careful comparison should be made with the same area of
flow from vessels within the retina, choroid, and optic nerve. the contralateral orbit, using a similar volume level on the
A Doppler response can be either directional or diffuse. Doppler instrument.
A directional response, as produced by a normal orbital ves- Color flow Doppler has also been shown to be useful in
sel, disappears as soon as the sound beam is shifted away evaluating and documenting blood flow within orbitalle-
from the vessel. Conversely, a diffuse response, as produced sions. The instrumentation and examination techniques are
by a vascularized lesion, persists as the probe is moved over explained in detail in Chapter 14.
Chapter11 EXAMINATION TECHNIQUES FOR THE ORBIT 309
Figure 11-32 Transocular B-scan echo grams of well-outlined orbital hematoma demonstrat-
ing shifting fluid. A, Layered blood (arrow) is oriented obliquely with patient in reclined position.
B, Obvious shift of layered blood (arrow) with patient re-examined in sitting position (same
probe position as top).
Mobility within a lymphangioma or cystic contents). This is similar

The mobility of an orbital lesion or movement of its con- to the aftermovement observed with membranes in the
tents can be evaluated. Lesion mobility is usually best as- globe (see p 36 and Figure 2-27).
sessed with B-scan by observing the echo gram as the pa-
tient blinks or performs a saccade. When a lesion is mobile, REFERENCES
it moves independently of surrounding normal structures. 1. Byrne SF: Standardized echography in the differentiation of orbital le-
In contrast, a nonmobile lesion that is attached to the globe, sions. Surv OphthalmoI1984;29:226.
optic nerve, muscle, or bone either does not move or moves 2. Byrne SF: Standardized echography of the eye and orbit. Neuroradiol-
ogy 1986;28:618.
in conjunction with normal structures. 3. Byrne SF, Glaser JS: Orbital tissue differentiation with standardized
Three types of nonvascUlar movement may occur within echography. Ophthalmology 1983;90:1071.
a lesion. One is the shifting of fluid levels caused by changes 4. Ossoinig KC: Echography of the eye, orbit, and periorbital region, in
Arger PH (ed): Orbit Roentgenology. New York, J Wiley & Sons, 1977,
in body position. This may be seen in lesions such as lym- p224.
phangiomas with hemorrhage, hematomas, and cysts (Fig- 5. Ossoinig K: The role of clinical echography in modern diagnosis of
ure 11-32). Another type of movement is the continuous, periorbital and orbital lesions, in Bleeker G (ed): Proceedings of the 3rd
International Symposium on Orbital Disorders. Amsterdam, Dr W Junk,
convection-like motion that is sometimes observed in cho- 1977, P 496.
lesterol within a hematic cyst. This movement is similar to 6. Ossoinig KC: Standardized echography: Basic principles, clinical ap-
that of cholesterol beneath a longstanding retinal detach- plications and results.lnt Ophthalmol Clin 1979; 19: 127.
7. Ossoinig KC: Standardized Ophthalmic Echography of the Eye, Orbit and
ment (see p 37 and Figure 3-25). A third type of movefuent Periorbital Region. A Comprehensive Slide Set and Study Guide, ed 3, Iowa
is the aftermovement of nonsolid structures (e.g., septa City, Goodfellow, 1985. .
Orbital Tumors
Many of the different types of tumors (e.g., vascular, neu- (periscleritis), myositis (see p 396), and perineuritis (see op-
rogenic, lymphoproliferative, metastatic, etc.) that affect tic neuritis, p 423).21,24,25,33
soft tissues in the body also can occur in the orbit. As a re- Pseudotumorllymphomas may be focal or multifocal and
sult, the clinical diagnosis of an orbital mass may be difficult can be located anywhere in the orbit. These lesions can be
and the differential diagnosis may be quite extensive. In well circumscribed with relatively smooth contour or, more
many cases, however, echography can provide important commonly, are diffuse and irregularly shaped (Figures 12-1
information augmenting that obtained with other imaging and 12-2). In many cases they are attached to orbital struc-
modalities. * tures such as the extraocular muscles, optic nerve, perios-
Many of the nonvascular orbital tumors that one can ex- teum, or globe (Figure 12-3; see also Figures 12-1 and 12-2).
pect to encounter are described in this chapter (Table 12-1), Lesions of the pseudotumor/lymphoma group are com-
including those that involve the lacrimal system. The vas- posed of small, densely packed cells, resulting in a homo-
cular tumors and malformations that commonly occur in geneous histologic architecture 34,55 (see Figure 11-24).
the orbit are numerous and are described separately in Consequently, they are usually low to medium reflective
Chapter 13. with regular internal structure. Typically, they do not pro-
The more common orbital lesions can usually be diag- duce significant sound attenuation. In some cases, connec-
nosed reliably with echography. Those that occur less fre- tive tissue septa are present, giving them a slightly irregular
quently, however, may present a problem in differentiation. appearance (Figure 12-4). Pseudotumorllymphomas may
Consequently, echography may be able to provide a specific be nonvascular or can show mild to moderate internal
diagnosis in many cases but only a list of likely possibilities blood flow.
in others. Furthermore, some lesions can only be generally Although the echographic differentiation of pseudotu-
categorized as vascular or nonvascular, solid or cystic, and mor from lymphoma cannot be made in most cases, occa-
so forth. sionally there are findings that may suggest one diagnosis
more than the other. For example, thickening of an adja-
PSEUDOTUMOR AND LYMPHOMA cent extraocular muscle, edema in sub-Tenon's space,
and/or scleritis are more commonly seen with pseudotu-
(LYMPHOPROUFERATIVE DISEASES)
mor than with lymphoma. On the other hand, lymphomas
Inflammatory mass lesions (i.e., pseudotumors) and lym- often seem to be bilateral and mildly compressible, whereas
phoid lesions have a similar appearance echographically and pseudotumors are more frequently unilateral and more
are therefore classified as one entity.34 Lesions of the firm.
pseudotumorllymphoma group include idiopathic orbital Other highly cellular, homogeneous lesions (e.g., sarco-
inflammatory masses, granulomatous disorders (e.g., sar- mas) can have a low internal reflectivity similar to that of
coidosis, Wegener's grahulomatosis), reactive and lymphoid pseudotumor/lymphoma. However, differentiation some-
hyperplasias, and lymphomas. 45 times can be made based on history and the clinical exami-
The term "pseudotumor" is frequently used to describe nation in combination with other echographic features.
a wide spectrum of inflammatory disorders.28 In this chap-
ter, however, the term is reserved for an inflammatory mass. PRIMARY ORBITAL TUMORS
Other manifestations of inflammatory orbital disease, oc-
Rhabdomyosarcoma
curring alone or in conjunction with a pseudotumor, are
termed according to the particular structure involved. 28 Rhabdomyosarcoma is the most common primary orbital
These include scleritis (see p 195), tenonitis/episcleritis malignancy of childhood and frequently presents with a
rapidly developing exophthalmos. 48 In general, rhab-
domyosarcomas are highly cellular, vascularized lesions that
*References 4, 6,13,14,19,26,35-40. echographically may appear very similar to pseudotumorl
310
Chapter 12 ORBITAL TUMORS 311
~lFABI..E 12-1 ,
Differential Diagnosis of Orbital Tumors*
Internal Internal Sound
TumorTy~e Sha~e Borders Reflectivity Structure Attenuation Vascularity Consistency Bone
Pseudotumorl Variable Variable Low-med Regular Weak +1- Firm WNL
lymphoma
Rhabdomyosarcoma Variable Variable Low-med Irregular Mod + Firm WNUdefects
Schwannoma Oval Well outlined Low-med Regular, Mod + Firm WNU

(neurilemmoma) cystic excavated
cavities
Neurofibroma
Solitary Roundloval Well outlined Low Regular Weak/mod +1- Hard WNL
Plexiform Irregular Poorly outlined High Irregular Weak + Soft WNL
Fibrous Oval Well outlined Low-med Regular Mod +1- Firm WNL
histiocytoma
Metastatic
carcinoma
Infiltrative Irregular Poorly outlined Med-high Irregular Weak Hard WNUdefects
Confined Variable Well outlined Low-med Regular Weak/mod Hard WNUdefects
Med, Medium; Mod, moderate; WNL, within normal limits.

*This table lists the main echographic findings for the most common orbital tumors.
A B
Figure 12-1 Orbital pseudotumor (multifocal). A, Vertical axial B-scan echo gram displays mul-
tiple areas of infiltration in retrobulbar orbit (arrows). ON, Optic nerve. B, Vertical transverse
B-scan through anterior aspect of optic nerve shows lesion infiltrating orbital fat and surround-
ing nerve.
312 THE ORBIT
B E
c F
D G
Figure 12-2 Orbital pseudotumor (diffuse). A, External photograph showing proptosis ofleft
eye and ptosis of left upper lid. Transocular echograms (B, C, D, F, and G) show large, diffuse
orbital lesion (L). B, Transverse B-scan echogram through supratemporal orbit shows large, rel-
atively well-circumscribed mass. C, Longitudinal B-scan through temporal orbit shows mass ex-
tending posteriorly outside of the muscle cone between lateral rectus muscle (LR) and orbital
bone (B). ON, Optic nerve. D, A-scan echogram shows low reflective, regularly structured lesion.
S, Sclera; B, bone. E, Axial CT scan demonstrates proptotic left eye and diffuse mass in tempo-
ral and medial aspect of left orbit, outside of the muscle cone. F, Horizontal transverse B-scan
through anterior aspect of orbit superiorly shows diffuse extraconallesion extending along roof
of orbit. SR, Superior rectus muscle. G, Longitudinal B-scan along 12-o'clock meridian shows
lesion extending back into orbit above superior rectus/levator muscle complex (lvl).
A c
B D
Figure 12-3 Large orbital lymphoma. A, Axial B-scan shows lesion (L) adjacent to optic nerve
(ON). Note irregular posterior contour of mass (arrows). B, Transocular A-scan shows low re-
flective lesion with regular internal structure. S, Sclera; P, posterior surface spike. Axial (C) and
coronal (D) CT scans show large mass (arrows) in supratemporal aspect of orbit.
314 THE ORBIT
A C
B D
Figure 12-4 Large orbital lymphoma with septa. Transocular (A and B) and paraocular
(C and D) echo grams display large lesion (L) with septa. A, Transverse B-scan echogram shows
diffuse lesion with septum (arrow). V,Vitreous cavity; E, bone. B, A-scan echo gram displays very
low reflective lesion with distinct spikes from septa (arrows). S, Sclera. C, Transverse paraocular
B-scan shows large mass with septum and irregular posterior border (P). D, Paraocular A-scan
displays low reflective lesion with multiple spikes from septa. P, Posterior surface spike.
Schwan noma (Neurilemmoma)

lymphomas. However, the echographic features of this tu-
mor usually allow it to be differentiated from the other more Schwannomas are rare orbital tumors arising from a pro-
common tumors in children, such as capillary hemangioma, liferation of Schwann cells; these tumors can occur as iso-
lymphangioma with hemorrhage, and dermoid cyst. lated lesions or may be associated with neurofibromatosis. 52
Rhabdomyosarcomas can be located anywhere in the or- Schwannomas can be located either within the muscle cone
bit. They have previously been reported to most commonly or in the extra conal space. These oval, encapsulated lesions
occur superiorly 27 but may be located inferiorly as well. appear smooth and well outlined echographically. Schwan-
Rhabdomyosarcomas are generally well circumscribed but nomas are generally low to medium reflective and usually
vary in shape and are often quite large. The bone may be have regular internal structure, although cystic cavities are
intact or, in more advanced cases, bone defects may be de- frequently present9,1l (Figure 12-6). They typically produce
tected. The internal reflectivity is predominantly low to moderate sound attenuation and are usually firm with some
medium, with moderate sound attenuation. Connective tis- degree of vascularity. 5 These lesions are not usually associ-
sue septa sometimes can be identified (Figure 12-5). In ated with bone defects, but bony excavation may occur. A
some cases, the internal structure can be somewhat irregu- schwannoma can have a similar echographic appearance to
lar, with areas of both low and medium reflectivity. Internal a hemangiopericytoma.
blood flow usually can be detected, but the degree may vary
significantly from one tumor to another. Similarly, the con-
Neurofibroma (Solitary Type)
sistency is generally firm, although these lesions can be
moderately compressible. As a rule, the differential diagno- Three cases of the solitary type of neurofibroma s6 have been
sis of any low reflective lesion in a child should include examined by the authors. All three tumors were located in
rhabdomyosarcoma. the supratemporal quadrant of th~ orbit. The lesions were
A 8
Figure 12-5 Orbital rhabdomyosarcoma. Transocu1ar echograms show large lesion (L) with
septa (arrows) in nasal orbit. A, Transverse B-scan displays lesion causing mild flattening of globe.
V,Vitreous cavity; B, bone. B, Longitudinal B-scan view demonstrates very large lesion extend-
ing from sclera into apex of orbit. C, Transocular A-scan echogram shows very low reflectivity
with medium-high spike from septum (arrow). S, Sclera.
Fibrous Histiocytomas
round to oval, hard, and well outlined. Two exhibited low
internal reflectivity and mild to moderate sound attenua- Fibrous histiocytomas are the most common type of mes-
tion, whereas the third tumor was medium to high reflec- enchymal tumor occurring in the orbit of adults.27 This
tive with strong sound attenuation (Figure 12-7). The in- tumor has, in the past, been histologically confused with
ternal structure was regular or slightly irregular, and hemangiopericytoma. 56 Fibrous histiocytomas can occur
vascularity was mild or absent. extraconally or, rarely, may completely fill the orbital cavity.
They are generally oval and well outlined and exhibit reg-
ular internal structure, low to medium internal reflectivity,
Neurofibroma (Plexiform Type)
and moderate sound attenuation (Figure 12-9). Fibrous his-
Plexiform neurofibromas have a much different appearance tiocytomas are usually noncompressible, vascularized, and
than the solitary type, both echo graphically and histologi- not associated with bony abnormalities.
cally.27 The plexiform neurofibroma is an infiltrative, non-
encapsulated lesion and is, therefore, irregularly shaped and
METASTATIC AND SECONDARY TUMORS
poorly outlined on echography. The few plexiform lesions
assessed by the authors have shown irregular internal struc- Malignant tumors can occur in any area of the orbit,
ture with predominantly high internal reflectivity and'ruin- metastasizing from elsewhere in the body, or secondarily
imal sound attenuation (Figure 12-8). These lesions are invading the orbit from the globe (e.g., retinoblastoma
compressible and quite vascularized. In some cases, the ex- or melanoma [see p 131 D. They also can extend into the
traocular muscles are thickened. The differential diagnosis orbit from adjacent cavities, the skin, or conjunctiva. 46
of this tumor includes capillary (infantile) hemangioma. Metastatic infiltration of the extraocular muscles and
316 THE ORBIT
A D
B E
c F
Figure 12-6 Orbital schwannoma. Coronal (A) and axial (D) CT scans show large mass
(arrows), with low-density area centrally. Transocular (B and C) and paraocular (E and F)
echo grams show large tumor with central cystic cavity (white arrows). B, TransverseB-scan
shows well-circumscribed mass (black arrows) and large cystic cavity centrally. V, Vitreous cav--
ity;B, bone. C, A-scan echo gram displays medium reflective mass, moderate sound attenuation,
and very low reflective cystic cavity. S, Sclera. E, Transverse paraocular B-scan shows well-
circumscribed tumor (black arrows) extending posteriorly along orbital bone (B). Note cystic
cavities anteriorly. P, Posterior border of lesion. F, Paraocular A-scan echogram displays
medium intenial reflectivity, moderate sound attenuation, and large cystic cavity. A, Anterior;
P, posterior surface spikes. (From Byrne SF, Byrne BM: Differential diagnosis of orbital
neurilemmoma [schwannoma] with standardized echography, in Ossoinig KC led]: Ophthalmic
Echography. Dordrecht, Dr W Junk, 1987, P 487.)
317
A B
Figure 12-7 Solitary neurofibroma. A, Transverse B-scan (at high gain setting) shows oval-
shaped lesion (L) with smooth borders (arrows). Note marked decreas~ in brightness of internal
echoes and weak appearance of bone. (B) due to strong sound attenuation.- V, Vitreous caVity.
B, Transocular A-scan shows medium reflective lesion producing strong sound attenuation
(arrows). Also note decreased height of bone spike due to strong sound attenuation. S, Sdera.
D E F
Figure 12-8 Plexiform neurofibroma of right anterior lid and orbit with involvement of tem-
poral fossa. A, External photograph showing right upper lid swelling in 28-year-old man. Paraoc-
ular echo grams display lesion in orbit (B and C) and temporal fossa (D to F). B, Transverse
B-scan echo gram shows lesion (L) within lid and very anterior aspect of orbit. B, Orbital bone.
e, A-scan shows irregular internal structure of lesion. B, Orbital bone; M, multiple signals.
D, B~scan probe is shifted temporal to orbit, overlying temporal fossa. Echogram shows irreg-
ular appearance oflesion that fills temporal fossa. B, Temporal bone. E,A-scan of temporal fossa
als.o demonstrates irregular internal structure of mass. Double-headed arrow indicates depth of le-
sion in fossa between skin and temporal bone. F, A-scan during compression testing shows de-
creased size of mass in temporal fossa (double-headed arrow), indicating very soft consistency.
318 THE ORBIT
A 0
B E
C F
Figure 12-9 Fibrous histiocytoma. Transocular echograms (A to C) show large orbital lesion (L)
in temporal orbit. A, Vertical transverse B-scan shows well-circumscribed extraconal tumor between
globe and orbital bone (B). B, Longitudinal B-scan view shows extraconal mass extending posteri-
orly between lateral rectus muscle (1W) and orbital bone. C, A-scan echogram shows low internal re-
flectivity and regular structure. S, Sclera. D, External photograph shows fullness and ptosis of left
upper lid. Axial (E) and cQronal (F) MRI scans demonstrate well-circumscribed mass (amnvs).
the optic nerve is discussed in Chapters 15 and 16, neoplasms are most often medium to high reflective with a
respectively. moderately irregular internal structure (Figure 12-10). Os-
Metastatic tumors are usually infiltrative, although they soinig has described a V-shaped A-scan pattern for tumors
can appear very well circumscribed, especially when grow- of an infiltrative nature such as metastatic tumors to the or-
ing within a confined space (e.g., beneath Tenon's capsule bit39 (Figure 12-11).
or the periosteum). These lesions can invade the orbital Carcinomas that grow within a confined space areusu-
walls and produce extensive bony destruction. They are ally more regularly shaped and better outlined than infiltra-
typically hard and nonvascular, and they generally produce . tive tumors. Their shape can vary according to the space in
weak sound attenuation. The infiltrative metastatic tumors which they are confined. Also, these tumors tend to be more
tend to be irregularly shaped and poorly outlined. These low to medium reflective and regularly structured than the
B c
Figure 12-10 Metastatic carcinoma from breast. A, External photograph shows slight upward
displacement ofleft eye. B, Vertical transverse B-scan echogram through lesion (L) located in-
ferotemporally shows irregular contour (arrows). B, Bone. C, Transocular A-scan shows medium-
high reflectivity and irregular structure of lesion. S, Sclera.
higher reflective, infiltrative tumors described previously. pansively within the orbital cavity. Their internal reflectivity
These lower reflective metastatic tumors sometimes can be is usually similar to that of the primary tumor!6,2!,29,43 (Fig-
difficult to differentiate from pseudotumorllymphomas. ures 12-14 through 12-16). Tumors extending into the orbit
One case of metastatic renal cell carcinoma47 and two from adjacent sinus cavities are discussed in Chapter 17.
adenocarcinomas, one from lung and one from colon, have
been examined by the authors. The renal cell tumor was oval LACRIMAL SYSTEM DISORDERS
shaped, well outlined, and highly vascular: The lesion
lacrimal Gland
showed medium internal reflectivity with essentially regular
internal structure, moderate sound attenuation, and small Echography can make an important contribution in evalu-
cystic spaces (Figure 12-12). The two adenocarcinomas were ating lesions situated in the lacrimal fossa region. 2,3,41 It is
very well outlined and exhibited medium to high internal re- an ideal screening tool for detecting abnormalities and in
flectivity and vascularity. Although these two lesions resem- many instances can augment the information obtained with
bled cavernous hemangiomas in shape and reflectivity, both computed tomography (CT) or magnetic resonance imag-
were hard and significantly indented the globe. In addition, ing (MRI).
one of these tumors showed bony erosion. Because a large variety oflesions can occur in the lacrimal
The authors have examined one case of metastatic carci- fossa region, differentiation can be challenging. The lesions
noid that occurred in the inferior orbit. This tumor in- most commonly found in this area include those of inflam-
dented the globe and had a lobulated configuration. The matory or lymphoid origin, primary lacrimal gland epithelial
mass demonstrated low to medium internal reflectivity and tumors, and cysts.! Ultrasound can be of great value in help-
regular internal structure. In addition, it produced moder- ing to differentiate lesions of the pseudotumorllymphoma
ate sound attenuation, was firm in consistency, and showed group from the epithelial tumors (Table 12-2).
moderate vascularity (Figure 12-13). The normal lacrimal gland and surrounding orbital soft
As previously mentioned, secondary tumors can extend tissue are extremely high reflective. As a result of their sim-
into the orbit from the globe (see Chapter 5), lids, and peri- ilar reflectivities, the gland per se usually cannot be delin-
orbital cavities. These tumors can grow infiltratively or ex- eated from adjacent orbital soft tissue (Figure 12-17).
Text continued on p 324.
320
A B
c D
E F
Figure 12-11 Metastatic carcinoma from breast. External photographs (A and B) show almost
total ophthalmoplegia of left eye. C, Axial CT scan shows large, poorly defined mass within left
orbit. Transocular echograms (D to F) show large orbital lesion (L). D, Transverse B-scan shows
irregularly shaped mass conforming to globe and infiltrating orbital soft tissue. E, Longitudinal
B-scan echogram shows irregularly shaped tumor within muscle cone and around optic nerve
(ON). Arrows, Medial rectus muscle. F, A-scan shows medium-high internal reflectivity of tumor
and V shape. S, Sclera; P, posterior surface spike.
A c
Figure 12-12 Metastatic renal cell

carcinoma. Transocular echo grams
show large orbital lesion (L). A, Trans-
verse B-scan shows well-circumscribed
tumor with small cystic cavity (arrow).
B B, Longitudinal B-scan shows long sec-
tion of mass as it extends back into pos-
terior orbit. C, A-scan shows medium
internal reflectivity with decreasing am-
plitude of spikes, indicating moderate
sound attenuation. S, Sclera; E, bone.
A D
B E
c F
Figure 12-13 Metastatic carcinoid from stomach involving left orbit. Transocular (A to C) and
paraocular (E and F) echograms show large lesion (L) in inferotemporal aspect of left orbit.
A, Vertical axial B-scan echogram shows well-circumscribed, irregularly shaped retrobulbar mass
indenting globe (arrow). B, Transverse B-scan through inferior orbit shows cross-section of mass
and globe indentation. C, A-scan shows medium to low internal reflectivity. V,Vitreous cavity;
S, sclera; P, posterior surface spike; B, bone. D, External photograph shows very mild proptosis
of left eye. E, Transverse paraocular B-scan shows more lobulated appearance of tumor in this
view.F, Paraocular A-scan shows medium internal reflectivity. P, Posterior surface spike.
322 THE ORBIT
B C
Figure 12-14 Squamous cell carcinoma of conjunctiva with extension into anterior orbit.
A, External photograph shows large conjunctival mass in fornix. B, Longitudinal para ocular
B-scan echogram shows lesion (L) extending into anterior orbit next to globe. V,Vitreous cavity;
arrow, area of globe wall, not well shown because of edge artifact. C, Paraocular A-scan shows
medium reflectivity of lesion. P, Posterior surface spike.
A
A
c
c
Figure 12-15 Orbital extension of melanoma from skin. Figure 12-16 Recurrent melanoma following enucleation.
Transocular echo grams show tubular-shaped lesion (arrows) ex- A, External photograph shows marked hemorrhagic chemosis.
tending back into orbit, presumably along an orbital nerve. B, B-scan echogram shows extensive lesion (L) with irregular ap-
A, Longitudinal B-scan shows long section of lesion as it extends pearance in orbital cavity. C, A-scan echo gram demonstrates low
posteriorly, adjacent to orbital bone (B). B, Transverse B-scan internal reflectivity of lesion. P, Posterior surface spike. The le-
shows cross-section bf tubular-shaped lesion. C, A-sean-displays sion was hard and highly vascularized.
low internal reflectivity and regular structure of mass. The tumor
was hard and moderately vascularized. S, Sclera; B, bone.
324 THE ORBIT
TABLE 12-2
lacrimal Gland: Pseudotumor/lymphoma (Pl) vs. Benign Mixed Tumors (BMT)
and Adenoid Cystic Carcinoma (ACC)*
Internal Internal Sound Unilateral/
Tumor Ty(:1e Sha(:1e Reflectivity Structure Attenuation Vascularity Consistency Bilateral
PL Spindle Low-med Regular Weak +/- Normal Either
BMT Round-oval Med-high Regular Mod Normal/excavated Unilateral
ACC Irregular Med-high Irregular Mod/strong Excavated/defects Unilateral
Med, Medium; Mod, moderate; WNC within normal limits.

*The main echographic findings for pseudotumorllymphomas and the most common epithelial tumors are listed.
A c
B D
Figure 12-17 Paraocular A-scan technique for evaluating lacrimal gland. A, A-scan probe is
positioned on the lid overlying lacrimal gland. B, Normal appearance of tissue in lacrimal gland
region (arrow). C, Edema of tissue in lacrimal gland region. D, Infiltrated lacrimal gland (L).
P, Posterior surface spike.
Benign Mixed Tumor (Pleomorphic Adenoma)

tion.27 However, when involving only the palpebral lobe,
Benign mixed tumors are the most common benign ep- the lesion usually remains anterior and does not cause
ithelial tumors of the lacrimal gland. 56 These tumors bonyabnormalities. 42
most often involve the orbital lobe of the gland but in Typically, benign mixed tumors are medium to high
rare cases may affect the palpebrallobe. l When benign reflective with regular internal structure, and they produce
mixed tumors develop within the orbital lobe, they tend moderate sound attenuation lO (see Figure 11-24). These tu-
to extend farther back into the orbit and can become mors are round to oval and are very well outlined because
quite large. l In some cases, these lesions cause indenta- of the capsule surrounding the tumor (Figure 12-18). They
tion of the ocular wall, choroidal folds, and bony excava- have a very firm consistency, are nonvascular, and may con-
B D
c E
Figure 12-18 Benign !nixed tumor. A, Coronal CT scan shows mass in left lacrimal gland fossa
(closed arrow) with bony excavation (open arrow). Transocular (Band C) and paraocular (D and E)
echograms show large orbital lesion (L). B, Vertical transverse B-scan shows well-circumscribed
mass in supratemporal orbit. Note indentation of globe (open arrow) and excavation of orbital
~one (closed arrow). LR, Lateral rectus,muscle. C, A-scan shows medium-high internal reflectiv-
ity, regular structure, and moderate sound attenuation. S, Sclera; B, bone. D, Transverse paraoc-
ular B-scan demonstrates rounded, smooth posterior surface of tumor (P). E, In this view,
paraocular A-scan shows higher internal reflectivity; moderate sound atteilUation; and distinct,
double-peaked posterior surface spike (P) from encapsulated lesion.
326 THE ORBIT
tain one or more small cystic cavities; Very large cystic cav- found in the lacrimal gland region. Two other lesions that
ities have been identified in one tumor (Figure 12-19). should be considered in the differential diagnosis include
Benign mixed tumors can have a shape and reflectivity dermoid cyst and the well-circumscribed form of adenoid
similar to that of cavernous hemangiomas. Hemangiomas, cystic carcinoma.
however, generally have a softer consistency and are rarely A benign mixed tumor can undergo malignant trans for-
A D
8 E
c F
Figure 12-19 Benign mixed tumor with cystic cavities. A, External photograph shows prop-
tosis of right eye. Transocular (B and C) and paraocular (E and F) echograms show large tumor
(arrows) containing large cystic cavities (C). B, Transverse B-scan shows well-circumscribed mass
with cystic cavity next to sclera. C, Corresponding A-scan shows medium-high internal reflec c
tivity of tumor with very low reflective cystic cavity. S, Sclera; B, bone. D, Axial CT scan shows
large, relatively well-circumscribed tumor with large cystic cavity (arrow). E, Transverse paraoc-
ular B-scan shows mass with very large cystic cavity. F, Paraocular A-scan shows predominantly
medium internal reflectivity with very low reflective cystic space in center. P, Posterior surface
spike.
Mucoepidermoid Carcinoma
mation; echographically, however, this can only be sus-
pected if the tumor breaks out of its capsule. Mucoepidermoid carcinoma is a rare epithelial tumor of the
lacrimal gland 49 that has varied histologic features. 56 Two
children and one adult with this tumor have been evaluated
Adenoid Cystic Carcinoma
by the authors. All three lesions had firm consistency, were
Adenoid cystic carcinoma is the second most common ep- relatively well circumscribed, and had predominantly
ithelial tumor and the most common primary malignant medium to high internal reflectivity. Also, all three lesions
tumor of the lacrimal gland. 56 These tumors are usually had moderately irregular internal structure. Cystic spaces
infiltrative, although in some cases they can appear well were noted in one case (Figure 12-22). One lesion produced
circumscribed. Their internal reflectivity is generally very strong sound attenuation, and significant internal vas-
medium to high with an irregular internal structure, al- cularity was not appreciated in any of the tumors. Excava-
though the better-circumscribed lesions may appear more tion of the lateral orbital wall and globe indentation were
regular. Adenoid cystic carcinomas typically have a hard noted in one case. These tumors are difficult to differenti-
consistency and are nonvascular. In addition, these lesions ate from other epithelial tumors of the lacrimal gland.57
usually produce moderate to strong sound attenuation, and
cystic cavities can often be identified (Figures 12-20 and
Pseudotumor and lymphoma
12-:-21). These tumors frequently affect the bone, causing
(lymphoproliferative Diseases)
either excavation or, in some cases, extensive bony de-
struction. A well-circumscribed adenoid cystic carcinoma Inflammatory lesions (i.e., pseudotumors) and lymphoid
may, at times, be difficult to differentiate from a benign tumors occur quite commonly in the lacrimal fossa re-
mixed tumor or even a dermoid cyst due to their similar gion. 51 They can be either unilateral br bilateral. As de-
acoustic features. scribed earlier, pseudotumorllymphomas are classified as
A c E
B D F
Figure 12-20 Adenoid cystic carcinoma (circumscribed). Transocular (A and B) and paraocu-
lar (C and D) echograms shows large orbital lesion (L). A, Transverse B-scan shows well-
circumscribed mass is indenting the globe (open arrow) and excavating the bone (closed arrow).
B, A-scan shows medium internal reflectivity and moderate sound attenuation. S, Sclera; B, bone.
C, Transverse paraocular B-scan with sound beam directed toward bone shows excavation (note
concave shape of bone line). D, Paraocular A-scan displays medium internal reflectivity of tumor
with moderate sound attenuation. P, Posterior surface spike. E, Coronal CT scan shows large or-
bital mass (arrow) indenting the globe and excavating the adjacent orbital bone. F, Gross patho-
logical specimen shows very well-circumscribed tumor.
328 THE ORBIT
A D
8 E
c F
Figure 12-21 Adenoid cystic carcinoma (infiltrative). Transocular (A to C) and paraocular

CD and E) echograms show large orbital lesion (L). A, Transverse B-scan through supratempo-
ral orbit shows extensive tumor with irregular shape inferiorly (curved arrow). Also, note inden-
tation of globe (open arrow) and excavation of bone (closed arrow). Band C, A-scans from two ar-
eas of the tumor show predominantly medium reflectivity but moderately irregular internal
structure. S, Sclera; B, bone. D, Transverse paraocular B-scan shows poorly defined posterior
border (P), indicating infiltrative nature of tumor. E, Paraocular A-scan shows medium internal
reflectivity with strong sound attenuation in this view. Also note low to medium reflectivity of
posterior surface spike (P), indicating lack of encapsulation. F, Axial CT scan obtained after
biopsy and radiation therapy shows tumor extending posteriorly along lateral orbital wall (closed
arrow) and into cavernous sinus (open a7'row).
B c
D E
F G
Figure 12-22 Mucoepidermoid carcinoma. A, External photograph shows downward dis-

placement of left eye. Axial (B) and coronal (C) CT scans show extensive orbital mass in left
orbit. Transocular CD to G) and paraocular (II and I) echo grams show large orbital lesion (L)
containing cystic cavity (white arrow) in some views. D, Longitudinal B-scan shows well-
circumscribed tumor in this view. V,Vitreous cavity; ON, optic nerve. E, Corresponding A-scan
shows medium-high reflectivity of lesion. S, Sclera; B, bone. F, Transverse B-scan shows more
diffuse, irregularly shaped appearance of tumor and cystic cavity. G, Corresponding A-scan
shows medium-high internal reflectivity with very low reflectivity of cystic space. H, Transverse
paraocular B-scan shows irregularly shaped tumor with large cystic cavity centrally. I, Corre-
sponding paraocular A-scan shows medium reflectivity of tumor with veryJow reflective cystic
cavity. P, Posterior surface spike.
330 THE ORBIT
one entity (pseudotumor/lymphoma) because they have a (Figure 12-23). Pseudotumorllymphomas often show inter-
very similar histologic, and therefore echo graphic, appear- nal vascularity, and their consistency can be either hard or
ance (see p 310).34 Lesions in this group include a wide slightly compressible (see p 302). Bony defects and/or exca-
spectrum of conditions, such as idiopathic (nongranuloma- vation are usually not associated with these lesions. 53 Echo-
tous) inflammatory pseudotumor, benign reactive lym- graphically, these lesions can often be shown to be bilateral
phoid hyperplasia, malignant lymphoma, and various types even though clinically they may appear to be unilateral.
of granulomatous inflammatory processes such as those as- In some cases, pseudotumors exhibit high internal
sociated with sarcoidosis. 53 reflectivity. Although these inflammatory lesions are easily
Most pseudotumor/lymphomas occurring in the lacrimal distinguished from the low reflective lymphomas, they can
gland region are irregularly shaped or have a spindle like be more difficult to differentiate from other lesions that oc-
configuration on B-scan. On A-scan the posterior border cur in the lacrimal fossa. They may be either well circum-
spike can vary from indistinct to well defined. Lesions of this scribed or can have a more diffuse, irregular shape. Char-
group typically have regular or slightly irregular internal acteristics that may help to distinguish these tumors from
structure and low to medium reflectivity. They produce weak other lesions in this region include thickening of adjacent
sound attenuation, and septa sometimes can be identified extraocular muscles and the presence of vascularity. In ad-
A D
B E
c F
Figure 12-23 Lymphoma involving lacrimal gland. Transocular (A to C) and paraocular

(E and F) echograms show lesion (L) in lacrimal gland region. A, Transverse B-scan shows ex-
tensive, well-circumscribed tumor next to bone (B). B, Longitudinal B-scan displays typical
fusiform shape of mass as it extends posteriorly along bone. C, A-scan shows low-medium in-
ternal reflectivity. S, Sclera. D, Axial CT scan shows mass in lacrimal gland region (arrow).
E, Longitudinal paraocular B-scan displays fusiform-shaped tumor extending back into orbit
along orbital bone (closed a770WS). V, Vitreous cavity; open arrow, area of globe wall not shown
well because of edge artifact. F, Paraocular A-scan shows low internal reflectivity and weakly re-
flective posterior surface spike (P), caused by fusiform shape of mass.
dition, they may show an area of inflammatory infiltration Ultrasound may show diffuse, highly reflective, nonvascu-
surrounding the lacrimal gland (Figure 12-24). lar enlargement of the lacrimal gland per se, as well as the
surrounding orbital soft tissue. In addition, areas of low
reflective infiltration may be present. With follow-up ex-
Dacryoadenitis
amination, progressive enlargement of a circumscribed, low
Acute infection of the lacrimal gland can be difficult to dis- reflective lesion suggests the development of an abscess (see
tinguish echographically from inflammatory pseudotumor. p 439 and Figure 17-3).
B E
c F
Figure 12-24 Pseudotumor involving lacrimal gland. Transocular (A, B, C, and E) and paraoc-
ular (F) echo grams show enlarged, inflamed lacrimal gland (G). A, Vertical transverse B-scan
through temporal orbit shows inferior aspect of enlarged lacrimal gland just above lateral rectus
muscle (LR). Note homogeneous appearance of infiltration surrounding lacrimal gland (cuT7Jed
arrow). B, Transverse B-scan through supratemporal orbit shows upper aspect of enlarged
lacrimal gland and surrounding infiltration next to thickened levator muscle (small arrows).
SR, Superior rectus muscle. C, Transocular A-scan shows high internal reflectivity of gland and
lower reflectivity from surrounding infiltration (arrow). S, Sclera; B, bone. D, Axial (top) and
coronal (bottom) CT scans show lesion in lacrimal gland region (arrows). E, Longitudinal
B-scan shows fusiform shape of enlarged gland and surrounding infiltration (curved arrow).
F, Paraocular A-scan shows medium-high reflectivity of inflamed gland and low reflectivity of
surrounding infiltration. P, Posterior surface spike.
332 THE ORBIT
lacrimal Ductal Cyst {Dacryops}

(Figure 12-27). In addition, this can allow for display of
This is a rare cystic lesion that results from obstruction and the nasolacrimal duct. The immersion technique also can
ectasia of the lacrimal gland ducts.27 Dacryops may be uni- be helpful for evaluating lesions in this region (see Figure
lateral or bilateral and can involve either the palpebral or 11-23).
orbital lobe of the gland. S These lesions may be round,
oval, or lobulated and are very well outlined. They usually
Dacryocystitis
have smooth contour and are very low reflective. Dacryops
are nonvascular and soft in consistency. Because these le- Dacryocystitis is an inflammation of the lacrimal sac. 23 In
sions are often small and located anteriorly, their evalua- these cases, ultrasound can demonstrate dilatation of
tion may be facilitated by using the immersion technique the sac and its opening into the nasolacrimal duct.IS,53
(Figure 12-25; see also Figure 11-23). The dilated sac is typically very low reflective, although
higher reflectivity may be detected if mucus is present.
The demonstration of a mucous plug or layered mucus
lacrimal Sac
can help to distinguish this condition from a neoplasm
Echography can be useful for evaluating lesions located in (Figures 12-28 and 12-29). These dilated sacs are non-
the region of the lacrimal sac. In normal situations, the vascular and slightly compressible. A dacryolith may ap-
sac can be identified as a small, low reflective structure pear as a highly reflective, echo-dense nodule within the
(Figure 12-26). A dilated sac is much easier to image dilated sac.?
A c
B D
Figure 12-25 Lacrimal ductal cyst (dacryops). A, External photograph shows lesion with cys-
tic appearance involving palpebral lobe oflacrimal gland. B, Immersion B-scan echogram shows
well-outlined, echolucent lesion on surface of globe (a7'rows). F, Fluid within scleral shell;
A, small air bubble. C, Longirudinal paraocular B-scan shows well-outlined, echolucent lesion
with cystic appearance (closed arrows). Open arrow, area of globe wall not well shown because of
edge artifact. V, Vitreous cavity. D, Paraocular A-scan shows very low reflectivity of lesion (ar-
row). P, Posterior surface spike.
A c
B D
Figure 12-26 Normal lacrimal sac. Transocular (A and B) and paraocular (C and D)
echo grams of sac (arrows). A, Longitudinal B-scan through anterior aspect of nasal globe and or-
bit shows small echolucent area from normal sac. B, Lacrimal bone. B, Corresponding A-scan
shows thin defect from sac. Transverse B-scan (C) and A-scan CD) were obtained with probes
placed in medial canthal region. Arrow, Lacrimal sac.
334 THE ORBIT
A C
B 0
Figure 12-27 Dilated lacrimal sac due to dacryocystitis. Transocular (A and B) and paraocular
(C and D) echograms show dilated sac (large arrows). A, Longitudinal B-scan through anterior
aspect of nasal globe and orbit shows enlarged sac. AC, Anterior chamber; B, lacrimal bone.
B, Corresponding A-scan shows very low reflectivity of dilated sac. S, Sclera; B, bone; small ar-
rows, multiple signals. C, Transverse paraocular B-scan shows enlarged sac next to lacrimal bone.
Small arrows, Multiple signals. D, Corresponding paraocular A-scan shows low internal reflec-
tivity of enlarged sac.
Superficial dermoids most often occur in infants or

Tumors of the lacrimal Sac
young children. 50 When a superficial lesion is present,
Tumors of the lacrimal drainage system are rareY Al- echography may be useful to determine whether it extends
though experience with such lesions is limited, they posteriorly into the orbit (Figure 12-30).
would be expected to exhibit characteristics similar When dermoids are situated deeper in the orbit, they
to those of other orbital tumors, depending on their may not become apparent until later in childhood or early
origin. 44 in adulthood. 50 These more posterior cysts may become
very large and can erode the adjacent bony waIF? (Figure
12-31). In other cases, they may actually extend through a
CYSTIC LESIONS
small solitary bone defect into adjacent cavities, most often
Various types of cystic lesions may occur in the orbit (Box into the temporalis fossa.
12-1). Most cystic lesions share the common features of Dermoid cysts can be filled with various substances, such
smooth contour, round to oval shape, sharp outline, and ab- as keratin, sebaceous materials, hair follicles, and inflamma-
sence of internal vascularity. As a result, these lesions usu- tory cells. 56 Since their contents are so variable, these lesions
ally can be easily differentiated from solid tumors. can produce many different quantitative characteristics. 12 In
general, however, dermoid cysts are predominantly high
reflective with slightly irregular internal structure. Some
Dermoid Cyst
dermoids produce marked sound attenuation, whereas oth-
The most common orbital cyst is the dermoid, which usu- ers attenuate minimally. These lesions are usually firm to
ally occurs supra temporally or supranasally.27 These lesions hard in consistency, but recurrent dermoids are typically
may be located superficially within the lid, at the orbital compressible. Settling ofliquid contents may be appreciable
rim, on the conjunctiva, or within the orbit. in some cases. When located in the lacrimal gland region, a
B o
c E
Figure 12-28 Dacryocystitis in newborn. A, External photograph shows swelling in region of

left lacrimal sac (arrows). Paraocular echograms show dilated sac (S). B, Transverse B-scan shows
mucous fluid layer (arrow) within sac. B, Lacrimal bone. C, Corresponding A-scan shows
medium-high reflectivity of mucus within sac and high reflective spike from surface of layered
mucus. D, B-scan with probe angled slightly inferiorly shows opening of nasolacrimal duct
(curved arrow). Note the layered mucus overlying opening of duct. Chain of echoes (small ar-
rows) originates from nasolacrimal duce E, Corresponding A-scan shows medium-high internal
reflectivity of sac and chain of spikes from within nasolacrimal duct.
336 THE ORBIT
Figure 12-29 Dacryocystitis with mucous plug. A, Trans-

verse paraocular B-scan probe position for evaluating
lacrimal sac. B, Transverse para ocular B-scan shows dilated
sac (S) with mucous plug (closed arrow) adjacent to opening
A of nasolacrimal duct (open arrow). B, Lacrimal bone;
connected arrows, echoes from within nasolacrimal duct.
C, Transverse paraocular B-scan with probe pressed against
sac shows movement of plug into opening of nasolacrimal
duct.
B c
Dermolipoma
dermoid cyst sometimes can be difficult to distinguish from
a benign mixed tumor of the lacrimal gland. Dermolipomas are fat-filled lesions and thus may be very
difficult to distinguish from normal orbital soft tissue.
These lesions demonstrate extremely high reflectivity, are
Epidermoid Cyst
often compressible, and are nonvascular (Figure 12-33). If
Histopathologically, epidermoid cysts differ only slightly large enough, the cyst wall may be shown as a highly reflec-
from dermoids in that their walls do not contain adnexal tive posterior border spike.
structures,27 Therefore, these two lesions usually cannot be
distinguished from one another echographically. One patient
Epithelial Cyst
with bilateral biopsy-proven epidermoid cysts has been eval-
uated by the authors. 3! Both lesions were oval and located Epithelial cysts can arise from conjunctiva and may occur
within the upper lid. They exhibited moderately irregular in- within the orbit. They are usually secondary to previous
ternal structure with variable reflectivity and sound attenua- trauma or surgery where conjunctival or cutaneous epithe-
tion (Figure 12-32). These cysts were soft and nonvascular, lium has been inadvertently implanted in the orbit. 32 Less
and aftermovement of the mobile internal lesion echoes was commonly, these lesions are of congenital origin. 56
observed.
B D
c E
Figure 12-30 Superficial dermoid cyst. A, External photograph shows swelling of nasal aspect
of left upper lid. Paraocular echograms show lesion (L) in anterior orbit. B, Transverse
B-scan shows very echo-dense lesion. C, Longitudinal B-scan shows echo-dense lesion anteriorly
adjacent to globe. V,Vitreous cavity; arrow, area of globe wall not shown well because of edge ar-
tifact. D, A-scan at Tissue Sensitivity shows high internal reflectivity and highly reflective pos-
terior surface spike (P) from cyst wall. E,. A-scan at reduced sensitivity setting shows distinct na-
ture of posterior surface spike.
338 THE ORBIT
B 0
C E
Figure 12-31 Deep dermoid cyst. A, Axial CT scan shows large retrobulbar mass (arrow) along
lateral orbital wall (note mild bony excavation). Transocular (B to D) and paraocular
(E) echograms show large orbital lesion (L). B, Transverse B-scan displays well-circumscribed
mass with excavation of bone (arrow). V,Vitreous cavity. C, A-scan shows medium-high internal
reflectivity. S, Sclera; B, bone. D, Longitudinal B-scan shows well-circumscribed lesion extend-
ing into posterior orbit between lateral rectus muscle (!vI) and slightly excavated bone (arrow).
Note displacement of optic nerve (ON). E, Paraocular A-scan shows more irregular internal
structure and strong sound attenuation in this view. Note that posterior surface spike (P) from
cyst wall is reduced in height as a result of sound attenuation.
B c
Figure 12-32 Epidermoid cyst. A, External photograph shows patient with upper lid swelling
supratemporally. B, Paraocular transverse B-scan echogram shows well-circumscribed lesion (L)
with heterogeneous contents. P, Posterior border of encapsulated lesion. C, Paraocular A-scan
echogram oflesion shows irregular internal strncture with high spikes from keratin debris within
the cyst. Note steeply rising, high double-peaked posterior surface spike .from encapsulated le-
sion. D, Photograph shows encapsulated cyst as it was excised from the right upper lid.
Histopathologically, this lesion was filled with keratinous material. (Clinical photographs cour-
tesy Dr. Jan Kronish, Delray Beach, Florida.)
340 THE ORBIT
8 C
Figure 12-33 Dermolipoma of conjunctiva and orbit. A, External photograph showing sub-
conjunctival lesion on temporal aspect of right globe (arrows). B, Transverse B-scan echogram
displays echo-dense lesion (L). C, Paraocular A-scan with probe placed directly on mass shows
high internal reflectivity of lesion similar to normal orbital soft tissue. .
These lesions are round with smooth contour and are globe is usually deformed and microphthalmic. VVhen these
very well outlined. They are filled with serous fluid or other cysts are large and extend anteriorly, they tend to be bluish-
homogeneous liquid contents and so are very low reflective gray and to transilluminate well. 56 Large cysts are most of-
(Figure 12-34). Epithelial cysts are nonvascular and are typ- ten located inferiorly and thus displace the globe upward.
ically quite soft. These lesions have been detected anterior Echographically, the cyst usually appears to be attached
to an orbital implant following enucleation (Figure 12-35, to the globe wall. It may communicate directly with the
A and B). globe or it may be separated from the globe by"a thin mem-
brane. These cysts are typically very low reflective; have
smooth, round contour; and are very well outlined22 (Figure
Hematic Cyst (Cholesterol Granuloma)
12-37). Additionally, they have a soft consistency and are
Hematic cyst appears to occur following longstanding sub- nonvascular.
periosteal hemorrhage. 30 These cysts are located beneath the
periosteum in the superior, more temporal aspect of the or- Anophthalmos/Congenital Cystic Eye
bit and are associated with a well-demarcated, solitary bone
(Anophthalmos With Cyst)
defect. They are well circumscribed and have a round or oval
configuration. The internal reflectivity is generally low, but Anophthalmos is a developmental anomaly in which the eye
higher reflective clumps of mobile cholesterol debris some- is absent at birth. 15 In these cases, echography shows the or-
times can be identified (Figure 12-36; see also p 37). bital cavity to be filled with normal-appearing highly reflec-
tive soft tissue, but a globe is not detected (Figure 12-38).
Congenital cystic eye is a term that denotes a vestige
Microphthalmos with.Cyst
rather than total absence of an eye. 56 These cystic structures
Microphthalmos with cyst results from failure of the fetal can vary in size and can be located superficially or situated
fissure to close and is therefore present at birth. 50 The deep within the orbit. VVhen the cyst is visible clinically, it
Figure 12-34 Conjunctival epithelial cyst. A, External photograph shows cystic lesion in fornix
supranasally. B, Longitudinal paraocular B-scan echogram shows very well-outlined, echolucent
cyst (C) along anterior aspect of globe. V, Vitreous cavity; small arrows, multiple signals within
cyst and vitreous cavity; large arrow, area of globe wall not shown well because of edge artifact.
C, Paraocular A-scan shows very low reflective, well-outlined cyst. Note steeply rising, smooth
posterior surface spike (P) of this encapsulated cyst. 0, Normal orbital soft tissue behind lesion.
342 THE ORBIT
Figure 12-35 Epithelial implantation cysts. A, Exter-

nal photograph shows marked right upper lid swelling
in patient 2 years after evisceration. B, B-scan echogram
with probe overlying swelling displays cystic lesion (L)
D
filled with dense hemorrhage. Note layering of fluid
blood (arrows) at bottom of cyst that shifted with
changes in head position. Orbital implant (1), located at
inferior aspect of echo gram, indents cyst wall. P, Poste-
rior surface of cyst. C, Schematic drawing and
echograms CD and E) from implantation cyst in another
patient that developed 4\1, years after enucleation.
C, Drawing indicates sound beam direction in
echograms. D, B-scan view in axial orientation with
probe placed on lid and directed toward orbital apex
shows extensive cystic lesion (arrows) anterior to or-
bital implant (1). Diffuse opacities within cyst represent
fluid blood. Note shadowing (S) of posterior orbital tis-
sue from implant. E, Transverse B-scan echogram E
through cyst anterior to implant shows diffuse, dense
hemorrhage.
A B
c D
E F
Figure 12-36 Hematic cyst. A, Coronal CT scan posterior to bone defect shows smooth mass
along roof of orbit (arrow). B, Very anterior coronal CT scan shows large bone defect in roof of
orbit (arrows). Transocular (C and D) and paraocular (E and F) echograms show orbital lesion (L)
associated with large bone defect supratemporally. C, Oblique transverse B-scan view through
anterior aspect of supratemporal orbit displays extensive subperiosteal mass with bone defect.
V, Vitreous cavity; arrows, edges of bone defect. D, A-scan shows low reflectivity of the lesion
with a few higher spikes from large clumps of cholesterol debris (i.e., slightly irregular internal
structure). V,Vitreous cavity; S, sclera; B, bone. E, Transverse paraocular B-scan shows lesion ex-
tending from orbit through large defect in orbital roof (closed straight arrows). B, Orbital bone;
open arrow, bone not shown in this area due to edge artifact; curved arrow, layer of bone at base
of defect. F, Paraocular A-scan shows very low reflectivity of lesion in this view and smooth,
high, double-peaked posterior surface spike (P) from the cyst wall. I, Initial spike.
344 THE ORBIT
Figure 12-37 Microphthalmos with cyst. A, External

photograph shows small, esotropic right eye with
leukokoria. B, Axial B-scan echo gram displays small, mi-
A crophthalmic globe with large echolucent orbital cyst (C).
P, Posterior lens capsule; V, vitreous cavity. C, Transverse
A-scan shows large, very low reflective cyst posterior to
globe. S, Sclera; B, orbital bone.
B c
Figure 12-38 Anophthalmos. A, External photograph

shows newborn whose globes are not detectable clinically.
Echograms were obtained with probes placed on lid and
A sound beam directed toward apex of orbit. B-scan (B) and
A-scan (C) show normal orbital soft tissue (0) and no ev-
idence of formed globe. I, Initial line (B-scan) and spike
(A-scan).
B c
Figure12-39 ·Congenital cystic eye. A, External

photograph of newborn whose globes are nof de-
. tectable clinically. Echograms were "obtaIned with
probes placed on lid and sound beam directed to-
A ward apex oforbit. B-scan (B) and A-scan (C) show .
relatively well-outlined, low reflective lesion (L) with
cystlikeappearance. No identifiable ocular structures
were detected.
B c
A B
Frgure 12-40 Teratoma in newborn. B-scari echograms (A and B) show well-circumscribed,

echolucent cystic lesion (L) in posterior orbit. Arrow, Calcified nodule within cyst; V, vitreous
cavity.
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346 THE ORBIT
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Vascular Lesions
Lesions of vascular origin are among the most common or- Cavernous hemangiomas have a relatively firm consis-
bital abnormalities encountered in echography. In most tency, although mild compressibility often can be demon-
cases, because of their distinct anatomy and histologic ar- strated. Ossoinig describes the finding of "delayed com- .
chitecture, they can be easily detected and differentiated pressibility" in these lesionsY Because the blood within
with Standardized Echography.2-4,7,13-16 the cavernous spaces is for the most part stagnant, they
Color Doppler imaging 10 can also be used to further exhibit medium-high reflectivity and no internal vas-
evaluate these types of lesions (see Chapter 14). Vascular cularity18 (see Color Plate 11). Occasionally, however, a
lesions of the orbit are divided into two main groups: neo- hemangioma may contain mild blood flow within lower
plasms and malformations 8 (Box 13-1). reflective cavernous spaces.
VASCULAR NEOPLASMS Capillary (Infantile) Hemangioma

Vascular neoplasms commonly occur in both children and These lesions can be apparent at birth or may become no-
adults. Specific echographic criteria are used to differenti- ticeable at a few months of age. 23 Like cavernous heman-
ate many ofthese lesions (Table 13-1). giomas, capillary hemangiomas have very characteristic
findings that, in most cases, make the echo graphic diagno-
sis straightforward.
Cavernous Hemangioma
The histologic architecture of these lesions is quite
Cavernous hemangiomas are one of the most common tu- mixed. They are composed of capillary-sized blood vessels
mors in adults.23 The histologic architecture is heteroge- and endothelial cells, as well as large endothelium-lined
neous because of the multiple blood-filled vascular chan- ectatic spaces. 22 As a result, pathologists sometimes describe
nels that comprise the tumor. The vascular channels are them as mixed capillary/cavernous hemangiomas. 8
filled with relatively stagnant blood, and the walls that form This varied histologic architecture can result in irregular
the vascular spaces are relatively large interfaces, resulting internal structure, although reflectivity is usually high
in high reflectivity.4,14,18 These highly reflective lesions have because of the predominance of dense capillaries. In some
regular internal structure and exhibit moderate sound at-
tenuation (see Figure 11-24).
Cavernous hemangiomas are typically situated within BOX 13-1
the muscle cone, without attachment to the globe or other
orbital structures (Figure 13-1). These tumors can become Vascular lesions
very large (Figure 13-2) and may cause mild flattening of
Neoplasms
the globe with choroidal folds, 8 but marked indentation of
Cavernous hemangioma
the ocular wall rarely occurs. The lack of significant inden-
Capillary (infantile) hemangioma
tation sometimes can be helpful in distinguishing heman-
Lymphangioma
giomas from other more solid tumors, which often indent Hemangiopericytoma
the globe to a greater extent. Also, hemangiomas can
markedly displace the optic nerve (Figure 13-3). Vascular Malformations
Cavernous hemangiomas are round to oval and are very Carotid-cavernous sinus fistula
well outlined. 6 The capsule that surrounds the tumor pro- Dural-cavernous sinus fistula
duces a well-demarcated border on B-scan and a steeply ris- Superior ophthalmic vein thrombosis
Orbital varix
ing, high posterior surface spike on A-scan (see Figure 13 -1).
Arteriovenous malformation
Occasionally, a cavernous hemangioma may be found out-
Orbital aneurysm
side of the muscle cone or even within the lid (Figure 13-4).
347
348 THE ORBIT
~B~1~1 . .
Differential Diagnosis of Vascular Neoplasms*
Tumor Internal Internal Sound Vascularity Consistency
Type Shape Borders Reflectivity Structure Attenuation
Cavernous Round/oval Well outlined High Regular Moderate Firm/soft
hemangioma
Capillary Irregular Poorly outlined High Irregular Variable + Soft
hemangioma
Lymphangioma Irregular Poorly outlined Lowt Irregular Variable Soft; firm
(heme)
Hemangio- Round/oval Well outlined Medium Regular Moderate + Hard
pericytoma
*This table lists the main echographic findings for the most common vascular neoplasms of the orbit.
tThis lesion is low reflective with highly reflective septi.
c
A
D
B
Figure 13-1 Small intraconal cavernous hemangioma. A, Horizontal axial B-scan echo gram
from aphakic eye shows oval-shaped lesion (L) situated temporal to optic nerve (ON).
E, Transocular A-scan echogram shows high reflectivity and moderate sound attenuation (ar-
l'OWS). P, Posterior surface spike; S, sclera. C, Axial CT scan shows well-circumscribed intraconal
mass. D, Gross pathologic specimen of encapsulated tumor.
Chapter 13 VASCULAR LESIONS 349
A c
B D
Figure 13-2 Large intraconal cavernous hemangioma. A, Transverse B-scan echogram shows
oval lesion (L) situated between globe and orbital bone (B). V, Vitreous cavity. B, Transocular
A-scan shows high reflectivity and moderate sound attenuation (arrows). S, Sclera. Axial (C) and
coronal (D) CT scans demonstrate large orbital tumor in the right orbit.
Figure 13-3 Vertical axial B-scan echogram shows cavernous hemangioma (arrows) displacing
the optic nerve (ON) inferiorly.
350 THE ORBIT
B D
C E
Figure 13-4 Cavernous hemangioma of right lower lid. A, External photo shows right lower
lid lesion. B, Paraocular B-scan echo gram shows lesion (L) and thick posterior surface (P).
I, Initial line corresponding to probe face. C, Paraocular A-scan echogram shows high reflectiv-
ity of lesion and distinct, highly reflective posterior surface spike (P). I, Initial spike. D, Immer-
sion B-scan view shows well-circumscribed, round lesion near lid surface (open aT·TOW). The ini-
tialline is shifted to the left and is not seen. F, Fluid (methylcellulose) within scleral shell; small
arrows, small air bubbles; P, posterior surface oflesion. E, Immersion A-scan shows highly re-
flective lesion adjacent to lid (open aTTow). I, Initial spike; F, fluid; small a770WS, air bubbles;
P, posterior surface spike.
tumors, areas of lower reflectivity are produced by more both A-scan and Doppler instruments (see Color Plate 14).
cellular portions of the lesion, as well as by large cavernous Additionally, these lesions are soft and thus are easily com-
spaces (Figure 13-5). The cavernous spaces occur most of- pressible.l 5,25 As the patient becomes older, capillary hem-
ten in more longstanding lesions. 8 angiomas normally involute,9 and vascularity gradually
Capillary hemangiomas can be located superficially or diminishes.
deep within the orbit. 21 These tumors are not well circum-
scribed and therefore typically have indistinct borders (Fig-
lymphangioma
ure 13-6). Lesions presenting at birth often fill the entire
orbital cavity. At this stage the tumors tend to be more Lymphangiomas are detected most often in children and
highly reflective and therefore may be mistaken for normal young adults. 16 They may be confined to the orbit or may
orbital soft tissue. However, a widened orbital soft tissue also involve the conjunctiva and/or lid. These lesions can
pattern compared with that of the normal fellow orbit grow slowly, producing lid swelling or displacement of the
should alert the echographerthat abnormal vascular tissue globe, or they may present with sudden, acute proptosis
maybe present. In some cases, there can be thickening of secondary to spontaneous hemorrhage. 9
the extraocular muscles and/or mild dilatation of thesupe- Histopathologically, lymphangiomas consist of multiple
rior ophthalmic vein. lymph-filled spaces (that are low reflective) with thin, en-
The key point in diagnosing a capillary hemangioma is dothelium-lined walls (that are highly reflective). This
the marked internal blood flow, which can be detected with mixture of low and high reflectivity makes their internal
A B
c D
Figure 13-5 Capillary hemangioma. A, External photograph shows child with swelling of left
lower lid. B, Transverse paraocular B-scan echo gram shows large, irregularly structured lesion
(L). Arrow, Large posterior cavernous space. C, Longitudinal paraocular B-scan view shows le-
sion (L) beneath globe. Note large posterior cavernous space (closed arrow). V, Vitreous cavity;
open arrow, area of globe wall not shown well because of edge artifact. D, Paraocular A-scan
echogram shows high reflectivity of lesion (L) anteriorly with low reflective cavity posteriorly (ar-
row). Sound beam is partially directed toward orbital bone (B).
352 THE ORBIT
B D
C E
Figure 13-6 Capillary hemangioma. A, External photograph shows child with extensive cap-
illaryhemangioma of forehead and right upper lid. Paraocular B- and A-scan echograms show
large lesion(L) within lid and orbit. B, Transverse B-scan shows large, diffuse mass. C, A-scan
shows high reflectivity and indistinct posterior surface spike (P). D, Longitudinal B-scan through
superior orbit shows lesion (L) above globe extending posteriorly. V,Vitreous cavity; arrow, area
of globe wall not shoWn well because of edge artifact. E, Different A-scan position shows more
irregular internal structure and weaker reflective posterior surface spike (P) in this view.
structure somewhat irregular (see Figure 11-26). In addi- reflective, although reflectivity is slightly higher than clear
tion, lymphangiomas are usually infiltrative and conse- . lymph (Figure 13-9). In some cases, the blood layers so that
quently produce indistinct borders. These tumors can be a fluid level can be demonstrated within some of the large
small and localized but frequently are large and diffuse. cavernous spaces (Figure 13-10; see Figure 11-32). Al-
Occasionally, a lymphangioma can even fill the entire or- though the lesion can have a very firm consistency imme-
bital cavity (Figure 13-7). Similar to capillary heman- diately after hemorrhage has occurred, it usually becomes
giomas, lymphangiomas can have a very soft consistency more compressible with time.
but do not exhibit internal vascularity as is typically seen , A lymphangioma with hemorrhage that presents with
in capillary hemangiomas. sudden proptosis must be differentiated from rhab-
"When a sudden hemorrhage occurs within a lymphan- domyosarcoma. Echographically, the large dilated lym-
gioma, the cavernous spaces become markedly dihited (Fig- phatic spaces usually allow a lymphangioma to be easily
ure 13-8). This blood does not clot and is usually low differentiated from the solid, more homogeneous patterns
A B
Figure 13-7 Transocular echograms of large orbital lymphangioma. A, B-scan view shows
large mass (arrows) with multiple, dilated lymph-filled spaces. B, A-scan view shows lesion be-
tween sclera (S) and orbital bone (B). Internal structure is irregular due to the multiple, low re-
flective lymph-filled spaces. Arrows, Surfaces oflymphatic spaces.
B c
Figure 13-8 Lymphangioma with hemorrhage filling the orbital cavity. A, External photo-
graph of child with proptosis of the right eye. B, Axial B-scan echogram displays large lesion
(aTTows) with dilated lymph spaces (S) surrounding the optic nerve (ON). C, Transverse B-scan
view through superior orbit shows several large dilated spaces. V, Vitreous cavity.
354 THE ORBIT
A 8
c E
D F
Figure 13-9 Lymphangioma with hemorrhage. A, External photograph shows child with
marked proptosis of right eye at presentation. B, Axial CT scan at presentation shows massive le-
sion filling right orbit and causing marked proptosis. Transocular echograms (C to F) demonstrate
large mass. Closed arrlYWs indicate walls of dilated spaces. C, Transverse B-scan echogram displays
extensive orbital mass with multiple blood-filled spaces. V, Vitreous cavity. D, Corresponding
A-scan shows low reflective spikes from hemorrhage (open arrow) within large space. S, Sclera;
B, bone. E, Longitudinal B-scan (at reduced gain setting) through anterior portion oflesion shows
smaller spaces. F, Corresponding A-scan shows multiple, small, dilated spaces. Note that oblique
sound beam incidence results in lower than normal reflectivity of sclera (S). G, External photo-
graph of child 4 weeks after drainage of orbital hemorrhage shows decrease in proptosis.
,
Figure 13-10 Lymphangioma with layered hemorrhage. Axial B-scan echogram at decreased
gain shows very extensive retrobulbarlymphangioma with hemorrhage. Note layering of fluid
blood (open arrows) within markedly dilated lymphatic spaces. Massive dilatation of spaces is
causing marked indentation of posterior ocular wall (closed arrows). ON, Optic nerve.
seen in a rhabdomyosarcoma (see p 310). Decompression can occur. These fistulas have been classified as either fast
of a lymphangioma is sometimes necessary when the hem- flow or slow flow. 19 Generally, a fast flow shunt is due to an
orrhage causes marked proptosis. In these cases, ultrasound internal carotid-cavernous sinus fistula, whereas slow flow
may help determine the best areas for needle aspiration, shunts are more often associated with dural-cavernous si-
and B-scan echography may be used to guide positioning nus communication.
of the needle 24,26 (see Figure 17-4).
Carotid-Cavernous Sinus Fistula (Fast Flow)
Hemangiopericytoma
This type of fistula is usually the result of severe head
Hemangiopericytomas are relatively uncommon orbital tu- trauma. It presents with characteristic clinical signs and
mors.2l They usually occur within the superior portion of symptoms and is easily detected with echography. Clinical
the orbit, are round to oval, and are well outlined. The in- signs include dilated episcleral blood vessels, pulsatile ex-
ternal reflectivity is predominantly medium, and the inter- ophthalmos, chemosis, audible bruit, and, in some cases, in-
nal structure can be regular or slightly irregular 3 (Figure creased intraocular pressure. 19 ,21
13-11). In addition, cystic spaces of variable size may be The classic finding is a dilated superior ophthalmic vein
present. These tumors have hard consistency, usually show that is often undetectable in normal orbits. This vessel typ-
prominent internal blood flow, and produce moderate ically courses between the superior rectus muscle and the
sound attenuation (Figure 13-12; see also Color Plate 12). optic nerve as it extends from the supranasal orbit to the
Other tumors that can produce similar echo graphic find- superior orbital fissure ll ,12 (Figure 13-13). Other orbital
ings include schwannomas, fibrous histiocytomas, and the findings that can be associated with cavernous sinus fistulas
rare metastatic renal cell carcinomas. include (1) orbital soft tissue swelling causing widening of
Other tumors (e.g., pseudotumor/lymphomas, rhab- the normal orbital soft tissue pattern; (2) mild enlargement
domyosarcomas, and fibrous histiocytomas) that are not of the extraocular muscles, with medium to high reflectiv-
classified pathologically as vascular lesions can exhibit ity; and (3) widening of the optic nerve pattern as a result
various degrees of internal blood flow. Consequently, these of increased subarachnoid fluid. 19 In addition, ciliocho-
lesions occasionally can be confused with true vascular roidal detachments can be observed in association with this
neoplasms. condition.
The vein, depending on the speed of flow within the
VASCULAR MALFORMATIONS fistula, can be either mildly or markedly dilated. On A-scan,
the dilated vein is typically very low reflective and demon-
Cavernous Sinus Fistula
strates marked blood flow (Figure 13 -14; see also Color
Fistulas within the cavernous sinus can result in dilation Plate 9). Pulsation of the vein sometimes can be seen on
and arterialization of the orbital veins, as well as conges- A- and/or B-scan. Additionally, the audio Doppler re-
tion of the orbital soft tissue. Although these fistulas (i.e., sponse, with the probe placed on the nasal aspect of the up-
shunts) are usually unilateral, bilateral orbital involvement per lid, is markedly positive. ll The marked blood flow
356 THE ORBIT
B D
C E
Figure 13-11 Echograms and CT scan ofhemangiopericytoma. A, Axial CT scan shows large,
well-circumscribed orbital mass supranasally (arrow). Transocular echograms show large orbital
lesion (L) located supranasally. B, Transverse B-scan shows well-circumscribed, oval lesion. Note
decreasing brightness of internal echoes due to sound attenuation. C, Longitudinal B-scan dis-
plays well-circumscribed, oval lesion extending back into orbit. D, A-scan displays medium in-
ternal reflectivity oflesion with relatively strong sound attenuation. S, Sclera; B, bone; M, mul-
tiple signal. E, Gross pathologic specimen shows well-circumscribed mass.
A D
B E
c F
Figure 13-12 Large hemangiopericytoma with cyst examined over 6-month period. All
echograms oflesion (L) were obtained with a transocular approach. A, Initial examination. Trans-
verse B-scan shows intraconal mass with fluid-filled cystic cavity (F) anteriorly. V,Vitreous cav-
ity. B, A-scan corresponding to A shows fluid-filled cavity and medium to'low reflective, solid le-
sion. V, Vitreous cavity; S, sclera; A, anterior and P, posterior surface spikes of solid portion of
lesion; 0, orbital soft tissue. C, Follow-up examination 6 months later shows increased size ofle-
sion and cystic area is no longer present. D, A-scan corresponding to C shows medium reflec-
tivity and moderately strong sound attenuation. E, Vertical axial B-scan from second examina-
tion shows lesion above optic nerve (ON). F, Axial CT scan from time of second examination
shows the large, well-circumscribed intraconal mass in the left orbit.
358 THE ORBIT
A B
Figure 13-13 Dilated superior ophthalmic vein secondary to carotid-cavernous sinus fistula.
A, Transverse B-scan view through superior orbit (just above optic nerve) shows superior oph-
thalmic vein (SO). Note that the vein courses from the supranasal aspect of the orbit back toward
the orbital apex. B, Photograph shows horizontal transverse B-scan probe position for display~
ing superior ophthalmic vein.
A c
B D
Figure 13-14 Carotid-cavernous sinus fistula involving right orbit following severe head
trauma. A, Vertical axial B-scan echogram shows cross-section of dilated superior ophthalmic
vein (SO) above optic nerve (ON). B, Horizontal para-axial B-scan view (through superior orbit)
shows long section of dilated vein. C, External photograph shows proptotic globe with dilated
episcleral vessels. D, A-scan view shows cross-section of dilated vein (arrows) with blurred, low
reflective spikes from fast-flowing blood. M, Multiple signal.
A c
Figure 13-15 Two examples of dilated medial col-

lateral ("vertical") veins in nasal aspect of orbit.
A, Vertical transverse B-scan echo gram displays long
section of vertically oriented vein (arrows). B, Lon-
gitudinal B-scan shows cross-section of dilated vein
8 (arrow). C, B-scan shows markedly dilated medial
collateral vein in patient with carotid-cavernous si-
nus fistula. Vertical transverse B-scan view through
nasal aspect of orbit shows vein (arrow) extending
downward from its connection to the dilated supe-
rior ophthalmic vein (SO).
through these veins results in a firm consistency during In cases where the vein is not dilated but the extraocular
compression testing. Other tributary veins, such as the me- muscles are enlarged, this condition may appear echo-
dial collateral or "vertical" vein described by Ossoinig et graphically similar to thyroid ophthalmopathy.
al,17 can also be dilated in this condition (Figure 13 -15).
Superior Ophthalmic Vein Thrombosis
Dural-Cavernous Sinus Fistula (Slow Flow)
Thrombosis of the superior ophthalmic vein can occur in
This type of fistula, also known as "red eyed shunt syn- carotid-cavernous sinus fistulas and, as discussed previously,
drome," usually occurs spontaneously in middle-aged to may also be seen in dural-cavernous sinus fistulas. Acute
elderly women and causes orbital congestion. 19 These pa- thrombosis of the superior ophthalmic vein can present
tients typically show dilated episcleral blood vessels, min- with proptosis, chemosis, and lid edema. 21 In some in-
imal proptosis, and increased intraocular pressure. Fur- stances, thrombosis can cause increased dilatation of the su-
thermore, no bruit or pulsation of the eye is usually perior ophthalmic vein. Blood flow is usually markedly di-
detected. minished or totally absentY The clotted blood within the
The primary echographic findings in dural-cavernous si- vein produces large interfaces and thus medium-high in-
nus fistulas include mild to moderate widening of the or- ternal reflectivity (Figure 13 -17).
bital soft tissue pattern and thickening of the extraocular
muscles in the affected orbit l (see p 406). The superior
Orbital Varix
ophthalmic vein can be of normal size (and thus unde-
tectable), or it can be moderately dilated (Figure 13-16). Orbital varices are venous malformations that may cause a
In these cases, the internal reflectivity of the dilated vein characteristic intermittent proptosis, which is often exacer-
is usually low to medium, higher than that seen in fast bated with bending of the head or performance of a Val-
flow carotid-cavernous sinus fistulas. This higher inter- salva maneuver.23 This increase in venous pressure, caused
nal reflectivity may be due to partial thrombosis of the either by bending over or by the Valsalva maneuver, allows
low flow fistula, resulting in larger interfaces and thus a blood to collect passively in the abnormal venous spaces.
more heterogeneous echographic pattern. Audio Doppler These patients may eventually become enophthalmic,20
ultrasound may show findings similar to the normal fel- presumably from fat necrosis due to fluctuation in size of
low orbit, or there may be a low-grade positive response. the lesion over time.
360 THE ORBIT
Figure 13-16 Dural-cavernous sinus fistula. A, External

photograph shows marked dilatation of episcleral veins.
B, Transverse B-scan echo gram through supranasal orbit
A displays cross-section of dilated superior ophthalmic vein
(arrows). C, Longitudinal B-scan through supranasal orbit
shows moderately dilated superior ophthalmic vein (arrows).
B c
A c
B D
Figure 13-17 Thrombosis of dural-cavernous sinus fistula. A, External photograph showing

marked conjunctival chemosis and hyperemia of the left eye. Patient also complained of pain
and was found to have high intraocular pressure as well as bullous, serous choroidal detachments
(not shown). B, Longitudinal para ocular B-scan echo gram supranasally shows dilated superior
ophthalmic vein (SO) anterior to globe. V, Vitreous cavity; arrow, area of globe wall not shown
well because of edge artifact. C, Transverse paraocular B-scan shows dilated vein. D, Transocu-
lar A-scan shows medium reflectivity of vein filled with clotted blood. Arrows, Wall of vein.
Chapter 13 VASCULAR LE~JONS 361
A c
B D
Figure 13-18 Tubular-shaped orbital varix before and during Valsalva maneuver. Transocular
B-scan echo grams before (A and B) and during (C and D) Valsalva maneuver. Transverse
(A) and longitudinal (B) views show normal orbital pattern before Valsalva maneuver with no ev-
idence of varix. C, Transverse section shows cross-section of varix (arrow) during Valsalva ma-
neuver. D, Longitudinal view shows long section of varix (arrows) during Valsalva maneuver.
ON, Optic nerve.
If a varix is collapsed, the lesion may not be detectable ternal vascularity is not appreciable because of their venous
during the basic screening examination. However, if the supply. In order to detect a varix, in some cases the exam-
patient then performs a Valsalva maneuver or leans for- iner may need to bend over or actually sit on the floor for
ward, the venous space(s) can fill, resulting in the appear- proper probe placement. The examiner should be aware
ance of a well-outlined, low-to-medium reflective orbital that even in normal situations, mild dilation of the superior
lesion. is A varix can have the tubular shape of a blood ves- ophthalmic veins can occur in both orbits when the patient
sel (Figure 13-18; see also Color Plate 10), or it can appear bends forward. Thrombosis of an orbital varix also can oc-
as a large mass. Varices are usually compressible, but in- . curs (Figure 13-19,A and B).
362 THE ORBIT
Figure 13-19 Orbital varix. A, Thrombosed orbital varix

at initial presentation. 1, Transverse B-scan echogram
shows large, oval lesion (L) extending to orbital apex. V,Vit-
reous cavity. 2, Corresponding transocular A-scan shows
very low reflective lesion. Aftermovement of the internal
echoes of the lesion was observed during the examination
and the Valsalva maneuver was negative. A, Anterior sur-
face spike; P, posterior surface spike. Axial (3) and coronal
(4) CT scans show lesion (arrows) and slightly proptotic
right globe. Continued
Figure 13-19, cont'd B, Follow-up examination of orbital varix 6 weeks after initial examina-
tion. 1, External photograph now shows enophthalmos on right side. Transocular echograms
(2 to 5) show lesion (L). 2, Transverse B-scan echogram displays marked decrease in size of mass
compared with 1 in figure A. V,Vitreous cavity. 3, Corresponding A-scan shows smaller size and
higher reflectivity compared with 2 in part A. A, Anterior and P, posterior surface spikes. 4 and
5 show expansion of lesion during Valsalva maneuver (compared with 2 and 3). This indicates
varix is no longer completely thrombosed.
364 THE ORBIT
B E
c
F
Figure 13-20 Congenital arteriovenous malformation involving left lids and orbit. External
photographs (A and D) show marked thickening and irregularity of lids as well as hyperemia, in-
jection, and swelling of conjunctiva. Paraocular echograms (B, C, E, and F) show extensive mass
with irregular internal structure (arrows). Blurring of A-scan spikes (C and F) indicates marked
internal blood flow. (Clinical photographs courtesy Dr. Latif Hamed, Gainesville, Florida.)
A c
B D
Figure 13-21 Large orbital aneurysm. Transocular (A to C) and paraocular (D) echograms
show orbital lesion (L). A, Transverse B-scan echogram shows well-outlined mass that is slightly
indenting globe (arrow). B, Transocular A-scan shows very low reflective, well-outlined lesion.
B, Bone. C, Longitudinal B-scan view shows lesion indenting globe (arrow). D, Paraocular
A-scan shows very low reflective, well-outlined lesion. P, Posterior surface spike.
Arteriovenous Malformation
have a tubular shape and contain fast blood flow similar to
Arteriovenous malformations can be congenital, or they that of a carotid-cavernous sinus fistula, aneurysms nor-
may develop spontaneously following trauma. 8 These le- mally can be differentiated by their course in the orbit. In a
sions are often diffuse and irregularly shaped because they fistula, the dilated superior ophthalmic vein extends from
can be composed of "tangled malformed arteries and the anterior aspect of the supranasal orbit to the orbital
veins."9 The internal structure of these lesions is typically apex. In contrast, an orbital aneurysm is more localized and
irregular because of the very low reflective, fast flowing is usually situated in the anterior aspect of the orbit. 16
blood and the higher reflectivity of the vessel walls. The
marked blood flow can normally be observed on A-scan
REFERENCES
(Figure 13-20) and can be demonstrated on both audio
1. Atta HR, Dick AD, Hamed LM, et al: Venous stasis orbitopathy: a
Doppler and color Doppler imaging (see Color Plate 15). clinical and echographic study. Br J OphthalmoI1996;80:129.
These highly vascularized lesions are soft and compressible. 2. Bettelheim H, Till P: Diagnosis of orbital vascular disorders by oph-
Other associated findings can include generalized swelling thalmodynamography, in ThijssenJM, Verbeek AM (eds): Ultrasonog-
raphy in Ophthalmology. Dordrecht, Dr W Junk, 1981, p 299.
of the orbital soft tissue and secondary glaucoma. Serous 3. Byrne SF: Standardized echography in the diagnosis ofhemangioen-
choroidal detachments sometimes occur in association with dothelioma, in HillmanJS, Lemay MM (eds): Ophthalmic Ultrasonog-
these lesions. raphy. Dordrecht, Dr W Junk, 1984, p 347.
4. Byrne SF, Glaser JS: Orbital tissue differentiation with standardized
echography. Ophtbalmology 1983;90:1081.
5. BullockJD, Goldberg SH, Connelly PJ: Orbital varix thrombosis.
Orbital Aneurysm Ophthalmology 1990;97 :251.
6. Coleman DJ, Jack RL, Franzen LA: High resolution B-scan ultra-
Orbital arterial aneurysms are well outlined and low reflec- sonography of the orbit. II: Hemangiomas of the orbit. Arch Ophthal-
tive, with regular internal structure (Figure 13-21). These mol 1972;88:368.
lesions are usually highly vascularized on both A-scan and 7. Dutton JJ, Byrne SF, Proia AD: Diagnostic Atlas of Orhital Diseases.
Philadelphia, WE Saunders Co, 2000.
Doppler and are slightly compressible. Although they can
366 THE ORBIT
8. Henderson JW: 01'bital Tumors, ed 2, New York, Thieme-Stratton, 18. Ossoinig KC, Keenan TP, Bigar F: Cavernous hemangioma of the or-
1980. bit: A differential diagnosis in clinical echography. Bibl Ophthalmol
9. Jakobiec FA, Font RL: Orbit, in Spencer WH: Ophthalmic Pathology: 1975;83:236.
An Atlas and Textbook, ed 3. Philadelphia, WE Saunders Co, 1986, 19. Phelps CD, Thompson HS, Ossoinig KC: The diagnosis and prog-
p 2546. nosis of atypical carotid-cavernous fistula (red-eyed shunt syndrome).
10. Lieb WE: Color Doppler imaging of the eye and orbit. Radial Clin Am J Ophthal71zo11982;93 :423.
North,Am 1998;36:1059. 20. RootmanJ: Frequency and differential diagnosis of orbital disease, in
11. MacNeillJR: Standardized echography in C.C. fistulas, in Ossoinig RootmanJ: Diseases of the Or'bit. Philadelphia, JB Lippincott Co, 1988,
KC (ed): Ophthalmic Echography. Dordrecht, Dr W Junk, 1987, p131.
P 521. 21. Rootman J, Graeb D: Vascular lesions, in Rootman J: Diseases of the
12. Moster MR, KennerdellJS: B-scan ultrasonic evaluation of a dilated Orbit. Philadelphia, JB Lippincott Co, 1988, p 525.
superior ophthalmic vein in orbital and retro-orbital arteriovenous 22. RootmanJ, Hay E, Graeb DA, et al: Orbital-adnexal lymphangiomas:
anomalies. J Clin NeuroophthalmoI1983;3:105. A spectrum of hemodynamically isolated vascular hamartomas. Oph-
13. Ossoinig KC: Die ultraschalldiagnostik orbitaler gefassprozesse. Klin thalmology 1986;93: 15 58.
MonatsblAugenheillkd 1971;158:526. 23. Shields JA: Diagnosis and Management of Orbital Tumors. Philadelphia,
14. Ossoinig KC: Standardized echography: Basic principles, clinical ap- WE Saunders Co, 1989.
plications and results. 1nt Ophthal71zo1 Clin 1979; 19(4):127. 24. Skalka Hw, Callahan MA: Ultrasonically aided percutaneous orbital
15. Ossoinig KC: Echographic differentiation of vascular tumors in the aspiration. Ophthalmic Surg 1979;10(11):41.
orbit, in ThijssenJM, Verbeek AM (eds): Ultrasonography in Ophthal- 25. Sklar EL, Quencer RM, Byrne SF, et al: Correlative study of the com-
mology. Dordrecht, Dr W Junk, 1981, p 283. puted tomographic, ultrasonographic, and pathological characteris-
16. Ossoinig KC: Standardized Ophthalmic Echography of the Eye, Orbit and tics of cavernous versus capillary hemangiomas of the orbit. J Clin
Periorbital Region. A Comprehensive Slide Set and Study Guide, ed 3. Iowa NeuroophthalmoI1986;6: 14.
City, Goodfellow, 1985. 26. Spoor TC, KennerdellJS, Dekker A, et al: Orbital fine needle aspira-
17. Ossoinig KC, Frieling E, Tamburrelli C, et al: Superior ophthalmic tion biopsy with B-scan guidance. Am J Ophthal71zo11980;89:2 74.
vein thrombosis-an echographic diagnosis, in Ossoinig KC (ed):
Ophthalmic Echography. Dordrecht, Dr W Junk, 1987, p 529.
Wolfgang E. Lieb
Color Doppler Imaging

of the Eye and Orbit
Color Doppler imaging (CDr) is one of the most impor- rate from the B-scan image. The Doppler spectra are ob-
tant developments of the last decade in ultrasonography. It tained without precise localization of the vessel being
allows for simultaneous, two-dimensional structural imag- studied because the diameter of intraocular and orbital
ing (B-scan), as well as Doppler evaluation of blood flow. vessels is too small to be imaged with conventional B-scan.
Doppler ultrasound detects changes in the frequency of With CDr, the Doppler blood flow information is en-
sound reflected from flowing blood, allowing estimation of coded in color and superimposed on the B-scan echo gram
flow velocity. rn medicine, CDr has come to playa role in in real time to localize vascular structures (Figure 14-1).
the assessment of blood vessels, organ perfusion, and tu- Since the ability to display a color Doppler image is not
mor neovascularity. Use of CDr in ophthalmology was first limited by the resolution of the B-scan echo gram, CDr
introduced in the late 1980s. can detect very small vessels and depict their course. * A
With CDr, it is possible to display indirectly the fine or- complete Doppler spectrum analysis is performed byeval-
bital vessels, including the ophthalmic artery (OA) and its uating both the superimposed color display and the more
branches, the central retinal artery (CRA), the posterior cil- quantitative graphic waveform.
iary artery (PCA), and the lacrimal artery. rn addition, ve- A new, important step in CDr technology is "power
nous structures, such as the superior ophthalmic vein Doppler." This technology improves sensitivity, allowing
(SOV), the vortex veins, and the central retinal vein (CRV) the study of very small or very slow flowing vessels.t
can be demonstrated. Aside from this qualitative assess-
ment, CDr can also assess the hemodynamics of these ves- PHYSICAL BACKGROUND AND IMAGING
sels by measuring flow velocities during various phases of
DEVICES
the cardiac cycle (Doppler spectrum analysis).
CDr is now being used in ophthalmology to evaluate The physical principles of the Doppler effect were first
vascular lesions and tumors in the eye and orbit. It can described by C. ]. Doppler in the early 19th cen-
also document hemodynamic changes in patients with tury.91,113,124,158,169 The Doppler effect (i.e., Doppler shift) is
retinal vascular disease (e.g., CRA occlusion [CRA~], defined as a change in the frequency of the sound wave
CRV occlusion [CRVO], and diabetic retinopathy) and caused by movement of a reflector (e.g., blood). If reflec-
enable study of the effects of drugs on these hemodynam- tor motion is toward the transducer, the frequency of
ics. rn addition, CDr can evaluate the carotid arteries and the returning echo is greater than that of the emitted
periorbital vessels in patients with ischemic ocular disease frequency. Conversely, if reflector motion is away from
(Box 14-1). the transducer, the frequency of the returning echo is
lower than that of the emitted sound beam. The greater
the velocity of the reflector (e.g., the faster the blood
Color-Duplex Scanning
flow), the greater the difference between the reflected
CDr incorporates the use of color with conventional du- and emitted frequencies. The magnitude of the frequency
plex scanning. The technology of duplex scanning allows change (Doppler shift) depends on not only the velocity
for simultaneous B-mode imaging and Doppler spectral of the reflector (V) but also the sound velocity in the
analysis. Doppler spectral analysis is a means of assessing
blood vessel flow characteristics. rn conventional duplex
scanning of the eye and orbit, the Doppler information is *References 56, 57, 114, 117-119, 135, 136, 139.
displayed graphically as a waveform on the screen, sepa- tReferences 3, 6, 7, 9, 11, 58, 59, 65,111,121,137,144,175,182.
367
368 THE ORBIT
The maximum velocities of flowing blood usually en-

BOX14~1
countered clinically range from 1 to 100 cm/sec and result
Indic~ticms for· Color Doppler Imaging in a frequency shift from 40 Hz to 11 kHz, depending on
inithe~y~ and Orbit the transducer frequency. The nominal sound velocity of
tissue is approximately 1,540 m/sec. In clinical practice,
transducers range in frequency from 1 to 10 MHz. In oph-
thalmology, higher frequency transducers, with a range of
7.5 to 10 MHz, are preferred to achieve better resolution.
Note that CDI instruments use linear array transducers. A
linear array transducer consists of a group of closely spaced
piezoelectric elements (see p 5) that are excited sequentially.
This is in contrast to conventional ophthalmic B-scan, in
which a single transducer element mechanically oscillates
within the probe (see p 9).
With conventional duplex scanning, a pulsed Doppler
signal is detected from only one area of an imaged blood
vessel (sample volume). In this type of scanning, the ex-
aminer needs to evaluate multiple sample volumes along
the two-dimensional image of the vessel to rule out patho-
logic Doppler signals. CDI, on the other hand, provides
Doppler information from multiple sample volumes
throughout the image simultaneously. Different color
B scan
imaging codes are used for flow direction with various color shades
grossly indicating mean flow velocities. In this manner,
blood flow is depicted in real time throughout the image.
Doppler
Direction of the flow is usually encoded in red (toward the
flow direction transducer) or blue (away from the transducer), with the
higher flow velocities represented by lighter hues. Since
Doppler sensitivity for detecting very small blood vessels exceeds
flowvelclcitv '
the gray scale image resolution of most B-scan instru-
ments, vessels of very small size can be identified only in-
directly by the color depiction of the Doppler shifts along
Figure 14-1 Schematic display of CDI system. (Modified from the vessel course. With a color Doppler unit equipped
McDicken ViN: Diagnostic Ultrasonics. Principles and Use ofInstru- with a 7.5 MHz linear array transducer, even very low
ments. ed 3, Edinburgh, Churchill Livingstone, 1990, p 228.) Doppler shifts of 37.5 Hz (i.e., 0.385 cm/sec with a
Doppler angle of 0 degrees or 0.77 cm/sec in 60 degrees)
can be depicted.
medium (C) and the frequency of the sound source (e.g., Several modifications of CDI have greatly enhanced its
transducer) (Fo). The detected frequency change (LlF) is clinical applicability. The most important of these is
as follows: power Doppler. 26 ,58,65 For a given sample volume, power
Doppler estimates the total strength of the Doppler sig-
LlF= 2VFo/C
nal, ignoring the blood flow velocity information. The
This equation shows that the greater the transducer fre- power Doppler signal is primarily related to the number
quency, the greater the frequency change for a given reflec- of red blood cells moving within the sample volume. In
tor velocity. This equation can also be converted to deter- addition, the power Doppler is not significantly affected
mine the flow velocity of the reflector. This equation is only by the Doppler angle and varies little with the direction of
valid, however, when the transducer and the reflector are the flow. Because the power Doppler signal is unaffected
parallel. If they are not parallel, a correction factor must be by the blood flow velocity, vessels that are very small or
introduced, taking into account the angle (a) between the contain slow flow can be detected. In the power Doppler
vessel and the axis of the sound beam (Doppler angle). display, the total strength of the Doppler signal is indi-
Note, however, that as the angle increases, there is greater cated in yellow as opposed to the red and blue used for
uncertainty in the accuracy of the velocity measurement. the CDI image. However, in newer instruments, some of
More recent CDI equipment displays the velocity directly the power Doppler information is depicted in red and
and includes the angle of correction in the calculation: blue. Other modifications include tissue harmonic imag-
ing,46 three-dimensional CDI,88,134 and the use of contrast
V= ~FC/(2Fo cos a) agents. 32,38,126,145
Chapter 14 COLOR DOPPLER IMAGING OF THE EYE AND ORBIT 369
CLINICAL APPLICATIONS OF COLOR

V (em/s)
DOPPLER IMAGING
Blood Vessel Evaluation
CDI can detect and measure arterial stenosis and flow- - Vsystol
restricting or flow-disturbing abnormalities. Blood vessels
that can be evaluated include large abdominal vessels (e.g., ---'---:II!!"II!!!"II!Ir------:- V mean
aorta and iliac) as well as femoral, popliteal, and other pe- Vdiast
ripheral arteries. The large vessels of the head and neck,

the carotid bifurcation, and the vertebral arteries can also
•
t (s)
be studied.
Figure 14-2 Schematic display of the Doppler spect~ (fre-
quency-time display) from an arterial vessel. The peak systolic, the
Organ Perfusion mean, and the end diastolic velocity can be measured from the
Doppler spectrum.
CDI is used to visualize the perfusion of abdominal or-
gans,97,129,174 such as liver, kidneys,167,176 spleen, testes,116 satility. Pulsed Doppler spectral analysis also helps to dis-
and placenta,96 as well as the heart,l64 the skeletal system, 154 tinguish between the pulsatile arterial flow and the usual~y
and the brain. 147 CDI is used as a guide to obtain selective more continuous or minimally pulsatile venous flow. This
Doppler information and to allow better assessment of the difference allows for the quantification of data. Note, how-
hemodynamics in those organs. The major use in this cat- ever, that when the ultrasound beam is at a 90-degree angle
egory is the assessment of perfusion in renal and hepatic to a vascular structure or if a vessel contains only stagnant
transplants. 74,95,141 blood, no Doppler flow information is obtained and the
structure is shown in gray scale display only.
CDI instruments offer different flow settings for study-
Tumor Neovascularity
ing different types of vessels. Examinations are first per-
CDI adds a new dimension to the ultrasound evaluation of formed using a low or medium flow setting to allow for ~p
mass lesions. * This technique is already being employed timal detection of low to medium Doppler frequency shifts
successfully in some cases to differentiate benign from ma- of the slow flowing blood in the small orbital vessels.
lignant tumors of the liver,31,54,71,87,156 tumors of the female Medium to high flow settings are applied for the OA since
breast,35 and tumors of the testicles,73 as well as tumors of flow in this vessel is faster. Color threshold levels are ad-
the eye and orbit. t justed to minimize artifacts caused by movement of the eye-
lid or involuntary eye movements. To then perform
Doppler spectral analysis of a particular vessel, a sa~p~e
OPHTHALMIC EXAMINATION TECHNIQUE
volume of approximately 0.2 X 0.2 mm is chosen W1thm
The CDI probe is applied against the closed eyelids using the vessel. The proximal and distal portions of the vess~l
sterile ophthalmic methylcellulose as a coupling gel. Dur- are imaged to determine the Doppler flow angle for es~
ing the examination, the patient is kept in a supine position. mation of velocity. The maximal systolic (VsysJ and end di-
Care is taken to avoid pressure on the eye that might pro- astolic (VdiasJ velocity (EDV) are two points on the wave-
duce artifacts. Horizontal and vertical scans through the eye forni used to characterize this spectrum. The mean flow
and orbit are performed. Depending on the direction of velocity is calculated from the spectral band as a frequency
flow with respect to the transducer, the blood flow data is weighted mean (VmeaJ (Figure 14-2).
displayed in either red or blue. The colors can be arbitrar- It is also possible to use indices in the assessment of
ily assigned, but in this chapter, flow toward the transducer blood flow velocities. Doppler indices yield information
is depicted as red and away from the transducer as blue. about blood flow and vascular resistance that cannot be ob-
The color saturation in the image represents the av~rage tained from blood flow velocities alone. Various indices
frequency shifts from a spectral analysis performed at each have been defined, including ratios of maximum systolic,
sample site. These frequencies are converted into velocities end-diastolic, and mean velocity throughout a cardiac cycle.
by the CDI instrument by solving the Doppler equation for These indices are independent of the Doppler angle. ~
velocity (see p 368). healthy individuals, the pulsatility (i.e., the ratio of systolIc
When the eye and orbit are examined through the eye- to diastolic velocity) can be used to assess vascular resistance
lids, the ultrasound beam is essentially parallel to th~ .or- distal to the area of measurement. The higher the vascular
bital and ocular vessels; thus, most arterial flow is depicted resistance, the lower the end-diastolic flow velocities. The
in red and most veins are depicted in blue. Arteries can also three most commonly used indices are:
usually be distinguished from veins by noting their pul-
Ratio ofVsys/Vdiast = Vsys/Vdiast
*References 127, 128, 130, 151, 155, 157, 159. Resistance index ofPourcelot (RI) = (Vsyst - V diasJNsyst
tReferences 18, 33,45,61,62,80,99,103-105,143,160,178,179,183.
Pulsatility index (Gosling) = (Vsyst - V diasJNmean
370 THE ORBIT
Color Doppler Imaging
Dept. of Ophthalmology, Julius-Maximilians-Universily, WOrzburg
name, first name
date of birth
ioMl
date' ~ weight
RR pulse rate
diagnosis
diabetes o yes 0 no other
hypertension o yes 0 no
hyperlipidemia o yes 0 no
00 (cm/sec) OS (cm/sec)
~ ~
CRA syst
P.R P.R
CRA diast.
CRAmean
CRVmax.
lat med. lal. med.
PCA short syst P.R P.R
PCA short diast
PCA short mean
PCA long syst
PCA long diast.
PCA long mean
ophthalmic art. syst

P.R P.R
ophthalmic art. diast.
ophthalmic art. mean
sup. ophthalmic vein max.
lat med. lat med.

vortex veins sup. max.
vortex veins. in!. max.
Kommentar
Figure 14-3 Sample sheet for documentation of ophthalmic CDI examinations.

The scan images can be recorded on videotape for later re- tinuous flow in systole and diastole. The spectrum of the
view, using cine-loop and frame-by-frame analysis of se- CRA usually shows a venous overlap from the CRY (see
lected segments. During cine-loop replay, images can be Color Plate 1, C). The short and long PCAs can be
photographed with a 35-mm camera directly from an iso- identified on either side of the optic nerve, slightly poste-
lated onboard color monitor. Quantitative measurements, rior to the CRA. Several research groups have published
as well as ratios for the various vessels, can be documented their experiences and normal values with good overall re-
online or on a documentation sheet (Figure 14-3). The ex- producibility. *
amination takes 20 to 30 minutes.* The Doppler spectrum of the PCAs shows velocity-time
spectra similar to those of the CRA. However, the end-
diastolic flow in the PCAs is higher, indicating the low
VASCULAR TOPOGRAPHY OF THE NORMAL
resistance vascular channels of the choroid 98 ,103 (Figure
EYE AND ORBIT
14-4). Segments of the main OA can be seen in the poste-
Horizontal and vertical sections of the globe and normal rior orbit. The OA can be traced temporally to the optic
orbit at the level of the optic nerve display Doppler signals nerve to the point where it usually crosses over the optic
along the course of the CRA and the CRY (see Color Plate nerve toward the medial orbit. 67 ,68,93
1,A and B). The flow velocity waveform of the OA is similar to that
The CRA and the CRY can be depicted within the an- of the internal carotid artery, showing a high maximum
terior 2 mm of the optic nerve shadow (void). In some in- peak systolic flow and low diastolic flow velocity (see Color
stances, these vessels can be traced to their entry point into Plate 2). Sometimes the superior orbital artery and the
the optic nerve. The CRY usually runs next to the CRA. It lacrimal artery can be identified. The SOY can be identified
can be differentiated from the artery not only by its color at the posterior aspect of the globe and in the supranasal or-
coding but also by its Doppler characteristics and its con- bit (see Color Plate 3, A). The SOY can be traced posteri-
orly until it crosses over the optic nerve. 22 ,40,98,173 Flow in
*References 2,13,14,18,25,40,60,63,100-102,143,173.
the vortex veins can be demonstrated in all four quadrants.
The spectrum with the continuous nonpulsatile flow pat-
tern together with the blue color-coding is characteristic of
venous flow (see Color Plate 3, B).
Several authors have performed reproducibility studies
30 30 for quantitative velocity measurements of the various or-
bital vessels (Table 14-1). The most reliable and repro-
25t 25 ducible results were for the OA, the CRA, and the CRY
20 20 Greater variation was noted in the posterior ciliary vessels,
whereas both the detection and velocity measurement of
the SOY were unreliable. 14 When performing a more de-
tailed analysis for quantitative measurements, the best in-
traindividual reproducibility, expressed as the relative error,
was found for the peak systolic velocity (PSV) and the re-
sistance index (RI) measured in the OA (PSV 5.9%, RI
A. centralis A. cilia res A. aphtha/mica 3.1 %) and the CRA (PSV 7.7%, RI 4.7%). The PSV and
retinae RI were less reproducible for the PCAs but were similar to
Figure 14-4 Schematic depiction of Doppler pulse curves (fre-
quency-time spectra) for the eRA CA. centralis retinae), ciliary *References 1, 13, 14, 17, 18,25,40,51,52,70,82,98,100,102,125,148,
artery CA. ciliares), and the OA CA. aphthalmica). 161, 172, 173.
TABLE 14-1
Blood Flow Velocities (em/sec) in Orbital Vessels (n = 222 Normal Eyes)
Mean (STD) Peak Systolic Mean (STD) End Diastolic
Central retinal artery (CRA) 9.6:J:: (1.4) 2.4 :J:: (0.8)
Central retinal vein (CRV) -4.2 :J:: (0.8)
Ophthalmic artery (OA) 37.7 :J:: (7.0) 8.8:J:: (2.8)
Posterior ciliary artery (PCA) 11.3 :J:: (2.2) 3.6 :J:: (1.2)
Superior ophthalmic vein (SOV) -7.6:J:: (1.8)
Vortex vein (VV) -8.5 :J:: (2.2)
372 THE ORBIT
the reproducibility of the EDV measured in the OA When CDr was used to examine patients with CRAOs,
(11.8%) and CRA (19.9%). No systematic trend could be blood flow in the CRA was either absent or markedly de-
found between the first and second measurements of flow creased compared to normal controls. 69 Both maximum
velocities in various orbital vessels, but consistent trends systolic amplitude and diastolic flow were decreased. Mas-
were observed when multiple measurements were taken. 148 sive calcifications of the vessel walls of the intraocular reti-
For comparative measurements, it is quite important to nal vessels can be detected in CRA~. The technique can
measure at similar portions of the vessels. For the CRA, also be used to study the extracranial vascular system, which
some authors noted significant changes according to the might be a source of emboli to the retina.
depth of measurement. The maximum velocity was found CDr can answer several questions in patients with arte-
at 1.98 mm behind the optic disc surface. 39 rial occlusion of the retinal vessels:
• Are there emboli along the course of the CRA behind
the optic disc?
RETINAL, RETINAL VASCULAR, AND OTHER
• Are the flow velocities in the OA, CRA, and ciliary
VASCULAR DISEASES OF THE EYE
artery reduced?
Few reports have dealt with CDr in the evaluation of reti- • Are there collaterals from the external carotid circula-
nal disorders. Wells et aP70 and others have used CDr to tion?
depict a patent hyaloid artery in a case of persistent hyper- • rs there atherosclerotic disease of the carotid and ver-
plastic primary vitreous (see p 185). Wong et al 180 used the tebral artery system?
vascularity in the retinal vessels of detached retinas as an Ho et al72 published the first study using CDr for the in-
additional criterion to distinguish a detached retina from vestigation and diagnosis of ocular ischemic syndrome
dense vitreous strands (Figure 14-5; see also Color Plate 4 (OrS). These investigators demonstrated reduced ocular
and p 56). rn a study of the flow velocities of the CRA and blood flow in the OA, PCAs, or CRA in eyes with ors.
OA of patients with arterial hypertension and carotid artery Furthermore, in some eyes with ors, CDr showed unde-
disease, Cesarone and coworkers found significantly re- tectable or reversed blood flow velocities in the corre-
duced systolic and end-diastolic flow velocities compared sponding PCAs or OA (see Color Plate 5).84,168,177,181 rn
to a normal control group.28 One group of patients with general, lower flow values represent compromised blood
proliferative diabetic retinopathy was found to have flow proximal to the point of sampling by CDr or increased
significantly decreased PSV end-diastolic flow velocity of resistance distal to the sampling point. *
the CRA. The blood flow velocities in the PCAs and OA Although the posterior ciliary circulation can be difficult
were unchanged compared with age-matched controls. 53 to assess, some reports indicate decreased flow velocities in
Other groups had similar results; however, this technique patients with anterior ischemic optic neuropathy.48 Several
does not predict the course of an individual patient with di- authors studying arteritic optic neuropathy found that no
abetic retinopathy.32,43,64,146 blood flow could be detected in up to three arteries in the
Fluorescein angiography is the preferred technique for the affected (ipsilateral) orbit of six patients with giant cell ar-
study of retinal vascular disorders; however, CDr can add teritis (GCA) at presentation. Five of these patients also had
valuable information about CRA and PCA circulation byex- undetectable blood flow in the PCAs of the contralateral
amining these vessels posterior to the retina and choroid. orbit. Serial CDr examination revealed blood flow alter-
ations in arteritic patients, despite treatment. Return of
normal blood flow was slow and was related to the clinical
features. By contrast, only one patient with nonarteritic an-
terior ischemic optic neuropathy showed undetectable
blood flow in a PCA. These studies thus demonstrate that
GCA leads to widespread and prolonged alterations in or-
bital blood flow. CDr allows the detection and monitoring
of alterations in orbital blood flow that correlate with the
clinical features of GCA. Serial CDr examinations in GCA
may be used to aid management decisions. 50 ,81
A characteristic Doppler spectrum pattern can be seen in
patients with CRVO. Flow velocity in the CRA during sys-
tole is decreased, the peak systolic waveform is blunted, and
diastolic flow is absent or markedly reduced. This decreased
flow is an indication of the high resistance caused by the
blockage of venous outflow in CRVO (see Color Plate 6).15,86
A highly turbulent flow with extremely high Doppler
Figure 14-5 Total retinal detachment in a patient with stage V
retinopathy of prematurity. Longitudinal B-scan shows a tight,
closed funnel posteriorly (arrow) inserting into the optic nerve
(ON). See Color Plate 4 for CDr findings. *References 36, 49, 75, 76, 94, 112.
Chapter 14 COLOR DOPPLER IMAGING OF THE EVE AND ORBIT 373
shifts and a high resistance flow pattern within the CRA The initial hope of differentiating various tumors based on
have been found in several patients with drusen of the op- their vascularity pattern and flow characteristics has not
tic nerve and visual field defects. These findings support a been fulfilled. The detection of low blood flow in neoplasms
direct compromise of the vasculature in the optic nerve has been improved with the use of ultrasound contrast
head and a mechanical compression of the nerve fibers. agents such as Levovist* and the power Doppler mode.92,152
Belfort19 and Baxter et aP6 used CDI to investigate the
influence of pharmacological factors on flow parameters.
ORBITAL DISORDERS
Belfort detected a significant reduction in pulsatility and
Pourcelot's index of the CRA and PCAs in a group of pre- CDI has been used to study orbital vascular lesions, such as
eclamptic women treated with magnesium sulfate. Baxter carotid-cavernous sinus fistulas and orbital varices, as well
and coworkers studied the effect of posture and topical [3- as orbital mass lesions. The use of conventional ophthalmic
blockers on the hemodynamics of orbital vessels. They ultrasound for the evaluation of orbital tumors and vascular
found no postural effect, but there was a fall in Pourcelot's lesions is described in Chapters 12 and 13.
index. Since the orbital vessels are difficult to identify in
these studies, caution should be used when interpreting this
Carotid-Cavernous Sinus Fistulas
information as an indication that CDI can demonstrate
subtle pharmacologic effects on orbital hemodynamics. Various diagnostic modalities can be used to evaluate carotid-
Decreased flow velocities in the long and short posterior cavernous sinus fistulas (CCSF) or dural-cavernous arteri-
ciliary vessels have been found in patients with primary ovenous malformations (DCAVM), also referred to as dural-
open angle glaucoma (pOAG). These findings support the cavernous sinus fistulas. These modalities include A- and
theory that POAG causes vascular changes in the ciliary B-scan ultrasonography,12o,l3l (see pp 355 and 359), orbital
and choroidal vascular system.* CDI also provides a greater and cranial computed tomography (CT) scanning,85 carotid
understanding of normal-tension glaucoma (see p 215). angiography, magnetic resonance imaging (MRI),150 and or-
bital venography. 166 In these patients, CDI clearly shows the
INTRAOCULAR TUMORS *References 5,12,23,24,27,87,137,142,145,163.
Effective vasculature is essential for all tumor growth. New
vessels form and existing host vessels are incorporated into
the tumor mass. Other than the qualitative information
provided by intravenous fluorescein angiography and real-
time conventional ultrasound, there has been no technique
to assess tumor-associated blood flow in the eye and orbit.
Several groups have used conventional duplex scanning
and CDI to assess intraocular tumors. t These researchers
demonstrated flow within the intraocular tumors and noted A
a decrease in Doppler shift after radiotherapy. One group
found vascular changes not only within the tumor but also
in the normal ocular vessels after gamma knife therapy for
choroidal melanoma. 165
The abnormal Doppler signals reported from breast
carcinomas,35,140 hepatomas,1O,55,74,77,78 and renal tu-
mors 29 ,97,133,138 are useful for differential diagnosis.
Histopathologic examination of tumor vessels often reveals
primitive vascular channels, lacking smooth muscle and
consisting of an endothelial layer and connective tissue
alone.130 Low resistance to flow is expected since the vessels
in most neoplasms lack normal arteriolar smooth muscle,
the recognized site of peripheral vascular resistance. B
High sensitivity to minimal flow is necessary to detect
fine tumor vascularity (see Color Plate 7). Since lesions that
can simulate uveal melanomas, such as large subretinal
hemorrhages, usually do not have a distinctive blood supply,
they can be differentiated from melanomas based on the ab-
sence of Doppler flow (Figure ·14-6; see also Color Plate 8).
Figure 14-6 Dome-shaped choroidal melanoma. A, B-scan at
reduced gain shows moderately elevated dome-shaped tumor.
*References 30.,41,42,44,66,149,161,162. B, A-scan at Tissue Sensitivity shows medium-low internal re-
tReferences 61, 62, 71,t05, 132, 178, 179. flectivity. See Color Plate 8 for "CDr findings.
374 THE ORBIT
dilated, arterialized SOV with high velocity blood flow to-

ward the transducer, indicative of a CCSF (see Color Plate
9, A).47,90 Furthermore, CDI depicts the high preseptal vas-
cularity and the thickened extraocular muscles characteristic
of this entity.8,37,llO,122 The Doppler spectrum is similar to
that typically seen with arteriovenous shunts, i.e., high sys-
tolic and diastolic flow velocities (see Color Plate 9, B). A re-
cent report from Soulier-Sotto et al lS3 confirmed these find-
ings and stressed that CDI can also be used to monitor the
clinical course of CCSF and/or to document the effect of
embolization or balloon occlusion (see Color Plate 9, C).
The insidious onset of a red eye and elevated intraocular
pressure in older women suggests a DCAVM. Often, how-
ever, the diagnosis cannot be made since CT fails to show a
dilated SOv. Using CDI, the examiner can diagnose
DCAVM by the presence of arterialized flow in the SOV
together with the clinical signs.
Orbital Varix Figure 14-7 Optic nerve sheath meningioma. T2-weighted

MRr of the orbit demonstrates the dilated left optic nerve. See
In contrast to CCSF, orbital varices demonstrate rela- Color Plate 13 for CDr findings.
tively low blood flow velocities with CDI. In addition,
dynamic evaluation of a varix during inspiration and Val-
salva maneuver shows both inflow and outflow of blood
(see Color Plate 10 and p 359).83,99,171
Orbital Mass Lesions

CDI adds a new dimension to the study of orbital mass le-
sions. Although CT, MRI, and conventional ultrasound
provide an excellent topographic display of these lesions
and some indication of vascularity (see p 306 and Chapter
13), CDI directly displays active blood flow when contrast
enhancement or signal intensities are studied.
After studying several tumors, Jain and coworkers80 re-
ported that they were unable to attribute specific vascularity
patterns to individual tumors. Others have reported that cav- Figure 14-8 Capillary hemangioma located in the anterior orbit
ernous hemangiomas of the orbit usually show very little to of a child. Paraocular B-scan shows diffuse orbital mass. See Color
almost no flow and that venous flow velocities are extremely Plate 14 for CDr findings.
low throughout the lesion (see Color Plate 11). In contrast,
lymphomas, metastatic lesions, and highly vascular tumors
SAfETY CONSIDERATIONS
such as hemangiopericytomas (see Color Plate 12) contain
large arterial and venous vessels that supply the tumor. 98 As with any diagnostic test, there may be some risk in diag-
Compression of the CRA has been shown in a case of gaze- nostic ultrasound. The potential risks are primarily related
induced amaurosis caused by a cavernous hemangioma. 89 to the intensity of energy output by the ultrasound instru-
In patients with optic nerve sheath meningioma, CDI ment. The measurement of energy output in ultrasound,
demonstrates progressive compression of the optic nerve referred to as the spatial peak temporal average (SPTA), is ex-
and its vasculature. In advanced stages, a high resistance pressed in mW/cm2. The SPTA is the highest intensity of
flow pattern is found in the CRA (Figure 14-7; see also energy occurring within the ultrasound field average over
Color Plate 13). an entire scan frame period.
Several groups have found CDI quite helpful, inconjunc- The American Institute of Ultrasound in Medicine
tion with CT and MRI, in planning the surgical approach to (AlUM) has reviewed reports and issued a statement about
a tumor79 ,183 and in the treatment of patients with thyroid the bioeffects of ultrasound on in vivo mammalian tissue. 4
ophthalmopathy.20,2l,123 Using CDI for the preoperative eval- According to the AlUM statement, with low frequency
uation of orbital lesions, the surgeon can predict large arte- transducers (0.5-10 MHz) there is no independently
rial or venous vessels that might be encountered during the confirmed significant biological effect on mammalian tis-
surgical procedure (Figure 14-8; see Color Plates 14 and 15). sue exposed in vivo to unfocused ultrasound with intensities
below 100 mW/cm2 or focused ultrasound with intensities 13. Baxter GM, Williamson TH: Colour flow imaging of the orbit-
below 1000 mW/cm 2 • 107 ,115 Currently, in the United States concept or diagnostic tool? [editorial]. Clin RBdioI1994;49:845.
14. Baxter GM, Williamson TH: Color Doppler imaging of the eye:
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the limits indicated by the AlUM. These limits are linked Radio11996;51 :411.
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thalmic and certain other particular applications prior to trasound of orbital and optic nerve blood flow: Effects of posture and
timolol 0.5%. Invest Ophthalmol Vis Sci 1992;33:604.
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York, Raven Press, 1988, p 1.
A B c
Color Plate 1, A, 8, and C
Color Plate 2
A B
Color Plate 3, A and 8

Color Plate 4 Color Plate 5
Color Plate 6
A 8
Color Plate 7, A and 8

A
Color Plate 8 Color Plate 9, A
B c
Color Plate 9, Band C
Color Plate 10
A B
Color Plate 11 Color Plate 12, A and 8
Color Plate 13
Color Plate 14 Color Plate 15

Color Plates
Color Plate 1 CDr of normal eye and orbit. A, Horizontal sec- Color Plate 8 CDr of dome-shaped choroidal melanoma. Blood
tion tbrough the globe at tbe level of tbe optic nerve (ON). The flow is shown within tbe tumor. See B- and A-scans of saine case
central retinal artery (CRA), central retinal vein (CRV) and tem- . in Figure 14-6.
poral short posterior ciliary arteries (PCA) are shown. B, Power
spectrum display of tbe optic nerve region. The CRA, PCA, CRV Color Plate 9 CDr of carotid-cavernous sinus fistula (high
and tbe ophtbalmic artery (OA) are detectable witbout coding for flow). A, A dilated, arterialized superior ophthalmic vein (V
flow direction. The sensitivity for detecting small vessels or low ophth.sup.) is demonstrated. Flow reversal witbin tbe vein is de-
flow is higher tban in tbe CDr mode. N, Optic nerve. C, Analysis picted in red. B, Spectrum analysis of tbe arterialized vein shows
of tbe Doppler spectrum. A cursor is placed on tbe vessel, and tbe characteristic high flow shunt pattern witb high-end diastolic flow
angle is corrected according to tbe vessel course. The spectrum . velocities.C, Spontaneous partial tbrombosis of the vein. The
of tbe CRA usually shows venous overlap caused by tbe nearby blunted spectrum witbin tbe vessel is a sign of diminished flow.
CRV: (A and C courtesy Paula Heggerick, RVT, RDMS, Boston,
Massachusetts.) Color Plate 10 CDr of superficial orbital varix. The paraocular
image was captured during a Valsalva maneuver. Note tbat venous
Color Plate 2 CDr showing course and Doppler spectrum of inflow appears red due to a change in flow direction during Val-
the ophtbalmic artery. salva maneuver. The venous nature of tbis flow can be confirmed
by demonstrating the continuous venous pattern on spectrum
Color Plate 3 CDr of normal superior ophtbalmic vein and vor~ analysis.
tex veins. Blood flow in venous structures is directed away from
tbe transducer and is thus coded in blue. A, The superior oph- Color Plate 11 CDr of cavernous hemangioma witbin tbe mus-
tbalmic vein (0 V) is demonstrated. B, Vortex veins with spectrum cle cone. There is only minimal vascularity witbin tbe tumor (Tu).
analysis showing characteristic continuous flow pattern below tbe
baseline. Color Plate 12 CDr ofhemangiopericytoma (paraocular scans).
A, The tumor shows significant vascularity in arterial (A) and ve-
Color Plate 4 CDr of total retinal detachment in stage V nous (V) vessels. B, The Doppler spectrum clearly identifies a
retinopatby of prematurity. Blood flow witbin tbe detached retina draining venous vessel (Vim.) witb a continuous flow spectrum. An
is demonstrated. See B-scan of same case in Figure 14-5. artery (art.) is shown in tbe anterior aspect of tbe lesion.
Color Plate 5 76-year-old patient witb clinical signs of ocular Color Plate 13 CDr of optic nerve sheath meningioma. The
ischemic syndrome (OIS). CDr shows significantly reduced flow Doppler spectrum of the CRA in tbe eye witb tbe meningioma
velocity in tbe CRA and a flow reversal (blue) in tbe OA (arrows). (OS) is lower and has a higher Pourcelot's ratio than the unin-
The Doppler spectrum shows typical collateral high-end diastolic volved side (aD). N, Optic nerve; PCA, posterior ciliary artery.
flow velocities as a sign of low vascular resistance. See MRI scan of same case in Figure 14-7.
Color Plate 6 Doppler signal from tbe CRA in a patient witb a Color Plate 14 CDr of capillary hemangioma located in tbe an-
complete CRVO. There is a plump spectrum in systole and an ab- terior orbit (paraocular scan). Note tbe highly vascular nature of
sence of flow in diastole. The calculated Pourcelot's ratio is 1. the tumor. See B-scan of same case in Figure 14-8.
Color Plate 7 CDr of a large choroidal melanoma at tbe poste- Color Plate 15 CDr of superficial arteriovenous malformation.
rior pole. A, The tumor shows large feeding vessels. B, Spectrum Note significant blood flow witbin mass involving tbe lid and an-
analysis of tumor vessels demonstrating neoplastic vasculature terior orbit.
witb low resistance flow characteristics. TU, Tumor.
379
Extraocular Muscles
EXAMINATION TECHNIQUES
Extraocular muscle thickening is the most common ab- FOR RECTUS MUSCLES
normality encountered in orbital echography. Although
B-Scan Technique
other imaging techniques are very useful in showing
moderate to marked muscle enlargement, echography is The B-scan examination is usually performed at a medium
more effective for detecting subtle or early changes in gain setting. The examiner may wish, however, to display
muscle size. 15 ,34 the muscle at a high gain level initially and then decrease
Occasionally, a slightly oblique section on computed to- the setting until the muscle is clearly shown (Figure 15-3).
mography (CT) or magnetic resonance imaging (MRI) can The patient usually fixates in primary gaze or approxi-
result in misinterpretation regarding muscle enlargement. mately 10 degrees toward the muscle being examined. The
This is less likely to occur with ultrasound because the ex-· muscle is evaluated with both transverse and longitudinal
aminer constantly adjusts the probe position to prevent approaches.
oblique sectioning. Echography is also useful for differ-
entiating the various causes of muscle enlargement, for de- Transverse Scans
tecting associated orbital abnormalities, and for follow-up Transverse scans display a muscle in cross-section. For this
during therapy. approach, the probe is placed on the globe near the equator,
The most common cause of extraocular muscle thicken- on the side of the globe opposite from the muscle being
ing, both clinically and echo graphically, is Graves' dis- evaluated. With a transverse probe position, the sound
easey,27 Some of the other more common causes include beam cuts across a muscle, imaging it as an oval-shaped de-
idiopathic orbital myositis, venous congestion, tumors (e.g., fect within the echo-dense orbital soft tissue. The insert-
metastatic carcinoma), and hematoma. 7 ing tendon is first displayed as a thin defect adjacent to the
The extraocular muscles are surrounded by a smooth sclera. Then, as the probe is angled posteriorly toward
sheath that produces distinct, highly reflective interfaces. thicker portions of the muscle, the defect enlarges and ap-
The muscle fibers are relatively compact and homoge- proaches the bone line on the right side of the echo gram
neous. As a result, the normal muscle is medium-high (Figure 15-4).
reflective onA-scan and less echo-dense than surrounding The marker is directed superiorly for vertical scans (to
orbital soft tissue on B-scan (Figure 15-1). B-scan is very evaluate the medial or lateral rectus muscles) and nasally
useful for documenting the gross size and contour of a mus- for horizontal scans (to evaluate the superior rectus/levator
cle, whereas A-scan evaluation allows precise measurement complex or the inferior rectus muscle).
of thickness. A-scan also can be useful for differentiating
the various causes of muscle enlargement. 3,15,24 Longitudinal Scans
Comparison of contralateral muscles always should be Longitudinal scans usually are performed with the patient
performed. This should be carried out using the same gain fixating slightly away from the probe, toward the muscle
setting with both eyes fixating similarly. If strabismus is being examined. The probe is placed on the side of the
present, fixation should be adjusted so that the eye being globe opposite to the muscle. For this approach, the probe
examined is as close as possible to primary gaze. However, is rotated 90 degrees from the position of the transverse
if one globe is either esotropic or exotropic and cannot be scan. The marker is always directed toward the center of
brought to primary gaze, the contralateral muscle should the cornea and the muscle being scanned. In longitudinal
be measured using a similar gaze. scans, the transducer oscillates perpendicular to the limbus,
The rectus muscles, with their similar course and inser- and the sound beam moves back and forth along the exam-
tions into the globe, are all examined with the same basic ined muscle, thus showing it in long section. This produces
techniques. The oblique muscles, on the other hand, ne- an echogram with the insertion of the muscle displayed at
cessitate different examination techniques due to their var- the upper portion of the screen and the wider muscle belly
ied course and broad insertions (Figure 15-2). displayed at the lower portion (Figure 15-5).
380
Chapter 15 EXTRAOCULAR MUSCLES 381
A c
Figure 15-1 Normal extraocular muscle. Transverse

B-scan (A) and A-scan (B) echograms of normal
muscle (arrows). B, Bone; M, multiple signals.
B C, Histopathologyshows relatively compact muscle
fibers OW) compared with heterogeneous orbital soft
tissue (0).
A B
Figure 15-2 Schematic drawings indicate course of rectus and oblique muscles. Frontal (A)
and axial (B) views. SR, Superior rectus; MR, medial rectus; LR, lateral rectus; lR, inferior rec-
tus; SO, superior oblique; 10, inferior oblique; Lev, levator muscle.
382 THE ORBIT
Figure 15-3 Transverse B-scan echograms of rectus muscle at various gain settings. A, Muscle
(arrow) first located with high gain setting. B, Muscle at medium gain setting. C, Gain is re-
duced further until muscle is clearly delineated.
A-Scan Technique
cle belly. As the sound beam progresses more posteriorly,
For A-scan examination, the Tissue Sensitivity setting is the defect widens with the display of thicker portions of
used, and the patient fixates at or near primary gaze. With the muscle belly. At the same time, the muscle defect
the globe in this position, it is easiest to direct the sound moves from left to right in the echogram, i.e., away from
beam perpendicular to the muscle sheath. The A-scan the scleral spike and toward the bone spike (Figure 15-6).
probe is placed on the globe near the equator, opposite As the sound beam is shifted along the muscle, it may be
the muscle to be examined. The sound beam is aimed an- necessary to angle the probe somewhat to maintain per-
teriorly toward the inserting tendon, which produces a pendicular sound beam incidence to the muscle sheath.
small defect just to the right of the scleral spike. Once the Perpendicularity is achieved when maximally high,
insertion is demonstrated, the probe is angled more pos- steeply rising, double-peaked sheath spikes are displayed
teriorly, thereby shifting the sound beam along the mus- (Figure 15 -7).
Figure 15-4 Dynamic B-scan evalu~tion of rectus muscle using transverse approach. With
medium gain setting, probe is angled so that the muscle (arrows) is scanned from its insertion an-
teriorly (1) toward orbital apex posteriorly (5). Note that muscle defect moves from left to right,
gradually widens, and approaches the bone as the sound beam sweeps posteriorly.
384 THE ORBIT
Figure 15-5 Longitudinal B-scan technique for evaluation of rectus muscle. The probe marker
is directed toward the cornea. The muscle (lVI) is imaged in long section from its insertion ante-
riorly (arrow) toward the posterior orbit. A, Anterior aspect of globe; B, bone; ON, optic nerve;
P, posterior aspect of globe.
One should always try to display the widest portion of the values for all four rectus muscles together and to com-
the muscle. Because some muscles are thickest near the or- pare this total to a normal overall value (see Table 15-1).
bital apex (where it can be difficult to be perpendicular), the Often, the determination of whether a muscle is en-
apparent maximum width may not truly represent the larged is easily made by comparing its thickness with that of
widest portion of the muscle. Despite this shortcoming, A- the contralateral muscle (see Table 15-1). If, however a dif-
scan can reveal whether mid-portions of the muscle are ab- ference is found, it is important to be certain that the ap-
normally thickened, which is usually sufficient for detecting parent difference is not the result of examiner error.
muscle enlargement. Sources of possible error include lack of perpendicularity
Measurements can be obtained from the screen using (see Figure 15-7) and failure to obtain measurements from
electronic cursors or taken directly from photoechograms the widest portions of the muscle.
by using calipers and conversion tables (with sound veloc- Internal structure and reflectivity also should be as-
ity of 1,550 mlsec) (Figure 15-8; see Appendix A). It is rec- sessed. Because of sound attenuation, reflectivity should be
ommended that at least two measurements be taken of each evaluated within the anterior one-third to one-half of the
muscle, using the widest measurement of the best quality muscle (see Figure 15-6). As with thickness, reflectivity
echograms. should be compared with that of the contralateral muscle.
Normal values for the rectus muscles have been deter-
mined by two different studies: one by McNutt et aPO,21 EVALUATION OF INDIVIDUAL MUSCLES
(University ofIowa) and a second study by Byrne et aP
Rectus Muscles
(University of Miami) (Table 15-1). It should be pointed
out, however, that these normal values may not truly reflect Medial Rectus
all age and population groups. More importantly, it may be The medial rectus is best examined as the patient fixates in
best for individual echographers to establish their own con- primary gaze with the A- or B-scan probe placed at the
trol values to account for variability in technique. equator temporally. The medial is the easiest of the four
To determine whether an individual muscle is enlarged, recti to examine because temporally the recessed orbital rim
its thickness can be compared with the normal values allows easy probe positioning. Also, the medial rectus is the
shown in Table 15-1. In thyroid disease, it is useful to add thickest of the four rectus muscles (Figure 15-9).
Figure 15-6 Dynamic A-scan evaluation of medial rectus muscle. As probe is angled posteri-
orly, the muscle (arrows) is examined from its insertion (1) toward the orbital apex (5). The mus-
cle defect moves from left to right as it extends back into the orbit. Note decrease in reflectivity
of muscle more posteriorly as a result of sound attenuation. Maximal thickness of muscle is mea-
sured between the steeply rising sheath spikes (arrows). B, Bone.
386 TH E ORBIT
A B
Figure 15-7 A-scan echograms of extraocular muscle displayed with perpendicular (correct)
and oblique (incorrect) sound beam incidence. A, Steeply rising, distinct sheath spikes indicate
perpendicular sound beam incidence (arrows). B, Sheath spikes are indistinct because of oblique
sound beam incidence.
A B
Figure 15-8 Measurement of muscle thickness with A-scan. A, Echogram with no gates.
Arrows, Muscle sheath. B, Electronic gates (cursors) on sheath spikes indicate muscle thickness
(3.4mm).
TABLE 15-1
Normal Extraocular Muscle Values*
Difference Between
Muscle Normal Range (mm) Contralateral Muscles
Superior rectus/levator complex 3.9-6.8 0.8
Latera I rectus 2.2-3.8 0.4
Inferior rectus 1.6-3.6 0.4
Medial rectus 2.3-4.7 0.5
Sum of all muscles 11.9-16.9 1.2
From Byrne SF, Gendron EK, Glaser JS, et al: Diameter of normal extraocular recti muscles with echography. Am J Ophtha/mo/1991;112:706.
*This table indicates 95% confidence limits for the diameter of normal rectus muscles as well as the difference in the diameter of contralateral fellow
muscles.
Figure 15-9 Technique for evaluation of medial rectus muscle with A-scan (A) and B-scan
(B and C). A, A-scan probe is placed at 9~o'clock near the equator, and sound beam is directed
perpendicular to sheath of medial rectus (arrows). B, Vertical transverse B-scan displays cross-
section of medial rectus muscle (M). Probe marker is oriented toward 12-o'clock. SO,· Superior
oblique muscle. C, Longitudinal scan displays long section of muscle (M). Probe marker is di-
rected toward cornea and 3-o'clock meridian. Muscle insertion (arrow) is displayed at top of
echogram.
388 THE ORBIT
Lateral Rectus Inferior Rectus

The lateral rectus is examined with the A- or B-scan probe The inferior rectus may be particularly difficult to examine
placed medially. When examining this muscle, the patient's because of the prominent superior orbital rim. Conse-
nose may sometimes interfere with probe movement. This quently, this muscle is most easily evaluated when the globe
problem usually can be alleviated, however, by having the is somewhat proptotic. Fixation normally should be ap-
patient fixate approximately 10 degrees temporally (Figure proximately 10 degrees inferior to primary gaze in order to
15-10). provide enough room for the probe (A- or B-scan) to be
Figure 15-10 Technique for evaluating lateral rectus muscle with A-scan (A) and B-scan
(B and C). A, A-scan probe is placed near equator at 3-o'clock nasally, and sound beam is di-
rected perpendicular to sheath of lateral rectus muscle (arrows). B, Vertical transverse scan dis-
plays cross-section of lateral rectus muscle (1V1). Probe marker is oriented toward 12-o'clock.
C, Longitudinal scan displays long section of muscle. Probe marker is directed toward cornea
and 9-o'clock meridian. Muscle insertion (arrow) is displayed at top of echogram.
maneuvered on the superior aspect of the globe (Figure cency above the superior rectus muscle. The longitudinal
15-11). If the orbital rim is particularly prominent, it may view shows both the insertion of the superior rectus into
be easier to place the B-scan probe on the lid. the globe and the levator extending forward into the lid (see
Figure 15-12, C). If the patient blinks, the levator muscle
Superior Rectus and Levator Palpebrae Superioris can be seen to move back and forth above the superior rec-
Although the superior rectus and levator muscles often can tus muscle. In. some cases, an extremely thick levator mus-
be imaged as separate structures on B-scan, these two muscle may produce a defect during the paraocular examina-
cles are usually displayed and measured as one complex on tion when the A-scan probe is placed supratemporally.
A-scan, thereby yielding a considerably larger normal value
than the other muscles. The muscle complex is examined
Oblique Muscles
with the patient fixating in primary gaze or slighdy superi-
orly for both A- and B-scan (Figure 15-12). A different approach is needed to evaluate the oblique mus-
In transverse view, B-scan may show the two muscles to cles because of their varied course and broad insertions 39,40
be separate anteriorly but as one large complex posteriorly. (Figure 15-13). Routinely, gross thickening of the oblique
The tendon of the superior rectus muscle is thin andoval- . muscles is best detected with B-scan. Then, ifan abnor-
shaped as it inserts into the globe anteriorly, whereas the mality is suspected, A-scan can be used to more carefully
levator aponeurosis produces a broad, umbrella-like lu- assess thickness and reflectivity.
Figure 15-11 Technique for evaluating inferior rectus muscle with A-scan (A) and B-scan
(B and C). A, A-scan probe is placed near equator at 12-o'clock, and sound beam is directed
perpendicular to sheath of inferior rectus muscle (arrows). B, Horizontal transverse scan displays
cross-section of inferior rectus muscle (M). Probe marker is directed toward 3-o'clock meridian.
C,Longitudinal scan displays long section of muscle. Probe marker is directed toward cornea
and 6-o'clock meridian. Muscle insertion (arrow) is displayed at the top of the echo gram. ON,
, . . Optic nerve.
390
Figure 15-12 Technique for evaluation of superior rectus and levator muscles with A-scan
(A) and B-scan (B and C). A, A-scan probe is placed near equator at 6-o'clock, and sound beam
is directed perpendicular to sheaths of superior rectus/levator complex (arrows). B, Horizontal
transverse scan shows cross-section of superior rectus (SR) and levator (Lev) muscles. Note the
broad, umbrella-like appearance oflevator aponeurosis compared to the superior rectus muscle
in this very anterior section. Probe marker is directed toward 3-o'clock meridian. C, Longitu-
dinal scan shows long section of the superior rectus (SR) and levator (Lev) muscles. Probe marker
is directed toward cornea and 12-o'clock meridian. Note levator muscle extending anteriorly,
beyond insertion of superior rectus muscle. ON, Optic nerve; curved arrow, muscles appear to
merge more posteriorly.
Figure 15-13 Schematic drawings illustrate the insertions and course of the superior oblique
(SO) and inferior oblique (fa) muscles in frontal view (A) and posterior view (B). Note the more
posterior insertions of the oblique muscles and their varied courses as they pass inferior to the su-
perior and inferior rectus muscles. SR, Superior rectus; MR, medial rectus; lR, inferior rectus;
LR, lateral rectus; SO, superior oblique; 10, inferior oblique.
Superior Oblique of the medial orbit demonstrates a cross-section of the su-

Because the tendon and belly of the superior oblique muscle perior oblique muscle, which is located above the medial
course through the orbit at different angles, separate tech- rectus muscle near the orbital bone (Figure 15-15, B; see
niques are necessary for displaying each of them. On B-scan, also Figure 15-9, B). However, a better view of the muscle
the tendon is best shown with a horizontal transverse scan can be obtained by centering it in the echogram with an
through the superior orbit, using a similar but more anterior oblique transverse scan of the supranasal orbit. A longitu-
approach than that used for displaying the superior rectus dinal scan is also performed to provide a long section of the
muscle complex (Figure 15-14). The tendon also can be im- muscle (Figure 15-15, C).
aged with a longitudinal view, but it usually cannot be dis- Although the trochlea cannot be demonstrated under
played entirely in one echogram. A-scan evaluation of the normal conditions, it often can be displayed if inflamma-
normal tendon is difficult; therefore, it is only performed tion (e.g., trochleitis) is present. In such cases, a longitudi-
when enlargement has been noted on B-scan. nal B-scan view may show the muscle looping around the
A-scan evaluation of the superior oblique muscle is eas- trochlea40 (Figure 15-16).
iest to perform by first displaying the belly 0f the medial
rectus. The sound beam is then shifted slighdy upward un- Inferior Oblique
til the superior oblique defect appears (Figure 15-15, A). The inferior oblique muscle inserts into the globe inferior
The muscle belly then can be evaluated by scanning an- to the macula. It courses along the ocular wall, then extends
teroposteriorly along this area, from trochlea toward the horizontally beneath the inferior rectus to its origin at the
posterior orbit. Unlike that of the other muscles, the belly orbital bone (see Figure 15-13).
of this muscle remains close to the orbital bone at all times. The insertion of this muscle is easily demonstrated with
The muscle belly can be shown with both transverse and B-scan instruments. A vertical transverse scan of the lateral
longitudinal B-scan approaches. A vertical transverse view rectus muscle is performed. WIth this approach, the tendon of
Figure 15-14 Horizontal transverse B-scan technique to display superior oblique tendon.
A, Note slitlike defect (arrow) at upper aspect of echogram (supranasally). B, Probe marker is di-
rected toward 3-o'clock.
392 THE ORBIT
Figure 15-15 Technique for evaluation of the superior oblique muscle with A-scan (A) and
B-scan (B and C). A, A-scan probe is placed near equator at 7:30 o'clock position, and sound
beam is directed perpendicular to sheath of superior oblique muscle (arrows). B, Oblique trans-
verse scan displays cross-section of superior oblique muscle (black arrow). White arrow, Medial
rectus muscle. Note that probe marker is oriented toward the 10:30-o'clock meridian. C, Lon-
gitudinal scan displays long section of superior oblique muscle (black arrows). Probe marker is di-
rected toward cornea and 1:30 clock meridian. Note how muscle belly lies adjacent to orbital
bone throughout its course.
A E
B F
c G
D H
Figure 15-16 Echograms and CTscans showing left superior oblique myositis at initial pre-
sentation (A to D) and following corticosteroid therapy (E to H). A, Axial CT scan demonstrates
irregular mass (arrow) in supranasal orbit. B, Longitudinal B-scan shows thickened superior
oblique muscle (straight arrow) passing :;mteriorly around trochlea (curved arrow) and enlarged
tendon that courses to the globe. C, Oblique transverse B-scan shows cross-section of thick-
ened muscle (arrow). D, A-scan shows low reflective thickening of muscle (arrow). E, Axial CT
scan shows decreased size of muscle (straight arrow) and now clearly delineated tendon (curved ar-
row). F, G, and H, Corresponding B- and A-scans show decreased size of muscle following ther-
apy. (From Wan WL, Cano MR, Green RL: Orbital myositis involving the oblique muscles: An
echographic study. Ophthalmology 1988;95:1522.)
394 THE ORBIT
the inferior oblique is displayed as a thin defect located just through the most anterior aspect of the inferior orbit. As
below the insertion of the lateral rectus muscle (Figure 15 -1 7, with the inferior rectus muscle, it may be necessary to
A). The tendon can be centered in the echogram by perform- place the B-scan probe on the closed lid with the patient
ing an oblique transverse scan through the inferotemporal or- fixating slightly away from the probe (Figure 15-19).
bit (Figure 15-17, B). A longitudinal scan along the infero- The easiest way to detect a thickened inferior oblique
temporal meridian also can show the tendon (Figure 15 -18). muscle with A-scan is to use a paraocular approach with the
The belly of the inferior oblique muscle is generally probe positioned inferotemporally. If the muscle is en-
difficult to display because of its anterior, inferior loca- larged, a defect will be apparent as the sound beam is di-
tion. If, however, this muscle is thickened, it can be more rected just next to the globe wall. If extremely large, the
easily imaged. This muscle is usually best displayed with thickened muscle also may be seen with a paraocular B-scan
horizontal transverse scans. The sound bearri is directed approach (Figure 15-20).
Figure 15-17 Transverse B-scan technique for displaying cross-section of inferior oblique ten-
don. A, Vertical 'transverse scan with patient fixating slightly temporally. Probe marker is di-
rected toward the 12-o'clock meridian. Insertion of the lateral rectus muscle (open arrow) and
tendon of the inferior oblique (closed arrow) are both displayed. B, Oblique transverse scan with
patient fixating slightly inferotemporally. Probe marker is directed toward 10:30 o'clock merid-
ian. Lateral rectus muscle (open arrow) is displayed near top of echogram and inferior oblique ten-
don (closed arrow) is centered in echogram.
A B
Figure 15-18 Longitudinal B-scan technique for displaying long section of inferior oblique
tendon. A, Patient fixates slightly toward inferotemporal quadrant, and probe is placed at
I-o'clock. Probe marker is directed toward cornea and 7-o'clock meridian. B, The tendon pro-
duces a long, thin echolucent pattern adjacent to the sclera (arrows).
A c
B D
Figure 15-19 Dynamic B-scanning of thickened inferior oblique muscle belly. A, Horizontal
transverse approach is used with probe placed on lid. Patient fixates slightly downward, and
marker is oriented toward 3-0'clock meridian. B, Cross-section of inferior rectus muscle (open ar-
row) and inferior oblique muscle (closed arrow). C, Slightly more anterior section. Inferior rectus
(open arrow) inserts into globe, and inferior oblique (closed arrows) courses toward nasal orbit.
D, Very anterior section shows inferior oblique muscle (closed arrows) extending toward nasal or-
bit. Open arrow, Insertion of inferior rectus muscle.
A c
Figure 15-20 Thickened inferior oblique muscle

shown in paraocular echo grams (A- and B-scan probes
placed inferotemporally). A, Longitudinal B-scan dis-
plays muscle defect (M) beneath globe. V,Vitreous cav-
B ity; arrow, area of globe wall not shown clearly because
of edge artifact. B, Horizontal transverse B-scan shows
inferior oblique muscle (M) as it courses beneath
globe. C, A-scan shows thickened inferior oblique
muscle (M). p, Posterior surface spike of muscle.
396 THE ORBIT
EXTRAOCULAR MUSCLE DISORDERS

(Figure 15-23; see also Figure 16_22).11,22,26,27,36 In rare
Thyroid Ophthalmopathy (Graves' Disease)
cases of acute thyroid ophthalmopathy, thickening of the
Thyroid ophthalmopathy is the most common cause of ex- tendon may occur and fluid may be noted in the episcleral
traocular muscle enlargement (Box 15 _1).27,3 7Many of these space.
patients are referred for echography with unilateral pro- As stated previously, bilateral, asymmetric muscle thick-
ptosis of unknown etiology. In other cases, thyroid dys- ening is the rule in thyroid ophthalmopathy and is the key
function may be suspected based on clinical findings, but finding in the diagnosis of this condition with echography.
blood studies or radiologic findings are normal. Echogra- On follow-up examination, these muscles often fluctuate in
phy can be very helpful in establishing or confirming the size, with some being larger and others being smaller than
diagnosis of thyroid ophthalmopathy in these patients. * on previous examinations. The muscles found to be most
Thyroid ophthalmopathy is typically a bilateral condi- commonly enlarged with echography are the superior rec-
tion that affects multiple extraocular muscles,?,27 It may, tus/levator complex and the medial rectus, followed by the
however, be very asymmetric, with marked changes in one inferior and lateral rectus muscles. This differs from the
orbit and only very subtle changes in the other. Even when clinical presentation of Graves' disease, in which the infe-
the condition appears to be unilateral, echography often re- rior rectus muscle is most frequently affected. 30 Thicken-
veals mild changes in the clinically uninvolved orbit. In rare ing of the levator muscle very often corresponds to the clin-
cases, however, only unilateral findings can be detected. ical presence of lid retraction,38 and in mild cases may be
Muscle thickening in thyroid ophthalmopathy usually the primary or even the only abnormal echographic finding
has a very characteristic appearance. In most cases the in- (Figure 15-24). In some instances, there can be difficulty in
serting tendon is spared while the mid- and posterior por- distinguishing the highly reflective thickened muscle from
tions of the muscle belly are involved. The internal reflec- surrounding orbital tissues, thus making accurate measure-
tivity of the thickened muscles in thyroid disease is typically ments hard to obtain. To avoid this problem, it can be help-
medium to high, and the structure is quite irregular 23 (Fig- ful to decrease the gain by a few decibels to better delin-
ure 15-21 and Table 15-2). This appearance results from eate the muscle sheath.
large interfaces within the muscles that are created by the
separation of muscle fibers due to edema and inflammatory
Myositis
cells.27 Other associated findings can include swelling of the
orbital fat and lid tissues, thickening of the periorbita (Fig- Myositis is an inflammatory condition of the extraocular
ure 15 -22), and enlargement of the lacrimal gland. muscles 3I that produces specific echographic findings that
In cases of marked apical muscle swelling, the superior are quite different from those seen in thyroid ophthal-
ophthalmic vein (or other orbital veins) can be enlarged mopathy. This condition can be acute and associated with
and the optic nerve sheaths thickened or distended (i.e., severe pain and restrictive extraocular movements, or it can
increased subarachnoid fluid) secondary to compression be more chronic, with less severe clinical symptoms. I8
Myositis can be primary, without associated changes in
*References 3, 6,11-13,20,25,34,41. other orbital structures, or it can occur along with other or-
bital processes such as scleritis or an inflammatory mass
(i.e., pseudotumor). Although some clinicians use the terms
BOX 15-1 myositis and pseudo tumor of the orbit interchangeably, the au-
thors designate an inflamed, thickened muscle as myositis
Extraocular Muscle Disorders
and reserve the term pseudo tumor for an orbital mass of
Thyroid eye disease (Graves' ophthalmopathy) inflammatory etiology (see p 310).
Myositis Myositis can be unilateral or bilateral, and it can affect
Tumors one or all of the extraocular muscles. I8 ,3I,32 Typically, the
Venous congestion
muscle is diffusely thickened, with involvement of both the
Trauma
Muscle thinning
muscle tendon and belly fibers. In thyroid disease, however,
the tendon is classically spared, and more posterior aspects
Chapter 15 EXTRAOCU LAR MuscLEs 397
B D
c E
Figure 15-21 Thickening of medial rectus muscle in thyroid ophthalmopathy. A, External

photograph shows bilateral exophthalmos and lid retraction. B, Longitudinal B-scan echogram
of muscle (M) displays thin insertion (arrow). C, Vertical transverse B-scan of thickened muscle.
D, A-scan shows normal insertion of muscle (arrow). E, A-scan through thickened muscle belly
shows typical medium to high internal reflectivity and irregular structure.
TABLE 15-2
Differential Diagnosis of Extraocular
Muscle Disorders*
Internal
Disorder Reflectivity Structure Insertions
Thyroid Medium-high Irregular Normal
ophthalmopathy
Myositis Low Regular Thickened
Tumors Low-medium Regular Normal
Venous congestion Medium-high Variable Normal
Hematoma Low-medium Regular Variable
*This table is a summary of the most typical echographic features of

disorders causing thickening of the extraocular muscles.
398 THE ORBIT
A C
B D
Figure 15-22 Thickening of periosteum in patient with thyroid ophthalmopathy (A and B)

compared to normal orbit (C and D). A, Longitudinal B-scan through medial orbit shows
periosteal thickening (P). B, Bone; M, medial rectus muscle. B, Corresponding A-scan. C, Lon-
gitudinal B-scan through medial aspect of a normal orbit. D, Corresponding A-scan.
Chapter 15 EXTRAOCU LAR MUSCLES 399
Figure 15-23 Advanced thyroid ophthalmopathy. A, External photograph shows bilateral

lower lid retraction, injection, and lid swelling. Axial (B) and coronal (C) CT scans show marked
bilateral extraocular muscle enlargement. A-scan montage of very thick rectus muscles in right
orbit (D) and left orbit (E). I, Inferior rectus; L, lateral rectus; M, medial rectus; S, superior
rectus/levator complex; arrows, muscle sheaths. See left optic nerve in Figure 16-22.
400 THE ORBIT
1 4
2 5
3 6
Figure 15-24 Thyroid ophthalmopathy. A (1), External photograph shows mild left upper lid
retraction. Echograms displ:iynormal right superior rectus/levator complex (2 and 3) and thick-
ened left superior rectus/levator complex (5 and 6). 2, Horizontal transverse B-scan of right su-
perior rectus (RSR) and levator muscle (arrows). 3, A-scan shows muscle complex as one defect.
M, Multiple signals; arrows, muscle sheath. 4, Coronal CT scan shows normal, symmetric ap-
pearance of muscles in the two orbits. 5, Horizontal transverse B-scan of left superior rectus
(LSR) and levator muscle (arrows). Note that the left levator muscle is thicker than the right le-
vator muscle. ·6, A-scan shows widened muscle complex. Continued
2 4
3 5
Figure 15-24, cont'd B (1), Axial CT scan suggests possible slight enlargement of right medial
rectus muscle (arrow). Longitudinal B-scan (2) and A-scan (3) show enlargement of right medial
rectus (lVI). ATTOWS, Muscle sheath. Normal left medial rectus is shown in longitudinal B-scan (4)
and A-scan (5).
402 THE ORBIT
A C
B D
Figure 15-25 Thickened muscles due to thyroid ophthalmopathy (A and B) and orbital myosi-
tis (C and D). Longitudinal B-scan echograms (A and C) show enlarged muscles (lYf) with nor-
mal insertion in thyroid disease (A) and thickened insertion in myositis (C) (arrows). A-scans
(B and D) show thickened muscle to be irregular and medium-high reflective in thyroid (B) but
regular and low reflective in myositis CD).
of the muscle are affected 27 (Figure 15-25; see also Table ing of the lacrimal gland or optic nerve. In situations in
15 -2). The internal reflectivity in myositis is usually low, which myositis is secondary to scleritis or episcleritis, mus-
owing to diffuse invasion of muscle fibers by inflammatory cle thickening can be limited primarily to the region of the
cells, which renders the tissue more homogeneous than tendon 35 (Figure 15-27).
normaF8 (Figure 15-26). There may be a number of asso- Echography is an effective way of following and monitor-
ciated findings, such as episcleritis or scleritis adjacent to ing the response to therapy. A positive therapeutic response
the inserting tendon of the muscle, swelling of surround- results in decreasing thickness of the inflamed muscle and a
ing orbital fat and lid tissues, or inflammation and thicken- gradual increase in reflectivity to normal (Figure 15-28).
Chapter 15 EXTRAOCU LAR MUSCLES 403
A D
B E
c F
Figure 15-26 Myositis of right medial rectus muscle. A, External photograph demonstrates
restricted abduction of right eye. E, Longitudinal B-scan echo gram shows enlarged muscle (J\IJ)
with thickened insertion (arrow). C, Vertical transverse B-scan shows cross-section of markedly
enlarged muscle. D, Axial MRI scan demonstrates pronounced enlargement of medial rectus
muscle (arrow). E, A-scan echo gram displays low reflective, thickened insertion (arrow).
F, A-scan shows marked, low reflective enlargement of muscle belly.
404 THE ORBIT
8 E
c F
D G
Figure 15-27 Myositis secondary to scleritis. A, External photograph shows child with ptosis
and injection of left eye (patient complained of severe pain). Echograms are from normal right
eye and orbit (B to D) and corresponding echo grams from left eye and orbit with scleritis and
myositis (E to G). B, Vertical transverse B-scan echogram shows thin insertion of normal right
lateral rectus muscle (white arrow), inferior oblique muscle (black arrow), and sclera (S). C, Lon-
gitudinal B-scan shows thin insertion of normal lateral rectus muscle (white arrow). ON, Optic
nerve. D, Corresponding A-scan shows thin insertion of normal lateral rectus muscle (arrow).
E, Vertical transverse B-scan view shows thickening ofleft lateral rectus muscle insertion (white
arrow), inferior oblique muscle (black arrow), and sclera (S). F, Longitudinal B-scan shows thick-
ening ofleft lateral rectus muscle insertion (white arrow). Note thickening of sclera (S) and edema
in sub-Tenon's space (black arrow). G, Corresponding A-scan shows thickened insertion oflateral
rectus muscle (arrow).
Chapter1S EXTRAOCULAR MUSCLES 405
A D
B E
c F
Figure 15-28 Myositis of right superior rectus muscle, with follow-up examination after treat-
ment. Patient presented with pain and ptosis of right upper lid. Echograms A to C are from ini-
tial examination; D to E are following 1 week of corticosteroid therapy. A, Horizontal trans~
verse B-scan shows cross-section of thickened muscle (1\1) in mid orbit. B, Longitudinal B~scan
shows thickened muscle belly and insertion (arrow). C, Corresponding A-scan displays low re-
flective thickening of muscle. D, Horizontal transverse B-scan shows muscle is smaller in cross-
section. E, Longitudinal B-scan shows muscle is also smaller in long section. Arrow, Insertion of
muscle. F, Corresponding A-scan displays decreased width and increased reflectivity of muscle.
Tumors
Metastatic carcinoma to the extraocular muscles may be
Various types of tumors can infiltrate the extraocular mus- unilateral or bilateral and may affect one or more muscles.
cles. * Although infiltration by tumor is an uncommon find- The tumor may involve the entire muscle, including the
ing, enlarged muscles due to metastatic carcinoma, 'lym- tendon, but is more commonly localized to the mid- and
phoma, sarcoma, metastatic melanoma, and amyloidosis posterior portions of the muscle belly. Internal reflectivity is
may occurJ,l1 generally low to medium, with regular structure (Figure
15-29; see also Table 15-2). Differentiation between myosi-
tis and metastatic carcinoma sometimes can be difficult,
*References 4, 6, 7,10,14,16,31,32,37. both clinically and echographically, because both conditions
406 THE ORBIT
A B
c D
Figure 15-29 Carcinoma metastatic to right inferior rec-

tus muscle. External photographs show marked restriction
of motility in right eye in both up (A) and down (B) gaze.
C, Longitudinal B-scan echogram shows marked thicken-
E ing of right inferior rectus muscle (M) With normal appear-
ance of insertion (arrow). ON, Optic nerve. D, Horizontal
transverse B-scan shows cross-section of thickened muscle.
E, A-scan shows medium reflectivity of thickened muscle.
can be associated with pain and a thickened, low reflective volves all muscles on the affected side to a mild or moder-
muscle. Extraocular muscle enlargement may also be pro~ ate degree. Internal reflectivity of the· thickened muscles
duced by ~etastatic melanoma from skin6,32 (Figure 15 -30), can be normal or moderately high (see Table 15-2). In ad-
as well as by lymphoma that may involve the rectus and/or dition, there is usually orbital soft tissue swelling as well as
levator muscles (Figure 15-31). enlargement of the optic nerve (see p 428). Also, dilated or-
bital veins are often present, either secondary to compres-
sion or to arteriovenous fistula (see Figure 13-15). In pa-
Venous Congestion
tients with dural-cavernous sinus fistula, diffuse, mild
Extraocular muscles can become thickened as a result of ve- thickening of thc= extraocular muscles and orbital soft tis-
nous congestion. 1,29 This condition can be observed in or.!. sues is sometimes the only finding.
bits affected by carotid-cavernous or dural-cavernous sinus In venous congestion, the enlarged muscles can appear
fistulas, diffuse inflammatory disease, and compression by a similar to those of thyroid ophthalmopathy. Therefore,
lesion located in the orbital apex or the cavernous sinus. echographic differentiation between the two disorders
Congestion is most often a unilateral condition that in- sometimes can be difficult.
407
A c
B D
Figure 15-30 Melanoma metastatic to right medial rectus muscle. A, Longitudinal B-scan
echo gram shows markedly thickened muscle 01) with rounded appearance of anterior border.
B, Vertical transverse B-scan shows cross-section of thickened muscle. C, Axial MRI scan shows
very large right medial rectus muscle (arrow). D, A-scan shows very low reflectivity of thickened
muscle.
A c
B o
Figure 15-31 Lymphoma involving right levator muscle. A, External photograph shows bilat-
eral upper lid ptosis (OD > OS) in patient with biopsy-proved orbital lymphoma. Transocular
echo grams from the right orbit show lesion involving the levator muscle (closed arrows). B, Hor-
izontal transverse B-scan through the anterior aspect of the superior orbit shows lesion involv-
ing the levator muscle (arrows). SO, Superior oblique tendon. C, Longitudinal B-scan showing
thickening of the levator muscle, especially anteriorly as it extends into the upper lid.
SR, Superior rectus muscle. D, A-scan through very anterior aspect oflevator muscle shows low
to medium reflectivity.
408 THE ORBIT
Trauma
usually made by noting a decrease in the size of the muscle
Hematoma occurring within the muscle sheath can occur over time; some change often is apparent within a few
secondary to trauma. 4 Internal reflectivity is low when days.
swelling is pronounced, and the inserting tendon mayor Muscle slippage following strabismus surgery or tran-
may not be thickened. Hemorrhage also can be present section by trauma can result in retraction of the muscle
elsewhere in the orbit. Confirmation of the diagnosis is into the posterior orbit. 19 In such cases, ultrasound can
c E
D F
Figure 15-32 Severed left medial rectus muscle following penetrating trauma. External pho-
tographs (A and B) show chemosis, subconjunctival hemorrhage, and no horizontal movement
of the left eye. Normal right medial rectus muscle (lV1) is shown in vertical transverse (C) and
longitudinal D) views. Arrow, Insertion of muscle. Severed left medial rectus muscle is shown
well in transverse view (E), but the muscle is not identifiable in longitudinal section (F).
Muscle Thinning
sometimes show gross disinsertion from the globe (Fig-
ure 15-32). Very mild retraction or muscle slippage, how- Extraocular muscles can be abnormally thin in some situations.
ever, may be undetectable with ultrasound. Incarceration This is most commonly.seen in very long globes with large
of an extraocular muscle following trauma or sinus posterior staphylomas5,33 (Figure 15-34). Thinning of the ex-
surgery also can occur2,9 and can be shown with echog- traocular muscles can occur due to congenital fibrosis, as well
raphy (Figure 15-33; see also Figure 17-13). as from longstanding thyroid ophthalmopathy (Figure 15-35).
A c
Figure 15-33 Incarcerated medial rectus muscle follow-

ing sinus surgery. Longitudinal B-scan echograms show
incarcerated medial rectus (A) and normal medial rectus
B (B) muscle. S, Abnormal sinus signals; solid arrow, insertion
of muscle; open arrow, bone defect where muscle is en-
trapped. C, Axial CT scan also shows incarceration of mus-
cle (arrow).
A B
Figure 15-34 Posterior staphyloma in eye with restricted motility. Patient had refractive error
of -18 diopters OU and restricted eye movement. A, Horizontal axial B-scan echogram ofleft
eye shows large posterior staphyloma (large arrow) and thin lateral rectus muscle (small arrows).
ON, Optic nerve. B, A-scan contac.t axial length measurement = 35.7 mm.
410 THE ORBIT
B C
Figure 15-35 Thinning of left lateral rectus muscle in patient with longstanding thyroid oph-
thalmopathy. A, External photograph shows hypertropia of left eye. Longitudinal B-scans display
normal right lateral rectus muscle (B) and very thin left lateral rectus muscle (C). Arrows, Muscle.
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1. Atta HR, Dick AD, Hamed LM, et al: Venous stasis orbitopathy-a An Atlas and Textbook. ed 3. Philadelphia, WB Saunders, 1986, p 2766.
clinical and echo graphic study. Br J OphthalmoI1996;80: 129. 18. Kennerdell JS, Dresner SC: The nonspecific orbital inflammatory
2. Buus DR, Tse DT, Farris BK: Ophthalmic complications of sinus syndromes. Surv OphthalmoI1984;29:97.
surgery. Ophthalnzology 1990;97:614. 19. Mark LE, Kennerdell JS: Medial rectus injury from intranasal surgery.
3. Byrne SF, Gendron EK, Glaser JS, et al: Diameter of normal extraoc- Arch OphthalmoI1979;97:459.
ular recti muscles with echography. Am J Ophthalmol1991; 112: 706. 20. McNutt L: Ultrasound of Graves' orbitopathy [seminar). Iowa City,
4. Capone AJr, Slamovits TL: Discrete metastasis of solid tumors to ex- Iowa, Department of Ophthalmology, University of Iowa Hospitals,
traocular muscles. Arch Ophthalmol1990; 108:23 7. 1975.
5. Derner JL, von Noorden GK: High myopia as an unusual cause of re- 21. McNutt LC, Kaefring SL, Ossoinig KC: Echographic measurement
strictive motility disturbance. Sun) Ophthalmol1989;3 3:281. of extraocular muscles, in White D, Brown RE (eds): Ultrasound in
6. DiBernardo CL, Pacheco EM, Hughes JR, et al: Echographic evalu- Medicine. New York, Plenum Press, 1977, P 927.
ation and findings in metastatic melanoma to extraocular muscles. 22. NeigelJM, RootmanJ, Belkin RI, et al: Dystllyroid optic neuropa-
Ophthalmology 1996; 103: 1794. thy: The crowded orbital apex syndrome. Ophthalmology 1988;
7. Dutton JJ, Byrne SF, Proia AD: Diagnostic Atlas of Orbital Diseases. 95:1515.
Philadelphia, WB Saunders, 2000. 23. Ossoinig KC: Standardized echography: Basic principles, clinical ap-
8. Fledelius HC, Gyldensted C: Ultrasonography and computer tomog- plications and results. 1m Ophthalntol Clin 1979;19(4): 127.
raphy in orbital diagnosis with special reference to dysthyroid oph- 24. Ossoinig KC: The technique of measuring the extraocular muscles,
thalmopathy.Acta OphthalmoI1978;56:751. in Gernet H (ed): Diagnostica Ultrasonica in Ophthalmologica. Meun-
9. Flynn JT, Mitchell KB, Fuller DG, et al: Ocular motility complica- ster, RA Remy, 1979, p 166.
tions following intranasal surgery. Arch Ophthalmol1979;97 :453. 25. Ossoinig KC: The role of standardized ophthalmic echography in
10. FriedmanJ, KareshJ, Rodrigues M, et al: Thyroid carcinoma metasta- the management of Graves' ophthalmopathy. Dev Ophthalmol
tic to the medial rectus muscle. Ophthalmic Plast Reconstr Surg 1989;20:28.
1990;6:122. 26. Ossoinig KC: Early detection of compressive optic neuropathy in
11. Glaser JS: Orbital diseases and neuro-ophthalmology: An overview, Graves' disease with standardized A-scan, in Ossoinig KC (ed): Oph-
in Glaser JS (ed): Neuro-ophthalmology. ed 2. Philadelphia, JB Lippin- thalmic Echography. Dordrecht, Dr WJunk, 1987, p 569.
cott, 1990, p 453. 27. Ossoinig KC: Ultrasonic diagnosis of Graves' ophthalmopathy, in
12. Hasenfratz G: Standardized echography in Graves' disease, in Os- Gorman CA, Waller RD, Dyer JA (eds): The Eye and Orbit in Thyroid
soinig KC (ed): Ophthalmic Echography. Dordrecht, Dr W Junk, 1987, Disease. New York, Raven Press, 1984.
P 557. 28. Ossoinig KC, Hermsen VM: Myositis of extraocular muscles diag-
13. Hodes BL, Stern G: Contact B-scan echo graphic diagnosis of oph- nosed with standardized echography, in Hillman JS, Lemay MM
thalmopathic Graves' disease. J Clin Ultrasound 1975;3:255. (eds): Ophthalmic Ultrasonography. Dordrecht, Dr W Junk, 1984,
14. Holstrumom GE, Nyman KG: Primary orbital amyloidosis localised p 383.
to an extraocular muscle. B1' J OphthalmoI1987;71:32. 29. Phelps CD, Thompson HS, Ossoinig KC: The diagnosis and prog-
15. HoltJE, O'Connor PS, DouglasJP, et al: Extraocular muscle size nosis of atypical carotid-cavernous fistula (red-eyed shunt syndrome).
comparison using standardized A-scan echography and computerized Am J OphthalmoI1982;93:423.
tomography scan measurements. Ophthalmology 1985 ;92: 13 51. 30. Rootman]: Graves' orbitopathy, in Rootman J: Diseases of the Orbit.
16. Hornblass A, Jakobiec FA, Reifler DM, et al: Orbital lymphoid tu- Philadelphia, JB Lippincott, 1988, p 248.
mors located predominantly within extraocular muscles. Ophthalmol- 31. RootmanJ, Robertson W, Lapointe: InflammatOlY diseases, in Root-
ogy 1987;94:688. man]: Diseases of the Orbit. Philadelphia, JB Lippincott, 1988, p 165.
32. Rootman J, Ragaz J, Cline R, et al: Tumors (orbital metastasis, in 37. Slamovits TL, Burde RM: Bumpy muscles. Szwv Ophtbahnol1988;
Rootman]: Diseases of the Orbit. Philadelphia, JB Lippincott, 1988, p 33:189.
426. 38. Small RG: Enlargement oflevator palpebrae superioris muscle fibers
33. Ruttum MS, Lloyd MA, Lewandowski MF: Echography in the diag- in Graves' ophthalmopathy. Opbtbalmology 1989;96:430.
nosis of restrictive motility caused by severe myopia. Am J Ophthalnzol 39. Tychsen L, Tse DT, Ossoinig K, et al: Trochleitis with superior
1990;109:350. oblique myositis. Opbtbalnzology 1984;91: 107 5.
34. Shammas HJF, Minckler DS, Ogden C: Ultrasound in early thyroid 40. Wan WL, CanoMR, Green RL: Orbital myositis involving the
orbitopathy. Arch OphthalmoI1980;98:277. oblique muscles: An echo graphic study. Ophthalmology 1988;95: 1522.
35. Siatkowski RM, Capo H, Byrne SF, et al: Clinical and echographic 41. Werner SC, Coleman DJ, Franzen LA: Ultrasonographic evidence of
findings in idiopathic orbital myositis. Am J Opbtbalmol 1994; a consistent orbital involvement in Graves' disease. N Engl J Med
118:343. 1974;290:1446.
36. Skalka HW: Perineural optic nerve changes in endocrine orbitopathy.
Arch OphthahnoI1978;96:468.
Optic Nerve
One of the most important uses of echography in the orbit pearance is due partially to the homogeneous nature of the
is evaluation of the optic nerve. Techniques have been de- optic nerve, as well as to artifact from oblique sound beam
veloped to evaluate subtle abnormalities of the optic nerve. incidence to the nerve borders. Consequently, the axial ap-
Echography can sometimes provide information that is not proach provides only limited information and is primarily
apparent with other imaging modalities. This chapter ad- of value for documenting marked enlargement of the optic
dresses techniques and findings in the assessment of the nerve. The transverse and longitudinal views provide more
retrobulbar optic nerve and the optic disc. perpendicular sound beam incidence and therefore a more
accurate display of the nerve.
With the longitudinal approach, the sound beam by-
RETROBULBAR OPTIC NERVE
passes the lens and is directed more perpendicular to the
The intraorbital portion of the optic nerve is a distinct, ho- optic nerve than the axial approach. Longitudinal scans are
mogeneous, tubular structure that courses through the orbit typically performed as the patient fixates slightly nasally
in a sinuous fashion. Using appropriate examination tech- with the probe placed on the temporal, horizontal meridian
niques, echography can enable one to detect, and often dif- (i.e., longitudinal scan of the 3-o'clock meridian of the right
ferentiate, optic nerve abnormalities associated with or orbit, and the 9-o'clock meridian of the left orbit). With
caused by inflammation, tumor or trauma (Box 16-1). the marker oriented toward the cornea, the probe is posi-
tioned close to the limbus and the nerve is thus displayed at
the lower aspect of the echogram (Figure 16-3).
8-Scan Technique
B-scan is used to evaluate general topography of the retro-
bulbar optic nerve. Additionally, B-scan can show the rela- BOX 16-1
tionship of the optic nerve to normal structures such as the
Optic Nerve Abnormalities
globe, extraocular muscles, and orbital bones, as well as to
retrobulbar lesions. Other associated changes, such as ab- Retrobulbar Optic Nerve
normalities of the optic disc (e.g., disc edema) and alter- Increased subarachnoid fluid (e.g., pseudotumor
ations in contour of the globe wall (e.g., thickening and flat- cerebri)
tening) also can be well shown. " Optic neuritis
The B-scan examination is usually performed with a Glioma
medium gain setting. The examiner may wish, however, to Optic nerve sheath meningioma
display the nerve at a high gain level initially and then de- Tumors
Arachnoid cyst
crease the gain setting until the optic nerve is clearly shown
Compressive optic neuropathy
(Figure 16-1). Comparison with the contralateral optic Trauma
nerve should always be performed at a similar gain setting. Vascular occlusive disease
Axial, longitudinal, and transverse views can be used to dis- Optic atrophy
play the optic nerve.
Optic Disc
For the axial approach, the patient fixates in primary
gaze, and the probe is centered on the cornea, with the Cupping
sound beam directed through the lens toward the optic Coloboma
Elevation
nerve. This approach displays the optic nerve as a wedge-
Drusen
shaped, echolucent defect (acoustic void) inserting into the
Pit
back of the globe (Figure 16-2). This wedge-shaped ap-
412
Chapter 16 OPTIC NERVE 413
ture of the nerve and its sheaths. 1,4,5,17,35 The instrument is

set at Tissue Sensitivity, and the examination is carried out
initially with the patient fixating in primary gaze. The
probe is placed on the globe temporally near the equator
(9-0'clock position right eye, 3-0'clock position left eye),
A and the sound beam is directed across the globe anteriorly
toward the insertion of the medial rectus muscle. The
probe is then slowly angled posteriorly and slightly superi-
orly until the optic nerve pattern appears just behind the
globe. When the sound beam is directed perpendicular to
the optic nerve, a distinct defect is displayed. This defect,
the optic nerve parenchyma, is low to medium reflective,
and the bordering perineural sheaths are highly reflective
(Figure 16-5). As previously explained for B-scan, perpen-
dicular sound beam incidence presumably occurs due to re-
B fraction at or near the surface of the perineural sheaths. 24,34
The optic nerve is first evaluated anteriorly. The probe is
then slowly angled toward the orbital apex to enable evalu-
ation of the nerve as far posteriorly as possible. During this
procedure, it may be necessary to tilt the probe slightly up
or down to maintain perpendicular sound beam incidence
to the perineural sheaths. Also, as the nerve is traced back
into the orbit, the sheath spikes tend to decrease in height
because of oblique sound beam incidence and sound atten-
c uation. Consequently, the sheath spikes should first be
identified anteriorly (where perpendicularity is easiest to
achieve) before tracing the nerve back into the orbit (Figure
16-6).
Measurements are made between the inner aspect of the
two steeply rising, high sheath spikes, which are typically
Figure 16-1 Transverse B-scan montage of normal optic nerve thick and double peaked. The inner peaks correspond to
at high, medium, and low gain settings. A, Optic nerve (arrow) is the pia mater and/or arachnoid sheath and the outer peaks
detected but is not shown well at high gain. B, Nerve is more ap- to the dural sheath. The diameter of the optic nerve should
parent as gain is decreased. C, Nerve is well delineated at medium-
be measured both anteriorly (a few millimeters behind the
low gain setting. Note that the optic nerve defect enlarges as gain
is reduced. (From Byrne SF: Evaluation of the optic nerve with globe) and posteriorly (as close as possible to the orbital
standardized echography, in Smith JL [ed]: Neuroophthalmology apex). Measurements can be made from the screen with
Now! New York, Field, Raicha and Associates, 1986, p 54.) electronic cursors (gates), or by hand from photographs us-
ing calipers (Figure 16-7). Regardless of the method used,
calculations of nerve size should be made based on a veloc-
The vertical transverse approach, also bypassing the lens, ity of 1,550 m/sec (see Appendix A).
provides a cross-section of the optic nerve anteriorly, near The normal optic nerve measures approximately the
the globe. This scan allows relative perpendicularity to the same thickness anteriorly as posteriorly and is usually sym-
optic nerve, presumably because of refraction that occurs at metric with the fellow optic nerve. The difference between
or near the perineural sheaths. Gross enlargement, as well as the two nerves is generally within 0.5 illill; larger differ-
abnormalities within the optic nerve, can be shown with this ences indicate probable abnormal thickness of one nerve.
approach. 4,5 This scan is performed with the patient fixating It is important, however, to be certain that these differences
in primary gaze with the probe placed temporally (marker are not the result of examination error such as measure-
directed superiorly). This results in the display of a circular ment of incorrect spikes or nonperpendicularity (Figure 16-
echolucent defect just behind the globe. In some instances, 8). Whenever a significant difference is detected between
edge artifacts (see p 466) are produced at the edge of the op- the two nerves, repeat measurements should be performed
tic nerve when it is viewed in cross-section (Figure 16-4). to confirm the findings.
The most important factor in detecting optic nerve dis-
ease is comparison of size with that of the fellow nerve. If,
A-Scan Technique
however, there is bilateral disease or if the fellow optic
A-scan provides cross-sectional measurements of the optic nerve cannot be measured, it can be helpful to refer to nor-
nerve and is used to analyze internal reflectivity and struc- mal, standard values. One study has shown normal optic
414 THE ORBIT
B c
Figure 16-2 Axial B-scan of normal optic nerve. A, Probe is centered on cornea, and sound
beam sweeps through posterior pole and optic nerve. B, Axial B-scan echo gram shows normal
wedge-shaped acoustic void behind the globe. I, Initial line corresponding to probe face on
cornea; L, lens; V, vitreous cavity; ON, optic nerve; arrows, orbital soft tissue. C, Gross pathologic
specimen of normal optic nerve.
A B
Figure 16-3 Longitudinal B-scan examination of normal optic nerve. A, Patient fixates slightly
nasally and probe is placed temporally, with the marker directed toward the cornea. B, Echogram
shows long section of normal optic nerve (ON).
B c
Figure 16-4 Vertical transverse B-scan examination of the optic nerve. A, Patient fixates in
primary gaze, and probe is placed temporally with marker directed superiorly. B, Echogram
shows cross-section of normal optic nerve (arrows). C, Cross-section of enlarged optic nerve.
D, Pathologic specimen showing cross-section of normal optic nerve. Note edge artifact in
Band C (curved arrows).
416 THE ORBIT
B c
Figure 16-5 A-scan examination of the optic nerve. A, Patient fixates in primary gaze, and
probe is placed temporally near the equator. B, Cross-section of normal optic nerve. Horizontal
arrows, Dural sheath; vertical a7'7"OWS, arachnoid sheath; connected arrows, surface of optic nerve
parenchyma (pia mater). C, Cross-section of thickened nerve. D, Pathologic specimen showing
cross-section of normal optic nerve and surrounding sheaths. Open arrows, Optic nerve
parenchyma; P, pia mater; black arrowhead, subarachnoid space; A, arachnoid sheath; D, dural
sheath.
Figure 16-6 Dynamic A-scan screening of the optic nerve. Drawing demonstrates how move-
ment of probe allows more posterior examination of optic nerve. Note that refraction at or near
the nerve surface produces perpendicular sound beam incidence to the perineural sheaths. Once
the optic nerve defect is detected anteriorly (1), the probe is angled to display the nerve defect
as far posteriorly as possible (5). The steeply rising, high sheath spikes (arrows) indicate perpen-
dicularity. Because amplitude of nerve and sheath spikes decreases as the sound beam progresses
posteriorly, assessment of reflectivity should be made anteriorly (1 and 2).
418 THE ORBIT
A B
Figure 16-7 Measurement of optic nerve thickness with A-scan. A, Echogram with no gates.
Arrows, Perineural sheaths. B, Electronic gates on sheath spikes (arrows) indicate optic nerve
thickness.
A B
Figure 16-8 Optic nerve displayed with perpendicular (correct) and oblique (incorrect) sound
beam incidence on A-scan. A, Steeply rising, distinct perineural sheath spikes indicate perpen-
dicular sOUl1d beam incidence (arrows). B, Indistinct sheath spikes (arrows) due to oblique sound
beam incidence.
nerve diameters to range between 2.2 and 3.3 mm, with a The optic nerve is normally displayed best with the
mean value of 2.5 mmY However, it may be useful for in- probe placed on the globe temporally, although placement
dividuals to establish their own control values, because of the probe in other areas is sometimes necessary. In some
techniques may differ somewhat among various examiners. cases, the optic nerve may be better displayed with the
Internal reflectivity and structure of the optic nerve can probe placed nasally or, less frequently, inferiorly near the
be assessed at the same time that the nerve is measured. fornix. The optimal approach may, in part, depend on how
The normal optic nerve produces low to medium internal the optic nerve courses in the orbit, which can vary among
reflectivity with regular structure, as shown in Figure 16-5. patients. Moreover, a different probe position may be re-
It is important, however, that reflectivity be evaluated pri- quired if the optic nerve is displaced by an orbital mass (see
marily in the anterior one-half of the optic nerve because Figure 13-3). Regardless of the approach used, a similar
sound attenuation typically causes lower reflectivity in the probe orientation should be employed when comparing
posterior orbit (see Figure16-6). with the contralateral optic nerve.
RETROBULBAR OPTIC NERVE DISORDERS

amination typically displays an irregular structure (see Fig-
Echography is very useful for the detection and differenti- ure 16-10, D). When sheath distention is marked, the sub-
ation of disorders that cause enlargement of the optic nerve arachnoid space surrounding the optic nerve appears very
or its sheaths l2 ,17 (Table 16-1). The optic nerve pattern may low reflective on A-scan and as an echolucent crescent or
be widened as a result of thickening of the optic nerve circle around the parenchyma of the nerve on B-scan (i.e.,
parenchyma (e.g., tumor or inflammation), increased sub- "doughnut sign") (Figure 16-12). To confirm the presence
arachnoid fluid (e.g., pseudotumor cerebri, inflammatory ofISAF, however, the thirty-degree test can beperformed
or vascular disorders), and thickening of the perineural with A-scan.
sheaths (e.g., tumor or inflammation).4,6,17 In some in-
stances, echography is also useful for differentiating optic The Thirty-Degree Test
nerve enlargement from a separate orbital mass located ad- The thirty-degree test, developed by Ossoinig et al,34 is a
jacent to the optic nerve (Figure 16-9). dynamic A-scan technique for differentiating ISAF from
The differentiation of optic nerve lesions is based pri- thickening of the optic nerve parenchyma or the perineural
marily on the degree of thickening, internal reflectivity, and sheaths. The thirty-degree test is based on the assumption
structure of the nerve, as well as outcome of the thirty-de- that when the eye is turned, the optic nerve and its sheaths
gree test. 4,17,34 When thickening of the optic nerve is de- are stretched, thus distributing the increased subarachnoid
tected, the internal reflectivity and structure are first eval- fluid over a greater area.
uated. If the A-scan pattern is regular and low reflective Once a widened optic nerve pattern has been detected,
and B-scan shows a homogeneous defect, thickening of the maximum thickness of the nerve is documented both
the optic nerve parenchyma is most likely present (Figure anteriorly and posteriorly as the patient fixates in primary
16-10). Conversely, irregularity of echograms is more in- gaze. The patient then re-fixates 30 degrees or more to-
dicative of sheath thickening and/or increased subarach- ward the probe, and the nerve is measured again (both
noid fluid. On A-scan examination, irregularity is indicated anteriorly and posteriorly). Ifincreased subarachnoid
by the presence of two or more high spikes between the fluid is present, measurements of the optic nerve pattern
sheath spikes (i.e., sheathing phenomenon).34 On B-scan, will decrease in size as compared with those obtained
a vertical transverse view can demonstrate a crescent-like with the patient in primary gaze (Figure 16-13). If a large
configuration of the optic nerve pattern (see Figure 16-10). volume of fluid is present, the nerve pattern may decrease
Furthermore, a longitudinal or, less frequently, an axial ap- by as much as 25% to 30%, whereas a reduction of as
proach, may show optic nerve doubling 10 or sheath accen- little as 10% may occur in mild sheath distention. The
tuation. 4-6 These signs, however, are nonspecific since they thirty-degree test is considered positive when the nerve
can be seen in both normal and abnormal optic nerves pattern decreases by at least 10% at 30-degree gaze
(Figure 16-11). compared with the measurement at primary gaze. When
ISAF is present, movement of the eye back and forth
may cause the widened optic nerve pattern to decrease
Increased Subarachnoid Fluid
temporarily when the patient re-fixates in primary gaze.
Increased subarachnoid fluid, most commonly seen in pa- The examiner should be aware that this can occur and
tients with pseudotumor cerebri, is a frequent cause of a may therefore need to wait a few minutes before repeat-
widened optic nerve pattern. 27 ,42 Other causes include optic ing measurements in primary gaze. Optic nerves of
neuritis, compressive optic neuropathy, trauma, and uveal normal size and nerves that are enlarged as a result of
effusion syndrome (see p 82).16 When mild to moderate in- solid infiltration of the nerve parenchyma or its sheaths
creased subarachnoid fluid (ISAF) is present, the optic have a negative thirty-degree test. B-scan can also be
nerve pattern may appear slightly widened and A-scan ex- used to demonstrate a positive thirty-degree test in
TABLE 16-1 .
Differential Diagnosis of Optic Nerve Disorders*
Disorder Reflectivity Internal Structure Thirty-degree Test
Increased subarachnoid fluidt Variable Irregular Positive
Glioma Low-medium Regular Negative
Meningioma Medium-high Irregular Negative
*This table summarizes the most typical echographic features of the disorders that most often cause enlargement of the retrobulbar optic nerve.
tSome of the more common conditions associated with increased subarachnoid fluid include benign intracranial hypertension, optic neuritis, compres-
sive optic neuropathy, and trauma.
420 THE ORBIT
A o
Figure 16-9 Intraconallymphoma adjacent to optic

nerve. A, Vertical axial B-scan echo gram displays le-
sion (L) just above and separate from optic nerve (ON).
B, Horizontal para-axial B-scan view (orbital screen ex-
pansion) shows tubular shaped lesion (L) in muscle
cone just above optic nerve. C, A-scan through lesion
(L) shows typical low reflectivity oflymphoma and dis-
tinct posterior surface spike (P). D, Axial CT scan
shows intraconal mass surrounding optic nerve.
c
A c
B D
Figure 16-10 Echograms of enlarged optic nerve show regular internal structure in optic neu-
ritis (A and B) and irregular structure in pseudotumor cerebri (C and D). A, Vertical transverse
B-scan shows echolucent optic nerve void (arrows). B, A-scan pattern is regular and low reflec-
tive. Arrows, Perineural sheaths. C, Vertical transverse B-scan shows crescent sign due to sub-
arachnoid fluid (open arrow) between optic nerve parenchyma (black arrows) and perineural
sheaths. D, A-scan pattern is irregular because of fluid around optic nerve parenchyma (connected
arrows). Vertical arrows, Perineural sheaths.
A B
Figure 16-11 Axial B-scan echograms show optic nerve doubling (sheath accentuation).
A, Normal optic nerve showing mild sheath accentuation (arrows). B, Sheath accentuation
(arrows) is more obvious when nerve is surrounded by increased subarachnoid fluid.
422 THE ORBIT
A B
Figure 16-12 Marked increased subarachnoid fluid surrounding optic nerve of patient with
pseudotumor cerebri. This results in doughnut sign on B-scan and irregular structure on
A-scan. A, Vertical transverse B-scan shows doughnut sign. Optic nerve parenchyma (arrow) is
completely surrounded by subarachnoid fluid (F). E, A-scan shows marked distention of arach-
noid sheaths (small arrows) and medium-high reflectivity from surfaces of optic nerve parenchyma
(large arrow). F, Fluid around optic nerve parenchyma.
Figure 16-13 Positive thirty-degree test with A-scan. A, Patient fixates in primary gaze, which
allows maximal fluid accumulation beneath the arachnoid sheath. Top echogram shows corre-
sponding widening of optic nerve pattern between arachnoid sheath spikes (a77'ows). E, Patient's
gaze is redirected to at least 30 degrees toward the probe causing subarachnoid fluid to be re-
distributed over a longer area, thus decreasing effective diameter of the nerve and its echogram.
some cases, but it is not as reliable as is the A-scan (Fig- Optic Neuritis
ure 16-14). In optic neuritis (either infectious or noninfectious), the op-
In some cases, an optic nerve tumor that is located pos- tic nerve pattern is enlarged because of swelling of the op-
teriorly can be associated with increased fluid around the tic nerve parenchyma, thickening of the perineural sheaths,
anterior portion of the nerve. This can result in a positive or most often, ISAF.21,41 Consequently, internal structure
thirty-degree test anteriorly and a negative test posteriorly. can be regular or irregular, and results of the thirty-degree
Consequently, it is important that the thirty-degree test test can vary from patient to patient. The authors have
routinely be performed both anteriorly and posteriorly. found that inflammation of the optic nerve and/or
its sheaths can be secondary to other conditions such as
scleritis, myositis, orbital cellulitis, or an inflammatory
Optic Nerve Lesions
mass. In addition, syphilitic optic neuritis has been shown
Lesions involving the optic nerve parenchyma or the peri- to cause marked enlargement of the optic nerve 28 ,41 (see
neural sheaths often can be differentiated with echography. Figure 6-26).
"When there is solid thickening of the optic nerve pattern of
at least twice normal size, a tumor should be suspected. 17 ,34 Optic Nerve Glioma
In contrast, inflammatory processes of the optic nerve typ- An optic nerve glioma often appears as a smooth, fusi-
ically produce only mild to moderate enlargement of the form, or ovoid mass that replaces the normal optic nerve
nerve pattern. This type of thickening, however, can be void. A-scan shows regular internal structure and low to
difficult to differentiate from smaller tumors involving the medium reflectivity (Figure 16-15). In some cases, the
nerve or sheaths. nerve can appear very convoluted behind the globe before
A c
8 o
Figure 16-14 Positive thirty-degree test with B- and A-scan. Echograms with patient fixating
in primary gaze (A and B) and 30 degrees temporally (C and D). A, Vertical transverse B-scan
echo gram shows widened optic nerve pattern (closed arTows) with crescent sign. Open arrow, Sub-
arachnoid fluid. B, Corresponding A-scan shows widened optic nerve pattern (arTows), measur-
ing 6.4 mm. C, Vertical transverse B-scan shows decrease in size of optic nerve pattern and
smaller crescent sign, suggesting positive thirty-degree test. D, Corresponding A-scan shows
decrease in optic nerve pattern (now 5.7 mm), indicating positive thirty-degree test (11 %
decrease).
424 THE ORBIT
Optic Nerve Sheath Meningioma

expanding into a more smooth, fusiform-shaped mass
(Figure 16-16). Optic nerve sheath meningiomas are irregularly structured,
The thirty-degree test is usually negative unless ISAF with predominantly medium to high reflectivity on A-scan
has accumulated around or anterior to the tumor. In long- (Figure 16-17). The thirty-degree test is negative in the
standing cases, cystic degeneration may result in small area of tumor, but it can be positive in cases in which fluid
echolucent spaces on B-scan and areas of very low reflec- is present anterior to the tumor (Figure 16-18). In contrast
tivity on A-scan. to gliomas, large meningiomas tend to appear irregular and
nodular on B-scan. Abnormalities within the optic nerve
pattern, such as sheath accentuation and/or calcification,
also may be apparent4-6, 8-10 (Figure 16-19). Color Doppler
imaging can also be used to evaluate optic nerve sheath
meningiomas (see Figure 14-7 and Color Plate 13).
Secondary and Metastatic Tumors

Tumors arising from the globe, such as retinoblastomas and
melanomas, can extend into the retrobulbar optic nerve. Such
A extension, however, has been reported to occur more com-
monly with retinoblastomas than with melanomas. 37 How-
ever, the extension of retinoblastoma can be very difficult to
detect echographically because of the calcification that is usu-
ally present within these tumors. This is an area where other
imaging methods, such as CT scan, can be very useful.
Invasion of the optic nerve also can occur from neo-
plasms located within the orbit, periorbital sinuses, na-
sopharynx, and intracranial cavity.43 Moreover, metastatic
processes (e.g., leukemia and carcinoma) can infiltrate the
. optic nerve or its sheaths. 37 ,38 All of these conditions can
cause thickening of the optic nerve, the perineural sheaths,
B or ISAF (Figure 16-20). As a result, these various processes
can be difficult to differentiate echographically from pri-
mary lesions of the optic nerve.
Arachnoid Cyst of the Optic Nerve

Arachnoid cyst is a rare lesion that can affect the retrobul-
bar optic nerveY B-scan shows a well-outlined, roundish,
Figure 16-15 Large optic nerve glioma. A, Axial MRI scan Figure 16-16 Vertical transverse B-scan echogram shows
shows large glioma (arrows). B, Para-axial B-scan at medium-high kinked appearance of optic nerve secondary to optic nerve glioma.
gain setting demonstrates large tumor (arro~vs) replacing normal The anterior portion of the optic nerve (ON) angles superiorly
optic nerve void. C, A-scan shows cross-section of thickened op- and then bends inferiorly as it expands from the glioma (arrows).
tic nerve (arrows) with regular internal structure and low to
medium reflectivity. (A courtesy Dr. Steve Feldon, Rochester,
New York.)
B E
c F
o G
Figure 16-17 Right optic nerve sheath meningioma. A, Coronal CT scan shows enlarged right
optic nerve (arrow). Echograms are from normal left orbit (B to D) and meningioma in right or-
bit (E to G). B, Axial B-scan of normal left optic nerve (ON). Arrow shows normal, flat optic
disc. C, Vertical transverse B-scan shows cross-section of normal optic nerve (arrows). D, A-scan .
cross-section of normal optic nerve. Arrows, Perineural sheaths. E, Axial B-scan of abnormal
right optic nerve shows optic disc elevation (arrow) but no obvious abnormality of reo:obulbar
optic nerve (ON). F, Vertical transverse B-scan through anterior aspect of right optic nerve shows
enlarged nerve pattern (black arrows) and disc elevation (white arrow). G, A-scan cross-section of
widened right optic nerve echogram shows irregular internal structure that is typical of menin-
gioma. Arrows, Perineural sheaths.
426 THE ORBIT
B D
c E
Figure 16-18 Optic nerve sheath meningioma located in orbital apex, with increased sub-
arachnoid fluid anteriorly. A, Axial CT scan shows enlarged left optic nerve (open arrow) with
maximum enlargement posteriorly (closed arrow). A-scans of enlarged optic nerve were taken in
primary gaze (B, anteriorly and C, posteriorly) and at 30 degrees (D, anteriorly and E, posteri-
orly). S, Peri-neural sheaths. Note that remeasurement of optic nerve at 30 degrees shows nar-
rowing of pattern and thus positive thirty-degree test anteriorly (D) but no change and thus
negative test posteriorly (E). This indicates increased subarachnoid fluid anteriorly but solid
nerve posteriorly near orbital apex. (From Byrne SF: Evaluation of the optic nerve with stan-
dardized echography, in SmithJL led]: Neuro-ophthalmology Now! New York, Field, Raicha and
Associates, 1986, p 57.)
Figure 16-19 Various abnormalities in B-scan echo grams of different optic nerve sheath
meningiomas. A, Longitudinal scan demonstrates nodular enlargement (arrows) of optic nerve
pattern (ON). B, Vertical transverse view of optic nerve (closed arrows) shows large focus of cal-
cium (open arrow). C, Longitudinal view shows sheadl accentuation (arrows). ON, Optic nerve.
428 THE ORBIT
B E
c F
D G
Figure 16-20 Metastatic carcinoma from lung to optic nerve. A, Axial MRI scan shows thick-
ened right optic nerve (arrows). E, Axial B-scan echogram shows elevation of optic disc (arrow).
A-scan echo grams in primary gaze (C and D) and at 3D-degree gaze (F and G) show widened op-
tic nerve (arrows), with negative thirty-degree test. C, Optic nerve anteriorly. D, Optic nerve
posteriorly. E, Vertical transverse B-scan at low gain setting shows marked enlargement of the
optic nerve (arrows). Thirty-degree test is negative because there is no significant change in size
of optic nerve pattern either anteriorly (F) or posteriorly (G).
echolucent lesion adherent to the optic nerve. In some tion. 36 The most common cause of this condition is thyroid
cases, actual communication with the nerve can be ap- ophthalmopathy, in which very large extraocular muscles
preciated (Figure 16-21). The lesion is very low reflec- can cause apical compression (see p 396).29,32,33,39 Com-
tive on A-scan, and the optic nerve may be enlarged with pression typically results in widening of the optic nerve pat-
ISAF. tern with increased subarachnoid fluid (Figure 16-22).
Other conditions that cause extraocular muscle thickening
Compressive Optic Neuropathy (e.g., myositis, tumors, and venous congestion) also can
The optic nerve can become secondarily enlarged as the reproduce compression of the optic nerve. Additionally, large
sult of compression by a lesion that is located at or near the orbital tumors within the muscle cone can markedly dis-
orbital apex; this can be due to injury, tumor, or inflamma- place and stretch the optic nerve (see Figure 13-3).
Figure 16-21 Optic disc coloboma and arachnoid cyst associated with Aicardi's syndrome.
A, Optic disc coloboma (arrow). Cyst (C) is shown communicating with optic nerve (ON).
B, Horizontal transverse scan with sound beam directed just above optic nerve through the cyst
(C). The optic nerve was enlarged with a positive thirty-degree test on the A-scan. C, Sagittal
MRI scan shows enlarged optic nerve (arrows).
Optic Nerve Trauma be enlargement of the retrobulbar optic nerve with a pos-
Traumatic or spontaneous hemorrhage can occur in the itive thirty-degree test. In more longstanding cases, there
subarachnoid space,6,43 resulting in an enlarged optic nerve may be proliferative tissue at the optic disc, as well as an
pattern with a positive thirty-degree test. Hemorrhage can unusual appearance of the nerve insertion into the globe 20
be present elsewhere in the orbit, as well as in the globe. (see Figure 4-11).
Avulsion of the optic nerve produces various findings.
In an acute injury, vitreous hemorrhage can be present Vascular Occlusive Disease
and B-scan may show an actual break in the sclera near The retrobulbar optic nerve is usually not enlarged in cen-
the optic disc (see Figure 4-10). Additionally, there can tral retinal vein or artery occlusion, or in anterior ischemic
430 THE ORBIT
A c
8 D
Figure 16-22 c::ompressive optic neuropathy in patient with advanced thyroid ophthalmopa-
thy (same patient as shown in Figure 15-23). A, Fundus photograph ofleft eye shows blurred disc
margins and horizontal choroidal folds. Echograms show optic disc swelling and thickened op-
tic nerve. B, Axial B-scan echogram shows optic disc elevation (arrow). ON, Optic nerve. C, Op-
tic nerve pattern is widened in primary gaze on A-scan (arrows). D, Remeasurement at 30 degrees
shows marked decrease in diameter of optic nerve pattern, indicating positive thirty-degree test.
A 8
Figure 16-23 Calcification at level oflamina scleralis in eye with previous vascular occlusion.
Small, bright nodule (arrow) shown in vertical transverse (A) and longitudinal (B) B-scan
echograms.
optic neuropathy. However, both sheath thickening and Postoperative Findings

ISAF have been observed occasionally in anterior ischemic It may be helpful to re-examine the optic nerVe following
optic neuropathy as well as central retinal artery occlu- decompression to determine whether there has been a de-
sion. 26 Additionally, a small, calcified nodule may some- crease in ISAF surrounding the nerve. In one case of
times be observed within the optic nerve of patients with pseudotumor cerebri, a marked reduction in ISAF was doc-
vascular occlusive disease. 3 ,3o These nodules have been umented echographically immediately following spinal
demonstrated in the region of the lamina cribrosa, as well as tap I5 (Figure 16-24). In addition, re-examination following
a few millimeters posteriorly (Figure 16-23). optic nerve sheath decompression frequently shows a de-
crease in ISAF that sometimes is also seen in the unoper-
Optic Atrophy ated fellow nerve. 27 Another occasional finding on B-scan is
Echography is indicated in eyes with optic atrophy to detect a track of fluid located near the site of surgical incision. The
tumors or inflammatory lesions of the optic nerve, or other fluid may develop into a lesion with a cystic appearance 23
compressive orbital mass lesions. When optic atrophy is (Figure 16-25).
present but no causative lesion is detected, the optic nerve
is typically of normal size or smaller than normal; similar
OPTIC DISC
findings have been observed in orbits with hypoplasia of the
optic nerve. In some cases, when optic atrophy is present, B-scan can be used to demonstrate excavation, elevation,
the internal reflectivity can be higher than is typically seen and drusen of the optic disc (Box 16-1),7,2 5The axial, lon-
in the normal nerve. 4,5,34 gitudinal, and vertical transverse approaches can be useful
A c
Figure 16-24 Echogramsfrom patient with pseudotumor cerebri taken just before (A and B)
and immediately following (C and D) lumbar puncture. A, Vertical transverse B-scan shows en-
larged optic nerve pattern (arrows). B, A-scan cross-section of optic nerve prior to procedure
measures 4.9 mm. C, Vertical transverse B-scan after procedure shows decreased optic nerve
pattern. D, A-scan cross-section of optic nerve following lumbar puncture measures 2.6 mm.
(From Galetta S, Byrne SF, Smith JL: Echographic correlation of optic nerve sheath size and
cerebrospinal fluid pressure. J Clin Neuro-OphthalmoI1989;9:79.)
432 . THE ORBIT
c
A
Figure 16-25 Pseudotumor cerebri With ethograms taken before and after optic nerve sheath
fenestration. A, Fundus photograph showing papilledema and choroidal folds. B, Sagittal MRI
scan shows lesion in area of optic nerve near globe (arrows}. C, Preoperative axial B-scan shows
optic disc elevation due to papilledema (arrow). ON, Optic nerve. D, Vertical para-axial B-scan
10 days following fenestration shows echolucent fluid track (arrow) emanating from area of in-
cision. E, Vertical axial B-scan 2 months after fenestration shows lesion with cystic appearance
(C) in area where fluid track was previously seen.
for evaluating the optic disc (Figure 16-26). A-scan some- Colobomas involving or adjacent to the optic disc are
times can be of additional use in assessing the reflectivity easily imaged with B-scan. These can be small and shallow
and height of certain lesions at the optic disc (e.g., drusen (see Figure 16-21), or they can be large and deep, such as
and tumors, see Figure 5-53). those associated with the morning glory syndrome 22 ,4o,43
(Figure 16-27). Occasionally, a coloboma is associated with
a cystic appearance of the retrobulbar optic nerve (Figure
Optic Disc Excavation
16-28).
The optic cup is best displayed with a vertical transverse B- Optic pits are excavations of the optic nerve head and
scan view, although a longitudinal scan performed along the are probably a form of coloboma. 44 They appear as small
12-0'clock meridian sometimes helps to confirm cup size. circular or triangular depressions, usually located in the in-
Large, deep cups (glaucomatous or physiologic) are easily ferotemporal quadrant of the disc. They tend to be unilat-
imaged with these views. A large cup mayor may not be eral and are often associated with serous retinal detach-
imaged in an axial view (see Figure 7-1). ments, often involving the macula. B-scan shows a distinct
Small to medium-sized cups can also be demonstrated, excavation at the optic nerve head (Figure 16-29).
but detection is less reliable than with larger cups.!! Large, Pseudo cupping of the optic disc can be seen in eyes with
shallow cups also can be difficult to detect. Whenever pos- marked, diffuse thickening of the retina and/or choroid sur;:
sible, comparison should be made with the fellow optic rounding the optic disc. In such cases, B-scan shows a cav-
nerve. Such comparison is especially helpful when size ity or depression overlying the optic nerve head that can
of the cup in the other eye is known so it can be used as a simulate a large optic cup (see Figure 6-18). However, by
reference. comparing the thickness of the peripapillary retinochoroid
A
Figure 16-26 B-scan probe positions and corresponding echo grams of normal optic disc.
A, Vertical axial approach. The probe is centered on the comea (marker up). A medium-high gain
setting is used, and the sound beam is directed through the lens (L) toward the center of the op-
tic nerve. Note flat appearance of normal optic disc (arrow). B, Vertical transverse approach. The
probe is positioned temporally (marker up). A medium gain setting is used, and the optic nerve is
displayed in the center of the echogram (arrow). C, Longitudinal approach (marker to comea). A
low-medium gain setting is used, and the optic disc is displayed at lower edge of echogram.
A B
Figure 16-27 Large optic disc coloboma. Coloboma (arrow) is shown on axial CT scan (A)
and B-scan (B). ON, Optic nerve. (From Byrne SF: Evaluation of the optic nerve with stan-
dardized echography, in SmithJL led]: Neuro-ophthalmology Now! New York, Field, Raicha and
Associates, 1986, p 63.)
434 THE ORBIT
Figure 16-28 Optic disc coloboma with cystic appearance

in orbit. A, Fundus photograph displays large coloboma of
optic disc. B, Horizontal axial B-scan echogram shows
A coloboma(arrow) and cystic component (C). C, Longitudi-
nal B-scan along nasal fundus also shows coloboma and cys-
tic component.
B c
layer with other areas of the fundus and/or the fellow eye, verse and longitudinal B-scan approaches, which bypass the
differentiation from true optic cupping can usually be lens, often demonstrate the highly reflective calcified nod-
made. ule more clearly than the axial approach (Figure 16-32).
Optic Disc Elevation Crowded Optic Disc (Pseudopapilledema)

Elevation of the optic disc (e.g., edema, papilledema and Congenital anomalies of the optic disc can create an eleva-
tumor) can be easily shown with B-scan. Elevation usually tion of the optic nerve head and the appearance of
can be detected with any of the three B-scan positions, but pseudopapilledema (crowded optic disc) (see Figure 3-70,
the axial approach is often best for documentation (Figure A). This appears to be due to narrow scleral canals through
16-30). which the optic nerve enters the globe. It has been shown
that the crowded disc appearance is associated with smaller
hyperopic eyes, as well as some eyes of average length. 14,16
Optic Disc Drusen
It is postulated that these anomalous optic discs are impli-
Optic disc drusen can simulate papilledema clinically, or cated in the pathogenesis of ischemic optic neuropathy.2,13
they can be buried and unappreciable with ophthal- B-scan examination of these eyes demonstrates that the
moscopy.3,19 These calcified nodules can be easily identified posterior sclera is thickened and that the scleral optic nerve
echo graphically, because they produce an echo of extremely canals are elongated (see Figure 3-70, B and C). It should be
high reflectivity at or within the optic nerve head 3,31 (Figure noted, however, that it is usually very difficult to image
16-31). Drusen can be large or small and are most often bi- the scleral optic nerve canals in eyes with normal posterior
lateral, although they may be asymmetric in size. Trans- scleral thickness.
A B
Figure 16-29 Optic nerve pit. A, Fundus photograph shows well-circumscribed pit in in-
ferotemporal aspect of optic disc (black-arrows). B, Reverse longitudinal B-scan (see p 32) shows
well-outlined, deep excavation corresponding to optic pit (black arrow). Note shallow macular
retinal detachment (white aTrow) extending from edge of optic pit. ON, Optic nerve. (Courtesy
Dr. Brian Leonard and Diane Chialant, COT, RDMS, Ottawa, Canada.)
A B
Figure 16-30 Axial B-scan echograms show elevated and normal optic discs. A, Elevated op-
tic disc (al'row). ON, Optic nerve. B, Normal flat optic disc.
436 THE ORBIT
B D
C E
Figure 16-31 Large optic disc drusen. A, Fundus photograph shows elevated optic disc with
small cup and no evidence of dilated vessels. Longitudinal B-scans (B and C) and A-scans
(D and E) show calcified drusen (arrows). B, B-scan at high gain setting shows elevation of op-
tic disc. ON, Optic nerve. C, B-scan at lower gain setting shows drusen better than does B.
D, A-scan at Tissue Sensitivity shows extremely high reflective spike from drusen. E, A-scan at
reduced gain setting shows persistence of spike.
Figure 16-32 Optic disc drusen. Calcified drusen (arrows) is shown in vertical transverse (A)
and longitudinal (B) B-scan views at low gain setting. ON, Optic nerve. C, Drusen is less ap-
parent in axial B-scan echogram.
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438 THE ORBIT
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Orbital Trauma and
Periorbital Disease
Orbital echography can be useful for evaluating the orbit cases, this subtle difference may be helpful in attempting to
following trauma and for detection of abnormalities sec- differentiate between the two. In other situations, follow-up
ondary to periorbital disorders. examination may be the only way of distinguishing between
these two conditions. Over time, hematomas usually de-
crease in size, whereas abscesses tend to enlarge. In certain
TRAUMA
instances, needle aspiration may be necessary for diagno-
Blunt or penetrating injury to the eye or lids can result in a sis. Ultrasound can be helpful to guide the insertion of the
variety of orbital abnormalities and lesions 27 (Box 17-1). The needle into the abscess cavity31,32 (Figure 17-4).
orbital fat can become edematous or infiltrated by hemor- Hemorrhage or abscess can occur in the subperiosteal
rhage or pus; the optic nerve and extraocular muscles can space following trauma to the orbit or periorbital sinusesP
become thickened from inflammation or hemorrhage, or Additionally, subperiosteal abscess may develop secondary
they can be avulsed or transected; foreign bodies can lodge to sinus infection 29 ,33 (Figure 17-5). These lesions are well
in any aspect of the orbit or within an adjacent sinus cavity. outlined, located adjacent to the orbital wall, and are
Severe trauma can result in a fracture of the orbital bone. In sharply demarcated from the orbital soft tissue by the
addition, air (e.g., emphysema) can enter the orbital tissue smooth, highly reflective periosteum.1 5,33 On B-scan, these
from an adjacent sinus cavity as the result of a fracture. Al- lesions have a tapered (fusiform) appearance when exam-
though examination of the traumatized patient may be quite ined in longitudinal orientation. This fusiform shape re-
difficult as a result of lid swelling and pain, in most cases, sults in the display of a weakly reflective posterior border
useful information can be obtained with ultrasound. spike on A-scan. Reflectivity of the subperiosteal fluid is
typically very low and the internal structure is regular (Fig-
ure 17-6). "When compression testing is possible, these le-
Orbital Cellulitis
sions are quite firm. Subperiosteal hematomas may persist
Cellulitis may result in diffuse swelling of all orbital struc- for weeks or months (Figure 17-7).
tures. In this condition, echo grams of the orbital fat are
widened but reflectivity remains predominantly high (Figure
Orbital Foreign Bodies
17 -1). If, on follow-up examination there is a progressive de-
crease of reflectivity in certain areas, abscess formation should Echography can be used to evaluate foreign bodies within
be suspected. 8 the orbit. 9,21,22,3o The echographic appearance of foreign
Orbital Hematomas!Abscesses
BOX 17-1
Echography can be used to detect and localize hemorrhage
Orbital Trauma
or abscess that is present within the orbital cavity. These
low to medium reflective lesions can appear multiloculated Orbital cellulitis
(Figure 17-2) or as asolitarymass 13 (Figure 17-3). Com- Orbital hematomas/abscesses
pressibility may be difficult to evaluate in these patients due Orbital foreign bodies
to pain and lid swelling. Emphysema
Orbital fractures
Blood and pus may be difficult to distinguish from one
Extraocular muscle trauma
another by ultrasound. Blood, however, has a tendency to
Optic nerve trauma
layer more than pus (see p 309 and Figure 11- 32). In some
439
440 THE ORBIT
E
B
c F
o G
Figure 17-1 Orbital cellulitis. A, External photograph shows marked lid swelling and propto-
sis of left eye. Echograms are of normal right orbit (B to D) and abnormal left orbit (E to G).
Diffuse swelling of orbital structures was detected in the left orbit. B, Normal paraocular
A-scan pattern (arrow). C, Vertical transverse B-scan echogram of nasal orbit shows normal or-
bit and medial rectus muscle (M) in cross-section. D, longitudinal B-scan view of nasal orbit
shows normal orbit and medial rectus muscle (M) in long section. E, Widened paraocular
A-scan pattern from cellulitis (arrow). F, Vertical transverse B-scan view of nasal orbit shows
widened orbital soft tissue, thickened medial rectus muscle (M), and fluid in sub-Tenon's space
(arrow). G, Longitudinal B-scan echogram of nasal orbit shows widened orbital soft tissue and
medial rectus muscle (M) in long section.
Chapter 17 ORBITAL TRAUMA AND PERIORBITAL DISEASE 441
Figure 17-2 Loculated orbital abscess, A, Transocular B-scanechogram shows multifocal

pockets of abscess (A) in orbital cavity. V,Vitreous cavity. E, Transocular A-scan shows multiple
low to medium reflective abscess cavities (A). B, Bone.
442 THE ORBIT
A B
D F
E G
Figure 17-3 Large orbital abscess. Axial (A) and coronal (B) CT scans show large orbital ab-
scess located inferonasally (arrows). Transocular (C to E) and paraocular (F and G) echograms
show large inferior orbital abscess (A). C, Vertical axial B-scan reveals abscess behind globe and
beneath optic nerve (ON). D, Transverse B-scan shows extensive mass with irregular contour.
V,Vitreous cavity. E, Corresponding A-scan shows low reflectivity of abscess. V,Vitreous cavity;
S, sclera; P, posterior surface spike. F, Transverse paraocular B-scan displays irregular shape and
loculated appearance of abscess in this view. G, Corresponding paraocular A-scan shows more ir-
regular structure in this view as a result of loculation. P, Posterior surface spike.
A E
B F
c Figure 17-4 Abscess in lacrimal gland region

with needle biopsy. A, External photograph shows
marked swelling of left upper lid. B, Transocular
longitudinal B-scan echogram of superior tempo-
ral orbit shows large abscess cavity (A). V,Vitreous
cavity. C, Transverse paraocular B-scan through
lacrimal gland region demonstrates irregularly
shaped abscess (A). D, Paraocular A-scan through
lacrimal gland region shows low reflective abscess
(A). P, Posterior surface spike. E, External photo-
graph shows needle biopsy with B-scan guidance
using longitudinal approach. F, Transocular lon-
gitudinal B-scan (corresponding to E), displays
needle (aI7ow) within the abscess.
D
444 THE ORBIT
B E
C F
D G
Figure 17-5 Subperiosteal abscess with follow-up examination. A, Axial CT scan shows ab-
scess in right ethmoid sinus (arrows) extending through bone defect into subperiosteal space.
Transocular echograms display abscess (A) at initial examination (B to D) and at follow-up after
antibiotic therapy (E to G). B, Transverse B-scan shows subperiosteal abscess between medial
rectus muscle (large arrow) and orbital bone (B). Abscess extends into orbit from sinus through
large bone defect (small arrow). S, Echo in sinus. C, Longitudinal B-scan shows subperiosteal ab-
scess between medial rectus (l\1) and bone (B). Abscess extends from sinus through bone defect.
ON, Optic nerve. D, Corresponding A-scan displays subperiosteal abscess between medial rec-
tus muscle (l\1) and bone (B). Note echoes within sinus (S). E, Transverse B-scan shows marked
reduction of subperiosteal abscess as compared with initial examination. Defect in bone (B) is
much less apparent. Arrow, Medial rectus muscle; S, echo in sinus. F, Longitudinal B-scan shows
marked reduction of abscess as well as sinus echoes. G, Corresponding A-scan displays resolu-
tion of abscess; only medial rectus muscle (M) is shown. Also, note that sinus echoes are no
longer present. B, Bone.
A B
c E
o F
Figure 17-6 Subperiosteal hematoma following trauma. A, External photograph shows right
upper lid swelling and ptosis, as well as downward displacement of globe. E, Coronal CT scan
shows lesion in superior aspect of right orbit (arrow). Transocular (C to E) and paraocular
(F) echograms show lesion (L). C, Transverse B-scan shows extensive lesion beneath smooth
periosteum (jJlack arrows) with layering of contents (white aI7ows). Patient was examined in up-
right position so that blood layered toward periosteum rather than bone. D, Corresponding
A-scan shows well-demarcated, extremely low reflective lesion beneath periosteum (arrow).
S, Sclera; B, bone. E, Longitudinal B-scan shows typical fusiform shape of subperiosteal lesion
with pointed appearance posteriorly (white arrow). Black arrows, Periosteum; ON, optic nerve.
F, Paraocular A-scan shows very low reflectivity oflesion and weakly reflective posterior surface
spike (P).
446 THE ORBIT
A F
B D,G
C E,H
Figure 17-7 Subperiosteal hematoma occurring spontaneously in child with sickle cell disease.
A, External photograph shows lid swelling, proptosis, and downward displacement of the right
eye at initial presentation. Transocular echo grams show subperiosteal lesion (L) at presentation
(B and C), at 5 days (D and E), and 15 days (G and H). Band C show large subperiosteal
hematoma with low internal reflectivity. S, Sclera; B, bone. D and E show marked reduction in
size of lesion at 15 days. Also note much lower reflectivity on A-scan because of decreased den-
sity of hemorrhage. F, External photograph taken at 15 days shows marked improvement. G and
H (corresponding to F) show almost complete resolution of hematoma at 15 days.
bodies has been described in Chapter 4. Most foreign bod- tissue. 22 In addition, spherical foreign bodies, that produce a
ies (e.g., glass, metal, and stone) have a very echo-dense ap- characteristic chain of multiple signals, are relatively easy to
pearance on B-scan (Figure 17-8) and are very high reflec- detect21 (Figure 17-11).
tive on A-scan. Foreign bodies occurring within the orbit
are, however, generally much more difficult to detect than
Emphysema
intraocular foreign bodies because the foreign body signal
may be masked by surrounding highly reflective orbital Air may enter the orbit from a paranasal sinus following a
structures (fat, bone, and so forth). As a general rule, for- fracture. 16,18 A large volume of air may result in proptosis
eign bodies that are located anteriorly are more readily de- and crepitus. 27 Marked narrowing of the orbital pattern can
tected than those closer to the orbital apex. In some cases, be seen echo graphically (Figure 17-12). When air bubbles
however, those foreign bodies located more posteriorly may are small, they appear echographically similar to spheri-
produce a hemorrhagic track through the orbital soft tissues cal foreign bodies, thus producing extremely high reflec-
that can be easily identified with ultrasound II (Figure 17-9; tive, pointlike echoes followed by multiple signals (Figure
see also Figures 4-18 and 4-19). The detection of an orbital 17-13).
foreign body can be enhanced if it is surrounded by a ho-
mogeneous material such as blood or abscess 9 (Figure 17-
Orbital Fractures
10). Wooden foreign bodies often can be detected soon af-
ter the injury, but over time they may become more soft and Orbital fractures can be due to direct trauma to the or-
thereby less distinguishable from surrounding orbital soft bital bones or can occur indirectly as a result of a blowout
Text continued on p 4S0.
A B
Figure 17·8 Shell casing located in orbit next to globe. A, Transverse B-scan echogram shows.
cross-section of foreign body (arrow) and slight indentation of globe. B, Longitudinal B-scan
view shows long section of shell casing adjacent to sclera (arrows).
A B
Figure 17-9 Perforating BB injury of right globe with

hemorrhagic track through globe and orbit. A, External
photograph shows hemorrhagic chemosis and lid swelling.
B, Axial CT scan shows BB lodged in wall of sphenoid sinus c
(arrows). C, Transverse B-scan echogram of nasal globe and
orbit shows hemorrhagic track through vitreous cavity
(white arrows) as well as orbital soft tissue (black arrows).
448 THE ORBIT
A C
Figure 17-10 Orbital foreign body surrounded by hem-

orrhage. Transocular echo grams show foreign body (arrows)
surrounded by well-circumscribed hemorrhage (H).
A, Horizontal axial B-scan at medium gain shows foreign
body located temporal to optic nerve (ON). B, Horizontal
B para-axial B-scan at low gain setting shows persistence of
foreign body signal. C, A-scan shows highly reflective for-
eign body surrounded by low reflective orbital hemorrhage.
S, Sclera; B, bone. (From Green RL, Byrne SF: Diagnostic
ophthalmic ultrasound, in Ryan 5] [ed]: Retina. ed 3,
A B
Figure 17-11 Orbital BB. A, Plain radiograph shows

BB within orbital cavity (arrow). B, B-scan echo gram at
medium gain setting shows BB (large arrow) indenting
sclera. Note characteristic chain of multiple signals pos-
terior to spherical foreign body (small a77ows). C, A-scan C
echo gram shows highly reflective foreign body just be-
hind sclera (S). Note characteristic chain of multiple sig-
nals that decrease in height.
Figure 17-12 Air in sub-Tenon's space following retrobulbar injection. A, B-scan shows
marked shadowing (S) of orbital soft tissue due to sub-Tenon's air. V, Vitreous cavity. B, Corre-
sponding B-scan echo gram from normal orbit. 0, Orbital soft tissue.
A c
Figure 17-13 Orbital emphysema following blow-out

fracture of orbital floor. A, Coronal CT scan shows air
(closed arrow) and hemorrhage in orbit as well assmall defect
(open arrow) in orbital floor. B, Longitudinal trans ocular
B-scan along 6-0'clock meridian shows air bubble anteri-
orly (large white arrow) followed by characteristic chain of
8
multiple signals (small arrows). Inferior rectus muscle (black
arrow) is incarcerated within bone defect (open arrow).
C, Transverse paraocular B-scan shows swollen orbital
soft tissue and air bubble (large aT'row). Note characteristic
chain of multiple signals (small arrows) emanating from air
bubble.
450 THE ORBIT
Extraocular Muscle Trauma

fractureP In these cases, echography may be unable to im-
age the actual fracture but the fracture often can be indi- Hemorrhage within the muscle sheath can occur following
rectly diagnosed by detecting incarceration of orbital tissue trauma. 4 This results in thickening of the muscle and a de-
(see Figure 17-13). Other findings that can be associated crease in the normal internal reflectivity. Follow-up exam-
with fractures include orbital and subperiosteal hematomas, ination typically shows a gradual decrease in size.
emphysema, and bony fragments. Incarceration of an extraocular muscle (especially the in-
A bony fragment may lodge within the orbit following ferior or medial rectus muscles) has been observed follow-
severe injury to the orbital wall.! In one case, the fragment ing sinus surgery (see Figures 17-13 and 15-33).2>7 If a mus-
was surrounded by a large orbital hematoma and there was cle tendon is disinserted from the globe as a result of
marked indentation of the ocular wall (Figure 17-14). strabismus surgery or other trauma, the muscle may retract
A D
B E
c F
Figure 17-14 Bone fragment and orbital hematoma following trauma. A, Fundus photograph
shows deep choroidal folds extending from the superotemporal quadrant. Transocular (B and
C) and paraocular (E and F) echograms show bony fragment (arrow). B, Longitudinal B-scan
along 1:30-o'clock meridian shows marked indentation of ocular wall by fragment. V,Vitreous
cavity. C, A-scan of 1:30 meridian at reduced gain setting shows very high reflective spike from
bony fragment and thickened retinochoroid/sclerallayer (S). D, External photograph shows
proptosis, ptosis, and downward displacement of left globe. E, Transverse paraocular B-scan
shows bright signal from fragment surrounded by echolucent hemorrhage (H). F, Paraocular
A-scan shows low reflective hemorrhage adjacent to highly reflective bony fragment. (A to D
from Atta HR, Byrne SF: The findings of standardized echography for choroidal folds. Arch
OphthalmoI1988;106:1236.)
Normal Bone and Sinuses

into the orbit,17 In these cases, echography may show that
the inserting tendon is not located in its proper position at The normal orbital wall has a smooth contour and appears
the globe (see Figure 15-32). either straight or slighdy concave, except inferiorly, where
the concavity is more pronounced. The bone produces an
echo-dense line on B-scan and a highly reflective spike on
Optic Nerve Trauma
A-scan (see Figure 11-2). In some areas of the orbit, normal
Hematomas of the optic nerve have also been detected fol- small irregularities of the bone are present (Figure 17-15).
lowing severe ocular or orbital injury.3,12 The optic nerve Abnormalities of bone include defects, excavation and hy-
pattern is widened and the thirty-degree test is positive (see perostosis (see Figure 11-22). It is important to always com-
p 419). Avulsion of the optic nerve produces various find- pare the appearance of the bone being elevated with that of
ings that are dependent on whether the injury is acute or the same area in the fellow orbit.
longstanding (see p 92 and Figures 4-10 and 4-11).
PERIORBITAL DISEASE
Echography can be useful for evaluating periorbital disor-
ders and diseases of the orbital bones.1 9,2o Computed to-
mography and magnetic resonance imaging are the proce-
dures of choice for assessments of the bony orbital wall,
periorbital sinuses, and the retro-orbital region. There are
many situations, however, in which echography can provide
additional information (Box 17-2). In these cases, it is par-
ticularly important to be familiar with the appearance of the
normal bony orbital walls and sinuses.
Figure 17-15 Normal irregularity of medial orbital wall. Small discontinuity in bone (white
arrows) is shown in vertical transverse (A) and longitudinal (B) B-scan echograms through mid-
portion of nasal orbit. This irregularity is presumably due to a vessel communicating between
ethmoid sinus and orbit. Medial rectus muscle is indicated by black arrows.
452 THE ORBIT
A C
Figure 17-16 Severe ethmoid sinusitis compared with a normal sinus. Normal echo grams are
shown in A and B and sinusitis is shown in C and D. A, Longitudinal transocular B-scan shows
medial rectus muscle (1), orbital bone, and characteristic absence of signals from normal air-
filled sinus (arrow). B, Paraocular A-scan with sound beam directed toward sinus shows normal
highly reflective echogram and lack of echoes from air-filled sinus.C, Longitudinal trans ocular
B-scan through abnormal sinus shows abnormal echoes (S). M, Medial rectus muscle. D, Paraoc-
ular A-scan shows abnormal spikes within sinus (S).
Excavation
The normal sinus is air filled and totally reflects the
sound waves so that no echoes are usually detected. How- Excavation, or remolding, of a bony wall is due to pres-
ever, mucosal swelling, fluid accumulation, or tissue sure exerted by a mass of longstanding duration 26 (e.g.,
within a sinus create abnormal echoes (Figures 17-16 and benign mixed tumor or dermoid cyst). B-scan echograms
17-17). show a concave indentation of the bone line (see Figure
11-22).
Bone Defects
Hyperostosis
Bone defects can be solitary or multiple. In addition, they
can be secondary to benign processes or related to malig- Thickening of the orbital bone (e.g., fibrous dysplasia and
nant tumors. On B-scan, a large bone defect appears as a sphenoid wing meningioma) usually produces an expansion
discontinuity of the bone line (see Figure 11-22). This may of the bone into the orbit (see Figure 11-22). This expansion
be seen in trans ocular and/or paraocular views, depending may, in turn, cause narrowing of the orbital soft tissue pat-
on the size and location of the defect (Figure 17-18). On tern in the space between the thickened bone and the globe.
A-scan, a zig-zag movement of the bone spike lO may be ap-
parent during the dynamic examination; this up-and-down
Periorbital lesions
motion of the spike is observed when the sound beam is
shifted back and forth across the defect (Figure 17-19). Mucocele
When numerous bone defects are present, the bone may Mucoceles are sinus lesions of a cystic nature that are
appear very irregular on R-scan and less reflective on A- caused by obstruction of the normal sinus drainage open-
scan. ings. 24 This leads to a build up of pressure within the sinus,
B D
c E
Figure 17-17 Polyposis of left ethmoid sinus. A, Axial CT scan shows mass filling left eth-
moid sinus (arrows) with expansion of medial orbital wall toward orbit. Transocular (B and C)
and paraocular (D and E) echograms show abnormal echoes from polyps within sinus. B, Verti-
cal transverse B-scan of medial orbit and ethmoid sinus. Roundish polyp within sinus (vertical ar-
rows) is causing lateral displacement of medial orbital wall (open arrow) and compression of orbital
soft tissue. MR, Cross-section of medial rectus muscle. C, Corresponding A-scan through
medial orbit and ethmoid sinus shows orbital bone (B) followed by abnormal sinus spikes (S)
from polyps. D, Transverse paraocular B-scan shows abnormal echoes from polyposis in sinus
(S). E, Corresponding paraocular A-scan shows numerous abnormal spikes from polyposis in
sinus (S).
454 THE ORBIT
Figure 17-18 Bone defect secondary to periorbital malignancy. A, Transverse B-scan

echogram of medial orbit displays mass extending through large defect in orbital wall (arrow) into
ethmoid sinus (S). This view demonstrates the superior and inferior edges of the defect. V,Vit-
reous cavity. B, Longitudinal B-scan of medial orbit also shows mass extending through bone
defect into sinus. This view demonstrates the anterior and posterior edges of bone defect.
ON, Optic nerve.
which results in enlargement and eventually extension ~f ing from the sinus into the orbit, and may mistakenly deter-
the mucocele into the orbit. Although frontoethmoidal mu- mine that the lesion lies totally within the orbit (Figure 17-
coceles occur most commonly, these lesions also can origi- 20). Such errors can be avoided, however, by remembering
nate in the sphenoid and, less frequently, in the maxillary to compare the area of investigation with the fellow orbit.
sinus. 14,24 Additionally, if the mucocele originates in the frontal sinus
Echographically, a mucocele appears usually as a large, and is located far anteriorly, the bone defect may be best de-
very low reflective, nonvascular mass 5 that is most often lo- tected with a paraocular approach (Figure 17-21).
cated in the supranasal quadrant (frontoethmoidal).lO Mu- When it appears that the lesion extends laterally in the
coceles in this region most often produce outward and subperiosteal space, a mucopyocele may be present. These
downward displacement of the globe. 25 Typically, these le- patients also may have inflammation of the orbital soft tis-
sions are very well outlined, producing highly reflective bor- sue 24 (Figure 17-22).
ders. In most instances, they have a very firm consistency
and often compress the globe. The key diagnostic finding is
Sphenoid Wing Meningioma
a large, solitary bone defect through which the lesion ex-
tends from the sinus into the orbit. However, difficulty in Intracranial meningiomas can secondarily involve the or-
diagnosis may arise when the bone defect is so large that it bit. 23 Of these lesions, the sphenoid wing meningioma is
cannot be readily identified. In such situations, the echog- the most common and is the most amenable to detection
rapher may not appreciate that the lesion is actually extend- by echography. Typically, these tumors cause hyperostosis
A D
B E
c F
Figure 17-19 Drawings and corresponding A-scan echograms of large periorbital lesion
demonstrating zigzag phenomenon. A and D, Sound beam directed through orbital portion of
low reflective lesion (0) and perpendicular to orbital bone (B) at edge of bone defect. S, Sclera.
B and E, Probe is shifted slightly so that sound beam now strikes edge of bone defect (B) and
posterior bony wall of sinus (P). Both orbital (0), and extraorbital (B) portions oflesion are now
shown. C and F, Further movement of probe now directs sound beam entirely through bone
defect, bypassing edge of orbital bone.
456 THE ORBIT
8 D
C E
Figure 17-20 Frontoethmoidal mucocele extending into orbit. A, Axial CT scan shows large
mucocele extending from sinus into orbit (arrow). Transocular (B and C) and paraocular (D and
E) echo grams show large mucocele (M). B, Transverse B-scan shows mucocele extending from
sinus into orbit through very large bone defect (arrows). V,Vitreous cavity; B, bone within silius.
C, Corresponding A-scan shows very low reflective lesion with regular internal structure be-
tween sclera (S) and posterior bony wall of sinus (B). D, Transverse paraocular B-scan with sound
beam directed through bone defect into sinus shows mass extending from sinus into orbit.
E, Corresponding paraocular A-scan with sound beam directed through bone defect into sinus
shows very low reflectivity of lesion.
Chapter 17 ORBITAL TRAUMA AND PERIORBITAL DISEASE
457
B D
c E
Figure 17-21 Frontal mucocele extending into orbit through large anterior bone defect.
A, External photograph shows swelling of nasal aspect of right upper lid and ptosis. B, Transverse
paraocular B-scan echogram shows large mass extending through bone defect into orbit (0) from
sinus (S). Arrow, Edge of large defect in orbital bone; B, posterior bony wall of sinus; M, multi-
ple signals. C, Paraocular A-scan with sound beam directed through both orbital (0) and sinus
(S) portions of lesion as well as edge of bone defect (arrow). B, Posterior bony wall of sinus;
M, multiple signals. Axial CD) and coronal (E) MRI scans demonstrate large frontal mucocele
(arrows) extending into orbit. (MRI scans courtesy Dr. Myron Tannenbaum, Miami, Florida.)
458 THE ORBIT
A C
B 0
Figure 17-22 Left frontoethmoidal mucopyocele with subperiosteal extension. Transocular

echo grams (A, B, and D) show orbital portion of lesion (L) extending beneath smooth perios-
teum (bone defect not shown). A, Transverse B-scan shows large, smooth subperiosteal lesion.
B, Longitudinal B-scan shows posterior extent of mucocele. Note typical tapered appearance
(arrow) of subperiosteal lesion. ON, Optic nerve. C, External photograph shows complete
ptosis of left upper lid. Globe was proptotic and displaced downward. D, A-scan shows very
low reflective subperiosteal lesion. Arrow, Surface of periosteum; S, sclera; B, bone; M, multiple
signal.
or irregularity of the orbital bone in the supratemporal reflective than normal. If such a lesion is detected in the
quadrant (Figure 17-23). In some cases, a low to medium supratemporal, posterior orbit, a sphenoid wing menin-
reflective soft tissue mass (i.e., en plaque meningioma) can gioma should be considered in the differential diagnosis.
be demonstrated adjacent to the orbital wall supratempo-
rally (Figures 17-24 and 17-25).
Eosinophilic Granuloma
This rare disorder, usually seen in the supratemporal orbit
Periorbital Malignancy and Bony Metastasis
of children and teenagers, can be associated with inflam-
Malignant tumors that invade the orbit from periorbital mation. 6 The lesion is normally low reflective, hard, slightly
cavities are usually associated with multiple bony defects. vascularized, and relatively well circumscribed, with a
Once these lesions reach the orbit, they tend to grow ex- roundish or somewhat irregular shape. Eosinophilic granu-
pansively, often in the subperiosteal space. These tumor loma is almost always associated with a bone defect superi-
extensions typically have low internal reflectivity and are orly (Figure 17-27).
sharply demarcated from the normal orbital soft tissue,
as are all subperiosteal lesions. The overall structure may
Fibrous Dysplasia
appear irregular because of the numerous bone defects
and the echoes received from the tumor within the ex- Fibrous dysplasia occurs typically in children and causes ab-
traorbital space (Figure 17-26). These lesions usually normal expansion of the orbital bone. 28 This bony expan-
have a very hard consistency and are typically not highly sion decreases the size of the orbital cavity and thus com-
vascularized. presses the orbital soft tissue. Echo graphically, such
Tumors that metastasize to orbital bone often result in compression is most evident when comparing the involved
the bone appearing irregularly shaped, thickened and less orbit with the normal fellow orbit (Figure 17-28).
B D
c E
Figure 17-23 Left sphenoid wing meningioma. A, External photograph shows proptosis of
left eye and slight lid retraction (patient had history of thyroid disease). Transocular B-scans m:e
of normal right orbit (B and C) and abnormal left orbit (D and E). Vertical transverse (B) and
longitudinal (C) B-scans of right temporal orbit show normal contour oflateral orbital wall
(arrows). Vertical transverse (D) and longitudinal (E) B-scans ofleft temporal orbit show local-
ized convexity of orbital wall due to hyperostosis of sphenoid bone (arrows). F, Axial CT scan
shows hyperostosis of sphenoid wing (arrow).
460 THE ORBIT
A D
B E
C F
Figure 17-24 Sphenoid wing merungioma (en plaque). Axial (A) and coronal (D) CT scans
display hyperostosis ofleft orbital roof and sphenoid bone (arrows). Transocular echograms are
from superior aspect of normal right orbit (B and C) and abnormal left orbit (E and F). B, Hor-
izontal transverse B-scan shows normal orbital soft tissue and orbital bone (arrows). C, Corre-
sponding A-scan shows normal highly reflective orbital soft tissue. S, Sclera; arrow, bone.
E, Horizontal transverse B-scan shows convex-shaped indentation of the orbital roof (arrows)
and thin soft tissue mass lesion (L) adjacent to roof. F, Corresponding A-scan shows narrowing
of orbital soft tissue pattern, as compared with E. Also note medium reflective lesion (L) adjacent
to orbital bone (arrow). S, Sclera.
Figure 17-25 Sphenoid wing meningioma (en plaque). A, External photograph shows left upper
lid swelling and ptosis as well as downward displacement of eye. B, Transocular B-scan echo gram
of temporal posterior orbit shows large lesion (L) and irregularity of orbital bone (B). C, Transoc-
ular A-scan shows low internal reflectivity of lesion.
462 THE ORBIT
B D
C E
Figure 17-26 Metastatic breast carcinoma to right orbit. A, Axial MRI scan shows mass in-
volving temporal aspect of orbit with erosion of lateral orbital wall and extension into frontal lobe
(amrws). Transocular echograms show subperiosteal lesion (L) extending through bone defect in
lateral orbital wall. B, Transverse B-scan shows subperiosteal lesion, irregular bone defects
(arrows) and extraorbital echoes (B). C, Corresponding A-scan shows tumor involving both sub-
periosteal and extraorbital regions. S, Sclera; B, orbital bone. D, Longitudinal B-scan also shows
tumor, bone defect, and extraorbital echo. E, A-scan with sound beam directed through bone de-
fect in lateral orbital wall. Note markedly different appearance and much larger size of lesion in
this echogram compared with C, thus emphasizing extraorbital involvement and irregular in-
ternal structure of lesion.
B D
c E
Figure 17-27 Eosinophilic granuloma in a child. A, External photograph shows proptosis and
downward displacement of right eye. Axial (B) and coronal (C) CT scans show supratemporal
orbital mass extending through large bone defect into anterior cranial fossa (arrows). D, Transoc-
ular B-scan shows orbital lesion (L) located superiorly associated with large defect in orbital roof
(arrows). Note that majority of the mass is located above the orbital roof. V, Vitreous cavity.
E, Transocular A-scan shows low reflectivity oflarge lesion.
464 THE ORBIT
B D
C E
Figure 17-28 Fibrous dysplasia involving roof of right orbit. A, Coronal CT scan shows hy-
perostosis of orbital roof (arrow). Transocular echograms are from superior aspect of abnormal
right orbit CB and C) and normal left orbit CD and E). Transverse B-scans shows convex inden-
tation of orbital roof (arrows) in area of mass in B compared with normal concave appearance of
bone in D. 17, Vitreous cavity. C, A-scan shows narrowed orbital soft tissue pattern (0) due to
compression by protruding bone compared with normal orbital pattern in E.
Other periorbital disorders that may be encountered 16. Linhart WOo Emphysema of the orbit: A study of seven cases. JAMA
include hematic cyst (see p 340), osteoma, meningocele and 1943;123:89.
17. Mark LE, Kennerdell JS: Medial rectus injury from intranasal surgery.
encephalocele, osteomyelitis, and osteosarcoma. Arcb Opbtbalmol1979;97 :459.
18. Murray RS: Orbital emphysema following fracture of nasal sinuses.
REFERENCES J Fac RadioI1949;1:121.
19. Ossoinig KC: A-scan echography and orbital disease. Mod Prohl Oph-
1. Atta HR, Byrne SF: The findings of standardized echography for tbalmoI1975;14:203.
choroidal folds. Arch OpbtbalmoI1988;106:1236. 20. Ossoinig KC: Echography of the eye, orbit, and periorbital region, in
2. Buus DR, Tse DT, Farris BK: Ophthalmic complications of sinus Arger PH (ed): Or'bit Roentgenology. New York,] \Viley & Sons, 1977,
surgery. Opbthalmology 1990;97:614.
p 221. . .
3. Byrne SF, Glaser JS: Orbital tissue differentiation with standardized 21. Ossoinig KC, Bigar F, Kaefring SL, et al: Echographlc detection and
echography. Ophthalmology 1983 ;90: 1071. localization of BB shots in the eye and orbit. Bibl Opbtbalmol
4. Capone A, Slamovits TL: Discrete metastasis of solid tumors to ex- 1975;83:109.
traocular muscles. Arcb Ophtbalmol1990; 108:241. 22. ReshefDS, Ossoinig KC, NeradJA: Diagnosis and intraoperative lo-
5. Coleman DJ, Jack RL, Franzen LA: B-scan ultrasonography of orbital calization of a deep orbital organic foreign body. Or'bit 1987;6:3.
mucoceles. Eye Ear Nose Thr'oat Mon 1972;51:207. 23. Rootman J: Secondary tumors of the orbit, in Rootrnan J: Diseases of
6. Feldman RB, Moore DM, Hood Cl, et al: Solitary eosinophilic gran- tbe Orbit. Philadelphia, JB Lippincott, 1988, p 433.
uloma of the lateral orbital wall. Am J OphtbalmoI1985;100:321. 24. Rootman J, Allen L: Acquired lesions, in Rootman J: Diseases of tbe
7. FlynnJT, Mitchell KB, Fuller DG, et al: Ocular motility complica- Orbit. Philadelphia, JB Lippincott, 1988, p 496.
tions following intranasal surgery. Arcb OphtbalmoI1979;97:453. 25. Rootrnan J, Allen L: Acquired lesions, in Rootman J: Diseases of tbe
8. Goodwin VVJ Jr, Weinshall M, Chandler JR: The role of high resolu- Orbit. Philadelphia, JB Lippincott, 1988, p 499.
tion computerized tomography and standardized ultrasound in the 26. RootrnanJ, LapointeJS: Tumors of the lacrimal gland, in RootrnanJ:
evaluation of orbital cellulitis. Laryngoscope 1982;92:729. Diseasesoftbe Or'bit. Philadelphia,JB Lippincott, 1988, p 394.
9. Green RL, Byrne SF: Diagnostic ophthalmic ultrasound, in Ryan SJ 27. Rootman J, N eigel J: Trauma, in Rootman J: Diseases of tbe Orbit.
(ed): Retina. St Louis, Mosby, 1989, P 191. Philadelphia, JB Lippincott, 1988, p 504.
10. Hasenfratz G, Ossoinig KC: The diagnosis of orbital mucoceles and 28. Rootman J, Robertson WD: Orbital tumors originating in bone, in
pyoceles with standardized echography, in Hillman JS, LeMay MM Rootlnan J: Diseases of tbe Orbit. Philadelphia, JB Lippincott, 1988, p
(eds): Opbtbalmic Ultmsonography. Dordrecht, Dr W Junk, 1984, 356.
p407. 29. Rootman J, Robertson W, Lapointe JS: Inflammatory diseases, in
11. Hughes RL, Byrne SF: Detection of posterior ruptures in opaque me- Rootrnan J: Diseases of tbe Orbit. Philadelphia, JB Lippincott, 1988, p
dia, in Ossoinig KC (ed): Opbtbalmic Ecbograpby. Dordrecht, Dr W 144.
Junk, 1987 p 331. 3O. Skalka HW: Ultrasonography in foreign body detection and localiza-
12. Hupp SL, Buckley EG, Byrne SF, et al: Post traumatic venous ob- tion. Opbtbalmic Surg 1976;7(2):27.
structive retinopathy associated with enlarged optic nerve sheath. Arcb 31. Skalka Hw, Callahan MA: Ultrasonically aided percutaneous orbital
OpbthalmoI1984;102:254. aspiration. Opbtbalmic Surg 1979; 10(11):41.
13. Jacobson DM, ltani K, Digre KB, et al: Maternal orbital hematoma 32. Spoor TC, Kennerdell JS, Dekker A, et al: Orbital fine needle aspira-
associated with labor. Am J OpbtbalmoI1988;105:547. tion biopsy with B-scan guidance. Am J OpbtbalmoI1980;89:274.
14. Jakobiec FA, Font RL: Orbit, in Spencer WH: Ophthalmic Patbology; 33. Tannenbaum M, Tenzel J, Byrne SF, et aI: Medical management of
An Atlas and Textbook. ed 3, Philadelphia, WE Saunders, 1986, p 2746. orbital abscess. Surv OpbtbalmoI1985;30:211.
15. Katz RS, Abrams G: Orbital subperiosteal hematoma (epidural
hematoma of the orbit). J Clin Neuro Opbtbalmol1981; 1:45.
Artifacts
Acoustic artifacts may be encountered during the course of trips of the sound wave between the transducer and the
an ultrasound examination (Box 18-1). Awareness of these originating acoustic interface. It is of note that the true
artifacts allows accurate interpretation of the ultrasound echo and the subsequent reverberation echoes are equidis-
findings. 1,2 Certain artifacts can be avoided simply by tant and generally decrease in strength (Figure 18-1; see
changing the position of the probe or by applying more also Figures 2-30, 4-42, 10-12, and 10-16). In addition,
methylcellulose to the probe tip. Other artifacts will always movement of this type of multiple reverberation signal,
be present, but they can usually be identified when their when the probe is gently pressed against the eye or lid tis-
cause is understood and their typical appearance is recog- sues, is different from that of true echoes. Multiple signals
nized. Some artifacts, such as those produced by a BB, can move to a much greater degree than do true echoes.
actually aid in the interpretation of echograms.
Internal Multiple Signals
MULTIPLE SIGNALS (REVERBERATIONS)
Internal multiple signals are artifactual echoes caused by
Multiple signals are artifactual echo signals produced by re- reverberations (ringing) within certain types of foreign
verberations of the sound wave between interfaces. It is im- bodies. They most commonly occur when the sound beam
portant that multiple signals be distinguished from true strikes a spherical foreign body, such as a BB, gunshot pel-
echoes. Two types of multiple signals can occur: external let, or small bubble of air or gas. They can also be pro-
and internal. External multiple signals are due to reverber- duced by certain nonspherical, flat foreign bodies with
ations of the sound wave between the probe tip and a highly closely spaced, parallel surfaces, such as a glass sliver. The
reflective acoustic interface. Internal multiple signals result echo pattern for this type of foreign body is unique in that
from reverberations within a solid object (e.g., metallic or it appears as a chain of closely spaced signals emanating
glass foreign body), as well as within small gas bubbles. from the foreign body echo. This echo complex is some-
times referred to as the comet tail artifact. 1,2 It occurs be-
cause some of the energy is trapped when the sound wave
External Multiple Signals
enters the object. The trapped energy then bounces back
External multiple signals result from reverberations be- and forth like echoes within a silo. 2 As the sound wave
tween the transducer (probe tip) and an acoustic interface, bounces back and forth within the object, a portion of the
such as the surface of the crystalline lens, an intraocular wave escapes and returns to the probe. This results in a
lens, a foreign body, an air bubble, the sclera, or the orbital chain of echoes of decreasing amplitude that extends from
bone. These types of interfaces reflect a portion of the the foreign body echo (see Figure 4-26). In many in-
sound wave back to the transducer (true echo), resulting in stances, the comet tail artifact can be useful for identify-
the display of a strong signal in the echogram. If the true ing the location and type of foreign body (see Figures 2-34,
echo is of significant magnitude, it is partially reflected at 4-26,4-27,4-28, and 4-47).
the transducer surface (probe tip) and redirected back to-
ward the originating acoustic interface. The originating
SHADOWING
acoustic interface then produces a second echo (reverbera-
tion echo) that appears in the echogram distal to the true Shadowing is caused by strong sound attenuation. Partial
echo. Thus, a reverberation echo is produced when the shadowing can result in the diminution of echoes poste-
sound wave travels back and forth twice (two round trips) rior to a lesion, such as a large choroidal melanoma.
between the transducer and the acoustic interface. 1,2 In the Complete shadowing causes an absence of echoes poste-
echogram, the first reverberation echo is displayed in a po- rior to an extremely dense interface such as bone, calcium,
sition corresponding to twice the distance between the a large foreign body, or a large bubble of air/gas. In some
probe tip and the originating acoustic interface. Subsequent cases, this artifact can prevent the evaluation of structures
reverberation signals may be caused by additional round and lesions located posterior to the source of shadowing
466
Chapter 18 ARTIFACTS 467
BOX 18-1
.CommOn Artifacts
Reverberations (multiple signals)
External
. Internal (comet tail)
Sl;Iadowing
Sound attenuation
R13fra<:tion (edge)
EnHancement
Perpendicularity
Baum's bumps
Figure 18-1 External multiple signals. Artifacts are due to in-

sufficient contact between the B-scan probe and the eye. B-scan
echo gram shows multiple signals (arrows) from air located be-
(see Figure 4-46 and p 109). Conversely, the presence of tween the probe face and the eye. (From Green RL, Byrne SF:
shadowing can help diagnose the lesion being examined, Diagnostic ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed 3, St
such as in an osteoma (see Figure 5-48), a retinoblastoma Louis, Mosby, 2001, p 300.)
(see Figure 5-95), or an intraocular foreign body (see Fig-
ure 4-24).
Another type of shadowing is caused by refraction at the
edges of smooth, curved interfaces rather than by sound at-
tenuation. This artifact, sometimes referred to as refraction
or edge artifact, commonly occurs from the surface of the
globe (see Figures 11-9 and 12-34) or from a cystic lesion in
the orbit, or it can be caused by a scleral fold (see Figure
4-23). This type of shadowing also partially explains the
wedge-shaped appearance of the optic nerve when dis-
played with an axial B-scan approach.
ENHANCEMENT
Enhancement is the increased amplitude of echoes located
posterior to a very weakly attenuating structure or lesion.
Figure 18-2 Baum's bumps. Axial B-scan shows mild elevations
This explains why the soft tissue and bone of the orbit are at the posterior fundus (arrows), caused by refraction of the sound
so well demonstrated when examined through the very low beam by the peripheral lens. (From Green RL, Byrne SF: Diag-
reflective vitreous cavity (see Figure 11-1) or through a nostic ophthalmic ultrasound, in Ryan S] [ed]: Retina. ed 3, St
serous orbital cyst (see Figure 12-37). Louis, Mosby, 2001, p 300.)
PERPENDICULAR SOUND BEAM

INCIDENCE
BAUM'S BUMPS
A specific echographic finding caused by perpendicular
sound beam incidence can occur in B-scan echo grams. It Baum's bumps are B-scan artifacts that appear as elevations
may be observed when the sound beam is directed perpen- of the fundus. These artifacts are typically caused by refrac-
dicular to a very smooth, highly reflective interface. This tion of the sound beam as it sweeps through the peripheral
finding appears as a bright, focal signal in the center of the aspect of the lens when an axial approach is used. Baum's
echogram when a medium or low gain setting is used. It is bumps can be misinterpreted as tumors, or they may give the
commonly produced by the surface of the retina in the nor- impression of a posterior staphyloma (Figure 18-2; see also
mal eye, although it can occur at any very smooth surface p 263). To eliminate these artifacts, the probe can be reposi-
(see Figure 2-13, B). To avoid confusion of this echo signal tioned peripheral to the limbus to avoid the lens.
with a foreign body or a localized area of calcification, the
probe can be reoriented to display the area in question at
REFERENCES
the periphery rather than in the center of the echo gram.
1. Kremkau FW: Diagnostic Ultrasound-Principles, Instruments and Exer-
The sound beam then engages the area in question cises, ed 3, Philadelphia, WE Saunders, 1989, p 147.
obliquely rather than perpendicularly. 2. Zagzebski AA: Essentials of Ultrasound Physics. St. Louis, Mosby, 1996.
Glossary
Absorption The loss of sound energy as it passes through Echography The utilization of ultrasound as a diagnostic
a medium due to heat conversion. modality (also known as ultrasonography).
Acoustic Impedance The sound velocity of a medium Echolucent An absence of echoes (anechoic).
multiplied by its density.
Edge Artifact A type of shadowing caused by refraction at
Acoustic Interface A surface separating two media of dif- the edges of smooth, curved interfaces.
fering acoustic impedance.
Enhancement An artifact whereby the reflectivity of a tis-
A-scan Time amplitude display. A one-dimensional dis- sue that is located behind a weakly attenuating medium
play where echoes are depicted as vertical deflections is increased.
from a baseline. The strength of an echo is indicated by
Frequency Oscillations (cycles) of ultrasound waves per
the amplitude (height) of the spike.
unit of time. 1 Hertz (Hz) = 1 cycle/sec.
Attenuation A decrease in the strength (amplitude) of ul-
Gain The echo amplification, expressed in decibels, of an
trasound energy as it passes through a medium.
ultrasound system (also known as sensitivity setting).
Axial Resolution The minimum distance between two in-
Gray Scale The gradation of brightness levels (shades of
terfaces (located along the axis of the sound beam) that
gray) between minimum and maximum intensities on B-
can be displayed separately.
scan.
Biometry The measurement of distances within the eye
Impedance See Acoustic impedance.
and orbit.
Internal Reflectivity The amplitude of echoes within a tis-
B-scan Brightness intensity-modulated display. A two-
sue (e.g., tumor).
dimensional display where echoes are depicted as dots.
The strength of an echo is indicated by the brightness Internal Structure The degree of uniformity of internal
of the dot. echoes, correlating with histologic architecture of a tis-
sue (e.g., tumor).
Color Doppler Imaging (CDI) An imaging modality that in-
corporates the use of color with conventional duplex Kinetic Echography A technique that is used to assess the
scanning (see Duplex scanning) motion of or within a lesion.
Decibel A relative unit that measures ultrasound intensity. lateral Resolution The minimum distance between inter-
faces that can be resolved when the interfaces are located
Doppler Effect A change in the frequency of the sound
perpendicular to the sound beam.
wave that is caused by movement of a reflector (e.g.,
blood) either away from or toward the transducer. longitudinal Scan B-scan probe orientation where the
moving sound beam is directed along a given meridian,
Duplex Scanning Ultrasound modality that combines
in an anterior-posterior direction (also known as radial
Doppler spectral analysis with simultaneous B-scan
scan).
Imagmg.
Multiple Signals Artifacts caused by reverberations of the
Dynamic Range The range of echo intensities (minimum
sound waves. These usually occur between the probe
to maximum) that an instrument can display.
and a highly reflective interface or between two highly
Echo-dense Highly echo genic. reflective interfaces (also known as reverberations).
Echogenic A medium (e.g., tissue) that is capable of pro- Piezoelectric Element An element that converts electrical
ducing echoes. to mechanical energy and vice versa.
469
470 GLOSSARY
Probe A device containing a piezoelectric element that is Sound Wave A mechanical vibration of particles in a
used to scan the eye or orbit (also known as a trans- medium.
ducer).
Spectral Analysis A process by which a complex signal is
Pulse-echo Technique A system that emits pulses of ultra- broken down or analyzed into simple frequency compo-
sound and detects returning echoes between the pulses. nents (e.g., distribution of frequencies in a Doppler sig-
nal).
Quantitative Echography A technique that is used to as-
sess the reflectivity, internal structure, and sound atten- Three-dimensional Ultrasonography (3DUS) A technique
uation of a lesion. that combines sequential two-dimensional (2D) digital
image acquisition (tomograms) with computerized re-
Real-time The ability of an ultrasound instrument to dis- construction software. This image processing allows oc-
play movement of structures within the body as it is ular pathology to be viewed in "3D."
occurring.
Topographic Echography The shape, location, and exten-
ReflectivityThe strength or amplitude of an echo pro- sion of a lesion.
duced by an interface.
Transducer See Probe.
RefractionThe bending of a sound wave as it passes from
one medium to another. Transverse Scan B-scan probe orientation where the mov-
ing sound beam is directed across a given meridian. This
Resolution The smallest distance between two interfaces probe orientation displays the lateral extent of a struc-
that can be displayed. ture or a lesion.
Reverberations See Multiple signals.
Ultrasonography See Echography.
Scattering The spreading of sound waves in multiple di- Ultrasound An acoustic wave that consists of an oscilla-
rections, occurring primarily from small or coarse inter- tion of particles within a medium with a frequency
faces. greater than 20,000 Hertz (cycles/sec).
Sensitivity The ability of the ultrasound system to detect Ultrasound Biomicroscopy (UBM) High resolution B-scan
echoes. ultrasound technology using frequencies in the 40-100
Sensitivity Setting See Gain. MHz range. This technique provides imaging of ocular
tissue at microscopic resolution.
Shadowing The reduction in echo amplitude posterior to
a strongly reflecting or attenuating interface. Vector A-scan An A-scan that is derived simultaneously
from one portion of a B-scan echogram.
Sound Attenuation A decrease in the amplitude of ultra-
sound energy as it passes through a medium; caused by Velocity See Sound velocity.
scattering, reflection or absorption.
Wavelength The distance between any two similar points
Sound Beam The directed sound waves produced by an on two consecutive cycles of a sound wave.
ultrasound transducer.
Sound Velocity The speed at which ultrasound energy
travels through a given medium.
Appendices
APPENDIX A
Table for Converting Microseconds (/-Lsec) to Millimeters (mm)
AqueouslVitreous* Tissuest lens:!:
lL sec (1,532 m/sec) (1,550 m/sec) (1,631 m/sec)
0.1 0.08 0.08 0.08
0.2 0.15 0.16 0.16
0.3 0.23 0.23 0.25
0.4 0.31 0.31 0.33
0.5 0.38 0.39 0.41
0.6 0.46 0.47 0.49
0.7 0.54 0.54 0.57
0.8 0.61 0.62 0.66
0.9 0.69 0.70 0.74
1.0 0.77 0.78 0.82
2.0 1.53 1.55 1.64
3.0 2.30 2.33 2.46
4.0 3.06 3.10 3.28
5.0 3.83 3.88 4.11
6.0 4.60 4.65 4.93
7.0 5.36 5.43 5.75
8.0 6.13 6.20 6.57
9.0 6.89 6.98 7.39
10.0 7.66 7.75 8.21
*Aqueous/vitreous: fLsec x 0.766.

tTissues: fLsec x 0.775.
:l:Lens: fLsec x 0.821.
471
472 APPENDICES
APPENDIX B
Basic B-Scan Screening: Probe Orientation*
Areas Probe
Examined Gaze Position Marker
A Superior Up Horizontal Nasal
B Nasal Nasal Vertical Superior
C Inferior Down Horizontal Nasal
D Temporal Temporal Vertical Superior
*These transverse probe positions are used to evaluate the eye during the basic
screening examination.
.A B
00 c D
Limbus 12 12 12 12
9 3 9 3 9 3 9 3
Probe /
6 6 6 6
Face
12 9 3 6 9
I
r
l
I
f
OS j
A B C D t
I
I
Limbus 12 12 12 12
II
9 3 9 3 9 3 9 3 II
t
6 6 6 6
Probe
Face
12 9 6 3
Appendices ApPENDIX C 473
APPENDIX C the bandlike lesion that produces a pointlike echo in one

view and a line in the other.
Topographic Evaluation of Intraocular lesions
The A-scan echograms are obtained with the sound
with A- and B-Scan
beam directed perpendicular to the lesion (column 3) and
Four different types of intraocular lesions (pointlike, mem- with the probe repositioned approximately 90° from the
branelike, bandlike, and masslike) can be distinguished with first position (column 4). Note that echograms for the point-
topographic echography. This can be achieved with both like and mass like lesions have a similar appearance in both
A- and B-scan by using varied probe positions. sound beam directions. For both membranelike and band-
In the B-scan echograms, the lesion is displayed with like lesions, however, a single spike is obtained when the
transverse (column 1) and longitudinal (column 2) probe po- sound beam is directed perpendicular to the lesion and a
sitions. Note that all lesions have the same general config- chain of spikes is displayed when the sound beam is directed
uration in both transverse and longitudinal views except for along the lesion's surface.
Lesion Type 8-Scan A-Scan
#1 #2 #3 #4
Pointlike
GO
Membranelike
GO
Bandlike
GO
Masslike
00
474 APPENDICES
APPENDIX D
Scleral Shells for Use with the Immersion
Technique
Darling Shell (Conventional A- or B-scan probes) Flanged Shells (13 High resolution B-scan [20 MHz] probe)
Laurie Darling, e.O.T. Innovative Imaging, Inc
Eye Associates Medical Group, Inc. 9940 Business Park
P.O. Box 1777 Sacramento, California 95827
6880 Palm Avenue
Sebastopol, California 95472 Hansen Shells (A- or B-scan probes)
Hansen Ophthalmic Development Laboratories
Eye Cups (Ultrasound biomicroscope) 2412 Towncrest Drive
Paradigm Iowa City, Iowa 52240
2355 South 1070 west
Salt Lake City, Utah 84119 Prager Shell (A-scan biometry probe)
Tom Prager, PhD
1819 North Rainbow Ranch Road
Wimberely, Texas 78676
Appendices ApPENDIX E 475
APPENDIX E Echograms are labeled according to the area of the eye

where the sound beam is directed (rather than where on the
Echogram labeling
globe the probe is positioned). Labeling of A- and B-scan
Schematic fundus drawings (top) and sagittal sections (bot- photo echo grams for the lesion shown above would be as
tom) of normal eye (left) and fundus lesion (right). These follows: A-scan, lOE; transverse B-scan, 10E; longitudinal
diagrams indicate the labeling system for localizing a lesion B-scan, L 10; axial B-scan, 10AX.
in the posterior segment of the eye. P, Posterior; PE, pos- In orbital examinations, a similar procedure is used for
terior-equator; EP, posterior to equator; E, equator; EA, an- labeling transocular scans. Paraocular scans are labeled ac-
terior to equator; 0, ora serrata; GE, ciliary body; and AX, cording to where the probe is positioned on the closed
axial. Right, Lesion centered on 10 o'clock meridian at the eyelid.
equator (i.e., 10 E).
12 12
9 1--+-+-+-1-1 I-I-IH-I---I3 9 I--+-+-+-t--I I-I-IH-I---I3
6 6
EA E E
AX AX
476 APPENDICES
APPENDIX F 4. Perform measurement B: take a photograph of the

screen and, using a millimeter ruler, measure the dis-
Method for Obtaining Measurements
tance between the two cursors on the photograph.
from B-Scan Echograms*
S. Determine conversion factor (CF): divide measurement
1. With the B-scan running, set the gain level to zero and A by measurement B (AlB = CF). This factor will then
then switch to the vector A-scan (without the B-scan) allow millimeter measurements to be obtained directly
2., Place the vector through the center and freeze the from B-scan photographs (e.g., if A = 9.9 mm and B =
screen. 19.8 mm, then the conversion factor = 9.9/19.8 = 0.50).
3. Perform measurement A: display the two electronic cur- 6. To obtain a final measurement, multiply the measure-
sors and position them centrally, so that they measure ment obtained from the photograph (in millimeters) by
approximately 10 mm apart (arrows). Note that the mea- the conversion factor. This value will provide an ap-
surement is 9.9 mm in this example. proximate measurement that correlates with A-scan
measurements. This method may be used for any given
*This method is only necessary for B-scan instruments that do not have a instrument/probe/camera combination. If any of these
measuring scale but have a vector factor A-scan with electronic cursors for three components is changed, the conversion factor
measurements (e.g., Ophthascan S, Alcon Surgical, Inc). should be recalculated.
Index
A Adenoid cystic carcinoma (ACC) Air
Abscesses of lacrimal gland bubbles, 103, 104f, 109, 112,265
choroidal, 191, 193f description and illustration of, 327, entering orbit
dacryoadenitis, 331 328f with emphysema, 446, 449f
versus hematomas, 439, 441£ orbital in normal sinus, 451-452
lacrimal gland, 439, 443f versus BMT and PL, 324t in Tenon's space, 449f
large orbital, 442f Adenomas Air bubbles
loculated orbital, 441 f benign affecting AEL measurements, 265
orbital associated with glaucoma, 212-213 intraocular, 103, 104f
due to trauma, 439, 441£-446f mimicking ciliary body melanomas, with penetrating ocular injuries, 103,
within sclera, 199, 200f 173, 177, 178f, 179f 104f
subperiosteal, 439, 444f, 445f, 446f Adnexal diseases postsurgical, 109, 112
Absorption UBM imaging of, 234 Airbags
affecting echoes, 2, 3f, 4-5 Adnexal structure causing blunt trauma, 87
glossary definition of, 469 evaluating with UBM, 226 American Institute of Ultrasound in
of high versus low frequency sound AEL; see axial eye length (AEL) Medicine (AIUM)
waves, 4-5 measurements on color Doppler imaging (CD I)
Acoustic artifacts Aftermovement safety, 374-375
definition of, 466-467 of choroidal detachments, 74-75 Amplification
Acoustic hollowing, 117, 118f definition of, 36, 37f curve types, 7f
Acoustic impedance detecting, 115 of echoes with gain setting, 249
definition and formula, 2 as diagnostic parameter of signals, 7-8
glossary definition of, 469 of intraocular lesions, 24, 26b Ampulla
illustration of, 3f to differentiate PVD, CD, and TRD, of vortex vein, 142b, 166, 167f·
Acoustic interfaces 50t Amyloidosis
affecting echoes, 2, 3f, 4-5 illustration of, 36f enlarged muscles due to, 405-406,
glossary definition of, 469 ofPVD, 49, 50t 407f
illustration of types, 4f of retinal detachments, 54 Aneurysms
Acoustic lens, 5 Age-related macular degeneration orbital, 365
Acoustic signature (AMD) (See also disciform Angle closure glaucoma, 209
analyzing with spectrum analysis, 122 macular degeneration) symptoms and characteristics of, 210-
Acoustic spectrum axial eye length measurements, 265 215
definition of, 223 calcification, 68, 69f, 70, 148b Angle kappa
Acoustic void, 412 causing total retinal detachment, A-scan showing, 119f
Acoustic waves 214 definition and illustration of, 34
angles of, 2, 3f choroidal hemorrhage and, 161£ gain setting, 305f
definition and characteristics of, 1-2 definition and types, 68 in ocular melanoma, 117, 118f
Acquired cysts, 170, 171f differential diagnosis of, 68 for orbital lesions, 302, 304f
Acquired immunodeficiency syndrome eccentric, 68, Angle of correction
(AIDS) dry form, 68, 69f, 70 in color Doppler imaging (CDI), 368
eye infections associated with, 205, hemorrhagic RPE detachment, 70 Angle of reflection, 2, 3f, 4-5
206£,207 longstanding, 68, 69f, 70 Angle of sound incidence
new problems created by, 205 serial examinations, 70 affecting echoes, 2, 3f, 4-5
Acquisition time serous RPE detachment, 66-67, 70 Angle opening distance (AOD)
3DUS versus 2D, 237t subretinal hemorrhage, 68, 70 measuring with UBM, 228
Acrylic IOL, 255 versus metastatic carcinoma, 70 Angle region
Acute avulsion vitreous hemorrhage, 45 high resolution B-scan (20 MHz) and,
of optic nerve, 92f Aging 41£
Acute dacryoadenitis, 331 posterior vitreous detachment with, measured with UBM, 227-228
Acute retinal necrosis (ARN) 46f Ankylosing spondylitis
and herpes simplex, 205, 206£, 207 vitreous body changes with, 45 and uveitis, 194-195
Acute thyroid ophthalmopathy, 396, Ahmed implants Annular ciliochoroidal detachments
397f-401£ without bleb, 220 associated with glaucoma surgery, 216
Page references followed by f, t, and b indicate figures, tables, and boxes, respectively. 477
478 INDEX
Anophthalmos with cyst Anterior segment-cont'd Aqueous misdirection, 216

description and illustration of, 340, lesions, detection and measurement Arachnoid cysts
344f,345z of,115 optic nerve
Anterior chamber pediatric examination and, 44 description and illustration of, 428,
corneal compression causing penetrating trauma sequelae, 93b, 94f, 429f
shallowing of, 250f, 256 95-99 Armed Forces Institute of Pathology
high resolution B-scan (20 MHz) and, retrolenticular traction, 62, 64f (AFIP), 120, 122f
41£ scleral shell; See. scleral shells Arteriovenous fistulae; See also carotid-
hyphema, 40f, 87-93, 90, 91£ sequelae of blunt trauma, 88b cavernous fistula and dural-
hyphema and iris bombe sequelae of penetrating trauma, 93b cavernous sinus fistula
with glaucoma, 213 tumors, 169-187,231 and glaucoma, 214-215
opacification in phacolytic glaucoma, ultrasound biomicroscopy (UBM), Arteriovenous malformations
211 223-234; See also ultrasound Color Doppler imaging, Color Plate
phacomorphic glaucoma, 212 biomicroscopy (UBM) 15
shallow following penetrating trauma, Anterior segment tumors description and illustration of, 364f,
93b, 94f, 95-99 evaluating with UBM, 231 365
Anterior chamber depth (ACD) and glaucoma, 212-213 Artifacts; See also multiple signals,
A-scan measurement of, 259f, 261£ Anterior staphylomas refraction, and shadowing
measured with UBM, 227 illustration of, 199f Baum's bumps, 467
standard value for, 244 Anterior synechiae comet tail, 42f, 101£,466, 467b
vector A-scan, 264f evaluating with UBM, 230 definition of acoustic, 466-467
Anterior ischemic optic neuropathy and glaucoma, 215 edge, 467
(AION) Anterior trabecular meshwork, 228 enhancement, 467
causes of, 84 Anterior uveitis list of common, 467b
crowded optic disc, 434 and glaucoma, 215 multiple signals, 466
thickening sclera with, 80 with Vogt-Koyanagi-Harada (VKH) postsurgical, 108, 109b, 112
Anterior lens syndrome, 200-201 refraction, 5,470,
echoes produced from, 2 Anterior vitrectomy pseudophakia and, 255-256, 257f,
Anterior lens capsule retained lens material following, 106, 258f,260
and acoustic impedance, 2, 3f 108f shadowing,466-467
echo gram illustrating, 8f Anticoagulant therapy silicone oil, 112, 113 f
Anterior longitudinal B-scans hemorrhagic lesions associated with, A-scan biometry; see Axial eye length
showing intraocular thorn, 102f 160-161 (AEL) measurements
Anterior orbital mass lesions Anti-inflammatory therapy A-scan probes
topographic evaluation of, 295f for scleral tumors, 155, 158f, 159 for AEL measurements, 245-247
Anterior scleritis Apex for evaluating macula lesions, 32f
description and illustration of, 196, orbital example of movements of, 25f
198 evaluation of, 287, 288f standardized, 8-9
necrotizing, 84-85 optic nerve meningiomas "in, 426f A-scan; See also A-scan probes; probes
UBM and, 233 role in intraocular tumor for anterior segment tumors, 169-179
Anterior segment; See also high measurement, 122-123, 124f, assessing reflectivity in, 33
resolution B-scan [20 MHz], 125f asteroid hyalosis, 45, 46f-48f
immersion technique, scleral Aphakia; See aphakic eyes basic screening examination
shells, and UBM Aphakic eyes, 92 techniques, 24, 25f, 26
anterior chamber; See anterior AEL measurements of, 253, 255 of collar button-shaped melanomas,
chamber complications following surgery, 104, 118-120, 121£,122,188f
A-scan immersion techniques, 37, 38f, 105f, 106 definition and characteristics of, 8-9
40 causing macula edema, 67-68 to detect extrascleral extension, 131-
blunt trauma, 87, 88b, 89-90 sound velocities, 247f 132, 133f, 134, 135f
B-scan, immersion techniques, 37, Apical tumor height measurements, 122- echo grams
38f,39-40 129 of choroidal melanomas, 116f
ciliary body; See ciliary body 3D measuring of, 236, 239-240 of endophthalmitis, 191, 192f-193f,
corneal opacification, 87, 88f-89f, 90; Apparent axial length (AAL), 262, 267 194
See also cornea Appendices, 471-476 of extraocular muscles
cyclitic membrane and Applanation technique technique to examine, 382, 385f,
evaluation of, 37-40 for AEL measurement 386f
foreign bodies; see foreign bodies description and illustration of, 251- glossary definition of, 469
high resolution B-scan (20 MHz), 41£; 252 history of, 1
See also high resolution B-scan illustration of, 247f illustrating bandlike lesions, 27f
(20 MHz) Appositional choroidal detachments immersion technique
hyphema; See hyphema description and illustration of, 75, 76f description and illustration of, 38f,
immersion technique for, 37-41 following scleral rupture, 92 40
IOL; See intraocular lens (IOL) hemorrhagic, 92, 104, 105f, 106 inner sclera spikes, 126, 127f
iris; See iris Aqueous media of intraocular lesions
lens; See lens, crystalline and and acoustic impedance, 2, 3f topographic evaluations, 473
cataractous lens sound wave velocity through, 2t of irregularlesions, 118, 119f, 120f
INDEX 479
A-scan-cont'd Axial B-scan-cont'd Axial myopia, 270

to measure axial eye length (AEL), . description and illustration of, 19t, 21- Axial resolution
244-249 22 3DUS versus 2D, 237t
to measure small tumors, 128f, 129 and echogram labeling, 475 factors determining, 5, 6f, 8
of metallic foreign bodies, 96f, 99, of funnel-shaped retinal detachment, and gain, 8
100f 56f,57f glossary definition of, 469
of normal bone and sinuses, 451-452, of globe, 21, 22f, 23f
with high resolution B-scan (20 B
453f
of normal eye and orbit, 276 MHz),41£ Baerveldt implants
of optic nerve of normal optic disc, 435f with bleb, 220
to evaluate topography, 412, 415, of normal optic nerve, 412, 414f Balloon-like devices
416f-417f, 418, 419 of posterior vitreous detachment on probes
of orbit (PVD),48f for anterior segment evaluation, 37,
following trauma, 439-451 probe marker orientation, 22f 38f, 39,41£
of phakic eyes, 252-253 using transocular approach, 281, 282f to examine foreign bodies, 87, 100
probe positions Axial eye length (AEL) measurements; in trauma cases, 87-93
for evaluating macula lesions, 32f See also contact axial eye length Bandlike lesions
retinal detachment appearance on, 54, (AEL) measurements and example of A and B-scans of, 27f, 473
55f,56f immersion technique Bands; See vitreous band
screening of aphakic eye, 253, 255, 260 Basal diameter measurements
with transocular approach, 285, axial myopia and, 270 of choroidal melanomas, 129, 130f,
287,288f cleaning and calibration of 131
technique for screening, 24, 25f, 26f instruments, 270 Basic screening examinations
thirty-degree test, 419, 422f, 423 contact technique, 251-257 function and techniques for, 22-24
tissue model for, 9 corneal compression, 250f Baum,G.
for topographic echography, 24, 25f, dense cataract, 265, 266f role of
26, 27f, 28 diagnostic uses of, 270 in history of ultrasound, 1
transocular and paraocular, 277f-279f errors, 256, 257f, 258f, 261£" 269 Baum's bumps
vector, 8 causes of short and long, 268b definition and illustration of, 466-467
Asteroid hyalosis examination procedures, 249 BBs, 100-101,446, 447f
AEL measurement and, 253, 254f eye type, 247 B-celllymphoma, 151-152
degree of opacities, 46f, 47f gain settings, 249 Benign adenomas
diagnosing, 45 gate positioning 247, 248f, 249 associated with glaucoma, 212-213
encountered during A-scan biometry, and glaucoma 209-210,218 Benign cysts
253, 254f history-taking, 250 mimicking ciliary body melanomas,
with posterior vitreous detachment, immersion technique, 257, 259-260; 173,177, 178f, 179f
47f see also immersion technique Benign mixed tumors
three-dimensional ultrasonography of, incorrect sound velocities, 262 orbital
242 instrument settings for, 246 versus ACC and PL, 324t
Astrocytic hamartomas instrumentation for, 244, 245, 246f description and illustration of, 324,
description and illustration of, 155, intraocular lens composition and, 255- 325f, 326-327
157f 256 Berlin's edema, 73
Atrophic retina, 54, 64t intraocular lesions and, 262-268 detecting following blunt trauma, 9(')
Atrophy keratometry,250 Bilateral diffuse uveal melanocytic
optic, 431 IOL calculations, 269, 270 proliferation (BDUMP), 166
Attenuation; See also sound attenuation listing of sound velocities, 247t Biometers; See also AEL measurements
coefficient, 223, 224f localization of macula, 257,. 258f cleaning and calibration of, 270
glossary definition of, 469 long, 249,251,257,263 description and illustration of, 244,
Audible bruit macular lesions, 263, 265 245f,246f
sign of carotid-cavernous sinus fistula, measurement modes, 246, 254f recommended features of, 246b
355, 358f, 359 minimizing errors, 268, 269 Biometric A-scan instruments, 244-249
Audio Doppler, 308 multiple signals, 249f, 256f, 253, 255 Biometry; See also biometers
Autoimmune disorders, 194-195 patient fixation, 261 glossary definition of, 469
Automatic measurement mode patient preparation 250,251 lesions affecting, 262-268
ofbiometers, 246, 254f, 261£ posterior staphyloma, 263 recommended instrumentation for,
Avulsion probes, 245-247 246b
of optic nerve, 92-93, 429 ofpseudophakic eye, 255-256, 260 of intraocular tumors, 122-131 .
sequelae to blunt trauma, 88b retinal detachment, 265 Biometry probes, 245-246
Axial approach short 80,81£,249,265 Bleb
for evaluatin:g lens, 40, 41£, 42 and silicone oil, 265-268 with glaucoma-filtering implant
Axial A-scans and sound velocity, 248-247 devices (shunts), 218-221
immersion, 259-260, 261£ standard dimensions, 244, 245t Blebitis, 218
Axial B-scan troubleshooting, 261 Blood; See also hemorrhage
for anterior segment, 39-40 velocity conversion equation, 262 and acoustic impedance, 2, 3f
artifacts from, 467 vitreous lesions, 265 clotlysis, 107f
demonstrating "T-sign;' 197f unanticipated postoperative refractive clots
errors, 270 suprachoroidal, 105f, 106, 107f
480 INDEX
Blood-cont'd Bony expansion B-scan-cont'd

flow of with periorbital diseases, 451-465 of macula, 28, 29f-3lf, 32
systolic and diastolic velocity, 369, Bony orbital wall, 451 of normal eye and orbit, 276
371t Borders oblique axial, 19t, 21, 22f
layering of orbital lesions, 293, 297 of optic disc, 209, 210f
in globe, 47f, 164f of various orbital tumors, 311 t of optic nerve
in orbit, 352, 353f, 354f, 355 Bowman's membrane to evaluate topography, 412, 413f-
in orbital hematomas/abscesses, versus endothelium, 227 415f
439,44lf-446f Branch vein occlusion, 49 of orbit
liquefaction, 162, 165f Bridging membranes, 62, 64f transocular approach, 275, 276f-
within lymphangioma, 352, 353f, Bronson, N.R. 279f,280
354f,355 role of orientations
measuring flow of, 10, 147, 308, 367- in history of ultrasound, 1 axial, 21, 22
368,369,371t Bruch's membrane longitudinal, 19-21, 22
organization of, 45, 48f calcifications of, 160-161 para-axial,21-22
versus pus choroidal ruptures of, 90, 9lf transverse, 18-19,22
echogram appearance of, 439, 44lf- and collar button tumors, 115, 116f, para-axial, 19t, 21, 22f
446f 117 paraocular approach, 275, 282-283
vascular neoplasms, 347 -355, 35 6f, creating irregular spikes, 119, 120f peripapillary, 21-22
357f illustration of ruptured, 120f perpendicular sound beam incidence,
Blood flow B-scan echo grams 467
of choroidal hemangiomas, 147 method of obtaining measurements retinal detachment appearance on, 54,
color Doppler evaluation of, 367-368 from, 476 55f,56f
diastolic velocity, 369, 371t B-scan probe screening
feature of ocular melanomas, 37, 115, balloon-like device for, 37, 39-40, 87 basic examination, 22, 23f
116f,117 basic orientation of, 472 basic probe orientation, 472
measured with color Doppler imaging characteristics of, 15, 16f for orbital lesions, 284-289
(CDI),367-368 high resolution B-scan (20 MHz), 39- showing bridging membranes, 62, 64f
orbital 40,4lf sound attenuation, 34-35
Doppler ultrasound evaluation of, positions for optic disc, 432, 433f, techniques
308 434,435f for basic screening examination, 22,
systolic and diastolic velocity, 369, three-dimensional ultrasonography 23f
371t (3DDS), 236, 237f, 238f, 239 to evaluate optic nerve, 412, 413f-
velocities UBM,223,225,226f 415f
in orbital vessels, 371 t B-scan; See also B-scan probe; probes of orbital examination, 275-283
Blood vessels anterior longitudinal radioactive plaque, 13 8, 13 9f, 140f,
congestion stimulating extraocular showing intraocular thorn, 102f 141
tumor, 134 for anterior segment tumors, 169-179 topographic, 24, 26.27f
dilated, 119, 120f apical tumor height measurement and, transverse approach, 15, 17-19
evaluation with color Doppler 122-123, 124f, 128f, 129f Bubbles
imaging (CDI), 367, 369 artifacts, 466-467 air, 103, 104f, 109, 112,265
Blunt trauma assessment of signal brightness, 32f, gas, 109, 112,265,466-467
to anterior segment, 87, 88f-89f, 90 33 perfluorocarbon, 109, 112f
causing lens dislocation, 87, 89f axial approach, 15, 17-18,21 Bullous choroidal detachments
peripheral retinal dialysis following, of bandlike lesions, 473 with metastatic carcinoma, 144, 145f
52,90 basal tumor diameter measurement topographic characteristics of, 76f
causing posterior scleral rupture, 90, and 129-131
9lf,92f 3D versus 2D, 236-242 C
to posterior segment, 90, 9lf, 92-93 definition and characteristics of, 9-10 Calcific lesions
sequelae of, 88b to detect extrascleral extension, 131- of choroid, 147-148, 149f, 151
vitreoretinal injuries, 90, 9lf 132, 133f, 134, 135f Calcification
Bombe iris, 211, 213 f 3DDS imaging, 236-243 causes of, 148-149, 150f, 151
Bone spike of endophthalmitis, 191, 192f-193f, with choroidal hemangiomas, 147
examples of, 382, 385f 194 conditions associated with, 148b
Bone to examine with disciform macular degeneration,
contour changes in orbital, 297, 299f optic nerve, 412, 413, 431, 432 159-160
defects rectus muscles, 380, 382f-384f in hemorrhagic disciform lesions, 160-
with various orbital tumors, 311 t focused sound beam, 5 161
normal orbital, 451-452, 453f glossary definition of, 469 with ocular melanomas, 120
orbital high resolution (20 MHz); see high optic disc drusen, 434, 436f, 437f
defects, 452, 454f, 455f resolution B-scan (20 MHz) orbital
fractures, 439b, 446, 450 history of, 1 with vascular occlusions, 430f, 431
relationship of optic nerve to, 412 immersion technique and phthisis bulbi, 114f
tumors that metastasize to, 458, description and illustration of, 37, with retinal hamartomas, 155, 156f
462f 38f,39-40 retinoblastoma, 180-184
and sound attenuation, 34-35 longitudinal approach, 15, 17-21 scleral, 85
sound wave velocity through, 2t
INDEX 481
Calcium; See also calcification Central retinal artery (CRA) Choroid-cont'd

and sound attenuation, 34-35 blood flow velocities, 371 t metastatic carcinoma to, 141-147
Calcium soaps color Doppler imaging of, 371-372 nevus of, 150f, 151
description and illustration of, 45, 46£, Central retinal vein (CRV) normal versus tumorous, 118
47f blood flow velocities, 371 t osteomas
opacities originating from, 45 Doppler color imaging of, 371-372 associated with calcifications, 148b
Calibration Central retinal veins (CRV) description and illustration of, 147-
A-scan biometry probes, 270 color Doppler imaging (CD!) of, 367 148, 149f
biometer, 270 Chemosis illustration of, 35 f, 149f
keratometer, 270 hemorrhagic, 90, 91£ ruptures
standardized A-scan, 8-9 sign of carotid-cavernous sinus fistula, detecting following blunt trauma,
Capillary hemangiomas 355, 358f, 359 90
orbital Children; See also newborns macular, 73
characteristics and illustrations of, axial eye length measurements in, 244, serous versus hemorrhagic
347,351,352f 245t detachment, 115
differential diagnoses of, 348t detecting glaucoma in, 209-210 tears in, 90, 91£
Carcinomas detecting retinoblastomas in, 180 thickening
BDUMP associated with, 166 echographic examinations of, 43-44 causes of, 74
invading optic nerve, 424, 425f-427f, endogenous endophthalmitis in, 191, with sympathetic ophthalmia, 201-
428 193f 202
orbital, 315, 318-319, 320f-323f eosinophilic granulomas in, 458, 463f with Vogt-Koyanagi-Harada
Carotid arteries glaucoma in, 213 0fK11)syndrome, 200-201
color Doppler imaging (CDI) of, 367, intraocular tumors in, 213 tumors; See also individual listing
368b orbital lymphangioma in, 351-352, diffuse, 74
Carotid-cavernous sinus fistulas (CCSF) 353f, 354f, 355 periph~ral
color Doppler imaging (CD!) of, 373- orbital rhabdomyosarcomas in, 310, UBM imaging of, 232-233
374 314,315f Choroidal abscess
description and illustration of, 355, scleral bowing, 118 with endogenous endophthalmitis,
358f,359 with sickle cell disease 191,193f
in globe, 214-215 subperiosteal abscesses in, 446f Choroidal detachments (CDs)
causing venous congestion, 406 with Sturge-Weber syndrome, 146£, with carotid-cavernous sinus fistula,
Cataract surgery 147, 148f 355
epithelial downgrowth following, 177, vascular neoplasms in, 347 -355, 356£, causes of, 74, 75b
179f 357f description and illustration of, 74-75,
lens side effects, 194 Cholesterol 76£,77f
retained lens material following, 106, granuloma, 340, 343f due to expulsive hemorrhages, 104,
108f subretinal, 58, 185, 187 105f, 106
Cataractous lens; See also lens, crystalline Choriocapillaris, 68, 69f, 70 following penetrating trauma, 93 b,
AEL measurements with 244, 252- Chorioretinal folds 94f,95-99
253,265 description and causes of, 80, 82 hemorrhagic; See hemorrhagic
due to blunt trauma, 87-93 as indication for orbital examination, choroidal detachments
calcified, 266£ 274t illustration of
dislocated, 168f, 169 Choroid; See also choroidal detachment with endophthalmitis, 193f
evaluation of, 42, 43 and choroidal hemorrhage intraocular echo graphic examinations
hypermature and secondary glaucoma, diseases of, 74-75, 76f, 77f of, 14t
194,211 edema with metastatic carcinoma, 141, 142f,
intumescent simulating melanoma, description of, 74 143, 145f, 146£
169 effusions with needle injuries, 108
after penetrating trauma, 93b. 94f, 95- and glaucoma, 214-215 with posterior uveitis, 194-195
99 excavation of, 118 versus PVD and RD, SOt
in phacolytic glaucoma, 211 hemangiomas versus scleral fold, 99
posterior subcapsular, 42, 43f associated with calcifications, 148b three-dimensional ultrasonography of,
swelling in phacomorphic glaucoma, associated with Sturge-Weber 242
211-212 syndrome, 147, 148f Choroidal edema
uveitis leading to, 194-195 description and illustration of, 74, description of, 74
Cavernous hemangiomas 147 Choroidal effusions
orbital echogram illustration of, 34f and glaucoma, 214-215
versus benign mixed tumors, 326 versus ocular melanomas, 143 Choroidal excavation, 118
description and illustration of, 347- hemorrhagic detachment Choroidal folds
348, 349f, 350f following penetrating trauma, 93 b, description and causes of, 80, 82
differential diagnoses of, 348t 94f,95-99 description of, 74
Cavitary melanomas, 173, 176£ inflammatory conditions of, 74, 199- with posterior scleriti£, 195-196
CDI; see Color Doppler imaging (CDI) 207 Choroidal hemangiomas
Cellulitis lesions associated with calcifications, 148b
orbital detection and measurement of, 115 associated with Sturge-Weber
from trauma, 439, 440f melanocytomas, 151, 152f syndrome, 146£, 147, 148f
482 INDEX
Choroidal hemangiomas-cont'd Ciliary body-cont'd Ciliochoroidal detachments

description and illustration of, 74, 147 ciliochoroidal detachment annular, 216
echo gram illustration of, 34f annular, 216 causes of, 74, 75b
venus ocular melanomas, 143 with anterior scleritis, 198, and glaucoma, 214, 215f, 216
Choroidal hemorrhages following glaucoma surgery, 216 illustration of, 198f
after blunt trauma, 92 malignant glaucoma and, with penetrating trauma, 95
clotted versus liquified, 106, 162 melanoma with inflammation, 207 with uveal effusion syndrome, 82, 83f
description and illustration of, 162- metastatic carcinoma and, 207 Ciliochoroidal effusions
163, 164f, 165f rranophthalmos and, 214 causing glaucoma, 214
explosive, 104, 105f, 106 ciliochoroidal effusion, 214 causing secondary angle closure
following glaucoma surgery, 218 contact evaluation of, 77, 78f, 174f glaucoma, 210-211
versus melanomas, 162-163, 164f, 165f cyclitic membrane, 93b, 94f, 195f Ciliochoroidal melanomas
versus ocular melanomas, 143 associated with uveitis, 194 displacing lens, 174f, 175f
Choroidal lesions cyclodialysis cleft, 77, 80f, examining with immersion technique,
detection and measurement of, 115 after trauma, 88b, 90 173,175f
Choroidal melanomas cystic cavities with large cystlike cavities, 120, 173,
A-scan measurement of, 126f within melanoma, 173, 176f 176f,177f
associated with calcifications, 148b cysts, 170-171, 173, 176f, 179f, 232, two examples of
associated with scleritis, 198-199 233f with cystic degeneration, 176f
3D accuracy, 236, 23 7t and secondary glaucoma, 212 Cleaning probes, 270
echogram illustration of, 34f detachment, 77, 78f, 79f Clear ocular media
echograms illustrating, 27f diktyoma, 187, 188f intraocular echographic examinations
with extrascleral extension, 131£ epithelial downgrowth, 108, 177, 179f of, 14t
initial exam of, 135f epithelial implantation cyst of, 170, Clefts
mixed cell type, 121£ 171,179f cyclodialysis, 80f, 90
with overlying retinal detachments, in ciliochoroidal melanoma, 173, Cloquet's canal, 50
126f 176f,I77f CMV retinitis, 205, 206f, 207
with scleritis glaucoma and UBM, 229-230, 231£ Coat's disease
illustration of, 129f high resolution B-scan (20 MHz) and, convection motion and, 37
and inflammation, 121£ 41£, 174f description and illustration of, 187,
small, 132f, 133f, 139f immersion evaluation of, 77, 79f, 188f
three-dimensional ultrasonography of, 174f,175f versus retinoblastoma, 183t, 184, 185,
238f,239-240 inflammation, 187
transverse B-scans of, 116f associated with glaucoma, 215 Cogan's plaques
Choroidal nevi Vogt-Koyanagi-Harada (VKH) associated with calcifications, 148b
description and illustration of, 150f, syndrome and, 215 Coleman, D.J.
151 iridociliary cyst, 233 role of
versus metastatic carcinoma to leiomyoma, 177 in history of ultrasound, 1
choroid,143-144 lesions involving, 169, 173, 177 Collagen vascular disorders
versus ocular melanomas, 143 measured with UBM, 226-228 and uveitis, 194-195
Choroidal osteomas medulloepithelioma and, 177, 187, Collar button
associated with calcifications, 148b 188f choroidal melanomas
description and illustration of, 147- associated with glaucoma, 213 illustrations of, 116f, 117f
148, 149f melanocytoma, 151, 152f ciliary body melanoma, 173 -1 77
illustration of, 149f melanoma, 172f, 173, 174f, 175f, 176f, metastatic carcinomas, 146f, 147
Choroidal ruptures 177f Coloboma
detecting following blunt trauma, 90 neurofibromatosis and, 213 optic nerve, 432, 433f, 434f
macular, 73 normal, 41£, 77, 78f, 79f, 228 posterior, 166, 167
Choroidal tumors supraciliary effusion, UBM and, 230 Color Doppler imaging (CD!); See also
description of, 74 tumors of, 169, 172, 177, 187, 188f color plates
peripheral associated with ciliochoroidal for carotid-cavernous sinus fistulas,
UBM imaging of, 232-233 detachments, 207 373-374
Chronic scleritis, 198, 199f producing secondary glaucoma, clinical applications of, 369
Cilia 212 to diagnose ocular ischemic syndrome,
intraocular imaged with UBM, 231-232 372
due to penetrating injuries, 102-103 Ciliary body melanomas documentation sheet, 370f
Ciliary body; See also high resolution description and illustration of, 173- to evaluate intraocular tumor, 373
B-scan (20 MHz) and 179 to evaluate orbital disorders, 373-374
ultrasound biomicroscopy UBM and, 228-229 examination technique, 369, 371
(UBM) Ciliary body tumors for glaucoma, 209-221
adenoma of, 177, 178f UBM imaging of, 232 glossary definition of, 469
annular ciliochoroidal detachment, Ciliary processes instrumentation, 368f
216 high resolution B-scan (20 MHz) and, introduction and history, 367
benign cyst of, 177 41£ normal vascular topography, 371-372
cavitary melanoma, 173, 176f, 177f Ciliary sulcus for optic nerve sheath meningioma,
ciliary processes, 41£, 22 8f, 230 definition of, 228 374
INDEX 483
Color Doppler imaging (CDI)-cont'd Conjunctival diseases Corticosteroid therapy

organ perfusion, 369 UBM imaging of, 234 to treat choroidal melanoma inflam-
physical principles of, 367-368 Consistency mation, 120, 12If, 136
of retinal and vascular diseases, 372- of orbital lesions, 302, 306, 307f VKH before and after, 201f
373 Contact AEL measurements; See also CRA occlusion (CRAO), 367
safety considerations, 374 axial eye length (AEL) Crowded optic disc, 84f, 434
schematic display of, 368f measurements CRVocclusion (CRVO), 367
for tumor vascularity, 369 advantages and disadvantages, 249 Cryoprobe,53f
Color plates, 379; See also color Doppler for AEL measurements, 251 Crystalline lens; See also lens, crystalline
imaging (CD I) of aphakic eyes, 253, 255 CALF factor, 253
Color threshold levels, 369 applanation for, 251-252 extrusion of, 90
Color-duplex scanning, 367, 368f B-scan for, 264f sound wave velocity through, 2t
Comet tail artifacts hand-held,252 CT scans; See computed tomography
definition of, 466-467 versus immersion, 249 (CT)
illustration of, 10 If of phakic yes, 252, 253 Cyclitic membranes
Commotio retinae of pseudophakic eyes, 255 -256 following penetrating trauma, 93b,
detecting following blunt trauma, 90 potential sources of error with, 256 94f,95-99
Compensation, 7-8 Convection motion immersion B-scan of, 80f
Complications Coat's disease and, 187 retrolenticular traction, 64f
surgical, 104-108 definition of, 37 ultrasound evaluation of, 42b
Compression retinal detachment and, 58f uveitis leading to, 194-195
corneal, 256 Conversion tables Cyclodialysis clefts
of molecules, 2 microseconds to millimeters, 471 following blunt trauma, 90
optic nerve, 428-429, 430f Copolymer polyvinylidene high resolution B-scan (20MHz), 80f
of orbital hematomas, 439, 446f di.flouride/triflouroethylene, sequelae to blunt trauma, 88b
paraocular test, 307f 225 UBM imaging of, 233-234
and probe positioning, 250f Cornea ultrasound to view, 77, 80f
of signals, 7-8 blood staining, 88f Cystic cavities
transocular test, 306f compression, 250f, 256 benign mixed tumors with, 326f
causing venous congestion, 406 diseases in ciliary body melanomas, 120, 173,
Compressive optic neuropathy UBM imaging of, 233 176f,177f
description and illustration of, 428- edema Cystic degeneration
429,430f with angle closure glaucoma, 210- in ciliochoroidal melanomas, 176f,
optic nerve 215 177f
description and illustration of, 428- examining with UBM, 226 Cystic lesions
429,430f keratometry readings of, 249 orbital
Computed tomography (CT) measured with UBM, 227 description and illustrations of, 334,
axial, 197f opacification, 87, 88f-89f, 90 336, 337f-339f, 340, 341f-344f,
to detect retinoblastomas in optic intraocular echographic 345
nerve, 180, 184 examinations of, 14t types of, 3 36b
of hemangiopericytoma, 35 6f perforated ulcer of Cystic spaces
oflacrimal system disorders, 319, 324t causing scleral folds, 97, 99 in ocular melanomas, 120, 176f, 177f
ofleft superior oblique myositis, 393f placing B-scan probe directly on, 15, Cysticercosis
of penetrating foreign: bodies, 99 16f, 17 associated with calcifications, 148b
of spherical foreign bodies, 102f thickness definition and appearance of, 203, 205
Computers A-scan, 259f venus retinoblastoma, 183t, 184, 187,
role in three-dimensional measuring with UBM, 233 188f
ultrasonography (3 DUS), 236- standard value, 244 vitreous cysts and, 51
243 wound rupture, 92 Cystoid macular edema (CME), 67-68
in UBM designs, 225-226 Corneal compression, 250f, 256 Cysts; See also lesions; tumors
Congenital arteriovenous malformations Corneal diseases anterior segment, 169-179
of eyelids, 364f UBM imaging of, 23 3 and glaucoma, 213-214
Congenital cystic eye Corneal edema benign ciliary body, 179f
description and illustration of, 340, with angle closure glaucoma, 210-215 ciliary body melanomas, 173, 176f,
344f,345 Corneal-scleral junction 177f
Congenital glaucoma differentiating in UBM, 227 of cysticercosis, 203, 205
AEL measurements to diagnose, 270 Corneoscleral ruptures intraretinal
diagnostic challenges, 209, 210f description and illustration of, 87 -93 following blunt trauma, 90, 91f
Congestion sequelae to blunt trauma, 88b intrascleral, 155, 158f, 159
causing extraocular muscle thickening, Coronal sections iris, 170, 171f
380 3DUS versus 2D, 237t longstanding retinal detachment and,
venous, 406 Corrected axial length factor (CALF), 58f
Conjunctiva 253 orbital
Dermoid tumor of, 177, 180t Correction factors anophthalmos, 340, 344f, 345f
examining with UBM, 226 for pseudophakic eyes, 255 t dermoid, 334, 336, 337f, 338f
placing B-scan probe directly on, 15, Cortical lens material dermolipoma, 336, 340f
16f, 17 retained in vitreous gel, 106, 107f, 108
484 INDEX
Cysts-cont'd Diabetic retinopathy Disciform macular degeneration

orbital-cont'd color Doppler imaging (CDI) and, (disciform lesion)-cont'd
description and illustrations of, 334- 372 chronic 159
345 hemorrhage following vitrectomy, definition of, 159
epidermoid, 336, 339f 109,111£ differential diagnosis of, 159-163
epithelial, 336 traction, 58,60, 61£, 62, 63f, 64f, 65f eccentric 160, 163f, 164
hematic, 340, 343f causing vitreous hemorrhages, 45 hemorrhagic disciform lesion 160-161
retinal with hemorrhage, 162, 165f Diabetic vitreous hemorrhages hemorrhagic retinal pigment epithe-
solid vitreous gel mimicking traction seen with, 58, 60, 61£ lial detachment (HRPED),
vitreous, 45 Dialysis of retina, 52, 90 161-162, 163f, 164f
DBM imaging of, 232, 233f sequelae to blunt trauma, 88b RPE detachment with hemorrhage,
vitreous, 51 Differential diagnoses 70, 160-162
Cytomegalovirus (CMV) of extraocular muscle disorders, 396t serial examinations, 161, 162f
associated with AIDS, 205, 206£, 207 of intraocular lesions, 26b subretinal hemorrhage, 160
of ocular melanomas, 143t suprachoroidal hemorrhage, 160
D of optic nerve disorders, 419t versus metastatic carcinoma, 161
3D I-scan, 236 of orbital tumors, 311 t versus ocular melanoma, 142
3D ultrasound; See three-dimensional Diffraction theory, 223, 224f vitreous hemorrhage, 45, 161
ultrasonography (3 DDS) Diffuse amelanotic melanoma Diseases
Dacryoadenitis versus uveal lymphoid hyperplasia, 153 adnexal, 234
of lacrimal gland Diffuse choroidal hemangioma; See also choroidal, 74-77
description of, 331 choroidal hemangioma conjunctival,234
Dacryocystitis, 332, 335f, 336£ associated with Sturge-Weber extraocular muscle, 396-410
with mucous plugs, 336£ syndrome, 146£, 147, 148f inflammatory of globe, 191-207
Dacryops, 332 versus diffuse choroidal melanoma, lymphoproliferative, 310-313, 330-
Damping material 137-138 331
within probe, 5, 6f DBM illustration of periorbital, 451-465
Decibels in congenital glaucoma, 210 retinal, 51-66
definition of, 7 Diffuse choroidal melanoma of sclera, 77, 80b
glossary definition of, 469 versus metastatic carcinoma to vascular, 23 3, 372
Demodulation, 7-8 choroid, 143, 144, 145f, 146£ vitreoretinal, 45 -85
Dense cataracts Diffuse choroidal nevus Dislocated intraocular lens, 95f, 108
affecting AEL measurements, 265 versus diffuse melanoma, 13 6-13 7 Dislocated lens; See lens, crystalline
Dense vitreous hemorrhage Diffuse choroidal thickening, 74, 199- Display screen
in older patients, 160-161 202 of ultrasound system, 7
Density Diffuse leukemic infiltration Distance
of various media, 2 of choroid, 154 formula for measurements, 8
Depth of field (DOF) Diffuse malignant melanoma Distilled water, 16£
definition of, 225 versus Vogt-Koyanagi-Harada Documentation of findings, 44
Dermoid cysts syndrome (VKH), 200-201 anterior segment examination, 37, 39-
orbital, 334, 336, 337f, 338f Diffuse melanoma 40
Dermoid tumors description and illustration of, 136- color Doppler imaging, 370f
conjunctival, 177, 180f 137 echo gram labeling, 475
Dermolipomas Diffuse posterior scleritis with three-dimensional
in orbit, 336, 340f description and illustration of, 196, ultrasonography, 242
Descemet's membrane 197f on ultrasound biomicroscopy (UBM),
versus endothelium, 22 7 Diffuse sub-Tenon's lesions, 121£ 226
Detachments Diplopia Dome-shaped melanomas
choroidal, 50t, 74-77, 93-99,141-146, as indication for orbital examination, showing calcified nodules, 122f
193t, 194-195, 355 274t Dome-shaped tumors
ciliary body, 77, 78f, 79f, 80f Disciform lesions; See also disciform choroidal, 130f
posterior vitreous detachment (PVD) macular degeneration Doppler effect
versus normal vitreous, 45, 46£, 47f, associated with calcifications, 148b definition of, 10, 367-368
48f versus diffuse choroidal melanomas, glossary definition of, 469
partial, 60, 61£, 71£, 72f 137-138 Doppler equation for velocity, 369, 371
reflectivity versus RD, 32-33 macular, 68, 69f, 70 Doppler pulse curves, 371£
versus retinal detachment (RD), 56, versus ocular melanomas, 143 Doppler shift
58, 59f, 60f simulating melanomas, 159-160 definition of, 367-368
separation from optic nerve, 49 Disciform macular degeneration Doppler spectral analysis
sequelae to blunt trauma, 88b (disciform lesion); See also age- to assess blood vessel flow, 367-368
subvitreal hemorrhages, 50-51 related macular degeneration Doppler spectrum
versus RD and CD, 50t (AMD) schematic display of, 369f
with Weiss ring, 49, 72 as pseudomelanoma, 142b Doppler ultrasound; See also color
retinal; See retinal detachments (RDs) associated with calcification, 148b, Doppler imaging (CD!)
Diabetes 159-160 audio, 308
AEL measurements and, 250 axial eye length measurements, 265 history of, 1
instrumentation for, 10
INDEX 485
Double-plate Molteno implants, 220 Echography-cont'd Epithelial cysts

"Doughnut sign," 419, 422f . orbit examination techniques-cont'd intraocular, 108
Downgrowth lesion differentiation, 289-297 orbitru, 336
epithelial, 108 quantitative echography, 297, 300- Epithelial downgrowth, 108
mimicking ciliary body melanomas, 302, 303f-305f mimicking ciliary body melanoma,
173,177, 178f, 179f transocular approach, 275, 276f- 177,179f
Drainage 279f,280 Epithelial implantation
following surgery, 106, 107f vascular lesions, 347-365 cyst
Drusen quantitative type II, 35 and glaucoma, 212
in disciform lesions, 159-160 Echolucency two examples of, 171£
optic disc, 412b, 431, 434, 436f, 437f of vitreous cavity, 33 Epithelial inclusion cysts, 108
optic nerve head, 148-149 Echoluceilt Ethmoid sinus
Duplex scanning defect, 412 polyposis of, 453f
glossary definition of, 469 glossary definition of, 469 Ethmoid sinusitis, 452f
Dural cavernous arteriovenous Edema Excavation
malformations (DCAVM) Berlin's, 90 of bony wall, 452
color Doppler imaging (CDI) of, 373- following radiation, 137 optic disc, 432, 433f
374 macular, 68 Exophthrumos
Dural-cavernous sinus fistula, 214-215 with persistent hypotony, 216, 217 f, as indication for orbitru examination,
description and illustration of, 359, 218 274t
360f of retinochoroid layer pulsatile
causing venous congestion, 406 sequelae to blunt trauma, 88b sign of carotid-cavernous sinus
3DUS; See three-dimensional in sub-Tenon's space, 310 fistula, 355, 358f, 359
ultrasonography (3DUS) Edge artifact, 467 Exophytic retinoblastomas, 181£
Dynamic examinations Elevation Expulsive hemorrhages
3DUS versus 2D, 237t optic disc, 434, 435f description and illustration of, 104,
Dynamic range Emphysema 105f,106
on B-scan signal display, 33 and orbital trauma, 439b, 446, 449f External sound beam locruization
definition of, 7 Endogenousendophthrumitis technique, 13 8, 141
glossary definition of, 469 definition of, 191, 193f Extraocular extensions
resolution and UBM, 223 Endophthrumitis melanoma mimicking, 136
associated with choroidal thickening, Extraocular muscles, 380-409; See also
E 202-203 individual muscles
Ecchymosis definition and illustration of, 191, A-scan
as indication for orbital examination, 192f-193f, 194 examination techniques, 382, 384,
274t following glaucoma surgery, 218 385f, 386f, 387f
Echo-dense opacities originating from, 45 B-scan
glossary definition of, 469 versus retinoblastoma, 183t; 184, 188f examination techniques, 380-381,
Echoes traction seen with, 58,60, 61f 382f, 383f, 387f
and acoustic impedance, 2, 3f Endophytic rednoblastomas, 180, 183f disorders, 396-409
amplification of, 249 highly calcified, 183f differential diagnoses of, 396t
and artifacts, 466-467 Enhancement thyroid ophthalmopathy, 380, 396,
in basic screening echograms, 22-24 definition of, 467 397f-401£
B-scan, 9-10 glossary definition of, 469 inferior oblique, 387t, 390f, 391, 394,
definition of, 2 Enophthalmos 395f
from different acoustic interfaces, 4f as indication for orbitru examination, inferior rectus, 387t, 388-389
microseconds to receive returning, 5 274t laterru rectus
spikes, 8-10 orbital varix and, 363f illustration of choroidru melanoma
Echogenic Entrance wounds, 100 overlying, 138f
glossary definition of, 469 Enucleation ultrsound evaluation of, 387t, 388
Echogram, labeling of, 475 melanoma following, 323f levator,407f
A-scans Eosinophilic granulomas, 458, 463f levator palpebrae, 387t, 389, 390f
of rectus muscles, 382, 385f Epidermoid cysts myositis, 396-397
basic screening, 22-24 orbital, 336, 339f mediru rectus
B-scan, labeling of, 475 Episcleral blood vessels examination of, 384, 387
Echography; See also ultrasound dilated melanoma, 407f
glossary definition of, 469 sign of carotid-cavernous sinus myositis of, 403f
introduction to, 13, 14t fistula, 355, 358f, 359 thickening of, 397f
kinetic, 35-36 Episclerru space normal, 381£, 387t
of optic nerve hemorrhages, 90, 91f, 92f oblique, 387t, 389, 390f
A-scan technique, 412-419 Episcleral venous pressure techniques for examining, 380,
B-scan technique, 412, 413f-415f elevation of 381£-384f
orbit examination techniques and glaucoma, 214-215 orbitru trauma, 439b, 449f, 450-451
kinetic echography, 302, 306, 307f, Episcleritis rectus
308-309 associated with tumor necrosis, 120, evaluation of, 384, 387
lesion detection, 283-289 122f normal thickness values, 387t
with myositis, 402, 404f techniques for examining, 380,
381£-384f, 387t
486 INDEX
Extraocular muscles-cont'd Fibrovascular proliferation F requencies-cont' d

refraction and, 5 in sub~RPE space, 160-161 ultrasound biomicroscopy (UBM),
relationship of optic nerve to, 412 Filtering 223-234
superior oblique, 387t, 391, 392f, 393f glaucoma, 218-221 (v) in FWHM equation, 223
superior rectus, 387t, 389, 405f surgery, 23 0 Frontal mucocele, 454, 457f
thickening of Filtering bleb, 219-221 Frontal sinus
diseases of, 396-410 Fistulas examination of, 291£
thinning of, 409, 410f carotid-cavernous sinus, 214-215, 355, Frontoethmoidal mucocele, 456f
thyroid ophthalmopathy, 396-401 359,373-374 Full width half maximum (FWHM)
transection of, 408 fast flow and slow flow, 355, 359 equation,223,224f
trauma, 408-409 Fixation light, 15, 16f, 247f at transducer focus, 22 5
tumors Floaters Full-thickness macular holes, 71£
echography to detect growth of, three-dimensional ultrasonography of, Funnel-shaped retinal detachments
115-141 242 description and illustration of, 56, 57f
venous congestion, 406 Fluid bleb, 218, 219f, 220, 221£ topographic B-scan evaluations of, 26,
Extraocular tumors Fluid meniscus, 251£, 256 27f,29f
echography to detect growth of, 115- Focal choroidal thickening, 74
141 Focal fibrosclerosis, 155, 158f, 159 G
Extrascleral extension Focal length (1) Gain
diagnosing with 3DUS, 238f, 239-240 of transducer, 223 B-scan setting
in diffuse melanomas, 13 6-13 7 Focal retinitis for optic nerve evaluation, 412, 413f
of intraocular melanoma, 131-132, with toxoplasmosis, 207 definition and measurement of, 7-8
133f, 134, 135f Folds glossary definition of, 469
Exudate retinal, in toxocariasis, 205f normal A-scan echograms at Tissue
in disciform lesions, 159-160 scleral, 97, 99 Sensitivity, 26f
Exudative retinal detachments, 124f- Folded retinal detachments, 54, 55f reduced, 26f, 32f
125f Foreign bodies setting
Eye cups versus air bubbles, 103, 104f for angle kappa, 305f
use in UBM, 22 5, 22 6f artifacts produced by, 466-467 in basic screening, 22-24
Eye length; See axial eye length (AEL) following penetrating trauma, 99b definition of, 249
measuring, 244-270 glass, 101-103,446, 447f high when examining through
Eyelashes in globe, 99-103 closed lids, 87, 88f
intraocular intraocular with immersion technique, 259-
due to penetrating injuries, 102-103 detecting, 99 260,261£
Eyelids echographic examinations of, 14t to measure tumors, 122-123, 124f,
abnormalities hemorrhagic tracks produced by, 125f
as indication for orbital 95,96f for subvitreal hemorrhages, 49-50
examination, 274t longstanding metallic, 100f for transverse scans, 22
B-scan through closed, 300f metallic, 96f, 99, 100f Tissue Sensitivity setting, 24, 26f, 32f,
cavernous hemangioma of, 347-348, orbital, 95, 97f, 103,439,446, 447f- 33, 34f, 122-131,412,415
350f 448f Gancyclovir implants
of children trauma from, 439, 446, 447f-448f in CMV patient, 205f
ultrasound challenges, 43-44 perforating injuries, 97f Gas bubbles
congenital arteriovenous proj ectile-type affecting AEL measurements, 265
malformation of, 364f causing penetrating trauma, 95-99 artifacts produced by, 466-467
examining through closed, 87, 88f, 89- versus scleral folds, 99 postsurgical, 109, 112
93 spherical, 100-10 1 Gates
and sound attenuation, 15,34 sympathetic ophthalmia following definition of, 247, 249
swollen penetration by, 201, 202f in phakic eye measurements, 252-253
with posterior scleritis, 195-196 UBM imaging of, 233-234 proper positioning of, 248f
Eye type for AEL measurement, 247 Foreign materials Ghost cells
and sound attenuation, 34-35 in vitreous hemorrhage, 213
F Fornix Giant cell arteritis (GCA), 372
Far field, 5, 6f placement of probe near, 18, 20, 21£, Glass
Fast flow fistula, 355 25f artifacts produced by, 466-467
Fast spontaneous motion, 37 Fractures foreign bodies, 101-103
Fibrosis from orbital trauma, 439b, 446, 450 intralenticular, 42f
with disciform macular degeneration, Frame rates, 10 in orbit, 439, 446, 447f-448f
159-160 Frequencies Glaucoma
retroperitoneal, 155, 159 and absorption, 4-5 AEL measurements to diagnose, 270
Fibrous dysplasia for cm, 367-368 angle closure, 210-215
orbital definition of acoustic wave, 1-2 filtering implant devices, 218-221
in children, 458, 464f determining resolution, 5, 6f, 8 due to ciliary body melanoma, 173-
Fibrous histiocytoma in 3DUS versus 2D, 237t 179
orbital glossary definition of, 469 and intraocular tumors, 212-213
description and illustration of, 315, levels for eye length measurement, 9 in children, 213
318f low versus high, 2f
differential diagnosis of, 311 t
INDEX 487
Glaucoma-cont'd Gray scale Hemorrhage-cont'd

malignant on B-scan signal display, 33 three-dimensional ultrasonography of,
causing secondary angle closure glossary definition of, 469 242
glaucoma, 210-211 Greenwood, 1. vitreous
UBM and, 230 role of associated with ocular melanoma,
from metastatic carcinomas, 144, 145f, in history of ultrasound, 1 118,119f
146f Gunshots Hemorrhagic chemosis, 90, 91£
normal tension, 215 artifacts produced by, 466-467 Hemorrhagic choroidal detachments
open angle, 211 as spherical foreign bodies, 100-103 after penetrating injury, 97, 98f
phacolytic due to blunt trauma, 92
with hypermature cataractous lens, H delayed, 104
211 Hair follicles layering of, 164f
phacomorphic in dermoid cysts, 334, 336 massive "supra," 104, 105f, 106
causing secondary angle closure Hamartomas sequelae to blunt trauma, 88b
glaucoma, 210-211 ofretina, 155, 156f, 157f with suprachoroidal hyphema, 162-
pigmentary Hand-held method 163, 164f, 165f
definition and causes of, 211 of AEL measurement, 252 Hemorrhagic disciform lesions, 160-161
pupillary block, 229 Head trauma; See also blunt trauma; Hemorrhagic retinal cysts, 162
secondary trauma two examples of, 165f, 166f
ultrasound to diagnose, 211-215 causing carotid-cavernous sinus Hemorrhagic retinal pigment epithelial
surgery fistula, 355, 358f, 359 detachment (HRPED), 161-
complications of, 216, 217f, 218 Heat 162, 163f, 164f
and hemorrhages, 214 generated by ultrasonic energy, 4-5 Hemorrhagic suprachoroidal
massive suprachoroidal Hemangioma detachments
hemorrhagic detachments choroidal, 143, 146f, 147 massive, 104, 105f, 106
following, 104 orbital, 347-351 Hemorrhagic track
ultrasound biomicroscopy of, 229- Hemangiopericytoma following penetrating trauma, 93b,
230 CDI of, 374 94f,95-97
ultrasound to evaluate, 209-221 differential diagnoses of, 348t Herpes simplex
Glaucoma-filtering shunts, 218-221 orbital, 355, 356f, 357f associated with AIDS, 205, 206f, 207
Glaucoma shunt surgery Hematic cysts, 340, 343f, 465 Herpes zoster
ultrasound to manage, 209 Hematoma of orbit associated with AIDS, 205, 206f, 207
Globe versus abscesses, 439, 441£ High frequency transducers
axial eye length measurements (AEL) causing extraocular muscle thickening, B-scan (20 MHz), 39,40,41£
of, 244-270 380 development of UBM, 22 5
blunt trauma to, 87-93 orbital PVDF
contour changes in, 297, 299f due to trauma, 439, 441£-446f illustration of, 225f
displacement Hemodynamics High frequency ultrasound
as indication for orbital assessing with color Doppler imaging early use of, 1
examination, 274t (CDI),367 High resolution B-scan (20 MHz)
echo graphic examination of Hemorrhage; See also blood; vitreous anterior segment tumors, 169
indications for, 13, 14t hemorrhage balloonlike device and, 40, 41£
examination techniques, 15-44 and acoustic impedance, 2, 3f ciliary body melanoma, 174f
inflammatory diseases of, 191-207 associated with retinal detachment cilary body cyst, 179f
Glossary, 469-470 (RD),54 ciliary processes, 41 f
Gonioscopy due to optic nerve trauma, 429, 430f cyclodialysis cleft, 77, 80f
definition of, 209 versus endophthalmitis, 193f, 194 detachment of ciliary body, 80f
to evaluate glaucoma, 210 episcleral space, 90, 91£, 92£ examination techniques, 39-40, 41£
Granulocytic infiltration expulsive flanged scleral shell, 474
causing pseudocupping, 209, 210f, description and illustration of, 104, hyphema, 213f
432,434 105f,106 iris bombe, 213f
Granulomas hemorrhagic retinal pigment iris melanoma, 171£
associated with calcifications, 148b epithelial detachment latex tonometer tip on probe, 40, 41£
with endogenous endophthalmitis, (HRPED), 161-162, 163f melanoma of ciliary body, 174f
191, 193f intraocular tumors and, 118, 146f normal anterior segment, 41£
Granulomatous disorders within lymphangioma, 352, 353f, probe, 41£
orbital tumors from, 310 354f,355 History
Graves' disease and ocular melanoma, 118, 119f of ultrasound, 1
extraocular muscle thickening with, orbital, 90, 91£ History-taking, 250
380 from orbital trauma, 439, 441£-446f Horizontal axial B-scan
causing intraocular muscle into retinal cysts/retinoschisis, 162, description of, 19t, 21
enlargement, 396, 397f-401£ 166 marker orientation for, 22f
Graves' ophthalmopathy; See Graves' in sub-RPE space, 160-161 probe positions
disease in subretinal space, 58f to evaluate macula, 28, 30
Gravity subvitreal,50-51 Horizontal transverse B-scans
blood layering due to, 45, 48f surrounding orbital foreign bodies, description and illustration of, 18-19,
439, 446, 448f 20f
orbital exam with, 280f
488 INDEX
HRPED (hemorrhagic retinal pigment Immersion axial eye length (AEL) Infants; See newborns
epi thelial detachment, 161- measurements-cont'd Infections
162, 163f, 164f vector A-scan, 263, 264f ocular, 191-207
Hughes, WF. Jr. versus contact, 249 acquired immunodeficiency
role of Immersion technique; See also axial eye syndrome (AIDS), 205, 206£,
in history of ultrasound, 1 length (AEL) measurements 207
Hyperemia and contact axial eye length of choroid, 193, 199
of optic disc (AEL) measurements endophthalmitis, 191, 192f-193f,
with Vogt-Koyanagi-Harada for AEL measurements 194
0fKl{)syndrome,200-201 advantages and disadvantages, 249 non-infectious uveitis, 194-195
Hypermature cataractous lens discussion of, 259-260, 261£ ocular tumor inflammation, 207
inflammation secondary to, 194 A-scan of sclera, 199
phacolytic glaucoma with, 211, 212f for AEL measurements, 244, 245f scleritis, 195-196, 197 f, 198-199
Hyperopia, 80, 81£ B-scan sympathetic ophthalmia, 201-202
history of to evaluate lens, 40, 41£, 42 toxocariasis, 203, 204f
and AEL measurements, 250 ultrasound biomicroscpy (UBM), toxoplasmosis, 207
with scleral thickening, 80, 81£, 88 223-234; see also ultrasound uveal lymphoid hyperplasia, 202
Hyperopic globe, 80, 81£ biomicroscopy (UBM) vitritis, 194-195
Hyperostosis to detect Vogt-Koyanagi-Harada 0fKl{)
definition of, 452 foreign bodies, 100 syndrome, 200-201
Hypertensive retinopathy, 72-73 glaucoma, 209-210 opacities originating from, 45
Hyphema small lesions, 297, 300f Infectious panophthalmitis, 194
anterior chamber, 87-93, 90, 91£ to evaluate Infectious scleritis
after blunt trauma, 87, 88f, 91£ anterior segment, 15,37-40, 38f, description and illustration of, 199,
following penetrating trauma, 93, 94f 39,41£ 200f
and glaucoma, 213 ciliary body; see Ciliary body Inferior oblique muscles, 387t, 390f,
intraocular examination of, 14t orbit, 297, 300f 391,394, 395f; See also
posterior; See posterior hyphema uveitis, 194, 195f extraocular muscles
sequelae of blunt trauma, 88b potential sources of error, 259-260, Inferior rectus muscles, 387t, 388-389;
sequelae of penetrating trauma, 93b, 261£ See also extraocular muscles
94f scleral shell; See scleral shells Inferotemporal peripheral fundus
Hypoechoic layer on secondary glaucoma, 211-215 retinoschisis, 65 -66
on iris tumors, 232 to view Infiltrative metastatic carcinomas
Hypotony ciliary body lesions, 173-179 orbital
with cyclodialysis cleft, 90 iris melanoma, 172f differential diagnosis of, 311 t
following glaucoma surgery, 84, 216, medulloepithelioma, 188f Inflammation
217f,218 retinal detachment (RD), 58f associated with ocular tumors, 120,
maculopathy, 72, 216, 217f, 218 using balloonlike device, 87-93 121£,136,207
UBM imaging of, 233-234 Impact sites choroidal, 74, 199-202
uveitis leading to, 194-195 of penetrating wounds, 94-99 disorders of
Hypotony maculopathy Impedance; See acoustic impedance acquired immunodeficiency
description of, 72 acoustic, 2, 3f, 469 syndrome (AIDS), 205, 206£,
irreversible, 217 f Implant devices; See also glaucoma- 207
ultrasound images of, 216, 217f, 218 filtering shunts of choroid, 199-202
glaucoma-filtering, 218-221 endophthalmitis, 191, 192f-193f,
I Implantation cysts 194
Idiopathic orbital myositis, 380 epithelial downgrowth and, 108 non-infectious uveitis, 194-195
Idiopathic posterior uveitis Incarceration ocular tumor inflammation, 207
versus Vogt-Koyanagi-Harada 0fKl{) vitreous, 97f scleral tumors, 155, 159
syndrome, 200-201 Incidence angles scleritis, 195-196, 197f, 198-199
Idiopathic sclerochoroidal calcifications perpendicular versus oblique, 4f summary of, 192b
definition of, 147-148, 149f Incident waves sympathetic ophthalmia, 201-202
Immersion axial eye length (AEL) mea- angles of, 5f toxocariasis, 203, 204f
surements; See also immersion Inclusion cysts toxoplasmosis, 207
technique epithelial downgrowth and, 108 uveal lymphoid hyperplasia, 202
air bubbles, 260 Increased subarachnoid fluid (ISAF) vitritis, 194-195
B-scan, using, 263-265 causing optic nerve enlargement, 419, Vogt-Koyanagi-Harada 0fKl{)
concluding, 260 421£-422f, 423 syndrome, 200-201
errors, 259, 261£, 268b, 269f thirty-degree test for, 419, 422f intraocular echo graphic examinations
misalignment of sound beam, 269f Infantile glaucoma of, 14t
patient positioning for, 259f, 260f evaluation of, 209 myositis, 396,402, 403f-405f
for posterior staphylomas, 263, 264f ultrasound biomicroscopy of, 229 with ocular melanomas, 120
potential sources of error, 260 Infantile hemangiomas vitreous
and posterior staphyloma, 263 orbital membranes, 194
Prager shell, 260 characteristics and illustrations of, with posterior vitreous detachment
scleral shells, 245f, 259, 260f, 474 347, 351, 352f (PVD),49
vitreous body, 45
INDEX 489
Inflammatory debris Internal vascularity Intraocular tumors-cont'd

three-dimensional ultrasonography of, . of intraocular lesions, 35-37 characteristics of, 115
242 of orbital lesions, 302, 306, 308 of childhood, 184, 213
Inflammatory disorders Internet color Doppler imaging (CDI) of, 373
of the eye future of 3DUS along with, 242 detection of, 115
acquired immunodeficiency Intraconal cavernous hemangioma, 347, evaluating with ultrasound, 115-188
syndrome (AIDS), 205, 206f, 348f,349f and glaucoma, 212-213
207 Intraconallymphoma inflammation associated with, 207
of choroid, 199-202 adjacent to optic nerve, 420f measuring, 122-131
endophthalmitis, 191, 192f-193f, Intracranial meningioma secondary angle closure glaucoma
194 involving orbit, 454, 458, 459f-460f causing, 210-211
non-infectious uveitis, 194-195 Intralenticular foreign bodies scleral, 155, 158f, 159
ocular tumor inflammation, 207 detecting, 100 spectrum analysis of, 122
scleral tumors, 155, 159 ultrasound evaluation of, 42b three-dimensional ultrasonography
scleritis, 195-196, 197f, 198-199 Intraocular BB's, 100-10 1 (3DUS) of, 236-241
summary of, 192b Intraocular B-celllymphoma topography and volume of
sympathetic ophthalmia, 201-202 description and illustration of, 151, with 3DUS, 236-242
toxocariasis, 203, 204f 152f,153 UBM and, 231-233
toxoplasmosis, 207 Intraocular cilia, 102, 103f Intraretinal cysts, 90, 91£
uveal lymphoid hyperplasia, 202 Intraocular foreign bodies Intrascleral cysts, 155, 158f, 159
vitritis, 194-195 hemorrhagic tracks produced by, 95, Intumescentlens, 169
Vogt-Koyanagi-Harada (VKH) 96f anterior dislocation of, 211, 212f
syndrome, 200-201 Intraocular glass splinters, 102f with phacomorphic glaucoma, 211,
producing secondary glaucoma, 215 Intraocular lens (IOL) 212f
Inflammatory infiltration, 119-120, calculation errors ultrasound evaluation of, 42b
121£ following glaucoma surgery, 218 IOL; See intraocular lens
Inflammatory vitreous membranes, 194 . considering in AEL measurements, Iridociliary cysts, 232, 233f
Inflammatory vitreous opacities 255-256, 257f, 258f Iridocyclectomy, 232
associated with retained lens material, dislocated Iridodialysis
106,108 illustration of, 95f following penetrating trauma, 93, 93b,
Injections with penetrating trauma, 93-94 94f,95-:-,99
inadvertent steroid, 108 extrusion of, 90 Iridotomy
penetrating eyes, 108 implants ultrasound biomicroscopy image
Injuries; See trauma following intraocular surgery, 109 following, 229
Insertions measuring through different types, Iris
in extraocular muscle disorders, 396t 255-256,257f Bombe,213f
illustration of muscle, 390f power calculation formula, 269~270 cyclitic membranes, 95
of optic nerve into globe, 412, 414f power in silicone-filled eyes, 266-268 cysts
Instrumentation subluxation description and illustration of, 169-
for 3D ultrasound, 236, 237f following penetrating trauma, 93b, 170,171£
A-scan biometry, 244-249 94f,95-99 with UBM, 233
recommended features of, 246b sequelae to blunt trauma, 88b epithelial inclusion cysts involving,
A-scan, standardized, 8-9 UBM imaging of complications, 233 108
audio Doppler 308 Intraocular lesions; See also intraocular high resolution B-scan (20 MHz), 41£
B-scan, 9-10 tumors lesions
color Doppler imaging, 368f affecting AEL measurements, 262-268 associated with glaucoma, 212-213
probes; See probes detection and differentiation of intraocular echographic
ultrasound biomicroscope, 223, 225 in globe, 15-44 examinations of, 14t
ultrasound system 7f differential diagnoses of, 26b presentation of, 169-170, 171£
Internal reflectivity; See also reflectivity topographic evaluations which affect, 169-179
characteristics with A and B-scans, 473 measuring with UBM, 226-228
of different vascular neoplasms, Intraocular perfluorocarbon bubbles, melanomas
348t 109,112f description and illustration of, 170,
of lacrimal gland tumors, 324t Intraocular pressure 171f, 172f
glossary definition of, 469 with angle closure glaucoma, 210-215 metastasis, 173f
of various orbital tumors, 311 t assessment of, 209-210 nevus
Internal structure and glaucoma, 214 description of, 170
definition and example of, 34 with hypotony, 72 rotation
as diagnosis parameters large blebs associated with, 218-221 evaluating with UBM, 230
of intraocular lesions, 24, 26b . sign of carotid-cavernous sinus fistula, thickness (ID), 227f
glossary definition of, 469 355, 358f, 359 tumors
irregular, 118-119 Intraocular tumors; See also individual evaluating with UBM, 231-232
of optic nerve, 416f, 417f, 419, 421£ listing Iris bombe
of orbit apical height of, 122-129 causing secondary angle closure
quantitative echography of, 297, biometry of, 122-131 glaucoma, 211, 213f
300,302,303£ calcification of, 148-149, 151 Iris pigment epithelium
detecting cysts, 212
490 INDEX
Iris-lens contact distance (ILCD), 227f, Lacrimal sac Lens, crystalline-contd

228,229 dilated, 334f true thickness of (TLT), 262
Iris-zonule distance (IZD), 227f, 228, echogram defects from, 287 ultrasound evaluation of, 42b
229 evaluating lesions in, 332, 333f, 334f Lens capsule
Irreversible hypotony maculopathy, 216, tumors of, 334 ruptured
217f Lamina cribrosa, 430f, 431 following penetrating trauma, 93b,
Ischemic ocular disease Lamina scleritis 94f,95-99
color Doppler imaging (CDI) of, 367, calcification sequelae to blunt trauma, 88b
368b with vascular occlusions, 430f, 431 Lens implants; See intraocular lens
Lasers (IOL)
J treating choroidal melanomas, 129f Lens material
Jansen, F. Lateral extent retained during cataract surgery, 106,
role of of tumors, 28f 107f, 108
in history of ultrasound, 1 Lateral rectus muscles Lens nuclei
illustration of choroidal melanoma dislocation
K overlying, 138f description and illustration of, 168f,
Keratin ultrsound evaluation of, 387t, 388 169
in dermoid cysts, 334, 336 Lateral resolution, 223 ultrasound evaluation of, 42b
Keratometers 3DUS versus 2D, 237t retained in vitreous gel, 106, 108
calibration of, 270 and gainiS Lens-induced uveitis, 194
Keratometry glossary definition of, 469 Lens-iris diaphragm
definition of, 249 Latex tonometer covers, 39-40,41£ rotation of, 214
Keratoplasty Leiomyomas Lenticular myopia, 270
complications following, 104, 105f, description and illustration of, 154, Lesions; See also cysts; topography;
106 155f tumors
Kinetic echography versus melanomas, 154, 155 f anterior segment, 169-179
of choroidal detachments, 74-75 mimicking ciliary body melanomas, calcific of choroid, 147-148, 149f, 151
consistency, vascularity and mobility, 173,177, 178f, 179f categories of, 28
302, 306-309 Lens, crystalline; See also cataractous lens choroidal hemangiomas, 146f, 147
definition of, 35-36 abnormalities ciliary body, 173-179
diagnosis parameters, 26b with secondary glaucoma, 211, 212f classification of, 27f
to differentiate orbital mass lesions, blunt trauma affecting, 87-93 detection of, 115
289,291b,292-293 capsule rupture, 87, 88b, 89f, 93b documenting with axial scans, 21, 22f
to differentiate PVD,CD,and TRD, extrusion of, 90 echogram appearance of, 27f
50t dislocation, 87, 89f, 168f, 169 intraocular
to evaluate retinal tears, 52, 53f, 54f, description and illustration of, 168f, affecting AEL measurements, 262-
62 169 268
glossary definition of, 469 intraocular, 95f, 108 differential diagnoses of, 26b
versus quantitative evaluations, 24, 26, of nucleus, 106, 108f, 168f, 169 measuring, 122-131
27f,28 with secondary glaucoma, 211, 212f macular, 68b
"Kissing" choroidal detachments three-dimensional ultrasonography measuring
description and illustration of, 75, 76f of,242 intraocular tumors, 122-131
following scleral ruptures, 92 ultrasound evaluation of, 42b mobility
hemorrhagic, 104, 105f, 106, 107f effect of blunt trauma on, 87-93 B-scans to assess, 36, 37f
Kretztechnik 7200 MA, 1 interface and acoustic impedance, 3f definition of, 309
intumescent, 211, 212f optic nerve, 423-431
L liquefaction orbital
Labeling and glaucoma, 211 quantitative echography of, 297,
of echograms, 475 ultrasound evaluation of, 42b 300, 301£, 302
Lacrimal arteries measurements reflectivity classifications, 300,
color Doppler imaging (CDI) of, 367 ultrasound evaluation of, 42b 301£
Lacrimal ductal cyst, 332 methods of evaluation, 40, 41£, 42 size, shape and borders, 289, 291 b,
Lacrimal fossa region normal versus cataractous, 87, 88f 292-293
tumors associated with, 319-334 normal versus subluxated, 87, 88f special examination techniques,
Lacrimal gland opacification 289, 291b, 292-293, 294f, 295f
benign mixed tumors, 324, 325f, 326- versus normal, 87, 88f special techniques for differentiation,
327 with trauma, 87-114 24-37
echographic findings of, 324t posterior lenticonus, 43f topographic techniques for, 15-44, 27f
enlargement with Graves' disease, retained material, 87, 89f, 106, 107f, Leukemia
396, 397f-401£ 108 affecting the choroid, 154
para ocular A-scan technique for rupture of, 87, 89f causing premacular hemorrhages, 72-
evaluating, 324f simulating melanoma, 169 73
transocular approach to examine, 284 and sound beams Leukokoria, 183t, 184-189
tumors of axial scans, 21-22 AEL measurements to diagnose, 270
associated with, 319-334 through,32 conditions associated with, 183t
unilateral/bilateral characteristics, subluxation, 87 cysticercosis and, 203, 205
324t sequelae to blunt trauma, 88b
INDEX 491
Leukokoria-cont'd Lymphoid hyperplasia Manual measurement mode

other lesions associated with, 184-189 . orbital, 310 ofbiometers, 246, 254f
retinoblastoma and, 183t, 184, 187, uveal Marker; See probe markers
189 causing choroidal inflammation, 74 B-scan probe, 15, 16f
Levator muscles, 407f diagnosing, 153-154 Masses
Levator palpebrae muscle, 387t, 389, Lymphoma as indication for orbital examination,
390f,407f cm and, 374 274t
Lid retraction, 396, 397f enlarged muscles due to, 405-406, Massive suprachoroidal hemorrhagic
Lids; See eyelids 407f detachments, 104, 105f, 106
Limbal dermoid tumors, 177, 180f intraocular B-cell, 151, 152f Masslike lesions, 27f
Limbus involving lacrimal gland, 327, 330-331 Mature cataracts
movement of probe from, 25f in lacrimal fossa region, 327, 330-331 associated with calcifications, 148b
placement of probe near, 18,20, 21f orbital, 310 Mean end diastolic velocities, 371 t
wound rupture, 92 differential diagnosis of, 311 t Mean peak systolic velocities, 371 t
Linear amplification curves, 7f, 9 large, 313f Measurement modes
Linear analysis versus Vogt-Koyanagi-Harada automatic versus manual, 246, 254f
3DUS versus 2D, 237t syndrome (VKH), 200-201 Measurements
Location Lymphoproliferative diseases of extraocular muscles, 384, 386f, 387t
as diagnostic parameter in lacrimal fossa region, 327, 330-331 immersion technique, 259-260, 261f
of intraocular lesions, 26b with orbital tumors, 310, 311f, 312f, method of obtaining
Loculated orbital abscesses, 441f 313f from B-scan echograms, 476
Logarithmic amplification curves, 7f, 9 of uveal tract, 153-154 minimizing errors in AEL, 268-269
Long eyes of optic nerve
history of M with A-scan, 412, 415, 416f-417f,
and AEL measurements, 250 Macula 418,419
Longitudinal approach age-related macular degeneration three dimensional volume, 131
to evaluate lens, 40,41f, 42 (AMD); See age-related topographic 3D, 236-242
Longitudinal B-scan macular degeneration (AMD) of tumor bases, 129, 13 Of
for basal diameter measurements, 129, and disciform macular of apical tumor height, 122-129
130f, 131 degeneration (disciform lesion) with ultrasound biomicroscopy
description and illustration of, 17-21 choroidal hemangiomas located near, (UBM),226-228
to examine rectus muscles, 380, 384f 146f, 147, 148f using 3DUS, 236, 237t, 238f, 239
of funnel-shaped RD, 57f contact AEL measurements to, 258f Mechanical waves
glossary definition of, 469 detachment of, 30f, 31f, 72, 74f, 435f along acoustic spectrum, 223-225
measuring tumors, 122-131 edema of, 67-68 Medial rectus muscles
of normal optic nerve, 412, 414f evaluation of, 28, 29f-31f, 32 examination of, 384, 387
orbital examinations using, 281f holes, 70-72 melanoma of, 407f
paraocular from blunt trauma, 90 myositis of, 403f
of orbital cyst, 298f hypotony maculopathy, 72 thickening of, 397f
of peripheral traction RD, 63f hypotony after glaucoma-filtering Medications
probe marker orientation for, 19t, surgery, 217 toxic reactions to
20f reverse longitudinal B-scan of, 28, 32 and glaucoma, 214, 215f
reverse, 28, 32, 71f, 435f vertical B-scan of, 28, 29f-31f Medulloepitheliomas
sound beam penetration with, 17-22 Macular disciform lesions, 68, 69f, 70 in children
of superior orbit, 284, 285f Macular edema with glaucoma, 213
during topographic evaluations, 26 AEL measurements and, 265 of ciliary body, 187, 188f
using paraocular approach, 275, 283, description and illustration of, 67-68 cystic lesions with, 51, 189
284f detection of, 60 mimicking ciliary body melanomas,
using transocular approach, 281 with posterior uveitis, 194-195 173,177
Longitudinal waves Macular holes versus retinoblastoma, 183t, 184, 187,
characteristics of ultrasonic, 2 definition and causes of, 70-72 188f
transducer production of, 5-6, 8 from blunt trauma, 90 Melanocytomas
Longstanding avulsion Macular lesions; See also individual listing associated with glaucoma, 212-213
of optic nerve, 93f affecting AEL measurements, 263, description and illustration of, 151,
Lyme disease 264f 152f
associated with choroidal thickening, Magnetic resonance imaging (MRI) mimicking ciliary body melanomas,
202-203 to detect retinoblastomas in optic 173,177, 178f, 179f
versus Vogt-Koyanagi-Harada (VKH) nerve, 180, 184 Melanoma; See Ocular melanoma
syndrome, 200-201 oflacrimal system disorders, 319, 324t Membranelike echoes, 27f
Lymphangiomas Magnocellular nevi Membranes
orbital description and illustration of, 151, definition of, 45 .
in children, 351-352, 353f, 354f, 152f documenting with axial scans, 21, 22f
355 Malignant glaucoma; See also glaucoma in endophthalmitis, 191, 193f
differential diagnoses of, 348t evaluating with UBM, 230 stalklike, 61f
with hemorrhages, 352, 353f, 354f, causing secondary angle closure topographic B-scan evaluations of, 26,
355 glaucoma, 210-211 27f,29f
surgical complications, 216
492 INDEX
Meningiomas Miosis Muscles-cont'd

optic nerve sheath intraocular echographic examinations medial rectus-cont'd
description and illustration of, 424, of, 14t myositis of, 403f
425f-427f Mixed cell melanoma thickening of, 397 f
sphenoid wing, 454, 458f, 459f, 46lf choroidal, 120, 12lf, 122 oblique, 387t, 389, 390f
Meningocele, 465 illustration of, 121 f techniques for examining, 380,
Meridians Mobility 38lf-384f
example of 12 o'clock, 25f of intraocular lesions, 36, 37f rectus
and paraocular approach, 275, 282- definition of, 309 evaluation of, 384, 387
283 Molento implants, 218, 219f, 220, 22lf normal thickness values, 387t
in transocular approach, 275, 27 6f- "Morning glory syndrome," 432, 433f, techniques for examining, 380,
279f,280 434 38lf-384f,387t
of transverse scans, 18.19f Motility superior oblique, 387t, 391, 392£, 393f
Mesenchymal tumors disturbances superior rectus, 387t, 389, 405f
in orbit, 315, 318f as indication for orbital Mushroom shaped ocular melanomas;
Metallic foreign bodies examination, 274t See collar button shape
echographic findings for, 96f, 99, 100f Motion Myopes
longstanding, 100f convection,24,26b,37 history of
Metastatic and secondary tumors of reflector with CD I, 367 -368 and AEL measurements, 250
orbital, 315, 318-319, 320f, 322f three types of, 35-37 Myopia
Metastatic carcinoma MRI; See magnetic resonance imaging AEL measurements to diagnose, 270
versus age-related macular (MRI) history of
degeneration, 70, 161 Mucocele and AEL measurements, 250
to choroid, 142-144, 147 definition of orbital, 452, 454, 456f, and macular staphyloma, 73
collar button shaped, 144 457f and scleral thickness, 80, 88
versus diffuse melanomas, 136-137 Mucoepidermoid carcinomas with scleral thinning, 84
echogram illustration of, 34f orbital Myopic degeneration
enlarged muscles due to, 405-406, description and illustration of, 327, stimulating AMD, 68, 69f, 70
407f 329f Myositis
causing extraocular muscle thickening, Mucous plugs causing compressive optic neuropathy,
380,406f with dacryocystitis, 336£ 428-429,430f
histology of, 34f Multifocal fibrosclerosis, 155, 158f, 159 definition of, 396
to iris, 170-173 Multiple signals examination techniques, 396,402,
and optic nerve thickening, 424, 428f From air bubbles, 103, 112 403f-405f
orbital artifacts produced by, 466-467 left superior oblique, 393f
differential diagnosis of, 311 t from foreign bodies, 100, 10lf, 102f versus metastatic carcinoma, 405-406,
types of ocular, 142-144, 145f-146f, echo gram illustrating, 8f 407f
147 glossary definition of, 469
versus Vogt-Koyanagi-Harada (VKH) from pseudophakic eye, 255-256, N
syndrome, 200-201 257f,258f Nails
Metastatic melanoma produced by probe and bubbles, 109, eye injuries from, 94f
enlarged muscles due to, 405-406, 112 causing penetrating trauma, 95-99
407f Mundt, G.H. Jr. N anophthalmos
Metastatic processes role of AEL measurements to diagnose, 270
invading optic nerve, 424, 428f, in history of ultrasound, 1 description and illustration of, 82,
Metastatic renal cell carcinoma Muscle cone 83f
three cases of orbital, 319, 320f cavernous hemangiomas within, 347- and glaucoma, 214
Metastatic tumors 348, 349f, 350f Near fields, 5, 6f
orbital, 310 Muscle sheath Necrosis
description and types of, 315, 318- spikes illustrating, 380, 382, 385f, 386£ of ocular melanoma, 119, 120, 137,
319,320f-323f Muscles; See also extraocular muscles; 161
Methylcellulose individual muscles postradiation findings, 13 7-13 8
adding to probe tip evaluation of individual muscles, 384- renal due to herpes, 205
to avoid acoustic artifacts, 15, 466- 395 scleritis and episcleritis associated
467 inferior oblique, 387t, 390f, 391, 394, with, 120, 12lf, 122f
filling scleral shells, 37, 38f, 39, 87, 395f Necrotizing scleritis
88f,89f inferior rectus, 387t, 388-389 with scleral thinning, 84-85
used in paraocular approach, 287, 289 lateral rectus simulating melanoma, 198-199
used with sterile rubber sleeve, 139f, illustration of choroidal melanoma Needles
140f,141 overlying, 13 8f aspiration, 355
l1icrophthalmos ultrsound evaluation of, 387t, 388 biopsy in lacrimal region, 439, 443f
AEL measurements to diagnose, 270 levator,407f penetrating eyes, 108
with cyst, 340, 343f levator palpebrae, 387t, 389, 390f causing penetrating trauma, 95-99
l1icrovascular networks medial rectus Neoplasms
analyzing with spectrum analysis, 122 examination of, 384, 387 invading optic nerve, 424, 425f-427f,
I[iliary tuberculosis melanoma,407f 428
associated with AIDS, 205, 206f, 207 orbital, 315, 318-319, 320f-323f
INDEX 493
Neurilemmomas Ocular melanoma Ocular melanoma-cont'd

global acoustic properties of, 115, 116f, 117 small,132
description and illustration of, 154- acoustic hollowing and, 117, 118f small, measurement of, 129
155, 156f A-scan, angle kappa, 117, 118f sound attenuation, 117, 118f
orbital A-scan for localizing apex of, 123, spectrum analysis of, 122
description and illustration of, 314, 125f sub-Tenon's inflammation and, 120,
316f apical height measurements, 122-129 134,
differential diagnosis of, 311 t associated retinal detachment, 115, three-dimensional imaging for, 239-
Neurofibromas 118, 127f 241
orbital basal diameter measurements, 129- typical features of, 115, 117
description and illustration of, 314- 131 UBM and, 231-233
315, 316f, 317f biometry of, 122 -131 vortex vein involvement by, 132,
differential diagnosis of, 311 t B-scan for localizing apex of, 123, 134f
plexiform, 315, 317f 124f Ocular sequelae
solitary, 314, 317f calcification of, 120, 122f after blunt trauma, 88b
of uveal tract, 155 cavitary, 173, 177f following penetrating trauma, 93b
Neurofibromatosis choroidal excavation, 118 with persistent hypotony, 216, 217 f,
in children ciliary body, 173 -1 77 218
with glaucoma, 213 ciliochoroidal, 117f, 174f Ocular toxoplasmosis; See toxoplasmosis
Neurogenic tumors collar button shape of, 115, 116f Ocular tumors; See intraocular tumors
in orbit, 310 configuration of, 115, 116f Oksala, A.
Nevus cystic spaces in, 120, 176f, 177f role of
choroidal, 15 Of, 151 detecting, 115 in history of ultrasound, 1
iris, 170,231-232 differential diagnosis of, 142 Opacification; See also cataract; cataracts
Newborns diffuse, 13 6, 13 7 corneal, 87, 88f-89f, 90
AEL measurement values for, 245t episcleral inflammation following oflens, 87, 88f
dacryocystitis in, 335 f radiation, 138, 139f of ocular media, 14t
microphthalmos/anophthalmos in, episcleritis and necrosis, 120 Opacities
340, 343f, 344f, 345 erroneous height measurements, 128f definition of, 45
teratoma in, 345 external beam localization, 138, 141 due to endophthalmitis, 191, 193 f
Nodular posterior scleritis extraocular muscles mistaken for Opaque ocular media
description and illustration of, 196, extraocular tumor, 134, 138 causes of, 45-51
198f extrascleral extension of, 131, 13 2; See detecting melanoma in, 115 -141
Normal tension glaucoma, 215 also extrascleral extension echography to evaluate, 13, 14t
color Doppler imaging of, 373 glaucoma and, 212-213 following glaucoma surgery, 216,
growth of, 129f, 139f 217f,218
o hemorrhage and, 55f, 118, 119f Open angle glaucoma, 211
Oat cell carcinoma of choroid, 144, height change following treatment, Ophthalmic artery (OA)
145f 129f, 138 blood flow velocities, 371 t
Oblique axial scans high resolution B-scan (20 MHz) for, color Doppler imaging (CDI) of, 367,
description and illustration of, 19t, 21, 17lf, 174f 371-372
22f immersion technique for, 171, 172, Optic atrophy
probe marker orientation for, 22f 174,175 definition of, 431
Oblique muscles, 387t, 389, 390f iodine-12 5 plaque, B-scan localization as indication for orbital examination,
techniques for examining, 380, 38lf- of, 138, 139f, 141,241 274t
384f inflammation associated with, 120, Optic cups
Oblique sections 12lf, 136,207 evaluating size of, 209, 210f, 432, 433f
3DUS versus 2D, 237t irregular internal structure of, 118, illustration oflarge, 210f
Oblique sound beam incidence, 4f 119, 120 vertical transverse B-scans of, 432,
to confirm foreign bodies, 99 iris, 170, 17lf, 172f 433f
Oblique transverse scans involving iris and ciliary body, 172f Optic disc
for orbital exams, 280 monitoring size of, 129, 139f abnormalities
Occludable anterior chamber angles, necrosis of, 119-120, 137, 161, 199 echo graphic examination of, 14t
210 versus nodular scleritis, 196, 198f B-scan of
OCT to view macular holes, 70, 7lf orbital involvement, 132f, 133f, 323f to determine cup size, 209, 432,
Ocular coats, 84 and plaque localization, 138, 140f, 433f
Ocular coherence tomography (OCT) 141,241 coloboma, 432, 433f, 434
to view macular holes, 70-71 causing posterior scleral bowing, 118 crowded, 84f, 434
Ocular injuries pseudoextrascleral extension and, 134 cupping and, 209, 432
Blunt, 87, 93 136, 138, 139f disorders of, 412b, 431
penetrating, 93-103 radiation therapy for, 13 7-13 8, 14lf drusen, 412b, 431, 434, 436f, 437f
surgical, 104-108 regression of, 120, 131, 137f, 138, 139 edema
Ocular ischemic syndrome (OIS), 372 scleral bowing and, as indication for orbital
Ocular media scleral infiltration, 132, 133f examination,274t
clear versus opaque scleral thickening and, 123, 129f, 138 elevation, 434, 435f
summary of, 14t scleritis and, 120, 123, 129f, 138, 198 excavation, 432, 433f
sound velocities for individual, 247t
494 INDEX
Optic disc-cont'd Orbit-cont'd Orbital bone-cont'd

hyperemia cysts of-'-cont'd relationship of optic nerve to, 412
with Vogt-Koyanagi-Harada dermolipoma, 336, 340f tumors that metastasize to, 458, 462f
(VKH) syndrome, 200-201 epidermoid, 336, 33 9f Orbital cellulitis
illustration of normal, 414f, 433f, 435f epithelial, 336 due to trauma, 439, 440f
pit, 432, 435f hematic, 340, 343f produced by retinoblastomas, 207
proliferative membranes at, 61£, 92-93 mucocele, 452, 454, 456f, 457f, 458f Orbital cystic lesions
pseudocupping of, 209, 210f, 432, 434 teratoma, 345 types of, 33 6b
pseudopapilledema, 84f, 434 Doppler evaluation of, 10,308,367- Orbital disorders; See individual listing
retinal hamartomas at, 155, 156f 375 Orbital examinations
swollen examination techniques, 275-309 indications for, 274t
with posterior scleritis, 195-196 B-scans,275-283 Orbital foreign bodies, 103,439,446,
vitreous cysts of, 51 kinetic echography, 302, 306, 307£, 447f-448f
Optic disc coloboma, 432, 433f, 434 308-309 Orbital fractures
Optic nerve; See also optic disc; lesion detection, 283-289 description and illustration of, 439,
retrobulbar optic nerve lesion differentiation, 289-297 446, 450f
abnormalities, 412-436 quantitative echography, 297,300- Orbital hematomas
listing of, 412b 302, 303f-305f due to trauma, 439, 441£-446f
A-scan technique, 412 -419 soft tissue, 275, 276f-279f, 280 Orbital hemorrhages, 90, 91f
B-scan technique, 412, 413f-415f transocular approach, 275, 27 6f- Orbital inflammation
head drusen, 148-149 279f,280 choroidal melanomas with, 121£
lesions, 423-431 extraocular muscles; See extraocular with posterior scleritis, 195-196
measurements muscles within Tenon's space, 119-120, 121f
with A-scan, 412, 415, 416f-417f, foreign bodies of, 97f, 99, 439, 446, Orbital lesions
418,419 447f, 448f, 450f transocular approach to examine, 275,
Optic nerve disorders indications for examination of, 273, 276f-279f,280
differential diagnoses of, 419t 274t Orbital mass lesions
Optic nerve glioma internal structure, 297, 300, 302, 303f color Doppler imaging (CDr) of, 374
description and illustration of, 423- introduction to, 273 differentiation of, 289, 291b
424 malformations and glaucoma, 214-215 topographic echography, 289, 291b,
Optic nerve head melanoma extension into, 131-13 2, 292-293, 294f, 295f
crowded, 84f, 434 133f Orbital pseudotumors
determining cup size, 209 and optic nerve; See optic disc; optic diffuse, 310, 312f
drusen, 434, 436f, 437f nerve; retrobulbar optic nerve Orbital soft tissue
excavation, 432, 433f, 434 paraocular approach, 275, 282-283 A and B-scans of, 27 5, 27 6f
Optic nerve parenchyma periorbital diseases, 451-465; See also echogram illustrating, 8f
lesions involving, 423 -431 periorbital diseases Orbital trauma
Optic nerve pit, 432, 435f reflectivity, 300, 301£ from emphysema, 439b, 446, 449f
Optic nerve sheath sound attenuation, 297, 302, 304f, of extraocular muscles, 439b, 450-451
decompression, 431, 432f 305f from foreign bodies, 439, 446, 447f-
meningioma topographic echography of, 289, 448f
color Doppler imaging (CDr) of, 291b, 292-293, 294f, 295f fractures, 439b, 446, 450
374 trauma, 439-451; See also orbital hemorrhages, 439, 441£-446f
description and illustration of, 424, trauma of optic nerve, 439b, 451
425f-427f tumors of, 310-345; See also orbital orbital abscesses, 439, 441£-446f
Optic nerve void tumors orbital cellulitis, 439, 440f
versus shadowing, 99 ultrasound orbital hematomas, 439, 441£-446f
Optic neuritis advantages and disadvantages, 273 Orbital tumors, 310-345
description and illustration of, 419, vascular lesions, 347-365 adenoid cystic carcinoma, 327, 328f
420f, 421£, 423-424, 433f orbital varix, 359, 361-363 benign mixed, 324, 325f, 326-327
Optic rim vascular malformations, 355, 358f, cystic lesions, 334, 336, 337f
borders of, 209, 210f 359, 360f differential diagnosis of, 311 t
Ora serrata vascular neoplasms, 347-355, 35 6f, of extraocular muscles, 405-406, 407f
disinsertion from peripheral retina, 357f fibrous histiocytomas, 315, 318f
90 Orbital abscesses of lacrimal gland, 319, 324t, 327, 330-
disinsertion of retina from, 52, 54 due to trauma, 439, 441£-446f 331
Orbit Orbital aneurysms, 365 lacrimal system, 319-334
A-scan screening of, 285, 287, 288f, Orbital apex, 426f lymphoproliferative diseases, 310,
289 Orbital blood vessels 311£, 312f, 313f
B-scan screening of, 284-289 CDr assessment of, 367-375 metastatic and secondary, 315, 318-
color Doppler imaging (CDr) of, 367- using Doppler to determine blood 319, 320f, 322f
375; See also color Doppler flow in, 10 mucoepidermoid carcinoma, 327, 32 9f
imaging (CDI) Orbital bone neurofibroma, 314, 317f
cysts of defects, 452, 454f, 455f of optic nerve, 412b, 419, 423, 424,
anophthalmos, 340, 344f, 345f fractures, 439b, 446, 450 425f, 426f, 427f, 428f
dermoid, 334, 336, 337f, 338f hyperostosis of, 459-460, 464f primary, 310, 314, 315f
INDEX 495
Orbital tumors-cont'd Pars planitis, 194 Peripheral annular ciliochoroidal

pseudotumors and lymphoma, 310, Pars plicata, 77, 78f detachments
311£, 312f, 313f Patient associated with malignant glaucoma,
rhabdomyosarcoma, 310, 314, 315f fixation, 261-262 216
schwannoma, 314, 316£ positioning of, 15, 16f, 249, 259f, 260f Peripheral capillary hemangiomas, 155,
teratoma, 345 preparation for AEL measurements, 156£
Orbital varices 250 Peripheral eccentric HRPED, 161-162,
description and illustration of, 359, Pavlin, Charles]. 163f, 164f
361, 362f, 363f role of Peripheral iris melanomas
low blood flow velocities, 374 in history of ultrasound, 1 with extension into ciliary body, 172f
shapes, 361, 362f-363f Peak systolic velocity (PSV), 371 Peripheral lesions of eye
Organ perfusion Pediatric examinations measuring height of, 122-123
with color Doppler imaging (CDI), axial eye length measurements (AEL), Peripheral nerve sheaths
367,369 244,245t neurilemmomas arising from, 154-
Oscillating transducers challenge of, 43-44 155, 156£
in B-scan, 9, 15 Pencils Peripheral retina
illustration of, 10f causing penetrating trauma, 95-99 disinsertion from ora serrata, 90
Ossoinig, K.c. Penetrating ocular injuries; See also examining with UBM, 226
in history of ultrasound, 1 penetrating trauma Peripheral retinal dialysis
Osteoma, 465 Penetrating trauma definition of, 52
choroidal, 3Sf, 147-148, 149f to anterior segment, 93-95 detecting following blunt trauma, 90
orbital, 465 in extraocular muscles, 408-409 Peripheral retinal tears; See retinal tears
Osteomyelitis, 465 foreign bodies following, 99b Peripheral retinoschisis; See retinoschisis
Osteosarcomas, 465 to posterior segment, 95-99 Perpendicular sound beam incidence, 4f,
OTI machine, 236, 237t, 238f sequelae of acute, 93b 467
Outer sclera Penetration Perpendicularity
and intraocular tumor measurement, versus frequency, 224f definition of, 123, 124f-128f, 129,
122-131 loss with increased resolution, 223, 130f, 131
Ovarian cancer 224f in optic nerve B-scans, 412, 418f
BDUMP associated with, 166 sound beam, 17 -22 Persistent hyperplastic primary vitreous
Perfluorocarbons (PHPV)
p
postsurgical finding of, 112 cm of, 372
Pain Perineural sheaths versus retinoblastoma, 183t, 185, 186£
with angle closure glaucoma, 210-215 lesions involving, 423-431 causing secondary angle closure
as indication for orbital examination, Periorbita glaucoma, 210-211
274t enlargement with Graves' disease, Phacolytic glaucoma
with phacolytic glaucoma, 211 396, 397f-401£ description and illustration of, 211
severe ocular Periorbital diseases with hypermature cataractous lens,
with scleritis, 195-196, 197f, 198- definition and evaluation of, 451-465 211
199 orbital,451-465 Phacomorphic glaucoma
with traumatized globe, 87 orbital abnormalities definition and illustration of, 211
Paint balls bone defects, 452, 454f, 455f causing secondary angle closure
causing blunt trauma, 87 bone metastasis, 458, 462f glaucoma, 21 0-211
Palpable masses bones and sinuses Phakic eyes; See also axial eye length
as indication for orbital examination, 451-452,453f (AEL) measurements
274t eosinophilic granuloma, 458, 463f axial eye length measurements of, 244,
Palpebral lobe oflacrimal gland, 324 excavation, 452 245f,252-253
Panophthalmitis fibrous dysplasia, 458, 464f, 465 immersion technique to measure, 259-
description and illustration of, 194 hyperostosis, 452 260,261£
Para-axial scans mucocele, 452, 454, 456f, 457f peripheral traction, 62, 63f, 64f
to evaluate macula, 28, 29f sinus lesions, 452, 454, 456f, 457f sound velocities, 247t
Paraneoplastic syndromes sphenoid wing meningioma, 454, Phthisis bulbi
BDUMP, 166 458, 459f-460f AEL measurements to diagnose, 270
Paraocular approach, 282-283 Periorbital malignancies associated with calcifications, 148b
A-scan, 277f, 279f, 287, 289 invading orbit, 458, 462£ with chronic hypotony, 216
B-scan, 278f, 279f, 282-283 Periorbital vessels illustration of, 114f
definition of, 282 color Doppler imaging (CD I) of, 367, postsurgical findings of, 114
Paraocular compression test, 307f 368b PHPV (persistent hyperplastic primary
Paraocular echo grams Periosteum vitreous), 183t, 185, 186
of lacrimal gland tumors, 297f metastatic tumors of, 318, 319f, 320f Physics
Paraocular longitudinal B-scans thickening of of color Doppler imaging (CDI), 367-
of orbital cysts, 298f with Graves' disease, 398f 368
of examining orbit, 275, 277f, 278f, Peripapillary region of three-dimensional ultrasonography
279f, 280, 282-283, 287, 289, diabetic traction RDs in, 62, 64f (3DUS), 236, 237t, 238f, 239
296£ Peripapillary scans, 21-22 of ultrasound, 1-10
Pars plana, 77, 78f Peripapillary traction RDs, 62, 64f of ultrasound biomicroscopy (UBM),
Molento tube through, 221£ 223, 224f, 225
496 INDEX
Piezoelectric crystal, 5 Posterior coloboma, 166, 167; See also Posterior vitreous detachment (PVD)-
Piezoelectric element coloboma cont'd
glossary definition of, 469 Posterior hyaloid; See also posterior from blunt trauma, 90
of ultrasound transducer, 5-7 vitreous detachment (PVD) versus retinal detachment (RD), 32-33,
Piezoelectric polymer polyvinylidene incarceration of, 97f, 98f 35, 36f, 50t, 56, 58, 59f, 60f
diflouride (PDVF) inflammation, 19lf, 193 separation from optic nerve, 48f, 49
description and illustration of, 225 to lens nucleus, 108f sequelae to trauma, 88b, 93b
Pigment epithelium Posterior hyphema subvitreal hemorrhage, 50-51
serous versus hemorrhagic subhyaloidal, 50-51 with Weiss ring, 49, 72
detachment, 115 subretinal, 54, 56f Postoperative refractive errors, 270
Pigmentary dispersion syndrome suprachoroidal, 612, 164f Postsurgical findings
evaluating with DBM, 230 Posterior lens capsule following intraocular surgery, 108-114
Pigmentary glaucoma echogram illustrating, 8f glaucoma filtering shunts, 112
definition and causes of, 211 Posterior lenticonus, 43f intraocular lens implants, 109
Pilocarpine, 230 ultrasound evaluation of, 42b intraocular silicone, 112, 113f
Plaque Posterior nodular scleritis, 196 perfluorocarbon, 112
Cogan's, 148-149, 150f, 151 illustration of, 198f phthisis bulbi, 114
radioactive, 138, 139f, 140f, 141 versus metastatic carcinoma to scleral buckle, 109, 11 Of-11lf
Plaque localization techniques, 138, choroid, 143-144 vitreous skirtlhemorrhage, 109,
140f,141 Posterior ocular coats, 84 111f
Plaque radiotherapy Posterior sclera and trauma, 87-114
effect on choroidal melanomas, 137f, Intraocular tumor measurement error, Prager shell, 260
138f 128f Premacular hemorrhages
mimicking extraocular extension, 136 Posterior scleral bowing disorders which cause, 72-73
and pseudoextrascleral extension, 134, definition and illustration of, 118, Presumed ocular histoplasmosis (POH),
136, 138, 139f 133f, 154-155, 156f 68
for thinning sclera, 85 Posterior scleral ruptures Primary orbital tumors, 310, 314, 315f
three-dimensional ultrasonography after blunt trauma, 90, 9lf, 92f Probe markers
(3DDS),241 following penetrating trauma, 95-99 in axial B-scans, 21, 22f
Plateau iris syndrome, 229-230 sequelae to blunt trauma, 88b B-scan
Plexiform neurofibroma of orbit sequelae to penetrating trauma, 93b illustrations of, 16f, 18, 19f, 20f,
description and illustration of, 315, Posterior scleritis 22f, 23f, 29f-32f
317f description and illustration of, 195- orientation and direction of, 19t,
differential diagnosis of, 311 t 196, 197f, 198-199 20f
PMMA; See polymethylmethacrylate diffuse, 196, 197f orientation
Pneumocystis carinii and glaucoma, 215 for axial B-scans, 19t, 22f
associated with AIDS, 205, 206f, 207 nodular, 196, 198f Probe; See also A-scan probe; B-scan
Pointlike echoes, 27f versus Vogt-Koyanagi-Harada (VKH) probe; transducers
Polychondritis syndrome, 200-201 artifacts, 466-467
associated with choroidal thickening, Posterior segment of globe A-scan
202-203 blunt trauma sequelae, 88b biometry, 245, 247f
Polymethylmethacrylate (PMMA) IOL, blunt trauma to, 90, 9lf cleaning and calibration of, 270
255, 257f, 267 examination techniques for, 15-44 with immersion technique, 37, 38f,
average correction factor for, 255t indications for examination, 14t 40
Polyposis Posterior staphyloma, 72 standardized, 8-9
of ethmoid sinus, 453f affecting AEL measurements, 263, tissue sensitivity determination, 8-9
Positioning 264f B-scan
of patient Posterior subcapsular cataracts, 43f characteristics of, 15-22, 23f, 24
for A and B-scans, 15, 16f Posterior uveitis, 194-195 high-resolution B-scan (20 MHz),
to assess posterior hyphema, 51, 54, Posterior vitreoschisis, 60, 62 4lf
56f description of, 194 with immersion technique, 37, 38f,
of probe Posterior vitreous detachment (PVD) 39-40,4lf
for A-scan of optic nerve, 412, 415, in asteroid hyalosis, 45, 47f introduction to, 5
416f-417f, 418, 419 B-scan evaluation of, 191, 193f, 194 three-dimensional ultrasonography
to assess vascularity, 37 differentiating from choroidal (3DDS), 236, 237f, 238f, 239
for B-scan of optic nerve, 412, 413f- detachment (CD), 50t ultrasound biomicroscopy (DBM),
415f following penetrating trauma, 93b, 223,225-226
to evaluate glaucoma, 209, 210f . 94f,95-99 color Doppler imaging (CDI), 369,
Posterior lens capsule incarceration of, 97f 370f,371
rupture of, 106, 107f, 108 movement of, 36f, 49, 50t, 56, 58 soft-tipped
Posterior chamber convexplano PMMA normal versus vitreous hemorrhage, in trauma cases, 87-93
IOL,267-268 48f,49 solid versus water-filled, 247f
Posterior ciliary artery (PCA) versus normal vitreous, 45, 46f, 47f, Progressive outer retinal necrosis
blood flow velocities, 371 t 48f (PORN)
color Doppler imaging (CDI) of, 367, partial, 60, 6lf with herpes zoster, 205
371-372 relationship to macular hole, 7lf, Proliferative stalks, 6lf
72f
INDEX 497
Pseudocupping Q Reflectivity-cont'd
of optic disc, 209, 210f, 432, 434 Quantitative echography of globe, 32-35 as parameter for diagnosis
Pseudoenophthalmos B-scan, 29, 30, 32f of intraocular lesions, 24, 26b
AEL measurements to diagnose, 270 to differentiate orbital mass lesions, posterior vitreous detachment (PVD),
Pseudoexophthalmos 289, 291b, 292-293 49, SOt
AEL measurements to diagnose, 270 to differentiate PVD, CD, and RD, ofRD versus PVD, 32-33
Pseudoextrascleral extension SOt and sound attenuation
of melanomas, 134, 136, 138, 139f glossary definition of, 470 of ocular melanomas, 117-118
Pseudomelanomas of orbit, 297 -302 of various orbital tumors, 311 t
that simulate ocular melanomas, 142b of radiofrequency signals, 22 5 Reflector motion
Pseudomembranes type II in color Doppler imaging (CDI), 367-
versus retinal detachments, 45, 47f, 48f drawbacks of, 35 368
Pseudo-operculum in macular holes, 73 Quantitative measurements Refraction, 467b
Pseudopapilledema, 84f, 434 with color Doppler imaging (CD I), affecting echoes, 2, 3f, 4-5
Pseudophakia; See pseudophakic eyes 371-372 causing Baum's bumps, 467
Pseudophakic cystoid macular edema, Quartering technique definition of,S
67-68 using 3DUS, 241 edge artifact, 467, 469
Pseudophakic eyes effect on axial B-scans, 21-22
AEL measurements of, 255-256, 257f, R glossary definition of, 470
258f Racquetballs in optic nerve evaluation, 413
choroidal detachment, 92 causing blunt trauma, 87 postoperative errors in, 270
complications following surgery, 104, Radial basal diameter of sound waves, Sf
105f, 106 of intraocular tumors, 129, 130f, 131 Refractive surgeries
correction factors for AEL Radial extent UBM imaging following, 233
measurement, 255t of intraocular tumors, 28f Rejection
cystoid macular edema, 68 Radiation therapy; See also radiotherapy of signals, 7-8
measurement criteria, 244-249 three-dimensional ultrasonography Relapsing polychondritis, 202-203
sound velocities for, 247f (3DUS),241 versus Vogt-Koyanagi-Harada (VKH)
Pseudo tumor cerebri, 419, 420f, 421£, to treat choroidal melanomas, 137- syndrome, 200-201
431£,432f 138 Renal cell carcinomas
Pseudotumors Radioactive plaque three cases of orbital, 319, 320f
in lacrimal fossa region, 327, 330-331 B-scan for localization of, 138, 139f, Renal necrosis
and lymphoma 140f,141 with herpes, 205, 206f, 207
with orbital tumors, 310, 311£, 312f, three-dimensional ultrasonography of, Residual vitreous gel
313f 241 following vitrectomy, 109, 11 Of-111£
orbital, 310, 311£, 312f, 313f Radioactive seeds Resistance index of Pourcelot (RI), 369
versus BMT and ACC, 324t 3DUS imaging of, 241 Resistance index (RI), 371
differential diagnosis of, 311 t in plaque localization technique, 139f, Resolution
scleral, 155, 158f, 159 140f,141 axial,S, 6f
Ptosis Radiotherapy; See plaque radiotherapy equations in ultrasound
as indication for orbital examination, Rate of transducer oscillation, 10 biomicroscopy (UBM), 223,
274t Reactive hyperplasias, 310 224f
Pulsatile exophthalmos Real-time factors determining,S, 6f, 8
sign of carotid-cavernous sinus fistula, display and frequencies, 1-2
355, 358f, 359 of pulse-echo system,S glossary definition of, 470
Pulsatility index, 369 glossary definition of, 470 high to examine anterior segment,
Pulsed Doppler spectral analysis, 369 Receivers 41£
Pulse-echo systems within ultrasound system, 7 with high-frequency ultrasound, 223,
description of,S Rectus muscles 224f
Pulse-echo techniques evaluation of, 384, 387 lateral, 6f, 7
glossary definition of, 470 normal thickness values, 387t Retained lens material
Pulsers techniques for examining, 380, 389 and cataract surgery, 106, 107f, 108
within ultrasound system, 7 "Red eyed shunt syndrome," 359, 360f Reticulum cell sarcomas
Pupillary block glaucoma Reflected waves description and illustration of, 151,
UBMof,229 angles of, Sf 152f, 153
Pupillary membranes Reflection Retina
intraocular echographic examinations specular, 4 color Doppler imaging (CDI) of, 372
of, 14t Reflectivity; See also internal reflectivity dialysis of, 52, 90
Pupils categories of, 33t diseases of, 51-66
evaluation of, 43, 44f of different vascular neoplasms, 348t dislocated lens nucleus adhering to,
mid-dilated of ciliary body lesions, 173-179 106, 108
with angle closure glaucoma, 210- estimate, 32-33, 34f echo strength of, 8
215 in extraocular muscle disorders, 396t elevation by diabetic traction, 58, 60,
Purnell, E.W glossary definition of, 470 61£
role of of intraocular tumors, 143t granulomatous infiltration of, 203f
in history of ultrasound, 1 of lacrimal gland tumors, 324t incarceration of, 98f
PVD; See posterior vitreous detachment
(PVD)
498 INDEX
Retina-cont'd Retinal detachments (RDs)-cont'd Retinoschisis

peripheral tears three-dimensional ultrasonography of, description and illustration of, 65 -66
following blunt trauma, 90 242 hemorrhages into, 162, 166
sequelae traction; See traction retinal Retrobulbar mass lesions
of blunt trauma to, 88b detachment topographic evaluation of, 295f
serous versus hemorrhagic traumatic Retrobulbar optic nerve
detachment, 115 illustration of, 91f, 94f, 96f, 97, 98f abnormalities, 412-436
topographic B-scan evaluations of, 26, with underlying hemorrhage, 54, 5Sf listing of, 413 b
27f,29f Retinal dialysis, 52, 90 arachnoid cysts, 428, 429f
traumatic detachment of, 97, 98f sequelae to blunt trauma, 88b A-scan technique, 412-419
Retinal angiomas Retinal disorders avulsion, 92-93
associated with calcifications, 148b color Doppler imaging (CD I) of, 372 sequelae to blunt trauma, 88b
associated with von Hippel-Lindau Retinal fold B-scan
syndrome, 155, 156f scleral, 97, 99 reference point, 17, 18f, 20
Retinal artery micro-aneurysms in toxocariasis, 205f technique, 412, 413f-415f
causing premacular hemorrhages, 72- Retinal hamartomas cavernous hemangioma displacing,
73 at optic disc, 155, 156f 347, 349f
Retinal astrocytic hamartomas Retinal incarceration, 90, 92f detecting radioactive plaque near,
associated with calcification, 148b, Retinal rieovascularization 139f, 140f, 141
155, 157f description and illustration of, 49 disorders, 419-434
Retinal breaks; See retinal tears Retinal operculum arachnoid cysts, 428, 429f
Retinal detachments (RDs) macular hole and, 72 compressive optic neuropathy, 428-
affecting AEL measurements, 265 Retinal pigment epithelium (RPE) 429,430f
associated with calcification, 58, 148b choroidal ruptures of, 90, 91f following surgery, 431, 432f
versus CD, SOt description and illustration of, 66-67 increased subarachnoid fluid, 419,
and cholesterol, 58 hemorrhagic detachment of,161-162, 421f-422f,423
with choroidal melanomas, 115, 118, 163f, 164f lesions, 423 -431
124f,127f inflammation, 202-207 optic nerve glioma, 423-424
color Doppler imaging (CDI) of, 372- other tumors of, 142-159 optic nerve sheath meningioma,
373 with Vogt-Koyanagi-Harada (VKH) 424, 425f, 426f, 427f
with cysts, 56, 58f, 162, 165f syndrome, 200-201 optic neuritis, 423-424, 433f
cysts of, 58, 162, 166 Retinal tears trauma, 429, 430f
from dense vitreous membrane, 35, definition and illustration of, 52, 53f, vascular occlusive disease, 430f,
36f 54f 431
echogram evaluation of, 27f dialysis and, 52, 90 evaluation and glaucoma, 209-210
etiologies of, 54 giant, 52, 54f head drusen, 148-149
exudative, 115, 118, 124f, 127f sequelae to blunt trauma, 88b illustrations of normal, 413 f-414f
with fixed folds, 56, 57f with shallow RD, 53f intraorbital portion
following penetrating trauma, 93 b, causing vitreous hemorrhages, 45 definition of, 412
94f,95-99 Retinal vascular diseases lesions, 423-431
funnel-shaped color Doppler imaging (CDI) to measurements
shape of, 56, 57f analyze, 367 with A-scans, 412, 415, 416f-417f,
topographic B-scan evaluations of, Retinoblastomas 418,419
26, 27f, 29f associated with calcification, 148b pattern disruption, 419, 422f, 423
with herpes infections, 205 in children and refraction,S
intraocular echo graphic examinations with glaucoma, 213 retinoblastomas in, 180-184
of, 14t cystic lesions with, 51 separation from
lesions simulating, 65b 3D imaging of, 240-241 with posterior vitreous detachment
longstanding, 56, 58f detection and diagnosis of, 180-184 (PVD),49
of macula, 30f, 31f, 72, 74f, 435f differential diagnoses of, 183t, 184 swelling, 191, 193f
with metastatic carcinoma, 143, 144f, endophytic versus exophytic, 180, with AIDS, 205
145f,146f 181f, 183f thickening with myositis, 402, 404f
movement of, SOt, 54, 56, 58 3DUS images of, 240-241 tumors, 424, 425f-427f, 428
with needle injuries, 108 producing orbital cellulitis, 207 Retrolenticular membranes
other lesions simulating, 65b Retinochoroid intraocular echographic examinations
from peripheral retinal dialysis, 90, thickening of, 14t
91f with endophthalmitis, 191, 193f ultrasound evaluation of, 42b
pitfalls in diagnosing, 65b with posterior uveitis, 194-195 Retrolenticular traction, 62, 64f
versus posterior vitreous detachment Retinochoroid layer Retroperitoneal fibrosis, 155, 159
(PVD), 56, 58, 59f, 60f diffuse thickening of, 90, 91f Reverberations; See multiple signals
reflectivity versus PVD, 32-33 edema of artifacts produced by, 466-467
rhegmatogenous, 52,97, 98f sequelae to blunt trauma, 88b Reverse longitudinal B-scan
serous Retinopathy of prematurity (ROP) and full-thickness macular hole, 71f
associated with choroidal description and illustration of, 184- of optic pit and retinal detachment,
melanomas, 118, 119f 185 435f
with subretinal hemorrhage, 54, 55f, versus retinoblastoma, 183t, 184-185 technique, 28, 32
56,117-118,119f causing secondary angle closure
glaucoma, 210-211
INDEX 499
Rhabdomyosarcoma Sclera-cont'd Scleral shells-cont'd

of ciliary body foreign bodies next to the wall of, 99 flanged for high resolution B-scan
in child, 184 illustration of echoes from, 24f (20 MHz), 474
orbital infolding, 97, 99 to examine lids and anterior orbit,
in children, 310, 314, 315f inner 297,300f
differential diagnosis of, 311 t role in tumor measurement, 122- Prager, 260
Rhegmatogenous 123, 124f, 125f Scleral sponges, 109
versus exudative measured with UBM, 226-228 Scleral thickening
intraocular echo graphic normal, 77, 80 causes of, 80, 81£
examinations of, 14t other tumors of, 142-159 with needle injuries, 108
Rhegmatogenous retinal detachments, posterior rupture of, 90, 91f, 92f with scleritis, 195-196, 197f, 198-199
97,98f following penetrating trauma, 93b, Scleral thinning, 84-85, 198, 199f
retinal tears; See retinal tears 94f,95-99 Scleral tumors
Rheumatoid arthritis pseudotumor of, 155 description and illustration of, 155,
causing scleritis, 195 thickness of, 77, 80 158f, 159
Rotation thickening Scleritis
of images causes of, 80, 81£ anterior and posterior, 84
3DUS versus 2D, 237t from needle injuries, 108 associated with
Rupture from scleritis, 195-196, 197 f, 198- choroidal thickening, 202-203
choroidal, 90 199 intraocular tumors, 198-199
lens, 87, 88b, 89f thinning of, 84-85 tumor necrosis, 120, 122f
lens capsule, 88b, 89f tumors, 155, 158f, 159 choroidal melanomas with, 121£
following penetrating trauma, 93b, ultrasound to evaluate diseases of, 77, definition of, 195
94f 80b diffuse posterior, 196, 197f, 198f
ultrasound evaluation of, 42b Scleral bowing with myositis, 402, 404f
ocular melanoma and, 188, 133f necrotizing, 84-85
S uveal schwannoma and, 154-155, 156f nodular, 196, 198f
Safety Scleral buckle posterior
considerations of CD I, 374 history of description and illustration of, 195-
Sarcoidosis and AEL measurements, 250 196, 197f, 198-199
and uveitis, 194-195 postsurgical finding of, 109, 11Of- within Tenon's space, 119-120, 121£
Sarcomas 111£ Sclerochoroidal calcifications, 148b
enlarged muscles due to, 405-406, versus scleral fold, 99 Scolex
407f Scleral calcifications of parasite, 205
reticulum cell, 151-152 causes of, 85 Screwdriver
Scanners Scleral cysts causing penetrating trauma, 95-99
color-duplex, 367, 368f description and illustration of, 155, Sebaceous materials
rotating 3DUS, 236, 238f 158f, 159 in dermoid cysts, 334, 336
ultrasound biomicroscopy (UBM), Scleraldeforrnities Secondary angle closure glaucoma, 210-
223,225 causes of, 85 211
Scarring Scleral depression Secondary glaucoma
with disciform macular degeneration, to differentiate retinoschisis from ultrasound to diagnose, 211-215
159-160 RDs,66,67f ultrasound to evaluate, 209
Scattering Scleral diseases; See also sclera Secondary tumors
of echoes, 4 UBM imaging of, 23 3 orbital
glossary definition of, 470 Scleral fold description and types of, 315, 318-
Scheimpflug technique, 229 versus choroidal detachments, 99 319,320f-323f
Schisis cavities, 60 description and illustration of, 97, 99 Sector angles
Schocket tube shunts, 220 following penetrating trauma, 93b, of moving transducer, 10
Schwannomas 94f,95-99 Senile disciform macular degeneration,
orbital with ruptured cataract wounds, 99f 68, 69f, 70; See also age-related
description and illustration of, 314, versus scleral buckle, 99 macular degeneration (AMD)
316f Scleral infiltration, 132, 133f and disciform macular
differential diagnosis of, 311 t Scleral pseudotumors . degeneration (disciform
uveal melanocytic, 154, 155, 156f description and illustration of, 155, lesions)
Sclera 158f, 159 Sensitivity
bowing Scleral rupture of high frequency transducers, 225
definition and illustration of, 118 after blunt trauma, 88b, 90, 91£, 92f Sensitivity setting; See gain
with macular staphyloma, 73 following penetrating trauma, 93b, Sequelae
disorders of 94f,95-99 of blunt trauma, 88b
discussion of, 80-85 Scleral shells; See also balloonlike device of penetrating trauma, 93 b
summary,80b to evaluate anterior segment, 37, 38f, Sequential two-dimensional (2D) digital
echo strength of, 8 39 imaging, 236
echo-density of, 33 for axial eye length m.easurements, Serial examinations; See also examinations
echogram illustrating,8f 245f,259-260 ofAMD,70
examining with UBM, 226 eye cup for UBM, 225, 226f of choroidal detachments, 75, 77
500 INDEX
Serial examinations-cont'd Silicone Sound beam-cont'd

of choroidal hemorrhages, 218 affecting AEL measurements, 265-268 longitudinal B-scan and, 17, 19-21,
of choroidal melanomas correction factors 130
with extrascleral extension, 135f for pseudophakic eyes, 255 t misalignment with contact AEL
of diabetic retinopathy, 60, 62f in glaucoma filtering devices, 220-221 method,256
following corticosteroid therapy, 121f history of narrowing, 8
of hemorrhagic choroidal and AEL measurements, 250 oblique incidence, 99
detachments, 104, 105f, 106, sound velocity of, 112, 113f, 247t parallel versus focused, 6f
162, 164f Sinuses penetration
of hemorrhagic disciform lesions, 160- mucocele, 452, 454, 456£, 457f with transverse and longitudinal
161 normal orbital, 451-452, 453f scans, 17-22
to rule out melanoma, 118, 119f surgery, 409f, 450 UBM versus frequency, 229
of peripheral traction RDs, 63f Skin refraction of, 5
Serous choroidal detachments orbital extension of melanoma from, "slicing" in B-scans, 9-10
illustration of, 75f 323f striking glass, 10 1-1 03
Serous retinal detachments Slip-lamp examinations transducer production of, 5-6, 8
associated with choroidal melanomas, of iris lesions, 169-179 transverse B-scan and, 17-19, 13 0
118,119f Slow flow fistula, 355, 359 zones of,S, 6f
associated with metastatic carcinoma, Slow spontaneous motion Sound incidence
143, 144f definition of, 37 perpendicular versus oblique, 4f
with posterior scleritis, 195-196 Small cell carcinoma Sound velocity; See also velocity
Servo motion systems, 22 5 BDUMP associated with, 166 in A-scan echography, 8-9
Shadowing of lung, 144, 145f correction factors
of air bubbles, 104, 104f Smooth retinal detachments, 54, 55f for pseudophakic eyes, 255 t
definition of, 117, 466-467 Soft stand-off technique; See balloonlike in 3DUS versus 2D, 237t
from foreign bodies, 96£, 202f device glossary definition of, 470
glossary definition of, 470 Soft tissue instruments which change, 244
of intraocular thorn, 102f orbital listing of, 247 t
of metallic foreign bodies, 96f, 99, swelling of, 355, 35 8f measurements
100f tumors, 310-345 and AEL, 246-247
orbital sound wave velocity through, 2t medium
two examples of, 302£ Solitary neurofibromas in color Doppler imaging (CD I),
retinoblastoma, 180-184 orbital 367-368
Shaken-baby syndrome description and illustration of, 314, in phakic AEL measurements, 252-
causing premacular hemorrhages, 72- 317f 253
73 differential diagnosis of, 311 t of silicone oil, 112,265-268
Shallow anterior chamber Sound attenuation through various media, 2
following penetrating trauma, 93b, affecting tumor echograms, 117-118, troubleshooting settings, 262
94f,95-99 119f, 120 velocity conversion equation, 262,
Shallow hemorrhagic choroidal avoiding, 32 266-268
detachments on B-scan, 34-35 Sound waves
following penetrating injuries, 98f characteristics absorption of, Sf
Sheath accentuation, 419, 42lf of different vascular neoplasms, in color Doppler imaging (CD!), 367-
Short axial eye length; See axial eye 348t 368
length considering generation process of, 5-8
Short eyes in ocular melanomas, 115, 116f, 117 glossary definition of, 470
history of definition and example of, 34-35 refraction of, Sf; See also refraction
and AEL measurements, 250 as diagnostic parameter velocities through various media, 2t
Short hyperopic globe, 80, 8lf of intraocular lesions, 24, 26b Spatial analysis
Shrunkenlens,42b,95f effect on axial B-scans, 21-22 3DUS versus 2D, 237t
Shunts by eyelids, 15 Spatial peak temporal average (SPTA),
fast flow and slow flow, 355, 359 glossary definition of, 470 374
Sickle cell disease in intraocular BB injury, 10lf Spectral analysis
subperiosteal abscess with, 446f by large ocular melanomas, 117-119 glossary definition of, 470
Signal processing, 5-8 of orbit Spectrum analysis
Signals quantitative echography and, 297, of blood flow, 10
brightness of, 32f, 33 302, 304f, 305f of ocular melanomas, 122
Doppler, 367-368 by scleral buckles, 109, 110f-l1lf Specular reflection, 4
multiple and shadowing, 466-467 Speed of sound
artifacts produced by, 466-467 of various orbital tumors, 311 t (c) in FWHM equation, 223
echogram illustrating, 8f Sound beam considering in UMB measurements,
glossary definition of, 469 axial B-scan and, 17,21-22, 130 226
produced by probe and bubbles, definition and angles of, 2, 3f, 4 Sphenoid wing meningiomas
109,112 in cm, 367-368 involving orbit, 454, 458, 459f-46lf
pseudophakia and, 255-256, 257f, and gain settings, 249 Spherical foreign bodies
258f glossary definition of, 470 artifacts produced by, 466-467
diagram and illustration of, 10lf
INDEX 501
Spherical foreign bodies-cont'd Subluxation Surgery-cont'd

echographic findings for, 100-101 of intraocular lens (IOL) complications following, 104-108
orbital, 448f following penetrating trauma, 93b, filtering
Spike chains 94f,95-99 evaluating with UBM, 230
illustration of, 8f, 9f of lens, 87, 89f glaucoma
Spikes following penetrating trauma, 93, complications of, 216, 217f, 218
A-scan 94f filtering, 218-221
indicating internal structure, 300, sequelae to blunt trauma, 88b massive suprachoroidal
302, 303f ultrasound evaluation of, 42b hemorrhagic detachments
and orbital sound attenuation, 302, Subperiosteal abscesses, 439, 444f, 445f, following, 104
304f,305f 446f optic nerve
and reflectivity, 32-33, 33t, 34f Subretinal hemorrhage disorders following, 431, 432f
and intraocular tumor measurement, from blunt trauma, 90 postoperative optic nerve findings,
122-131 with glaucoma, 214 431,432f
measurements using, 415, 417 f, 418 with metastatic carcinomas, 144, 146f, postsurgical findings, 108-114
in phakic eye A-scans, 248f, 252-253 147 Swelling
spinal tap, 431£ with ocular melanoma, 55f, 118, 119f as indication for orbital examination,
of tumor surface, 123, 124f-128f, 129, Sub-retinal pigment epithelium (sub- 274t
13 Of, 131 RPE) space oflids
Spindle B cell melanoma withAMD, 151, 152f, 153 with trauma, 87, 88f-89f, 90
versus mixed epithelioid cell, 122 detachment, 66-67 with myositis, 402, 404f
spontaneous motion in reticulum cell sarcoma, 151, 152f, of optic nerve, 191, 193f
fast blood flow, 37, 306 153 Sympathetic ophthalmia
slow due to convection, 37,187, Sub-Tenon's capsule causing choroidal inflammation, 74
340 metastatic tumors involving, 318, definition and illustration of, 201-
Squamous cell carcinoma 319f, 320f 202
of conjunctiva, 322f Sub-Tenon's injections, 195 and glaucoma, 215
S-shaped amplification curves, 7f, 9 Sub-Tenon's space versus Vogt-Koyanagi-Harada (VKH)
Standardized A-scan; See also A-scan edema, 310 syndrome, 200-201
techniques inflammation of, 120, 134 Syneresis
comparing measurements to swelling with scleritis, 195-196 definition of, 45
B-scans, 123, 124f-128f, 129, Subvitreal hemorrhage Syphilis
13 Of, 131 description and illustration of, 49-50, associated with AIDS, 205, 206f, 207
Standardized echography 50-51 Syphilitic optic neuritis, 205, 207
definition of, 10 and glaucoma, 213-214
to diagnose ocular melanomas, 115- Subvitreal opacities T
141 with posterior uveitis, 194-195 Tabletop retinal detachment, 62, 61f
to evaluate intraocular tumors, 115 Superior oblique muscles, 387t, 391, Tantalum rings, 141
evolution of, 1 392f, 393f Tears
of orbit Superior ophthalmic vein (SOV) associated with retinal detachment
introduction to, 273 blood flow velocities, 371 t (RD),54
Staphylomas color Doppler imaging (CDI) of, 367, Telemedicine
anterior simulating melanoma, 198, 371-372 and the Internet, 242
199f dilated, 355, 358f role of 3DUS imaging, 236-243
causing AEL error, 263, 264f thrombosis, 359, 360f Temporal quadrants
versus chronic scleritis, 198, 199f Superior rectus muscles, 387t, 389, 405f examination techniques for, 22, 472
eccentric to macula Suprachoroidal blood clots, 104-108 Tennis balls
illustration of, 263f Suprachoroidal hemorrhages, 98f, 104, causing blunt trauma, 87
macular, 73 105f, 106, 107f Tenon's capsule
with scleral thinning, 84 with glaucoma, 214 illustration of, 129f
Sterile vitritis, 194-195 Suprachoroidal hyphema interface
Steroids with choroidal hemorrhages, 162, and tumor measurement, 122-131
inadvertent injection 164f, 165f Tenon's space
into vitreous cavity, 108 Suprachoroidal space edema within, 310
sub-Tenon's injection, 195 choroidal detachments, 76f inflammation within, 120, 121£
Strands hemorrhagic detachments, 104, 105f, Tentlike detachments, 62, 63f
vitreous 106 Teratoma
attached to dislocated lens, 87, Supraciliary effusions in newborns, 345
89f evaluating with UBM, 230 Terson's syndrome
Sturge-Weber syndrome, 74,147,1 Supratemporal mass lesions causing premacular hemorrhages, 72-
48f topographic evaluation of, 294f 73
congenital glaucoma with, 210 Surgery; See also postsurgical findings Tertiary syphilis, 207
Subarachnoid fluid acquired cysts from, 170, 171£ Thirty-degree test
increased cataracts for optic nerve, 419, 422f, 423
in optic nerve, 419, 421£-422f, massive suprachoroidal hemor- for optic nerve sheath meningioma,
423 rhagic detachments following, 424,426f
104, 105f, 106, 107f, 108
502 INDEX
Thirty-degree test-cont'd Topographic B-scan evaluations Transducers-cont'd

positive, 422£ description and illustration of, 26, 27f function of, 2
in pseudotumor cerebri, 419, 420f, Topographic echography processing signals from, 7-8
42lf, 43lf, 432£ A-scans, 24, 25f, 26, 27f rate of oscillation of B-scan, 10
with optic nerve trauma, 429, 430f B-scans, 26, 27f sensitivity and performance
Three-dimensional imaging; See three- to determine lesion topography, 15 in UBM systems, 22 3
dimensional ultrasonography to determine shape, location, and for three-dimensional ultrasono-
(3DUS) extension, 24, 27f, 473 graphy, 236, 237f, 238f, 239
Three-dimensional ultrasonography diagnosis parameters, 26b Transmitted waves
(3 DUS) to differentiate PVD, RD, and CD, angles of, 5f
advantages and limitations of, 242-243 SOt Transocular approach
choroidal detachment and, 242 glossary definition of, 470 for A-scan screening, 285, 287, 288f
for choroidal melanoma, 239, 240 of intraocular lesions of examining orbit, 275, 276f-279f,
with extrascleral extension, 238f with A and B-scan, 473 280
imaging of radioactive plaque, 24lf of orbital mass lesions, 289, 291b, to measure lesion consistency, 302,
definition of, 236 292-293, 294f, 295f 306
development of, 1 Topographic mapping, 236-242, 239f Transocular compression test, 306f
future of, 243 Topographic surface Transverse B-scan
glossary definition of, 470 3DUS rendering of choroidal for basal diameter measurements, 129,
instrumentation, 236, 237f, 238f melanoma, 240f l30f, l31
for intraocular tumors, 236, 238f; 239- Topography to detect extrascleral extension, l3 3f
241 3D versus 2D measurement of, 236- for measuring tumors, 122-l31
to measure tumor volume, l31, 236, 242 montage, 293f
239 graphic 3D presentations of, 239, 240f orbital exam with, 280f
and "quartering" technique, 241 of optic nerve during topographic evaluations, 26
for radioactive plaque position, 241 A-scans of, 412, 415, 416f-417f, Transverse paraocular approach, 27 5,
in retinal detachment, 242 418,419 282-283
for retinoblastoma, 240-241 B-scans of, 412, 413f-415f Transverse B-scan
calcification of, 24lf Total retinal detachment (RD) description and illustration of, 17-22
scleral thickness and, 241 versus PVD and CD, SOt for evaluating orbit, 275, 276f-279f,
topography and volumetric analysis, Toxocara; See toxocariasis 280
236,239 Toxocariasis to examine rectus muscles, 380, 383f
topographic mapping, 239 associated with calcification, 148b gain setting for, 22
topographic surface rendering, 240 definition and characteristics of, 203 glossary definition of, 470
versus 2D imaging, 23 7t versus retinoblastoma, 183t, 184, 187, sound beam penetration with, 17-22
vitreoretinal disease and, 242 188f using paraocular approach, 282-283
Thrombosis ultrasound images of, 204f Trauma; See also blunt trauma and
of dural-cavernous sinus fistula, 359, Toxoplasmosis penetrating trauma
360f associated with AIDS, 205, 20M, 207 acquired cysts from, 170, 17lf
Thyroid in immmlocompromised patients, 207 associated with calcifications, 148b
Graves' disease, 396, 397f-40lf Trabecular-ciliary process distance blunt, 87-93
Thyroid disease (TCPD), 227f, 228, 229 causing epithelial downgrowth, 108,
ocular muscle thickening with, 380 Trabecular-iris angle, 228 177, 179f
Thyroid ophthalmopathy Trabeculectomy extraocular muscle, 408-409
and advanced glaucoma, 214-215, endophthalmitis following, 218 intraocular
399f Traction retinal detachment three main categories of, 87-108
Time gain compensation (TGC) after trauma, 73, 93b, 94f, 96f, 97 macular, 73
description of, 8 caused by toxocariasis, 203, 204f optic nerve
Time-gain circuits, 225 complex in diabetic retinopathy, 62, description and illustration of, 429,
Tissue Model, 9f 65f 430f
Tissue Sensitivity description of, 58 orbit, 439-451
description and illustration of, 9 from diabetic retinopathy, 58, 60, 6lf, from emphysema, 439b, 446, 449f
to measure intraocular tumors, 122- 62, 63f, 64f, 65f of extraocular muscles, 439b, 450-
l31 in endophthalmitis, 191, 193f 451
for quantitative echography in globe, following vitrectomy 62, 63f from foreign bodies, 439, 446, 447f-
32-35 retrolenticular, 62, 64f 448f
for quantitative echography in orbit, due to retinopathy of prematurity, fractures, 439b, 446, 450
297-302 184-185 hemorrhages, 439, 44lf-446f
Tomograms traumatic involving macula, 73 of optic nerve, 439b, 451
creating 3D images with, 236 Transducer crystal, 5-7 orbital abscesses, 439, 44lf-446f
Topical anesthetic drops, 15,259 Transducers; See also probe orbital cellulitis, 439, 440f
Topographic anatomy B-scan orbital hematomas, 439, 44lf-446f
with three-dimensional characteristics of, 15-22, 23f, 24 penetrating, 93-103
ultrasonography (3 DUS), 236 development of UBM, 22 5 and postsurgical findings, 87-114
Topographic A-scan evaluations focal length, 223 severe head
description and illustration of, 26, 27f focused,9 causing carotid-cavernous sinus
fistula, 355, 358f, 359
INDEX 503
Trauma-cont'd Tumors-cont'd UBM-cont'd

sllfgical complications, 104-108 necrosis factors, 120, 121f, 122f scanner design, 223,225
and sympathetic ophthalmia, 201- neovascularity of scanning techniques for, 227f, 228f
202 with color Doppler imaging (CDI), sensitivity and performance, 223
traction seen with, 58, 60, 61f 369 showing supraciliary effusion, 230f
UBM imaging of, 233-234 optic nerve theoretical considerations, 223-225
causing vitreous hemorrhages, 45 metastatic orbital, 424, 425f-427f, transducer characteristics, 225
Troubleshooting AEL measurements, 428 trauma, evaluation of, 233-234
261 orbital; See orbital tumors . tumors of ciliary body evaluation with,
True axial length measurement (TAL), radioactive plaque technique, 138, 232f
262,267 139f, 140f, 141 zonules, imaging with, 227f, 228
True lens thickness (fLT), 262, 266-267 retinoblastomas, 180-184 Ultrasonography; See ultrasound
True optic cupping, 432, 434 and sound atrenuation, 117 -12 0 Ultrasound instruments;· See
True vitreous length (TVL), 266-267 topographic evaluations of, 24-28 instrumentation
T-shaped typical echograms of, 34f Ultrasound intensity
detachments, 56, 57f vascular orbital, 347-355, 356f, 357f decibel levels and, 7
"T-sign" vascularity, 37 Ultrasound system
axial B-scans demonstrating, 197f volume measurements schematic diagram of, 7f
Tuberculosis with three dimensional imaging, Ultrasound transducers; See transducers
associated with AIDS, 205, 206f, 207 131 Ultrasound waves
Tuberous sclerosis, 155, 157f Two-dimensional (2D) imaging characteristics of, 1-2, 3f
Tumor apex versus 3DUS, 237t U.S. Food and Drug Administration
maximum elevation of, 122-123, 124f, (FDA),375
125f U Uvea
Tumor biometry UBM; See ultrasound biomicroscope other tumors of, 142-159
description and illustrations of, 122- (UBM) Uveal effusion syndrome ' '
131 angle opening distance evaluation ciliochoroidal detachment with, 82,
of ocular melanomas, 122-123, 124f- with,228 83f
128f,129-131 of anterior chamber, 227f, 228f, and glaucoma, 214 .
Tumor margins 234f versus Vogt-Koyanagi-Harada (VKH)
distinct versus indistinct, 129, 130f, for anterior lens capsule, 227f syndrome, 200-201
131 anterior synechia and, 230 Uveal lymphoid hyperplasia; 202
Tumor surface spikes" assessing iris nevi with, 232f associated with glaucoma, 212-213
versus inner scleral spikes, 123, 124f- assessing scleral disease with, 233 description and illustration of, 153-
128f, 129, 130f, 131 ciliary body and, 228f 154
Tumors; See also cysts; lesions ciliary processes and, 228, 230 versus diffuse melanoma, 136-137
anterior segment cornea and, 227 233 versus metastatic carcinoma to
evaluating with UBM, 231 conjunctival lesions and, 234 choroid,143-144
basal diameters of, 129, 130f, 131 " cyclodialysis cleft and, 233-234 Uveal melanoma; See also ocular
base measurements; 129, 13 Of, 131 definition of, 223 melanoma
biometry of, 122-131 design of instrumentation, 223, 225 Uveal schwannomas
choroidal development of, 223-225 description and illustration of, 154-
description of, 74 diagnosing adnexal disease with, 234 155, 156f
choroidal hemangiomas, 146f, 147 examination techniques for, 225-226, Uveal tract
ciliary body, 173-179 228f,229f disorders, 153-154
color Doppler imaging of eye, 10 eye cups for, 225, 226f, 474 Uveitis
causing compressive optic neuropathy, filtering surgery after, 231f associated with choroidal thickening,
428-429,430f foreign body detection with, 234f 200-203
extraocular muscle future of, 234 definition of, 194
various types of, 405-406, 407f glaucoma evaluation with, 229-230, opacities originating from, 45 .
causing extraocular muscle thickening, 231f versus reticulum cell sarcomas, 151,
380 glossary definition of, 470 152f
extrascleral extension, 131-13 2, 13 3f, hypotony evaluation with, 233 traction seen with, 58, 60
134,135f imaging cysts with, 232, 233f
intraocular intraocular foreign body detection V
lesion detection, 115 with,234 Valsalva maculopathy
intraocular echographic examinations iridociliary cyst and, 232,233f causingpremacular hemorrhages, 72-
of,14t iris evaluation with, 228, 230, 231f 73
malignant iris tumors evaluation with, 231-232 Valsalva maneuver
invading orbit, 458, 462f malignant glaucoma and, 230f and orbital varix, 359, 361, 362f, 363f
measuring, 115, 129, 130f, 131 measuring ocular structures with, Varices
metastatic carcinoma to choroid, 141- 226-228 CDIand,374
147 penetration versus frequency, 224f orbital, 359, 361, 362f, 363f
mimicking ocular melanomas, 142, plateau iris syndrome detection and, Vascular diseases
143t, 144-159 229 color Doppler imaging (CDI) of, 367-
monitoring growth of, 136-138 resolution of, 223, 224f 375
504 INDEX
Vascular lesions Vertical macula scans Vitreous cavity-cont'd

orbital, 347 -365 definition of, 28, 29f-31£ hemorrhages within, 118, 119f
categories of, 34 7b probe positions, 28-31 hemorrhagic tracks through, 95-99
Vascular malformations showing bridging membranes, 62, 64f opacification of, 87, 88f
cavernous sinus fistula, 355, 358f, 359 ofVKH,201£ Vitreous cysts
Vascular neoplasms Vertical orientations characteristics of, 51
orbital of probe, 18-19, 20f Vitreous gel
differential diagnoses of, 348t Vertical transverse approach blood infiltrating, 45, 48f
Vascular occlusive disease to evaluate macula, 28, 29f lens material retained in
calcifications, 430f, 431 Vertical transverse scans following cataract surgery, 106,
description and illustration of, 430f, B-scans 107£,108
431 to display optic cup, 432, 433f residual after vitrectomy, 109, 11 Of,
optic nerve of optic nerve, 415 f 111£
description and illustration of, 430f, trans ocular approach, 280f solid versus vitreous cyst, 45, 47f
431 description and illustration of, 18-19, Vitreous hemorrhage; See also
Vascular resistance, 369, 371 20f hemorrhage
Vascular topography Vibrations AEL measurements and, 265
of normal orbit and eye along acoustic spectrum, 223-225 associated with ocular melanoma,
color Doppler imaging of, 371-372 Vision 117-118,119f
Vascular tumors blurred dense
in orbit, 310 with angle closure glaucoma, 210- confused with hemorrhagic
Vascularity 215 choroidal detachments, 104,
characteristics Vitrectomy 105f,106
of different vascular neoplasms, hemorrhages following, 45, 48f, 111£ encountered during A-scan biometry,
348t retained intraocular perfluorocarbon 253,254f
of lacrimal gland tumors, 32 4t bubble, 109, 112f following penetrating trauma, 93b,
definition of, 37 retrolenticular traction following, 62, 94f,95-99
as diagnosis parameters 63f,64f and glaucoma, 213
of intraocular lesions, 24, 26b Vitreoretinal adhesions illustration of, 52f
feature of ocular melanomas, 115, description and illustration of, 49 incarceration of, 97f, 98f
116£, 117 Vitreoretinal diseases layered versus retinal detachment, 45,
of lesions, 143 t assessment and evaluation of, 45-85 47f
definition of, 306, 308 asteroid hyalosis, 45, 46£, 47f metastatic carcinoma and, 143
orbital posterior vitreous detachment with needle injuries, 108
definition of, 306, 308 (PVD), 48f, 49 in older patients, 160-161
of various orbital tumors, 311 t retinal tears, 52, 53f causing opaque media, 45, 47f, 48f
Vector A-scans subvitreal hemorrhages, 49-50 from penetrating trauma, 95-99
for AEL measurements, 264f vitreous cysts, 51 pointlike echoes illustrating, 27f
description of, 8-9 three-dimensional ultrasonography of, in posterior segment
glossary definition of, 470 242 from blunt trauma, 90
to measure intraocular tumor height, Vitreoretinal injuries pseudomembranes in, 45, 47f, 48f
122 from blunt trauma, 90, 91£ reflectivity of, 45, 47f
Vegetable matter from penetrating trauma, 95-99 sequelae to blunt trauma, 88b
echo graphic characteristics of, 102-103 Vitreoretinal surgery Vitreous incarceration
Veins to treat macular holes, 70-72 with needle injuries, 108
dilated orbital, 355, 35 8f Vitreous Vitreous lesions
Velocity; See also sound velocity inflammation affecting AEL measurements, 265
blood flow versus cysticercosis, 203, 205 Vitreous media
in orbital vessels, 371 t Vitreous band, 473 sound wave velocity through, 2t
calculations definition of, 45 Vitreous membranes
in color Doppler imaging (CDI), illustration of, 27f attached to dislocated lens, 87, 89f
368 PHPVand, 185 dense, 35, 36f
in color Doppler imaging (CDI), 367- Vitreous body Vitreous opacities, 7
368 diseases of definition of, 45
glossary definition of, 470 evaluating with ultrasound, 45-51 Vitreous skirt
listing of, 2t, 247t normal,45 description ancl illustration of, 109,
sound wave, 2 Vitreous cavity 111£
Velocity conversion equation (VCE), echo gram illustrating, 8f Vitreous skirtlhemorrhage
262,266-268 echolucency of, 33 postsurgical findings of, 109, 111£
Venous congestion, 406 examining endophthalmitis in, 191, Vitreous strands
causing compressive optic neuropathy, 192f-193f,194 attached to dislocated lens, 87, 89f
428-429,430f expulsive hemorrhagic filling of, 104, Vitreous traction
Venous occlusion 105f, 106 causing macular holes, 70-72
causing vitreous hemorrhage, 45 foreign bodies penetrating, 96f, 99, Vitritis
Vertical axial scan 100f with posterior uveitis, 194-195
description and illustration of, 19t, 21, hemorrhages and glaucoma, 213-214 simulating retinoblastomas, 180
22f
INDEX 505
Vogt-Koyanagi-Harada syndrome (VKH) Vortex veins (VV) Weiss ring

causing choroidal inflammation, 74 Ampulla of simulating melanoma, associated with macular hole 72
definition and illustration of, 200-201 142b, 166, 167f definition of, 49 '
differential diagnoses of, 200b blood flow velocities, 371 t Wood
versus diffuse melanomas, 136-137 color Doppler imaging (CDI) of, 367, echographic characteristics of, 102-
and glaucoma, 215 371-372 103
versus metastatic carcinoma to extending melanoma into orbit, 131, \Vound dehiscence, 87, S8t, 89f, 90, 91£,
choroid, 143-144 133f 92-93
Volume Wounds; See also trauma
calculating intraocular tumor, 236, w dehiscence, 92
237f, 238f, 239 Water open, 87, 88f
3D versus 2D measurement of, 236-242 sound wave velocity through, 2t rupture, 87, 88t, 89f, 90, 91£, 92-93
measurements Water-filled latex tonometer covers, 39- spherical foreign body, 100-101
with three dimensional imaging, 40,41f
131 Wavelengths X
with UBM, 227f, 228 characteristics of ultrasound, 1-2, 3f X-rays
Volume image block in FWHM equation, 223 or CT scan of foreign bodies, 99
of retinoblastomas, 240-241 glossary definition of, 470
sectioning of, 236, 2327t illustration of high versus low Z
Volumetric analysis frequency, 2f Zonule
3DUS versus 2D, 237t Waves B-scan imaging of, 195
Von Hippel-Lindau syndrome absorption of, Sf definition of, 228
associated with peripheral capillary refraction of sound, Sf pigmentary glaucoma and, 211
hemangiomas, 155, 156£ Wegener's granulomatosis, 310 UBM and, 228

Ultrasound of The Eye and Orbit-Frazier

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Ultrasound of The Eye and Orbit-Frazier

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VI trasound of the

Eye and Orbit

SANDRA FRAZIER BYRNE

Illustrations by Timothy G. Hengst, FAHI

An Imprint of Elsevier Science

F. STUART FOSTER, PhD

Jack Rootman, MO, FRCSC

13 Vascular Lesions, 347

A Low ...JC\~v~,...6_lr-V......f-(\-+-v---+(\.........trV-"-3I."'" Distance

B High -,-Q"""v-lQ"",,,I+-v~Q_1~V+O~Vr-"--------...- Distance

A :. '. ·0•.. ' ..

beam in such a way that the surfaces of the nerve or of an

Medium 1 Medium 2 ProbelTransducer

Figure 1-9 Schematic diagram of an ultrasound system.

aligned perpendicular to the direction of a scanning sound

a display screen (Figure 1-9).

Figure 2-1 Patient positioned properly for echographic exami-

vertical transverse scans (i.e., transverse scans of the 3- or 9-

In longitudinal scans, the marker is always directed to-

Basic B-Scan Screening Examination Technique

7:30 ------ /'

SPECIAL EXAMINATION TECHNIQUES

Topographic 8-Scan Evaluation

Figure 2-19 Three-dimensional conceptualization of funnel-shaped retinal detachments (RDs)

,,;--- ...... , .",,---.... .......

Quantitative Echography: Reflectivity, Internal

INTERNAL STRUCTURE SOUND ATTENUATION

Figure 2-26 Quantitative echography type II to differentiate

reous membrane (e.g., posterior vitreous detachment).8 It

Figure 2-29 A-scan echogram of large melanoma shows inter-

beneath a tight funnel-shaped retinal detachment. Coat's

Figure 2-32 Anterior chamber hyphema. A, Axial

significant pathology involving the lens, iris or ciliary

Figure 2-35 Posterior subcapsular cataract demonstrated iIi

EVALUATION OF THE PUPIL

Figure 2-38 Young child in restraining device for ultrasound

Figure 3-4 Dense vitreous hemorrhage layered

Figure 3-9 PVD with Weiss ring. Longitudinal B-scan demon-

On B-scan, in a normal eye, a PVD usually appears

Figure 3-12 Posterior hypheina .in subvitreal space.

a dense, smooth membrane on B-scan and as a highly

Retinal tears, RD, retinoschisis, and many other disorders

Figure 3-16 Ultrasound localization of retinal tear during

Retinal Detachment (RD)

Figure 3-29 Proliferative, stalklike membrane in diabetic retinopathy. Longitudinal B-scan

Figure 3-38 Retinoschisis. A, Transverse B-scan echogram

Figure 3-40 Scleral indentation for differentiating retinoschisis

3-41, or hemorrhagic, see p 161) or massive, secondary to c

Figure 3-43 Cystoid macular edema. Longitudinal B-scan

P 71), inflammatory lesions of the retina (e.g., tuberculous

Figure 3-45 Disciform macular lesion. Horizontal axial

Figure 3-47 Fundus photograph showing full-thickness macu-

Figure 3-48 OCT showing full-thickness macular hole (arrow).

Figure 3-50 Two cases of full thickness macular holes resolved

vitreous in relation to the macula and can provide addi-

known macular hole. It has been shown that the presence of

Retinal Detachment of the Macula

Figure 3-57 Peripheral serous choroidal detachment.

vated, a thin band stretching from the inner aspect of the

Figure 3-58 Topographic characteristics of bullous,

peciallynasally. Whenever an abnormality is suspected,

Examination Techniques for the Sclera '.