B- Scan Ul tras onogr aph y

Guide:
Dr. S. S. Kubre

Presented by:
Dr. Samreen Arif
RSO- Ophthalmology
Gandhi Medical College.
Introduction :
 Ultrasonography of the eye is an
indespensible tool in the diagnosis and
management of various ocular and orbital
abnormalities
 It was first used in ophthalmology in 1956
by Mundt and Hughes as A scan
 Baum and Greenwood introduced first
Bscan in 1958 and first commercially
available B-scan was developed Coulmn et
al in the seventies

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Physics :
 Ultrasound is an acoustic wave that
consists of oscillations of particles within
a medium, the waves have frequency
greater than 20khz(20,000
oscillations/sec)
 Diagnostic ophthalmology utilizes
frequency of 8-10Mhz
(1Mhz=1,000,000cycles/sec)

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Basic elements of ultrasound
 Pulser
 Transducer
 Receiver
 Display

Modes of display
 A scan or amplitude modulation scan
 B scan or brightness modulation scan
 Vector A scan
 Three dimensional ultrasound tomography
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Ele ct ri c Lead Zirco nate - Multip le Sho rt
ti tanate C rystal Puls e w ith
Curren t
brief in ter val
be twe en th em

Lo ngitu din al
Ultras ound W av e
Propogated
through
medium
Elec tri cal Echoes Tiss ue
Transd uce
Si gn als r
Produced Ultra soun d
Inter action
• Reflection

Re ceiv er
• Refraction
Display ed • Scattering
on • Absorption
Sc ree n
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Modes of display
A-Sca n /Amp litu de Modu lati on Sca n
 It is a one dimensional acoustic display

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B-Sca n / Bri gh tn ess Mod ul at ion Sca n

 It provides a real time, two

dimensional, grey scale display of
the eye and the orbit, where
different echodensities are depicted
in gradations of brightness
 Echoes are represented as dots and
there strength as brightness of dots
on the screen

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Vector A Scan:
 It is the combination of both A Scan
and B Scan

Thr ee di mens ion al ul tras ou nd tomog ra phy:

 It utilizes ultrasound technique and
digital computer technology where
ocular pathology can be viewed in
three dimension

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Modes of B-scan
 Low frequency:
Useful in detecting orbital pathology
 Moderate frequency:(7-10MHZ)
Useful in globe examination
 High frequency:(30-50MHZ)
Useful for imaging anterior segment
Penetration depth of 5 -10mm
 Immersion technique:10MHZ
Useful for evaluation of anterior chamber
Uses sceleral shell filled with methyl cellulose
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Screening technique
 It is best to begin with maximum gain
on B scan
 Eye is anesthesized with topical
paracaine if transducer is kept on
sclera
 Alternatively eye need not to be
anesthesized if probe is kept on close
eyelid
 Probe is placed on the globe opposite
to the area examined
 Marker on the probe act as the
orientation point
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Techniques used for Evaluation
Transverse technique
 Horizontal transverse:Evaluate superior and inferior

fundus and marker is kept towards nose

 Vertical transverse:Evaluate the nasal and temporal

fundus and marker is kept towards 12 o’clock

 Oblique transverse:Evaluate the pathology not
located at major meridians (3,6,9,12 o’clock)

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Techniques used for Evaluation

Axial technique
 Horizontal: marker towards the nose
 Vertical: marker towards 12o’clock position

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 Techniques used for Evaluation

Longitudinal technique
 Evaluate single meridian from its most
posterior aspect to far periphery
 Once the cross sectional examination is
completed area of interest is scanned by
longitudinal scan

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INDICATIONS
Anterior Segment
a. Opaque ocu lar me dia
• Pupillary membrane
• Dislocation/subluxation of lens
• Cataract/after cataract
• Posterior capsular tear in traumatic
cataract
• Pupillary size/reaction
b. Clea r ocu lar med ia
• In diagnosis of suspected iris and ciliary
body tumours
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Posterior Segment
a. Opaque ocu lar me dia
• Viterous haemorrhage
• Viterous exudation
• Retinal detachment (type/extent)
• Posterior viterous detachment (extent)
• IOFB (size/site/type)

b. Clea r ocu lar med ia

• Tumour (size/site/post treatment follow
up)
• Retinal detachment (solid/exudative)
• Optic disc anomalies

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Biometry
 Preoperative scanning and calculation of IOL
power

Orbital Examination
 Exophthalmos
 Motility disturbances/diplopia
 Palpable orbital mass
 Optic disc oedema and atrophy
 Syndromes (superior orbital fissure/orbital apex)

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NORMAL EYE ON B-SCAN

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 NORMAL EYE ON B-scan

 It reveals two ecographic areas seperated by an echo

free area
 Echographic area at the beginning represent
reverberation at the tip of probe and has no clinical
significance
 On high resolution scan posterior convex surface of lens
can be seen
 Large echo free area represent viterous cavity
 Vitero retinal interface forms a smooth curved
curvature. Echoes from retina, choroid and scelera
merge
 Scleral fat boundry is well seen acoustically
 Orbital fat is seen as highly refractile mass with the
extra ocular muscles forming outline of the fat
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
Viterous haemorrhage
Bscan: seen as small white echoes
 Fresh and diffuse heamorrhage:little echo
response
 Location:within PVD,pre and post hyaloid
 Extent
 Associated fibrous changes

Ascan: low amplitude spikes

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Endophthalmitis
 B-scan:
Multiple small echogenic opacities with distinct
after movements,in severe cases membrane
formation .
Associated findings:choroidal
thickening,choroidal detachment,retinal
detachment,retained IOFB
 A-scan: chain of low amplitude spikes

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 Retinal tear

 B-scan: appear as breach of tissue

 A-scan: highly refractile tissue seperated from
other fundus spikes

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Retinal detachment

B-s ca n :
 Recent : bright continuos,somewhat folded
appearance,mobile retina and translucent
subretinal space

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Retinal detachment

B-s ca n :
 Proliferative viteroretinopathy: limited viterous
space,decreased mobility of retina,funnel
shaped(open or close) configuration of
detached retina. In triangular RD the sides of
triangle represent highly detached stiff retina
and base is the proliferating viterous
membrane

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Retinal detachment
 Longstanding RD may develop retinal
cyst and become partially calcified and
subretinal space filled with cholestrol
debris

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Retinal detachment
Tra ct ion ret in al det ach men t:

 Viteroretinal traction bands: focal/broad

 Concave configuration of detached retina

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Retinal detachment
Exu dati ve re ti nal de ta ch ment:
 Configuration of the detachment is convex and
bullous

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Retinoschisis

 Bscan :smooth thin dome shaped

membrane that does not insert on optic
disc
 Ascan : 100% high spike is produced

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Posterior viterous detachment
 Bscan:
undulating membrane in front of retina
showing movement with movement of eye
and brightness is reduced with reduction of
gain
 Ascan: tall spikes

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Choroidal detachment
B-scan :
 Smooth, dome shaped membranous structure that
does not insert on optic nerve
 May be localised or involve entire fundus(kissing
choroidal detachment)

A-scan :
 100% reflective ,double peaked spikes(retina and
choroid)

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Intraocular foreign body
 Metallic foreign body: very bright signals
that persist on lowering gain, shadowing
artefact can be seen on adjacent orbit
 Non metallic foreign body: more
challenging, produce bright signals

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Dislocated lens

 Round or oval globular structure in

posterior viterous and strand of
viterous may be attached to
dislocated lens

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Posterior globe rupture

 Breach of sceleral and choroidal

tissue with associated choroidal
thickeninig

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Optic nerve avulsion
 Acute injury: actual peripapillary
sceleral break , viterous haemorrhage
may be present
 Longstanding cases: proliferative tissue
at optic disc

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Retinoblastoma
 Bscan: large irregular ecogenic mass involving
viterous, retina or the subretinal space with area
of calcification seen as area of high ecogenicity
 Axial length is either normal or increased
 Ascan: high internal reflectivity due to areas of
calcification

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Choroidal naevus
 Localized flat or slightly elevated
lesion with high internal acoustic
reflectivity; a low internal reflectivity
on A scan is suggestive of malignancy

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Osseous choriostoma
 Highly reflective anterior surface with
orbital shadowing

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Choroidal melanoma
 Acoustic hollowness, choroidal excavation and
orbital shadowing

 Collar stud configuration is almost pathogonomic

(when tumour breakthrough the bruchs membrane)

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Choroidal haemangioma
 Acoustically solid lesion with the sharp
anterior surface and high internal
reflectivity but without choroidal
excavation and orbital shadowing

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Metastatic choroidal carcinoma
 Appear diffuse, typical bumpy and irregular
contour with central elevation
 A scan: irregular spikes of medium to high
amplitude

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Asteroid hyalosis
 B-scan:bright round signals showing movement
with movement of eye with eco free space just
in front of retina
 Ascan:medium amplitude spikes

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Cysticercosis
B-scan :
 Sharply outlined oval cyst within viterous cavity or
in the subretinal space
 Scolex seen as highly reflective ecodense nodule
located adjacent to inner wall of cyst

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Posterior sceleritis
 Sceleral thickening, sceleral nodules,
fluid in the tenon space give rise to “T
sign”

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Phthisis bulbi
 Smaller globe with multiple ecogenic
viterous opacities,choroidal thickening,
calcification of ocular coats with resultant
absence of high reflective orbital ecospikes
due to shadowing

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Atrophic bulbi

 Normal globe contour with normal axial

length and calcification of ocular coats

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Choroidal coloboma
 Excavation of posterior pole with sharp
edges
 Associated features: microphthalmos and
retinal detachment

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Posterior staphyloma
 Shallow excavation of posterior pole with
smooth edges in highly myopic eyes

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Optic nerve drusen
 Calcified nodules that produces echoes of
high reflectivity at or within optic nervr
head
 Best seen by transverse and longitudinal
approach that bypass lens

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Immersion technique
Iris melanoma

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High resolution B scan
Ciliary body detachment
 Large cleft seen in subciliary space

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High resolution B scan
Iri s me lanoma

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Shortcomings of B-scan
 Artefacts:
 Insufficient fluid coupling causes entrapment of
fluid between probe and eye leading to bright
echoes
 IOL may act as foreign body
 Tumours:
 Mass <0.75mm may be missed
 Viteroretinal disease:
 In retinal detachment usually the actual tears
may be missed

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Shortcomings of B-scan
 Intraocular foreign body
 IOFB <0.5mm can be missed
 Reflectivity of wooden foreign body can be
decreased with time
 Orbit
 Orbital mass cannot be differntiated or detected
if <3mm in size in anterior and <5mm in size in
posterior orbit
 Biometery
 Wrong axial length may be obtained if probe
does not aligned with optical axis,indentation of
cornea,fluid meniscus in front of cornea
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Contraindications of B-scan
 Recent surgery
 Open globe injury
 Active infection of ocular surface
 HIV infection

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