Ординатура / Офтальмология / Английские материалы / Ophthalmic Ultrasound A Diagnostic Atlas 2nd edition_ DiBernardo, Greenberg_2006

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Figure 4–28 Retinal pigment epithelial (RPE) detachment, hemorrhagic. This patient has a history of posterior uveal bleeding syndrome, which is characterized by multiple, variably sized serosanguinous RPE detachments that are usually seen throughout the posterior pole. (A) Transverse scan showing the dome-shaped elevation of an area of RPE detachment (arrow) and hemorrhage beneath (H). (B) A-scan showing the high spike from the surface (arrow) and chain of low spikes from the hemorrhage beneath (H). Without the clinical history and presence of multiple lesions, this could have been mistaken for a small melanoma because of the dome shape and low reflectivity.

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Figure 4–29 Retinal pigment epithelial (RPE) detachment.

(A) B-scan showing the typical blister-like appearance of a localized retinal pigment epithelial detachment (arrow). (B) On the A-scan the surface of the RPE will produce a maximally high, thin spike (arrow). No internal spikes are noted beneath the lesion (S) because of the serous nature.

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Figure 4–30 Retinoschisis. (A) Transverse B-scan shows mild vitreous opacities and a smooth, thin, dome-shaped membrane located in the superotemporal periphery (arrow). (B) Longitudinal scan showing the radial extent of this lesion and its peripheral location (arrow). ON, optic nerve. (C) Standardized A-scan showing very mild vitreous opacities (V) and the maximally high, thin, singlepeaked spike obtained from the area of retinoschisis (arrow).

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Figure 4–31 Retinoschisis. This patient was referred for B-scan screening prior to cataract extraction. (A) There were bilateral, very shallowly elevated membranes in the far inferotemporal peripheries (arrow). (B) Longitudinal scan showing the radial extent of the very shallowly elevated retinoschisis (arrow). (C) Standardized A-scan showing the maximally high spike obtained from the area of retinoschisis (arrow). Notice the slenderness of the spike.

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Figure 4–32 Retinoschisis. These echograms were obtained from a young male patient with X-linked retinoschisis. (A) Transverse B-scan discloses the extent and elevation of the schisis cavity inferiorly in the right eye (arrow). (B) A-scan performed to obtain a baseline measurement of the height of the schisis cavity in the right eye (arrow). (C) There was also a schisis cavity inferiorly in the left eye; however, it was less elevated than the cavity in the right eye (arrow).

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Figure 4–33 Subretinal hemorrhage. (A) Transverse B-scan showing a localized, bullous retinal detachment (arrow) with dispersed hemorrhage beneath (S). (B) A-scan showing a high spike from the retinal detachment (arrow) and a low chain of spikes from the subretinal hemorrhage (S). (From DiBernardo C. Ultrasonography. In: Regillo CD, Brown GC, Flynn HW. Vitreoretinal Disease: The Essentials. New York: Thieme Medical Publishers; 1999. Reprinted by permission.)

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Figure 4–34 Subretinal hemorrhage. (A) Transverse scan discloses vitreous hemorrhage (V), extensive, folded retinal detachment (arrow), and dispersed subretinal hemorrhage (H).

(B)Longitudinal scan showing membranous vitreous hemorrhage (V) and the retinal detachment inserting into the optic disc (arrow).

(C)A-scan showing a chain of spikes from the vitreous hemorrhage (V), the 100% tall spike from the retinal detachment (arrow), and a low chain of spikes from the subretinal hemorrhage (H).

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Figure 4–35 Subretinal hemorrhage. This patient has a total retinal detachment that remains slightly opened in funnel configuration. However, because of the extremely dense nature of the subretinal hemorrhage, the retinal detachment appears as an echolucent funnel. This can also be explained because there is no hemorrhage in the remaining vitreous cavity. (A) Axial B-scan showing a dense anterior membrane (A), a slightly opened funnel-shaped retinal detachment (R), and dense subretinal hemorrhage (H).

(B) Transverse scan showing the echolucent retinal detachment in cross section (R) surrounded by extremely dense subretinal hemorrhage. (C) Longitudinal scan showing the anterior membrane (A) and the funnel-shaped retinal detachment (R) inserting into the optic disc (ON).

Figure 4–37 Macular thickening. Longitudinal B-scan using a 10-MHz probe to evaluate the macular region in a patient with decreased vision following cataract extraction and intraocular lens implantation. A focal area of mild fundus thickening is noted (arrow). ON, optic nerve.

Figure 4–39 Optical coherence tomography (OCT) of cystoid macular edema. OCT image taken at the foveal center of the same patient in Figures 4–37 and 4–38 showing the cystic nature of the macular thickening noted by ultrasound.

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Figure 4–38 Macular thickening. (A) and (B) Transverse and longitudinal B-scans using a 20-MHz probe to evaluate the macular region of the same patient shown in Figure 4–37. A focal area of fundus thickening with a central echolucent region is noted (arrows).

Echographic evaluation of choroidal thickening can be very useful in providing a diagnosis or to confirm clinical suspicions in patients with systemic disease. The reflectivity obtained when the sound is aimed through the choroid into the suprachoroidal space is the key echographic finding.

Low reflective choroidal infiltration is a significant finding in patients with Vogt-Koyanagi-Harada syndrome (VKH) lymphoid hyperplasia, Lyme disease, sympathetic ophthalmia, or lymphoma. Choroidal thickening that produces high reflectivity is most often associated with processes such as nanophthalmos, uveal effusion, sarcoid, and phthisis.

Choroidal detachments most commonly occur following trauma associated with rupture of the globe, trabeculectomy, or as an acute event associated with cataract surgery. Although rare, choroidal detachments have been reported in elderly patients following Valsalva maneuvers such as sneezing, straining, or bending.

Ophthalmoscopically, the diagnosis of choroidal detachments can be confusing, particularly if other pathology is present. Certain characteristic echographic features help distinguish choroidal detachments from other intraocular processes. On B-scan, a choroidal detachment appears as a smooth, dome-shaped, thick membrane. Choroidal detachments usually occur in the periphery and may involve the ciliary body (ciliochoroidal detachments). Although they can extend to the posterior pole, they do not insert into the optic disc. Choroidal detachments that involve the entire eye wall, extending 360 degrees, display a typical, scalloped appearance on B-scan. On standardized A-scan, choroidal detachments produce a maximally tall (100%) spike when the sound beam is aligned perpendicular to the surface. This spike is generally thicker than the spike produced by a retinal detachment and is usually double-peaked when there is no overlying retinal detachment.

Choroidal detachments may be hemorrhagic or serous in nature and can be mistaken for retinal detachment or mass lesions. Specific echographic features can facilitate the differentiation. Hemorrhagic choroidal detachments will display echo signals beneath the choroidal surface, whereas serous detachments will display an absence of echoes in the suprachoroidal space. On standardized A-scan, a maximally high, 100% tall, thick double-peaked spike will be produced by the retina and choroid together. If the spikes between the choroidal spike and the sclera are low reflective, it is likely that the hemorrhage is more liquefied. However, if these spikes are higher, or more irregular in distribution, the hemorrhage is most likely clotted. Serial ultrasound examinations to evaluate the consistency of the suprachoroidal hemorrhage can be useful to help the surgeon determine when to attempt drainage. On B-scan examination, the density of the suprachoroidal hemorrhage may be less reflective, an indication that the clot has begun to liquefy.

Serous choroidal detachments will display a flat baseline between the choroidal spike and the sclera. When bullous detachment of the choroid is present, band formation may be noted beneath the choroidal surface. This suprachoroidal band is thought to be a stretched vortex vein.

Echography can be very beneficial in ruling out the presence of “kissing” choroidal detachments (bullous choroidal detachments that meet and touch in the central vitreous space). Kissing choroidals are a serious condition that can lower a patient’s visual prognosis if not treated promptly. Serial ultrasounds are helpful in monitoring the elevation of these detachments during or following treatment.

Prolonged low intraocular pressure can lead to hypotony. Echographically, there will be diffuse thickening of the ocular coats and a shortened axial length. If the pressure remains low, scleral infolding may occur.

Atta HR, Byrne SF. The findings of standardized echography for choroidal folds. Arch Ophthalmol 1988;106: 1234–1241

Chang TS, Byrne SF, Gass JD, Hughes JR, Johnson RN, Murray TG. Echographic findings in benign reactive lymphoid hyperplasia of the choroid. Arch Ophthalmol 1996;114:669–675

Reynolds MG, Haimovici R, Flynn HW Jr, DiBernardo C, Byrne SF, Feuer W. Suprachoroidal hemorrhage. Clinical features and results of secondary surgical management. Ophthalmology 1993;100:460–465

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Figure 5–4 Uveal effusion, nanophthalmos. (A) Axial approach showing the relatively small globe. (B) Transverse scan showing thickened choroid. (C) A-scan showing the high reflectivity from the choroid (arrow). (From DiBernardo C. Ultrasonography. In: Regillo CD, Brown GC, Flynn HW. Vitreoretinal Disease: The Essentials. New York: Thieme Medical Publishers; 1999. Reprinted by permission.)

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Figure 5–5 Choroidal detachment. (A) Cross section showing typical scalloped appearance of 360-degree serous choroidal detachments. (B) Radial section showing bullous dome-shape of choroidal detachments with insertion away from the disc (arrow). ON, optic nerve. (C) A-scan showing the 100% tall spikes from the surface of the choroid. Generally, this spike is thicker than a spike produced by retinal detachment. (From DiBernardo C. Ultrasonography. In: Regillo CD, Brown GC, Flynn HW. Vitreoretinal Disease: The Essentials. New York: Thieme Medical Publishers; 1999. Reprinted by permission.)