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

Figure 5–6 Localized, serous choroidal detachment. (A) Transverse scan showing the localized, dome-shaped choroidal detachment (arrow). (B) Longitudinal scan showing the peripheral extent of the choroidal detachment and the fact that it does not extend to the posterior pole and optic disc (ON). (C) Standardized A-scan showing the thick, maximally high spike produced by the surface of the choroidal detachment (C). No significant signals are noted in the suprachoroidal space (arrow); this finding is consistent with serous fluid accumulation.

Figure 5–7 Suprachoroidal band. Occasionally, with bullous choroidal detachments, a fine band can be noted beneath the choroidal surface; this structure is thought to be a vortex vein.

(A) Transverse image showing bullous, serous choroidal detachments (C) and a suprachoroidal band (arrow). (B) Longitudinal view showing detached choroid (C) and suprachoroidal band (arrow). (C) Corresponding A-scan showing a thick, high reflective spike from the detached choroid (C), and a thin, medium reflective spike originated from the band (arrow).

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Figure 5–8 Hemorrhagic “kissing” choroidal detachments.

(A) Transverse scan showing 360-degree bullous, hemorrhagic choroidal detachments kissing centrally (arrow). (B) Longitudinal scan showing that there is no vitreous space. The optic nerve shadow (ON) is near the bottom of the image. (C) Standardized A-scan showing the clotted (high reflectivity) hemorrhage in the suprachoroidal space closest to the probe (short arrows), the choroidal surfaces meeting centrally (CC) and the more fluid hemorrhage beneath the choroid in the other quadrant of the globe (long arrows).

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Figure 5–9 Hemorrhagic choroidal detachments, clot. (A)

Transverse orientation showing bullous choroidal detachments (arrow) and subchoroidal hemorrhage that is partially fluid (F) and partially clotted (C). (B) Longitudinal scan showing choroidal detachments with fluid and clotted subchoroidal hemorrhage.

(C) Corresponding A-scan showing the high choroidal spike (arrow) and irregular subchoroidal spikes demonstrating areas of both high (C) and low (F) internal reflectivity from the clotted and fluid hemorrhage, respectively.

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Figure 5–10 Choroidal detachment and retinal detachment.

When there are multiple membranes, observing the specific echographic characteristics of each will aid in the differentiation.

(A) Cross section showing dense, folded retinal detachment (R) and scalloped appearance of extensive, shallow choroidal detachments

(C). (B) Longitudinal scan showing dense, folded retinal detachment

(R) inserting into the optic disc and peripheral shallow choroidal detachments (C). (C) A-scan showing thick, highly reflective spikes corresponding to the retina (R) and choroid (C) respectively.

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Figure 5–11 Retinal detachment and hemorrhagic choroidal detachments. (A) Transverse scan showing a dense, thick, folded retina detachment (R) in the central vitreous cavity and bullous, hemorrhagic choroidal detachments (arrow). (B) Longitudinal scan showing the narrow funnel configuration of the total retinal detachment (R) inserting into the optic disc (ON) and the more peripheral extension of the hemorrhagic choroidal detachments (arrow). (C) A-scan showing two tall spikes from the choroidal surfaces (C) and the maximally high signal from the retinal detachment centrally (R).

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Trauma

Echography can be a great aid to the ophthalmologist in the evaluation of the traumatized eye. Following ocular trauma, indirect ophthalmoscopy is frequently impossible because of the opacified media due to hyphema, cataract formation, vitreous hemorrhage, or edematous eyelids, and often poor patient cooperation. Echography can supplement the clinical findings by permitting evaluation of the intraocular structures that in turn may facilitate management and treatment.

An attempt at complete ophthalmoscopic evaluation is necessary prior to echographic evaluation to determine whether the globe wall has been compromised. Surgical repair of the rupture site is generally performed before ultrasound is attempted. However, in some instances when an intraocular foreign body is suspected

Suggested Readings

Green RL, Byrne SF. Diagnostic ophthalmic ultrasound. In: Ryan SJ, ed. Retina. Vol. 1. St. Louis: CV Mosby Company; 1989

and the exact location cannot be confirmed with either plane films or computed tomography (CT) scan, a very gentle ultrasound examination through the lids may yield the necessary information to assist in the removal of the foreign body. This can be done in the operating room under sterile conditions if necessary.

When an ultrasound examination is performed through the lids, a generous amount of methylcellulose is needed as a coupling agent so the echographer can apply a minimal amount of pressure on the globe while still obtaining useful information. Increasing the system sensitivity (gain) counterbalances the sound attenuation that occurs from the eyelids. As swelling and vitreous hemorrhage resorb, serial ultrasound studies may be necessary to confirm the initial findings.

Rubsamen PE, Cousins SW, Winward KE, Byrne SF. Diagnostic ultrasound and pars plana vitrectomy in penetrating ocular trauma. Ophthalmology 1994;101: 809–814

T

Figure 6–1 Vitreous track. A small metal wire entered this eye, went through the vitreous cavity, and struck the posterior globe wall before the patient pulled it out. In this longitudinal scan, the track has hemorrhage lined up along it (T). There is a focal area of fundus thickening at the posterior impact site (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 6–2 Dislocated lens. (A) Transverse scan shows the round, echolucent lens in the vitreous cavity. (B) Longitudinal view showing the dislocated lens being suspended by a hemorrhagic membrane (arrow).

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Figure 6–3 Dislocated lens. Patient with a blind, painful eye, sustained a blunt trauma and presented to the emergency room with an anterior chamber hyphema (A). Echographically, the lens

(L) was cataractous and dislocated, (B). A total optic disc cup was also noted (arrow).

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Figure 6–4 Dislocated lens. This patient had a history of cataract surgery with an intraocular lens implant (IOL) prior to sustaining a blunt trauma from a fall. (A) Transverse scan showing the IOL in the vitreous cavity and an area of shadowing from the implant (arrow). (B) Longitudinal scan showing the IOL and its anterior location in the vitreous (arrow). (C) Two distinct, highly reflective spikes are obtained from the surfaces of the implant (arrows).

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Figure 6–5 Choroidal rupture. Choroidal rupture is a common finding following severe blunt trauma. Echographically, a choroidal rupture will appear as a focal area of fundus thickening (arrows). These transverse (A) and longitudinal (B) scans were taken at a decreased gain setting to evaluate the retinochoroidal layer. At a higher gain setting, one may see dispersed hemorrhage in the vitreous adjacent to the area of the rupture but could easily miss the area of thickening.

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Figure 6–6 Posterior rupture. (A) Transverse scan showing hemorrhage emanating from a localized area of fundus thickening where a foreign body exited the posterior globe wall (arrow). (B) Longitudinal scan showing the same posterior exit site with a small amount of hemorrhage in the adjacent orbit (arrows).

Figure 6–7 Posterior rupture. An echogram, taken through the lids, on a small child, who sustained a penetrating injury after falling on a steak knife. Primary repair was performed. The child had a hyphema and was referred for an ultrasound to rule out posterior segment pathology. The ultrasound revealed a dense hemorrhagic vitreous track (white arrow) leading to a large posterior rupture (black arrow) and a large pool of blood in the orbit (H). (From DiBernardo C. Ultrasonography. In: Regillo CD, Brown GC, Flynn HW. Vitreoretinal Disease: The Essentials. New York, NY: Thieme Medical Publishers; 1999.)

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Figure 6–8 Scleral perforation during glaucoma procedure.

(A) Transverse B-scan shows disruption of the sclera (arrow) and subsequent bleb (B) that formed adjacent to the scleral perforation. (B) Longitudinal scan showing peripheral location of the scleral perforation (arrow) and bleb (B). (C) High resolution (20 MHz) B-scan directly over the bleb (B) that formed because of the perforation in the sclera (arrow).