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- •Ophthalmic Ultrasonography
- •Preface
- •Dedication
- •Ultrasound biomicroscopy (UBM)
- •Immersion B-scan
- •Color Doppler ultrasonography
- •3D ultrasonography
- •References
- •2 Practical Considerations
- •Introduction
- •Ultrasonographic instrument design
- •Axial resolution
- •Gain
- •Transcorneal scans
- •Acoustic wave
- •A-scan
- •Biometric A-scan
- •Standardized A-scan
- •B-scan
- •Special techniques
- •Transverse scans
- •References
- •5 Doppler and Contrast Agents
- •Introduction
- •CDI: background and physical considerations
- •Examination technique and device parameters
- •Clinical applications
- •Retinal detachment
- •Persistent fetal vasculature
- •Intraocular tumors
- •Ocular and orbital vascular diseases
- •Central retinal artery (CRA) and central retinal vein (CRV) occlusion
- •Anterior ischemic optic neuropathy (AION)
- •Orbital varix
- •Orbital tumors
- •Contrast agents
- •Conclusions
- •References
- •Introduction
- •Artemis digital ultrasound biomicroscopy
- •Method
- •Data acquisition
- •Signal processing
- •Corneal applications
- •Corneal epithelium
- •Normal corneal epithelium
- •Keratoconic epithelium
- •Epithelial thickness changes after refractive surgery
- •Corneal stroma
- •Normal cornea
- •Stromal thickness change after refractive surgery
- •Flap
- •Residual stromal bed
- •Anterior segment applications
- •Anterior chamber phakic IOL sizing
- •Posterior chamber phakic IOL sizing
- •In-situ intraocular lens imaging
- •Glaucoma
- •Hypotony
- •Conclusion
- •References
- •7 Ocular Biometry
- •Introduction
- •IOL Master®
- •Instrumentation and methods
- •Mechanism
- •Settings
- •Example:
- •Feiz–Mannis method
- •Example:
- •Wang–Koch–Maloney method
- •Example:
- •Topographic central cornea adjustment method
- •Example:
- •Example:
- •Corneal bypass method
- •Example:
- •Shammas method
- •Contact lens method
- •Haigis-L
- •Pentacam®
- •Galilei®
- •Consensus K technique
- •IOL calculation after hyperopic treatments
- •Post-radial keratotomy and cataract surgery
- •IOL calculations in corneal transplants
- •Piggyback IOL
- •Unusual power
- •A-constants and optimization
- •Troubleshooting
- •Opaque media
- •False positive readings
- •Biometric A-scan ultrasound
- •Contact
- •Immersion
- •Settings
- •Velocity settings
- •The electronic gates
- •Troubleshooting
- •Comparison of IOL Master® and immersion A-scan
- •Optimal use
- •Aphakic
- •Pseudophakic
- •Dense cataract
- •Silicone oil in vitreous
- •Macular pathology
- •Posterior staphyloma
- •Coloboma
- •Patient history
- •Preoperative refraction
- •Normative data for anterior segment structures
- •Intraocular lens power calculations
- •First-generation formula
- •Second-generation formula
- •Third-generation formula
- •Fourth-generation formula
- •Selection of the best formula
- •Post-refractive surgery
- •Double K formula method
- •Clinical history method
- •Example:
- •IOL selection in children
- •References
- •8 Corneal Diseases
- •Introduction
- •Cornea
- •Normal cornea
- •Congenital corneal opacity
- •Corneal edema
- •Corneal dystrophy
- •Corneal infection
- •Corneal transplants
- •Photoablative corneal surgery
- •Corneal biomechanical imaging
- •Intraocular lens implantation
- •Anterior segment trauma
- •Anterior segment foreign body
- •References
- •9 Glaucoma
- •Introduction
- •Anterior chamber angle evaluation
- •Secondary glaucoma
- •Congenital glaucoma
- •Evaluation after glaucoma laser and surgery
- •Optic disc evaluation
- •References
- •10 Vitreoretinal Diseases
- •Introduction
- •Vitreous
- •Vitreous hemorrhage
- •Posterior vitreous detachment
- •Asteroid hyalosis
- •Retinal detachment
- •Rhegmatogenous retinal detachment
- •Tractional retinal detachment
- •Exudative retinal detachment
- •Total retinal detachment
- •Differential diagnosis
- •Retinal tear
- •Associated retinal detachment
- •Giant retinal tear
- •Differential diagnosis
- •Retinal pigment epithelium detachment
- •Retinoschisis
- •Disciform lesions
- •Retinal cyst
- •Post-surgical changes
- •Scleral buckle
- •MIRAgel implant
- •Gas/air bubbles
- •Silicone oil
- •References
- •11 Intraocular Tumors
- •Introduction
- •Retinoblastoma
- •Clinical features, symptoms, and signs
- •Diagnostic evaluation
- •Differential diagnosis
- •Retinopathy of prematurity
- •Persistent fetal vasculature
- •Coats’ disease
- •Toxocariasis
- •Medulloepithelioma
- •Benign uveal tumors
- •Circumscribed and diffuse choroidal hemangioma
- •Clinical features, symptoms, and signs
- •Diagnostic evaluation
- •Iris and ciliary body nevus
- •Choroidal nevus
- •Uveal melanocytoma
- •Leiomyoma
- •Schwannoma (neurilemoma)
- •Malignant uveal tumors
- •Iris and ciliary body melanoma
- •Choroidal melanoma
- •Clinical features, symptoms, and signs
- •Diagnostic evaluation
- •Differential diagnosis
- •Choroidal metastasis
- •Age-related macular degeneration
- •Posterior scleritis
- •Astrocytic hamartoma
- •Choroidal osteoma
- •Others
- •References
- •Introduction
- •Anterior uveitis
- •Intermediate uveitis
- •Posterior uveitis
- •Panuveitis
- •Hypotony
- •Episcleritis
- •Scleritis
- •Anterior scleritis
- •Posterior scleritis
- •Intraocular tumor masquerading as scleritis
- •Endophthalmitis
- •References
- •13 Optic Nerve Diseases
- •Technique
- •Normal retrobulbar optic nerve measurements
- •30° test
- •Papilledema
- •Adults
- •Trauma
- •Children
- •Optic disc drusen
- •Congenital disk anomalies
- •Optic disc coloboma
- •Morning glory disk anomaly
- •Tilted optic disc
- •Pseudodoubling of the optic disc
- •Retrobulbar optic nerve lesions
- •Gaze-evoked amaurosis
- •Orbital trauma
- •Giant cell arteritis
- •References
- •14 Ocular Prenatal Imaging
- •Introduction
- •Embryology
- •Imaging modalities
- •Globe anomalies
- •Anophthalmia
- •Microphthalmia
- •Optic nerve coloboma
- •Cyclopia
- •High myopia
- •Delayed regression of the hyaloid artery and persistent hyperplastic primary vitreous
- •Cataract
- •Retinoblastoma
- •Retinal detachment
- •Orbit and adnexae
- •Hypertelorism and hypotelorism
- •Proptosis
- •Strabismus
- •Orbital cyst
- •Rhabdomyosarcoma
- •Teratoma
- •Dacryocystocele
- •References
- •15 Pediatric Eye Diseases
- •Introduction
- •Technique
- •Clinical conditions
- •Orbit
- •Hemangiomas and lymphangiomas
- •Orbital cysts
- •Rhabdomyosarcoma
- •Anterior segment
- •Peters’ anomaly
- •Limbal dermoid
- •Posterior segment
- •Persistence of the fetal vasculature (PFV)
- •Congenital retinal detachment
- •Retinopathy of prematurity (ROP)
- •Shaken baby
- •Optic nerve malformations
- •Morning glory disk anomaly
- •Coloboma
- •Tumors
- •Conclusions
- •References
- •16 Ocular Trauma
- •Introduction
- •Anterior segment
- •Angle trauma
- •Lens dislocation
- •Posterior segment
- •Rhegmatogenous retinal detachment
- •Hemorrhagic choroidal detachment
- •Intraocular foreign body
- •Posterior scleral rupture
- •Optic nerve avulsion
- •Endophthalmitis
- •Sympathetic ophthalmia
- •References
- •17 Ocular Laboratory Applications
- •Introduction
- •Instrumentation
- •Imaging modes
- •Contrast imaging
- •Ophthalmic applications
- •References
- •Introduction
- •Retrobulbar block
- •Peribulbar block
- •Sub-Tenon’s block
- •Rationale for USG-guided anesthesia
- •Published studies
- •Technique
- •Ultrasound devices
- •Ultrasound bioeffects
- •Limitations
- •Conclusions
- •References
- •19 Future Considerations
- •Historical aspects
- •High-frequency ultrasound and biomicroscopy
- •Doppler ultrasound
- •Harmonic and superharmonic ultrasound
- •Contrast-enhanced ultrasound
- •Compound imaging
- •Three- and four-dimensional ultrasound
- •C-scan ultrasound
- •Ultrasound elastography
- •Fusion imaging
- •Remote and robotic ultrasound
- •High-intensity focused ultrasound
- •Photoacoustic imaging
- •References


Ophthalmic Ultrasonography
Arun
Professor
Director, Department of Ophthalmic Oncology
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
D. Singh
of Ophthalmology
Brandy C. Hayden
Director of Ophthalmic Ultrasonography
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
MD
BS CDOS ROUB
For
additional online content visit
www.expertconsult.com
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2012

UNDERS is an imprint of Elsevier Inc.
SA
© 2012, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment
may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product
to be administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
ISBN: 978-1-4377-2636-7
British Library Cataloguing in Publication Data
Singh, Arun D.
Ophthalmic ultrasonograph
1. Eye–Ultrasonic
I. Title II. Hay
617.7’1543–dc22
W
orking together to grow
imaging.
den, Brandy C.
y.
libraries in developing countries
.elsevier.com | www.bookaid.org | www.sabre.org
www
in China
Printed
digit is the print number:
Last
9 8 7 6 5 4 3 2 1

Video
Video
contributors: Arun D Singh and Brandy C Hayden
Table of Contents
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3.1
Instructional video:
Instructional video:
3.2
Instructional video:
3.3
3.4
Instructional video:
3.5
Instructional video:
3.6
Instructional video:
Intraocular mass:
3.7
Intraocular mass:
3.8
3.9
Vitreous hemorrhage
3.10a
Intraocular mass:
Intraocular mass:
3.10b
Vitreous hemorrhage
3.11
7.1
Instructional video:
7.2
Contact biometric
Basic Positioning
Axial Scans
Longitudinal scans
Transverse scans
Five Scan Screening
Detailed B-scan Examination
Transverse scan
Longitudinal scan
with PVD: Mobility
B-scan: Vascularity
A-scan: Vascularity
with a retinal detachment: B-Scan: Convection Movement
Biometric A scan
A-scan: Compression
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7.3
Immersion biometric
Immersion biometric
7.4
Vitreous hemorrhage:
10.1
10.2
Vitreous hemorrhage:
10.3
Posterior
Tractional
10.4
Open funnel
10.5
11.1A
Choroidal melanoma:
11.1B
Choroidal melanoma:
12.1A
12.1B
16.1
Vitritis: Mobility
Vitreous lymphoma:
Dislocated cry
vitreous detachment: Mobility
retinal detachment: Mobility
retinal detachment: Mobility
A-scan: Non-compression
A-scan: Misalignment
Dispersed: Mobility
Layered: Mobility
Moderate vascularity
Marked vascularity
Mobility
stalline lens: Mobility

Preface
Ultrasonograph
in all aspects of ophthalmic practice. Ultrasonography
is routinely used not only for biometry for calculating
the power of intraocular lens implants prior to cataract
surgery but also in the management of patients with
trauma, uveitis, vitreoretinal disorders, and differentiation of intraocular tumors. The advent of high-resolution
ultrasonography of the anterior segment (ultrasound
biomicroscopy) has added new depth of understanding
of glaucoma and anterior segment disorders. Digital
ultrasound biomicroscopy of the cornea is essential for
planning refractive surgery.
The contents of Ophthalmic Ultrasonography have been
chosen with particular attention to recent advances. The
pertinent findings in most chapters have been illustrated
to improve understanding of key concepts. We have
included 26 video clips offering details of how to perform
and interpret ophthalmic ultrasonography. Chapters on
ocular prenatal imaging, laboratory applications, and
ultrasound-guided anesthesia broaden the horizons of
ultrasonography applications in ophthalmology. Concepts
currently under investigation are summarized in the
chapter on future considerations.
y has become an important clinical tool
Ophthalmic Ultrasonography represents the cumulative
experience of more than 30 contributors, the majority of
whom practice with us at the Cole Eye Institute. Despite
individual styles and preferences, great editorial care has
been taken to follow a uniform layout, to avoid overlap,
and to present balanced views.
Arun D. Singh, MD
Department of Ophthalmic Oncology
Cole Eye Institute
Cleveland Clinic
9500 Euclid Avenue
Cleveland, OH 44195, USA
Brandy C. Hayden, BS CDOS ROUB
Director of Ophthalmic Ultrasonography
Cole Eye Institute (i-10)
Cleveland Clinic Foundation
9500 Euclid Avenue
Cleveland, OH 44195, USA
ix

List
of Contributors
Norma
A
Department of Ophthalmology
Federal University of São Paulo
Medical Coordinator
Diagnostic Center in Ophthalmology
Fleury Medicina e Saúde
São Paulo, Brazil
Timothy
R
London Vision Clinic
London, UK
Brian
Cornea,
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Erin
R
Department of Radiology
Wake Forest University Baptist Medical Center
Winston-Salem, NC, USA
Hajir
Physician,
Valley Retina Associates Medical Group
Encino, CA, USA
Vikram
Pr
Director of Ultrasound
Department of Imaging Sciences
University of Rochester Medical Center
Rochester, NY, USA
William
Staff,
Cleveland Clinic
Adjunct Associate Professor of Biomedical Engineering
Case Western Reserve University
Cleveland, OH, USA
Steven
Pr
University of Miami’s Miller School of Medicine
Bascom Palmer Eye Institute
Miami and Palm Beach Gardens, FL, USA
Allemann MD
djunct Professor of Ophthalmology
J. Archer MA(Oxon) DipCompSci(Cantab)
esearch Manager
K. Armstrong MD
External Disease and Refractive Surgery Fellow
Broaddus MD
adiology Resident
Dadgostar MD PhD
Vitreoretinal Surgery
S. Dogra MD
ofessor of Radiology
J. Dupps Jr MD PhD
Cornea and Refractive Surgery, Biomedical Engineering
and Transplant
Gayer MD MBA
ofessor of Anesthesiology and Ophthalmology
Daniel
T. Ginat MD MS
R
adiology Resident
Department of Imaging Sciences
University of Rochester Medical Center
Rochester, NY, USA
Marine
R
London Vision Clinic
London, UK
Brandy
Dir
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Linda
Health
Bruce W Carter Department of Veterans Affairs Medical Center
Miami, FL, USA
Ronald
Medical
Cole Eye Institute
Professor of Ophthalmology
Lerner College of Medicine of Case Western Reserve University
Cleveland Clinic
Cleveland, OH, USA
Breno
Ophthalmology Resident
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Careen
Full
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Lisa
Staff
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Glauco
Cornea
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Gobbe MST(Optom) PhD
esearch Optometrist
C. Hayden BS CDOS ROUB
ector of Ophthalmic Ultrasonography
Kelley CRA COA ROUB
Technician Supervisor
R. Krueger MD MSE
Director, Department of Refractive Surgery
da Rocha Lima MD
Y. Lowder MD PhD
Professional Staff
D. Lystad MD
Neuro-Ophthalmology
Reggiani Mello MD
and Refractive Surgery Fellow
xi

of Contributors
List
Maria Helena Mandello Carvalhaes Ramos MD
ssistant Doctor
A
Diagnostic Center in Ophthalmology
Fleury Medicina e Saúde
São Paulo, Brazil
Dan Z. Reinstein MD MA(Cantab) FRCSC FRCOphth
Medical
London Vision Clinic
London, UK
Department of Ophthalmology
St. Thomas’ Hospital – Kings College
London, UK
Department of Ophthalmology
Columbia University Medical Center
New York, NY, USA
Centre Hospitalier National d’Ophtalmologie
Paris, France
Edward
A
Cleveland Clinic Lerner College of Medicine of Case Western
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Reecha
Ophthalmology
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Marcony
Cornea
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Lynn
Staff
Assistant Professor of Pathology
Cleveland Clinic
Cleveland, OH, USA
Jonathan
A
Cleveland Clinic Lerner College of Medicine
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Director
J. Rockwood MD
ssociate Professor of Ophthalmology
Reserve University
Sachdeva MD
Resident
R. Santhiago MD
and Refractive Surgery Fellow
Schoenfield MD
Pathologist
E. Sears MD
ssociate Professor
Sumit Sharma MD
R
esident, Ophthalmology
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Eric Scot Shaw BS
esearch Assistant
R
Department of Anesthesiology, Perioperative Medicine and Pain
Management
University of Miami, Miller School of Medicine
Miami, FL, USA
Ronald
Pr
Department of Ophthalmology
Columbia University Medical Center
New York, NY, USA
Riverside Research Institute
New York, NY, USA
Arun
Pr
Director, Department of Ophthalmic Oncology
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Rishi
A
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Staff Physician
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
H. Silverman PhD
ofessor of Ophthalmic Science
D. Singh MD
ofessor of Ophthalmology
P. Singh MD
ssistant Professor of Ophthalmology
Nathan C. Steinle MD
Vitreoretinal Fellow
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Virgínia
ost Doctoral Research Fellow
P
Federal University of São Paulo
São Paulo, Brazil
Elias
Head,
Director, The Center for Genetic Eye Diseases
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Mary
Clinical
Cole Eye Institute
Cleveland Clinic
Cleveland, OH, USA
Amit
Dir
Lerner Research Institute
Cleveland Clinic
Cleveland, Ohio, USA
L L Torres MD
I. Traboulsi MD
Department of Pediatric Ophthalmology and Strabismus
E. Turell MD
Fellow in Ophthalmic Oncology
Vasanji PhD
ector, Biomedical Imaging and Analysis Center
xii

Dedication
T
o my parents who educated me beyond their means, my
wife Annapurna, and my children, Nakul and Rahul, who
make all my efforts worthwhile (A.D.S.).
To my parents Michael and Barbara Hayden who
have always encouraged me, Judith Abel, Eric Carlson and
Timothy Murray for introducing me to academics, and
J. Douglas Woodrich and Gretchen Arnold Doran for
believing in who I am (B.C.H.).
xiii

A
cknowledgments
W
e are grateful to Daniel Martin, MD, Chairman, Cole
Eye Institute, for his encouragement. We gratefully
acknowledge the contributions of Rachael Briggs, Anne
Pinter, Karen King, Sharon Allen, Shawn Perry, Jennifer
Pertz, and the staff of the imaging department in retrieving and preparing the large amount of material used in
this book.
We could not have completed this project on time
without the support of Sharon Nash (Development
Editor), Vinod Kumar Iyyappan (Project Manager), and
Alison Woodhouse (copy-editor). We are indebted to
Russell Gabbedy (Acquisition Editor) for offering us the
opportunity to compile this book.
Arun D. Singh, MD
Department of Ophthalmic Oncology
Cole Eye Institute
Cleveland Clinic
9500 Euclid Avenue
Cleveland, OH 44195, USA
Brandy C. Hayden, BS CDOS ROUB
Director of Ophthalmic Ultrasonography
Cole Eye Institute (i-10)
Cleveland Clinic Foundation
9500 Euclid Avenue
Cleveland, OH 44195, USA
xv

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