Ultrasound examination of the orbit. The document provides information on: 1. Using ultrasound to examine the eye and identify normal anatomy and common pathologies. 2. Scanning techniques for assessing the anterior chamber, posterior chamber, and retro-ocular region. 3. Descriptions of common pathologies like vitreous hemorrhage, retinal detachment, choroidal melanoma, and more and how they appear on ultrasound. 4. Images demonstrating ultrasound findings for various eye conditions.

1. Ultrasound examination of the orbit.
Dr/ ABD ALLAH NAZEER. MD.

2. ULTRASOUND OF THE EYE: Normal
ANATOMY OF THE EYE

3. External eye anatomy Cross sectional eye anatomy.
Scan gently through a closed eye. The comparative anatomy between the eye
ultrasound and the anatomy diagram above.

4. Eye ultrasound:
Hover the cursor over to see highlighted
anatomy of the anterior chamber
Increase your depth to visualize the retro-
occular region.
View the eye with the patient looking to
extremes of up, down, left and right.

5. ULTRASOUND OF THE EYE PROTOCOL
ROLE OF ULTRASOUND
Ultrasound is used primarily to assess internal structures of the
globe, particularly when direct visualization is obscured by
cataracts or hemorrhage.
Assessment of intraocular masses & measurement of tumour
thickness for staging.
Differentiating between choroidal or retinal detachments.
Some retro-occular applications.
Relationship of normal anatomy and pathology to each other
EQUIPMENT SELECTION
Use of a high resolution, small footprint probe (10-15MHZ) is
essential when assessing the internal structures of the globe.
Good colour / power / Doppler capabilities when assessing
vessels or vascularity of a structure.

6. SCANNING TECHNIQUE:
Explain the procedure. Position the patient supine.
Scan the patient through closed eyes.
Give the patient some tissues and explain that should they need to open
their eyes, to let you know and they can use the tissues to wipe their eye.
If possible, use sterile gel. Apply a small amount of gel to the probe.
Be prepared to change frequency output of probe (or probes) to
adequately assess both superficial and deeper structures.
ANTERIOR CHAMBER:
Reduce the depth to include the posterior aspect of the lens and zoom
to fill the screen. Use thick gel and minimal to no pressure because the
anterior chamber is easily compressed. Sweep in both sagittal and
transverse checking for symmetry. Look for sharp margins where the
cornea meets the lateral margins of the iris & ciliary bodies. Ensure the
lens is intact, anechoic and normally located. A cataract will be seen as
echogenic heterogeneity of the lens. Document the normal anatomy and
any pathology found, including measurements and vascularity if indicated.

7. POSTERIOR CHAMBER
Increase the depth to include the entire globe and proximal optic
nerve.
In transverse, ask the patient to look left and right to facilitate
maximum scan range. Similarly, in sagittal, ask the patient to look
up/down. Look for a smooth inner wall of uniform thickness and
echogenicity. Check for homogeneity of the vitreous tumour.
Commonly in elderly people there will be some echogenic 'debris'
within the vitreous due to degenerative changes. A vitreous
hemorrhage will be seen as mobile, fibrinous, complex material
possible tethered.
Whilst rare to see pathology, check that the optic nerve is uniform
and symmetrical in size bilaterally with no retro-occular masses.
Document the normal anatomy and any pathology found, including
measurements and vascularity if indicated.

8. COMMON PATHOLOGY
Vitreous hemorrhage
Retinal detachment
Choroidal detachment
Melanoma
Lens replacement and pathology
Foreign body and trauma
Drusen
Staphyloma

9. A vitreous hemorrhage. Bleeding can occur as a result of a ruptured
microaneurism in diabetics (a small balloon-like protrusion from a weak
area in a blood vessel), leakage from abnormal vessels in retinal vascular
conditions, or from damage to the retina.
Microaneurism usually occur in patients who have diabetic retinopathy.
When the blood sugar is high, the blood vessels get damaged, causing
localized weak areas. Over time, these weak areas start to protrude out,
forming a microaneurism. When an aneurism bursts, blood enters into the
vitreous, causing a vitreous hemorrhage.
Abnormal vessels that grow in response to low oxygen levels in retinal
vascular conditions (proliferative diabetic retinopathy, vein occlusions, etc)
are very fragile and tend to leak. Sometimes these abnormal vessels grow
from the retina into the vitreous cavity and leak blood, causing a vitreous
hemorrhage.
Mechanical damage to the blood vessels of the retina can occur from a
retinal tear or trauma to the eye. Like any other part of the body, if a
blood vessel gets damaged, it will start to bleed. If mechanical damage
occurs to the retina, retinal blood vessels can get damaged and bleed into
the vitreous cavity, causing a vitreous hemorrhage.

10. Who can get a vitreous hemorrhage and what are the risk factors?
A vitreous hemorrhage can occur in anyone, though the incidence of occurrence is
relatively small with only 7 cases per 100,000 people in the United States. Factors
that increase the possibility of developing a vitreous hemorrhage include:
1. Age
2. Proliferative Diabetic Retinopathy
3. Retinal Tear
4. Retinal Vein Occlusion with proliferative retinopathy
5. Posterior Vitreous Detachment without a tear
6. Retinal Detachment
7. Trauma to the eye
What are the symptoms of a vitreous hemorrhage?
Depending on the severity of the vitreous hemorrhage a patient may not
experience any symptoms, though this usually isn’t the case. Typically a patient
will experience one or more of the following symptoms:
1. Decreased vision
2. Sensation of looking through hazy or smoke
3. Multiple new floaters
4. Cobweb shapes, dark streaks
5. Flashes of light

11. Vitreous Hemorrhage Ultrasound Vitreous hemorrhage.

12. Vitreous Hemorrhage Ultrasound Vitreous hemorrhage ultrasound.

13. VITREOUS HAEMORRHAGE.

14. RESOLVING VITREOUS HAEMORRHAGE ORGANISED VITREOUS HAEMORRHGAE

15. POSTERIOR VITREOUS DETACHMENT (PVD):
Any derangement in the vitreous cavity leads to the detachment of
the posterior vitreous from the retina. On the B mode, PVD is seen
as a thin irregular membrane with distinct after-movements. The
presence of after-movements is a hallmark of PVD. On A scan, PVD
has low reflectivity and the reflectivity decreases as we go
peripherally towards the ora-serrata.
RETINAL DETACHMENT:
Retinal detachment can be hematogenous (primary) or non-
hematogenous (secondary to other pathologies, e.g. choroidal
melanoma). On B scan, retinal detachment is seen as a highly
reflective, V-shaped membrane attached to the optic disc (4) . This
membrane classically has restricted mobility. On A scan, there is
100% reflectivity over its entire extent. It is very important to
differentiate retinal detachment from a thick PVD attached to the
optic disc.

16. Posterior Vitreous Detachment Ultrasound.

17. Ultrasound for Acute Retinal Detachment.

19. RETINAL DETACHMENTPOSTERIOR VITREOUS DETACHMENT (PVD).

20. Retinal detachment.

21. Ultrasound image of the thin, hyperechoic
retinal membrane detached and floating
in the vitreous humor.
Retinal detachment.

22. Retinal Detachment.

23. CHOROIDAL MELANOMA.
CHOROIDAL MELANOMA
Choroidal melanoma is the commonest
tumor of the eye in the middle-age
group. Melanomas on B scan are seen
as dome shaped or collar button shaped
tumour with the base over the choroid.
The collar button shape is due to the
break in the bruch`s membrane. The
collar button shape is pathognomonic of
melanoma. Melanomas are highly
vascular tumours. The vascularity is
seen as fast flickering motion within the
tumour. This motion is more marked at
the base of the tumour. Choroidal
excavation may also be seen at the base
of the tumour (6) . On A scan it has a
very characteristic appearance - there is
a high anterior surface spike followed by
low internal reflectivity with typical
cascading effect.

24. Choroidal melanoma

25. Choroidal typical melanoma. 6.a: A minimally raised lesion of approximately 5
mm in the posterior wall of the right eye , which corresponds to a melanoma
(arrow). 6.b: Retinography of the same patient : the irregularly pigmented lesion
corresponds to the melanoma 6.c: Angiography shows some areas of contrast
enhancement corresponding to the melanoma 6.d: Optical coherence
tomography showing a raised lesion developing minimal retinal detachment.

26. Amelanotic melanoma. 7.a: Raised polypoid lesion of about 6 mm proved to be an
amelanotic melanoma. 7.b: Retinography of the patient shows the mass, round and
shiny. 7.c: Angiographic study shows a strong contrast enhancement of the mass.

27. CHOROIDAL METASTASES
CHOROIDAL METASTASES
The commonest tumor
metastazing of the choroid, is
oat cell tumor of the lung in
male and breast in the female.
On B mode, metastasis is seen
as an irregular lobulated mass
arising from the choroid with
multiple hypoechoic areas
within it. On A scan, there is a
very high irregular reflectivity
because of multiple interfaces.
Typically, metastatic lesions do
not show any vascularity, either
on A scans, or Doppler studies.

28. CHOROIDAL HAEMANGIOMA
HAEMANGIOMA
Choroidal hemangiomas may occur
as solitary lesion or as part of
Sturge-Weber syndrome. Choroidal
haemangioma does not show
increased vascularity. On B scan,
choroidal haemangioma are seen as
dome shaped choroidal mass lesion
with a broad base. Choroidal
haemangioma has irregular
echotexture. The irregular
echotexture is due to multiple
interfaces within the tumour. A small
calcific area is noted over the surface
of choroidal haemangioma. This
calcific area is a Phleboliths. It may
or may not produce shadowing
depending on the density of calcium
within the phlebolith. The presence
of phlebolith is diagnostic of
haemangioma, but absence does not
rule out haemangioma.

29. Ocular Trauma.
Globe rupture.
Dislocated lens.
Retinal Detachment.
Vitreous hemorrhage.

31. Globe rupture-moderate vitreous loss.

32. Globe Rupture.Retro bulbar Hematoma.

33. Post-traumatic Vitreous hemorrhage.

34. Ultrasound of lens Dislocation.

35. A hyperechoic foreign body (blue) in the eye.

36. Intraocular Foreign Body.

37. Endophthalmitis. Ocular ultrasound (18 Hz) A) RE: increased echogenicity and the
anteroposterior diameter of the anterior chamber (on physical examination by slit
lamp showed hypopyon) and cataract. B) RE: anteroposterior diameter of anterior
chamber: 0.27 cm. C) OI: anteroposterior diameter of anterior chamber 0.20 cm

38. Endophthalmitis. Ocular ultrasound (18 Hz) mode B and color Doppler. A) Images show
increased anterior chamber, cataract, increased soft tissue of eyelid, vitreous membranes
and heterogeneous echogenicity in the vitreous. B) Intense color Doppler in soft tissue of
eyelid. C) Absence of color Doppler in the vitreous, which is compatible with vitritis.

39. Cataract is an opacification or thickening of the lens and is the leading cause of
blindness in the world .
Ultrasound
Ocular ultrasound is performed when there is suspicion of posterior globe
pathology but visualization of the back of the eye is obscured by the opaque lens.
Cataract.

40. Cataract with retinal detachment.

41. Cataract.

43. Cataract with retinal detachment.Cataract with uvieitis.

44. Annotated ultrasound of an eye with posterior lens luxation.
Direct visualization was impossible due to hyphema

45. Retinoblastoma is the most common intraocular
neoplasm found in childhood, and with modern treatment
modalities is, in most cases, curable.
Ultrasound
Orbital sonography can be performed without sedation
and can be repeated multiple times without exposing the
child to ionizing radiation. Retinoblastoma's appear as
echogenic soft-tissue masses with variable shadowing due
to calcifications and heterogeneity due to necrosis and/or
hemorrhage. At diagnosis tumours are usually vascular on
Doppler examination.
The vitreous may have multiple areas of 'floating' debris,
which may represent vitreous seeding or alternatively
necrotic debris, hemorrhage or increased globulin content.

46. RETINOBLASTOMA.

47. Retinoblastoma: Large tumor as seen in a 3D
ultrasound block demonstrates calcium (arrows).

48. Optic disc drusen (ODD) are also known as hyaline bodies
and are a relatively common entity. They are usually found
incidentally on CT or on follow-up of abnormal fundoscopy.
Ultrasound
Ocular ultrasound demonstrates an echogenic focus within
or on the surface of the optic nerve head. Posterior
acoustic shadowing may be present with larger lesions.
Fundoscopic findings depend on how deeply the drusen
is located in the optic disc. Superficial deposits exhibit
characteristic auto fluorescence making the diagnosis in
such cases obvious. Deeper deposits have less-specific
appearances with swelling of the optic disc that mimics
papilloedema (pseudopapilloedema.

49. Optic disc drusen.

50. B-scan ultrasound of the right and left eye showing increased reflectivity on the
optic nerve head and increased shadowing consistent with optic nerve drusen.

51. Staphyloma is the term given to an eye whose sclero-uveal coats
are stretched (also known as ectasia). This most commonly occurs
posteriorly, although anterior Staphyloma also is recognised. As
opposed to coloboma,staphyloma defect is located off-center from
the optic disc, typically temporal to the disc
Radiographic features
increased eye size
focal deformity (not as marked as coloboma): usually posterior
non-enhancing uveo-sclera.
Posterior staphyloma.

52. A/B-scan ultrasonography of an eye with posterior staphyloma.

53. Hyphema (blood in the anterior chamber). 3.a Eye with hyphema.
3.b: Ultrasound image of the same patient observing the presence
of small echogenic areas due to the bleeding (arrow).
Hyphema describes the condition of the aqueous
humor when red blood cells form a suspension in it.

55. Thank You.