B-scan script

Introduction :
B-scan is a simple, noninvasive tool for diagnosing lesions of the posterior segment of the eyeball
It produces 2-dimensional images of a series of dots and lines
And also provides the topographic information of shape, location, extension, mobility and gross
estimation of thickness of the tissue

History
Though the concept of ultrasound waves was known to humans in the 18th century
(Lazzaro Spallanzini’s observation on the use of ‘sound whistles’ by bats in darkness), it
was applied to ophthalmology only in the 20th century.
In 1956, Mundt and Hughes were the first to use A-scan (A stands for amplitude) to detect
and evaluate an intraocular tumor.
In 1958, Baum and Greenwood developed the first brightness-mode (B) scan in
ophthalmology.
Thereafter, Bronson introduced the portable, contact B-scan machine for ophthalmic use.
Evolution of these led to what is known today as Standardized Echography.

Principles & Physics

Ultrasound waves are acoustic waves that, by definition, have frequencies greater than 20
kiloHertz.
Ophthalmic ultrasound usually employs frequencies in the range of 8 to 10 MHz
wavelength determines its depth of tissue penetration and resolution
as the frequency increases, the wavelength decreases
Higher frequency → Shorter wavelength → Lesser depth of penetration → Better resolution
(useful for ophthalmic ultrasound)
Lower frequency → Longer wavelength → Greater depth of penetration → Lesser
resolution (useful for abdominal ultrasound)

Acoustic impedance – means the ability of a medium to resist the transmission of ultrasound waves
by virtue of its density. Hence it follows that denser the medium slower will be the velocity of sound
through it.

Echo – is produced by acoustic interfaces created at the junction of two media that have different
acoustic impedances. Greater the acoustic impedance difference between two media, greater is the
strength of reflection of the sound wave, i.e., stronger is the echo.

Ophthalmic ultrasonography uses high-frequency sound waves, transmitted from a probe into the
eye. As the sound waves strike intraocular structures, they are reflected back to the probe and
converted into an electric signal The signal is subsequently reconstructed as an 2-dimesional image
on a monitor,
Indications

Examination Techniques

Positioning the patient

patient is kept either in a reclined position on a chair or lying on a couch , the probe can be placed
directly over the conjunctiva or the lids

patient’s head and instruments are situated close together so that probe position and screen may be
viewed simultaneously

coupling medium applied to the face of the B-scan probe

In case the eyelids need to be open while performing the scan, the use of topical anesthesia is a
must.
Probe orientation

The transducer probe always has a marker, usually a dot, line, or a logo, that is represented
superiorly in the two-dimensional B-scan display. This explains the fact that the upper part of the
echogram corresponds to the area where the probe marker is placed. For e.g., if the probe marker is
placed directed nasally, the nasal quadrant of the globe will be displayed superiorly.

The B-scan can be used in three different orientations for the eye: transversal, longitudinal and axial. 

In a transverse scan, the probe is oriented perpendicular to the limbus with the probe marker pointing
superiorly for vertical scans and oblique scans, or nasally for horizontal scans. Hence the beam scans
across a single meridian at any given clock hour. Thus, it shows the anteroposterior extent of the
lesion. The oriented meridian is the one exactly opposite to the meridian in which the probe is
placed. For e.g., if the probe placed a 6’o’clock meridian, the picture displayed is the 12’o’clock
meridian.

In a longitudinal scan, the probe is oriented perpendicular to the limbus with the probe marker pointing
to the center of the cornea. The scanned meridian is designated by the clock hour opposite of where
the marker is placed. A longitudinal scan is used to determine the length (anterior to posterior) of the
lesion, or to identify the insertion of membranes. The imaging of longitudinal scans always displays the
anterior eye superiorly and the posterior eye inferiorly. For e.g., in the right eye, if the probe is held
horizontally with its face centered on the 6’o’clock meridian, the superior part of the echogram
denotes 3’o’clock meridian, the middle of the echogram denotes 12’o’clock meridian, and the inferior
part denotes 9’o’clock meridian.

In an axial scan, the probe is placed on the center of the cornea with the patient looking straight ahead
(fix in the primary gaze). The sound beam traverses posterior through the center of the lens,
intersecting the optic nerve in its path. This position is useful to evaluate the macular region, axial
length, and position of lesions in relation to the lens and optic nerve. Like transverse scans, axial
scans can be performed in the horizontal, vertical, and oblique probe orientations.

B-Scan Evaluation

Topographic B-Scan Evaluation

Using the appropriate transverse scans, the gross shape as well as the lateral extent of any lesion
can be deduced. The horizontal basal diameter of any three-dimensional lesion such as a tumor can
be derived from this scan. Then, using the longitudinal approach, directed perpendicular to the
transverse orientation, the anteroposterior extent of the lesion is scanned. This is helpful to derive
the apical height and vertical basal diameter of a lesion.
Quantitative B-Scan Evaluation

Three parameters are ascertained under this category:

Reflectivity: this is evaluated by observing the spike height on A-scan vector overlay and signal
brightness and B-scan. The types of lesions that can be assessed with this technique include
membranes, bands, opacities, tumors, and foreign bodies. The normal ocular structure causing the
highest reflectivity is the sclera (taken to be 100 percent). 

Internal structure: This property is studied by noting the differences in height and length of the A-
scan spikes and differences in echo densities on B-scan. The regular internal structure is
represented by little or no variation in A-scan spikes and uniform appearance of echoes on B-scan.
This indicated a homogenous internal structure within a lesion. Conversely, the irregular internal
structure is represented by significant differences in A-scan spikes and echo densities indicating
heterogeneous internal structure.

Sound attenuation: Attenuation of sound occurs when the sound energy is scattered, absorbed, or
reflected by any given medium. It is evaluated on both A- and B-scan. In B-scan, it is indicated by a
progressive decrease in the strength of echoes, either within or posterior to a lesion. On A-scan, it is
demonstrated by a spike decrease is measured by an angle (the Angle kappa) formed by drawing an
imaginary line through the lesion peaks with the A-scan baseline. The steeper the angle, the greater
is the sound attenuation.

Kinetic B-Scan Evaluation

Kinetic echography is used to dynamically assess the motion of or within a lesion.

After movement: is determined by observing the motion of the lesion echoes following cessation of
the eye movement. Depending on the extent of movement, the aftermovement may be classified as
good, restricted (or poor), and no aftermovement. This is important in the differentiation between
vitreous detachment (good aftermovement) and retinal detachment (restricted aftermovement).
Within the lesion, it is important to differentiate between mobile and non-mobile echoes, as this often
gives an idea regarding the nature of the substance within the lesion.

Vascularity: is assessed in tumors. Fast spontaneous motion (i.e., low-amplitude, continuous

flickering of internal lesion spikes) is best detected with standardized A-scan. Vascularity is assessed
with the probe held stationary and the eye steadily fixating on a target.

Convection motion: occurs because of convection currents that occur within blood or cholesterol
debris. It can be observed in eyes with longstanding intraocular hemorrhage and certain types of
orbital cystic lesions containing cholesterol debris or in Coat’s disease.
Anterior segment pathologies

SCC of limbus

Echogenic mass lesion at limbus with high degree of irregular reflectivity suggestive of SCC of
limbus

Iris cystic lesion

A well defined anechoic cyctic lesion is noted arising from iris without any echoes suggestive of iris
cyst. An iris cyst wall shows high reflectivity whereas cyst cavity has low reflectivity

Uveal melanoma

Small mass lesion is seen at uvea on B-scan, on A-scan this shows classical cascading reflectivity
characteristic of uveal melanoma

Subluxated cataractous lens with posterior capsule rupture

Image shows nasal subluxation of cataractous lens with posterior capsule rupture

Posterior segment pathologies

Asteroid hyalosis

Appears bright point like echo sources, opacities exhibit distinct movement on movement of the eye

Vitreous haemorrhage

 This is represented by dot-like, clump-like, or membrane-like mobile echoes in the vitreous

cavity.
 A fresh vitreous hemorrhage is echolucent or very low reflective, hence often difficult to pick
up. In such a situation, increasing the gain settings is helpful
 A posterior vitreous detachment may or may not be associated

Differentiation between asteroid Hyalosis and VH :

AH is highly echogenic,they are still visible when the gain setting is reduced upto 60dB whereas VH which
usually disappears by 60 dB
Posterior vitreous detachment (PVD)

 Seen as a freely mobile membranous echo.

 Attached to the optic nerve head in incomplete variety. Attachments could be focal or broad,
single, or multiple depending on etiology. In complete variety, there is no attachment to the
optic nerve head.
 Has good aftermovements.

Rhegmatogenous retinal detachment

 Usually seen as a uniform V-shaped membrane always attached to optic disc posteriorly
and ora serrata anteriorly
 It maintains echotextures even at low gains and has 100 percent reflectivity

 On dynamic B-scan, it moves with the eyeball and stops as soon as the eyeball stops

 Depending on configuration and chronicity, variations such as cyst formation, closed or

open funnel configuration can be observed.

Exudative Retinal Detachment

 Typical features on include the presence of smooth bullae, shifting fluid. The presence of
shifting fluid can be demonstrated by changing the patient’s position from supine to sitting
position. However, bullous rhegmatogenous retinal may also demonstrate shifting fluid sign.
 Since this type is usually associated with tumors or inflammatory conditions, always look for
associated signs such as vitreous echoes (suggestive of vitritis/ vitreous seeds), mass
lesions, and retinochoroidal thickening.

Tractional Retinal Detachment

 Typically seen as a concave membrane (compared to the usually convex configuration of

other forms)
 It is usually found in association with diabetic retinopathies, vascular inflammatory
conditions, trauma, or endophthalmitis.
 Depending on extent and location, the traction may be broad or focal, peripheral or central,
shallow, or highly elevated.

FVM

Appears as dense echogenic membrane over retina

Retinal tears

B-scan image of giant retinal tears with detachments appear as rolled out tissue with clear breach of
tissue
Large tears are visualized easily & smaller ones require meticulous examination

Mostly located in upper half of retina; in case if fresh vitreous haemorrhage due to the retinal tear
obscures the fundus view

Choroidal detachment

 Usually appears as a smooth, thick, dome-shaped convex membrane. Sometimes, it may

have a shallow configuration in the periphery
 It demonstrates a typical double-peak or ‘M’ spike on the A-scan vector, the two peaks
representing retina and choroid respectively
 There is none or very little after movement on kinetic echography. In cases with impending expulsive
haemorrhage or traumatic choroidal detachment, the sub choroidal space shows haemorrhage as
multiple dot like opacities on Bscan. There may be two or more domes which may meet in the
vitreous cavity to form kissing choroidals

Differentiation of PVD ,RD and Choroidal detachment

Endolphthalmitis

Opacities are seen with membrane formation in severe cases

Choroidal thickening,choroidal detachment, RD, retained IOFB are possible associated findings

Dislocated lens

B-scan:

- round or oval globular structure in the posterior vitreous

 - strands of vitreous may be attached to dislocated lens

Acoustic shadowing is seen, implying that the lens could be cataractous or calcified

Posterior globe rupture

Breach of sclera & choroidal tissue with associated choroidal thickening

Associated findings:

-Vitreous haemorrhage

-Retained intraocular or intraorbital FB

-RD

Intraocular foreign body

B-scan:

Metallic FB produce very bright signals

Shadowing artifact on the adjacent orbit

Round metallic FB-reverberation artifact behind FB

Choroidal hemangioma

Choroidal hemangioma with an associated exudative retinal detachment. This lesion is composed of
tightly compacted blood vessels and, therefore, demonstrates high, regular internal reflectivity on
both B-scan and diagnostic A-scan.

The Ascan spikes show a honeycomb pattern because of multiple tissue interfaces

Choroidal melanoma

solid dome shaped mass, arising from the choroidal layer with strong border echoes, projecting into the
vitreous cavity with exudative RD and retromass shadowing effect

Collar-button shaped choroidal melanoma indicating that tumor has broken through bruch’s
membrane.

A-scan pattern typical of melanoma, with the high retinal spike on the surface of the lesion but low-
to-medium internal reflectivity within the lesion. The sclera and orbital tissues are seen as spikes to
the right of the lesion.

Low reflective spikes behind the sclera.

Posterior staphyloma

common findings observed in high myopes.

It appears as a sudden bowing backward of the globe with thinning of the retinochoroidal layer. It is
usually seen at the posterior pole and the axial length of the globe is increased, indicating axial myopia.
There may be presence of vitreous debri

Retinoblastoma

Irregular echogenic mass involving vitreous, retina, subretinal space, within the vitreous cavity

The presence of calcification within the mass is a hallmark of retinoblastoma

It has mixed echotexture due to irregular distribution of tumor cells and calcification

Posterior scleritis

Nodular posterior scleritis with fluid in the Tenon capsule.

The scan on the right demonstrates a positive T-sign at the insertion of the optic nerve

Limitations

Multiple signals (Reverberations)

Occur between the probe tip and a highly reflective surface or between two highly reflective ocular
interfaces

May cause error in axial length measurements

Can be distinguished from true echoes by their position in the echograms as well as by their more
pronounce movements

Calcified lens, intraocular implants, foreign bodies, scleral buckles , air bubbles – common producers

Attenuation artifacts

Silicone oil disperses the ultrasound beam – difficult to perform

The sound attenuation prevents resolution of posterior ocular wall and orbital contents.

The velocity of sound in silicone oil is much less than in vitreous this causes the echograms of such
globes to appear larger than normal
Refraction Artifacts

The high lenticular propogation velocity can produce apparent abnormalities of the posterior pole that
resembles tumor formation or thickening of the choroid( Baum’s Bumps)

Absorption/ Shadowing effect

Blockage of sound wave transmission by a highly reflective interface. This appears as a hypointense
area behind a bright echo.eg calcium, glass, bone, air, metal.

Insufficient fluid coupling

Entrapment of air between probe and the eye

Display bright echoes that represents multiple signals between probe and entrapped air.

Low reflective spikes

 Seen in front of the retinal spike when performed at high gain

 This is because the lateral portion of the ultrasound beam reaches the concave retina earlier
than the central portion

Tumors

 To detect the acoustic structure its thickness should at least be 2mm

 Tumors located at the orbital apex are difficult to recognize because of the attenuation of the
sound and confluence of Optic Nerve and Muscles that are inseparable ultrasonically.

Intraocular foreign bodies

 If IOFB’s surface is less than 1mm or if it is embedded in the sclera

 Wooden FB initially be highly reflective but its decrease reflectivity makes difficult to localise

 Small air bubbles may mimic IOFB but usually disappear within a day or two.

Basic Screening Examination Protocol Recap

 Prior to beginning, make sure to disinfect the probe according to the manufacturer’s instructions

 Positioning of patient, the patient can be seated upright or reclined, with the head securely resting on
the headrest

 Instill one drop of topical anesthetic in each eye. This is especially important if you place the probe on
the patient’s cornea or conjunctiva
 Apply a coupling medium to the probe tip, often artificial tear gel or 2.5% methylcellulose are used
however be sure to avoid using abdominal ultrasound gel, as it is considered an ocular irritant

 Scan through the different meridians: transverse, longitudinal and axial, moving the probe tip from
limbus to the conjunctiva.

 Save images of bscan. This will be beneficial when performing topographical evaluation of the images
after completeing all the scans