The document discusses the use of B-scan ultrasound in ophthalmology, detailing its role in complementing clinical examination and the distinctions between high and low frequency B-scans. It highlights various ocular conditions assessed through B-scan, including the evaluation of opaque and clear ocular media, vitreous hemorrhage, retinal detachment, tumors, and post-surgical complications. The document also outlines methods for lesion description, reflection characteristics, and possible diagnoses based on B-scan findings.

1. B-SCAN
Moderator : Dr Gladys R
Rodrigues
Presenter : Dr Sriraj Alapati

2. INTRODUCTION
 Brightness scan
 Complements clinical examination but doesn’t replace it.
 High frequency : good RESOLUTION : UBM (20-50 MHz)
Low frequency : good TISSUE PENETRATION : B Scan (8- 10 MHz)
 Acoustic Impedance – reflectivity (returning echoes)
 Gain (40-100 Db) – amplitude of echoes
 Direct globe / via lid / immersion

3. INDICATIONS
A. OPAQUE OCULAR MEDIA
Anterior segment :
• Corneal opacification
• Hyphemia / Hypopyon
• Miosis
• Dense Cataract
• Pupillary or retrolental
membrane
Posterior segment :
(Point like in B Scan)
• Vitreous hemorrhage
• Asteroid hyalosis
• Vitreous inflammation
(endophthalmitis)

4. B. CLEAR OCULAR MEDIA
• Membrane like in B Scan : PVD, Choroidal detachment, RD,
Retinoschisis, PED, ROP, Vitreous cyst, PHPV.
• Infections / Inflammations: VKH, SO, posterior scleritis,
endophthalmitis, neurocysticercosis.
• Trauma : IOFB, IOL / nucleus subluxation / drop, globe / choroidal
rupture, retrobulbar hemorrhage, giant retinal tear.
• Tumors : RB, cavernous hemangioma, choroidal melanoma,
choroidal osteoma.
• Disc abnormalities : Disc oedema, drusen, coloboma.
• Orbit : thyroid, CCF.
• Post surgical : air / gas, silicone oil

5. PROBE ORIENTATION
Centre of cornea
Perpendicular to cornea
Position & relation of lesion
to lens & ONH
Axial Longitudinal Transverse
Perpendicular to limbus
AP extent of lesion
Parallel to limbus
Lateral extent of lesion
4 transverse scans: 94%

6. Upper part of screen corresponds to portion of globe
where probe marker is directed.

7. DESCRIPTION OF A LESION
1.Topographic : size, shape, borders, location (clock, disc)
2. Quantitative :
A. STRUCTURE
Regular homogenous – choroidal melanoma
Regular heterogenous – choroidal hemangioma
Irregular – RB, mets
3. Kinetic : after movements / mobility (move with eye)
Present – PVD
Absent – old RD/CD
B. REFLECTIVITY (A Scan)
High – asteroid, RD, CD
Medium – oldVH
Low – vit cells

8. POINT LIKE IN B SCAN
VITREOUS CELLS
• Point like on high gain settings
+/- membranes
• Endophthalmitis / uveitis
• Low reflectivity
• After movements present

9. VITREOUS HAEMORRHAGE
Fresh – Fine granular/ pin point echoes
with high gain settings
PVD / FVP / RD
Medium reflectivity
After movements present
Old – Blood clots and membranes (dot like
echoes organize) of varying reflectivity.
After movements absent
PVD
FVP

10. ASTEROID HYALOSIS
• Calcium salts in vitreous cavity
• Point like larger, more echogenic than
RBCs.
• Echolucent gap between vitreous and
posterior globe wall.
• High reflectivity
• After movements present

11. Point like Vitreous cells Vitreous hemorrhage Asteroid hyalosis
Topographic Point like with high gain
Endophthalmitis / uveitis
Point like with high gain
PVD / FVP – PDR / RD
Point like larger, more
echogenic than RBCs.
Echolucent gap
Reflectivity Low Medium (fresh)
low (old)
High
After movement Present Present (fresh) / absent (old) Present

12. MEMBRANE LIKE IN B SCAN
PVD
• Separation between posterior
vitreous cortex & NSR
• Myopes, old age
• Smooth, thin, mobile membrane,
open funnel +/- disc insertion, inserts
at ORA / CB
• Variable amplitude
• Low reflectivity
• After movements present
Vitreous attached to retina : vitreous base is strongest (ora serrata), optic disc margin,
macula, main retinal vessels, lattice degeneration.

13. RETINAL DETACHEMENT
• Bright, continuous
• Smooth or folded
• Open or closed funnel
• Disc and ORA insertion
• Steeply rising peak
• 80-100% reflectivity
• After movements present in fresh
(acute) and absent in old RD.
• Rhegmatogenous
Tractional
Exudative
Combined

14. Long standing RD with intra retinal cyst,
fixed retinal folds, thin retina.
Total RD : triangular / funnel (open/closed) shape
with insertion at optic disc and ORA serrata.

15. RD RHEGMATOGENOUS TRACTIONAL EXUDATIVE
Topographic Funnel / double membrane
Folds+, retinal break+
Attached to disc
Concave, tent like traction
+/- FVP /VH (PDR)
Convex, bullous
Shifting fluid
Scleral thickening
Mass lesions, Sys causes
Reflectivity High High High
After movement Present (fresh) / absent (old) Absent Absent

16. CHOROIDAL DETACHEMENT
• Smooth, dome shaped
• Multiconvex / multilobed
• Immobile
• Kissing choroids
• No disc insertion
• Inserts at ORA / CB
• Don’t extend to posterior
pole (vortex veins)
• Steeply rising double peak
(retina, choroid)
• 90-100% reflectivity
• After movements absent
Hypotony :
• GDD
• Sulfonamides
Expulsive choroidal Hg #PCA:
• Uncontrolled HTN
• Sudden decompression of
high pre op IOP
2. HEMORRHAGIC
1. SEROUS

17. Membrane Like PVD RD CD
Shape Concave Double membrane / concave / convex Multi convex (dome)
Location Variable Variable Periphery (vortex veins)
ONH Attachments Variable Yes No
Types - Rhegmatogenous / Tractional /
Exudative / Combined
Serous / hemorrhagic
Cause Myopia / age Break / FVP / Sys cause Hypotony / expulsive
choroidal hg
Other findings Prominently seen
inferiorly
Folds / FVP / shifting fluid Kissing choroids
Reflectivity (A scan) 40-90% 80-100% 90-100%
Spike Single Single Double (retina, choroid)
Mobility Marked Moderate Absent
Aftermovement + + (fresh Rheg) / - -

18. Dense anterior membrane
with narrow closed funnel RD
Elevated smooth
thin dome shaped
membrane, often
bilateral
RETINOSCHISIS
ROP

19. VITREOUS CYST
Dome shaped serous
lesion
PED
PHPV
Tent like retinal dragging
Fluid filled structure with
reflective walls

20. INFECTIONS / INFLAMMATIONS
CYSTICERCOSIS
• Pork tape worm
• S/R cyst with RD (reverse diamond ring sign)
• High reflectivity spikes
SCOLEX

21. ENDOPHTHALMITIS
Cobweb appearance
(highly reflective
membranes)
SYMPATHETIC OPHTHALMOPLEGIA
• 2 weeks After penetrating trauma
• Choroidal thickening with exudative RD

22. • B/L disc oedema
• Choroidal thickening &
areas of bullous retinal
elevation at posterior pole
VKH
1. T sign (tenons fluid + optic nerve hypo intensity)
2. Choroidal thickening
3. Scleral thickening
4. ERD
POSTERIOR SCLERITIS

23. SUBLUXATED LENS
PCR
IOL DROP
(Multiple high reflectivity echoes)
TRAUMA
NUCLEAS DROP
(Biconvex with shadow)

24. GLOBE RUPTURE
Hemorrhagic vitreous track
CHOROIDAL RUPTURE
Focal area of fundus thickening

25. RETROBULBAR
HEMORRHAGE
GIANT RETINALTEAR

26. • Posterior shadowing
• Persistence at lower gain
• High reflectivity spikes >100%
• Overestimation of size
• Vitreous / retinal / subretinal / orbital
• Metal & stone : higher reflective echoes
• Wood & vegetable matter : intermediate echoes
• Glass is picked only when sound beam strikes
perpendicular along smooth surface of glass.
• Spherical IOFBs produce strong reverberations due
to regular structure.
• Air bubble may mimic foreign body
IOFB

27. TUMORS
• Calcification produce high
reflectivity and shadowing
• Endophytic – vitreous echoes
• Exophytic – ERD with
subretinal echoes
RETINOBLASTOMA

28. CHOROIDAL MELANOMA
Collar-button / mushroom
/ dome shape :
Knapp roone tumor
break in bruchs membrabe
Exudative RD
Choroidal excavation
Steep angle
kappa
Acoustic
hollowing
Vascularity on
color doppler

29. CAVERNOUS HEMANGIOMA
High reflectivity with shadowing at
posterior pole, double optic nerve
CHOROIDAL OSTEOMA
• Intraconal
• Heterogenous structure
• Varying reflectivity
• No color flow on doppler

30. DISC ABNORMALITIES
Patient to fixate in primary gaze.
Probe placed longitudinal, temporally
with medium gain setting.
Normal ONH seen as round echo
lucent lesion adjacent to globe with
shadowing.
Disc oedema : crescent or doughnut sign

31. DISC ELEVATION
DRUSEN
Enlarged optic
nerve
With low gain
settings

32. GLAUCOMATOUS
OPTIC CUPPING
OPTIC DISC COLOBOMA
Bean pot
configuration

33. ORBIT
Enlargement muscle belly
sparing tendinous insertion
TED
Dilated SOV
CCF

34. • High reflective curvilinear echo with
comet tail shadowing.
• Echo seen in non dependent location
as air bubble floats.
• High reflective echoes.
• Single large air bubble causing strong
reverberations.
• Apparent lengthening of eye waves pass slow.
AIR / GAS SILICON OIL
POST
SURGICAL

35. THANKYOU

36. Q1. Patient c/o pain with blurring of vision. Fundus examination
shows choroidal folds with localized elevation of the retina
Findings on B scan and diagnosis?
• T sign
• Scleral & choroidal thickening
• RD
POSTERIOR SCLERITIS

37. Q2. Patient with sudden blurring of vision.
There is no view of the fundus. Findings
on B scan?
• VH
• PVD
• RD

38. Q3. Patient diagnosed to have bilateral disc elevation on routine
examination.V/A and colour vision is normal. Diagnosis?
DISC DRUSEN

39. Q4. Patient presents with blurring of vision. Examination shows low
IOP & mature cataract with no view of fundus. Findings on B scan?
RETINAL DETACHEMENT
Low IOP?
• Fresh : RPE actively pumps fluid
• Old : CB shutdown

40. Q5. Patient with h/o injury at workplace
with blurring of vision, S/P cataract surgery
2years ago.
Findings on B Scan & Diagnosis?
• Multiple high reflectivity echoes /
reverberations.
• IOL DROP / Spherical IOFB / Air