- Email: [email protected]
Ultrasonic Diagnosis of Ocular Pathology: Its Significance for Cataract Surgery with and without IOL Implantation
ultrasonic diagnosis of ocular pathology: its significance for cataract surgery with and without IOL implantation T. T. Tjan, M.D. Amsterdam, The Netherlands
Any sound with a frequency on the order of millions of cycles per second (megacycles per second) is called ultrasound. A piezoelectric transducer can produce ultrasonic vibrations of several megacycles per second. In a suitable liquid medium' such as saline or methylcellulose solution, the pulses of this transducer are transmitted, causing reflections at the boundaries between media with different acoustic properties. These reflections or echoes are picked up by the same transducer, converted to electrical signals and displayed on a cathode ray oscilloscope. The two methods of ultrasound in use are A-scan or time-amplitude ultrasonography and B-scan or scanned intensity modulated ultrasonography. Differential diagnosis of pathologic conditions within the eye and orbit may be made using quantitative, kinetic and topographic e<;:hQgraphy in which both A and B-scan examination techniques are applied. l However, although combined use of these techniques provides optimum results, the use of quantitative A-scan echography with standardized equipment (as developed and propagated by Oksala 2 and Ossoining3-6) is preferable for tissue differentiation. 7 A normal axial echogram of the human eye displays an echo of the cornea followed by two echoes of the aiuerior and posterior lens surface and echoes of the retina and scleral wall (Fig. 1). It is the result of a'"sound beam which is directed axially through the eye via a water bath or scleral lens filled with saline. This intervening liquid medium is necessary to separate the corneal echo from the transmitter echo "T". A diascleral echogram can be produced by placing the transducer on the sclera and directing the sound beam across the vitreous to the opposite side of the eye (Fig. 2). The normal diasc1eral
From the Ultrasound Department, University Eye Clinic (Director: R.A. Crone), Amsterdam, The Netherlands. "P.,resl!nted at the International Intraocular Implant Club Meeting in Nagoya, Japan, May 1978.
echogram shows only the transmitter echo and the complex of echoes created by the retina, scleral wall and retrobulbar tissue. Diagnostic ultrasound, now widely used in eye clinics, provides important information about pathological structures in the deeper sections of the eye which cannot be obtained by other methods of ophthalmological examination. Numbered among the advantages of this technique are the facts that (1) it is harmless (an intensity of 0.2 wattl cm2 for five minutes in direct coupling is completely risk-free), (2) it does not cause patient "discomfort, (3) it is painless, (4) it provides morphological data of use to the surgeon and (5) it is fast (an ultrasound exam may be done in ten to 15 minutes). Ultrasound is well-known for its use in determining the axial length of the eye, 8 the thickness of the lens and the depth of the anterior chamber. These data are used for calculation of intraocular lens power prior to lens implant surgery. Such calculations reduce the risk of aberrant lens power and subsequent high final refractive error or intolerable aniseikonia. However, prior to intraocular lens implant surgery, it is also important to ascertain the status of the posterior segment. Herein are described the uses of ultrasound for evaluation of posterior segment pathology in cataractous eyes and the cataract itself. VITREOUS, RETINAL AND CHOROIDAL PATHOLOGY Hemorrhages The echogram shows irregular, multiple echoes which disappear when sensitivity is reduced (Fig. 3).9-11
Exudates in uveitis Low and mobile echoes (Fig. 4).7 Crystals in synchisis scintillans These cholesterol crystals display high and mobile echoes in a fluid vitreous (Fig. 5).7.11 Connective tissues Both high and low echoes are found in retiriitis proliferans (Fig. 6). Vitreous membranes are often mistaken for retinal detachments. 12 Differential diagnosis is made by determining the reflectivity of the various interfaces. The echo of a vitreous membrane is about 20 dB lower than the scleral echo (Fig. 7), and a retinal detachment produces an echo which is about 6 to 15 dB lower than the scleral echo (Fig. 8).13 The echo of a persistent hyaloid artery can be produced by placing the transducer
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
15
diascle rally in the upper nasal quadr ant while the patien t is lookin g to the lower tempo ral side. This single echo may be easily differe ntiated from that caused by a retinal detach ment: very slight angula tion of the transd ucer will cause the echo of the persist ent hyaloi d artery to disapp ear immed iately (Fig. 9).
Retina l and choroidal detachments and tumor s A retinal detach ment produc es a high echo in the vitreou s cavity. Norma lly, the subret inal space reflects no echoes2.10; however, a secondary detachment caused by uveitis produc es low echoes in this area (Fig. 10). A choroi dal detach ment may be diagno sed by a high echo which is broade r than the echo of a retinal detach ment (Fig. 11).1 A tumor will cause high to mediu m echoes in the subretinal space (Fig. 12). Note that a hemor rhage in the subret inal space can only be differe ntiated from tumor tissue with quanti tative echography.Jl·13 Fig. 13 shows the low to mediu m echoes produced by a melan oma,lo which are occasi onally accom panied by echo waves indica ting a localized or total retinal detach ment (Fig. 14). In this case the transd ucer is placed on the tumor so that the sound beam is directe d to the oppos ite side of the eye. Foreign bodies Traum atized eyes often conceal intrao cular foreig n bodies which are not detectable by X-ray exami nation since they are not radiop aque. 9 . 14 However, nonra diopaq ue foreign bodies, such as woode n or plastic particles, produ ce echoes with an ampli tude higher than that of the scleral echo (Fig. 15). Altho ugh someti mes difficult, it is possib le to localize small foreign bodies in the lens, the vitreou s body or the scleral wall.
LENS PATHOLOGY Pathol ogy of the. lens also can be visualized throug h use of ultraso und. Fig. 16 shows the wave patter n associ ated with thinni ng of a catara ctous lens. ls This thinni ng may progre ss to the point where the lens becomes just a thick memb rane, identif iable only by ultraso und. A swolle n catara ctous lens is easily recognizable on the echog ram (Fig. 17); however a poster ior lentico nus can simula te the wave patter n produc ed by an abnorm ally thick lens. Differential diagno sis can be made with B-scan ultrasonography.16 This differe ntiatio n is impor tant because a poster ior lentico nus usuall y has a weak poster ior capsul e which necessitates carefu l irrigat ion and aspira tion techni ques during planne d ~xtracapsular catara ct 16
extrac tion in order to avoid poster ior capsul e ruptur e and possib le vitreou s IOSS.17 If B-scan exami nation reveals a swolle n cataractou s lens, it may be assum ed that the preope rative shallo w anterio r chamb er will deepen after catara ct extrac tion. 18 -20 This is particu larly releva nt when intrao cular lens impla ntatio n is planne d. Doubl ing of the anterio r lens surface echo can be caused by a thicke ned lens capsul e and epithe lial prolife ration (Fig. 18).15.20-23 Somet imes this thickened tissue proves to be impen etrable , necess itating incisio n or excisio n of the anteri or layer with scissors Fig_ I (Tjan). Normal axial echogram. With the use of a waterbath, the transmi tter echo "T" is separated from the echoes of the eye. Fig. 2 (Tjan). Normal diascleral echogram. No echoes appear between the transmi tter echo "T" and the retinal echo. Fig. 3 (Tjan). Vitreous hemorr hage . Irregula r, multipl e echoes (red) are displayed in the posterio r segment of the eye. Fig. 4 (Tjan). Vitreous opacities in a case of uveitis. Low and mobile echoes (red) in the vitreous cavity. Fig. 5 (Tjan). Synchisis scintillans. Very mobile, low and higher echoes (red) in the vitreous cavity. Fig. 6 (Tjan). Retiniti s proliferans. Immob ile echoes (red) of varying heights in the vitreous cavity. Fig. 7 (Tjan). One high echo (white) of a vitreous membra ne with irregula r lower echoes (red) of a vitreous hemorrh age. Fig. 8 (Tjan). Retinal detachment. Top: A-scan shows one single echo (red) and no echoes in the subretin al space. Bottom: B-scan shows the retinal echo (red) running through the posterio r segment. Fig. 9 (Tjan). Persistent hyaloid artery. One single echo (red) in the vitreous cavity. Fig. 10 (Tjan). A retinal detachm ent in a case of chronic uveitis. One high retinal echo (red) and multipl e low echoes (red) in the subretin al space. Fig. II (Tjan). A choroid al detachm ent. A doubled echo (red) in front of the scleral echo. Fig. 12 (Tjan). Secondary tumor in the choroid. High echoes (red) are displayed in the subretin al space. Top: A-scan. Bottom: B-scan. Fig. 13 (Tjan). Malign ant melano ma of the choroid . Top: A-scan shows medium to low echoes (red) in the subretin al space. Bottom: B-scan shows the patholo gical structur e in the posterio r segmen t with a silent core "S." Fig. 14 (Tjan). Malign ant melano ma with a total retinal detachm ent. Fig. IS (Tjan). Intravit real foreign body. An immobi le echo (red) with very high reflectivity. Fig. 16 (Tjan). Abnorm ally thin lens. Fig. 17 (Tjan). Abnorm ally swollen lens. Fig. 18 (Tjan). Catarac tous lens with an abnorm ally thickened anterio r capsule. A doubled echo (red) of the anterior surface of the lens. Fig. 19 (Tjan). Catarac tous lens with a sclerotic nucleus. Two echoes are displayed between the echoes of the anterior and posterio r surface of the lens.
AM INTRA-OCULAR IMPLANT SOC J-VOL . V, JANUARY 1979
FIGURE 4
FIGURE 1
FIGURE 5
FIGURE 3
FIGURE 6
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
17
FIGURE 9 FIGURE 7
FIGURE 10
FIGURE 8 18
FIGURE II
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
FIGURE 13 FIGURE 12
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
19
FIGURE 17
FIGURE 14
FIGURE 15
FIGURE 16 20
FIGURE 18
FIGURE 19
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
instead of the usual instruments for caps ulotomy or capsulectomy. Finally, ultrasound can be used to obtain information on the size and densities of the nucleus of a cataractous lens. 2o •24 A sclerotic nucleus will produce two additional echoes in the lens pattern when high frequency transducers are used (Fig. 19).15.25 Preoperative ultrasonic information on the size and densities of the nucleus can be useful to make a choice between phacoemulsification and classical extracapsular cataract extraction. SUMMARY The use of diagnostic ultrasound can alert the eye surgeon to certain pathologic conditions of the eye before cataract surgery, including problems associated with the vitreous, retina, choroid and lens. This knowledge may be applied to all cataract surgery and in particular to intraocular lens implantation.
REFERENCES 1. Purnell EW: Ultrasound in ophthalmological diagnosis, in Gitter KA, Keeney AH, Sarin LK et al (eds): Diagnostic Ultrasound: Proceedings of the First International Conference. New York, Plenum Press, 1966, pp 95-ll 0 2. Oksala A: A·mode diagnosis of intraocular diseases, in Wainstock MA (ed): Ultasonography in Ophthalmology. Boston, International Ophthalmology Clinics, 1969, vol 9, no 3, pp 543·572 3. Ossoinig KC: Grundlagen der Klinischen Echo·Ophthal· mographie. Wien, Verlag der Wiener Medizinischen Aka· kemie, 1971, pp 1·121 4. Ossoinig KC: Quantitative echography-an important aid for the acoustic differentiation of tissues, in de Vlieger M, White DN, McCready VR (eds): Ultrasonics in Medicine. Amsterdam, Excerpta Medica, 1974, pp 49·54 5. Ossoinig KC: Klinische echo·ophthalmographie, in Ultra· sonographia Medica. Wien, Verlag der Wiener Medizini· schen Akademie, 1969, pp 333·350. 6. Ossoinig KC: Preoperative differential diagnosis of tumors with echography (II) Instrumentation and techniques, in Current Concepts of Ophthalmology. St Louis, 1974, vol 4, pp 280·296 7. Hamard H, Massin M, Poujol J: Echographic de l'oeil et de I'orbite. Bulletin des Societes d'Ophthalmologie de France, Numero Special: 85, 1973
11.
12.
13.
14.
15.
16.
17.
sonography in Ophthalmology. Boston, International Oph· thalmology Clinics, 1969, vol 9, no 3, pp 573·584 Ossoinig KC: Uber die beurteilung der kinetischen eigen· schaften von echogrammen, in Ultrasonics in Ophthalmology. New York, Karger, 1967, pp 88·96 Oksala A: Ultraschall untersuchung bei synaresis des glaskorpers, in Ultrasonography in Ophthalmology. New York, Karger, 1975, pp 78·85 Ossoinig KC: Ultrasonic diagnosis on the eye-an aid for the clinic, in Ultrasonics in Ophthalmology. New York, Karger, 1967, pp 116·133 Ossoinig KC, Seher K: Ultrasonic diagnosis of intraocular foreign bodies, in Ophthalmic Ultrasound. St. Louis, CV Mosby Co, 1969, pp 311·320 Babel J, Psilas K, Itin W: Mesures echographiques de I'epaisseur du cristallin dans les cataractes unilaterales, in Ultrasonographia Medica. Wien, Verlag der Wiener Medizinischen Akademie, 1969, pp 547·555 Baum G: Ultrasonographic examination of the eye, in Fundamentals of Medical Ultrasonography. New York, GP Putnam's Sons, 1975, pp 166·196 Clapp CA: Congenital anomalies of the lens other than cataract, in Cataract; its Etiology and Treatment. Philadel· phia, Lea and Febiger, 1934, pp 52·67
18. Weekers R, Delmarcelle Y, Luyckx·Bacus J et al: Mor· phological changes of the lens with age and cataract, in The Human Lens in Relation to Cataract. Amsterdam, Excerpta Medica, 1973, pp 25·43 19. Weekers R, Delmarcelle Y, Luyckx·Bacus J: Biometrics of the crystalline lens, in Bellows JG (ed): Cataract and Abnormalities of the Lens. New York, Grune and Stratton, Inc, 1975, pp 134·147 20. Wolff E: Pathology of the Eye. Philadelphia, Blakiston Co, 1945, pp 91·103
21. Friedenwald JS: Pathology of the Eye. New York, Mac· millen Co, 1929, pp 125·139 22. Hogan MJ, Alvarado JA, Weddell JE: The lens, in Histology of the Human Eye. Philadelphia, WB Saunders Co, 1971, pp 638·677 23. Wolff E: Anatomy of the Eye and Orbit. London, HK Lewis and Co, Ltd, 1961, pp 138·149 24. Coleman DJ: Ultrasonic tomography in the evaluation of cataract, in Bellows JG (ed): Cataract and Abnormalities of the Lens. New York, Grune and Stratton, Inc, 1975, pp 148·153 25. Metz GA, Bronson NR: Ultrasound appearance of senile lens changes, in Ophthalmic Ultrasound. St. Louis, CV Mosby Co, 1969, pp 218·223
8. Coleman DJ: Ophthalmic biometry using ultrasound, in Wainstock MA (ed): Ultrasonography in Ophthalmology. Boston, International Ophthalmology Clinics, 1969, vol 9, no. 3, pp 667·683
9. Bronson NR: Foreign body management, in Wainstock MA (ed): Ultrasonography in Ophthalmology. Boston, Inter· national Ophthalmology Clinics, 1969, vol 9, no 3, pp 685·707 10. Gitter KA: Diagnostic time·amplitude ultrasonography of the posterior segment, in Wainstock MA (ed): Ultra· AM INTRA·OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
21
Any sound with a frequency on the order of millions of cycles per second (megacycles per second) is called ultrasound. A piezoelectric transducer can produce ultrasonic vibrations of several megacycles per second. In a suitable liquid medium' such as saline or methylcellulose solution, the pulses of this transducer are transmitted, causing reflections at the boundaries between media with different acoustic properties. These reflections or echoes are picked up by the same transducer, converted to electrical signals and displayed on a cathode ray oscilloscope. The two methods of ultrasound in use are A-scan or time-amplitude ultrasonography and B-scan or scanned intensity modulated ultrasonography. Differential diagnosis of pathologic conditions within the eye and orbit may be made using quantitative, kinetic and topographic e<;:hQgraphy in which both A and B-scan examination techniques are applied. l However, although combined use of these techniques provides optimum results, the use of quantitative A-scan echography with standardized equipment (as developed and propagated by Oksala 2 and Ossoining3-6) is preferable for tissue differentiation. 7 A normal axial echogram of the human eye displays an echo of the cornea followed by two echoes of the aiuerior and posterior lens surface and echoes of the retina and scleral wall (Fig. 1). It is the result of a'"sound beam which is directed axially through the eye via a water bath or scleral lens filled with saline. This intervening liquid medium is necessary to separate the corneal echo from the transmitter echo "T". A diascleral echogram can be produced by placing the transducer on the sclera and directing the sound beam across the vitreous to the opposite side of the eye (Fig. 2). The normal diasc1eral
From the Ultrasound Department, University Eye Clinic (Director: R.A. Crone), Amsterdam, The Netherlands. "P.,resl!nted at the International Intraocular Implant Club Meeting in Nagoya, Japan, May 1978.
echogram shows only the transmitter echo and the complex of echoes created by the retina, scleral wall and retrobulbar tissue. Diagnostic ultrasound, now widely used in eye clinics, provides important information about pathological structures in the deeper sections of the eye which cannot be obtained by other methods of ophthalmological examination. Numbered among the advantages of this technique are the facts that (1) it is harmless (an intensity of 0.2 wattl cm2 for five minutes in direct coupling is completely risk-free), (2) it does not cause patient "discomfort, (3) it is painless, (4) it provides morphological data of use to the surgeon and (5) it is fast (an ultrasound exam may be done in ten to 15 minutes). Ultrasound is well-known for its use in determining the axial length of the eye, 8 the thickness of the lens and the depth of the anterior chamber. These data are used for calculation of intraocular lens power prior to lens implant surgery. Such calculations reduce the risk of aberrant lens power and subsequent high final refractive error or intolerable aniseikonia. However, prior to intraocular lens implant surgery, it is also important to ascertain the status of the posterior segment. Herein are described the uses of ultrasound for evaluation of posterior segment pathology in cataractous eyes and the cataract itself. VITREOUS, RETINAL AND CHOROIDAL PATHOLOGY Hemorrhages The echogram shows irregular, multiple echoes which disappear when sensitivity is reduced (Fig. 3).9-11
Exudates in uveitis Low and mobile echoes (Fig. 4).7 Crystals in synchisis scintillans These cholesterol crystals display high and mobile echoes in a fluid vitreous (Fig. 5).7.11 Connective tissues Both high and low echoes are found in retiriitis proliferans (Fig. 6). Vitreous membranes are often mistaken for retinal detachments. 12 Differential diagnosis is made by determining the reflectivity of the various interfaces. The echo of a vitreous membrane is about 20 dB lower than the scleral echo (Fig. 7), and a retinal detachment produces an echo which is about 6 to 15 dB lower than the scleral echo (Fig. 8).13 The echo of a persistent hyaloid artery can be produced by placing the transducer
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
15
diascle rally in the upper nasal quadr ant while the patien t is lookin g to the lower tempo ral side. This single echo may be easily differe ntiated from that caused by a retinal detach ment: very slight angula tion of the transd ucer will cause the echo of the persist ent hyaloi d artery to disapp ear immed iately (Fig. 9).
Retina l and choroidal detachments and tumor s A retinal detach ment produc es a high echo in the vitreou s cavity. Norma lly, the subret inal space reflects no echoes2.10; however, a secondary detachment caused by uveitis produc es low echoes in this area (Fig. 10). A choroi dal detach ment may be diagno sed by a high echo which is broade r than the echo of a retinal detach ment (Fig. 11).1 A tumor will cause high to mediu m echoes in the subretinal space (Fig. 12). Note that a hemor rhage in the subret inal space can only be differe ntiated from tumor tissue with quanti tative echography.Jl·13 Fig. 13 shows the low to mediu m echoes produced by a melan oma,lo which are occasi onally accom panied by echo waves indica ting a localized or total retinal detach ment (Fig. 14). In this case the transd ucer is placed on the tumor so that the sound beam is directe d to the oppos ite side of the eye. Foreign bodies Traum atized eyes often conceal intrao cular foreig n bodies which are not detectable by X-ray exami nation since they are not radiop aque. 9 . 14 However, nonra diopaq ue foreign bodies, such as woode n or plastic particles, produ ce echoes with an ampli tude higher than that of the scleral echo (Fig. 15). Altho ugh someti mes difficult, it is possib le to localize small foreign bodies in the lens, the vitreou s body or the scleral wall.
LENS PATHOLOGY Pathol ogy of the. lens also can be visualized throug h use of ultraso und. Fig. 16 shows the wave patter n associ ated with thinni ng of a catara ctous lens. ls This thinni ng may progre ss to the point where the lens becomes just a thick memb rane, identif iable only by ultraso und. A swolle n catara ctous lens is easily recognizable on the echog ram (Fig. 17); however a poster ior lentico nus can simula te the wave patter n produc ed by an abnorm ally thick lens. Differential diagno sis can be made with B-scan ultrasonography.16 This differe ntiatio n is impor tant because a poster ior lentico nus usuall y has a weak poster ior capsul e which necessitates carefu l irrigat ion and aspira tion techni ques during planne d ~xtracapsular catara ct 16
extrac tion in order to avoid poster ior capsul e ruptur e and possib le vitreou s IOSS.17 If B-scan exami nation reveals a swolle n cataractou s lens, it may be assum ed that the preope rative shallo w anterio r chamb er will deepen after catara ct extrac tion. 18 -20 This is particu larly releva nt when intrao cular lens impla ntatio n is planne d. Doubl ing of the anterio r lens surface echo can be caused by a thicke ned lens capsul e and epithe lial prolife ration (Fig. 18).15.20-23 Somet imes this thickened tissue proves to be impen etrable , necess itating incisio n or excisio n of the anteri or layer with scissors Fig_ I (Tjan). Normal axial echogram. With the use of a waterbath, the transmi tter echo "T" is separated from the echoes of the eye. Fig. 2 (Tjan). Normal diascleral echogram. No echoes appear between the transmi tter echo "T" and the retinal echo. Fig. 3 (Tjan). Vitreous hemorr hage . Irregula r, multipl e echoes (red) are displayed in the posterio r segment of the eye. Fig. 4 (Tjan). Vitreous opacities in a case of uveitis. Low and mobile echoes (red) in the vitreous cavity. Fig. 5 (Tjan). Synchisis scintillans. Very mobile, low and higher echoes (red) in the vitreous cavity. Fig. 6 (Tjan). Retiniti s proliferans. Immob ile echoes (red) of varying heights in the vitreous cavity. Fig. 7 (Tjan). One high echo (white) of a vitreous membra ne with irregula r lower echoes (red) of a vitreous hemorrh age. Fig. 8 (Tjan). Retinal detachment. Top: A-scan shows one single echo (red) and no echoes in the subretin al space. Bottom: B-scan shows the retinal echo (red) running through the posterio r segment. Fig. 9 (Tjan). Persistent hyaloid artery. One single echo (red) in the vitreous cavity. Fig. 10 (Tjan). A retinal detachm ent in a case of chronic uveitis. One high retinal echo (red) and multipl e low echoes (red) in the subretin al space. Fig. II (Tjan). A choroid al detachm ent. A doubled echo (red) in front of the scleral echo. Fig. 12 (Tjan). Secondary tumor in the choroid. High echoes (red) are displayed in the subretin al space. Top: A-scan. Bottom: B-scan. Fig. 13 (Tjan). Malign ant melano ma of the choroid . Top: A-scan shows medium to low echoes (red) in the subretin al space. Bottom: B-scan shows the patholo gical structur e in the posterio r segmen t with a silent core "S." Fig. 14 (Tjan). Malign ant melano ma with a total retinal detachm ent. Fig. IS (Tjan). Intravit real foreign body. An immobi le echo (red) with very high reflectivity. Fig. 16 (Tjan). Abnorm ally thin lens. Fig. 17 (Tjan). Abnorm ally swollen lens. Fig. 18 (Tjan). Catarac tous lens with an abnorm ally thickened anterio r capsule. A doubled echo (red) of the anterior surface of the lens. Fig. 19 (Tjan). Catarac tous lens with a sclerotic nucleus. Two echoes are displayed between the echoes of the anterior and posterio r surface of the lens.
AM INTRA-OCULAR IMPLANT SOC J-VOL . V, JANUARY 1979
FIGURE 4
FIGURE 1
FIGURE 5
FIGURE 3
FIGURE 6
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
17
FIGURE 9 FIGURE 7
FIGURE 10
FIGURE 8 18
FIGURE II
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
FIGURE 13 FIGURE 12
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
19
FIGURE 17
FIGURE 14
FIGURE 15
FIGURE 16 20
FIGURE 18
FIGURE 19
AM INTRA-OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
instead of the usual instruments for caps ulotomy or capsulectomy. Finally, ultrasound can be used to obtain information on the size and densities of the nucleus of a cataractous lens. 2o •24 A sclerotic nucleus will produce two additional echoes in the lens pattern when high frequency transducers are used (Fig. 19).15.25 Preoperative ultrasonic information on the size and densities of the nucleus can be useful to make a choice between phacoemulsification and classical extracapsular cataract extraction. SUMMARY The use of diagnostic ultrasound can alert the eye surgeon to certain pathologic conditions of the eye before cataract surgery, including problems associated with the vitreous, retina, choroid and lens. This knowledge may be applied to all cataract surgery and in particular to intraocular lens implantation.
REFERENCES 1. Purnell EW: Ultrasound in ophthalmological diagnosis, in Gitter KA, Keeney AH, Sarin LK et al (eds): Diagnostic Ultrasound: Proceedings of the First International Conference. New York, Plenum Press, 1966, pp 95-ll 0 2. Oksala A: A·mode diagnosis of intraocular diseases, in Wainstock MA (ed): Ultasonography in Ophthalmology. Boston, International Ophthalmology Clinics, 1969, vol 9, no 3, pp 543·572 3. Ossoinig KC: Grundlagen der Klinischen Echo·Ophthal· mographie. Wien, Verlag der Wiener Medizinischen Aka· kemie, 1971, pp 1·121 4. Ossoinig KC: Quantitative echography-an important aid for the acoustic differentiation of tissues, in de Vlieger M, White DN, McCready VR (eds): Ultrasonics in Medicine. Amsterdam, Excerpta Medica, 1974, pp 49·54 5. Ossoinig KC: Klinische echo·ophthalmographie, in Ultra· sonographia Medica. Wien, Verlag der Wiener Medizini· schen Akademie, 1969, pp 333·350. 6. Ossoinig KC: Preoperative differential diagnosis of tumors with echography (II) Instrumentation and techniques, in Current Concepts of Ophthalmology. St Louis, 1974, vol 4, pp 280·296 7. Hamard H, Massin M, Poujol J: Echographic de l'oeil et de I'orbite. Bulletin des Societes d'Ophthalmologie de France, Numero Special: 85, 1973
11.
12.
13.
14.
15.
16.
17.
sonography in Ophthalmology. Boston, International Oph· thalmology Clinics, 1969, vol 9, no 3, pp 573·584 Ossoinig KC: Uber die beurteilung der kinetischen eigen· schaften von echogrammen, in Ultrasonics in Ophthalmology. New York, Karger, 1967, pp 88·96 Oksala A: Ultraschall untersuchung bei synaresis des glaskorpers, in Ultrasonography in Ophthalmology. New York, Karger, 1975, pp 78·85 Ossoinig KC: Ultrasonic diagnosis on the eye-an aid for the clinic, in Ultrasonics in Ophthalmology. New York, Karger, 1967, pp 116·133 Ossoinig KC, Seher K: Ultrasonic diagnosis of intraocular foreign bodies, in Ophthalmic Ultrasound. St. Louis, CV Mosby Co, 1969, pp 311·320 Babel J, Psilas K, Itin W: Mesures echographiques de I'epaisseur du cristallin dans les cataractes unilaterales, in Ultrasonographia Medica. Wien, Verlag der Wiener Medizinischen Akademie, 1969, pp 547·555 Baum G: Ultrasonographic examination of the eye, in Fundamentals of Medical Ultrasonography. New York, GP Putnam's Sons, 1975, pp 166·196 Clapp CA: Congenital anomalies of the lens other than cataract, in Cataract; its Etiology and Treatment. Philadel· phia, Lea and Febiger, 1934, pp 52·67
18. Weekers R, Delmarcelle Y, Luyckx·Bacus J et al: Mor· phological changes of the lens with age and cataract, in The Human Lens in Relation to Cataract. Amsterdam, Excerpta Medica, 1973, pp 25·43 19. Weekers R, Delmarcelle Y, Luyckx·Bacus J: Biometrics of the crystalline lens, in Bellows JG (ed): Cataract and Abnormalities of the Lens. New York, Grune and Stratton, Inc, 1975, pp 134·147 20. Wolff E: Pathology of the Eye. Philadelphia, Blakiston Co, 1945, pp 91·103
21. Friedenwald JS: Pathology of the Eye. New York, Mac· millen Co, 1929, pp 125·139 22. Hogan MJ, Alvarado JA, Weddell JE: The lens, in Histology of the Human Eye. Philadelphia, WB Saunders Co, 1971, pp 638·677 23. Wolff E: Anatomy of the Eye and Orbit. London, HK Lewis and Co, Ltd, 1961, pp 138·149 24. Coleman DJ: Ultrasonic tomography in the evaluation of cataract, in Bellows JG (ed): Cataract and Abnormalities of the Lens. New York, Grune and Stratton, Inc, 1975, pp 148·153 25. Metz GA, Bronson NR: Ultrasound appearance of senile lens changes, in Ophthalmic Ultrasound. St. Louis, CV Mosby Co, 1969, pp 218·223
8. Coleman DJ: Ophthalmic biometry using ultrasound, in Wainstock MA (ed): Ultrasonography in Ophthalmology. Boston, International Ophthalmology Clinics, 1969, vol 9, no. 3, pp 667·683
9. Bronson NR: Foreign body management, in Wainstock MA (ed): Ultrasonography in Ophthalmology. Boston, Inter· national Ophthalmology Clinics, 1969, vol 9, no 3, pp 685·707 10. Gitter KA: Diagnostic time·amplitude ultrasonography of the posterior segment, in Wainstock MA (ed): Ultra· AM INTRA·OCULAR IMPLANT SOC J-VOL. V, JANUARY 1979
21