 Basically, ultrasound kind of started in ophthalmology back in about 1956. The first paper was published by Moot and Hughes, and they talked about the reflectoscope they called it. It was kind of a primitive A-scan, and the first time in the literature did actually describe the use of ultrasound for ophthalmology. Ultrasound has been around a long time in other uses. Of course, sonar submarines, World War I, even, they used to use ultrasound for submarine detection. And then metal stresses and industries have been used for that for quite a while. So we're not the first ones to use it, but we're one of the first medical specialties to grab onto it. Of course, biometry has been a big use of ultrasound, but then diagnostic ultrasound has come along after that. I'm going to ask you to jump with me into the world of ultrasound, and we'll take off here in the mercy of it. I did a study. I looked at about 1,000 patients over a 16-month period and reviewed ultrasound, kind of the indications, what I used for, results of it. We'll talk about this during this talk. The patient population averaged 51 years, and the youngest was three months, the oldest is 91. And there were more women than men, and referral sources, about a third from university, and about two-thirds from the private community. We broke it down into nine categories of patients that were referred for ultrasound with the types of results based on the ultrasound findings. And this chart kind of breaks that down. Fundus lesions, post-irradiation from melanoma, in other words, patients that had melanomas that were treated by plaque and followed up by ultrasound, blood optic nerve heads, hanging around the eye, proptosis, I'll put on Joe's back there. On Joe's back it says, Diplopia, Opaque Media, Irosolation, miscellaneous. So those are the major categories referred for ultrasound, and this is how ultrasound kind of handled them. I confirmed the clinical impression in this category. I clarified it or altered it in this category. Negative findings and incorrect findings, so that's kind of the breakdown of what we found. This summarizes that. In just under half, the clinical impression was confirmed by ultrasound. No findings in 279 patients, and clinical impressions clarified or altered in 309 patients. Five patients were incorrectly diagnosed by the COGRAPHY. The fundus lesion category, 228 patients referred as a fundus lesion, and I confirmed that impression 21%. 174%, 114 Nevae, 52 melanomas. Now this category also probably included a lot of referred Nevae, but the clinician didn't specify that. So for the sake of the study, I just simply, if they didn't specify Nevaes and put fundus lesion, I put this in the clarified category to say that I felt that it wasn't Nevaes by ultrasound. I altered the referring diagnosis in 6%, 5 dystrophic cordal calcium, 2-demand geomas, 1 cordal attachment, 1 retinal attachment, 3 subretinal disciform lesions, and 1 retinal blastoma. Dystrophic calcium of the choroid. I see one of these about once a month or so. They're often referred as a fundus lesion, kind of yellowish, creamy color sometimes. They tend to be more superior to temporal, and they're often bilateral. Although it's interesting, a lot of the patients I see are sent with one eye with a lesion. If I look real carefully at the other eye, I'll find it there too, if I look in that area. They tend to be quite dense on the B scan, and they shadow out the orbit behind it. So that's always a sign of calcium or a foreign body signal, and you have a real bright signal, and then they're shadowing behind it. That means there's calcium. Fundus lesions, Nevae are the most common. They estimate about 6.5% of people in the population have Nevae. So in this group here, there's probably two or three Nevae among you. And most of these are benign, although the conversion rate to melanoma is about one in 9,000. Of all those who have Nevae, about one in 9,000 will convert to a melanoma. Shields give certain criteria that make you suspicious for Nevae. Symptomatic Nevae, visual field effects, or light flashes, et cetera. Subroutinal fluid, proximity to the optic nerve head. Thickness of a lesion, more than two millimeters, and orange pigment. These are all concerning things. If you see these with the Nevae, you've got to be more suspicious. There's a higher chance of conversion to melanoma. The ultrasound findings of Nevae tend to be high reflective. Here's the A scan. This is the vitreous here. Here's the surface of the tumor here. Here's the sclera. Here's the orbit. So the lesions from there to there, they're high reflective. They're regular, and they're not vascular. And they're usually less than two millimeters. So if I see these findings, that's pretty typical for a Nevae. Eucography is valuable because we can stage these lesions. You want to see if this can change over time. So to know exactly if it's changing, it sounds very helpful. You can actually measure it. I can give you numbers down to about a tenth of a millimeter accuracy as far as thickness. And so it's helpful to follow that over time. Is this lesion getting bigger? Is it changing? Also occasionally we see lesions growing behind the globe. I've seen a couple of those where they actually look pretty innocent anteriorly. But if you look with the ultrasound, you see them starting to break through sclera into the orbit. So it's important, I think, at least one time to do an ultrasound on a Nevae's and then based on your clinical judgment to repeat that later on. Discoform lesions, abrutinal discoform. These are pretty obvious and immaculate. There's of course an angiogram showing one. But sometimes they're eccentric. There's a lot of hemorrhage. They can be harder to diagnose. It's an ultrasound to be helpful. On the ACE game, see kind of a high internal spike, one or two spikes. This is probably Brooks' membrane as it thickens and scars. Here's reduced gain showing the thickened membrane. And helpful finding in these cases is to follow the patient over time. If you're not sure at first, bring it back in a month. You usually tend to get smaller as the blood kind of reabsorbed and they kind of scar down. They'll shrink in size. Metastatic lesions. This is probably the most common ocular tumor. But most of these aren't diagnosed. These are patients with cancer, often end stage cancer. They don't have symptoms. Other things are overriding the eye. You know, they're going through chemo and everything else. So they often die with a metastatic lesion in the eye, which isn't diagnosed. But metastatic lesions on a scan tend to be irregular. They're not regular. They tend to have low areas, high areas, sort of heterogeneous, kind of up and down. They tend not to be very vascular. So that's a good differential point for melanomas. So I'm pretty good at usually making that distinction. Imangiomas. These are kind of microcystic lesions, little micro cysts of blood, just like in the orbit with cavernous imangiomas. They tend to be high-reflective. Here's the lesion here. Here's the sclera. So from there to there is the lesion. This is the vitreous. There's the orbit. But that's the lesion there. So high-reflective, regular. And they're not vascular. These are slow, stagnant blood flows so you don't pick up vascularity on these lesions. Even though they are vascular, too, there's just a venous flow. It's not a arterial flow. Retinoblastomas. Calcium is the key in a child with a calcified lesion. That's retinoblastoma. It'll prove another way in a bit. About 10% of lesions in children will not be calcified in retinoblastomas. It's not always 100%. But if you see calcium, that's certainly very suggestive. CT scan can pick this up. With dense calcium, I've seen a number of cases of very fine calcium from this white CT scan. So it just sounds a bit more sensitive. You can pick up the calcium in retinoblastomas with the V scan. In fact, you've seen cases here, too. I saw one 35-year-old with retinoblastoma. So they can occur in adults. Noenoma. Mushrooming lesion, the classic lesion, breaks through Brooke's membrane. And you see the mushroom going into the eye. Dark lesion here. Pretty obvious clinically in this situation. But many times these aren't so obvious. In fact, the misdiagnosis rates have been 20% clinically in two large path studies. So clinically, there's a limit to how good we are at diagnosing melanoma. Ultrasan has changed that to less than 1% error rate in the large comp study done over the past over years. 99% plus accuracy rate for diagnosing melanomas by ultrasound. The A scan findings are very helpful. You see a solid spike. It's not moving. You see internal reflectivity, which is kind of low to medium. It's regular. It's not real high up and down, like the metastatic lesion. And it's quite vascular. This is rapid blood flow. It's blurred here because this is flowing rapidly. So these criteria, if they're all put together, diagnostic accuracy is about 99%. 130 patients have been treated with plaque therapy. We have the dentistry in Salt Lake of having two doctors that do plaque therapy. Years ago, they had to go to San Francisco or Philadelphia to have their plaque put on. A lot of logistics back and forth. So it's nice to have that capacity here. These are all patients that I saw after they were treated. And all the patients responding with tumor shrinkage and without signs of growth of the tumor. This shows a large melanoma here. Here's the lesion here. There's the sclerosis of the tumor. There's right from there to there. Internally low reflective, regular, vascular. There's the A scan of E scan. This is more like a dome shape than a mushroom that they can look like this to. Sobrettinal fluid around the lesion. But after plaque therapy, it shrinks down quite a bit. And also it changes internally. As the radiation kills the tumor, they become the chronic. They scar. So instead of the regular reflectivity and low reflectivity, they become medium to high. They become irregular. And vascularity goes away. I can see rapid vascularity here. I can't see it here. So that's always a sign to me that it's responded to treatment and the patient's probably in a good situation. Blur discs. I see a lot of these. And they're often sent to rule out drusen. I confirmed that in 32% of these. Unexpected drusen. And 13% that were sent as a papadema or blurred disc. Anomalous disc in 52%. Increased sheath fluid. About 30 degree test. I'll talk more about that in a minute. But 3% had a positive 30 degree test, which is a test for increased drusen fluid, like an increase in the cranial pressure. And one misdiagnosis of glioma. So we see a lot of these. Blur discs. Headaches. Of course the first reaction is to get a CT scan, MRI scan. They often send to neurologists. I see spinal taps done. I see angiograms done. So a lot of workup is done. But with a simple 10 second B scan, you can pick up the drusen and diagnose that in these cases. I would usually start with the sound. No bias intended here. But it really is a fast, cost effective way to screen these patients instead of going through everything else. When they're obvious. Here's a case here. Pretty lumpy disc. A little calcium flex on the surface. That's pretty apparent. That's probably a drusen. Even a very drusen. Here are the other eyes. Not quite so obvious. That's kind of a blurred disc. But big drusen in these cases. But sometimes it's not so obvious. Just to me, it looks like pathodema. Probably for an interest in the cranial pressure. But the fact it was a drusen in the situation. Another case here. Kind of some vessel changes on the surface. You can worry about pathodema. But again, ultrasound shows the drusen. Another case here. Kind of a nice, specific blurred disc. Calcium. Another case here. Another lumpy disc. This is an older B scan. This shows the calcium here, the calcium here. Another case here. Kind of a champagne court disc. Stereopsis. You can see this really protruding into the eye. You can see the drusen. So the point of all that was, it's hard to tell. Just by looking. Even we've got the experts here. Katherine, you just bragged. You look at this all the time. And sometimes it just can't tell. Especially for very drusen. So hope just sounds a very good way to screen those. I always also do an A scan. The B scan is positive. That's fine. But sometimes it's not. And what else is causing the disc to look like that? Well, the A scan, we do what's called a 30-degree test. I measure the output nerve. The patient looking straight ahead. So here's his case. Here's the nerve here to here. And this is called a sheath sign. In this case, there's increased fluid inside the sheath. Here's the sheath here. Here's the nerve parenchyma. So that space there is actually the nerve sheath. And here's the sheath over here on this side. So this is a large nerve with increased sheath fluid. And this is the case after the patient looks to the side about 30 degrees. If you look to the side, you kind of stretch the nerve out and thin the nerve. So if there's fluid around the nerve, it kind of thins out. If there's a solid thickening like a tumor, it's not going to thin out as the patient looks to the side. So it's called the 30-degree test. So this shows a positive test here. Here's a thickened nerve. Here's the same patient looking to the side with a nerve thinning. That actually the patient had a brain tumor. Had a meningioma with increased endophenyl pressure. So it's a valuable test. If you don't see the bruising on the B scan, I always do the A scan and look for the fluid. So that can be helpful. Case of ischemicopic neuropathy. A little B scan thickening here. But the A scan was normal. And that's often the case. There was a large study done years ago, which the U was part of. Dr. Serga was claiming he could resolve the vision loss from ischemicopic neuropathy by nursing feet compression and publish a series on that. So a large study was done funded by the N and I age. And they found that actually that wasn't the case. Most of these patients, it wasn't helped by the surgery. In fact, it was made worse in many cases. And about 40% got better spontaneously. So it kind of changed the thinking about this. But there may be a subcategory. I've seen a few cases with ischemicopic neuropathy that had a positive 30-degree test. So there might be a subcategory that do in fact respond to the surgery. And that's, I think I was kind of looked at again. It's still debatable. But anyway, there are mostly patients don't have a positive 30-degree test. They don't have the fluid around the nerve. Case of opichneuritis, classic opichneuritis, patient with pain, MS, looks pretty normal. The B scan and the A scan both. So most of these opichneuritis patients, I don't find much on the testing. So it's very valuable for the blurred death, especially the ruled out drusen. Also the 30-degree test will look for increased endocrinial pressure. This is a case that I misdiagnosed. This is a child with a large nerve tumor. This is the nerve from here to here, very thick and nerve, CT scan. And had a negative 30-degree test. In other words, a patient looked at the side and the nerve didn't change. So that was a case where it's all with lesion. It doesn't change on looking to the side. So I diagnosed a glioma just kind of based on the fact that it was a child. That's the most common tumor. But in retrospect, I should have thought of meningioma because of the, here's the nerve sheath and here's the parenchyma. So a very thick and sheath from there to there. The other side, here's the nerve sheath, here's the parenchyma. So thick and sheath, that's more typical from meningioma than glioma. In fact, that's what it was. So it's kind of an unusual child, but that was what that case turned out to be. 143 patients with pain around the eye. You'll see a lot of this, those in clinical practice every day, you know, shooting pain, it hurts here, it hurts a touch. You see that all the time. So what do you do with these patients? Now you certainly want to do a good, careful exam. So that lamp looking for dry eyes, lufferitis, the things that we look for. If that's all normal, then what do you do? Well, ultrasound could be helpful. It just takes a second to put the probe on the eye and look for anything that might be causing the pain. Although a large number don't have anything. I just couldn't find any cause for it. 65% so, you know, it's a screening test and a lot of times it's normal. So we can't pin it down. But in the cases that we can find something, it can be helpful. In 15% I found a cause of pain that was altered by the ultrasound or found that hadn't been thought of before. These are some of the things that I see. Myositis, sinusitis, suetitumor, dachyradinitis, scleritis, optic neuritis. And these are incidental. These didn't cause the pain, but I just found these on the exam. Shadowed detachment of the retina and dystrophic calcium in the coroid. It's a case of myositis. This is the B-scan showing the thickened muscle here. Here's the tendon insertion of the globe. And the A-scan shows the muscle here thickened. Also very low reflective. That's very helpful. I look for internal reflectivity. If it's low, that suggests of inflammatory infiltration versus a grave disease muscle, which I'll show you in a minute, which is different. So reflectivity patterns can be helpful to diagnose the cause of the thickened muscle. Of course, clinically, also these patients often have pain, pain on movement. These are helpful. Also the tendon tends to be thickened in myositis, whereas it doesn't tend to be so much in grave disease. But these are things that are helpful in diagnosing pain around the eye. Sinositis. It's not the best test for sinusitis, but it's a good screening test. This is the globe here. Here's the vitreous. Here's the retina, the coroid layer. Here's the normal orbit. And normally, if I put the probe temporally going towards the ethmoid sinus, it stops right here. The lamina paparacea beyond that is air in the sinus and air blocks ultrasound. It doesn't penetrate through air. That's why we have to use conducting media like Gonusol on the eye for the ultrasound, because air blocks it. So if I don't see, if it's not air, if there's something else like fluid or tumor, I'll see a bunch of spikes. These are all spikes from ethmoid sinus. That tells me something in the sinus besides air. I can't tell what it is. It may be fluid, it may be polyps, it may be even a tumor. At least I can say there's something besides air in the sinus. That can be helpful in a rapid screening test. The patient has pain, pressure, put a probe there for a second and pick up these spikes right away. I usually get a CT after that to verify them to look at it further. Dakarodinitis, this is a lacrimal gland normally. Put the probe superior temporally over the lacrimal gland. This is how it usually looks, kind of this high reflective, kind of tapering down as you go through the gland. This is a case of Dakarodinitis. This patient had pain in that area and you can see the thickened gland but also its reflectivity is low. Again, low reflectivity often means infiltration by something. Inflammatory cells could be blood, could be tumor, but with a case of pain, tenderness, that's usually suggestive of inflammation. So it's a good, good screening test to look at Dakarodinitis. I see several cases with buccal spasm. It's kind of unilateral. They're sitting there blinking at you while you're talking to them and if you view the ultrasound you find the thickened gland so it could be a cause of actually buccal spasm and often unilateral. So by treating that they'll often get better. A little pearl. Here's a case of posterior scleritis, usually severe pain, very boring pain. They can often have kind of a lesion in the fundus. Some nice misdiagnosis of tumor. You see the thickened sclera here, quite thickened. Here's tenon space. It's very helpful. Using most of these cases have a thickened subtenon space too. The sclera is inflamed. You have adjacent infiltration by inflammatory cells so you get a subtenon also signal. So if you don't see that I kind of question the diagnosis of scleritis. And here's the A scan. Here's the sclera here. Here's that subtenon area, that low area corresponds to the nuisance on the B scan. So this is the case of posterior scleritis. Fifty-five patients referred for proptosis. Board question. Most common cause of bilateral proptosis is graze. Most common cause of unilateral proptosis is graze. Right. So graze you always think about and not kind of confirm patients had graze disease as a cause of your proptosis. A lot of these were thought of by the referring clinicians so I confirmed it. Two cases of cavernous hemangioma confirmed. But I clarified it in about 18% some graze, daffaloma, mucosil, pseudotumor. No cause and about a third. I couldn't find a reason. I guess you're allowed a couple of millimeters of difference between the eye prominence but I could not find a reason. Incorrect diagnosis in two patients. One of the cavernous hemangiomas and one of the mucosil tumor of the lachmol gland. This is a case of graze disease which shows the classic muscle findings. This is the globe here. Here's the vitreous. Here's the orbit. Here's the muscle tendon right here as I go further back with the A-scan. The muscle thickens out and I go way back. The muscle gets quite thick and also internally it's irregular instead of being slow like the myositis case we showed you. It's kind of up and down. It's heterogeneous graze muscles or a mixed bag. They have some muscle tissue. They have inflammatory cells. They have edema so it gives a heterogeneous reflectivity which you can see on the A-scan. So it's very helpful for kind of sorting out what causes a thick muscle. This is the case of the castamose disease that I think has been submitted for publication and this shows this lesion here with these kind of dense follicle proliferation. It's sort of a weird proliferative disease B-scan related. The large parts of the body is kind of rare in the orbit this case occurred in the orbit but the A-scan looks just like a hemangioma it just looks the same exactly. It's up and down the signal that kind of go up and down called c-sa or cavernous structure and that's on the castamose disease so I missed that one but here's to show you a cavernous hemangioma it looks just the same it's up and down signals and this is explained by that same kind of architecture you have this multiple follicle structure comparable to the cavernous spaces in hemangiomas so it looks just the same on A-scan A-scan can't distinguish those two lesions this is a case of a mix cell tumor which I called mix I called a amnestistic carcinoma this is the lesion here on D-scan here's the A-scan this is a typical mix cell tumor it's kind of regular kind of tapers off it's called the sound goes through the tumor it sort of loses energy so you kind of drop off but it's irregular kind of a step fashion here's a lesion that we saw it's irregular there's a low area here there's a low area here it wasn't typical for a mix cell so I called it amnestistic carcinoma and turned out to be a mix cell so they can sometimes fool you turning on pace if you've heard prodiplopia confirmed grays my clinic had two large 1,000 case studies over a 10-year period and they looked at all these patients with double vision of various causes and about half of them they couldn't find a reason despite of all the imaging that they did so that's sands up here about half the patients I couldn't find a reason I clarified in 5% I had grays and a myosinic patient kind of a mixed bag stapoloma causing double vision miscellaneous causes in the 18% these of course weren't diagnosed by ultrasound by clinical studies the college of vascular disease o-fourth neuropause myosinograph supernuclear palsy vascular pathic endocrine swanoma so these were things that also caused double vision that were picked up on other testing it shows that grays muscle I talked about here's the muscle from here to here thickened muscle irregular reflectivity here's the pathology showing why you have normal muscle fibers you have inflammatory cells you have edema so all this activity on the A-scan so that's helpful to look at the muscle internally to see that that's suggestive of grays disease opaque media 167 patients no diagnosis confirmed 42% sent as vitreous hamburg sent as inflammation pysys I confirmed that I didn't buy any vitreous abnormalities 24% and they had a dense cataract or chronic horny but the back of the eye looked okay 39% unexpected findings these were things that weren't a note from the current doctor what causes of things that I found that hadn't been suspected a lot of these are vitro retinal traction vitreous hemorrhage with traction on the retina spontaneous vitreous hemorrhage with cut optic discs foreign bodies attached coroid as your cats for defect dislocated limbs with cut discs here a traction macular attachment lens particles and vitreous after a nail injury period of prosthesis with sublex IOL and the list goes on here's a diagnosis pre-desic patient with cut discs again a lot of traction lens particles post-op cataractivitis with endoplamitis but these are all things that I found on the ultrasound that hadn't been suspected previously which you can't see inside the eye so it's really one of the things you just sort of don't know what's going on but the ultrasound is very helpful about showing the pathology of the patient here's a lot of hemorrhage but here's a vitreous membrane with traction on the retina kind of tenting the retina up other cases here here's another case of focal traction with a vitreous membrane and one here I can also pick up retinal tears if you have a patient with acute hemorrhage and you can't see inside the eye you worry about a PBD with a retinal tear you see a little flap kind of sticking up that can be diagnosed on the B-scamp cup disc this is a total bean cup disc right here just kind of cups out B-scan is not great for cupping greater than or less than about 7 over 10 beyond that I can pick it up 7 to 8 over 10 or worse I can usually pick up a cup so it's helpful in advanced cupping it's not so helpful in less degrees of cupping obtained foreign body hadn't been suspected patient long history ago hammering metal and had some eye pain and forgot about it but had a lot of reaction and found a foreign body through the bright signal from the foreign body on the B-scan the A-scan equivalent right here interesting case here this is one of Albert the Tally's cases this is a patient with a cataract surgery months later kind of flared up patient's steroids got it better flared up again got better so you kind of think of P-acnes in that situation with the UBM the high frequency here's the iris here here's the cornea up here here's the answered chamber this is the IOL right here see this glob on IOL amorphous kind of stuff that was the from the P-acnes confirmed by later surgery took out the IOL found this on the IOL so very nice picture there showing that stuck right to the lens a case of cyclic membrane here's the cornea here's the iris here's the ciliary body these membranes are just pulling on that ciliary body you can just tell this is going to be hypotenuse this patient's going to go into tices that membrane just pulls out the ciliary body and causes profound hypotenuse shallow retina especially you know opaque media shows here kind of a real shallow membrane right against the fundus and here's the A-scan here's the here's the surface of the retina here here's the splara and here's the detachment right here that thin space right there corresponding to that here's a dislocated lens calcified crystalline lens a fillback in the eye floating around the eye a lot of vitreous membranes causing inflammation here's a dislocated IOL this patient had previous history of IOL years ago had trauma again couldn't see very well had kind of a clotty cornea but here's the IOL floating back in the vitreous here's the surface on the A-scan high reflective hemorrhage and corals detachment here's the coroid this kissing coroid will right up against each other with a lot of opacity as you watch these over time they tend to the blood tends to lice the clot's lice so it goes from being this dense high reflectivity to kind of this low reflectivity and lacing that can be a guide to when you try to drain these things initially you can't get much out if it's all clot of blood but as they lice and start to liquefy you can put a needle on there and drain these and drain the coroidal so it's a good guide to when to do that with the B-scan just as having patients had miscellaneous findings kind of things we see all the time flashes of light transient double vision eye strain ultrasound sometimes is helpful in these cases a lot of times I didn't find anything but I did find something at 15% these are things that we found shadow peripheral detachment with the IOL difficulty of the fundus shallow enter chamber with the large crystalline lens almost like an internessal lens hypotony with the psychotic membrane peripheral shadow detachment stapolomas causing difficult biometry large refractive undercorrection with the stapoloma eidus with chronic hypotony with the dislocated IOL chronic eidus with another case of IOL vegetations and swollen lids with fat colaps and chronic lipospasm with dechrobinitis so these are things that we saw this kind of miscellaneous mixed bag category this shows here an answer segment with a 20 megahertz probe here's the cornea here's the iris here's the IOL dislocated so everybody rubbing against so everybody causing the NUG syndrome chronic inflammation chronic hemorrhage in this patient with this dislocated IOL and here's a patient with a large lens almost incommescent here's the lens here on the emergency scan here's the cornea very shallow enter chamber here's the lens here's a multiple signal that shows a large lens here here's the A scan here's the cornea here's the lens from here to there very shallow enter chamber stapoloma see this kind of bulge in the back of the eye that can be a cause of incorrect biometry occasionally double vision the muscle slips over the stapoloma it can cause double vision so this is something that also sounds very good about picking up we're descending now we've completed our jump so we're getting there iris lesions we see a lot of these little bumps in the iris if you look real carefully it's a slight length so sometimes you see a little bulge that's worth checking out because sometimes either cis or nevi occasionally tumors like melanomas so I confirmed iris nevi 58% iris cis and pro percent I clarified the diagnosis in 19% two iris cis one foreign body one melanoma elevation the iris caused by dislocated haptic and then 12% with non detectable lesion biocography this shows kind of a montage here of the same patient this was with the 10 megahertz which is our standard B scan you can see the cis there but it's not real definable you can sort of get an idea of the cis here's the 20 megahertz which is the higher frequency so you can see the cornea here here's the iris here's the cis better shown to everybody and here's the 50 megahertz cornea here here's the iris here's the cis so it's the same patient just showing different resolution with the different megahertz this case was sent as an iris cyst in fact it was a solid lesion you can see the difference in the cystic structure it's just like clear inside there's nothing inside compared to a tumor which has a solid configuration in fact there's a melanoma so sometimes you're fooled so again the ultrasound could be helpful okay so again summarizing which I mentioned before the referring impression was confirmed in 407 cases no findings there were 79 patients and the clinical impression was altered or clarified in 309 patients so I guess it shows the value of ultrasound can be helpful in a lot of patients five patients incorrectly diagnosed so I raised the question to consider with all of our imaging capacity we have nowadays what's the best test to get for a patient certainly clinical judgment first a good careful history clinical exam most time you can make the diagnosis you sometimes jump too early to all these tests and back in Dr. Aldous's day and Dr. Taylor in my day we had PlainFilm X-rays that was it right during residency that's all you had was a radiograph so CT's MRIs all came along after so now we have so much to choose from it's kind of hard sometimes to make the choice but you gotta in these cost-effective medicine days you gotta think about the best test and again clinical judgment first but then what tests to get next and I think there's certain cases where ultrasound is probably the best test to get certainly inside the globe it's still the best test and the orbit it can be in addition to other scanning modalities so we've landed safely we arrived we made it made our jump so that's an overview of ultrasound I think that patient had not had a CT scan they had a PlainFilm X-ray with Mr. but hadn't had a CT scan I've seen a couple of cases of wood porn buddies that the CT didn't pick up so ultrasound picked them up it's really hard if they're right if they're in the orbit it's really hard to pick up porn buddies CT's much better in the orbit there's so much in the orbit going on so many high-reflective membranes put in the globe ultrasound is really sensitive especially in the vitreous at all it really can pick up small porn buddies like in a normal retina sclera but also it again subtenance space is very helpful it is hard sometimes to tell the here's that case so right here is kind of normal retina coroid over here and that can be hard I mean you kind of got the retina here you got the coroid where is the sclera and so subtenance really helps a lot if you can see that that little lucency sometimes in the normal life you can sort of get you can kind of guess that as I probably see subtenance there so anterior to that is the coroid and the retina but the sclera where that is in a relation can be really hard but in a case like this where it's thickened I mean again you assume retina's here coroid's probably behind it but what part of sclera what part's not again it's hard to tell the whole layer kind of gets thickened and that kind of goes along with the pathology I mean these are inflamed the sclera's inflamed everything around it gets inflamed so you inflame the coroid you inflame the retina so they all kind of merge together but subtenance really helps to see that lucency that means you know you've got a separation there here's the retina right here this is coroid right next to it and here's the sclera that's from there to there is the sclera so that corresponds probably to that right there and then here's subtenance going down right here so I know sclera's anterior to that but it can be hard normally in a normal eye you really can't I can't sort out retina, coroid, versus sclera I guess OCT in the past couldn't major coroid but now they have some that can the latest articles are showing OCT's can actually major the coroid a little thickener so that's probably going to be your better test for that yeah the poster is saying that we're not there yet the problem with the high resolution ultrasound beyond about about 15 megahertz you just can't get back up for the higher the frequency the less penetration you've got it's just a trade-off so that's why 50 megahertz is about maybe 3 to 5 millimeters as far as you can go 20 you can get back about maybe 5 to 6 and the 10 you go all the way back but I distribute a paper for the archives out of a group out of New York and they have a 20 megahertz probe now that they're claiming to see the poster segment there's some problems with the paper so we're still looking at that but that's kind of what they're looking at next but the macula certainly OCT is far superior but away from the macula there's still kind of a gray zone there that would be nice to have a high resolution and your second question about IOL yeah where the lens is in the bag or whatever yeah I can it's hard sometimes if you get a direct view of IOL you can sometimes estimate that I've had cases like that but sometimes it's hard it just depends on how you can your angle and everything that you get so it's not 100% reliable yeah I mean we have 20 megahertz here we don't have 50 I have 50 in my office we don't have one here we have a 20 that was a 50 if I have a case here that I really can't figure out I'll take it down to my office and just do it there as part of the same as you know yeah but Steve thank you for the plug I paid Steve that's right the blurred disc obviously I see a lot of those it really is just like I can predict every week I'll see easily as a teenage girl headaches kind of a funny-looking disc and if they get ultrasound first you know it really kind of makes a diagnosis but often they go the other way neurologist get all the tests so that's probably number one is a blurred disc really I think we could do that we'll do it more also grave disease a lot of graves out there one as obvious as obvious but a lot of times it's more subtle so clinical ultrasound can be helpful I can measure the muscles I can quantitate them the MRI CTs are great but they're qualitative you sort of look and say oh the muscle looks thick and I think it is it actually measure the muscle and quantitate it with the A-scan I can then it's more certain so I think muscle measurements I think optic disc measurements those areas eye pain I pick up a fair amount of causes of eye pain that are missed otherwise kind of subtle dacrobinitis subtle things like that that can be helpful so I mean those areas that I could use more just in my office trying to be not biased I often don't even charge the patient I'll just if it's there we've got this eye pain I'll stick the probe on there 10 seconds if I don't see anything fine but if I find something that's kind of exciting to find a reason for their pain and finally they've been to 10 different doctors they've got a bag of eye drops and I can say oh we've got dacrobinitis let's keep antibiotics or whatever mild muscle thickening or something so it's nice to have that available to do that that's where I relied on the A-scan because that's a good a good question you could have there certainly could be a case of a drusen with a brain tumor with a swollen optic nerve so I always do the A-scan along with it I'll do the 30 degree test so with those together I think that's pretty reliable to rule that out that's a good question that's why I always do the A-scan along with the d-scan anything else? okay thank you for your attention