 Here we go. We're gonna try to add a little bit to that knowledge and talk about ultrasound this morning. So first of all, proposition. Why is it important to know proposition? That was one of my questions I put out for the flip classroom. Any thoughts on that? Why that's important? I would say if you don't know where your proposition is, you can't tell where the macula is, for example, in these two. And say you had like an RD or something like that. And then when you're characterizing a lesion, you've got to know the dimensions of the lesion in which direction. All right, very good. And to be systematic, just like when you do indirect ophthalmoscopy, now you wouldn't just look at one thing with the indirect. And if you had a retinal tear, you certainly want to focus on that, but you also want to look at the entire fundus. So the same thing with the ultrasound, you need to have a systematic approach where you put the probe and look at the entire globe. So this proposition here on the left, there's two major positions that I use. I use a transverse and longitudinal. Which one would this be? Anybody know what proposition this is? The markers here and the probe is placed here against the eye. Right, has transverse and this is longitudinal. And the basis for that is the way the transducer moves. You might have to click the arrow on the bottom left. Okay. So then the other one on the right. Okay, gotcha. This is a transducer here with the head removed. And this shows the actual transducer that generates the ultrasound. So there's a little real thin crystal. It's a ceramic crystal. Very, very microscopically thin. And that's stimulated by electric pulses to vibrate and generate sound waves. And very high frequency obviously. So our standard B-scan probe is a eight megahertz probe or 10 megahertz, eight to 10. And that generates the sound. But this thing goes back and forth that oscillates side to side. So that oscillation here on the example on the actual probe against the eye with a white mark, that tells you which ways the transducer is oscillating. So let's say the white mark is here on the transducer and this would be it here. It is going back and forth in a parallel plane to the limbus. So the limbus is here. That transducer here in the slide of course is two dimensional but three dimensionally, that would be coming out of the slide and back into it. Towards you and back. So that's transverse longitudinal. You rotate the probe so that the white mark is superior and then the sound beam is generated. Again, going back this time up and down. So the sound wave here is actually showing the fundus in a horizontal side to side kind of direction. Whereas here it's showing an anterior to posterior direction. And usually if you wanna look at peripheral lesions it's important to get the longitudinal position. It actually shows you can get further out with the longitudinal position than with transfers. So that's all, it's academic perhaps sounding but really there's a practical application to that. And basically when you look at a lesion, example here's a, here's a coral lesion probably a melanoma. So this is a transfer position here. So the sound beam is going side to side. So you're actually measuring that dimension of a lesion. You know, in a horizontal or side to side dimension. And here's the lesion here, the displayed on the screen. Now also the proposition, the white, the mark on the probe whether it's white or other marks that orients it. So then when it's displayed on the screen that is up on the screen. So if you're the probe here or the white mark is here going let's say it's pointing to the side here. When you show it on the screen to actually display it in the superior part of the screen. So just remember that when you're looking at lesions that mark on the probe orient you just to which way is up on the screen. And then here is a longitudinal position of the same lesion. So the dimensions are a little different. So when you want to characterize a lesion you want to characterize it both in a horizontal direction and a vertical direction. And that's important, you know first of all for size of the lesion you've got a really weird lesion really elliptically shaped. If you just measured it in one dimension you would get probably a falsely low dimension compared to the other dimension where you would get a longer dimension. So those two together are how you characterize a lesion. And besides just for following a lesion to know consistently when you look at the lesion again be able to compare those measurements. Also when you start treating these lesions here, Hanson here is doing that with plaques. So you fabricate a radioactive iodine plaque and you sew it to the back of the eye and leave it there for three to five days to kill the tumor. To make that plaque you need to know those dimensions. So it's a very practical application of those positions. So again, proposition is important to be systematic. I used to teach a course at the Academy, American Academy and one of my co-teachers, Dr. Ron Green talked about the smear technique where residents and fellows tended to stick the probe on the eye and they're excited to see a lesion and that's where they focus it. But again, you can miss things that way despite sticking the probe there and not really being systematic and going exploring the whole globe. Again, just analogous to indirect ophthalmoscopy where you want to look at the whole fundus and you might miss a tear and you might have two tears instead of one or you might have a lesion that you didn't know about. So again, to be systematic is important. Is that sort of clear to people understand that? Any questions? Feel free to ask a question if you don't understand it. Okay, this is a, obviously a membrane in the fundus and the question is how do you determine if this is a corretal detachment or a retinal detachment? Any thoughts on this? I usually have the, especially if the patient's hopefully awake and able to move their eyes, you can see how the retinal detachment sometimes more bolus and will move whereas a corretal won't move as much. Okay, that's good. So moving that, kinetics, that's important. I think corretals often they're attached to the vortex veins as well. So there's a little bit of a limit there. Right. That's why you get this kind of a scalloping or kind of a convex shape like here, this right lower. This shows kind of a typical corretal. And as you said, it looks like that because it attaches to the vortex veins. They tether it so that it can't extend beyond that whereas a retina is not limited to that. So you get this kind of a scalloping, concave appearance, convex appearance. So again, mobility, they tend to be more rigid, they're kind of fixed because they're tethered down by the vortex. They don't move as much. They tend to have this scallop appearance. That's kind of a classic corretal. But if you're not sure, sometimes it's not so obvious, a case like here is obvious, but sometimes they can be more low-lying corretals or retinas can be more bolus, almost kind of this convex shape. A-scan can be helpful because when you do the A-scan, here's that surface on the A-scan. This is a corretal here. You get kind of this double peak. And the reason is double peak because you have both retina and corroid contained in this surface. Whereas a retina, you just have a single peak because it's only a retina. The corroid is still be attached. So this is helpful to see the double peak if you're not sure what a surface is if it's a corretal or retinal detachment. And here's another example. So usually corretals don't come right off the optic disc. Just look at the anatomy of the globe and the way the corroid, the optic nerve comes into the eye and the corroid starts here. So it really can't extend right off the disc like the retina does. So if you see a shape like this, again, that's consistent with corroidals. And here's that scalloped appearance more peripherally. But as you get towards the disc, you get this not directly off the disc. Now here's another example here. This is a kind of a low-lying corroidal. And this could be confused. See, this isn't that scalloped appearance. It's not the convex appearance. So this here could be thought to be possibly a retina. It could be retina or corroid. So that's, again, are the A-scan is helpful to do that. Look for that double peak. And if you see that, that pretty much nails it. It's a corretal detachment. This is a case I just saw recently and this is using an immersion technique where you can sort of see the whole globe. And actually the cornea is up here. Didn't quite get it on the slide. But again, the scalloping appearance consistent with corroidals and all the stuff under the corroid here is hemorrhage. This is a hemorrhage or corroidal. I think it's a post-surgical patient post glaucoma procedure. And you see the kind of this appearance all the way around the globe. And here's the optic nerve is back here. So it doesn't quite go up to the nerve. Now, again, with this immersion technique, I can get a better gestalt of the whole eye. I like to do that a lot when I have these cases where you want to kind of visualize the whole globe. And this is the corneas here. Here's iris, it lands up here. And here it's kissing. So that wasn't obvious on the initial exam when you did the initial could be scanned just to the posterior segment. It appeared to be like the corroidals were kind of maybe moderate. They weren't really touching the middle. But here more nasally, you can see that they actually are touching their adherence. And that's important because if you have adherence of the surface of the retina to each other, that could become permanent. You get fibrotic changes and things. So that would be a reason to consider drainage sooner than later in a case like this. So maybe watch it for a couple of days or so, but if it wasn't changing, that would be a reason to consider drainage of the corroidal. And again, stop me along the way. If you have any questions at all, feel free to don't feel like don't be embarrassed to ask the questions, basic concepts and things that sometimes aren't so obvious. I mean, I've done this so long, it's just obvious to me, but not to you. Dr. Harry, I get a question. Sorry, this is Tyler. And maybe you had covered it a little bit, but in our exam, we're always taught to like, as you said, follow that systematic approach. Do you go from structure to structure each time? Or do you, if you have a set, set steps that you go through and evaluating the whole globe or do you focus in on one area that has been previously identified or how do you do that? That's a good question. And I usually do the whole globe. I've done this again enough, I just do it rapidly. I just kind of really do a fast globe screen, but I always like to look at the whole globe because I've had a number of cases where I found something else. There wasn't the patient presented for either a lesion or a tear or something, but in exchange the globe, I find something else. I find another tear or I find another lesion. So here, let's go back to the transverse approach. I usually start with this. So I put the probe right against the limbus. I just kind of rotate the probe and like a fulcrum, I just kind of move it along the globe going from front to back. So if you think of the sound beam, if you put the probe right here and you kind of moved it, you kind of sweep that sound beam going across the globe. If you sweep it both ways, you kind of put it back here towards the disc, then move it more anteriorly towards the limbus and towards the part of the planar, I'm sorry. So you want to sweep the globe with that sound beam. Each sector of the B-scan covers about 60 degrees. So when you sweep the globe, you're covering 60 degrees. So if you think of the globe of 360 degrees, you'd want to do six different quadrants. So you would start, I would start in fairly, you start at six o'clock, go around to four o'clock, go around to two o'clock and just want to do that so that you're covering the entire globe as you're moving the probe. I usually do transfers. If I want to get real peripheral, then I'll rotate it. I'll do longitudinal with the same thing, kind of moving the probe along the eye. And so you want to cover the entire globe. Does that kind of answer your question? Dr. Harry, do you ever have the patient look in different directions? Because I remember back in Germany, when I was doing ultrasounds, we were instructed to have the patient kind of look straight, do what you just explained and then have the patient look up, like with the eyelid closed, of course, look up, look down, look right, look left just to get all the different eccentricities. Do you use, would you recommend that or would you not recommend that? Yes, I do, Liddy. Yes, I usually have the patient look up, look down, look left, look right. So because sometimes you get peripheral lesions that you would miss unless you do that. So that's a good point that I have the patient looking in different directions. Obviously, if it's around to see you with a child or something, then you can't do that. But I had a case one time that was interesting, that was just by looking straight back at the eye, you missed the lesion, but by having looking riparifally, you could pick up the lesion. So by actually actually put a cotton tip on the eye and kind of moved us, we could get more peripheral. So yeah, that's important to do that. So again, whatever system you wanna use, but to do it consistently, to kind of do the same thing every time you approach the eye and again, you'll find things that otherwise would have been missed. Any more questions on that on proposition? Okay, the concept of a PVD versus a detached retina, any thoughts on determining that? Like this case here, is this an RD or a PVD? It looks like a retinal attachment, seeing that it's coming from the optic nerve and going to the aura. Right, it does. And high reflectivity, it's kind of a dense membrane, high reflective membrane comes off the disc. But in this case, it isn't, actually it was a PVD. This is a longstanding, it was a diabetic and oftentimes you've had vitreous hemorrhage, it'll deposit on the posterior high-loid face and it can make it denser, thicker and it can look like an RD. These can deceive you sometimes, but one clue here was the way it comes off the disc, even though it attaches at the disc, it kind of has this, the leaves of the membrane come together, whereas in an RD, they're kind of separate, like they come, there's a little gap between them or this is almost like a stock where it sort of comes off. Does that kind of make sense? This is kind of attaching to the disc here as one unit, whereas here it's like a separate unit, there's one here and there's one here. So it's a subtle kind of difference, but that again, that can be a clue. But I agree, if I looked at this initially, you just showed me a picture of this, I'd say, yeah, probably RD, but it turned out actually to be just a PVD that had a lot of, you know, high-loid, dense high-loid because of vitreous hemorrhage. So... Yeah, Dr. Heria, I've seen PVDs, especially, you know, in trauma settings where there's vitreous hemorrhage, where just like you said, the hemorrhage will just adhere, especially on a young patient to the high-loid and it really looks convincing. And then again, if you can have the patient kind of look in different directions, then the lines that look really, really thick or the contours, they kind of just sort of disintegrate a little bit in the movement because you can see that it's more blood, but they can really, really be very convincing for an RD. All right, exactly. Yeah, that's a good point that again, it can be hard to tell sometimes even when you've had a lot of experience. So a membrane that attaches at the disc is usually an RD, but not always. So it's always those exceptions that get you. But generally, again, zebras and hoofbeats and horses, you sort of go with, you know, so you usually, you really suspect this as an RD and it wouldn't be that until proven otherwise. So everything else you would do to try to disprove it, but they can be deceptive sometimes. And this is more an example here. So this shows an RD here. So it's the dense membrane attaches right at the disc and again, the way it attaches, it's not like a single unit stock. It's more like two separate leaves coming out of the disc this way. And here's a PVD also in the same eye. So PVD, but again, it's kind of dense, you know, there's probably hemorrhage on this. So it's a denser posterior hyaloid. So these two surfaces over, you can, this doesn't, this does not attach at the disc whereas this one does. So you kind of separate them out that way. And again, the A scan can be helpful because reflectivity and the A scan usually with a redness can be very high. It's going to be almost as high as the initial signal. You get the initial signal here from the front of the eye. And here's a sclera. So this membrane here should be pretty close to the height of those surfaces. Whereas a vitreous detachment, even though it's a dense posterior hyaloid here, it isn't as high on the A scan. So I use the A scan. A lot to sort of help separate out the membranes. But again, there's always exceptions. I've had dense, you know, PVDs, dense hyaloid, poster hyaloids that looked high on this. So it's helpful. You kind of put clues together. You kind of gather these clues and sort of try to put them all together. And kind of help you decide. Let's see if I have. Here's another one. This shows. A member. Here's another one. This shows a surface here. Now this obviously is kind of a less dense surface. So again, you're really thinking PVD in this situation. And the A scan. Okay. The A scan shows the membrane here, but again, it's not very high. So this is that same membrane here. And so the heights of it really is a clue that this is not a retina detachment. So generally, if a membrane. Isn't as high as these other spikes. It almost is never retina. But occasionally a real high spike can still be a PVD. So that. That's helpful. But again, it's a clue that you kind of put in the hopper. Now again, sometimes you get vitrious membranes too. That's not enough. You kind of rule out a PVD or not. You see these membranes, it can be vitrious. And then you have the hemorrhiasis, you know, as you age the vitrious. As changes in the matrix of the vitrious. You get these little pockets of fluid and things that can look like a PVD, but a real clue is the W. I. And I always stress that when I teach, I teach your residents about ultrasound. You look for the wise ring and you can see that too. And you look with the 90 die up to early, even the direct ophthalmoscope. But here on the ultrasound is kind of a double ring to it because you have, like it's a circle because it comes off the optic disc where it detaches from the disc. You get this kind of a double surface. And if you look for the y-string and see that, then you know it's a PVD that nails that diagnosis. Now, here's a mobility picture. So this shows, again, that here's a PVD surface here. And just see how mobile that is as a patient moves their eye, it really just kind of flaps around in the breeze. I'll show that again. This is hemorrhage, all this other stuff here is hemorrhage, but this membrane here is really quite mobile. It's really kind of just easily moves and without a lot of tethering to it. Here's a little tumor, probably a small melanoma, but there's a detachment over it and there's some vitreous hemorrhage out here. But again, watch the mobility of this surface. This is a stiffer kind of movement compared to the vitreous, which is kind of more fluid, you know, more easily mobile. So you see that, just kind of that edge in the string or a rope that you kind of tidy the tree and twang it. It sort of has that tautness to it. I'll show that one more time here. So this watch is just kind of that just memory, just kind of, you know, vibrates in place like it's tethered down, like it's held by something. Whereas the vitreous is just flowing freely here, just moving very easily. So that's a good contrast in the difference of mobility of these two membranes. Here's another one. Here's a dense membrane, again, attaching the disc. And again, look at how it attaches. It doesn't have that single unit stock. It has these two leaves coming off, kind of spread from each other. That is more consistent with our detached retina. And here's vitreous hemorrhage. See that stiffness to it, that tautness where it, just, you know, it's just a stiffer membrane. It's less fluid, less mobile than the vitreous hemorrhage or the vitreous attachment. So mobility is very helpful. And I use that a lot. I just don't have the patient make little movements of the eye to kind of help pin that down. So those are all clues. Again, it's not always a hundred percent. I've had cases where I was wrong. I called it an RD and it turned out to be vitreous. So we just try to do the best we can and try to put everything together. But most of the time, if you do these things, you're gonna be right. But I know in the past, residents get called to the ER a lot, like middle of the night and the yard doc. So they got to detach retina because they do their ultrasound down there. Ends up being a PVD in many cases. So again, you know, it's taking the things that seem obvious sometimes aren't so obvious. So that's why it's good to know these little tricks. All right. Is that sort of clear about membranes and retina versus vitreous? Any questions on that? Yeah, thanks. The videos are really helpful. Okay. Yeah, mobility really helps. Okay, so Nevi. See a lot of these, you all see them in your practice, you know. One to worry about and one to not to worry about them. One to get an ultrasound and one not to. So the shield's criteria for a suspicious Nevis to, you know, you worry about becoming a melanoma or metastasizing and growing. What are some of those criteria? Kind of shout them out to anybody that wants to. Thicker than two millimeter. Okay. And you wouldn't know that unless you did ultrasound. So, you know, you can sort of guess elevation by looking, but it's really not that reliable. So ultrasound is helpful there. Sub-retinal fluid. What's that? Sub-retinal fluid. Okay, sub-retinal fluid, right. And again, sometimes, you know, you can tell on the exam, but sometimes again, ultrasound can be helpful there. So thickness, sub-retinal fluid and so. Lipophysin, lack of resin. Okay. Distance from nerves, evolution over time. Right. So orange pigment, lipophysicist pigment. And that's different than a drusen. If you have drusen, actually it's a good thing because drusen are more a sign of canicity, usually a less actively growing lesion, whereas lack of drusen can be a sign of more rapid growth in this orange pigment. Again, it's different than drusen. So that is a risk factor. So we talked about thickness, we talked about orange pigment, sub-retinal fluid. So clinical. Cloneness on ultrasound, like the lower reflectivity on. Right, right, exactly. And we'll talk a bit more about that too. So sub-retinal fluid, so what is the clinical consequences of sub-retinal fluid? If a patient came in and saw you, what would he say? He wouldn't say, I guess sub-retinal fluid, what would he say to you when he was complaining about something wrong? What would be a symptom of sub-retinal fluid? A visual distortion? Yeah, some kind of visual distortion. You see a shape or something funny off to the side or something. So clinically sub-retinal fluid translates to symptomatic, patient complaining about visual distortion. Somebody mentioned the optic disc proximity. Somebody said that about how close it is to the optic disc. Yes, right, myself. Right, is that Brandon? Yeah, sorry. So within what, how close to the disc are you worried about? If I remember, I think it's three millimeters, maybe. A couple of disc diopters. A couple of disc diopters. And that's about three millimeters because it's 1.5 millimeters for the optic disc. Yeah, so within two millimeters, so that's a risk factor. Again, why is that a risk factor? It's just statistical. They just took a bunch of patients and the ones that had lesions closer to the disc. Over time tended to do worse as far as growth and metastases. Okay, so those are kind of the major shields criteria that I learned just over a long time ago, but they've actually added a couple. So we get thickness, we talk about sub-retinal fluid symptoms because of the fluid, orange pigment, margin with three millimeters. Now, hollowness, ultrasonic graphic hollowness. Anybody know what that means? On your A-scan, you're gonna have a lower spike, basically. Okay, actually it's more of a B-scan finding, but also a correlates to the A-scan. And usually it's gonna be a bigger lesion. Usually a smaller lesion, you're not gonna see that, but a larger lesion usually four to five millimeters or greater. So here's a mushrooming tumor here. And as you go through the lesion towards the base, it is less echodense than it is. So right here, there's echolucency, which means it's darker. Here it's whiter, it means it's denser. And here the A-scan correlate. Here's the lesion A-scan. Here's the surface, here's the sclera. So initially you start out, it's kind of higher here, but as you go through it, it gets lower. That's due to sound absorption. The sound beam as it goes through the lesion which is absorbed by the tissue, reflected, refracted, absorbed, so you lose energy. So as you get towards the base, it becomes kind of a more hollow appearance. And both here's the B-scan, here's the A-scan. It's not all that helpful really. I mean, it's just kind of inherent. Obviously for lesion like this, that's gonna be a melanoma. So Hullan is really there to me, just doesn't mean much. I mean, it says there, that's nice, but it's not really to me a real helpful finding. And usually it's gonna be a bigger lesion that you already kind of know as a melanoma. So the smaller lesions, I just don't see that. They also talk about the halo sign. Anybody ever heard of that? I don't know what that is even about. It's not very common. Here's actually an example of it. So here's the Nevis here. Here's the darker area. There's kind of this whiteish yellowish rim around it. Kind of like a halo. So it's a pretty rare finding, but in fact, I looked it up. It's about 5% of Nevi have this finding. So it's really not very common. Most of them don't have this. But if they have it, there seems to be a protective finding. The ones that have a halo sign have less of a chance of growth and metastases. And it may be due to immune response. This may be the body's immune system causing this rim around it. We're not quite sure. And that's the halo sign. So if you hear that, that word again, that's not super helpful because it's so rare. It's like 5% of Nevi are going to have this. So if you see it, great. You feel more comfortable, but if you don't see it, it doesn't mean a whole lot to me because it's just a rare finding. So those are the shield criteria. So it's just, I think these, the first five are the most important. So remember the thickness, subordinate fluid symptoms, pigmented margin within the disc. But for, I guess, board questions, you probably should be aware of hollowness, halo and absence of drusen. Now we see a lot of lesions. I think we talked about this in a round, a couple of weeks ago, I think, with Lydia, her PLEO project to look at the long-term PLEO and sort of help characterize. Because we see anivis is usually fairly obvious. It's a small, dark lesion. It's not that elevated. You feel pretty comfortable. Do you get these lesions here with risk factors? Again, you want to look at these things clinically. Thickness and fluid pigment. But is this anivis? Is it a melanoma? So sometimes even pathologically, it's not that clear. Years ago, these eyes are often enuclated. When I was my residency in fellowship, nucleation was pretty much a standard approach to eye lesions. And a lot of eyes were taken out that didn't need to be taken out. They were 2020 eyes and they had a peripheral lesion. Ended up not being a melanoma, being some of the nine lesions. It really about 20% of the time we were wrong. So clinically, just looking at lesions is hard to tell. But when anivis starts to change to a melanoma, it's the question. So shield's calling the term nevoma. So it's kind of the word nevus, along with melanoma and calling the nevoma, where you have kind of characteristics that are not typical of a nevus, but yet not really full-blown melanoma. So it's that kind of transition zone. And that's where FLEO hopefully will help us kind of looking for the fluorescent patterns and things to sort of better characterize that. But there are older sound findings too that are helpful with that. So we'll talk a bit more about that. So risk factors for melanomas or anivis. So if there are no risk factors on that list that we showed, there's less than a 3% chance of that became a melanoma of growing or metastasizing. So you're really pretty safe just to watch these. One risk factor goes up 38% of growth or metastasis. So you wanna watch those more carefully. So if you saw a risk factor, I would recommend the patient come back, probably within three months and look at them again. And most of the time they're just gonna be stable and sit there, even with a risk factor, most of these aren't gonna really do much. But you get three more risk factors, 50% chance. So certainly that's more concerning Eric Hansen referral and possibly treatment at that point. So those are the kind of the correlation. So any questions about that? Nevi risk factors? Okay, we'll go to another one. So pathology, that's why I really first was attracted to ultrasound because of the correlation, especially the A-scan, even though the A-scan, like all these funny looking lines that don't mean too much, it really correlates well to pathology. And we'll talk more about that. So based on this A-scan, so here's the surface of a lesion here, here's the sclera. So the lesion's actually in here, here it does on B-scan. Any thoughts on the pathology of this? And again, you don't have to name the lesion, you just have to sort of tell me what you'd expect pathologically. Why are all these, why are the spikes, are they high, why are they kind of regular? What kind of lesion could do that? So regular high internal reflectivity for this lesion, I'd expect it would be pretty heterogeneous consistently throughout the lesion to cause the high spikes that stay level throughout the whole lesion. And on the bottom on the B-scan, you can see that the lesion looks pretty reflective or diffuse also in the choroid, I'd be suspicious for like a choroidal hemangioma. Okay, very good and very well summarized as far as the pathology, exactly right. So hemangiomas have a lot of interfaces because of all these little cavernous spaces or full of blood, what happens? The sound beam, it hits the lesion and it starts to go through one of these little spaces and it starts to get low because this is more homogeneous. Then it hits an interface between the two little cells, blood cells, and then it goes high because it's an interface. So sound reflection is based on interface difference. So if you have an interface of one sound velocity versus another, you get an interface that causes the reflection to go higher. So you kind of get this up and down. So it's a little bit low there, high there, low there. So this kind of monotonous seesaw kind of appearance that correlates pathologically to a lesion with a lot of interfaces, very irregular interfaces. So again, just in terms of pathology, there's a direct correlation. And the same applies to orbital lesions like cavernous hemangiomas. That's just a bigger version of this. They tend to be high reflective, kind of this regular kind of seesaw up and down kind of pattern. And the B scan, as you said, it is a little bit brighter and so the gray scale is helpful, but again, it can be a hard gray scale. It can be for us to interpret that with the human eye and our brain to really sort that out as to that versus another lesion. But A is kind of really kind of just amplifies it. It's like taking something, just expanding them, just taking those pinpoints of pixels on the B scan brightness and making lines out of them. And we can see lines better than we can see bright dots sometimes to correlate contrast. So you get this high reflectivity on this lesion. So that's sort of clear, people understand that concept. And it's really helpful because I've had a number of lesions sent to me that were thought to be melanomas and ended up with reflectivity. Just, and it surprised me too, sometimes, you know, they're just, I expected melanoma and I saw this and it just, that is not a melanoma. If I see that, I just, it can't be a melanoma. All right, here's another lesion. So reflectivity here, here's the lesion here. Here's a sclera. Here's internally. So reflectivity here and here's the B scan correlate. So Pat, the last week, what are you thinking here in this lesion? Yeah, for this one, it has a fairly low internal reflectivity also with kind of a classic de crescendo appearance after the initial lesion spike. And then on the ultrasound image, it also looks like there's maybe like sub-retinal fluid or at least a retinal detachment adjacent to the lesion. So I'd definitely be more concerned for a melanoma in this case. All right, exactly, very good. Pathologically, melanomas tend to be really just dense cell populations, just a lot of cells growing together, a few interfaces, you know, blood vessels and a couple of, you know, just other kinds of fibrotic interfaces. But usually it's a pretty uniform, homogeneous cell pattern. And on ultrasound, homogeneicity usually refers to low reflectivity. So on the A scan, it's low. Here's a vitreous, which is homogeneous usually and low. So you got a flat baseline here. Here's melanoma inside the tumor. And again, you get a lot of cells crammed together, a few interfaces, so low reflectivity. And again, the B scan, the darkness here correlates to low reflectivity and the brightness corresponds to, you know, more reflectivity. But again, you could be fooled here. If you looked at this only without the subredinant fluid and other things, that lesion, compared to the brightness of this lesion, the grayscale is just kind of, you know, it's not that helpful. So we're at the A scan again, it just kind of expands, it just takes these dots of pixels and just makes lines out of them. And you can see the lines better. This is low, that's obviously low on the A scan. So low reflectivity, certainly in a fundus lesion, you start thinking about a more homogeneous lesion. It's certainly like a melanoma. Okay, another lesion here. So here's the lesion here, here's the surface. Here's the sclera. Internally, you see kind of a low area, there's a high area, kind of up and down heterogeneous. Here's the B scan. Any thoughts on this pathologically? So, you know, based on our last discussion, so if a low area, what do you think can you see low on a lesion pathologically? What does low usually correlate to on pathology? Something that's homogenous, very cellular. Yes, homogenous, crammed together, whereas high or kind of up and down or heterogeneous. Yeah, heterogeneous or vascularity. Right, exactly. That's what you predict, you know, you predict a lesion pathologically is going to have kind of different parts of it. It'll have different characteristics on the ultrasound. And that's exactly what you see on this lesion here. So here's the lesion, here's cells growing together and they're kind of branching out, kind of invading the chloride. So here's the lesion, here's the fundus photo. So, diagnostically, what do you think this is? This could be suspicious for like a metastasis. Yeah, exactly right, this is a breast cancer. So again, they tend to be more heterogeneous. Now occasionally, if you look at the lesion, you'll see consistently a low area. So you start thinking melanoma, but if you look at the whole lesion, you have to scan the whole lesion and I'll just take one section, you'll see heterogeneity. You'll see different parts of it as up and down. So again, that's very helpful just to make that correlation with a metastatic lesion. Now occasionally, a subordinal hemorrhage can look like this. You get an initial discoform lesion with acute bleeding. They can be kind of heterogeneous because you're gonna have some blood pockets. You have fibrous tissue. So when I see this, I don't just call it metastatic immediately. I'll say, well, suspicious, watch, let's get him back in a few weeks and recheck it. And usually a subordinal hemorrhage, like a discoform, is gonna get smaller as a blood sort of absorbs or consolidates. This will get smaller, get a bit more homogeneous than this. Whereas metastatic lesions will be the same or even bigger as you follow them. So again, following the lesion, have him come back and repeat it could be helpful. Okay, lesion here. Here's the A-scan, high reflectivity here. Here's the B-scan. Here's a fundus photo. Any thoughts on this? That's very high reflective. That's really, you know, just much more than you'd normally see in our reflectivity and a lesion. Maybe something very dense, like osteoma. Corridor osteoma with a shadowing B-scan. That's calcium. You see that? You know, calcium is just real very bright. It shatters out the tissue behind it because the calcium just absorbs the ultrasound, bounces back off of it like a mirror reflects it. And then the A-scan is very high, just a spike that just jumps out at you. So this is a osseous chorostoma or corridor osteoma. And this is kind of yellowish, kind of diffuse, kind of lesion, usually more women, kind of 20-ish to 50-ish age group. And here's a pathology showing the calcium. So that's osteoma. When there's a famous case we'll talk about later that came out of this institution before it was ever Moran. So with all we've talked about and we've learned, so here's a lesion here. Here's a fundus picture, optos, kind of a darkest lesion here. Here's the B-scan, kind of looking like a mushroom. Here is the A-scan. So reflectivity. So here's the surface lesion, here's sclera. So what's the reflectivity here? Is that high, low? How would you characterize that? Pretty high. Yeah, pretty high. Yes, hear me out, maybe talk to me. Here's maybe hollowness. Here's some shadowing here. Here's kind of a loss of energy here. So is this a melanoma? This is a tough question. I'd be surprised when they got the answer to this. Because I didn't, I first saw this, I thought it was melanoma for sure. It was sent to me by a outside retina doctor as a melanoma, it's based on the darkness and the B-scan mushroom being characteristic. But the A-scan, I just, I couldn't call it melanoma based on this. I said, it's just not typical for melanoma. I just haven't seen one this high reflective. Was there any vascularity or flickering on B-scan? Minimal, minimal, that's a good question. Minimal vascularity. And that's an important criteria that I used to. So I really, I really was against melanoma. Well, this lesion was enucleated and this is a pathology. So it was very, very dark. There's kind of these little pseudosys within the lesion. That's what caused the reflectivity because you have these pseudosyses. A lot of it is kind of like the hemangoma. A lot of interfaces to reflect sound. So you get high reflectivity bouncing back from these interfaces. You don't get this real homogeneous, consistent say interlesion like a melanoma. This is a melanocytoma. And they, you know, this is a big one. Most of them are small. They come off the optic disc. They're just very, very dark. They're usually pretty obvious, but sometimes they can be more peripheral and they can get pretty big. And metastatic risk is very low with these, but still they can get big enough to start causing a lot of problems. You know, a lot of morbidity have a globe. So this, again, is a nucleated. But this is an interesting case that we're trying to get published in one of our clinical challenges. But again, the point of all this is reflectivity is very hopeful. When you see this, it's just, this is not typical for melanoma. It just, you know, to me, maybe you really think about other differential lesions. All right, differential diagnosed. We talked about all these hemangomas, metastatic, disciform, nebis, and osteoma. So again, there are two major AFIP, Armed Forces Institute of Pathology studies, done, I think, in the 60s and the 70s, repeated. And a lot of eyes were sent to pathology because a lot of eyes were taken out, thought to be tumors. And 20% were false positive. And that's, you know, it's not very good. I mean, if you're talking a fifth of the eyes, you're nucleating. I mean, that's, you know, taking a patient that has some vision, sometimes 20, 20, and taking all their sight away in that eye. And it's a benign lesion. That's not good form, you know, certainly. Now practice attorney's dream. But in those years, it was standard of care. So, you know, it was just something that we did, but because you're so afraid about melanomas and growth and metastatic risk. But these are lesions that were in that past series. And these are pathological case studies showing what lesions were confused with melanomas. So suspicious nebis that you can expect that as an eboma concept. And maybe that wasn't so bad to take those out because they could have been melanomas growing and transforming. But discoform lesions, central discoform peripheral, RPE, hypertrophy, emangiomas, reactive RPE hyperplasia, melanocytomas, corridors, retinal detachment, vitreous, the postures, the righto. So these are all eyes removed and nucleated because of the thought of melanoma. So we're a lot better nowadays. The collaborative octramelanoma study done what 15 years ago or so. Accuracy rates in real high, 99% plus. So we come a long way with our diagnostic capabilities. So ecographic criteria. These are kind of the criteria that I go by. And most of these are kind of a scan criteria. Internal structure is regular, reflectivity, low to medium, consistently solid, vascularity, fast, spontaneous, shape, mushroom, or collar button. If I see all of these, that's just almost always about the pathogenomonic for melanoma. If I see a couple of them and the other ones, then it's just less of a slam dunk, but again, usually melanoma. And here's examples of those criteria. So here's the lesion here. Here's the sclera internally. So this reflectivity here, it's sort of regular. You just have to type yourself into that. If you drew a line across here, it's not real high and not real low. Kind of this mid-range reflect. It's not here at the bottom. It's not here at the top. It's kind of in that middle. Here's another example, kind of the same. Another example. So these are kind of consistent. These are all that reflectivity patterns. And it says solid consistency. That means the surface is pretty steady. Sometimes when you do this, I didn't have an example as I couldn't find one to show you, but this spike here doesn't move much. If you get the probe perpendicular and you see the spike here, it's pretty steady. It's not just shaking like a vitreous membrane, but just kind of shimmer and shake and go up and down. This is a pretty solid surface. It's not moving much. Then once you're inside the lesion, you look for this consistency reflectivity, kind of medium to low, kind of regular. These are all examples of melanomas here that meet those criteria. Vascularity, if you look inside this lesion, you see this little flickering, this rapid flicker. Show that again. You see how it just flickers? It just jiggles and moves. That's vascularity, a spontaneous vascularity. And that's pretty rare with other kinds of lesions. Caves like metastatic lesions, like metastatic lung will look kind of like that. But usually if you see that kind of vascularity, that's very consistent with melanoma. So here's a subroutinal fluid here. Here's the tumor. Here's a real small lesion. And usually a small lesion is hard to tell vascularity because we're just so flat. It's really hard to pick it up. But this shows, you can see the flicker here. And this is the same lesion magnified. See that rapid flicker? You see it just kind of flickering within that. Just kind of that rapid oscillation. So that's vascularity. So that's another important characteristic we'll look for. And I can see it with A-scan when it's real vascular, but it's much more obvious on the B-scan. So that's something to always look for. Okay, mushrooming. So what does mushrooming refer to? Why does the tumor look like that? Why is it like a mushroom or a collar button, the old collar button? Kind of the same idea. Breakthrough Brooks memory. Right, right. It breaks through Brooks and it kind of squeezes it. It's sort of like toothpaste kind of being squeezed through a small aperture. It kind of just breaks through Brooks and it just, the cells just sort of bulge out. I've even seen this acutely. I've seen a couple of lesions I follow. They're like an Evoma. We're kind of watching. And also they'll come back and they're just, they've grown tremendously. They just, they suddenly doubled in size, tripled in size. You get real worried. What is this lesion just taking off? What's happened is it's broken through Brooks and just sort of, again, there's a squeezed out. It just, it bulges out because of that sudden breakthrough Brooks. So it's not that the lesion has grown so rapidly and so much bigger. It's just that it's broken through Brooks and just suddenly starts kind of just bulge out, kind of protrude. So that's that mushroom concept. So again, it's, when you see that, it's very helpful. It's, most lesions don't do that. I've seen a few metastatic lesions that did mushroom. So it's not a hundred percent. But if you don't see it, it isn't all that helpful because a lot of melanomas don't mushroom. They're not big enough. They haven't broken through Brooks yet. So it isn't, you know, hang your hat kind of situation, but again, if you see it, it's helpful to see that. Here's a patient I saw years ago. He was kind of an old chief perter kind of guy, just really hated doctors and his wife dragged him in, kicking him, screaming. And for, you know, I'm playing about a shadow in his vision. So we had the small lesion here, a little bit of vitreous opacities. So I thought it was probably a nevoma. You know, let's watch it. Let's bring it back in three or four months and check it again. He came back three years later and the lesion looked like this. So definitely looking more melanoma-like, broken through Brooks, subretinal fluid. So we're starting out. We need to send you to the oncologist, think about a plaque. No way he was just resistant to anything. His wife kind of rolled her eyes and he just wasn't gonna do anything. So let's get you back in another couple of months. Check it again. Came back two years later. Looks like this, you know, just doubled in size, you know, obviously melanomas. The point now where you probably can't put a plaque on it. Most oncologists probably beyond eight millimeters in thickness. They won't plaque him because you just, you can't kill all the tumor and morbidity to the eye is so high that you just cause a lot of destruction of surrounding retina. So probably a nucleation would be, you know, the thought in a case like this. But again, he was just no way he was gonna do that. This is showing the ACE scan, by the way, forgot to show this. Here initially, here was the neboma, kind of this lower area, high area, getting bigger here, getting more homogeneous. Here's this big lesion here with a lot of interfaces, a lot of hemorrhage inside necrosis, but you get more of the reflectivity here. You go through the lesion. Came back another year later as I was very painful, the pressure of 60, rubiosis, you know, this is all tumor just fills the eye. And he just insisted it was sinus. He said, no, my sinus is, I need antibiotics. I said, no, so no, it's your tumor. It's gotten so big as, you know, he just wouldn't listen, took off, went somewhere else. Here's the tumor here on the ACE scan. Here's the surface. Here's the sclerosis that is Eiffel, the tumor. And then he was an obituary six months later, metastatic melanoma. So it's just the natural course of a lesion that it just evolves, you know, naturally. So again, if he'd been plaqueed here at this point, a good chance could have saved his life. You can save the eye. So that's the natural history of melanomas. Here's the ample of treatment. This is a patient with the melanoma here. Here's the tumor. Here's the sclera. Here's the mushrooming lesion. This is after radiation. So the lesion shrinks and also becomes more irregular internally because of necrosis, edema, you get different interfaces. So instead of being homogeneous and regular, you get more heterogeneous up and down. And here's the B scan. So we see a lot of these or a lot of plaques are being put on, both Dr. Hansen and also several groups here in town through iodine plaques. So that's pretty much standard of care. Occasionally they'll have proton beam radiation, which is not available here. Huntsman has a proton beam, but it's not set up for eyes at this point. Had to have special markers and special software and things. So they haven't done that yet. Hopefully it'll be done. But they send them to San Francisco, Devin, Char, back to Massachusetts, Ioneer. So this is what happens when they're treated. And paradoxically, if you treat a melanoma with radiation, if it gets small fast, if it really shrinks down rapidly, that's actually a worse prognostic situation than if it's more slow. The thought is because these are more aggressive trimmers, they're higher risk for metastases. They shrink fast because they're more aggressive tumors, but then they have a higher chance of recurrence or metastasizing. So you kind of want slow gradual shrinkage over a couple of years of these tumors after radiation. Okay, extra squirrel extension of the melanoma. Any thoughts on that? What you'd worry about if you thought a tumor was extending beyond the sclera. Here's a lesion here. Here's the A-scan. Here's the surface. Here's the sclera. You can see that in the A-scan after the sclera, there is some low reflectivity, especially on the lower left image. And then on the B-scan, you can also see that acoustic hollowness after the sclera too posterior to it. All right, very good. So here's that he's talking about. So here's the sclera here and here's the orbital component of it. So you're actually got a lesion just right behind the tumor in the orbit. And the A-scan here, here's the posterior sclera and here's the lesion here inside the sclera. So this is an obvious one. If you saw this, you'd worry about extra squirrel extension. So sometimes it's not that obvious. Here's the lesion that we were following. Here's kind of an eboma. Here's the lesion here. Here's a couple of years later. Hadn't changed all that much on the clinical exam but yet on the A-scan and B-scan it showed a large lesion. So here's the lesion here in the globe. Here's the orbital component. Here's the lesion here. Here's the orbit. Here's the CT scan showing the lesion here. Not a huge lesion, but just broken through and got into the orbit. So you worry about that. When you do the ultrasound, if you see kind of the sclera kind of just kind of a ratty looking or irregular looking, you see something behind it. You always got to suspect extra squirrel extension. Here's a case that we published a while ago. Brad Jacobson was involved with this. We're here with the lesion here at the VA. And I didn't see any evidence of extra squirrel extension. I thought it was very looked intact, nothing in the orbit, but it had an MRI scan for some reason. And it showed this little area here and they called it extra squirrel extension on the report. We actually went down and looked at them with the radiologist. And several involved on the outside. Yeah, that's just suspicious for extra squirrel extension, but it turned out not to be. The eyes are nucleated and the sclera was intact and pathologically it did not extend beyond it. So ultrasound can be pretty helpful in these cases, you know, just really. And here's one that breaking through. Here's that echolucency behind the lesion. Here it is here. So again, if you see that, it's not always extension. Sometimes inflammation can do that. Pathetically growing tumor can cause inflammation of this like a posterior scleritis. Sub-T9s can get thickened because of that. So it's not a hundred percent, but you got to be suspicious if you see that, you got to alert the oncologist to it. If you put a plaque on, if you had extra squirrel extension, that could be a cause of dissemination if you start missing with the tumor in that area. So you want to kind of know ahead of time. So you get other studies, you don't want to look at it with MRIs and look at the lesion. So metastatic risk, about 40, 50% of melanomas metastasites are lower within 10 years. And unfortunately our statistics, across the board, all melanomas taken together, big, small, whatever, is still about 50% mortality risk over 10 to 20 years. And that's been the case for 50, 60 years. So in spite of all our things we do now, we haven't really moved that lever very much on olamide metastatic risk. Certainly small lesions, saving the globe, things like that are important and makes a difference, but we still have to address, probably just catching these early, catching the ones that are nearby, transforming to melanomas, that's where we got to really stress our efforts. A lot of publications about risk factors, both chromosomal, monosomal three is a high risk factor for metastases. AQ gain, AP loss, 1P deletion, 16Q deletion, these are all things on chromosomes that increase metastatic risk. So to do a needle biopsy, to look at these cytologically. And Dr. Hansen is sort of working with cytology to do these kinds of things. Genetics are the 15 gene array series that some people are using. Class one, low metastatic risk, class two, including the BAP one, high risk metastases. So once these metastasize, they really, you can't do much. There's a lot of work now with skin melanomas. Jimmy Carter, former president Carter, had metastatic melanoma to the brain, I think over 10 years ago now. And with checkpoint inhibitors and other treatments, he's still alive, teaching in sunny school in Georgia and building houses with habitat for humanity. So that's, they're making progress with cutaneous melanoma. But unfortunately, coroidal melanomas are a different animal for some reason and they just don't respond to those things at this point. So we'll hopefully get better, but so at least for a patient to give them an idea of metastatic risk, if they wanna know, sometimes they don't, but you can tell them it's low or it's high. So that can be helpful. Okay, calcification inside the globe. What are some things that can cause calcification? Any thoughts on that? Rhenoblastoma. Okay, for sure. Roy Golan. Like the case earlier, osteomas. Okay, osteoma, right? Tuberous sclerosis. Okay. Jerusalem. Okay, good. So what do you think this is? So here's the globe here, here's the lesion, calcium. I wouldn't drop it once. Okay, right. Is that a resident case? Yeah, right. Actually, it's a lens, but it's not dropped. You would think that it is, but if you put the probe really peripherally, if you go temporally with the V-scan probe and angle it towards the front, you'll pick the edge of the lens up. I see this all the time. And I've had cases referred to me that they were sure as tumor-enone talking about treatment, but it's just an artifact of pro-position. And this is really unique because this is calcified. It's a calcified lens. You can see the lens here. It's just probably traumatic and they tend to calcify over time. And this looks like a tumor. It's actually a lens and it wasn't even a droplet. So that can do with this, unusual. Okay, this case here. So here's a tumor here, but there's something in the vitreous that's bright. So what is this? Any astronomers in the group? Asteroid. Asteroid hyalosis. Asteroid hyalosis. So that can be a finding. Usually it's unilateral, sometimes chronic, vitreous changes, diabetics, but sometimes it just happens for no reason. But you get a little bit of B-scan. You get a lot of reflectivity here in the vitreous, the A-scan, just all these spikes. The amazing thing about asteroid hyalosis is, here's how dense it is. You can hardly see the fundus. You can just imagine this patient must be 2200 or so. They're often like 2030, you know, 2040. I mean, how does that work? So that's been studied and looked at. If anybody wants to be famous in the literature, figure that out, tell us why. But asteroid hyalosis. They talked about gerusin. So sometimes it's obvious you can see that actually looking at the fundus, but sometimes not so much. A lot of Pseudopathlodema, I refer to probably the case a week that's ruled out, Pathlodema. Young teenager with headaches, common scenario, and they look at the disk and it looks blurred, so they get all nervous. And if they're lucky, they send them for ultrasound first and for 200 bucks in five minutes. You can make the diagnosis. Other way is go neurology, MRI, CT, spinal tab, angiogram before they make the diagnosis. So gerusin can certainly fool you. Any rough idea in the population how common gerusin are? How many people have optic nerve gerusin just out of a hundred people? Any wild guesses? 11%. Okay, good guess. It's about two to three, two to three percent. So, you know, Freddie Lowe. And there's a genetic component. It's probably kind of a mixed pen and trends, probably out of the dominant, but a lot of people with gerusin have a family history of it or somebody in the family. That Brad Katz and I years ago did a study. We used to haul our equipment out to family reunions. I take my ultrasound machine and we draw blood and try to find the gene. Never found it yet, so we're still working on it. But in the family, if somebody has gerusin, somewhere in the family, about 50% of the time to find somebody else might be a cousin or an uncle or whatever. So they tend to run in families. Okay, so here's gerusin here. So here's the optic nerve coming in. This is on a Doppler study, but here's the right here. But this is a patient with a central retina artery occlusion. And I've told the residents a number of times, if you see that, just stick the B-scan probe on. It takes 10 seconds, you can look. If you see something like that behind the mimocrobosa, that's very suspicious for embolus. So if you have your five o'clock patient comes in and they have sudden loss of vision, they got central artery occlusion, grand artery. If you see that, right away you know it's embolic. So you kind of ruled out giant cellar varietas, other things, you can do the embolic kind of work up. So that's a very hopeful little thing to do. It just takes a few seconds to do that. So just keep that in mind. Okay, somebody mentioned retinal blastoma. So here's the tumor here, calcium. This brightness here is calcium. A lot of calcium here. They tend to have diffuse calcification. But not 100%, the literature varies, but they say five to 10% of retinal blastomas are non-calcified. So it's not, you know, if we always look for it, that's something we always, if we find calcium, that's almost always retinal blastoma. But if it's not there, it still could be. So a mask and a child is always retinal blastoma till proven otherwise. But calcium is something very important to look for. And again, here's a shadowing. There's dense calcium here. You see kind of like it's breaking through this flare. That's not really a scleral defect. It's just shadowing from the calcium that blocks the ultrasound. Okay, so what's this situation? Just looking at them. So clinically, if you saw that eye, what would you say? Just looking first glance. Tiesis ball eye? Yeah, tiesis. So tiesis galli tend to calcify. I'm not quite sure why that is, but you get this diffuse choral calcification kind of linear right along the coroid. So here's the eye, very small eye. Microphthalmic. And then you get this calcification. So that's common with tiesis. We talked about this case before. This is a rosteoma. So here's the calcium here. Here's the lesion. And Dr. Van Dyck, who was the initial chairman of the ophthalmology department before Randy came, published this case. In those days, he used to use a test called P32. They'd do a radioactive tracer they would inject it that they would examine for it in the body. And this lesion looked like this. It took up P32. So they nucleated it thinking it was a melanoma. And that's the first reported path case of a choral rosteoma. Dr. Harry, could you ultrasound to differentiate between meningioma and glioma for optic nerve with calcifications for meningioma nerve chief? That's a good question. And the answer is ultrasound is not very good for that. There's other things like it's good for as far as glioma, meningioma. But the calcium part of it is just, I guess the orb is just so high reflective in general. It kind of gets lost in that. So their CT scans much better. So yeah, good question. Okay, this lesion here, kind of a peripheral, kind of granuloma with this kind of vitreous membrane, kind of going across the globe. Any immediate pattern recognition thoughts to what this could be? Either clinically or by ultrasound. Toxicera, that's kind of a classic toxicera, kind of finding for some reason, like these peripheral granulomas and they get this kind of a vitreous, sometimes retinal fold going towards the disc. So that's toxicera and they can calcify. Okay, somebody mentioned astrocytoma, super splerosis, things like that, these astrosomal kind of lesions. It looks like this kind of funny, kind of a mulberry kind of looking lesion. You see that in a patient. And then it's calcified on the ultrasound. You want to do systemic workup, obviously, looking for neurofibromatosis, super splerosis, those kinds of things. And not uncommonly, we'll see dystrophic calcification. This is just this kind of yellowish, kind of a vague lesion here. And here's the calcification, kind of this corital calcification. When I see this, I always look from the other eye, it's often missed, it's often more subtle, but it's almost always bilateral. So if you see this kind of superiorly, temporally, kind of the insertion of the superior bleak muscle area, that's called dystrophic calcification, idiopathic. Here's another example of this is bilateral. Here's the right eye, here's the left eye. So what causes this, that's why it's called dystrophic idiopathic, because we don't know. Occasionally it's due to calcium problems systemically. So I always suggest they do serum calcium, serum phosphorus. So sometimes parathyroid dysfunction, case, many things like amylidosis, you get this calcification of tissue for some reason. But usually it's benign, it's just an incidental finding. So that's calcification of a globe. So just a lot of things you'll see that can cause calcification. Again, ultrasound is very helpful. It's just very sensitive to calcification. So that's why it's a good test to do. Okay, so great, great job on those questions. I appreciate your response and I'm looking those up and thinking about them. I think that'll help you down the road to thinking about things, instead of just a row responses, you kind of think of the locket behind it, the pathology, the correlation. That's where ultrasound is very helpful. So ultrasound basically is defined as sound above the range of human hearing. So we can hear out to about 20 kilohertz dogs or 40 wells, dolphin, 70 bats, 150. So we're kind of limited in what we can hear and also what we can see. Our part of the visual spectrum is really pretty low as far as light sensitivity. Medical ultrasound, abdominal, they tend to use lower frequencies, one to five megahertz. We use 860 with our UBMs. We can do that because the eye is small and it's full of fluid. So sound gets through it. Usually we can use higher frequency, better resolution, abdominal. You can't get very far in tissue if you increase the frequency. So you have to stay in the lower side. So you get less resolution, but you get better penetration. Being perpendicular is important. You kind of angle your probe. It's kind of a hand-eye contact. Like you're learning FACO, you do hand-eye. You practice out, same with ultrasound. You kind of move the probe, little micro movements, kind of get perpendicular. It's important because you can make misdiagnoses if you're not. Here's a lesion here. This is a nevoma. Here's a surface. Here's a sclera. This is perpendicular. You get a nice high spike. Initial, this spike here is high. It's almost as high as those spikes. Even regular. I had the same lesion. I kind of purposely made the probe oblique. And here you don't get that high spike. Internally, you get this. You would call this probably high reflectivity. You're regular compared to this where it's lower, more regular. So you can get the seed if you're not perpendicular. So just like actual length measurements, it's important to be perpendicular. Sound velocity, different tissues are correlated to density of tissue. The sound goes faster through low density, like water. Slow, faster through like bone. Impedance is defined as sound velocity times density. So the faster the sound velocity, the greater the density, the greater the impedance. And the major principle of ultrasound is difference in impedance. You have sound going through one tissue, then to another like through the vitreous and through a melanoma. That interface between those two is this impedance difference. And that's where you get the reflection of sound and the greater the difference, the higher the reflectivity. So the higher the A-scan spike, the brighter the B-scan spike. And here's the B-scan we talked about. And a lot of machines that you buy will have kind of a combined A and B-scan on the same machine. If you push a button, you can take the B-scan signal, make it into an A-scan signal. But it's not the same as the separate A-scan. This is what I use. It's a separate dedicated A-scan probe. And it's just more reliable. The B-scan, A-scan combination is just less reliable for sound diagnosis based on reflectivity patterns. Roger, Harry, I have a question on this. Sure. So is it the absolute difference? So either going from high to low, low to high that causes that big spike or does it depend on which way the impedance is going? I mean, as far as the, like, I mean, here? Yeah, so say the peak. Like if it's going from a very high impedance to a low impedance versus going from low to high. Yeah, either way is the difference. So, you know, obviously here, you have more homogeneous with the vitreous, you know, low interfaces, whereas here, you get a, you know, this change, even though it's still on the lower side it's still got interfaces. So that difference in the sound velocity and tissue density is what causes a spike. Okay, so it doesn't matter which way it's going. Either way, you go from low to high or high to low. This is, that's the difference that causes that spike. In fact, here's an example here. So you're going from low here to higher here with a spike. You're going from lower here to higher here with a spike. This is the orbit here. So again, you just show the, you know, it's either way. You didn't get that, that spike. So I did a study, looked at a thousand patients years ago and just to sort of see, you know, how am I helpful in this ultrasound and making the difference. So patients referred to me for ultrasound for whatever reason, you know, fundus lesion, real auto-detach, retina, vitreous hemorrhage. The clinical impression of the doctor was confirmed in 400 plus cases of these. I couldn't find something in almost 300. And that meant like it's often eye pain. Dr. My eye hurts, you know, we'll see those all the time in clinic. I do the ultrasound, I really couldn't find a reason. You know, there's no echographic basis now that there isn't. This is, I couldn't find it. Clinical impression, clarifier altered in over 300. So these are cases where the patient was sent in maybe for a vitreous hemorrhage and I found it detached retina. Send in for anivas, my fellow melanoma. So, you know, at least a third or so, it really made a big impact on the care of the patient. And I was wrong in five cases. Mostly orbital lesions were biopsy proven to be something else. But about a third had pathology that weren't suspected. So that's important to keep in mind. So that's the value of ultrasounds that really be helpful in these cases. Indications for ultrasound, opaque media, visible lesions, biometry, actual length, measurement of structures, tumors after treatment, et cetera. Vitroretinopathology and optic disc. So these are all things that really, I think ultrasound has a real important role in. So the blind pain, poli, patient comes in your practice, you know, and they just have this red eye like I saw in triage clinic two days ago. Very painful, Hispanic gentleman, illegal alien and had blind pain, poli, history of diabetes, but really kind of a sketchy history for medical follow-up. So, you know, what's going on here? And this is critical to do an ultrasound to find out what's inside the eye. The past studies from Zimmerman years ago were 10% of these will harbor unsuspected melanomas. So you definitely have to do ultrasound. As a little side pearl too, and a patient like this with a blind pain, poli, they're just, you know, really, you look, you do the ultrasound, it's just maybe total attached retina, chronic detachment, probably not surgically repairable. What would you do in this situation clinically for this patient? For getting ultrasound for a minute, you're the doctor, you're in charge. This patient's suffering, they can't sleep at night. They have really no insurance or minimal insurance. What is your solution to this patient's problem? You know, pressure is real high. It's 80, cloudy cornea. Anything you do clinically? Well, if they have like a lot of band carotopathy, could do sometimes a bandage contact lens. And sometimes atropine can help with these eyes, just if there is a lot of, but if they're pre-ticycle and I don't know, there's not a lot you can do if unless, you know, spraying them surgery. All right, those are good points. You know, bandage contact lens, if you see a lot of corneal irregularity, try to get the pressure down, drops, but usually these are, you know, rubiosas, neobascular glaucoma, so really drops just aren't gonna do much. So those kinds of things you would try, but generally it's not gonna be very helpful. So nucleation obviously is a solution, but a little trick I found over the years, keeps us in the back of your mind, is they used to do alcohol blocks, we'd actually inject, activated alcohol, retrovolverly, and that would kill nerve fibers and things and reduce the pain, but also causes lots of middle inflammation, they go through a period that really inflamed and painful and miserable, but thorazine or promazine has been found to be useful in these situations. And I've done that a number of times in my clinical practice, blind painful eyes that didn't wanna be nucleated, couldn't afford it, whatever reason. This injection of this, 0.5%, can help the pain, so just keep that in mind, there's a little pearl for trick in your practice someday. Okay, fundus lesions, and we show those studies, the 20% falls positive, so just looking at these clinically, indirect ophthalmoscope, fluorescing angiography, whatever, we're still wrong about 20% of the time, really can't tell what these are, so ultrasound can be very helpful in these kinds of lesions. Biometry, we use IL master all the time, light-based, but I'm probably 5%, 10%, they're getting better with software, improved much as still, there's certain cataracts, you just can't get good biometry, so I'm sent probably a case a week or they couldn't get measurements, so we'll do axial length, a mere emergent ultrasound, and so here's the spike from the probe, here's the cornea, double peak cornea, lens and retina, so axial length is important, vitro retinal pathology, here's vitrus membrane with kind of this hammock or tabletop retinal detachment, kind of a focal, kind of a characteristic diabetic kind of situation. Optic nerve droosin, the value of that, what's looking for calcium deposits behind the nerve, now one interesting thing with ultrasound, I can't detect a droosin unless it's calcified, so you always have these, I could kids send in, they got funny lick of nerves, Griffin will send me a case or Bob Hopman or the other pediatric folks, and is this, is this pathodema, is it droosin? The youngest I've seen with calcified droosin is four years old, and I look the literature, that's the youngest I've seen reported too, so under four or five, it's really ultrasound, not going to really help you that much, as far as trying to find no calcification, and there's OCT kind of goes back and forth, some people claim this is good or better than ultrasound, others that it's not, so I know calcium, if I see that then it's just for sure, so we're still trying to work out if we can find other ways to detect these before they calcify any younger patient. Doppler effects based on the Doppler phenomenon, astronomers use that for the redshift, for the Big Bang, you know, galaxy explosion, so this is the color Doppler of an eye, here's the back of the eye, behind the eye, so this is the ophthalmic artery here, central retina artery, ciliary vessels here supplying the coroid, this is a normal looking color Doppler, here's a branch artery occlusion, so this part is just gone, there's no blood flow through here, or as you get it on this side, here's a giant cell arthritis, this is why a giant cell is so devastating, once you lose vision from a giant cell, it's pretty well gone, high dose steroid, you try to save the other eye, but you're just not gonna get this back, it's just all dead, there's just no blood flow here at all, that's why it's so devastating to have, you know, artery occlusion from a giant cell, so I always keep that in mind, always suspect a giant cell, patient walks in, any kind of an artery occlusion, unless they're 20 years old and no symptoms, I wouldn't worry about it, but if anybody kind of past middle age, I always consider a CRP, I always rule out a giant cell, that's pretty critical, fistulas, kind of a red eye, kind of these corkscrew vessels, kind of tortuous vessels, sometimes patients complain about hearing their pulse in their head at night, hearing the brewery, sometimes you can hear it with your stethoscope, sometimes you can't, but here's a color Doppler showing the, the landlord's supra-optomic vein with blood flow, so usually it's blue because of venous, but here it's red because of arterial flow, so you get a fistula, and we're doing the study with the color Doppler on the temporal arteries, that's still ongoing, got about 30 plus patients now, and so far we're looking pretty good, as far as correlation, as we're around, a while ago, Nick Mamelis said that about 5% of our biopsies are positive, and that's been our correlation on the Doppler, so this is a normal temporal artery here, here's called a halo sign, see this echolocency around the vessel, that's due to vessel wall inflammation, so it's because they're inflamed, it gives this edema around them, so here's on the long section, here's the cross section, so this halo sign, the one problem with this is it disappears real fast, they start steroids, this goes away, I'm trying to find out how fast, whether it's a day or longer, but once we're on steroids, it probably isn't gonna be your helpful to get the color Doppler, if it's been more than a day or so, so just keep that in mind, but we appreciate any patients you see to let us know about it, and we'll do the ultrasound. Immersion techniques, when I trained at UCLA, this was the only way we used to do it, we used to drape the patient's face, fill this with a little water, drown them, they hated it, they were claustrophobic, but now we use immersion techniques, we use scleral shells, a little ton of tip covers and things, but here's a immersion scan of a ciliary body cyst, iris cyst, so here's just a regular 10 megahertz B scan, the same lesion here and a 20 megahertz, and a fifth, it just shows a resolution, just goes up with the increase in frequency, you see these nice cysts that are just really obviously there, and that's very helpful. UBM here, this is a case of chronic endopthamitis, and chronic uveitis after cataract surgery, even a year, this wasn't getting better, no response to antibiotics, steroids would kind of get better than it could get worse again, but here's the ultrasound, here's the iris up here, here's the lens optic, this little clump here is actually vegetation of P acne's bacteria growing there, we can actually see it with the ultrasound and they had to go in and take the lens and the bag out just to finally cure the patient. A lot of bug syndrome, I see these probably at least once or twice a week, here's the lens optic, kind of as you go towards the periphery, the haptics actually touching the back of the iris it's still everybody area, this patient had chronic recurrent hyphemia, increased pressure, so extant for uveitis, glaucoma hyphemia, so any of these can be caused by this, so that's something to always look for with ultrasound. Here's a correlation, this is an article by Shields showing the OCT versus ultrasound, so with a lesion anterior to the iris, they're probably comparable, here's a lesion on OCT, here it is on UBM, but behind the iris, then you can't see the lesion, this is a light based technology here with OCT, so the iris blocks it, so the ultrasound can get back there and show you lesions behind the iris, so that's why ultrasound is really helpful, so everybody, most of you are behind the iris, ultrasound is the best test for that. Okay, this patient, here's an ultrasound of a patient that has some symptoms, dysphiltopsia, which after cataract surgery is not uncommon, I'm sure in your practice, all of you will see this, you'll do a cataract surgery, everything goes great, FACO beautiful, flip the implant in just in the bag, and the patient's complaining bitterly about dysphiltopsia, they see flashes of light, they see shimmering, they see whatever symptoms are, and sometimes you can't find a reason, in this case it's obvious, this lens is displaced, probably kind of crimped hapik or something, maybe one hapik in the bag, one hapik out, but it's de-centered, and this patient really had a lot of symptoms, it's really unhappy, but sometimes it looks normal, I do the ultrasound and it's well placed, it's centered, it's in the bag, so it's something of the nature of lens implants, just with refraction of light or whatever, they're gonna get these symptoms, and they'll drive you crazy, they'll just come back repeatedly and just very unhappy, so only option sometimes is to replace the implant, but sometimes the same problem occurs with a different implant, so it's just one of those things we're still kind of agonizing about. This case I saw recently in surgery, Marfan's child, and the lens has been dislocated into the vitreous here, so the cornea is up here, here's the lens sitting there in mid vitreous, and David Ries was doing the case, this is his patient, and he was really worried about his kid, they had cataract, Marfan's eye, what are you gonna do, kind of corneal pacities, but he saw the lens here, he was all excited because the lens now had displaced out of the visual axis, here's the visual axis here, so he could do a retinoscope and he could actually refract the kid, there's like plus 15, but he could prescribe glasses for the kid because the lens is out of the way here, so interesting case here of lens dislocation. Dr. Harry. Yes. Can you diagnose like in the bag, UG or like any type of like a dynamic B scan to determine if there's any like sonar laxity? Right, good question. You know, the zonules, I can sometimes see a zonule with the UBM, but it's not, you know, I can't really say there's loose zonules or missing zonules, but you're right, by having the patient move the different positions, I'll have him move the head side to side or even sit up and kind of bend forward, if I see lens displacement, I've seen several cases of that where the lens seem to be okay, but then by positioning, you would get different, you know, the lens position in different positions. So a good question. So I do dynamic sometimes. Over the calligraphy, I think getting kind of low on time here, so I won't spend a lot of time in this, but just the incredible imaging technology. When I was an intern back at UCLA a long time ago in the 70s, we had her playing till max rays. So imagine trying to diagnose all these things with just an X-ray. So CTs had just come along kind of late 70s and then MRI followed and PET scans. My son's a PGY2 radiology resident in Denver. So he's just seeing things I never even dreamed of as a resident, but again, the correlation in pathology with ultrasound pattern recognition. So they scan of the orbit. Here's with normal orbit. So you get this high reflectivity kind of regular. Here's the manjoma with his up and down. We talked about the manjoma of the coroid. Here's a mixed cell tumor. Here's a swanoma. Here's a lymphoma. So again, even though these funny spikes look weird, there was a correlation to pathology. So that's why it really could be helpful and getting pattern recognition in different things. Indications for B scan. We talked about a lot of this, the geruzin, a reptile bull bar. I see patients often referred with a lot of eye pain. They have like an anterior scleritis and I'll pick up posteroscleritis. We always look for that on these cases and see if we can see anything in the subtenons, thickening, scleral thickening consistent with posteroscleritis. We saw a case I was involved with a couple of years ago as the recurrent hyphaema been seen on the outside for this child, like two year old, that keep having bleeding in the iris. Question was, was it like a xanthorrenuloma or something? So we're going to go with surgery and do an EUA and the UBM. I didn't see much on the UBM, but just while I was there, I stuck the probe on there. Here's a big orbital mass. So the kid's asleep, a two year old orbital mass, abdominal examination. They thought I was crazy. I suggested the anesthesia. I'll just take the abdomen. He had a mass in the abdomen. It was a neuroblastoma, metastatic. So keep that in mind. So this was again where B scan was helpful to show a mass that hadn't been suspected preoperatively. Superior thymic vein. If you see these fistulas without Doppler, you can still see these on a regular B scan, but you can't tell, is this a fistula or just kind of a occluded vein? Is it clotted off and just the vein is expanded, but there's not active blood flow. That's where Doppler can be helpful. Here again, here's the case of central artery occlusion. You get the cherry red spot, macular edema, paramacular, and then you get this brightness here, which is consistent with embolus. About 30% of these will have embolus diagnosable by B scan. So again, just a quick, easy test to do. A scan in the orbits, paracular. Here's a lacrimal tumor mixed cell with characteristic pattern. Pretty diagnostic with mixed cell. Optic nerve evaluation. Somebody asked about this. So here is the optic nerve on B scan. This is the A scan. So this is actually a white nerve. This spike there, spike there. This is called the 30 degree test. I have the patient abduct the eye 30 degrees and the nerve actually gets smaller. That's because this is a case of pseudotermal cerebroid increasing the critical pressure, where the nerve sheet fluid as you have the eye abducted is kind of thinned out and the nerve gets smaller. So this is a good test to rule out optic nerve edema due to like pseudotermal. Muscle exams using the A scan to look at the muscle from this tendon back to the muscle belly. Sinus disease. I pick up sinus disease, not uncommonly. You see a few spikes coming. So this is the globe here. Here's the normal orbit. Usually you don't see spikes from the sinus because it's air filled, air blocks, ultrasounds. You get nothing. But if you see a lot of spikes like this, that's very consistent with sinus disease. I picked up a lot of ethmoid frontal sinus disease. So you can sort of direct the work up there appropriately. Tumors, there's a hemangioma causing a disc edema in this kid with a hemangioma. Babies, they thought had orbital cellulitis. You know, this swollen lip, this was the old generation CT scan kind of amorphous, not very specific or something in the orbit. But what is it? Could that be abscess? Could it be a tumor? And this is the dop, the ultrasound. So it's this kind of low area, high area. These infantile hemangiomas tend to be kind of heterogeneous. And this blur here is due to vascularity. And I actually use this little OB Doppler. I'll put it right against the lesion. I listen for blood flow. And here is an example. So do you hear that? That's consistent with hemangiomas. So we see probably a case a month or so of that. Here's a kid with a AV malformation on the lesion on the CT scan, but by Valsalva, it went from this to this. So just have you been poor to have him bear down, increase the size of the lesion. Lymphangiomas, they can bleed into the cells spontaneously and get real big, real fast, but you get these multi-cystic areas on the B scan, also the A scan. He revved a mysarcoma, classic history, 10-year-old boy playing wiffle ball, just a ball hit his eye, kind of a soft ball. It wasn't really that hard. But a week later, he had a eye with proptosis, chemosis, and ultrasound had a low reflectivity, very cellular, very densely cellular, here's the B scan. So revved a mysarcoma, minor trauma, always keep that in mind in a child with a proptosis or a robot lesion. Check out the muscles, ultrasound is very hopeful. A lot of graves disease patients, we see rule out graves. You know, the spectrum of grave disease, simple hyperthyroidism to malignant exceptalamus, spectrum of eye disease. So overactive, I kind of characterize it. Lid lag, widened fissure, lid retraction stare, that can just be hyperthyroidism. Once you get the orbital findings called congestive, chemosis, hyperemia, muscle dysfunction, proptosis of the spectrum, sometimes there's a, you know, kind of both. Some patients have both of these going on. About 40% of patients with graves get thyroid eye disease. 90% with thyroid disease have grave thyroid. And it's not always the test, them always help you because about 6% can be euthyroid. This is the kind of the time spectral, about 25% of patients will actually present with graves orbitopathy before the thyroid test become abnormal. So a lot of these can still fool you. The internists always have a battle with us. Is this grave disease or not? Because the thyroid tests are normal. Yet if you watch them over time, most of these eventually become abnormal with their thyroid test. And looking at muscles, here's normal muscle with the A-scan showing the reflectivity patterns, kind of high reflective, a little bit irregular, but more homogeneous. Here's grave disease. You get a lot of edema, inflammation. You get more internal reflectivity, heterogeneity. You get bigger muscles, different interfaces. And large muscles, these are all causes of big muscles. Graves is the most common, board question. Most common cause of unilateral proptosis, grave disease. Most common cause of bilateral proptosis, grave disease. So very common in the population, myositis, infectious, other causes of big muscles. And I think I asked a question, because the time we'll just answer this real quickly. So myositis versus other kind of muscle. Usually the myositis is easily isolated, unilateral, but they can sometimes be multiple muscles. Thick and tendon is a big differentiation. Graves tend to have normal tendon thickness. Myositis tends to be thicker. Regularity on the A-scan more, on the myositis more low, more regular because of dense implication of inflammatory cells, pain on movement, if the grace doesn't have this, but there can be inflammatory graves. I see graves present as a myositis because graves is inflammatory disease. So acute graves can kind of mimic this. You can have pain, you can have thick and tendon. So again, spectrum, not a hundred percent. But here's the tendon on the B-scan, on the myositis. Here's the A-scan tendon. So low reflective, thick and tendon. So here's the collage. So normal muscle here. This is graves here, so thick muscle. And here's myositis, so thick muscle, but low reflective. So you can make that differentiation. Object nerve evaluation, we talked about the 30 degree test. It's a question about meningioma. So here's the gliaoma. This is a thick nerve here. The nerve sheath to sheath is thickened. And here's meningioma. You can actually see the nerve sheath thicken here and the nerve perechoma here. But again, calcification, I really can't tell because of the orbit. So that's it. Ultrasound in a capsule. So any burning questions or? Dr. Harry, I have a question. This is something that came up on call a couple of weeks ago when they have the ultrasound machine that has kind of the eye setting on it. And the physician there was wondering if we would hold the ultrasound with a normal abdominal ultrasound setting on the eye or did it do any damage? There's no proof of damage. In fact, we did a color doppler studies initially, not just on the temporary, but actually on the globe. We had to go through all kinds of, you know, board review and things like that to get approved. But there's no proof of high frequency causing damage. So I think they're fine to use that, you know? I'm not aware of any problem. I mean, the machines all have the atomic setting, but it was just a question that I couldn't really answer. I wouldn't think so, but yeah. I think you're fine. I think frequency is just not, you know, the frequency is related to thermal energy. So if you get real high, that's why they use therapeutic ultrasound that they treat tendonitis and things with. That frequency would obviously damage the eye, but the ones that we use just for diagnostic just is not a problem. So I think you're fine. Okay, thank you. Sure. And then I said a quick question I put in the chat earlier about utility for anterior segment stuff, such as like senile plaques with calcification versus like OSSI in there, band care top three versus other corny illusions. I know we have better imaging modalities and clinical, you know, assist, but do you ever use those for anterior segment pathology or not necessarily? So summarize the question. I'm sorry, the question. So I'm raising it again. I'm not sure what you're asking. Do you use ultrasound for anterior segment like corneal or scleral pathology, like senile plaques with calcification versus like another type of lesion? Yeah, I sure do. UBN is very helpful. I can see, you know, like a lesion, you know, you're worried about it, you know, like squamous cell or something growing onto the, from the conjunctiva to the cornea ultrasound. The value of there is just the depth, the penetration of the lesion or so CT can help there too, but I can actually see the plane of the invasion of the lesion whether it goes into the globe or whether it's just, you know, stops halfway through. And also epiysploritis, I see a lot of that where I put the probe on the UBM. I can tell if it's epiysplora versus sclera. So it can be helpful in the situations.