 Plain film x-rays, so you can do it with your bone, but my shell is really soft tissue, other problems, not very useful. Erty generation CT scans, one of the first generation CT scans, sort of getting better than plain film x-rays, but still not great for blood and for cranial processes or interorbital ulcers. It's a sound where you kind of fill the gap, you have here on this, you know, is that just to be on the top. Not on the mouse. Not on the mouse. You've gone off, make sure you're ready for that start. Okay, thank you. Anyway, so then these came along, of course, CTs, MRIs, incredible definition of soft tissue, certainly in the orbit, intercranially, even the globe, could show some things in the eye, so that was a big step forward. So the question kind of arose, who needs ultrasound? We have that kind of technology, but there's still a role for it, there's a kind of initiative filled, certainly in the globe, I think it's still superior. You can see detail here, mine otherwise, strutting with high frequency, get the UBMs really down to a very micron level, but even in the orbit, there's still a role for ultrasound, and the A-scan, all these spooky lines, they actually mean something. There's a correlation to pathology. I was doing my residency, I was repressed that you could actually sort of look at cell structure, architecture, and make a correlation of these lines. So a normal orbit would be like that, and then hemangioma, lymphoma, and angiomas, you almost get like tissue signatures based on pathology, so it really kind of makes you think and sort of what you're looking at, and so that's still an advantage to using ultrasound. And of course, the side of the globe, things like detach retinas or melanomas, things like that, still a lot of usefulness. So basic principles, sound reflection from interfaces, just like lights reflected, so a sound, a lot of the same principles, snows, a lot of things like those are followed by ultrasound reflections. So a long time ago, Bass discovered the same concept in the Wells, they use it in nature all the time. That's incredible, they all of a sudden can't see, there's a species that can, but they use sound to locate insects and little tiny gnats and things they can pick up middle of the night just by ultrasound. So it's a powerful technique to localize. And then again in nature, the animal kingdom, humans are a range of herrings up to about 20 kilohertz, and that's ultrasounds defined as sound above that range. So board question, if you have that on the boards, that's the definition of ultrasound. So dogs can do up to about 40 kilohertz, Wellesdorf in 70, Bass 150, so they have ability beyond our range of herring to hear things, and then again to use that to to localize. And medical ultrasound, abdominal ultrasound, commonly their frequencies are lower, because the higher their frequency, the less penetration. So there's an inverse correlation. So in the abdomen you want to get deeper into the abdomen, you want to see kidneys and livers and things. So you want to be able to go in great deeper. So you want to keep your frequency around the one to five megahertz range. At the albumic, we have the advantage of having a small structure of the eye, about an inch. And then we have a lot of fluids, so ultrasound, built through fluid easily. So you can get high frequencies of 60 megahertz of some of the high frequency ultrasounds to localize things. So it really gives us better resolution. Soundwave velocities, so the denser the media, the faster the ultrasound velocity. Water is about 1480 aqueous vitreous 1532. That's kind of a standard setting for most biometers, the ultrasound biometers that are set to that kind of average. So to really refine a lot of people who use the break it down, they'll look at the break it down for the aqueous, vitreous, and the lens and add it to those things together in a formula to actually give the true distance, you know, the actual length of the eye. But if you use a standard biometer, that's kind of your average setting for the biometer. Okay, so principle is going to sound reflection. So the B-scan, those stands for brightness amplitude. So basically you're just taking little pixels and coalescing them to make a picture. Same concept as a TV screen. You're just adding reflections to this picture. The A-scan is really the same thing as the B-scan. It's just instead of a pixel or a brightness, grayscale, it's actually a line. So it's just showing a line versus a dot. What's the advantage of that? I'll try to explain that to you. The UBMs down for ultrasound biomicroscopy, which is high frequency answer segment, usually requires an immersion technique to see that. So this is the one formula I'll throw at you. Acoustic competence equals sound velocity times density. So that's just a basic formula of physics. And in ultrasound, we depend on interfaces. So the greater the difference in impedance between two media, the higher the A-scan spike or the brighter the B-scan image. So when a sound way of goes from one media to another, that principle applies. Your reflection, your interface reflection depends on that. So to illustrate that, this is a Corotal Homanjeoma. As you can see the pathology there of the Coroid. And these tend to be a lot of interfaces. So compared to like the Vitria, so you're going through the Vitria's cabinet here. So the flatness on the A-scan, of course, the darkness on the B-scan. So there just isn't much there to reflect sound. Usually Vitria's just pretty homogeneous. So you don't get much reflection. So it's a flat line on the A-scan. Once you get an interface, again, this impedance principle, then you suddenly get a reflection of sound. So if you go through the Vitria's, you hit the interface of the tumor, the surface of it, you get a high spike, because you're suddenly changing that impedance concept, that velocity. And even once you're inside the tumor, there's still a lot of reflection, because you get a lot of interfaces. So some tumors are very homogeneous, very dense like melanomas. They don't give these high reflections, whereas Homanjeoma's do. So that principle, again, starts to help you sort out pathology. You can correlate that concept to what a legion is, both in the glow or in the orbit. So the B-scan, again, is a brightness concept. So brightness on the B-scan corresponds to height on the A-scan. So the brighter the B-scan image, the higher the A-scan. But there's a limit to this. Grayscale, the start ability to perceive grayscale, differentiated, it was limited. So B-scan legions often look a lot the same. They might be a little bit brighter or darker based on the tumor. But A-scan really kind of shows it to you, just sort of makes it stand out. It's more dramatic, more observable. So the B-scan probes, all the probes have a mark on them of some kind. There's a little mark on the tip of the probe. And that correlates to the transducer, which way it's going back and forth. So as I teach you guys a little for sound, I always stress about transverse longitudinal, which way the thing is going. And there's a reason for that. It actually helps you orient things. When you're looking at tumors and things to measure them, that's an important concept to have. So actually this is taking the tip off the B-scan probe and showing the transducer. So it's actually going back and forth. It's a two plane motion. It's a transverse back and forth that doesn't rotate at all. So this is going back and forth in that plane. So wherever the probe is turned, let's assume the marks over here, that shows you which way the transducer is moving back and forth, oscillating back and forth. And that translates to where you're looking at inside the lesion. So this transducer actually contains a little real thin crystal. It used to be kind of a membrane in the house. Like a ceramic crystal, very, very thin. And that little membrane crystal will vibrate based on electronic pulses. So the machine sends out electrical pulses, they stimulate that to vibrate, and that sends the sound way down. So that's the basis of the ultrasound technology. It's actually a generation of sound by electrical pulses. So techniques, I talked about transverse longitudinal. That's important when you're doing the B-scan to be systematic. Most of it is just a client just put the probe up there and you know, swap it on. I see something, you're all excited, but you can miss things that way. You know, you'd be systematic just like you do with an eye exam. I probably, I have a number of cases I picked up. The other eye, it's a normal eye that the patient didn't come in for, had us the pathology. I picked up several melanomas that were the other eye versus the eye that they came in for. So just always not just look at both and do systematic exams. Look at the whole eye. You'll miss things if you just focus on one element of it. So again, the concepts, the markers here, that means the transducer is going back and forth, kind of out of the plane of the slide here. It's going to be towards us, back into the slide. So that's the transverse view. And as that beam is oscillating back and forth, that is showing a lateral extend of the lesion. So if you had a lesion here, you're kind of going lateral, examining it. If you turn the probe this way, where the marker is up, the transducer isn't going like that. So this is a parallel for the limbis. We define it as a transverse view. So when the transducer is moving parallel to the limbis, that is called transverse. When you're longitudinal, like that, perpendicular to it, that's called longitudinal. And that show is answered opposed to your extended lesion. So the beam is actually going this way. It's going from the optic nerve up to the aura in that direction. So each sweep of the B-scan probe is about 60 degrees. So if you want to scan the whole globe, that requires six different sections. You get 360. So anyway, so that concept of a transverse, longitudinal, this is an axial where you're actually putting it right on the cornea going back right to the back of the eye. So those are the three basic probe positions over the years. So an axial scan, you can see the probe is up here. You can sort of see a little bit of made the posterior lens capsule. You miss most of the entire segment because physics of the probe, the way it works, you lose information up in here because you're touching the globe. And you go to the lens here, an optic nerve shadow, kind of the shadow in the back, that's the optic nerve. So you could use that for a view. The problem with the axial view is I don't use it a lot because first of all, patients don't like on the cornea. I hear I was kind of worried about conglomerations and things. And then also you lose energy, sound energy. As you go into the lens, it absorbs some of the sound energy. So you don't see as well, the resolution is not as good. So we often don't use axial views unless there's something right in the medium to back of the eye. So we often use just off the Olympus to see things. So again, the transverse v-scan versus longitudinal. So again, transverse is going this way. The transducer is going to take you back and forth out of the plane of the slide. And this is going perpendicular or longitudinal. And we can characterize reasons that way. This is the lesion or lump in the eye here as you want to examine it. So this is what kind of a transverse scan here. So we're kind of looking here at the lateral extension of the lesion so we can measure that. So when you see the lesion, the marker on the probe tells you on the screen which way is up. So it's always the way the equipment is made. It displays the image with the where the white mark is that is up on the screen. So this would be the superior part of the lesion. This would be the inferior part. And longitudinal, again, you're going this way. You're going perpendicular to the Olympus, back and forth that way. So you see the lesion there, kind of the anterior postural extension of the lesion versus lateral. So there's the optic nerve, there's the lesion. So this is the lesion here, nasally. So what kind of view is that, the way the probe is oriented there? There are transverses, longitudinal. This is a transverse view because you're parallel to the Olympus. Think about the transverses are moving. Olympus is here, so you're moving that way and so you're parallel to the Olympus, which would be a transverse view. So that lesion is seen that way. Rotate the probe this way, where you're going perpendicular. Okay, does that make sense? So it's perpendicular here. That's just going that way. So that shows the lesion of those views. So putting these all together, you have to kind of mentally construct this. You can actually see the lesion. You can see both the lateral extension and that's your posterior. That's important because when we measure these lesions, it's very common now to treat melanomas with radioactive plaques. So you actually make a plaque, radioactive iodine. So up to the eye on the sclera, leave it there for three days, then take it off. So you need to know how to make the plaque. So you have to have these measurements and I see patient referred by an ocular oncologist. I need to tell them the lateral and anterior posterior extension. So those are really important measurements. Then we follow lesions, either before we treat them or after they've been treated just to follow see if they're responded. Again, you need to be consistent, reproducible, systematic. So these are all important to do that. So it's just good to think that way and kind of think systematically. That's the e-scan concept. The e-scan, the transducer in the e-scan is not sweeping back and forth. It's a fixed beam. It's just a sound beam that comes out. So you don't have to worry about pro-position that there's no mark on the e-scan wherever you put it. The beam is the same. It just comes out of the probe as a comb. So the e-scan is placed on the globe. You get the initial spike from the surface of the eye. So again this area is kind of an area of lost information. Whatever is in there you really can't see because of the physics of the probe. Velocity of sound coming back and the crystal stimulation. That area is about three to five millimeters. So your anterior sclera, anterior vitreous, that's all in there somewhere. Don't really know what it is. The same on the e-scan. You go through the vitreous, again it's mostly homogeneous. So the beam goes through. You don't get much reflection of sound because it's homogeneous. And then you hit the surface of the tumor. Concept changing. Velocity. So then you get a spike. And once you're inside the tumor, melanomas tend to be rather homogeneous. They're intensely cellular. You don't get as many interfaces as you do with other lesions. So that's important. That kind of distinguishes melanoma from other things. That reflectivity. So it's kind of on the low to medium side. It's kind of regular. The lups and downs, but it's not huge difference in variance there. Again, so based on pathology, if you look at the pathology of the melanoma, that kind of makes sense. Why you see that pattern. Then you get the sclera and get another change in sound velocity. You get a spike in the sclera. And back in the orbit, the orbit has a lot of interfaces. You have fats, septic muscles, nerves. So the orbit is a high reflective versus a vitreous, which is low reflective. G keys is a coroid on that. On the coroid? Yeah. You can actually, if you look at the, turn the frequency, the gain down a little bit, you can actually separate out the coroid from the rep. But it's not as accurate as OCT. So I actually use this picture to kind of, that's a good pathology now. Because we do these OCT switch for you, so you're like macro CT. This is kind of the B scan. You're looking kind of closely, you're looking at the back of the eye of the poster segment with the B scan, just envision the B scan signal showing the retina surface. You're looking here with immaculate. This is the A scan. So the A scan and ultrasound, actually you take a section through that, you know, as you move this green line, the cursor, as you sweep it through the parts. It actually shows you those sections. That's what the A scan is doing. It's actually the B scan is showing the kind of a big image. The A scan is taking like a cross section through them, kind of like a needle biopsy versus a gross pass specimen. Does that kind of make sense? So they do complement each other. I use them a lot. I use, most patients I see, I use both. So again, here's melanoma, the pathology. Very densely cellular. Just a lot of cells packed together. There's a few blood vessels. So you get a few reflections from that. But usually they're pretty low. So here's going to the vitreous. Here's a spike of the tumor. Here's inside the lesion. Here's a splara. Here's the orbit. So you can see again that there's just a lot of dense cells packed together. So some interfaces, but not real high, not real irregular. The B scan shows the brightness. This is subrubinal fluid. The retina is being pushed off here. But here's the lesion. But again, you know, to look at this, that could be a lot of things. That could be a manjoma. That could be metastatic. So the B scan is really, it shows you there's a lesion there. It shows you kind of the general size and shape. So kind of morphology. But you're really defined of the A scan. It's a needle biopsy concept. You're going through the lesion, looking inside. What does the stretcher look like? Back of Horlase to pathology. So that was the neat thing about ultrasound. The first kind of attracted me to it. So the A scan probe has kind of this pencil-like probe. And again, there's not a transducer going back and forth. There's just a beam coming out. And there's some confusion about this. If you ever buy an ultrasound machine, if you go to a company and they say, if you have A scan, you have A scan, and you buy it, it really isn't. They kind of equate A scan to biometry. If you look at a biometry probe on the ultrasound machine, it kind of looks like that. Like we go to use a VA's machine all the time. The techs will hook up the A scan. I have to kind of switch probes, because the A scan probe, because of biometry, is not the same as we used for diagnostic A scan. They're not interchangeable. Like I can use this to do biometry. I can't use the biometry probe to do kind of sort of what I do with tumors and things. So that's a sort of confusion. Even a reps, a cell machine will just tell you, that's the same thing. And a lot of machines on the B scan image, they have a little thing you can turn and see a little A scan pattern at the bottom. Like the vector A scan is just, there's a line you can sweep through and see the lesion. And you'll see the A scan at the bottom. That isn't a true A scan. That's just kind of taken from the B scan envelope. And I just sort of use that information to make sort of an A scan out of the B scan information. But it's not a free standing separate A scan. So we're going to do an A scan accurately. You need to have a separate dedicated probe with a separate module on the machine. So returning that, because it's going to just lifelike, these are all things that light does and ultrasound does too. So sound is absorbed by things. I mentioned the actual view with the lens of serving sound, reflection, how you hold the probe, angle of incidence, Nels law, interfaces, size, shape, smoothness. These all affect the image that you see on the ultrasound. An example here of a little tumor. So here's going through the vitreous. Here's a lesion here with the first arrow, the second arrow. So you're inside the lesion. It's kind of small, small relations are harder to distinguish. It's probably a small melanoma because it's kind of low reflective that it could be something else. But anyway, the point of this is to show you, I'm perpendicular here, you get a nice high rising spike. I always stress out when you guys are doing ultrasound with me with A scan, I'm going to get this an ocean spike, high rising. You don't want to get kind of bumpy your off axis. This is the same lesion just by turning the probe purposefully, obliquely. I'm not perpendicular here. I'm oblique to it. But you see that by doing that, you don't get that nice high spike at the first and internal reflectivity is less distinguishable. It looks kind of maybe medium to low here. Here is sort of based on the initial spike is probably higher or irregular. So that bleakness just kind of clouds the internal information. So that's why being perpendicular is important. And people that do axial length measurements, the techs that do that always know you got to be perpendicular to really correct axial length measurements. So it's important to give and you know you're perpendicular based on the initial spike. If it's very high, it was smooth, and a lot of bumps in it. And I concept as you do, and you're watching the screen with your hand back before trying to maximize that initial signal. So indications for ultrasound glow, opaque media, obviously very important, dense cataract, lot of corny vitro sandwich. These are all things that we do all the time to use ultrasound for visible fundus lesions. You can see the lesion, but what is it? You know, we think we're good at it, but even the experts, the Shields group, we're saying inaccurate diagnosis of lesions based on a lot of past studies. So just looking at a lesion and direct ophthalmoscopy as good as it is, a lot of time we're fooled by how lesions look. Biametry, axial length, even though we have IOL master, we have the you know the light-paced measurements. About 20% of the time they still need to use ultrasound. The techs all the time have to go to a version ultrasound to see through dense cataracts, so dense, mature cataracts, PSE cataracts. A lot of things can give spurious measurements on the IOL master. So major necks of length, intraocular structures, majoring, high tumor high, things like that. That's critical. I do a lot of that. A lot of the patients I see are referred from the local groups here that do ocular oncology, and I'm majoring all the time. I'm majoring before treatment, I'm majoring after. So a lot of what I do is based on accurate measurements, and the A-stand is really more important. We draw in the pathology, I'll pick just a male. These are kind of major indications for ultrasound. So fake media, looking behind through dense cataracts. I think it's standard to care, and it's almost malpractice. If you do a cataract surgery without an ultrasound before, just to see what's going on inside the eye. And I've seen a number of cases that things are missed, including tumors. It's not a good idea to do surgery on an eye with a tumor in it. There's always a concern about spread. So what do you think it's important to do an ultrasound? Biometry doesn't count. You can do biometry and measure the eye. If you have a big tumor sitting there, you don't see it with biometry. So you got either dedicated A or B-stand or both. I just looked at a study of my own practice. I looked at a thousand patients over a couple of years, and I just found this. At the clinical impression, a patient referred to me for a diagnosis with a say that they said, there's a vitreous hemorrhage, or there's a detachment. I confirmed that in 400 of them. So clinical diagnosis was confirmed. I couldn't find anything in about 279. So a patient said for eye pain, common reason, my eye hurts, aches, you know, I can do the ultrasound, you don't find much going on to explain it. Clinical impression clarified or altered in about a third. So this meant that they were sent in for something like a vitreous hemorrhage and I found a detached retina under the hemorrhage or a tumor or something. So I changed the diagnosis or I added to it. Correct diagnosis in five. So this is kind of just an overview of an ultrasound practice where I see a thousand patients and kind of breaks down. So the value of it is, again, a third of these patients, refining things that the doctor didn't know was there to start with. So that's pretty important. And again, with the patients with opaque media, for a methodology not suspected by the referring doctor. Okay, visible fundus lesions, again, we're not that great. You can sort of tell sometimes looking at a lesion what you think it is. But two large past studies, AFIP, Armed Forces Institute of Pathology back in the six years and seven days, two different separate studies looked at this. And those days, nucleation was very common for eyes with tumors that was kind of standard to cure. You saw a tumor in the eye and often they're nucleated within a week or so. Radiation plaques weren't really being used yet or anything. So a new patient was pretty common. So a lot of eyes were sent to the pathology people. By looking at all these eyes, they found that 20% of the eyes had false positive diagnosis of melanoma. So that means 20% of eyes were taken out that didn't have to be there by nine lesions, often 20, 20 eyes or so. So that's not great figures. And so if you look at a lesion, it's hard to tell sometimes. This, in fact, was a nebis of some melanoma, just to look, just the criteria we go by. Sometimes it's not that obvious by looking at them. Biometry actually lengths, I mentioned that. So we use immersion techniques to do the biometry. We have to do that to be able to see the front structures of the eye. So if you put the floor right against the cornea, give it as information, you would have the cornea buried in there. You'd have the anterior chamber of the anterior lens. So you wouldn't be able to see that, be able to stand the probe back. You have to use some kind of a look at interface to put the probe in. And you get the spike from the probe itself. You get the, going through the, the splitle shell here. Then you get the cornea right there, anterior chamber, lens, anterior postural lens, vitreous and retina. So you can actually break it down and you can then use that to measure, electronic calipers to measure, breath to back of eye. And again, about 20% of the cases here, the techs tell me, they have to end up doing immersion ultrasound. As you're in doctor structures, I mentioned this following tumor for growth. So here's a little small melanoma. So here is a lesion. About a year later, it looked kind of the same on B-scan. Had already seemed to change a lot. But the A-scan, the actual thickness of it had changed slightly. But a big difference was reflectivity patterns. Here it is initially kind of high, probably like a nebis. It's getting lower here. It's getting lower reflectivity, more regular. That's conversion from the nebis to melanoma. I see this a number of times. You follow a lesion. That's what we do ultrasound on nevi, because some of these will start to change. You want to get baseline measurements, then follow over time and see if it's changing. Again, side wasn't all that much different, but reflectivity internally was. So that really clued us. This was starting to convert. Any ideas of the conversion rate of nevi to melanoma? So nevi and the population, rough guess how many people have nevi? Five percent higher. The numbers are kind of varied. It used to be six percent. Now kind of the current literature says about eight. So in this group, probably somebody had the nevus in there with you guys. So about eight percent, you do? Rachel likes pointy too. Anyway, so about eight percent of have nevi and at that group, rough guess how many can burn to melanomas over time? One. About one in 10,000. So what's that, point zero zero zero one? So it's pretty pretty unlikely, but it can happen. So again, that's what we follow, but the odds of that are not very high, but still it can happen. So vitro retinopathology, very important for vitro tumors you can't see inside the eye. So the classic kind of optic octave disc with a high reflective membrane of the optic disc, that's consistent with the tetra retina. You always suspect that vitro's membrane sometimes will do that, so it's not a hundred percent. But the ACE scan is helpful in these cases if you're not quite sure. You see a membrane on B scan, you can do the A scan and you look for a high spike, smooth reflection. That's pretty suggestive of the tetra retina. If it doesn't get that high, if it's just kind of down here somewhere, more likely a vitro's membrane. So I use that a lot in these kind of hard cases. You're not quite sure if it's a vitro's membrane versus a tetra retina. I'll show some videos. These are little video clips of just showing some motions and kinetics. So I'll show that. I got a separate little video clip I'll show you. This is showing just the motion of different membranes inside the eye. So this is a case, there's a small tumor here, don't worry about that, it's more, I'm trying to show the motion. This is the vitro's membrane over here. So when you see the kinetics of the vitro, you see a lot of fluidity. It's kind of just flowing as the eye moves, that's consistent with hemorrhage. This is another tumor, look over that as a membrane. This is a detached retina. There's kind of a stiff motion as the eye moves. It's sort of just stiff. It's not a real fluid, underlating kind of motion. Other one, this is a small tumor, but this again is the retina over a very stiff motion compared to vitreous, a lot of fluidity. So I'll show that in a minute here. And this is the same thing again here. So kinetics are important, showing how motion is. I watch, I do that a lot when I do the V scan especially. It's just to see how things move and that kind of helps sort out membrane versus other things. Yes, see a lot of these. You know, you have the patient with a funny looking disc. Two ways to go. They're here with the essential neurologist and they get MRI, CT, spinal tap, angiogram, everything you think of. $25,000 workout versus doing ultrasound a couple hundred bucks, two minutes. You see this, the optic disc bruising, very common. It can be deceiving. Sometimes the neurologist kind of scratch your head as I look. This is the case here, showing this disc, funny looking disc. This is pretty suggestive of bruising. You'd be looking at this very carefully with a 90 diopter. You can see kind of bumpy, lumpy, kind of glistening areas. So that you would think bruising in that situation, which is verified on the ultrasound that it was. But here's not so obvious. That's pretty scary looking. It's not like papillodema. You saw that kind of, you know, some vascular congestion, kind of very prone to optic disc. But yeah, this is a large, very bruising. The same thing here, kind of looks like papillodema, you know, big optic nerve bruising. So optic disc bruising, any guesses on the frequency of these? How many people in the population have optic disc bruising? Tim? Okay. The lower? Three. Yeah, two to three. That's sort of based on past studies. So genetics of it, genetically inherited trait, recessive, dominant. It's excellent. Probably dominant with mixed penetrance. So we've done some genetic study. We used to haul our group out to family reunions, Dr. Katz and I, and take our ultrasound blood and have potato salad with the cousins and the uncles and the aunts. Take everybody we found. Usually in a family, if you find somebody with it, there's a pretty good chance of finding somebody somewhere that has it, not always parents or direct relatives, but an uncle or a cousin, somebody has it. So we haven't found the gene yet. We're still looking for it. Just like Niko's looking. I guess you're looking for your gene? You gave the talk of residence to you, huh? Maybe that was? No, that's right. That's right. We're doing the same thing to gene hunters. I think we found a family a month ago. It's a mother and both kids have it. That's got to be a genius. I'm glad about it and we're going to look for it. So this is a case of wasn't gruesome. This had kind of a swollen look and nerve. And then here's the ultrasound showing the kind of the elevation, but there wasn't a brightness like that. Bright lump, you see, like a calcified gruesome. Here's the ace can to be helpful. I usually do ace can to most of these patients just to see, but here's the object nerve from there to there. So that's the one sheath. That's one sheath. And here, if you do what's called a 30 degree test, you imagine the patient looking straight ahead, you have an abduct the eye 30 degrees. And the theory is that you abduct the eye, you sort of squish the nerve, you sort of stretch it and then first fluid sort of push the fluid back. So the nerve thins. So the concept is you get a thinner nerve by doing this test. That's called the 30 degree test. So looking straight ahead, here was the nerve 30 degree test. Here you can see it's thinner reduced to about 50%. That's a positive test. So if I see that, that means there's fluid around the nerve, increased optic-nurse fluid, which goes along with increased intranagranial pressure. So a pseudo tumor cerebrale, things like that. Whereas a solid lesion, like a lioma, an angioma, would not do that. The nerve would not thin as you as you move it. It would be just a solid lesion. So the nerve is stayed the same. So it kind of differentiates fluid around the nerve versus my consumer of the nerve. So that's an important test to know about. Case here, this is a central red artery occlusion to the cherry red spot. It's kind of called box cornering. You actually watch the pumping of blood vessels inside the artery. You ever seen that anybody? You ever seen central red artery occlusion with box cornering? Okay. And the fluorescence shows that you see this kind of clumps of red cells as they kind of pump along because they're just stagnant moving. This is a patient that we saw, like a late Friday night gentleman that had sudden loss of vision. And so again, I mentioned this, I think it might talk, ran as it said. You can see kind of a brightness here. That's actually an embolus. So you can actually, about a third of these patients with central artery occlusions, you can find an embolus on the B scan. So it's easy to do. You just put the pro up there and look real quickly. The nerve takes 10 seconds. If you see that, you know it's symbolic. That's important. You get a older patient, sudden loss of vision. That could be castle arthritis. So how do you know the difference? So this can help you along with Mike and I study on another way to look at it. This is a drool. It shows the drools and they're different. They're more anterior. They're anterior. It's the lamina crevosa, whereas emboli are posterior to it. So it's further back. So it's not the same as a drool. But if you see that, you know it's symbolic. You got your job is to find the source of the emboli, but it really helps. You know that Friday night special where you don't know what's going on, the redirection of what to do. This patient had to blockage the crevosa with emboli coming up to the central artery. This is a robot called the Doppler, which I use some. Again, we're doing the study with temporary arteries with Mike and I. This is a machine. We don't have one here, but we have one in the vascular lab. You kind of borrow theirs and push it back and forth. The Doppler concept is based on movement. So it's so ultrasound, but it's a moving thing. So as the thing moves, it changes its frequency. You ever sit on a train track and heard the train coming towards you and hear the whistle and as it goes away, it just changes pitch or changes frequency. So that's the Doppler concept. Used in space to help with the whole concept of galaxies, big bang, receding promise of blue shift versus red shift. So you can use it for different things, blood flow to the globe, emboli detection, as I mentioned, orbital venous flow, tumor vascular turn of these things. This issue is a normal Doppler, so here's the globe up here. So you're behind the globe here, the optic herb shot would be kind of in here, ophthalmic artery, and then the feeder into the central retina artery, which you kind of get a part of it here, then more of it here. So central retina artery, central retina vein, use of the celery artery, poultry celery, artery arteries. This is a normal color Doppler, how it looks. Obviously, all the blood flow patterns. And this is like a hemi occlusion, had a hemi-central artery occlusion. So you can see this part is just dead, just blood flow is gone, whereas this part is still being vascularized. Yeah. With that, do you know that you're not just catching things? How many of you have knocked your nerve shadow? Yeah, I got it, nerve shadow helps you, you know, it kind of gives you orientation. Yeah. And then different views, that's a good question. If ever you see something to verify, you have to have just different views of it, just sort of move the probe different directions and make sure it's the same. I've seen, I reviewed papers that they had to reason, they didn't, because they were just looking in one section. It kind of caught an artifact, and if you move the probe differently, it goes away. So for us Jews and don't. This is a Janus Larderitis, and they're just devastating, that's why they're so bad. You lose vision from Janus Larderitis. They're, they're to gone, they're just, they wipe out everything, the blood flow is just gone, hemic artery, centroid artery. So it's just a dead orbit. So, you know, it's just, that's why it's so terrible to get Janus Larderitis, and then the danger is losing the vision on the other eye. 40% will go blind on the other eye within a couple weeks. So that's why it's so critical to make the diagnosis and institute proper therapy. So I need an embolol, an emboli, so you can see them, they're further back. So here's the optic disc up here. This is back behind it, behind the lamina. So there's a little brightness that consists of emboli. Over the venous flow, this is normal. It's a paraphthalmic vein. So it's kind of thin, just kind of bluish. So in the Doppler, this is programmed to show venous flow as blue, and arterial flow as red, just because that's what we're used to, we think of arteries as red, venous and blue. This is the case, came in, kind of, a lot of vascular congestion, these tortuous vessels. Patient kind of had aching around the eye, kind of at night, and they were sleeping there, kind of a wish in their head, so they're kind of a classic, you know, sort of think of the fistula. This confirms it, this is the vein, very dilated, arterialized. The flow is not venous, it's not blue, it's red, because the arterial flow is going through the vein, this reverse flow. So that's where the pressure builds up, and they're so congestive. So this shows it pretty rapidly. Humor vasculature, you can look at tumors inside vessels and the temporal artery. So again, from our study, showing kind of a normal, this is the temporal artery, this is a long section, this is a cross section, and so the artery wall, compared to here, see this kind of illusancy around the wall, that's because of edema, inflammation, so you get this called halo sign, where it's the halo around the, instead of being right around it, it's dark, echolusancy, consistent with that. So that's what we're looking at right now, we appreciate the patients, we're seeing patients probably, got about one nine or ten now, I think we're up to this. Yeah, so I appreciate the referrals. This is a melanoma, again showing vessels inside that, I can actually see vasculature without Doppler on my melanomas, I can see real-time, it's a real-time exam, so I can actually see the flow, and I'll try to show that to you here in a second. And then the high frequency, in my days at UCLA, we used to do this, we draped the page with all the drapes of the water, give them a scuba mask to snorkel, because I hated it because of the water, that's how we deal with these immersion scams. Now we're a lot gentler and kindler with these immersion shells and things that we use just to make it easier. So 20 megahertz, this is a case of a diktioma, I bet you looked at the female in a girl, so you had this lesion kind of up here on the contact, B-scans, kind of real peripheral, hard to see it, with an immersion scan, so here's the shell up here, cornea is up here, here's iris, that's a lesion right behind the iris, kind of in the silvery body, so you can just see it a lot better by doing an immersion scan, vacuum the probe off and seeing the end in the front of the eye. 15 megahertz, that's kind of what we use routinely to see real high frequency, you can see the cornea, iris, anterior lens, you see the zonules here, silvery body, so it just shows incredible anatomy. Here's the cysts, these are pretty common, we see a lot of, you know, we see an iris kind of bulging, it's always good to do an ultrasound if you're sure, it's not a tumor, you can see the big cyst here, not a small part of one here, so these are pretty common. Here's the case we saw with Dr. Vitaly a while ago, so here's a patient had kind of chynauric surgery, kind of chronic recurrent end of uveitis, they kind of get flare up, they treat it with steroids, kind of quiet down over about a year, this kind of kept coming, so I find the uvm, so the cornea is up here, here's the iris, here's the IOL, you see this clump of stuff on the IOL, actually the bacteria are growing, there's a vegetation on the IOL, so this is P. acne, it's actually showing on the IOL, so this patient had to have the lens removed, the caps removed, all that just to clear it out, freedom. Another case here, this is an ux syndrome, so uveitis, glaucoma, hyfema, so here's the iris, here's the IOL haptic, here's the optic, and here's the haptic, and as you follow it out, it actually gets right against the iris and rubs against it, so you get this chronic irritation called the ux syndrome. This shows you can see different things in the atrial segment, even with the 10MHz Pro, if you don't have a high frequency uvm, you can still use a 10MHz standard Pro, so here's a case of an iris cyst, right there with 10MHz, here's a 20, here's a 50, so you can see it better obviously with higher resolution, but you can still see it with a lower resolution, so you still don't have access to it, you can still use that to look down to your segment stuff with immersion techniques. Kind of comparing OCT to uvm, OCT is great in the anterior chamber, but it's not so great behind the iris, it's a light pace, you can't get it right behind the iris, so here's a patient with a tumor here, kind of a bulge in the iris on OCT, but you can define it much better with the uvm, so these are all examples of that just showing just down the board here, the uvm is superior to that area, so everybody, so if there's anything behind the iris in the anterior segment, you're better to get a uvm than an OCT. More examples here. Okay, so that is a sort of an overview, ultra-sing on, so there's a video, so it doesn't crash like very well, the PEC. Well, it might be just this little security setting. Okay, there you go. So again, this shows kinetics, this is a vitreous hemorrhage, you can see the fluidity of it here, and that could be a detached retina there, but so mobile, so fluid and re-attached to the optic disc, you see how it moves, how it flows, so that's an example showing the kinetics. The very, very corner, the red one. The top right here. This shows vascularity, so this is a melanoma here, but you see that little flicker inside of it, this is a rapid little flicker, that blood flow, so if you see that, you're always looking for that, whenever I see a tumor, because a lot of tumors don't have that, hemangioma is done at all because they're a slow venous stagnant flow, a lot of things are done. Yeah, basically, yeah, it's just not that fast arterial flow, and the same thing was like a capillary hemangioma and a baby with heavies, you know, there's bumps on the rounder eyelids and things, you can see the blood flow with you, so it's very helpful to see that, see that rapid flicker. You don't see that, appreciate the motion. A-scan can show it too, so here's the lesion here, and see that inside of it, everything's kind of moving, but there's such a real rapid independent motion inside that thing, which A-scan can also demonstrate the vascularity, but I think B-scan is better, it's easier to see it. It's another melanoma kind of mushroom, again, with rapid flickers inside of it. Here's that case I'm trying to show, here's a melanoma, but you can see the blood over it, so here's sub-high-loan hemorrhage. As the eye moves, it just kind of swishes, it just sort of flows really easily compared to the stiff motion of a detachment. Here's the tumor, but that's the membrane over, that's the detachment. See how stiff it is? This is not an undulated, really easy motion. That was thought to be the tumor, first looked at it, right behind you, go across the back of your eye. So it was a distalable, a true counteractor distalator. I think there's probably any one more vitreous, again, showing the vitreous, the hemorrhage and then the vitreous, the posterior hyaline phase, just a lot of fluidity. Okay, so that's it. Ultra-Sanctiated. Thank you very much for your welcome. I'm happy to spend time with you guys and everyone.