 All right, we're going to take off and descend into the stratosphere and ultrasound and come back down again I hope. So when I was an intern a long time ago, this is what we had for imaging. So we literally didn't have CTs MRI, so you get a plain film x-ray, and if you're lucky it showed something good for bone, but anything soft tissue, except for the orbit, it just weren't going to see much. Early generation CT scan, just really, you know, better than x-rays, but still really hard to tell detail, just not that refined. Ultrasound at that time was kind of a standard of care, certainly for the globe still is, but the orbit too, it was really best we had to look at orbital soft tissue, especially the hands here two-thirds of the orbit, but then this came along. So modern generation CT MRI scanning, the detail, incredible muscles, nerves, everything. So who needs ultrasound, I took the orbit, but there still is a place for it, which I'll try to show you. So basically I used two modalities, one's the V-stand, which you're kind of familiar with, and it makes sense, it looks like shapes of things, if you take a cross-section of the eye, a thermal detachment with the T-sign here, with the retina here, and fibrous membranes connecting the leaves together anteriorly, or a big melanoma mushrooming, so really very good, and we still use that all the time for ocular processes. But the orbit is a different area, and the A-scan is where I really use that a lot, and evenly, you know, nothing about A-scan, you can see the difference, you can look at the normal orbit pattern here with the A-scan, and hemangioma, lymphoma, meningioma. So not too much what they actually represent right now, but it's more the difference, you can see the distinction between the different tissues, and there's a very direct tissue correlation between A-scan and pathology, so, and that still is a case of orbit illusions and also ocular illusions, so there's still a very important role for that. So basic principles, sound reflection from interfaces, so sound goes out, hits things, and bounces back again. We're not the first to think about this a long time ago when their nature did, with bats, and that's how they fly around, so they emit sound at high frequency, get even small insects, and they can localize them and attack them and eat them, so ultrasound is a very old technology. Ultrasound is defined as sound above the range of human hearing, so we can hear in this range about the 20-deal hole killer range that our ability to hear things, dogs can hear up to 40, whales, dolphins, 70, and bats, 150, so we're still far below what we use for a diagnostic ultrasound, or in the megahertz level, the standard probes that I use are the 8 to 10, we go up to 50 or 60 with UBM, so high frequency, so medical ultrasound, abdominal, in this range of frequency here, up down like up to 60 as I mentioned, and we can do that because of the eye, the way it's structured, first of all it's kind of a thin wall, the wall of the square is not very thick, so you can penetrate rather easily compared to the abdominal tissue, other parts of the body which are thicker, and also the eye is full of fluid, so ultrasound travels rather way through fluid-filled structures, so you can use that in the eye and get away with real high frequencies. The higher the frequency you get, the better resolution you get, but also the less penetration you get, so to go already deeply in tissues, you really can't use these high frequencies, that's why UBM can use real high frequencies, if you don't go very far back in the eye, you get the initial anterior few millimeters of the eye before you lose sound energy. Sound weight velocities, how fast does ultrasound travel? Well with Dempster, the media, the faster it travels, so going through water, it's about 1480, aqueous vitreous, 1532, and that's where the standard velocity is set on our biometrics and instruments we use for ultrasound, soft tissue, crystalline land and bone, so the denser the tissue, the faster the sound velocity. I did a study a couple years ago on a thousand patients just to look at clinical correlation and these are the results of the study which I'll address a little bit further, but basically the impression of the referring doctor, he said this is probably a tumor, probably that NUVIS or melanoma was confirmed in about 400 of these patients, no findings in 279, clinical impression, halted or clarified in about a third of them, an incorrect diagnosis in five, so that's the results of a study that I did. So the basic principles again, sound reflection, traditional interfaces, B scan, brightness amplitude, A scan is time amplitude, I'll explain what that means a bit more, then UBM ultrasound biomarkeroscopy with high frequency immersion ultrasound. So the one equation for physics on the early Monday morning while you still have to sleep, acoustic impedance is equal to sound velocity times density, and this is the basic principle behind ultrasound. So the greater the difference of things between two media, the higher the A scan spike or the brighter the B scan image, so this is important, so ultrasound works by reflection from tissue interfaces, and the greater the difference between those interfaces, the sound velocity and density, the higher the spike on the A scan or the brighter the B scan pixel. An example here, this is a cordial hemangiooma, so there's the tissue region here, and this is a clinical photo of it, but these are very high reflective because of a lot of interfaces, it's kind of like a honeycomb, as the sound beam goes through this, it hits a septa, spikes up, it's a blood like, it goes down, septa up, down, so this constant interface sound velocity difference. So as you see going through the eye here, here's the A scan, so here's the vitreous. The vitreous is homogeneous, usually it's just a consistent media, so the sound just goes through it without much reflection, a little blip here or something, but as you hit the fundage, you suddenly change this impedance quality. You go from a sound velocity or one velocity to another, and you get a high spike from that retina, and once you're in the orbit, you get a lot of spikes because there's a lot of stuff in the orbit, you get blood vessels, muscles, septa, bat, so you get a lot of interfaces to reflect sound. The core led to the B scan is darkness, so again, there's not much reflection inside the eye, so it's dark, here's the vitreous cavity, corresponding to a flat line on the A scan, and once you hit something, you start getting reflection of sound. So the A scan displays that as spikes, the B scan has bright dots. So this Emanjohoma is quite hard to reflect it because there's a lot of interfaces, you get a bright lesion on the B scan and a high reflective on the A scan, so the actual lesion is from there to there. So that's all inside the lesion, and it's quite hard to reflect it because of the reflection of the tissue. And this is important because this is really very diagnostic, I can look at this until almost all the time, that's what it is, it's an Emanjohoma and not a melanoma, not something else, so there's a real good correlation to pathology. So B scan brightness amplitude, so the B scan probe looks like this, and there's a marker on it, and that marker is important because that tells you which way the transducer is oscillating, so it kind of oscillates in one plane, and that where you point the marker tells you which way it's oscillating, and that's important for localization of structures, and I'll discuss that a bit more. So for B scan, if you take off the tip, you see this transducer, and this is going to go back and forth about 15 to 20 seconds times a second, so you get this scanning of the eye, and as you point, you go across the eye, you look at different quadrants of it, each scan gets about 60 degrees of the surface of the inside of the eye, so you can go around the eye and look at the entire eye in about six different sections to get through the 60 degrees, and this is what a B scan picture looks like. Here's an axial scan going with the probe out against the cornea, and this is called the dead zone. When you put the probe against the eye, you lose information right in this area here because that's kind of where the sound is reflecting and being picked up by the same transducer who picks it up and sends the sound, so it's called the dead zone, so you really can't get much information there. Let's go and use immersion techniques to back the probe off to be able to see structures in that dead zone area, so when you're right against the eye, right in here is the cornea somewhere, the entire chamber is in there, front of the lens, so you really don't get much information. Once you get past that, then you're inside the eye here, so here's iris, here's the bacterial lens here, and going through the eye here, here's the optic nerve, so this is a B scan picture. Examination techniques, as I mentioned, the marker on the probe is important, and that tells you this way that the beam is rotating, the transducer is rotating, so by definition, when you have the marker this way, it's kind of in the plane of the slide here, this is parallel to the limbus, so here's a limbus here, and you're going back and forth in the plane of the picture, that's called a transversed position, so when you're parallel to the limbus wherever you are in the limbus, if you're parallel to it, that's called transverse. If you're perpendicular, so if you rotate it this way, so here's a marker up here, and you're going this way with the transducer, that's called a longitudinal position, so here's a limbus here, and you're perpendicular to it, so longitudinal transverse are two major probe positions that we use. And that's important because when you look at tumors and things, you want to be able to characterize the different dimensions of the tumor, and that really translates clinically to practical use, because we do plaques all the time, we plaque radioactive plaques right by the iodine for melanomas, you want to be able to tell the maker of the plaque what size to make the plaque when you put it on the eye to kill the tumor, so those dimensions are important, that's the ones that I do, and I measure these for the retina guys. Here's an axial scan right against the cornea, you're going through the eye here, axial scan, I don't like quite as much, because a couple reasons, first of all, patients are more skrimmished to put the fur right directly on the eye, they're more comfortable putting off to the side, and also you lose information as you go through the lens, you get some sound absorption, you don't get as much information from the sound by going directly, except by bypassing the lens, so that's why I prefer other positions besides axial, but I use this occasionally for certain things. So here's an example again, so putting the probe here, this is an axial view, going through the eye here, again, here's the back of the lens, close to your lens, you're losing information up in this area of the cornea, enter your chamber, and here's a small tumor, as you can see this, this would be superior to the optic nerve, or the optic nerve shadow, and here's a lesion just above that you're capturing, but it's kind of attenuated, you're losing information from the sound, because it's being absorbed by the lens, so that's why axial isn't the perfect view for this. Again, so transverse, so again, you're parallel to the limbus, going this way with the beam, so sweeping across the eye in this direction, kind of an anterior-posture direction, and here's the longitudinal view, you're going superior to the inferior, so you've got a lesion in this area, you're going to scan it in both directions, this way here, and this way here, the two major ways, you can also do obliquely in different views, but these are the two major that we use to characterize lesions to tell you information for the plaque making. So here's a transverse view, again, so you're sweeping the plane of the slide, here's the lesion here, so you go across the lesion this way, and then it displays it on this way. And the way the software is made of these machines, it always displays where the marker is on the probe, that's displayed as up on the screen. So wherever you point your marker, that will just slide us up, so if you're, in this case, the marker is towards us here, and so the lesion is here, so this is, it just rotates it, and you have to kind of think three-dimensionally when it shows that the lesion is always up, so you can turn the marker, and thoroughly, you're going to see the lesion on the screen as it's being up. So you have to think in those terms. Longitude will be scanned, again, here you're going perpendicular to the limb, so you're right here, and you're sweeping across the lesion this way, showing the lesion in this direction here. So those two views, the lesion, you get a transverse view, and a perpendicular view, longitudinal view, and it shows it here clinically. So this will be what kind of a scan here, with the probe here, markers up here, longitudinal or transverse, transverse goes parallel to the limb, right. And here's the lesion here, we're showing this lesion at three o'clock, so you're going across the eye, so here's the probes over here, going through the vitreous, the lesion is here nasally, so you display it here as the lesion. It's pretty single, it's right almost directly at three o'clock, so the lesion just pops up there right in the plane of the probe, and this is longitudinal, because again, you're perpendicular, the marker is this way, you're perpendicular to the limb, showing the lesion in this direction. So those two views of the lesion, this is at three o'clock, and you kind of put those together, so again, you've done your transverse view here, sweeping this way across the lesion, you've done longitudinal this way, this way across the lesion, and you show those two views of lesion, and you kind of get a good characterization of the base of the lesion, how white it is. For thickness measurements, you can use B-scan for that, but as always, it's not real accurate, because you try to measure from the tip there, so where is this coroid in there, you kind of get this shadowing effect from lesions, so A-scan is actually more accurate to measure, so I usually use both, I'll do an A-scan thickness measurement, and I'll do a B-scan dimensional measurement, so those are the ones that I usually do. And I mentioned A-scan, so again, the probe is here against the sclera, the dead zone here just like the B-scan, this information here is lost, because you're right against the eye, so about three to five millimeters here, you're in the sclera here, you're in the harsh plana and vitreous area, so you look at the information, doesn't really show you anything. You go across the vitreous cavity, and the vitreous is low baseline, because there's no reflection inside vitreous normally unless you have something in the vitreous. You hit the lesion, you get a difference in impedance going across the sample loss of the changes, you get a high spike from the surface of the tumor, and once you're inside, it depends on the structure of the lesion, so based on pathology, it's with a lot of interfaces, how dense they are, what side, portion of the size they are, all that information is inside, so that really helps characterize lesions. When you hit the back of the eye here, the sclera, you're back in the orbit, so the actual lesion is from there to there. It shows the distinction here. Here's a melanoma, rather densely cellular population of cells, few blood vessels, a few interfaces, they're really pretty homogeneous tissue, just like the vitreous, so if you go to the vitreous here, you hit the surface of the tumor right there, and then you're inside the lesion. This is quite low, here's the sclera, here's the tumor, so there's a lesion from there to there, you're back in the orbit over here, but that reflectivity is usually quite low, because these are really homogeneous dense lesions. Most melanomas are in this range from about here up to about here, and that really helps. That reflectivity height tells you a lot about the lesion, also regularity, how regular the structure is, and also vascularity, which I'll show you in a couple minutes, a picture of that or of the view. So that's the A scan of this lesion, and again the B scan of the vitreous here, here's the actual lesion, this little mound raising up here, they're often kind of mushroomy appearances, they break through a bunch of membrane, they'll kind of pop through and have a narrow neck, it's called a color button or mushroom effect, the redness being pushed off right here, but you can see the correlation on the A and the B scan. And the A scan probe looks like this, kind of like a pencil thinner than the B scan probe, and there's no mark on this probe, it doesn't really matter, the sound beam is generated by the transducer in all directions, it doesn't sweep like the B scan probe does, so there's no marker of this orientation, it's just a single sound beam coming out in a way. Now there's often a source of confusion about A scan, this is often even the reps, if you go to the academy or through the displays, they often will tell you our instrument has a B scan too. Well in their mind, A scan is the same as biometry, biometry probes are an A scan modality, but I use a separate dedicated diagnostic A scan probe, and it's really important because you can't do what I do with tumors and things with a biometry A scan probe, it doesn't work. I can do biometry with this probe, I can do it all the time, I do convergent technique, or I can use this A scan to actually measure the length of the eyes, I do that, but you can't go the other way and take a biometry A scan probe, which most machines come with, and do tumor work and things like that for quantitation, so it's different reflection of sound, it's different lens imaging, focusing things like that, so that's the difference, so it's important to know that, so if you have a biomachine and trying to get an A scan, reps often confuse that. It's a separate probe and there's also a lot of B scan units have called a vector A scan, if you look at turn the B scan on, at the bottom there's kind of this A scan signal, I rarely ever use that, sometimes I use it for like a staff aloma, trying to line up the vector with the staff aloma to do a measurement, but really otherwise it's not useful. The information from there just doesn't correlate to what we get with standardized A scans, so it's got to be a separate A scan probe, a separate software, and that adds cost, that's more expensive, but really to do complete ultrasound, that's what I need to do. We have those machines here at Marana, so we use it all the time, we're trying to get one for the VA on these days. So returning echoes, so what influences what the ultrasound looks like on the display, absorption of sound, we talked about that, so I go through the lens, that's again the way axials seem to be good, they can be absorbed by the blood of tissue, reflection of sounds, just like light, the same optic equations apply to sound waves, so snails, a lot of things like that, reflection, angle of incidence, angle of direction, interfaces, size, smoothness, these all influence what the sound wave looks like when you get reflections on the B scan. Being perpendicular is really important when you do biometry, again we're doing more and more IOL masters, so probably don't think about these things, but you're still going to have occasions to do ultrasound, like the techs here, the LASA hers about 10% or so, probably a little better with modern units, but they still need to do immersion and A scan on cataract patients, real dense cataracts, dense PSEs, IOL masters just doesn't work as well, they can't get readings, so we still use ultrasound a lot, and being perpendicular is really important to do biometry, but also to measure lesions also, so here's a lesion, you're going through the vitreous here, here's the first surface of the lesion, here's a flare, also the actual lesion is right in there, and if you're not perpendicular, this is the same lesion just by angling the probes, I wasn't perpendicular, I get this, so here's the surface of the lesion, but inside reflectivity patterns are different, you hear you call this kind of a medium to low reflection, here it looks like it's higher, so that can deceive you, so by not being perpendicular, you can get spurious both measurements of things, and also internal structure is skewed by that, so really being perpendicular is important, how do you know you're perpendicular, well you get a real high spike, when it's real high and tall like that, as tall as the initial spike, that means you're perpendicular by definition, you start to angle the probe away from that, this kind of drops off, so you're less perpendicular, you don't get as high as a nice rising spike there, so that's the difference. So indications for ultrasound, opaque media, obviously you can't see inside the eye, that's the reason to do ultrasound, medical legally, there's been a number of cases of dense cataract removed, and they found a tumor hiding behind the cataract, that's not good to have that happen, in a sense the patient's not happy because they don't have great vision, there's also probably some risk of doing surgery in an eye with a tumor, that you might disseminate tumors, so you need to know beforehand what's behind the cataract, so opaque media, visible fundus lesions, you can see the lesion, accuracy rate, to know what they actually are, even with pretty good people that do a lot of this, it's probably 80% in that range to actually tell what it is by looking at it, so ultrasound really enhances that ability to diagnose, biometry, mentioned axolength, measurement of structures inside the eye, tumors and things, which are run in pathology and optical abnormalities, it's kind of the major things that I think ultrasound is useful for, and again there's a niche here with with retina issues and things like that, with the MRI CT scanning, you still can do a lot with ultrasound to fill those gaps in them, so opaque media, so again the dense cataracts, one of the studies years ago stated that patients with a blind painful eye, for whatever reason, about 10% will harbor unsuspected melanomas, so it's pretty high, so you have to always be thinking about, now if you follow the patient, so you're a patient, you watched him as a cataract developed and grew, the odds of that are pretty small, but have a patient walk in the clinic the first time, no history, no old trauma, whatever's gone on, and their eye hurts and is opaque, that has a pretty good chance of having something behind that, so definitely ultrasound's indicated, so the patients that I saw in the study that I mentioned, about a third have pathology not suspected by the doctor, so they sent me with the dense cataract or robotic hornea, whatever, I found something inside the eye that had a real life with there, so whether it's vitric tamarace, detach retina, whether it's a tumor, those things, so I guess important, at least a third of patients are going to have something unsuspected when they walk in the door, have opaque media, visible fundus lesions, differentiation, so to look at something to tell what it is, really even if you're good and do a lot of this, you can still be deceived by these lesions, and there were two large past studies, one back in the 60s by Fond and Ferry out of AFIP, they looked at all the eye-submitted that nucleated, in those days nucleation was really more common, I trained at UCLA, patients walked in the door with a suspected melanoma, even a small one, they were often nucleated within the same week, almost like a commercial procedure, and unfortunately about a fifth of these had the nine lesions, they had 20-20 visions, and I'm not great to have that kind of result, so this past study verified that, the AFIP looked at all these eyes and nucleated in the 60s, and that was with techniques of examination at that time, indirect tophthalmoscopy, fluorescent angiography, and they found that about a fifth had faults positive, and that was repeated in the 70s, the same study looked at, again, eyes of AFIP, they found the same result, 20%, so ultrasound radius changed that equation, we're up in the 99.7% accuracy rate with the collaborative octamermal study that was done a few years ago, so it's changed that, so to look at a lesion, you know, is that a nevus, is that a melanoma, you know, what's what, you really just by looking it's really hard to tell, unless you do ultrasound, so biometry, axolength, I mentioned, we use immersion techniques where we put a shell between the lips and stand the probe back, and that way you don't have this dead zone I mentioned, so here's actually the dead zone here, from the probe itself, the physics of the probe, reverberation, you get this dead zone, but then once you're past that, you're going through the shell here, hitting the cornea, so here's the cornea spike, you're going through the entry chamber here, here's enter, lands, posterior, lands, vitrious, and rett, as you can separate out the different tissues and distinguish them, begin with immersion, ultrasound, majoring lesions, here's a lesion I saw years ago, there's a B scan of those little lip right here, this will look like a probably nevus, nevoma sort of thing, and over time it didn't seem to change that much, it looked about the same as far as the height, and the A scan right here looked about the same as far as the thickness, but you actually see change of reflectivity, you can see it pretty high here, see how it's starting to get lower here, it will change to getting lower, it usually means it's getting more homogeneous, it's going from a nevus, nevoma situation to more of a melanoma, as they get more homogeneous, denser cells, reflectivity starts to just get lower, like we talked about before, the denser the restructure is, the more homogeneous the more the flatter the ultrasound is or the lower it is, so it really helped us in this case to know it was actually, it looked like about the same size, it was actually changing pathology characteristics and getting more aggressive, so we watched them more carefully and actually grew more, had to have the inuclated after, I mean not inuclated, but plaque, radiation plaque. Dermatopathology, so classic funnel detachment, seropidinous structure, where it can be fixed folds or more fluid folds, and then the A scan shows a real high spike, and sometimes it's hard to tell on B scan, you see these membranes, especially on vitreous hemorrhage, diabetics, trauma, there's a lot going on inside the eye, you know, is it retina, is it not, but the A scan can be helpful, because if you see a real high spike on A scan, it usually is retina, and even though it's a dense vitreous membrane, you won't get that high, as you scan the eye, look at different membranes, you'll see membranes in this area here, but to get that real high spike, that's very suggestive of retina, so if I see that, I lean more to work retina compared to a vitreous membrane, so it can be helpful to do the A scan, in those cases we're not sure, shows different configurations of detached retinas, there's kind of a shallow one, but it attaches the optic nerve, you always look for that, you find upon the optic nerve shadow, and then you look and see if there's an attachment of the membrane there, again that's more suspicious for retinas, not diagnostic, you can have a dense vitreous membrane that still attaches at the optic disc, but it's still, you see that with a high A scan spike, that's almost always going to be retina, there's kind of an interesting affinity pattern on the long-standing detachment with cysts inside the retinal cyst, there's kind of an interesting pattern there and this is supposed to play, but it just somehow never works on my, you know, what I'll do is I'll hook up my laptop after this and show you some of the kinetics, have it on that, it will play and then I show this, it'll actually show the movement of these different membranes, this is case of a vitreous hemorrhage and you'll see the kinetics of it versus retina detachment and other things, there's a small melanoma right here with an overlined retinal detachment and it shows the top membrane versus the more fluid membrane of a vitreous membrane and here's a melanoma, here's a retinal detachment over it and here's a vitreous hemorrhage, it's kind of fluid flow as the eye moves, I'll try to show all those to you with my laptop, and the A scan shows a high spike here and it can actually have movement of the A scan, there's a little wiggle of the A scan that goes along with the membrane versus a solid lesion, so indication, vitro and pathology, optic disandermalities, so this is a very common thing we see in clinic, you know, headaches, especially the younger person and women, teenage years, headachey and have these funny looking discs, everybody gets nervous and sends them to the neurologist, MRI, CTs, angiograms, whatever else, 25,000 over a workout, you do this in about five seconds to see the drusen popping out at you there, and sometimes it's obvious that you see the drusen just looking at the disc, you'll see these, but in fact all bodies on the surface of the disc which go on with the dense disc drusen, sometimes you're not so obvious, sometimes you're more buried, they actually look like pathodema, they can look pretty scary sometimes, but again by doing the ultrasound you can see the bright refraction from the drusen, everyone here varies looking like pathodema, but again the bright refraction, now sometimes it's not drusen, this is exactly where the A scan can be helpful, here's a swollen looking nerve here, but the B scan doesn't show any bright, in fact all bodies, you see just a normal optic disc appearance here, but you see a little bulge of it there, so this is an elevated disc, but the A scan actually quantitated it, so here is the left eye, so this was the normal eye, so right here is the surface of the optic nerve, here's the other side, so the actual nerve thickness is right there which is pretty normal, like two and a half or something, but here's a thickened optic nerve from there to there, so rather thick, as you have the patient look to the side three degrees, it actually thins out, it's called the 30 degree test, you may hear that neuro ophthalmology to go through it, and as the patient looks straight ahead you measure the nerve and you have to look 30 degrees to the side, optic the eye, and actually thin the nerve out, as the theory is as you stretch the nerve the fluid kind of distributes and thins the nerve out, watch this thing just kind of thin down as they look to the side, so it can be helpful to distinguish a swollen nerve from a pseudo pathodema situation, here is a case, so Reese, what is this, look at this patient walks in, sudden loss of vision, just right first, you got a reaction, pattern recognition, what's that? Think of an artery? Yeah, central retinal artery, check that red spot, and actually it just stands out because it's the edema around it and just makes it look more prominent, and this is a boxcarine, if he's lucky to see this fast enough, he'll see the red cells actually get this, kind of move along, just like little boxcars, just like a train going by, they're all clumped together, there's a fluorescent, the same thing, this shows a difference, so this case, I looked with the v-scan, and there was a embolus right, the optic nerve, right the central retinal artery, and this is the reason, you see the difference, the reason is more anterior, the anterior to the lamina crevosa, where this is posterior to it, so these are more posterior, so about a third of the time, one of the studies by Sear got out of wills, then about a third of these patients, the central retinal artery occlusion, blocks can have the demonstrable embolus on v-scan, so it's worth doing that, from the five o'clock Friday night situation, you're on call, you've got a v-scan handy, just look for that, if you see that, right away you know what it is, it's an embolus, causing that, this patient went on to have a CTN geography, and join the blockage here, and also right this area here, so color doppler, I do some of this, we don't really have a capacity here, it's over in the main hospital, but that's kind of our goal, these are doppler units, which is used for general ophthalmology, I mean general ultrasound, licking its vascular occlusions and things, being the thrombosis, crotted arteries, things like that, but also it can be adapted for the orbit, so the doppler effect, change in frequency of the sound wave caused by movement of the reflector, kind of stand on the train tracks, and the train comes towards you here, blows the whistle, and goes past you, you hear a different change in the pitch of the whistle, that's a doppler effect, same thing used in astronomy for the big bang theory about the blue red ship, anyway a color doppler in the orbit can be helpful for blood flow, so here's a normal color doppler, so the eyeballs up here, your optic nerves down in this area here, and this shows red is arterial flow, blue is venous flow, this is a normal looking doppler, here's the central artery over here, I'll mention the ophthalmic artery, central artery here, carotid vessels here, as you can see this distribution of blood flow, just nice and healthy looking, here's a hemorrhage inclusion, because the half is just wiped out, so here's the half is normal, this half is gone, so the blood flow is blocked by a small embolus sitting up there, here's the giant solar doritis, these just wiped out the orbit, it's just like a dead orbit, they really, every blood flow blocks, these are really just kind of, that's why they lose vision so rapidly and so profoundly, because they just have total occlusion of the blood flow to the orbit, from the giant cell, that's why they're so dangerous, you gotta read them right away, say the other time, I've not mentioned the embolus before, so here's an embolic plaque here, again behind the lamina, we're also up here, right there, over with venous flow, here's the normal subterraphthalmic vein, kind of a nice venous pattern right there as it looks apparently, here's a patient with fistula, the arterialization of the venous flow, it comes red, blueish, kind of makes this very high flow situation, we can actually measure flow with color Doppler and get the flow rate, it's a lot faster than these, tumor vascular cure, you can use this to look at tumors and look at blood flow in sight, but I don't usually do that, I just look with the A and the B scan, I can usually see kinetics with that, UBM, this is my days at UCLA, we used to do it this way, it's a different form of torture, we graved the whole phase, fill it full of water, and the patients love that, it's like they were scuba diving, put the probe in sight, some things were left, I'm working now with these little shells, I think we use covers on the tip, high immersion, you can go again, the standard probe is 10 megahertz, this is a 20 megahertz, so here's a, here's kind of a peripheral view of a tumor with the B scan, if you put immersion shell on and look at it here, you can see the tumor much better, this is aditinoma, good to make a urge to get these beautiful pictures, corn is up here, here's the iris, there's a silver body, there's the lens, you see some zonials down here, it's really eye make, pictures of the front of the eye, there's iris cis, we see these, not uncommonly, you see this multiple cis pushing the iris forward, here's a case we had years ago with Albatali, this kind of a chronic endophthalitis after a cataract surgery, several years out, kind of a chronic inflammation, kept coming back, it's about a treatment, and we looked at the UVM, and here's the IOL, you see a plaque stuck right to the IOL, this is p-acne, plaque growing there, on the surface of the limb, and here's a case of an oxyndrome, UV-itis, hythema, glaucoma, chronic inflammation after cataract surgery, here's a haptic here, if you get closer, if you follow it, it actually touches the iris and rubs on the iris and causes this chronic inflammation, so nice way to demonstrate that, case I saw not too long ago of a, during the cataract surgery, probably the tip of the fecotip, hits an instrument inside the eye, a little burst of particles blow up, when I've got stuck to the lens, right there, you see that, causing kind of a chronic inflammation, and here's a case of a cyclobalysis patient had a trauma, so their body was just detached completely and causing hypotomy, here is, here's a neurodotalysis again, showing just the breakthrough here for the eye were separated, this shows a different, same lesion here, this is a cystic lesion with a 10 megahertz standard ultrasound with immersion, here's a 20 megahertz in terms of 50, just showing the resolution we can get with these higher frequencies, studied by Shields, I copied this out of one of the journals, interesting showing the versus OCT versus UBM, OCT is great in the answer chamber, you just get great resolution, you start getting behind the iris though, you really can't see, behind the iris that's a problem with the light based technology like OCT versus ultrasound, so you see that bulge in the iris here, but here's the actual lesion behind it, here's the bulge, here's the lesion, bulge, lesion, so you just can't see these unless you do the UBM, you can see the iris bulging forward on the front surface, but you can't see what's behind it, again a number of cases, again the same thing, large lesion here, so you can just see how much you can miss without doing the UBM, so it really is important, and I thought about iris pathology, so everybody you have to do these, so we're descending now, so hopefully I can get this video to play to show you how to do kinetics. Alright, so here's a attached retina, some vitreous hemorrhage, and you can see as the eye moves, see again that stiff movement, just a stiff, it doesn't really flow freely like a vitreous membrane would, see again the stiffness of that membrane versus the fluid nature of the vitreous, you can see the difference, it attaches there at the optic disc, again here's that tumor, but this is the vitreous, this is the attached retina over it, you can see as the eye moves it just kind of that taut, like you tighten a rope or a string and twang it, whereas the vitreous stuff really is just moving very fluidly, now there here's a tumor, but there's the attached retina over it, just very stiff, just not fluid moving, here's a PVD, you can see the fluid movement of the vitreous, the posterior highlight phase, put some vitreous hemorrhage, just kind of that very flowing motion, compare that stiff movement of a retina, so kinetics are helpful, so when I see a membrane like this, and you're not sure if it's retina versus vitreous, I do a number of things, I look at reflectivity on both A and B scam, I look at movements, kinetics, I try to follow it out, because often vitreous membranes will not, they kind of disappear, as you follow them peripherally they get weaker and weaker, whereas retina detachments stay strong all the way they're periphery, so those are things that I kind of watch, the vitreous hemorrhage again, this is a dense membrane here, but it's again very fluid as the eye moves, it just kind of flows, it's not that stiff movement like a detached retina, so a posterior highlight phase can be rather dense, so they give blood deposits on them over time, it'll get kind of dense and B scam look like a detached retina, but again by the movement of the B scam kinetics, and also the A scam reflectivity, you can rule out detached retina versus vitreous hemorrhage here, this is actually a tumor, but there's blood over it, you can see the blood is kind of flowing, it kind of moves, it just kind of flows under the retina, under the detached highlight phase, I'm sorry the retina's not detached, so again kinetics are helpful, I do this a lot, look at these membranes that are deceiving, you can also actually see blood flow on the, I'll discuss this a bit more tomorrow, talking a bit more about tumors, but you can show what I've got here quickly, so the A scam I look internally, there's a lot of movement going on here, this is really this rapid flicker inside, this has to be rapid spontaneous flicker, consistent with blood flow, I'll show you one more here of the B scam, this rapid little internal flicker to see inside the lesion is this flickering, it looks like starry night, stars in the sky at night is kind of flickering, so again it's very helpful to see that with real time because not many things do that except melanomas, it's that rapid flicker inside the lesion, okay, so that's it, it's kind of an overview of what we can do with ultrasound, A B scan, Doppler, UBM, so there you go, see you tomorrow