 Well, I was talking about popular tumors today, and there's some overlap before we talked about yesterday, but some of the principles apply. So a roll of the calligraphy with eye tumors. Again, opaque media, you can't see inside the eye. There's a certain percent of people that will have hidden tumors you need to know about, differentiation of visible lesions, measurements for growth. This is really important. We do this a lot now. When I trained it was like, and I came in with a possible tumor and you took the eye out the next day, so you didn't have to measure for growth because they didn't have an eye, but now a lot of it we follow just to see if they're growing or not. Post-radiation therapy, how they look after radiation, if they're changing, and the detection of poster extensions. These are kind of the roles for ultrasound with eye tumors. So a opaque meeting we talked about yesterday. Anything that blocks your view of the fund is, I think, an indication for ultrasound, especially in a patient you don't have a history of if you followed them over years and watched your character slowly grow. That's probably not so critical, but somebody knew they haven't seen before. Is that with anything unusual, inflammation or pain or kind of a vague history? That's always a reason to do ultrasound. In the old Zimmerman's pathology series years ago, about 10% of these patients will have harbor unsuspecting ononomous with blind painful eyes. I think that still holds up. Important, too, that evisceration, which is a common way to treat blind painful eyes, because it's cosmetically better to leave the sclera intact, yet they can harbor unsuspected tumors. And you miss those if you just do regular contact poster segment B scan. You have to do an immersion technique, look at the enter segment, because .62% of these patients in this series had tumors in the enter segment that hadn't been picked up on a poster segment evaluation. So you're always going to do that as part of your look at the eye of the whole eye. Differentiation of lesions. I think we're pretty good. We look at lesions. But it's surprising how even the experts could miss lesions and misdiagnose them. So in this case here, this actually was a melanoma here, a melanotic melanoma, which a certain percent can be. This is a metastatic breast to the coroid. This was a enevas here, melanoma here. And this is a cordial hemangiooma. Right here is the hemangiooma, but here's a melanoma, a melanotic. So again, just to look at these, you really, you know, you'd be wrong at least a fifth of the time. That was the, I mentioned AFIP series twice, two decades apart. In both of those times, they were 20% wrong. It's amazingly consistent. These are things that were misdiagnosed of melanomas. And we knew this because these are eyes that were taken out. Again, in those days, enevaluation was pretty much standard of care. So these eyes are actually in the path lab. So we knew what they actually were. And suspicious new via were number one, just more than a fourth. The central disciform lesions, peripheral disciform, RP hypertrophy, hemangioomas, reactive RP hyperplasia, melanysolatomas, oral detachment, hemorrhagic rebel detachment, vitreous hemorrhage, detachment in the culture of coridus, or all other things that were misdiagnosed as melanomas. Those were things that were eyes were taken out for. Measurements for growth. It's a patient that I saw several years ago. They came in with kind of a small tumor. And it met the criteria for melanoma by ultrasound, the A-scan from here to here. It was low reflective, regular, has ambascularity. So very treatable. You could have either plucked it or just kind of watched it. He kind of gave the option to him. He liked to not treat it. He came back unfortunately two years later, instead of three months later, which we advised him. And the tumor had grown quite a bit, starting to kind of mushroom here a lot bigger by A-scan. So definitely need to be treated. And we recommended radiation plaque. And again, he had some kind of nature therapy. And he was seeing a naturopath guy. And he said, I'm going to do that instead. So he came back six months later. It was this big. So just really growing. So now you're passing point of plaque in these things. The guys here in town, Kirklandward, others, do these say that 8 millimeters is kind of their limit for plucking. Once you're passed that, you're ready to the morbidity to the eyes. Probably not worth putting a plaque on. So he was really to the point where nucleation was recommended. He still refused it. He was going to get better by taking natural therapy. And then finally came back six months later with a lot of pain in his eye and overbiotic eye. Pressure was 60. And he thought it was a sinus. He wanted a sinus medicine. I said, no, it's a tumor. It's filled your eye. He still wouldn't do anything. So he was in the pituitary six months later. So that's a natural course of this if you don't treat it. So just as a study on that, a patient refused treatment. And we watched over about a four-year period. This tumor grew from very treatable to a killing. So that's the story. Post-radiation therapy. If you treat these, so here again is a melanoma. The B-scan shows the lesion here. The A-scan here. So here's the tumor. Here's the sclera. Inside the lesion, it's low-reflective, regular. Those are criteria that we go by for diagnosing. And this is after-radiation. So what happens, they get smaller, of course. That's your hole. But also, reflectivity changes internally. As they necrose, as they become blood vessels, atrophy, different things happen. Instead of being low-reflective and regular, they become irregular-reflective, kind of high-reflective. Again, because of interface changes. Always be thinking of interfaces, pathology. The melanomas tend to be very homogeneous, very dense, which gives this low appearance. But as they become more necrotic, more interfaces are created, you get more reflectivity inside the lesion. So to follow what you want to do too, then you want to look at the size of the lesion, getting smaller, but also internal reflectivity changing. And also vascular, these things tend to be quite vascular, and they become avascular as they die. So that's what you watch for after treatment. It's interesting, too, that when you treat these with radiation plaques, if you get a real fast response, like within three months, they start to shrink down rapidly. That's actually a bad thing. Those tumors tend to be more aggressive. They're the ones, I guess, that are so vascular or so, aggressive that the radiation kills them, but they just have a higher chance of recurrence. So you don't want a real fast shrinkage. You want kind of a slower back. We used to even get a little bit increased in size after several months. They'd come back and they were thicker than they had been before surgery, before radiation. We used to get worried about that, but actually it's probably from necrosis, or edema, and then they get gradually smaller over time. So what you want is to get, when you first see the tumor after about six months, maybe the same size or slightly smaller and gradually smaller over several years. That's what a good response. Poster extension. Here's the large tumor here, melanoma from there to there, and this is the Abiscan, that little density in the orbit. That's a posterior nodule. It's broken through the sclera. It's actually in the orbit, so you see that. That changes the situation. Especially if you want to nucleate these, you've got to be really careful, because if that's not intact, if that's encapsulated, you probably are okay, but if it's not, you get into the orbit, you're talking exeneration, which is really a horrendous procedure. You ever seen any exenerations here at all? In the institute you've been here? Yeah. Pretty rare. Yeah, it's not very common. Pretty rare. Yeah. It's waiting to sell something like that. Pretty mutilating procedure. This is a case that I saw years ago. It's kind of a not great picture, but there was a lesion here, and looked again a couple years later. It looked about the same. It wasn't all that elevated looking. I could change that much, making it slightly bigger, basal dimensions. With the ultrasound, Joe actually was breaking through into the orbit. So the lesion was there, which is not very big, but actually the big part is in the orbit, so it's actually growing posteriorly. The CT scan verified that. Here's a lesion here with a large orbital component. Again, it's a reason to look at these with ultrasound, even if they look kind of small, because sometimes they are growing posteriorly, and you wouldn't know that, unless you did the ultrasound and looked in the orbit. That was a spindle, a melanoma. So correlation, microanatomy, we talked about this yesterday. Dense cells, not a lot of interfaces, a few blood vessels there and there, but they really get lower reflectivity because of this. The homogeneous the tissue is, the low reflectivity, the more regular it is on the ACE scan especially. This shows going through the eye here, here's where the probe is against the sclera. The vitreous here is rather flat because it's homogeneous. Then the tumor, you change the sound velocity. You go from one velocity to another, and you get the end time, it's inside the tumor. These are kind of key criteria for melanoma diagnosis, and the collaborative ocular melanoma study done probably 10 to 15 years ago used these criteria, ultrasound was the standard to follow these lesions, and the ACE made about 99.7% accuracy with ultrasound to be gone from 20% misdiagnosis to 0.2% or so misdiagnosis. So it's really changed the game to follow these lesions. So it's really the standard of care. These are criteria, most of these are ACE scan criteria, so you want to have the internal structure to be regular. The spikes inside don't go up and down a lot, they're kind of the same. Level of spike, reflectivity, low to medium, consistency, solid, that means the surface is not moving a lot. Vascularity, fast, montaneous vascularity, and this is a real-time study, so you can actually see vascularity on both the end B scan. And then the B scan criteria is shaped mushroom or color button. So I'll go through all of these, but these are the criteria that I use. So I like to use both A and B scan to look at these lesions. By doing that, we're almost approaching pathology. Yes? What would be non-spontaneous vascularity? With non-spontaneous. Some of these are not that vascular, especially for some reason. Silver body tumors tend to be real vascular. They can still be melanomas, especially smaller ones, had to be a certain size before it starts showing up. But most tumors are not that vascular. Most cordial hematomas aren't. They're just a low flow, venous flow. Metastatic tumors really aren't that vascular. So vascularity is really a pretty important criteria. If I see that, it really helps aid the diagnosis. So regular structure. So here's a tumor here. Here's the surface. Here's the sclera. Inside the lesion, these spikes and others a little bit up and down. They're really pretty much, if you took a line through these, it's not like really an up and down line. It's kind of a slope. So that's fairly consistent. Regularity is not really all over the place as far as the spike height. Low to medium reflectivity. So the general, if you take the average of these spikes, compare them to the initial signal over here, you're going to be from this range to about this range. And that range is where you see melanomas. If they're real high, that's against it. If they're super low, like flat, that's against it. So that's kind of where you want to be looking for the reflectivity height. Solid consistency again. This doesn't play out. I'll show you a couple of videos if you're going to improve it. This is a tumor here. This is a retina over it. But I was trying to demonstrate the fact that this retina is moving as the eye makes micro-psychotic movements. This is kind of juggling. But the tumor is solid. It doesn't move. That's even more apparent on the A-scam. It's just through the spike. The spike is solid. It doesn't jiggle where it does with the membrane. Another case here. This is a melanoma here showing a retina detachment over it. And the retina was moving a lot and this tumor was solid and not moving so solid. The surface is another criteria. And then vascularity, I'm going to show you a good slide of this that I just actually got a couple of days ago. A good video. So here's a mushrooming tumor. And this showed little tiny vessels just kind of like stars in the night, tweaking the night as the vascularity is inside the tumor. So both A and B-scan could show that. And the A-scan, another video I'll show you too is showing little spikes moving inside the A-scan. So vascularity is something I look for when I look at these lesions. So kinetics of motion of membranes and also spontaneous motion. When the eye is not moving, the eye is still, you still see the rapid flicker of the vascularity. So it's an independent of eye motion. Okay, shape, mushroom, color button. A lot of these have this shape and that they break through the bruce membrane. The neck of the tumor gets constricted and it pops through the bruce membrane. You see the tumor pop into the vitreous cavity with the remainder of it inside the coroid. So you see this neck constricture here is a real extreme example here. It is popping through. So these are all shapes of the mushroom, color button. It can also be dome shaped. This is another one here that's not really mushrooming. That's also melanoma compared to this one showing mushrooming shape. So shape is important. If you see mushroom shape, that's almost always melanoma. Though I've seen a couple of metastatic lesions that also look like that as they grow rapidly and broke through the bruce membrane. But generally that's going to be a melanoma if you see the mushroom. All right. Difference of diagnosis. What else do you think of? So here's the orangish lesion here which could be melanoma. It could be amelanotic. A certain percent of these are without any pigment. But the A-scan is very hopeful. You see that going through the vitreous here here's your flat vitreous base here because it's homogeneous. Hit the surface of the tumor. Here's the sclera. Here's the orbit over here but the actual tumor is from there to there. So very high reflective. So that's not melanoma. They don't get that high. And it's rather regular this up and down pattern to it which goes along with pathology. The lesion itself is kind of like a honeycomb. These little blood fill spaces in the hemangioma. As the sound meme goes through this it hits a septa, goes up, hits a blood lake, goes down, septa up. So it goes up and down. This up and down kind of motion like that. So that's typical for man-joan but not melanoma. If I see that it really isn't melanoma. Very helpful. The B-scan is kind of nondescript. That could be anything. That could be melanoma. That could be metastatics. You just don't really know from the B-scan. The A-scan gets to have to pathology correlation. That's why it's so valuable from our A-scan. You really get that correlation to what the pathologist sees. Another lesion here. There could be a lot of different things. The A-scan shows this. Now if you look in this part of it that looks like a melanoma. Here's the surface. Here's the sclera. It's rather regular. Kind of medium reflective. Yet as you scan the lesion and look in different areas you'll see spikes going up and down. Right here. Here's inside the lesion. Another part of the lesion. Very regular. Higher than normal. That would be from melanoma. So this is not melanoma. It's too irregular internally. So this is a metastatic lesion. Again, here's the B-scan. It could be a lot of different things. The A-scan again is quite helpful. You correlate to pathology. The reason they look like this is because the way the tumor invades the coroid it invades it kind of sporadically. So here's a dense population of cells. Here's more sparse invasions. So it's kind of, the melanomas tend to be very dense. They invade this coroid very densely. They replace the whole thing. Metastatic lesion is kind of invaded in fingers. Little fingers poke out and kind of invade it like that. So he gets this interface irregularity. So again, if you get interfaces I think the way the pathology works that explains the A-scan correlate. It's irregular. It's high and low areas, different areas of cell pockets and different areas of coroidal infiltration. Again, the B-scan doesn't really help that much. So A-scan again is very helpful to know what this is. Another lesion here, kind of this hemorrhagic lesion. A dark area that looks kind of scary like could be melanoma with some hemorrhage around it. And the A-scan actually in this case isn't all that helpful because this looks like a melanoma. Here's the surface of the lesion. Here's the splara. And it's kind of regular. It's kind of medium, low reflective. That could be a melanoma. But if I'm not sure a case like this I'll just have the patient come back in about four to six weeks and check them again. If it is hemorrhagic lesion like a discoform this will tend to get smaller as that blood reabsorbs. Whereas melanomas are going to stay the same and get bigger. But as repeated in this case we looked at it again after about two months and the lesion had shrunk way down. So this is a lesion here. So instead of being that big lesion with low reflectivity it was higher, more irregular as a discoform scar scar down over bricks and membrane to get irregularity inside the lesion. So again by following the lesion over time we could actually tell what it was. See a lot of these. Any rough idea. How many people have Nevi? Portal Nevi? Is it rough guys? Ten percent. Ten percent? That's always a good number to pick. I used to teach about six to eight percent of people have these. But the latest studies out of Shields studies they looked at this again all their cases they've collected thousands over the years. They're guessing like 20, 25 percent. People actually have some form of nevus in their lentus. So one of you in this room probably has one if we look at you. So they're really pretty common. We see a lot of these and again most of these are pretty obvious. The question is should these always be ultrasounded? Of course I say yes because I do have it. In a practical situation I'm not sure if it's critical if you'll follow them carefully but the one concern is poster extension. That's the one thing you're going to miss is by looking at these at the fundus you might miss the poster extension. So that's the one reason I would probably suggest at least a baseline ultrasound at least one time you don't have to do it consistently but at least to look at it one time and then follow with the fundus photos and looking at them. The pathology of these again here's a little tiny blip in the coroid not very big. These tend to be under two millimeters and reflectivity is hard to tell because they're so small but it's high it's not low like millinomas because these again these are kind of the pathologies of these they're not real dense they tend to kind of invade the coroid kind of sparsely so you get interface creation so with interface you're going to get high reflectivity right in the region right there so that is helpful to look for reflectivity. I showed a case yesterday of a patient the lesion which is about the same size on B-scan but yet internally is starting to get lower reflective over time which meant conversion from a nevus to a spindle A probably millinoma. In fact, she'll join the term nevoma any VOMA which they made up which is sort of a transition from nevus to spindle A and it can be tough even the pathology as you talk to Nick sometimes they look at the lesions especially the days of a nucleation with more prominent it was sometimes hard to tell is it a nevus is it spindle A too can be difficult so nevoma is probably a reasonable term and I watch those more carefully if I see some of the criteria for reflectivity being lower or more regular I will suggest we watch them more carefully than otherwise all right I think this case out of Utah actually this is not the actual case but a similar a woman about 30 had come in Henry Van Dyke was a treatment here years ago and she was seen and had this lesion and there was a test in those days called the P32 test it actually inject a radioactive isotope of radioactive phosphorus and be taken up by rapidly growing lesion like a melanoma so she had a positive P32 test they gave her the injection they scanned the eye with the detector and they found out she had a positive P32 test so just looking at this lesion the way it looked and the P32 they took the eye out well this is a first path proven case of an osteogenic corastoma so osteoscorostoma so it was actually calcium in the coroid get this real dense bone like looking lesion here's the B scan with shadowing behind it this sound is just absorbed by the lesion so behind the in the orbit you don't see much there's a real high spike on the A scan and actually gas first published as reported in these cases in the same journal that this was published in so famous Utah case pathology animals but this is one of them tending the 20 to 40 age group these often these are not malignant but they can cause a lot of visual problems because they grow in the posterior pole they can involve the macular, the nerve result in visual loss there's really no treatment for them but they are calcified and the ultrasound is really very dramatic I mean just instantly you see the calcium there's no question what it is melanomas don't look like this nothing else really does except these lesion you know the implications are so profound if you miss retinoblastoma you know you're going to have a dead child if you overreact take the eye out then you've got a lesion that wasn't malignant and you've taken the eye out so I know the pediatric guys here still worry about these all the time and see these cases they agonize over so the list of things to think about when you see leucocorin a child of course retinoblastoma is number one PHPV ROP these are all things that can give leucocoria in a child but ultrasound has a real role in these cases certainly with retinoblastomas there's a lesion here you see this kind of diffused scattered calcium throughout the lesion and again what happens is it shadows the orbit looks like the sclerosis missing here it really isn't it's just the lesion is so dense with the calcium the appearance of scleral breakthrough with orbital invasion which really isn't there you just have to understand that but these calcified lesions here on the ASCII can give a lot of high spikes because of the calcium foreign body like signal get real high reflectivity irregular reflectivity so most of these lesions are calcified the literature varies a little bit but it's probably 85 to 95 percent you have calcium but a small percent are not calcified but still in the child with a mass lesion you'll have to assume retinoblastoma but the calcium really helps to see that it can be very fine calcium sometimes it's very diffused and even CT scans will miss it so here's one that's calcified on CT scans it's obvious but here's one that's really very very faint calcium was picked up barely by the ultrasound which the CT had missed I think the current victim is the CTs are not indicated in children retinoblastoma anybody know why that is? radiation yeah there's a high incidence of secondary tumors in these kids up to 20 percent certainly the old days of radiation actually treating with radiation are pretty well gone because of that danger they sometimes get remote secondary cancers too oxygenic sarcomas even away from the eyes of what that is we're not quite sure it's a second hit philosophy but anyway so ultrasound is now the standard to look at these for calcium very cholesterol yeah little tiny cholesterol crystals driving me crazy cause I saw two cases like that couple months ago these real diffuse retinoblastoma that had little tiny bright spots and that can I always worry about that you know I thought it probably one actually had calcium one didn't in those two cases but that can be hard you know the little tiny pinpoint cholesterol crystal could sort of simulate calcium sometimes so the calcium logically so that explains the ultrasound findings the anterior segment lesions here was a case we saw years ago that had this kind of lesion peripherally kind of hard to pick up as you came the ultrasound probe really peripherally you could kind of pick it up but by doing immersion technique you put a shell between the lids and fill a full of fluid and then you can see the anterior segment quite well here's the iris here's the stupid kind of hiding behind the iris and the fact was there was a high frequency 15 megahertz B-scan showing the lesion here and there was the eye nucleated okay this is a not uncommon artifact if you look at a patient and put the probe peripherally the B-scan probe and kind of aim it towards the anterior segment sometimes this will pop up and it sure looks like a lesion right there that round looking thing actually a case sent to me once I think radiation the next day or something and they asked me to ultrasound it and it wasn't a tumor it was a lens and you get real periphery you catch the edge of the lens and so to verify that I did an immersion scan and show that the lens was dense and had a cataract there was no tumor besides this but you can actually do that so something to be aware of in fact here's a case where has the eye moved this kind of rolled across the fund and I'll show that to you that is overview of ultrasound of eye tumors so let me just get this video and show you a couple of these so this is a case that I just got off the flash drives that didn't copy real well but I think we can see enough to get it but this is a patient I saw in clinic referred up here a few days ago and here is the tumor here as you can see behind it see that can behind the sclera that lucency so it looks like a tumor probably melanoma with extra scleral extension you can see that rapid flicker inside that little flickering motions inside the tumor and then also behind it see that lucency behind it so that's concerning that this might be extra scleral extension the one thing it also could be besides melanoma though is a typical lymphoid hyperplasia that's been reported inside the eye these lymphoid cells can get into the chloride they can also have this extra scleral kind of a component to it so it could be that so we're still kind of watching it doing a workout to do some things okay here's I think I showed this yesterday but there's this rapid little flicker inside that see that this kind of little shimmery motion that's spontaneous vascularity right there you see that little rapid flickering inside that so if you see that that's consistent with the blood flow that's usually inside this lesion so if I see that that's very helpful if I don't see it it still doesn't roll out in melanoma but it really most other lesions aren't going to cause that I think I have an A-scan here and also inside this you can just see this rapid really jerking motion things are kind of moving here throughout the order because there's blood flow there but right inside the lesion it really is rapid it's just kind of spontaneous independent of eye motion so both the view of eye tumors I think we have a little time to show you a little bit about the orbit again with modern imaging techniques being so good you kind of wonder what you need and ultrasound that really isn't that helpful especially the v-scan because we can see so far with CTs and MRI scans but there are indications for it so I found these things the v-scan especially helpful for optic nerve rousin which we see a lot which MRIs don't pick up v-scan to see rousin so I'm excited they will miss them and ritual bull bar lesions subtenance lesions wrap the screen for Poptosis just in the clinic enlarged paratomic vein and supposed fistula embolic material in the central artery so these are things I think the v-scan still has a role in can augment other imaging techniques we talked about rousin any rough idea how many people have optic nerve calcified rousin 10% right? it's about 1% 1-2% depends on clinically versus autopsy studies they find more in autopsy studies because they they combine hidden rousin but probably 1-2% Brad Cass and I did a study several years ago looking for the gene which we had not found yet unfortunately we used to go out family reunions in the summertime and take my ultrasound machine and he'd draw blood check people's eyes out in reunions and get all the cousins and relatives that came for the reunion got potato salad on with it too so it was okay but anyway so that's kind of the incidence in the population and these can show up in children although usually I've not really seen calcification before about 8 or 9 years old so I think they can be there but if they're not calcified I have a hard time picking them up by ultrasound so the question is when do they and they can run into families if a family has them in the family tree like somebody else has it then there's a higher incidence of drusen in the whole family but if there's just one isolated individual then it's probably 1% or so anyway so these tend to run sometimes they have it kind of a very funny dominant penetrance but it's really kind of sporadic so in the family group I'll sometimes see a parent with us sometimes a cousin sometimes another relative that's kind of just sporadic throughout the family but you can save a lot of money and a lot of grief if you just think of ultrasound for these cases I still see probably at least a couple times a month I'll see kids send to me that you know seen somebody by their local doctor and you see the swollen nerve and get all nervous and they're sent to neurologist and get a big work up and go through a lot of stuff and they've come back and pick up the drusen so it's just easy to pick them up and if they're not I'm not so convinced yet I've looked at a number of cases with OCT and I think sometimes it's hard you really aren't looking I mean it's really obvious on ultrasound you see the calcium it just stands out at you but OCT is you have to kind of sometimes kind of imagine it but anyway I think it's a standard of care for these cases you're just not sure and again if you don't find drusen like in this swollen nerve here we can do this 30 degree test where we look at the nerve in primary gaze so here's the nerve from here to here and if you had the patient at 30 degrees the nerve thins out so this nerve has gone from here to here which is called a positive 30 degree test which is positive for fluid around the nerve which means it's probably so to term it serobri something like that so all the tumors like liomas don't tend to do that they tend to stay thick so they're thick primary gaze they stay thick as you look to the side because they're a solid lesion but a fluid around the nerve is going to thin out as you stretch the nerve by looking to the side ritual vulvar lesion sub-tenons lesions ulcerous doritis things like that but hyperplasia they get behind the sclera sub-tenon space gets hyperlucent and that's very helpful you can pick this up on the ultrasound sound bird usually so that's a good test for it so this is a case of ulcerous doritis as you can see the scleral thickening here with the sub-tenons lucency behind it with inflammation behind the sclera in the sub-tenon space rapid screen for proptosis Friday night at 5 o'clock you're flogging away and that last patient comes down and they look kind of bulgy and it takes five seconds to put the ultrasound on and see they got a lesion compared to something like pseudo-proptosis like myopia or something like that so it's a very helpful rapid screening test as far as ophthalmic vein you start thinking you see these kind of torture vessels on the conjunctiva you listen for a brewery but a lot of times you don't hear a brewery with these low flow fish but if you see this in large epithelmic vein kind of creeping across the orbit of the temporal this tributary structure that's consistent this is a more dramatic example here showing the enlarged epithelmic vein right here so if you see that that means it's increased blood flow color Doppler is very helpful for these but you can still see this with that color Doppler just on that in the B-scam embellic material I talked about this yesterday the central minority occlusion is about a third of these will have embellic material on B-scam so you can see behind the lamina crevosa this bright density so that's worth doing just a Friday 5 o'clock case just to if you see that you know it's embellic so you have to really pursue the embellic work up send them right away for the stroke work up so I think we do now and I think that's pretty much standard of care now I guess central minority occlusion just send them for the stroke work up anyway but just kind of verify that's what you're thinking of what I do kind of a transocutor going through the globe into the orbit so you go through the eye here here's the orbit tissue here here's a paracutor bypassing the globe right into the orbit so the orbit tends to be high reflective because it's full of interfaces it's got septa, fat, blood vessels, muscles you get a lot of reflection in the orbit and again the vitreous is homogeneous so it just shows a contrast of reflectivity between homogeneous media versus high reflective you can see on the lacrimal gland here's a thickened lacrimal gland from there to there and this kind of up and down movement inside the gland goes along with the mixed cell kind of tumor with the way the pathology shows the different cystic spaces within the lesion quantitation of optic nerves muscles this is very valuable all the time we get CT's MRI's are the muscles big well I think they are or it all just looks I think it looks big it's subjective though this is actually a native test you can actually do the A scan and major things so this is a optic nerve here from there to there and this again is a 30 degree test this is the nerve thickened here and this is thinner here there's some papers out there claiming the B scan can be used to major nerve thickness especially in the ER literature they claim to be able to do that I really don't think so it's really hard these nerve shadows can really you can fool yourself to major nerve thickness but A scan you can actually quantitate it I can actually put a caliper there electronic caliper and major the thickness of the nerve and then the muscles majoring muscles we scan the muscle going here's medial rectus muscle kind of towards the insertion further back towards the orbit so we can actually go along the muscle and major the thickest point of it and quantitate that sinus disease this is not of course the best test for sinus the patient has a lot of pain around the eye kind of fullness feeling all these signals here from the sinus normally sinuses are air filled and air blocks ultrasound that's why you have to use conducting media when you use ultrasound but if you have fluid in the sinus or other things tumors, pollocks you get a lot of signals from the sinus so you pick that up you see that that means there's a sinus disease whatever it is I don't know I get a CT scan at that point but it's just a nice screening test showing the different topographic quantitative kinetic but the point is even though there's nothing about a scan you can still see the difference in different tissue structures so here's a normal orbit here I reflect to all the different interfaces in the orbit this is a cavernous evangeloma you can see the high and low spikes going up and down consistent with the cavernous faces inside the lesion this is a mixed cell tumor we talk about that with lacrimal glands showing the up and down from the cavernous plastic spaces this is a lymphoma right here this is a lymphoma cell tumor right here with real low reflectivity regularity and here is a glioma so it just shows again the difference of pathology correlation to the A scan so it's very hopeful and we can do kinetic we can actually push on things you can push against lesions and see the lesion here and as you push a little bit you can see how solid they are so that's cavern overview of the orbit so we'll just cover it off there any questions? okay so ultrasound could be useful and so you know very helpful especially in third world stuff I do a fair amount of that and they're really valuable get these clinics out there that don't have access to CTs, MRIs and we can donate an ultrasound to them it really helps them increases their capability for both intraocular and orbital processes so really it's a useful technique check thanks