Ultrasound Principles

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Ultrasound Principles

http://emedicine.medscape.com/article/1228447-overview#aw2aab6b2

Sound is defined as a vibratory disturbance within a solid or liquid that travels in a wave pattern. When the
sound frequency is between 20 hertz (Hz) and 20,000 Hz, the sound is audible to the human ear. To be
considered ultrasound, sound waves must have a frequency of greater than 20,000 Hz (20 KHz), rendering
them too high in frequency to be audible to the human ear.[1] In ophthalmology, most A-scan and B-scan
ultrasound probes use a frequency of approximately 10 million Hz (10 MHz) that is predesigned by the
manufacturer. This extremely high frequency allows for not only restricted depth of penetration of the
sound into the body but also excellent resolution of small structures. This meets unique needs, because, at
times, the probe is placed directly on the organ to be examined, and its structures are quite small, requiring
excellent resolution.

The velocity of sound is determined completely by the density of the medium through which it passes.
Sound travels faster through solids than through liquids, an important principle to understand because the
eye is composed of both. In A-scan biometry, the sound travels through the solid cornea, the liquid
aqueous, the solid lens, the liquid vitreous, the solid retina, choroid, sclera, and then orbital tissue;
therefore, it continually changes velocity.

The known sound velocity through the cornea and the lens (average lens velocity for the cataract age group,
ie, approximately 50-65 y) is 1641 meters/second (m/s), and the velocity through the aqueous and vitreous
is 1532 m/s. The average sound velocity through the phakic eye is 1550 m/s. The sound velocity through
the aphakic eye is 1532 m/s, and the velocity through the pseudophakic eye is 1532 m/s plus the correction
factor for the intraocular lens (IOL) material.[2] The cornea is not routinely factored in because of its
thinness. If one were to consider 1641 m/s at about 0.5 mm, only 0.04 mm would need to be added to the
total eye length, which in no way alters the IOL calculation.

In A-scan biometry, one thin, parallel sound beam is emitted from the probe tip at its given frequency of
approximately 10 MHz, with an echo bouncing back into the probe tip as the sound beam strikes each
interface. An interface is the junction between any two media of different densities and velocities, which, in
the eye, include the anterior corneal surface, the aqueous/anterior lens surface, the posterior lens
capsule/anterior vitreous, the posterior vitreous/retinal surface, and the choroid/anterior scleral surface.

The echoes received back into the probe from each of these interfaces are converted by the biometer to
spikes arising from baseline. The greater the difference in the two media at each interface, the stronger the
echo and the higher the spike.[2] If the difference at an interface is not great, the echo is weak and the
displayed spike is short (eg, vitreous floaters, posterior vitreous detachments). No echoes are produced if
the sound travels through media of identical densities and velocities, eg, young, normal vitreous or the
nucleus of a noncataractous lens, in which the A-scan display goes down to baseline.
High  quality  contact  A-­‐scan  of  the  phakic  eye.  Note  the  5  high-­‐amplitude  spikes  and  the  steeply  rising  
retinal  spike,  as  well  as  the  good  resolution  of  the  separate  retinal  and  scleral  spikes.  

 
 

In the case of a cataractous lens, multiple spikes occur within the central lens area as the sound beam
strikes the differing densities within the lens nucleus. This spike height, or amplitude, is therefore what
gives the information on which to base the quality of the measurements. In fact, the "A" in A-scan is from
the word "amplitude."

Spike height is not only affected by the difference in density as it travels through the eye but also by the
angle of incidence, which is determined by the probe orientation along the visual axis. If the probe is held
in a perpendicular manner to the visual axis, it is in the proper position to receive the echoes back into the
probe tip so they can be converted to spikes. Because sound waves can be reflected and refracted the same
as light rays, if the probe is held in a nonperpendicular manner, part of the echo is diverted at an angle away
from the probe tip, and, therefore, is not received by the machine.[2] The more nonperpendicular the angle of
incidence, the weaker the signal and the shorter the spike amplitude.

 
 

When  the  sound  beam  incidence  is  perpendicular  to  the  visual  axis  (upper  image),  most  returning  
echoes  are  received  back  into  the  probe  tip  to  be  interpreted  on  the  display  as  high-­‐amplitude  spikes.  
When  the  sound  beam  incidence  is  nonperpendicular  to  the  visual  axis  (lower  image),  part  of  the  
returning  echo  is  reflected  away  from  the  probe  tip,  with  only  a  portion  received  by  the  probe.  As  a  
result,  the  spikes  will  be  compromised.  

The  shape  and  smoothness  of  each  interface  also  affects  spike  quality.  An  
irregularity  in  the  surface  of  an  interface  causes  reflection  and  refraction  of  the  
returning  sound  waves  away  from  the  probe  tip  and,  therefore,  weaker  echoes.[2]  
That  is  why  it  is  important  to  know  whether  macular  pathology  is  present  that  could  
adversely  affect  spike  quality.  A  perfect  high,  steeply  rising  retinal  spike  may  be  
impossible  when  macular  pathology  is  present  (eg,  macular  edema,  macular  
degeneration,  epiretinal  membranes,  posterior  staphylomas).  
 
If  the  macular  surface  is  smooth  (upper  image)  more  of  the  echoes  are  received  back  into  the  probe  to  
be  displayed  as  high-­‐amplitude  spikes.  If  the  macular  surface  is  convex  (center  image),  as  with  macular  
edema  or  pigment  epithelial  detachments,  part  of  the  echoes  is  reflected  away  from  the  probe  tip.  If  the  
macular  surface  is  irregular  (lower  image),  as  in  macular  degeneration  or  epiretinal  membranes,  
reflection  of  the  echoes  away  from  the  probe  tip  also  will  occur.  

 
In  addition,  sound  is  absorbed  by  everything  through  which  it  passes  before  it  
travels  on  to  the  next  interface.  The  greater  the  density  of  the  structure  it  is  passing  
through,  the  greater  the  amount  of  absorption.  This  principle  explains  why  retinal  
spike  quality  is  reduced  in  the  case  of  an  extremely  dense  cataract;  the  lens  absorbs  
much  of  the  sound  and  less  sound  actually  reaches  the  retinal  surface.  

Ultrasound Biometry Instrumentation


Ultrasound biometers use a pulse system, pulsing electricity to the probe tip where a crystal element
vibrates and emits the sound beam at its given frequency. Then, a pause of a few microseconds occurs, so
the returning echoes can be received by the probe tip and converted to spikes on the display.[2]

The gain setting on biometers is measured in decibels and affects amplification and resolution of the
displayed spikes. When on highest gain, the spike height and the sensitivity of the display screen are
maximized, enabling visualization of the weaker signals, but the resolution is affected adversely. When
gain is lowered, the spike amplitude and the display sensitivity are decreased, which eliminates the weaker
signals but improves the resolution.

Resolution is defined as the ability of the machine to display two interfaces that lie in close proximity, one
directly behind the other, as separate echoes or spikes (eg, retinal and scleral interfaces). When the gain is
too high, the retina and sclera appear as one thickened spike with a wide, flattened peak. The examiner
should reduce the gain until the retinal and scleral surfaces are seen as separate spikes to the right of the
display. The density of the cataract determines the need for changing the gain setting due to absorption of
the sound. The more dense the cataract, the higher the necessary gain. Patients who are aphakic require less
gain to prevent merging of the retinal and scleral spikes. Therefore, the gain setting may vary not only from
patient to patient but from one eye to the next in the same patient, depending on cataract density.

 
 

 
When  the  gain  setting  is  too  high,  the  resolution  of  the  separate  retinal  and  scleral  spikes  is  lost,  
resulting  in  1  thick,  flattened  spike.  
Gates  are  electronic  calipers  on  the  display  screen  that  measure  between  two  
points.[2]  Biometers  are  designed  so  that  between  each  pair  of  gates  a  measurement  
is  rendered.  Biometers  vary  in  the  appearance  of  these  gates,  with  some  units  not  
displaying  them  at  all.  Gates  should  be  readily  visible  for  accurate  editing  of  the  
scans,  because  if  any  one  of  them  is  aligned  along  an  incorrect  spike  the  entire  eye  
length  measurement  will  be  erroneous.  The  biometer  automatically  places  a  gate  on  
what  it  believes  to  be  the  corneal  spike,  the  anterior  lens  spike,  the  posterior  lens  
spike,  and  the  retinal  spike,  and  it  is  programmed  to  measure  the  distance  between  
each  pair  of  gates  at  a  given  velocity.  

 
Gates  are  electronic  calipers  on  the  display  (see  arrows)  that  between  each  pair  render  a  measurement.  
In  this  4-­‐gate  system,  each  of  the  3  sections  of  the  eye  is  measured  individually  at  its  correct  velocity,  
then  added  together  for  the  total  eye  length.  Equipment  will  vary  in  the  appearance  of  these  gates.  

Ultrasound is measured based on how long it takes the sound to travel from one point to the next at a given
velocity. The formula, distance = velocity X time, is programmed into biometers to calculate the distance
between each pair of gates. Then, the formula is divided by 2 because the sound also must echo back into
the probe tip. By selecting the eye type in the measurement mode (phakic, aphakic, or pseudophakic), the
equipment is instructed to use this distance formula with the proper velocities between each gate pair for
that particular eye type.[2]

For example, in the phakic mode, the machine has been programmed to measure distance between the first
pair of gates using a velocity of 1532 m/s, the velocity through the anterior chamber. The velocity of 1641
m/s is used between the second and third gates because this is the velocity through the lens. The velocity of
1532 m/s is once again used in the formula between the third and fourth gates because this is the velocity
through the vitreous cavity. The most accurate machines measure each of these 3 sections of the eye
individually at the proper sound velocity and then add them together for the total eye length. If any one gate
is incorrectly placed, the machine will calculate the 2 sections involved using the incorrect velocity and
time, which will make the total length erroneous.

Proper gate placement is on the ascending edge of each appropriate spike. If a gate has been placed
incorrectly, move it to the appropriate spike before it is stored and used in the calculation. Equipment varies
greatly in the ability to see and move gates; refer to the manual for each specific unit to determine if it is
possible to move the gates, and, if so, the steps required to do so. If the biometer does not allow for
movement of gates, scans must be repeated until they automatically align properly.

When the machine is set for phakic average, only 2 gates are present, measuring the total eye at its average
velocity of 1550 m/s. The 2 gates should align along the corneal surface and the retinal surface,
respectively. The disadvantages to this setting are that the anterior chamber depth and the lens thickness
cannot be monitored and that the use of average sound velocity is simply not as accurate. The average
sound velocity of 1550 m/s is only accurate through an average length eye. In eyes that are shorter or
longer than average, this method of measuring produces an innate error.

When setting the measurement mode to aphakic, 2 gates will be present (on the respective corneal and
retinal surfaces), and the biometer will calculate the distance at a velocity of 1532 m/s, the correct velocity
for the aqueous and vitreous.

When setting the measurement mode to pseudophakic, depending on how many pseudophakic options the
equipment possesses, the eye length is calculated using 1532 m/s for the aqueous and vitreous, then the
correction factor for the given implant material is added. If only one pseudophakic mode option is
available, it only will be accurate for polymethyl methacrylate (PMMA) IOLs.

Routinely using automatic mode on most equipment increases the risk of error because every biometer will
capture poor quality scans. Biometers are programmed to capture any scans with spikes that are of high
amplitude within their given area. However, they often cannot determine if the spike arose steeply from
baseline or if a slope or step is present in the spike origin. Manual mode is sometimes preferable, in which
the examiner presses a foot switch to capture the scan when it is seen to be of high quality. Equipment
varies greatly with some manufacturers only using a 4-gate system on automatic mode, which means that
anterior chamber depth can be monitored only in automatic mode. If this is the case, automatic mode is
preferable, but the examiner must carefully edit the scans stored by the machine.

Accuracy and Standard Dimensions


It is critical that the examiner use methods that are standard of care in performing biometry. A 0.1 mm error
in an average length eye will result in about a 0.25 diopter (D) postoperative refractive error.[3] Therefore,
an error of 0.5 mm will result in approximately 1.25 D refractive error, and an error of 1.0 mm will result in
approximately 2.50 D postoperative refractive error.

Longer eyes are more forgiving, with a 1.0 mm error in an eye of 30 mm length resulting in a post-
operative error of about 1.75 D. Small eyes are the least forgiving, and even more postoperative error
occurs from inaccurate measurements. For example, an error of 1.0 mm in an eye that is 22.0 mm long will
result in a post-operative error of about 3.75 D. If the error is in measuring the eye erroneously small, such
as is common from corneal compression, the postoperative refractive error will be in the myopic direction.
Conversely, if the examiner measures the eye erroneously long, which is common when the sound beam is
not perpendicular to the retinal surface, the postoperative refractive error will be in the hyperopic direction.

A good biometrist must be able to recognize when readings appear abnormal; therefore, one must first
know standard dimensions of the eye. The average axial eye length is 23.5 mm, with a range of 22.0-24.5
mm.[2] In general, the smaller the eye, the more hyperopic the refractive error. The longer the eye, the more
myopic the refractive error. Of note, a patient can be myopic because of steep corneal curvature rather than
long axial length, and a patient can be hyperopic because of flat corneal curvature rather than short axial
length.

Once the eye length is measured, compare it to the precataract refractive error of the patient to ensure that
the readings appear accurate. The precataract refractive error is important because the cataractous lens
changes can induce a more myopic prescription. The reference range between the right eye and the left eye
of the same patient is within 0.3 mm, unless evidence suggests the contrary (eg, previous scleral buckling,
anisometropia, corneal transplantation, keratoconus, refractive surgery, hypotony).

The average anterior chamber depth is 3.24 mm but varies greatly.[2] If the biometrist is documenting a
shallow anterior chamber depth, examine the medical chart for clinical correlation of this finding. The
average lens thickness is 4.63 mm but this also varies, and, with cataractous changes, the lens will increase
in thickness to as much as 7.0 mm in extremely dense cases.

The average keratometry (K) reading is 43.0-44.0 D, with one eye typically within a diopter of each other.
Check these readings against the refractive error of the patient for accuracy. If one eye is found to differ
from the other by more than 1 D, immediately begin researching the cause and alert the physician. For
instance, if the patient had refractive surgery, corneal transplantation, an injury with a resultant corneal
scar, or has keratoconus, the K readings may vary between the eyes. It is rare for the patient to have
disparate K readings biologically. If any of the above eye measurements is found to be unusual, another
technician should recheck the measurements and immediately alert the physician.

Just as precise keratometry and biometry are critical for good surgical outcomes, correct IOL placement by
the surgeon is essential. A 0.19 D postoperative refractive error occurs for every 0.1 mm posterior chamber
intraocular lens (PCIOL) displacement. A 0.12 D postoperative refractive error occurs for every 0.1 mm
anterior chamber intraocular lens (ACIOL) displacement. Lens displacement can also be caused by the
patient's ciliary body pushing the lens out of position rather than by the surgeon's placement of the lens.

Using the correct IOL calculation formula is extremely important in good surgical outcomes. Third- and
fourth-generation formulas are the most accurate; these formulas include the Hoffer Q, SRK/T, Holladay I,
Haigis, and Holladay II IOL Consultant formulas. For average length eyes with average K's, these formulas
give almost identical calculations.[3] However, when the eye is small, formula selection is more critical. In
eyes that are less than 22.0 mm in length, the Hoffer Q and the Holladay II IOL Consultant formulas are the
most accurate. For long eyes, the SRK/T and the Holladay II IOL Consultant formulas are the most
accurate.

The Holladay II IOL Consultant formula is considered by most experts to be the best no matter the axial
length. The Holladay II IOL Consultant formula is also the only formula that calculates for piggyback IOL
procedures (ie, when 2 IOLs are implanted, which may be necessary when the eye is so small that 1 implant
does not contain enough converging power, or when a piggyback lens is inserted to correct a postoperative
surprise that results from the first implant), and is most recommended for patients that have had previous
refractive surgery.

The Haigis formula is also proving to be accurate no matter the axial length but must be optimized first,
which requires 200-300 eyes, preferably. Optimization is done in the United States by Warren Hill, MD,
and in Europe by Dr. Wolfgang Haigis.

 
 
Contact and Immersion Techniques
Historically, the contact (or applanation method) of biometry was accomplished by gently placing the probe
on the corneal vertex and directing the sound beam through the visual axis. This handheld method was
most easily and accurately performed with the patient in a reclined position with the patient's head placed in
front of the display screen of the biometer. The examiner was seated on an adjustable stool to the other side
of the patient, resting his or her arm on the patient's shoulder and the side of his or her hand on the patient's
cheek. The patient was instructed to look at a target affixed to the ceiling. Using a gentle on-and-off
technique allowed for less corneal compression since the examiner's hand was braced more firmly. It was
also easier for the patient to brace the head against the headrest in this reclined position and for the
examiner to simultaneously monitor both the display screen and the patient's fixation.

Because of the indentation of the globe caused by the contact (or applanation method) of biometry as well
as the current patient expectations, this method is being completely abandoned in favor of more accurate
noncontact instrumentation.

The immersion technique of biometry is accomplished by placing a small scleral shell between the patient's
lids, filling it with saline, and immersing the probe into the fluid, being careful to avoid contact with the
cornea. This method is more accurate than the contact method because corneal compression is avoided.
Eyes measured with the immersion method are, on average, 0.1-0.3 mm longer than when measured by the
contact method since no indentation of the globe occurs.[2, 3] The display screen will exhibit 6 (rather than 5)
spikes in the phakic patient because the probe and the cornea are no longer in contact with each other, thus
appearing separate.

Of note, some machines have the probe spike shifted so far to the left in the immersion mode that it does
not appear on the display screen; therefore, the corneal spike will be seen first. The correct axial pattern
past the probe spike consists of 5 tall spikes that represent the cornea, the anterior lens, the posterior lens,
the retina, and the sclera. Perpendicularity is achieved when all spikes are of high amplitude and the retinal
spike is steeply rising from the baseline.

Another advantage of the immersion technique is that the corneal spike will have two peaks corresponding
to the epithelium and endothelium. If both of these peaks are not equally high, the sound beam is not
directed through the corneal vertex and, therefore, is not aligned along the visual axis. Care should be taken
to keep the gain low enough to appreciate and resolve these two peaks. If the gain is set too high, poor
resolution of these two interfaces will occur and the corneal peak will appear wide and flattened.
 

Immersion  scan  of  the  phakic  eye.  The  probe  and  cornea  are  now  separate  spikes  since  they  are  not  in  
contact  with  each  other,  and  the  corneal  spike  demonstrates  2  peaks  (see  arrow),  representing  the  
epithelium  and  endothelium.  If  these  2  peaks  are  not  both  high,  the  sound  beam  is  not  aligned  through  
the  corneal  vertex.  Gain  must  be  reduced  enough  to  appreciate  and  resolve  these  2  peaks.  

Other advantages of the immersion technique are that it is a faster method than the contact technique and
that it reduces technician dependency. When using the contact technique, axial lengths will vary on
subsequent scans by the same technician, as well as between technicians depending on the amount of
corneal compression. When using the immersion technique, as long as the spikes are of high quality, the
axial lengths will not vary from one scan to the next or from one biometrist to the next. Any practice that
changes from the contact technique to the immersion technique must repersonalize their IOL constants in
their IOL calculations, since they are achieving true rather than slightly shortened eye length
measurements. A study should be completed of at least 20 eyes with the new technique, the same surgeon,
and the same IOL to determine the correct personalization of the constant.

Another current method for highly accurate axial length measurements uses optical coherent light rather
than ultrasound. In this method, optical coherent light passes through the visual axis and reflects back from
the retinal pigment epithelium. Interferometry is then used to measure the distance from the cornea to the
retina. Because this is a noncontact method, as is immersion ultrasound, its accuracy is superior to contact
ultrasound biometry. In fact, when it can be used it is as accurate as immersion ultrasound and was
calibrated to immersion ultrasound in its development by Dr. Wolfgang Haigis.

However, this method cannot be used in the event of significant media opacity (eg, dense cataracts or
corneal or vitreal opacity) due to absorption of the light, or an inability of the patient to fixate on the target.
Optical coherence cannot measure anterior chamber depth or lens thickness; however, a slit beam is in
place for anterior chamber depth measurements. For highly accurate anterior chamber depth and lens
thickness measurements, immersion ultrasound should be used.

For those practices using optical coherence, immersion ultrasound will be necessary for patients who
cannot be measured by optical coherence to ensure the same high level of accuracy.
Biometry Through Various Intraocular Lens Materials
Biometry through an already pseudophakic eye most commonly is performed to compare to the fellow
phakic eye for accuracy. Other reasons to measure the pseudophakic eye include patients who are
scheduled to undergo an IOL exchange or checking an unwanted postoperative refractive error.
Measurement through the pseudophakic eye will result in multiple reverberation echoes in the vitreous
cavity that tend to decrease in amplitude from left to right. The number and strength of these reverberations
is dependent on the IOL material. Decreasing the gain in the pseudophakic eye is helpful, so that spike
amplification of these artifacts is reduced, reinforcing correct gate placement on the retinal spike.

 
 

Reverberation  artifacts  in  the  vitreous  cavity  resulting  from  intraocular  lens.  The  left  image  
demonstrates  the  longer  chain  of  artifact  spikes  from  polymethyl  methacrylate  implants.  The  image  on  
the  right  demonstrates  the  shorter  chain  of  artifact  spikes  from  foldable  implants.  

To obtain accurate measurements through the pseudophakic eye, knowledge of the implant material is
essential. Most IOLs are currently made of PMMA, acrylic, or silicone. The velocity of sound through each
of these materials is different because of their differing densities and if measured with the wrong modality
can result in significant error. If an eye with an acrylic IOL is measured on pseudophakic PMMA mode, a
0.2 mm error will occur. If an eye with some silicone IOLs is measured on PMMA mode, a 1.2 mm error
will occur.

The velocity of sound through the pseudophakic eye is 1532 m/s plus the correction factor for the implant
material. The velocity through PMMA is 2718 m/s, through acrylic is 2120 m/s, and through silicone is
980-1107 m/s, depending on the silicone used.[2] (Because acrylic and silicone lenses are foldable, they are
not as dense as PMMA and, therefore, have a slower velocity.)

If a biometer only has one pseudophakic setting, it will be accurate for PMMA only because it was
manufactured when PMMA was the only implant material being used, and some biometers do not have
upgrades for the various IOL materials. If this is the case, the way to achieve accurate measurements is to
use the aphakic setting, which uses a sound velocity of 1532 m/s. Then, the examiner should manually add
the correction factor for the IOL material to the results obtained on aphakic mode. The correction factor is
+0.4 mm for PMMA, +0.2 mm for acrylic, and -0.4 mm to -0.8 mm for silicone, depending on the silicone
velocity.[2] Therefore, if an eye measured 23.32 mm on aphakic mode and the IOL is made of PMMA, the
correct axial length is 23.72 mm. If the IOL is acrylic, the correct axial length is 23.52 mm. If it is low-
velocity silicone, the correct length is 22.52 mm.
When any new implant material is produced, the correction factor can be calculated using the CT of the
IOL and the sound velocity of the material at body temperature (35°C), which must be supplied by the
manufacturer. The formula for this calculation is the CT multiplied by 1 minus 1532 divided by the
velocity of that material, or CT X (1-1532/vel).[2] For example, if the IOL has a CT of 0.8 mm, and the
sound velocity of the material is found to be 1040 m/s, then 0.8 X (1-1532/1040) = 0.8 X -0.473 = -0.378.
Therefore, the correction factor for this eye is -0.378 from the length obtained on aphakic setting.

Another problem arises when the implant material is unknown. If the patient has a wallet card showing the
implant used, the manufacturer may need to be called to determine implant material if the model is
unfamiliar to the examiner. If the patient does not have a wallet card, contact the surgeon's office to
determine the implant used. If the patient cannot recall the surgeon's name, it may be necessary to contact a
family member in the case of an IOL exchange. However, the implant reverberation pattern may prove
helpful because PMMA has a longer chain of reverberation echoes, followed by acrylic and then silicone.

Common Errors and Challenging Situations


A problem should be suspected if a difference between the 2 eyes of more than 0.3 mm is present or if a
difference in consecutive measurements occurs on the same eye of more than 0.1 mm. In these instances,
consult the patient's history to see if a medical reason exists for a difference or macular pathology that
could explain the variation on the same eye (eg, posterior staphyloma).

The most common error in the contact technique is corneal compression. This inevitably occurs because the
eye is pliable and the cornea is indented even with minimal pressure from the probe tip. The lower the
intraocular pressure the softer the eye and the more significant the corneal compression. Therefore, the
amount of compression can vary even with the same technician. If the contact technique must be used, the
anterior chamber depth must be monitored and the shallower anterior chamber depths deleted even if the
spikes appear to be of high quality. Of course, the immersion method completely avoids corneal
compression, which is why the contact method is becoming obsolete.

 
 

Corneal  compression  is  demonstrated  in  the  A-­‐scan  on  the  right.  Note  the  more  shallow  anterior  
chamber  depth  of  2.63  mm  as  compared  to  the  scan  of  the  same  eye  on  the  left,  with  an  anterior  
chamber  depth  of  3.20  mm,  indicating  0.57  mm  of  corneal  compression.  Note  also  that  the  total  eye  
length  is  shortened  from  24.60  mm  in  the  scan  on  the  left  to  24.18  mm  in  the  scan  on  the  right.  This  
error  would  result  in  an  unwanted  postoperative  refractive  error  of  about  -­‐1.25  D.  
 
The  second  most  common  error  is  misalignment,  either  by  not  obtaining  
perpendicularity  to  the  macular  surface  or  by  not  directing  the  sound  beam  through  
the  visual  axis.  Perpendicularity  to  the  macular  surface  is  achieved  when  the  retinal  
spike  and  scleral  spike  are  of  high  amplitude,  and  the  retinal  spike  arises  steeply  
from  baseline.  No  sloping  of  the  retinal  spike  should  be  present  and  no  jags,  humps,  
or  steps  should  be  present  on  the  ascending  edge  of  that  spike.  

Misalignment  errors.  The  A-­‐scan  on  the  left  demonstrates  a  contact  scan  with  a  sloping  retinal  spike.  
The  A-­‐scan  on  the  right  demonstrates  an  immersion  A-­‐scan  with  steps  in  the  initial  rise  of  the  retinal  
spike.  

If  either  the  posterior  or  anterior  lens  spike  are  not  of  high  amplitude,  the  sound  
beam  could  be  misaligned  at  an  angle  through  the  lens  and,  therefore,  not  through  
the  visual  axis.  The  posterior  lens  spike  may  be  slightly  shorter  than  the  anterior  
lens  spike  because  the  convex  curvature  of  the  posterior  lens  is  steeper  than  the  
convex  curvature  of  the  anterior  lens  surface,  allowing  for  reflection  of  the  echoes  
away  from  the  probe  tip.  Also,  if  a  dense  nuclear  sclerotic  cataract  is  present,  more  
sound  absorption  could  occur  within  the  lens,  causing  the  posterior  lens  spike  to  be  
shorter.  In  these  instances,  the  gain  can  be  increased  to  obtain  better  posterior  lens  
and  retinal/scleral  spikes.  
Misalignment  demonstrated  by  the  decreased  amplitude  of  the  posterior  lens  spike  (arrow).  When  
either  of  the  lens  spikes  is  too  short,  the  sound  beam  is  aligned  at  an  angle  through  the  lens  rather  than  
through  its  center,  and  thus  not  aligned  along  the  visual  axis.  

Misalignment  along  the  optic  nerve  is  an  error  that  is  easily  recognized,  since  the  
scleral  spike  will  be  absent.  The  retinal  spike  will  be  present  and  of  high  amplitude  
and  can  even  appear  steeply  rising,  but,  if  the  scleral  spike  is  not  as  high  in  
amplitude  as  the  retina,  the  sound  beam  is  misaligned  along  the  nerve.  No  sclera  is  
present  at  the  optic  nerve;  the  sound  beam  is  passing  through  the  nerve  cord  with  
only  short  amplitude  echoes  present,  because  the  sound  beam  is  striking  blood  
vessels  within  the  nerve  cord.  In  the  normal  eye,  there  will  generally  not  be  a  great  
difference  in  axial  length  when  aligned  along  the  optic  nerve,  but,  in  cases  of  a  full  
optic  disc,  papilledema,  or  optic  disc  drusen,  this  will  result  in  an  erroneously  short  
axial  length  measurement.  In  cases  of  optic  nerve  cupping,  as  seen  in  glaucomatous  
eyes,  this  error  results  in  an  erroneously  long  axial  length  measurement.  
Misalignment  along  the  optic  nerve.  Note  the  missing  scleral  spike.  

Another possible error in the contact method is a fluid meniscus between the probe tip and the cornea
caused from ointment use, methylcellulose in the eye from previous examinations, or abnormally thick tear
film. If either of these is suspected, rinse the eye with sterile saline prior to biometry.

Extremely dense cataracts can be a challenge because of absorption of the sound beam as it passes through
the lens. A higher gain setting may be necessary to achieve high-amplitude spikes from the retina and
sclera. Improper gate placement also can occur easily, because a dense cataract produces multiple spikes
within the lens. The posterior lens gate may erroneously align along one of the echoes within the lens
nucleus, resulting in an erroneously thin lens thickness and erroneously long vitreous length, which results
in an error in the total length of the eye. In this case, manually realign the gate to the correct posterior lens
spike, and if the equipment does not allow for manual gate placement, repeat scans until the gates
automatically align properly.

Posterior staphylomas are among the greatest biometry challenges. These occur primarily in high myopes,
where the globes are so elongated and thin that the posterior uvea bulges outward into the sclera, most
commonly in the posterior pole. This causes the macula to be sloped in configuration, which in turn causes
reflection of the sound beam away from the probe tip and a poor retinal spike. It is impossible to obtain
perpendicularity to a macular surface that is sloped; thus, it is impossible to obtain a proper retinal spike.
Also because of the sloped surface, the measurements will be not only long but extremely variable. Patients
must be alerted that because their eye is misshapen, they have a higher risk of the postoperative result not
being as accurate as a patient with a normally shaped, round globe.

In these cases, a B-scan examination is necessary, with a horizontal macular scan performed and the axial
length measured from the B-scan. The proper B-scan probe position for this measurement is to have the
patient in primary gaze with the B-scan probe face (using a generous amount of gel-type tear solution)
centered on the corneal vertex and the probe marker aimed nasally. (The probe marker is either a line or a
dot on one side of the probe, near the probe face.)

When this probe position is achieved, the B-scan display will demonstrate the epithelial and endothelial
corneal echoes centered to the left, the posterior lens surface just to the right, and the optic nerve void just
above the center to the far right. The macula will lie centered on the right, about 4.5 mm below the center
of the optic disc. Simply place calipers on the vertex of the epithelial corneal echo and on the macula to
measure the axial length at average sound velocity of 1550 m/s. Compare this axial length measurement to
the various biometry measurements, and use the measurement that has the most comparable vitreous length
in the IOL calculation, preferably within 0.1 mm.

High  myope  with  a  long  eye.  Note  the  poor  quality  of  the  retinal  spike  on  the  A-­‐scan.  The  axial  length  
from  the  anterior  corneal  surface  to  the  central  macula  was  measured  on  the  B-­‐scan  (left  image),  and  
compared  to  the  variable  A-­‐scan  measurements.  The  A-­‐scan  that  was  within  0.1  mm  of  the  B-­‐scan  
measurement  was  used  in  the  intraocular  lens  calculation.  

Optical coherence biometry has been shown to be beneficial in the case of the highly myopic globe because
it measures to the fixation point of the patient and the lack of perpendicularity is not prohibitive. But again,
optical methods are not always usable if the patient has a dense cataract or other media opacity or the
inability to fixate, so ultrasound techniques still need to be used in these situations.

Known macular retinal detachments are yet another challenging situation. In retina practices, the physician
may decide to remove the cataract while the patient is undergoing retinal detachment repair and will need
accurate IOL calculations. In these cases, the retinal spike will appear further to the left in the vitreous
cavity, depending on the elevation of the macula. In these instances, the retinal gate should be moved from
the detached retina to the next more posterior spike, since the retina should lie back into this position once
repaired. The examiner should inquire if the surgeon plans to place a scleral buckle around the globe to
repair the detachment, and if so manually add another 0.5-1.0 mm to the total eye length to account for
lengthening of the globe by the buckle postoperatively.
IOL Calculations Following Refractive Surgery
When cataract surgery is performed on a patient who has had a previous refractive procedure, accurate
keratometry readings are not obtainable by standard manual or automated keratometers. Because myopic
refractive procedures flatten the central cornea, keratometer mires are spread over a larger area and now
measure approximately the central 4.5 mm of the cornea rather than the central 3.0 mm. Therefore, use of
standard corneal measurements for IOL calculations results in hyperopic postoperative refractive errors.
Topography also is not accurate for postrefractive corneal curvature measurements.

While this section is in no way a comprehensive listing of the methods suggested by the experts for
calculating corneal curvature following refractive surgery, the more common methods will be described.

One of the most accurate methods for determining corneal curvature after refractive surgery is the clinical
history method.[3] The data needed in this method include the spherical equivalent refractive error prior to
refractive surgery, the average keratometry reading prior to the refractive procedure, and the spherical
equivalent refractive error postrefractive procedure. (The examiner should use caution not to use the current
refractive error as the patient may have a myopic shift due to the presence of the cataract.) The formula for
this method for patients who are myopic and undergoing refractive surgery is as follows:

K = Preoperative Average K - Change in Manifest Reaction Prerefractive and Postrefractive Surgery

Because any change in refractive error from a refractive procedure is due to corneal flattening, the change
in refractive error from the refractive procedure subtracted from the average K prior to the procedure is the
current central corneal curvature. For example, if a patient had an average K of 45.75 D and a refractive
error of -8.25 D prior to refractive surgery with a plano postoperative result, that is a change of 8.25 D of
corneal flattening. The K reading to use in the IOL calculation is 37.5 D (ie, 45.75 D - 8.25 D = 37.5 D).
The examiner should not be concerned with the resultant low corneal curvatures. As high myopes, many
patients underwent extensive corneal flattening from the refractive procedure.

If the patient underwent hyperopic refractive surgery, the history method can still be used; however, rather
than subtracting the amount of correction, it should be added because the cornea was in effect steepened
rather than flattened by the procedure.

If the patient's previous medical records and measurements are unobtainable, the contact lens method of
determining corneal curvature can be used. This method can also be used for comparison even when other
methods are utilized. The formula for this method is as follows:

K = Base Curve + (Difference in Refractive Error From Without Contact Lens to With Contact Lens)

First, refract the patient without a contact lens and note the spherical equivalent. Then, place a hard contact
lens (PMMA) of known base curve and plano power on the eye, and refract the patient again. The
difference in refractive error is algebraically added to the known base curve of the contact lens. For
example, if a patient refracts to a -1.5 D without a contact lens, and a plano contact lens with a base curve
of 40.0 D is placed on the eye and the patient now refracts to a -4.25 D, that is a difference in refraction of
3.75 D in the minus direction. The formula K = 40.0 D + (-3.75) = 36.25 D is used as the K reading in the
IOL calculation. Care must be taken to note the direction of the change in refraction.

For example, if another patient refracts to a -2.0 D without a contact lens and then +0.25 D with the same
40.0 D contact lens, the difference in refractive error is 2.25 D in the plus direction, so K = 40.0 D +
(+2.25) = 42.25 D to be used in the calculation. Regardless of the base curve of the contact lens used for the
refraction, this formula results in the same K power because the difference in base curve of the contact lens
causes the refraction with it in place to vary.
Many experts suggest using a consensus approach for determining corneal curvature after refractive
surgery, rather than one method alone.[4]

Other methods currently being used include the corneal power correction equation by Shammas.[3] This
equation involves measuring the K's now and then averaging them into one number. So, the corrected K =
1.14 (average K) - 6.8.

Another method, referred to as the topography method, as published by Wang et al, involves measuring the
eye with topography, multiplying that number by 1.114, and then subtracting the correction factor of 6.1.

Gaining confidence is the method from Wake Forest University, sometimes known as the corneal bypass
method. In this method, the original K's prior to the refractive surgery are entered into the calculation
formula along with today's axial length measurement. In order to achieve emmetropia, however, the
refractive target entered into the calculation is the amount of correction from the refractive surgery. In their
study, all patients had better outcomes than using the standard clinical history method and the implants
were calculated to be closer to the perfect IOL power.[5]

Another method faring well in recent studies is the Masket Formula.[6] This formula involves an adjustment
in the final IOL power rather than an adjustment of the keratometry readings in the refractive surgery
patient. In Dr. Masket's study, keratometry and biometry were performed with the IOL Master as with
standard cataract patients, and then the following formula was used to adjust the calculated power from
those measurements:

IOL adjustment = LSE X (-.326) + 0.101, where LSE = the spherical equivalent of change after laser vision
correction. If the patient had myopic correction, the LSE should be a negative number, and if hyperopic
correction, a positive number. In other words, if a myopic refractive patient has standard calculations of
+16.0 D, and LSE was 6.0 D of myopia, -6.0 X (-0.326) + 0.101 = +2.057, which should be added to the
calculated +16.0 D for a final IOL power of +18.0 D. If a patient had hyperopic refractive surgery and the
calculation yielded a power of +22.0 D, and LSE was 3.0 D of hyperopia, +3.0 X (-0.326) + 0.101 = -
0.877, which is added to the calculated implant power of +22.0 D, for a final IOL power of +21.0 D.

On a final note, using a formula where the patient's actual preoperative anterior chamber depth is entered
into the calculation is best (ie, the optimized Haigis formula, the Holladay II IOL Consultant formula).
Formulas that only take into account axial length and keratometry falsely assume that these patients with
such flat K's after myopic correction must also have shallow anterior chamber depths, resulting in incorrect
IOL powers. Also, the history method has been shown to be not as accurate in the postradial keratotomy
patient, since the postoperative refraction never completely stabilizes.

Velocity Conversion
The velocity conversion equation is helpful in many biometric circumstances, including cases of silicone
oil in the vitreous, using an incorrect velocity setting on the biometer or measuring an eye filled with
silicone oil.[2] The equation is as follows:

Velocity (correct)/Velocity (measured) X Apparent Length = True Length

In the event of an incorrect eye type setting, this equation is quite simple to use and will preclude the need
for the patient to return for repeat measurements. For example, an aphakic eye was measured incorrectly
with the phakic average setting. The correct velocity for this eye is 1532 m/s. The velocity used was 1550
m/s. If the eye length obtained was 24.1 mm on the phakic average setting, then 1532/1550 X 24.1 = 23.82
mm = true eye length.
For eyes that have silicone oil in the vitreous cavity, this formula is used to determine the true vitreous
length. Silicone oil is used surgically to replace the vitreous in some cases of recurrent retinal detachment
and macular hole. The oil is removed several months later, but while in the eye, it causes a cataract, often
requiring the removal of the cataract at the time of oil removal. The velocity conversion equation is
necessary because the velocity through silicone oil is only 980 m/s, much slower than the 1532 m/s the
biometer uses in determining vitreous length. Therefore, the biometer measures the vitreous erroneously
long, and, consequently, the total length also is erroneously long. In a 4-gate system with silicone oil, the
ACD and lens thickness are accurate, so they should be subtracted from the total length to isolate the
erroneous apparent vitreous length. Then, the formula used is as follows:

980/1532 X Apparent Vitreous Length = True Vitreous Length

The corrected vitreous length is now added back to the anterior chamber depth and lens thickness for an
accurate total eye length. Biometry is best performed with these patients sitting upright so the bubble will
not separate from the retinal surface, causing a spike to arise at the back of the bubble, which can be
confused easily with the retinal spike. If an aphakic patient has silicone oil in the eye, it must be determined
whether or not the oil is in the anterior chamber or only the posterior chamber. If the oil is only in the
posterior chamber, the ACD should be subtracted from the total length, the vitreous length corrected using
the velocity conversion equation, then added back to the ACD.

 
An  eye  with  silicone  oil  in  the  vitreous  cavity.  The  erroneous  vitreous  length  was  isolated  from  the  
measurements  and  the  velocity  conversion  equation  used  to  correct  for  the  sound  velocity  through  
silicone  oil.  The  corrected  vitreous  length  was  added  back  to  the  anterior  chamber  depth  and  lens  
thickness  for  a  true  eye  length  measurement.  

If the oil reaches anteriorly to the back of the corneal endothelium, the entire eye length should be corrected
using the following equation:

980/1532 X Apparent Eye Length = True Eye Length

If oil is in the vitreous cavity of the pseudophakic patient, the ACD should be subtracted to isolate the
posterior chamber, using the following equation:

980/1532 X Apparent Vitreous Length = True Vitreous Length

Then, add back to the ACD along with the correction factor for the IOL in place.

Some newer ultrasound units have adjustable velocities or silicone filled eye types. In these cases, the
vitreous velocity is simply changed to the appropriate velocity through the silicone oil, and the
measurement is taken while the patient is sitting upright. Also, optical coherence biometry has been shown
to be effective in measuring these eyes, although the cataract must be mild enough for it to be used and the
patient must have the ability to fixate.

If the silicone oil is to be left in the eye permanently, power must be added to account for the index of
refraction of the silicone oil. Consulting the Holladay II IOL Consultant formula for this calculation is best.
Also, a silicone IOL should not be implanted in these eyes, because it will adhere to the silicone oil.

Contributor  Information  and  Disclosures  


Author  

Rhonda G Waldron, MMSc, COMT, CRA, ROUB, RDMS Senior Associate in Ophthalmology,
Diagnostic Echographer, Senior Technologist, Department of Ophthalmology, Emory University School of
Medicine

Rhonda G Waldron, MMSc, COMT, CRA, ROUB, RDMS is a member of the following medical societies:
Association for Technical Personnel in Ophthalmology, International Society for Ophthalmic Ultrasound,
and Ophthalmic Photographer's Society

Disclosure: Quantel Medical Honoraria Speaking and teaching; Quantel Medical Consulting fee Testing
new equipment; Accutome Honoraria Speaking and teaching; Alcon Laboratories Consulting fee
Ultrasound expert for animal research project

Coauthor(s)  
Thomas M Aaberg, Jr, MD Clinical Assistant Professor, Department of Surgery, Michigan State
University College of Human Medicine; Consulting Staff, Department of Ophthalmology, Associated
Retinal Consultants

Thomas M Aaberg, Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists,
Michigan Society of Eye Physicians & Surgeons, and Retina Society

Disclosure: Novartis Consulting fee Consulting

Specialty  Editor  Board  

Richard W Allinson, MD Associate Professor, Department of Surgery, Texas A&M University Health
Science Center; Senior Staff Ophthalmologist, Scott and White Clinic

Richard W Allinson, MD is a member of the following medical societies: American Academy of


Ophthalmology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy, Pharmacy Editor, eMedicine

Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment
from broker recommendation

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida

J James Rowsey, MD is a member of the following medical societies: American Academy of


Ophthalmology, American Association for the Advancement of Science, American Medical Association,
Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American
Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

Lance L Brown, OD, MD Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital,
Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief  Editor  

Rick Kulkarni, MD Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine,
Yale-New Haven Hospital

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American
Academy of Emergency Medicine, American College of Emergency Physicians, American Medical
Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic
Emergency Medicine

Disclosure: WebMD Salary Employment

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