Bedi et al.

Head and Neck Imag ing • Pictorial Essay

Sonography of the Eye

A C E N T U
R Y O F

MEDICAL IMAGING
Sonography of the Eye
Deepak G. Bedi1 OBJECTIVE. The purpose of this study is to show how sonography can reveal pathology
Daniel S. Gombos2 of the eye and to highlight its usefulness as a simple and cost-effective tool in investigating
Chaan S. Ng1 eye symptoms.
Sanjay Singh3 CONCLUSION. The cystic nature of the eye, its superficial location, and high-frequency
transducers make it possible to clearly show normal anatomy and pathology such as tumors, ret-
Bedi DG, Gombos DS, Ng CS, Singh S inal detachment, vitreous hemorrhage, foreign bodies, and vascular malformations. Sonography
is useful as a treatment follow-up technique because it has no adverse effects. Sonography is well
tolerated by patients and relatively easy to perform for those familiar with real-time sonography.

he superficial location of the eye, and an 8–10-MHz A-mode probe (Innova-

T its cystic composition, and the

advent of high-frequency ultra-
sound make sonography ideal
for imaging the eye [1]. MRI is favored by
radiologists, so there are few reports on oc-
ular sonography in the radiology literature
[2, 3]. Sonography is used more commonly
by ophthalmologists to evaluate the eye,
particularly when direct examination by
slit-lamp and funduscopy is not sufficient.
Detailed cross-sectional anatomy of the en-
Keywords: eye sonography, ocular imaging, ocular tire globe is possible with conventional
melanoma, ocular sonography
sonographic equipment [1–4]; anterior
DOI:10.2214/AJR.04.1842 chamber visualization requires a dedicated
sonographic biomicroscope [5]. Color Dop-
Received December 3, 2004; accepted after revision pler and A-mode sonography [1, 6] are re-
August 31, 2005.
ported to be useful in characterizing masses.
1Department of Radiology, The University of Texas M. D.
The sonography examination is rapid and
Anderson Cancer Center, Box 57, 1515 Holcombe Blvd., cost-efficient, without the contraindica-
Houston, TX 77030. Address correspondence to tions, such as pacemakers, that MRI has.
D. G. Bedi (dbedi@di.mdacc.tmc.edu). Sonography avoids the irradiation associ-
2Department
ated with CT and the need for sedation in
of Ophthalmology (Plastic Surgery), The
University of Texas M. D. Anderson Cancer Center, children [7]. Therefore, it can be used re-
Houston, TX 77030. peatedly during treatment of tumors to as-
sess response to therapy.
3Department of Radiology, Methodist Hospital, Houston,
TX 77030.
Technique
CME Conventional gray-scale sonographic equip-
This article is available for 1 CME credit. See www.arrs.org ment (Elegra, Siemens Medical Solutions;
for more information. ATL, Philips Medical Systems) and 7.5–15-
AJR 2006; 187:1061–1072
MHz transducers were used by the radiol-
ogy department, scanning through the
0361–803X/06/1874–1061
closed eyelid (Fig. 1A). The ophthalmology
© American Roentgen Ray Society department used a 10-MHz B-mode probe
tive Imaging Systems), scanning through
the open eye after paralyzing the blink re-
flex (Fig. 1B). A dedicated ocular sono-
graphic biomicroscope, using frequencies
up to 50 MHz (Fig. 1C), was available for a
limited time.
In the illustrations shown here, the radiol-
ogy transducers were linear and the images
are axial in a traditional anterior-to-poste-
rior orientation. Ophthalmology used sector
transducers, and their images are also axial
but rotated in a left-to-right orientation to
show the A-mode echo patterns. The term
“reflectivity” is used in some figure legends
to describe A-mode echo patterns and is
similar to the term “echogenicity,” but in ad-
dition describes amplitude of tissue inter-
face reflection.
Normal Anatomy
The cornea, conjunctiva, anterior cham-
ber, posterior chamber. and iris (Figs. 2
and 3) rarely require sonography and are
not well visualized with conventional
sonography, but they are excellently de-
tailed with newer sonographic biomicro-
scopes. The lens is best inspected directly,
with no need for sonography. A mature cat-
aract of the lens may obscure the retina on
funduscopy, necessitating sonography. The
vitreous body is gelatinous and anechoic,
with loose attachments to the retina, and it
stabilizes the eyeball. The choroid is part
of the uveal tract, which also includes the

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 Bedi et al.

Fig. 1—Technique for sonography of eye.

A, Radiologists use compact “hockey-stick” linear transducer with patient’s eyelid
closed. Small amount of gel is sufficient for posterior eye anatomy; standoff pad or
abundant gel can be used for anterior chamber.
B, Ophthalmologists perform examination after paralyzing blink reflex and scan open eye.
C, Ultrasound biomicroscope transducer, operating at 50 MHz, scans through water
bath (arrow), incorporated into transducer, which is placed on open eye.

B C

Fig. 2—Axial cross-section of eye and diagrammatic representation of pathology.

C = cornea, A = anterior chamber, L = lens, V = vitreous body, CH = choroid,
CB = ciliary body, I = iris, R = retina, S = sclera, CRA = central retinal artery,
ON = optic nerve, PCA = posterior ciliary arteries. Sonographic anatomic correlation
is shown in Figure 3; some vascular structures are seen only in Figures 3 and 16.

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 Sonography of the Eye

A B

Fig. 3—Normal eye anatomy.

A and B, Axial sonograms show normal anterior chamber (A), lens (L), choroid (CH),
ciliary body (CB), iris (I), and sclera (S) in A and V = vitreous body (V) and optic nerve
(ON) in B.
C, Axial color Doppler sonogram shows normal central retinal artery (CRA).
C

ciliary body and iris, and is the site of a rich vascular supply from the long and the retina is pigmented, direct inspection
many intraocular tumors. The choroid has short posterior ciliary arteries. Because of the choroid by funduscopy is limited,

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 Bedi et al.

Fig. 4—34-year-old man with cystic lesion of iris (arrow), illustrated with use of Fig. 5—47-year-old man with iris melanoma. Ultrasound biomicroscopic image
standoff gel pad to visualize anterior eye anatomy. C = cornea, A = anterior chamber, provides better anatomic detail of anterior portion of eye than conventional
P = posterior chamber, V = vitreous body. sonogram shown in Figure 4.

A B
Fig. 6—52-year-old woman with choroidal melanoma.
A, Typical sonographic features include hypoechoic mass, lobular in shape, with marginal retinal elevation (large arrow). Hyperechoic rim is combination of elevated retina
and peripheral blood vessels. Characteristic hypoechoic echotexture is also seen in A-mode scan (graph at bottom), which shows decreased reflectivity between two small arrows
corresponding to margins of mass, a feature that sometimes helps distinguish it from other types of tumor (see Figs. 13–15).
B, Funduscopy shows large dark melanoma (large arrows) with peripheral retinal elevation (small arrows), which appears translucent yellow because red color of underlying
choroid, seen elsewhere, is lost.

and sonography plays an important role in static tumors. The retina and choroid are the normal eye; the sclera is a highly re-
diagnosing choroidal melanoma and meta- sonographically perceived as one layer in flective outer layer.

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 Sonography of the Eye

Fig. 7—45-year-old
woman with ciliary body
melanoma.
A, Sonogram shows
tumor is large and round,
which is common for
melanoma. C = ciliary
body, A = anterior
chamber.
B, Color Doppler
sonogram shows blood
vessels (arrows)
encircling and
penetrating tumor.
C, Ophthalmoscopy
shows dark tumor
(arrows) partially
obscuring normal “red
reflex” of retinochoroidal
pigmentation seen
through dilated pupil.

A B

Fig. 8—62-year-old man

with melanoma (arrow)
arising from ciliary body
(C), which is small and
buttonlike. Small
melanoma of ciliary body
can be missed because of
its small size and location
if funduscopy is performed
without depressing sclera
externally.
C D

The retina has a rich blood supply from the
central retinal artery, which is clearly seen on
color Doppler sonography, as are the adjacent
posterior ciliary arteries that supply the chor-
oid and the optic disk. The optic nerve is vis-
ible sonographically as a hypoechoic band
starting at the scleral zone and extending pos-
teriorly and medially.
Pathology
Lesions of the Iris
Cystic or solid lesions of the iris are difficult
to show on conventional equipment (Fig. 4) but
are well detailed on dedicated ultrasound biomi-
croscopic imaging (Fig. 5). This equipment, op-
erating at 50 MHz or sometimes higher, has a
resolution of 30 µm, far in excess of CT or MRI.
Malignant Melanoma
Malignant melanoma (Figs. 6–8) is the
most common primary intraocular tumor
and occurs more often in the choroid than in
the iris or ciliary body. Iris melanomas can
cause secondary glaucoma. Ciliary body
melanomas may cause changes in accom-
modation from lens displacement. Choroi-

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 Bedi et al.

Fig. 10—Complications
of melanoma in 69-year-
old woman with
diminished brightness of
vision. Vitreous
hemorrhage, seen as
low-level echoes filling
vitreous body (V),
completely obscures
direct view of tumor
(arrow) by funduscopy.

Fig. 9—Complications of melanoma in 56-year-old man

with blurred vision. Retinal elevation (small arrows) is
caused by tumor mass (large arrow) or by possible
transudation of fluid.

dal tumors present with decreased visual

acuity and visual field defects. A small mel-
anoma of the ciliary body (Fig. 8) can be
missed if funduscopy is performed without
depressing the sclera externally. Melanomas
of the eye are usually rounded, hypoechoic,
and very vascular. They can be complicated
by retinal elevation and vitreous hemor-
rhage (Figs. 9 and 10).

Vitreous Hemorrhage
Vitreous hemorrhage spreads diffusely in
the gelatinous vitreous, obscuring the optic
disk, and does not form a fluid meniscus un-
less the bleeding is in the space around the
vitreous. The causes of vitreous hemorrhage
include vitreous detachment, diabetic retin-
opathy, retinal microaneurysm, trauma, and Fig. 11—Complications of melanoma in 42-year-old
vascular tumors. The patient complains of man with severe loss of vision in one eye. Location of
melanoma (large arrow) on and adjacent to optic disk
“black rain” and has reduced visual acuity. (small arrows) may prevent radiation treatment and
The hemorrhage is absorbed slowly, and the could necessitate enucleation of eye.
clinical course depends on the exact cause.
If choroid tumors are large or near the optic
disk (Fig. 11), enucleation of the eye is
sometimes necessary. However, brachyther- sites (Figs. 13 and 14). Metastatic tumors are Rhabdomyosarcoma
apy—that is, radiation plaques [8] placed discoid in shape and hyperechoic compared Rhabdomyosarcoma is the most common
outside the sclera adjacent to the tumor—is with melanoma. A-mode sonography shows the primary malignancy of the orbital cavity in
the preferred mode of treatment (Fig. 12). difference in echogenicity (also called “reflec- children, presenting with proptosis, inflam-
tivity” in ophthalmology literature; see Figs. 6 mation, and loss of vision. A combination of
Metastasis and Lymphoma and 13) between melanomas and metastases. radiation and chemotherapy makes a cure
Metastasis to the choroid is most common Lymphoma can occur in isolation or as metasta- possible in many cases. Sedation for re-
from the breast, lung, and unknown primary sis to the choroid or the vitreous body (Fig. 15). peated CT or MRI during follow-up was

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 Sonography of the Eye

A B
Fig. 12—55-year-old man with choroidal melanoma.
A, Sonogram shows melanoma (M) before brachytherapy (radiation plaque treatment). Melanoma is biconvex, with slight elevation of retina (arrow) at one margin because
of serous fluid transudate.
B, After radiation plaque treatment, tumor (M) shows significant decrease in volume. Apical tumor dimensions can be obtained using A-mode sonography (not shown).

avoided in the child shown in Figure 16 by

using sonography.

Hemangioma
Hemangioma is the most common benign
tumor of the orbital cavity and can be capillary
(in children) or cavernous (in adults, Fig. 17).

Retinoblastoma
Retinoblastoma is the most common pri-
mary intraocular malignancy of childhood
[9] (Fig. 18), often occurring before the
Fig. 13—50-year-old age of 3 years, and presenting with a white
woman with primary pupil (leukocoria) and strabismus. Retino-
breast cancer blastoma is quite vascular and can invade the
metastasizing to eye.
Although flat hyperechoic vitreous body.
tumor (long arrow) is
morphologically similar to Microphthalmos and Coloboma
lymphoma (Fig. 15) or
treated melanoma
Microphthalmos and coloboma are con-
(Fig. 12), its surface is genital anomalies caused by incomplete fu-
more irregular, and A- sion of the optic cup in the sixth week of preg-
mode sonography nancy. They cause a posterior eyeball defect
(tracing at bottom)
shows high reflectivity with a posterior orbital cyst and an abnor-
(short arrows). mally short eye (Fig. 19).

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 Bedi et al.

A B
Fig. 14—67-year-old man with metastatic adenocarcinoma from unknown primary site.
A, Tumor is flat hyperechoic mass (arrows), well seen sonographically in nasal field of rotated eyeball.
B, MR image shows subtle, isointense flat mass in nasal aspect of right eye (arrow), which is best seen on this T1-weighted image; T2-weighted images showed similar
intensity for tumor and adjacent orbital fat.

Foreign Bodies
Foreign bodies can be metallic, plastic, or
wood. The bodies usually lodge in the con-
junctiva or cornea, and the diagnosis is made
by direct examination. Occasionally pene-
trating through the cornea (Fig. 20), metallic
foreign bodies may lodge anywhere up to the
retina and can cause severe inflammation
Fig. 15—38-year-old and infection.
woman with lymphoma.
Sonography depicts
Asteroid Hyalosis
rather flat mass of
moderate echogenicity Asteroid hyalosis (Fig. 21) is character-
(long arrow). A-mode ized by the presence of minute opacities due
sonographic tracing, to calcific deposits in the vitreous body,
taken through black-line
axis, shows moderate mainly in patients with diabetes and hyper-
reflectivity (short arrows) cholesterolemia. It is usually unilateral and
that iSs greater than that rarely bothersome to the patient, but it can
of melanoma (low
reflectivity) but less than
obscure the examiner’s view of the fundus. If
that of metastasis (high visual acuity is affected, the deposits are re-
reflectivity). moved by vitrectomy.

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 Sonography of the Eye

A B
Fig. 16—2-year-old boy with rhabdomyosarcoma of extraocular muscle.
A, Hypoechoic, conical tumor (short arrows) is seen posterior to eye and slightly superior to optic nerve (long black arrow). Retinal detachment is also present (white arrow).
Advantages of sonography in this infant outweigh those of MRI because sedation was avoided with minimal loss of anatomic information.
B, Color Doppler sonogram shows that despite tumor infiltration around optic nerve (arrows), blood flow through central retinal artery (CRA) and posterior short ciliary arteries
(PCA) is intact.

Fig. 17—37-year-old man with hemangioma of orbit.

A, Nasal superior location is common, as seen on this sonogram, which shows
superior ophthalmic vein (black arrow) draining hemangioma (white arrows).
B, IV contrast-enhanced CT scan of orbits shows prominent draining vessels
(arrows) more clearly than sonogram, but repeated irradiation from CT during
follow-up was avoided by using sonography, which provided satisfactory images
and flow information.
C, Color Doppler sonogram shows blood flow of mixed color (arrows), indicating
some turbulence in larger vessels of hemangioma in medial aspect of image.
Draining ophthalmic vein seen on gray-scale images and CT is not visible,
presumably because of low-velocity flow.
A

B C

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 Bedi et al.

A B
Fig. 18—1-year-old girl with retinoblastoma.
A, Irregular shape of tumor (short arrows) is hard to outline on this sonogram, but hyperechoic calcific foci (long arrow) are characteristic of retinoblastoma.
B, Large retinoblastoma is cream-colored on funduscopic image and partly overlies optic disk (arrow).

A B
Fig. 19—37-year-old man with microphthalmos and coloboma.
A, Axial left-to-right sonogram shows abnormally short length of eye (double arrow), posterior defect or coloboma (single arrow), and cyst (C) behind eye.
B, Abnormality, particularly cyst (C), is better detailed on axial MR image although coloboma is clearer on sonography.

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 Sonography of the Eye

Fig. 20—32-year-old male iron foundry worker with foreign body in eye, which Fig. 21—72-year-old man with asteroid hyalosis. Sonogram shows scattered
appears as hyperechoic focus (arrow) in vitreous body of eye. hyperechoic foci (arrow) in central vitreous body.

Fig. 22—58-year-old man with optic disk drusen. Sonography shows characteristically Fig. 23—42-year-old man with retinal detachment. Sonography shows severe
hyperechoic spots at fundus (arrow) and is particularly helpful in revealing drusen posterior, central detachment (arrow). See Figures 6 and 9 for other examples of
buried in optic nerve, which are otherwise invisible on funduscopy. detachment.

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Optic Disk Drusen
Optic disk drusen (Fig. 22) are calcified lob-
ular bodies in the tissues of the optic disk and
nerve that are bilateral in most cases. Usually
asymptomatic, optic disk drusen can cause vi-
sual field defects if buried deep in the disk
because of compressive atrophy of nerve fibers.
Retinal Detachment
Retinal detachment (Fig. 23) is a sepa-
ration of the neurosensory retina from the
underlying pigmented layer. This condi-
tion can be asymptomatic for a long time,
then presents with flashes of light, float-
ers, “black rain” (if there is accompanying
vitreous hemorrhage), a dark shadow, or
loss of visual acuity, depending on the ex-
act location and severity of the detach-
ment. The three types are based on the
cause: Rhegmatogenous detachment—that
is, associated with a retinal tear—is the
most common type and is seen with ad-
vancing age, a familial disposition, and as-
sociated myopia. Tractional detachment
F O R YO U R I N F O R M AT I O N
This article is available for 1 CME credit. See www.arrs.org for more information.
1072
Bedi et al.
originates in adjacent vitreous strands. Ex-
udative detachment is due to fluid, blood,
or lipids behind the neurosensory retina
and can be associated with tumors of the
choroid.
Conclusion
Sonography of the eye shows a variety
of diseases with remarkable clarity. The
technique is more cost-efficient than other
diagnostic techniques and is well tolerated
by the patient. We have experienced no
limitations and have received no com-
plaints from patients. We do not advocate
the routine use of sonography in the
asymptomatic eye, but it may serve as a
useful extension of the initial investigation
of the symptomatic patient.
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