A scan biometry

Dr pooja patil

Principles of ultrasound
Frequency 10MHz
Resolution
Velocity of sound and density of
media
cornea and lens 1641m/s
Aqueous and vitreous 1532m/s
Phakic vs aphakic

A scan
In A-scan biometry, one thin, parallel
sound beam is emitted from the
probe tip, 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,

 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

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.

 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 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.

 Spike height depends on angle of

incidence
Probe orientation to the visual axis.
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,

 Macular pathology- adverse effect

over spike quality
Spike quality is reduced in the case
of an extremely dense cataract.

 The gain setting on biometers is

measured in decibels and affects
amplification and resolution of the
displayed spikes
Highest gainweak signals
visualized -Resolution is affected.
Low gain - eliminates weak signals
and 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).

 Gates are electronic calipers on the

display screen 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 that measure between two
points.

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.
error of 0.5 mm -1.25 D refractive error,
error of 1.0 mm - 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.

 The average ACD is 3.24 mm but varies

greatly.
If the biometrist is documenting a shallow
ACD, 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

 Current 2-variable formulas that are

considered the most accurate include
the Hoffer Q, SRK/T, and Holladay I.
Two-variable formulas are those that
only take into consideration the axial
length and the corneal curvature.
Multivariable formulas have proven
to be the most accurate due to more
of the eye anatomy being
considered.

 The Haigis formula is a 3-variable equation,

using not only axial length and corneal
curvature but also the anterior chamber
depth of the eye. The Holladay II formula is
a 7-variable equation widely thought to be
the most accurate formula; it takes into
account axial length, corneal curvature,
horizontal white-to-white, anterior chamber
depth, lens thickness, precataract
refractive error, and age of the patient

 Predicting lens position is one of the most common

causes of a postoperative surprise; by taking more
of the eye anatomy into account, this can be more
accurately predicted. For average-length eyes with
average Ks, 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 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.

BIOMETRY THROUGH DIFFERENT IO

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.

 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
PMMA is 2718 m/s,
acrylic is 2120 m/s,
through silicone is 980-1107 m/s
depending on the silicone used.

 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 (35C), 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).
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.

Common Errors and Challenging Situations

The most common error in the contact

technique is corneal compression.
The lower IOP .
If the contact technique used, the
ACD must be monitored and the
shallower anterior chamber depths
deleted even if the spikes appear to
be of high quality.

 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.

 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 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.

 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.

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.
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.

 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.The equation is as
follows:
Velocity (correct)/Velocity (measured)
X Apparent Length = True Length