Dr. Ursea: Good morning, everyone. It's a pleasure to be here this morning. So, I am going to talk about the ultrasound biomicroscopy technology, and also I would like to present how does it compare with the anterior segment OCT.

Many of us, we do know that looking at the anterior segment, many times it does present some difficulties. And it's not always very easy to visualize with the routine exam methods, and that's where imaging comes into place. My goal this morning is to present in the time allowed, of course, the utility and the benefit of the ultrasound biomicroscopy compared with the anterior segment OCT in pathology that involves the anterior segment.

It's been quite some time that ultrasound is available. And it was a French scientist in fact, Paul Langevin, who, together with Constantin Chilowsky, in 1926 developed an ultrasonic echo-sounding device. At the time, it was called the hydrophone and it was the basis for the development of the naval pulse echo sonar.

It's quite interesting to look at these very old images. And you can see how elaborated those machines were, how big, and the patient probably was not very comfortable. The technology improved so much over the years, and you can see nowadays that the ultrasound is available. Critically, you do have a very small, easy to use device linked to a computer which provides the images.

And UBM technology, the most useful one and the one that Quantel has, is the linear scanning technology. And the benefit is in fact that it visualizes the entire anterior chamber with the 16-millimeter linear scanning. And in one scan, either if it's 25 or the 50-megahertz, you has--you have a good view of the anterior segment.

Also, comparing with what was used during the last 10 years, right now the noncontact method, it's available. And the advantage is significant both for the patient as well as for the examiner. And you can see on the top left, it's been years back when we used the water bath. And the setup was a little bit--not very comfortable for the patient, and also sometimes you could have the leakage

On the right top you can see a baby, and probably they are doing a screening for the ROP, for the retinopathy of prematurity. You can see on the bottom the scleral shell. Some of them are more flexible. Some of them are a little bit more rigid. And they allow the BSS, the saline, which is the contact media for the transducer so we can take the images.

And you can see that the patient actually not necessarily needs to lie down anymore nowadays. The important, and something that I'm sure that you are going to be much more familiar with, is this ClearScan. And the big advantage is that actually the patient is much more comfortable. It's sitting in the chair and it's not the whole water bath and the setup that we used to have before.

So, with the new technology, everything was made so much easier. And you can see on the right bottom corner that the BSS, it's practically hold in that bullet shape type of a tip. And I'm sure that Dr. Prager is going to go into many details about this technology.

What are the clinical application of the imaging devices? They are quite extensive, starting with the anterior part of the eye with the corneal pathology. Refractive surgery is a hot topic nowadays, as well as the phakic IOLs. It's always useful in cases of trauma both before and after the surgery. Anterior segment tumors is a key area in which ultrasound is used. And without the ultrasound, practically you do not have a diagnosis and you cannot really relay to the patient about a prognosis and what is going on. Many times we use it for patients that had cataract surgery and in which there were some difficulty, surgical problems. And we can assess with the ultrasound and see exactly what's going on. And a very extensive field in which ultrasound is used is glaucoma. And this morning you are going to hear also from Dr. Norager [sp].

I am at the University of Arizona, and I'm fortunate enough to have two systems for the ultrasound biomicroscopy. I do have a Quantel and also a Sonomed. We do have the anterior segment OCT that was made by Zeiss and also I do have the Artemis, which is the top of the line. It's the very high frequency ultrasound which is not yet commercially available. So, these are my little toys, and it's very interesting to see the different pathology and also to use the advantages that each technology is offering.

While the ultrasound biomicroscopy involves a coupling media, the BSS, it does require a setup in which you can saw that there is a scleral shell, not anymore now with the ClearScan, but the presence of the coupling media is necessary in order to take the images. In comparison with the anterior segment OCT, it's a noncontact method and it does provide high resolution of the anterior segment.

When you look at the different characteristics between the two, I would like to point that the penetration depth in ultrasound, it's six times more than it is in the Visante or the anterior segment OCT. This is a key factor that provides the many advantages the ultrasound has and that I am going to talk about. We did talk about the fluid presence in the UBM, and then you don't need that. So, it's just air in the case of the OCT.

The scan geometry is also different. So, for the UBM, we are using a linear scanning. For the anterior segment optical coherence tomography, it's rectangular, a telecentric type of scanning. And then, for the Artemis, which is a very high frequency ultrasound, it's the so-called arc or concentric, in which in fact you do have a laser point which is the target. And the patient does not need to move the eye, but the transducer is moving on the arc.

What about the ultrasound? Maybe it's not the best thing to call them limitations, but it does require some skills and we need to know about them. So, the first requirement, the coupling media, it's improving over time. And as I mentioned with the Aviso and with the ClearScan, it was improved in terms of comfort for both patient and the examiner.

Sometimes there is inadvertent pressure on the eyecup. And this, while you scan, it can influence especially the angle configuration. And then, if you look at the cornea, sometimes you realize that it might be too pressure. So, when I am scanning, in fact I look at the monitor and on the screen on the computer. And if I see a little bit of deformity in the cornea, it tells me that I apply a little bit too much pressure.

Also, you can use--or in the past it was just one quadrant that can [unintelligible] at a time. It's not a very fast method, but with time, with practice, nowadays it doesn't take me more than a few minutes to take the--all the images that I need and also to scan 360 degrees each eye. So, it does require some skills that, with practice, comes pretty handy.

One thing that we need to be careful about is the possible risk of the infection or corneal abrasion. And in patients with trauma, you need to have a judgment call at what time and in which condition you are going to use. This being said, of course it's contraindicated in open globe injuries. Nevertheless, in patients with significant trauma, I still use the ultrasound. And the way that I do it is I put the transducer in a finger of a glove in which we put the BSS, so it's going to be very gently application on the eye. And you can see very good images that would help you to see exactly what the trauma was before you take the patient to the operating room.

What are the advantages? And these are very important that makes it a very important technology. First of all, it's practically the main technology that visualizes the ciliary body. So, because of that, it's essential in defining the mechanisms of closure in angle closure glaucoma. Also, I mention the ocular tumors. So, when we do have an iris lesion, it's very important to visualize and to see is the ciliary body involved or not. In this way, we can give feedback to the patient regarding the prognosis.

The gold standard technology is in plateau iris and also in retroiridal processes, where nothing can replace the ultrasound in terms of imaging what the pathology is. So, all the anatomic relationships, either that it's in normal patients or in patients that present different pathology, can be visualized very well with the ultrasound.

And the advantage is, even if you have a cloudy cornea or opaque media, you can go and see in depth what's happening. In pre-operatory assessment of the anterior segment, it does offer us best surgical planning and it avoids surprises in the operating room.

The very high frequency ultrasound, 30 to 70 megahertz, is limited to the anterior segment. And I would like to present a few slides about different pathology. As you can see, I mention glaucoma and trauma and the refractive and corneal pathology, but also in cases of foreign body or displaced IOL it's a very useful tool.

These are some images that were taken with the Quantel technology. And you can see on the top left large irises. On the bottom you can see the irises, but also there is also a little cyst in the ciliary body. On the right top corner, you see an iris tumor. So, the iris is distorted and it's thickened. On the bottom, you'll see that there is a ciliary body tumor. The ciliary body is much increased and pushing a little bit forward the iris

So, just getting on a few indications of the ultrasound, I am going to present a few perioperative assessments in which I used the ultrasound. This is a patient that came with Peters anomaly, and he had a significant cataract. He was referred for surgery.

And I used both techniques, the ultrasound and also the anterior segment OCT, in order to visualize before I took him over to the operating room. And as you can see on the top over here, all these are ultrasound images comparing with the anterior segment OCT. You can see the cornea, the iris, and look at the depth of the image and how much details it's giving comparing with the anterior segment OCT.

Here I do recognize that the cornea looks much better and it's high resolution, but you cannot see anything what's happened behind that. I would like to point out over here how almost closed the angle is. So, it's very, very narrow and the iris is pushed forward.

So, we went ahead and he had the cataract surgery performed. There was peripheral anterior synechiae with some thinning of the cornea over here that was still present. But, comparing the before surgery with the image after surgery, you can see the deepening of the anterior chamber and then the opening of the angle.

This is a patient that has a long history of Sjögren disease, and he--she could hardly open her eyes. With the anterior segment OCT, in fact we were able to see how thin the cornea is, and in fact it was down to 210 microns. So, we could take her to the operating room before perforation.

In patients that have keratoconus and they do have INTACS placed, the intrastromal corneal rings, we can use the technology in order to see exactly how deep the segments were placed. So, this is the ultrasound image and also the Visante image, and we can see the site of the INTACS.

In cases that did not go very well during surgery with a cataract surgery or maybe something happened like a trauma later on, there is inflammation sometimes because haptics are rubbing against the ciliary body. You can see very well over here that this lens, posterior chamber intraocular lens, was displaced and also it's tilted. So, these Quantel images are showing exactly what happened. It's very important to see the positioning of the lens in order to decide what you are going to do in the surgical room.

The technology is very, very useful for patients that are doing ICLs. And in fact, without having the ultrasound, it's hard to take the patient to the operating room. Why do I say that? It's because there are certain criterias which are pretty rigid if the patient is a good candidate for the ICL or not.

And ultrasound is the practically the only technology that can allow visualization angle to angle so you can measure and see if the patient would be suitable for this technology. Also, in patients that do have the ICL, once in a while I do get some referrals in order to visualize them and to see what's happening. Patients with glaucoma that--like this one that had also a corneal transplant and had a tube placed, in fact he had a Molteno valve, you can easily visualize the position of the tube and also if there is endothelial touch or not.

This patient was pretty interesting. It was sent over before the surgery and it was more an unusual case in which there were large cysts. And you can see there are multiple ones in the anterior chamber. So, I am waiting, in fact, for pathology after the surgery was done elsewhere. But, you can see exactly the dimensions of the cyst and also you can delineate very well so you don't have some surprises in the operating room.

This was a 50 years old patient that had trauma, so he went--underwent the PKP. And you can see that it was a very big laceration, full thickness. After he had the corneal transplant, he developed a dellen. So, you can see actually how thin the cornea was in this particular site. So, we decided to re-graft him.

We always get trauma in the hospital, and most of the injury is secondary to blunt objects. The ultrasound is essential because that it's necessary to do a very meticulous evaluation and to select the appropriate treatment in patients with trauma, because otherwise the patient has significant visual impairment and they can lose the eye.

The traditional methods of evaluation were imaging, but the ultrasound brought new features that overcome the limitations of the previous methods like x-ray or CT. So, in trauma causes we can use either the 10 megahertz or, for the anterior segment, we can use the higher frequency, the 35 megahertz.

This is a patient that had a trauma, and in fact she had high pressure. And we can easily visualize the blood clot in the angle over here that induced the high spike. Another patient with a significant trauma that induced a cataract, a dense cataract. There was no visualization of the posterior pole. And we can use both technologies.

Look at the difference between the Visante here on the left and the ultrasound. You can see the cornea very well and just the tip of the iceberg, I would call it, over here. There is nothing behind and nothing deeper than that that you can see or tell about. In comparison, the ultrasound allows us to visualize everything that was going on. And despite the cornea and the angle, we can see how deep the pathologic trauma was induced in this particular patient.

Also, the same very significant comparison between the Visante and the UBM. Look how much of the pathology it's missing on the anterior segment ultrasound. And again, the ability of the ultrasound to penetrate deeper, again it's six times more, it's that it can show what the angle--it's obstructed.

Another patient with thinning of the sclera. And I wanted to present in some inflammatory type of cases. We can actually visualize, in patients with scleritis, the thickening of the pathology. And the ultrasound can tell us in millimeters how much it is, and then see the response to the treatment.

A patient with ciliary body detachment and also pars plana exudates. In a patient with chronic uveitis, we can see the reason for the low pressure. And it was the ciliary body detachment. I am going to wrap up over here in order to have some time for my colleagues. Thank you.