Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
179
Real-Time Trauma
J. Stephen Kwong1 Peter L. Munk1 David 1. C. Lin2 A. Dale Vellet1 Morris Levin1 Anne R. Buckley3
Sonography
in Ocular
Real-time sonography was evaluated retrospectively in 71 consecutive patients with ocular trauma. A total of 51 vitreous hemorrhages, 20 hemorrhages in the anterior chamber, 22 retinal detachments, seven choroidal detachments, five foreign bodies, and 12 dislocated lenses were identified sonographically. In 10 instances (three choroidal detachments, six retinal detachments, and one lens dislocation), these sonographic findings were not apparent on clinical examination. One hemorrhage of the anterior chamber was missed on sonography. Both sonography and clinical examination failed to visualize one retinal detachment. The results of this study show that real-time sonography is valuable in the assessment of ocular
trauma
and
158:179-182,
AJR
supplements
January
clinical
examination
with
valuable
information.
1992
Ocular trauma is a commonly encountered clinical problem, and generally, ocular assessment is first done by clinical examination. After trauma, clinical examination often is difficult because of opacification of the ocular media, or because of the patient’s inability to cooperate. Sonography has been used to examine ocular abnormalities since the late 1 950s, and since this time, surprisingly little about the use of nondedicated high resolution real-time sonography in the evaluation of ocular trauma has appeared in the ophthalmologic or radiologic literature. We reviewed the sonographic findings in a group of patients who sustained eye injuries
and
in this
clinical
Materials
were
referred
and
1990.
7.5-MHz
clear Medicine,
excluded
University
Hospital and University
339 Windermere Rd. , London, Canada. Address reprint re
quests to P. L. Munk. 2
Department
of
Ophthalmology,
Vancouver
General Hospital and University of British Columbia, 855
W.
12th
Ave.,
Vancouver,
B.C.
V5Z
1M9,
Canada. 3
Department
Hospital
of Radiology,
and University
12th Ave., Vancouver, 0361 -803X/92/1 © American
Vancouver
General
Columbia,
855 W.
of British
B.C. V5Z 1M9, Canada.
81 -01 79
Roentgen
Ray Society
trauma, minimize
ruptured The
was
transducer,
were not scanned
of Western Ontario, Ontario N6A 5A5,
studied
Scanning
Received July 1 , 1991 ; accepted after revision August 13, 1991. I Department of Diagnostic Radiology and Nu-
linear-array by
an are
the
globe. sonograms
7i
patients
done
with
or occasionally
transducer.
we
institution,
to evaluate
the
use
of this
technique
Methods
We retrospectively March
to our
situation.
possibility
of
Conventional obtained
not
causing
by
to apply
reviewed
between
globe
a qualified of
transducer by two
the
January
scanner
(Mountain
technique
pressure
expulsion
sonographic were
scanner
of an open
performed
careful
trauma
small-parts
or closed-lid
the presence
examination always
ocular
an Acuson
A paraocular
until
with
a Diasonics
View,
was
injury
(Milpitas,
used
intraocular
rupture In cases
traumatized contents
and with
a
CA) with a 5-MHz
in all cases.
or globe
ophthalmologist. to the
i989 CA)
globe
Patients
had been of
ocular
in order
from
an
occult
with
the
report
to
gel was used. radiologists
and
correlated
made at the time of scanning. In addition, the charts of 40 patients were available for review. By reviewing the charts, the clinical history, time of injury, previous ophthalmologic history, and surgical findings were obtained. Surgical correlation was available in 27 cases. In many instances, scans were obtained only postoperatively. The average patient age was 37 years old; 63 were men and eight were women. Of the 40 cases with available clinical histories, 30 were acute (4 weeks since injury).
Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
180
KWONG
El
AL.
AJR:158,
January
1992
Fig. 1.-Vitreous hemorrhage. A, Transverse sonogram through globe. This patient had a direct blow to eye I day before examination, with a massive vitreous hemorrhage, which could readily be seen on funduscopy. Only a few scaftered, low-amplitude echoes are visible within vitreous body. In this situation, increasing gain setting is often helpful for detecting acute hemorrhages, which are often only minimally echogenic. Also, note posterior displacement of lens (arrows) into anterior aspect of vitreous body. B, Transverse sonogram of eye 1 week after surgery to repair a ruptured globe and extraction of a dislocated lens. Entire vitreous body is filled with homogeneous echoes, representing a diffuse hemorrhage. Usually within 1-3 days after acute hemorrhage, vitreous body becomes markedly echogenic.
Fig. 2.-Retinal detachment. A, After a blow to head in a motor vehicle accident, this patient lost vision in one eye. Ret-
ma is detached
from underlying
choroidal
layer
and is seen on sonogram as two thin, echogenic lines at posterior aspect of vitreous body, emanating from region of optic nerve head, which is seen as an hypoechoic band behind globe (arrow). Detached retina is not seen to pass any farther anteriorly than ora serrata, which is antenormost aspect of retina that inserts slightly posterior to ciliary body. Acute retinal detachments are seen as thin echogenic lines, whereas chronic retinal detachments become thicker and less mobile. B, In another patient, a focal retinal detachment is present with an accompanying tear, al-
lowing detached
segment to assume a wrinkled
appearance.
the
Results
iris plane;
previously Hemorrhage
was
the
most
common
sonographic
finding
cases of bleeding into the vitreous body and 20 cases of bleeding into the anterior chamber were identified. Nineteen of 20 cases of hemorrhage in the anterior chamber had an accompanying hemorrhage in the vitreous body. In addition, subchoroidal hemorrhage was present in four patients, subretinal hemorrhage in nine patients, and subhyaloid (Fig.
1). Fifty-one
hemorrhage
in four
patients.
Membrane detachments were seen in 37 cases. Twentytwo of these cases were retinal detachments (Fig. 2). Most of the detachments were large, involving most of the retina. Seven patients had choroidal detachments (Fig. 3). In eight instances, the hyaloid body was detached (Fig. 4). Foreign objects intraocular
were
encountered
air was
identified
in five (Fig.
cases.
In four
instances,
5).
Abnormalities of the lens also were relatively common. The lens was noted to be echogenic in 1 3 patients, consistent with cataract. Dislocation of the lens was identified in 12 instances (eight posterior, three anterior, one laterally within
been
Figs.
1 A and
extracted,
6). In 1 3 instances, and
in six
of these
the lens had 1 3 instances,
a prosthetic lens was identified. Surgical correlation was available in 27 cases. Five abnormahities were not identified sonographically: one hyphema, one cataract, one retinal detachment, and two instances of ruptured
globe
(Fig.
7). Clinically,
rupture
of the
globe
was
common, occurring in 26 patients, 24 of whom had the globe repaired before sonographic examination. The two ruptures that were not detected sonographically were subsequently detected clinically. In one instance, choroidal detachment was suspected clinically, but was not confirmed by sonography or during surgery and is therefore not included as a falsenegative.
No
sonographic
false-positive
results
were
encountered. Comparison of sonographic with clinical findings reveals 10 cases in which a significant abnormality that was not detectable clinically was identified sonographically. These included three choroidal detachments, six retinal detachments, and one dislocated lens (Fig. 8). The patient with the dislocated lens found with sonography also had a retinal detachment
AJR:158,
January
SONOGRAPHY
1992
Fig. 3.-A and B, Choroidal patient had bilateral, extensive
detachment.
choroidal
OF
OCULAR
TRAUMA
181
This
detach-
ments after a motor vehicle accident. Sonograms show choroidal detachments as thick, convex membranes that almost touch at center of vitreous body, with a large quantity of echogenic subchoroidal hemorrhage beneath them. Cho-
.... ..
..‘s,
Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
roidal membrane
may extend farther anteriorly not usually extend to Choroidal detachment invariably is thicker than an acute retinal detach-
to ora serrata and does optic nerve posteriorly. ment and considerably
less mobile.
A
!-:E’j
j
B
..
Fig.
4.-Subhyaloid
sonogram
hemorrhage.
of eye shows
posterior
Transverse
boundary
of vitreous body has separated from underlying retma (arrow), allowing potential subhyaloid space, which is occupied by echogenic hemorrhage, to be visualized. Vitreous body is a gelatinous structure, which may at times separate from retina, producing a space that may fill with effusion or hemorrhage. Interface between this effusion or
Fig. 5.-Foreign objects. A, A metallic foreign object in anterior portion of vitreous body is seen on an echogenic lesion (arrow) with extensive reverberation artifact behind it. Nonmetallic foreign objects will not produce same degree (if any) of reverberation. B, In this instance, metallic fragment is not as easily seen as on A, because it is embedded in iris plane; however, artifact posteriorly serves as a useful marker. When foreign objects are within sclera or orbital fat, they may be difficult to visualize. If air is present in eye, visualization of ocular lesions may be greatly compromised.
hemorrhage and posterior boundary of vitreous body is typically seen as a moderately to weakly echogenic line, which may at times detachment if a persistent adhesion gion of optic nerve head.
mimic a retinal occurs in re-
that had not been seen either clinically Clinical examination revealed hemorrhage ber that was not shown sonographically.
or sonographically. in an anterior cham-
Sonography provides good visualization of ocular anatomy, often allows accurate localization of intraocular foreign objects [3], and is sensitive to changes in the soft tissues of the globe and its contents [4]. It is inexpensive, fast, and readily available in most raphy is indicated
Discussion
Ocular trauma is a common problem. Its annual incidence is estimated at approximately 423 cases per 1 00,000 [1]. Although most of these injuries are minor, 1 -5% are severe enough to compromise vision [1 2]. ,
radiology whenever
departments. opacification
Ophthalmic sonogof the media pre-
vents adequate clinical examination of either the anterior or posterior segments. The sonographic examination of injured eyes, principally performed with dedicated eye sonography units has been described
before
[3, 4]. No estimates
of the sensitivity
of real-
Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
182
Fig. 6.-Dislocated lens. In this patient, lens is shown in cross section on sonogram as an echogenic, circular structure within vitreous body. Iris plane anteriorly(arrow) is flat because lens has been displaced. Lens is more echogenie than normal, indicating presence of a cataract.
KWONG
El
AL.
AJR:158,
Fig. 7.-Retinal detachment missed on sonogram. Convex membranes characteristic of choroidal detachment were easily appreciated; however, focal retinal detachment posteriorly (arrow) is difficult to see even in retrospect.
time sonography have, to our knowledge, been reported. As definitive clinical and surgical correlation is unavailable in a large portion of the patients in our series, we are unable to estimate the sensitivity and specificity of this technique in the evaluation of posttraumatic ocular abnormalities. In spite of this, we think that it is apparent from our findings that sonography is useful in the assessment of ocular trauma whenever the clinical examination is incomplete or unsatisfactory. We have found sonography to be most useful in the presence of extensive hemorrhage in the posterior segment of the globe, particularly for the detection of retinal and choroidal detach-
January
1992
Fig. 8.-Retinal detachment missed on funduscopy. A retinal detachment (arrow) is clearly visible posteriorly on sonogram, but could not be seen on clinical examination because of extensive hemorrhage.
ments. It also is useful of the lens.
in confirming
or excluding
dislocation
REFERENCES 1 . Karlson TA, Klein EK. The incidence of acute hospital-treated Arch Ophthalmol 1986:1 04: 1473-1 476
2. Schei OD, Hibberd PL, Shingleton ocular
injury.
Ophthalmology
BJ, et al. The spectrum
and burden of
i988;95:300-304
3. Munk PL, Lin DT, Gibney RG, Kidney MR. Introduction real-time ultrasonography 4. Fielding JA. Ultrasound non-dedicated scanner.
eye injuries.
to high-resolution
of the eye. Perspect Radiol 1989:2:163-17S imaging of the eye through the closed lid using C/in Radiol 1987:38: 1 31 -1 35
a
179
Real-Time Trauma
J. Stephen Kwong1 Peter L. Munk1 David 1. C. Lin2 A. Dale Vellet1 Morris Levin1 Anne R. Buckley3
Sonography
in Ocular
Real-time sonography was evaluated retrospectively in 71 consecutive patients with ocular trauma. A total of 51 vitreous hemorrhages, 20 hemorrhages in the anterior chamber, 22 retinal detachments, seven choroidal detachments, five foreign bodies, and 12 dislocated lenses were identified sonographically. In 10 instances (three choroidal detachments, six retinal detachments, and one lens dislocation), these sonographic findings were not apparent on clinical examination. One hemorrhage of the anterior chamber was missed on sonography. Both sonography and clinical examination failed to visualize one retinal detachment. The results of this study show that real-time sonography is valuable in the assessment of ocular
trauma
and
158:179-182,
AJR
supplements
January
clinical
examination
with
valuable
information.
1992
Ocular trauma is a commonly encountered clinical problem, and generally, ocular assessment is first done by clinical examination. After trauma, clinical examination often is difficult because of opacification of the ocular media, or because of the patient’s inability to cooperate. Sonography has been used to examine ocular abnormalities since the late 1 950s, and since this time, surprisingly little about the use of nondedicated high resolution real-time sonography in the evaluation of ocular trauma has appeared in the ophthalmologic or radiologic literature. We reviewed the sonographic findings in a group of patients who sustained eye injuries
and
in this
clinical
Materials
were
referred
and
1990.
7.5-MHz
clear Medicine,
excluded
University
Hospital and University
339 Windermere Rd. , London, Canada. Address reprint re
quests to P. L. Munk. 2
Department
of
Ophthalmology,
Vancouver
General Hospital and University of British Columbia, 855
W.
12th
Ave.,
Vancouver,
B.C.
V5Z
1M9,
Canada. 3
Department
Hospital
of Radiology,
and University
12th Ave., Vancouver, 0361 -803X/92/1 © American
Vancouver
General
Columbia,
855 W.
of British
B.C. V5Z 1M9, Canada.
81 -01 79
Roentgen
Ray Society
trauma, minimize
ruptured The
was
transducer,
were not scanned
of Western Ontario, Ontario N6A 5A5,
studied
Scanning
Received July 1 , 1991 ; accepted after revision August 13, 1991. I Department of Diagnostic Radiology and Nu-
linear-array by
an are
the
globe. sonograms
7i
patients
done
with
or occasionally
transducer.
we
institution,
to evaluate
the
use
of this
technique
Methods
We retrospectively March
to our
situation.
possibility
of
Conventional obtained
not
causing
by
to apply
reviewed
between
globe
a qualified of
transducer by two
the
January
scanner
(Mountain
technique
pressure
expulsion
sonographic were
scanner
of an open
performed
careful
trauma
small-parts
or closed-lid
the presence
examination always
ocular
an Acuson
A paraocular
until
with
a Diasonics
View,
was
injury
(Milpitas,
used
intraocular
rupture In cases
traumatized contents
and with
a
CA) with a 5-MHz
in all cases.
or globe
ophthalmologist. to the
i989 CA)
globe
Patients
had been of
ocular
in order
from
an
occult
with
the
report
to
gel was used. radiologists
and
correlated
made at the time of scanning. In addition, the charts of 40 patients were available for review. By reviewing the charts, the clinical history, time of injury, previous ophthalmologic history, and surgical findings were obtained. Surgical correlation was available in 27 cases. In many instances, scans were obtained only postoperatively. The average patient age was 37 years old; 63 were men and eight were women. Of the 40 cases with available clinical histories, 30 were acute (4 weeks since injury).
Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
180
KWONG
El
AL.
AJR:158,
January
1992
Fig. 1.-Vitreous hemorrhage. A, Transverse sonogram through globe. This patient had a direct blow to eye I day before examination, with a massive vitreous hemorrhage, which could readily be seen on funduscopy. Only a few scaftered, low-amplitude echoes are visible within vitreous body. In this situation, increasing gain setting is often helpful for detecting acute hemorrhages, which are often only minimally echogenic. Also, note posterior displacement of lens (arrows) into anterior aspect of vitreous body. B, Transverse sonogram of eye 1 week after surgery to repair a ruptured globe and extraction of a dislocated lens. Entire vitreous body is filled with homogeneous echoes, representing a diffuse hemorrhage. Usually within 1-3 days after acute hemorrhage, vitreous body becomes markedly echogenic.
Fig. 2.-Retinal detachment. A, After a blow to head in a motor vehicle accident, this patient lost vision in one eye. Ret-
ma is detached
from underlying
choroidal
layer
and is seen on sonogram as two thin, echogenic lines at posterior aspect of vitreous body, emanating from region of optic nerve head, which is seen as an hypoechoic band behind globe (arrow). Detached retina is not seen to pass any farther anteriorly than ora serrata, which is antenormost aspect of retina that inserts slightly posterior to ciliary body. Acute retinal detachments are seen as thin echogenic lines, whereas chronic retinal detachments become thicker and less mobile. B, In another patient, a focal retinal detachment is present with an accompanying tear, al-
lowing detached
segment to assume a wrinkled
appearance.
the
Results
iris plane;
previously Hemorrhage
was
the
most
common
sonographic
finding
cases of bleeding into the vitreous body and 20 cases of bleeding into the anterior chamber were identified. Nineteen of 20 cases of hemorrhage in the anterior chamber had an accompanying hemorrhage in the vitreous body. In addition, subchoroidal hemorrhage was present in four patients, subretinal hemorrhage in nine patients, and subhyaloid (Fig.
1). Fifty-one
hemorrhage
in four
patients.
Membrane detachments were seen in 37 cases. Twentytwo of these cases were retinal detachments (Fig. 2). Most of the detachments were large, involving most of the retina. Seven patients had choroidal detachments (Fig. 3). In eight instances, the hyaloid body was detached (Fig. 4). Foreign objects intraocular
were
encountered
air was
identified
in five (Fig.
cases.
In four
instances,
5).
Abnormalities of the lens also were relatively common. The lens was noted to be echogenic in 1 3 patients, consistent with cataract. Dislocation of the lens was identified in 12 instances (eight posterior, three anterior, one laterally within
been
Figs.
1 A and
extracted,
6). In 1 3 instances, and
in six
of these
the lens had 1 3 instances,
a prosthetic lens was identified. Surgical correlation was available in 27 cases. Five abnormahities were not identified sonographically: one hyphema, one cataract, one retinal detachment, and two instances of ruptured
globe
(Fig.
7). Clinically,
rupture
of the
globe
was
common, occurring in 26 patients, 24 of whom had the globe repaired before sonographic examination. The two ruptures that were not detected sonographically were subsequently detected clinically. In one instance, choroidal detachment was suspected clinically, but was not confirmed by sonography or during surgery and is therefore not included as a falsenegative.
No
sonographic
false-positive
results
were
encountered. Comparison of sonographic with clinical findings reveals 10 cases in which a significant abnormality that was not detectable clinically was identified sonographically. These included three choroidal detachments, six retinal detachments, and one dislocated lens (Fig. 8). The patient with the dislocated lens found with sonography also had a retinal detachment
AJR:158,
January
SONOGRAPHY
1992
Fig. 3.-A and B, Choroidal patient had bilateral, extensive
detachment.
choroidal
OF
OCULAR
TRAUMA
181
This
detach-
ments after a motor vehicle accident. Sonograms show choroidal detachments as thick, convex membranes that almost touch at center of vitreous body, with a large quantity of echogenic subchoroidal hemorrhage beneath them. Cho-
.... ..
..‘s,
Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
roidal membrane
may extend farther anteriorly not usually extend to Choroidal detachment invariably is thicker than an acute retinal detach-
to ora serrata and does optic nerve posteriorly. ment and considerably
less mobile.
A
!-:E’j
j
B
..
Fig.
4.-Subhyaloid
sonogram
hemorrhage.
of eye shows
posterior
Transverse
boundary
of vitreous body has separated from underlying retma (arrow), allowing potential subhyaloid space, which is occupied by echogenic hemorrhage, to be visualized. Vitreous body is a gelatinous structure, which may at times separate from retina, producing a space that may fill with effusion or hemorrhage. Interface between this effusion or
Fig. 5.-Foreign objects. A, A metallic foreign object in anterior portion of vitreous body is seen on an echogenic lesion (arrow) with extensive reverberation artifact behind it. Nonmetallic foreign objects will not produce same degree (if any) of reverberation. B, In this instance, metallic fragment is not as easily seen as on A, because it is embedded in iris plane; however, artifact posteriorly serves as a useful marker. When foreign objects are within sclera or orbital fat, they may be difficult to visualize. If air is present in eye, visualization of ocular lesions may be greatly compromised.
hemorrhage and posterior boundary of vitreous body is typically seen as a moderately to weakly echogenic line, which may at times detachment if a persistent adhesion gion of optic nerve head.
mimic a retinal occurs in re-
that had not been seen either clinically Clinical examination revealed hemorrhage ber that was not shown sonographically.
or sonographically. in an anterior cham-
Sonography provides good visualization of ocular anatomy, often allows accurate localization of intraocular foreign objects [3], and is sensitive to changes in the soft tissues of the globe and its contents [4]. It is inexpensive, fast, and readily available in most raphy is indicated
Discussion
Ocular trauma is a common problem. Its annual incidence is estimated at approximately 423 cases per 1 00,000 [1]. Although most of these injuries are minor, 1 -5% are severe enough to compromise vision [1 2]. ,
radiology whenever
departments. opacification
Ophthalmic sonogof the media pre-
vents adequate clinical examination of either the anterior or posterior segments. The sonographic examination of injured eyes, principally performed with dedicated eye sonography units has been described
before
[3, 4]. No estimates
of the sensitivity
of real-
Downloaded from www.ajronline.org by 206.214.5.30 on 10/06/15 from IP address 206.214.5.30. Copyright ARRS. For personal use only; all rights reserved
182
Fig. 6.-Dislocated lens. In this patient, lens is shown in cross section on sonogram as an echogenic, circular structure within vitreous body. Iris plane anteriorly(arrow) is flat because lens has been displaced. Lens is more echogenie than normal, indicating presence of a cataract.
KWONG
El
AL.
AJR:158,
Fig. 7.-Retinal detachment missed on sonogram. Convex membranes characteristic of choroidal detachment were easily appreciated; however, focal retinal detachment posteriorly (arrow) is difficult to see even in retrospect.
time sonography have, to our knowledge, been reported. As definitive clinical and surgical correlation is unavailable in a large portion of the patients in our series, we are unable to estimate the sensitivity and specificity of this technique in the evaluation of posttraumatic ocular abnormalities. In spite of this, we think that it is apparent from our findings that sonography is useful in the assessment of ocular trauma whenever the clinical examination is incomplete or unsatisfactory. We have found sonography to be most useful in the presence of extensive hemorrhage in the posterior segment of the globe, particularly for the detection of retinal and choroidal detach-
January
1992
Fig. 8.-Retinal detachment missed on funduscopy. A retinal detachment (arrow) is clearly visible posteriorly on sonogram, but could not be seen on clinical examination because of extensive hemorrhage.
ments. It also is useful of the lens.
in confirming
or excluding
dislocation
REFERENCES 1 . Karlson TA, Klein EK. The incidence of acute hospital-treated Arch Ophthalmol 1986:1 04: 1473-1 476
2. Schei OD, Hibberd PL, Shingleton ocular
injury.
Ophthalmology
BJ, et al. The spectrum
and burden of
i988;95:300-304
3. Munk PL, Lin DT, Gibney RG, Kidney MR. Introduction real-time ultrasonography 4. Fielding JA. Ultrasound non-dedicated scanner.
eye injuries.
to high-resolution
of the eye. Perspect Radiol 1989:2:163-17S imaging of the eye through the closed lid using C/in Radiol 1987:38: 1 31 -1 35
a
