1

Immersion Biometry:
Its Not a Water Bath
Anymore
March 19, 2006
ASCRS
San Francisco
Rhonda G Waldron
MMSc, COMT, CRA, ROUB, RDMS
Diagnostic Echographer, Senior Associate in Ophthalmology
Emory Eye Center, Atlanta GA
Owner, Eye Scan Consulting
rwaldro@emory.edu
Financial Interest
Speaker has been advisor to the following
companies, both compensated and
noncompensated, regarding their ultrasound
equipment: Accutome, Alcon Surgical,
Innovative Imaging, Inc., Quantel Medical,
Sonomed, and Tomey Corporation
Speaker has functioned as a compensated
ultrasound expert in a research capacity for
Alcon Laboratories in Fort Worth, TX
Speaker has received donations of eye drops
from Accutome, as well as Prager shells and
tubing from ESI, Inc. for ultrasound workshops
Improving Surgical Outcomes
Most common causes for post-op surprises:
Axial eye length error
Erroneous K-readings
IOL position
Importance of Accuracy
0.1 mm error = ~0.25 - 0.3 D post-op
surprise!
Therefore, 1.0 mm error = ~2.5 - 3.0 D
post-op!
In short eyes,
0.1 mm error = up to 0.75 D post-op!
Post-Op Surprises
If measurement too short,
post-op error = myopic direction
If measurement too long,
post-op error = hyperopic direction
Accurate Biometry
How do I know its a good scan?
Understand ultrasound principles
to accurately interpret spike
patterns
Use most accurate technique
Use good equipment
Avoid common errors
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How does biometry work?
As the thin, focused
sound beam passes
through the eye, each
time it strikes an
interface part of the
sound beam is reflected
back into probe (the
echo)
An interface is the
junction of two media
that have different
densities/velocities
The greater the
difference at the
interface, the higher the
spike will be
An Amplitude scan
1 2 3 4 5 6 What happens with dense cataracts?
Multiple
spikes within
the lens
Caused from
changes in
density
within the
nucleus
What caused these spikes?
Small blips along
vitreous baseline
Slightly more
highly reflective
spike to the left
of the retinal
spike
What caused these spikes?
What caused these spikes?
Reflection and Refraction
Sound is
reflected
and
refracted,
just like
light rays
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How do I know Im
perpendicular to visual axis?
Five high
spikes
Retinal spike
should be
steeply
rising
1 2 3 4 5
Perpendicularity Errors:
Misaligned along retina
Bad retinal spike
Not perpendicular to macular surface
Perpendicularity Errors:
Misaligned through the lens
Lens spike too short
Sound beam through lens at an angle rather
than center of front and back surfaces
Why is it more difficult to get the posterior
lens spike as tall as the other spikes?
The posterior surface
has a steeper
curvature, causing
scattering of the sound
In dense cataracts,
there is absorption of
the sound within the
nucleus, weakening the
echo from the posterior
surface
The more dense the
cataract, the more
difficult
Some manufacturers
dont amplify this spike
as much as others
Perpendicularity Errors:
Misaligned along optic nerve
Sound beam
misdirected to
optic nerve rather
than macula
No sclera at optic
nerve, therefore
no scleral spike
present on
display
Perpendicularity Errors:
Misalignment along optic nerve
24.22 23.90
4
Retina and Sclera
Short Eye vs. Long Eye
In long eyes the retinal and scleral spikes are
closer together since the eye is stretched over
larger area
In short eyes they are farther apart
25.16 21.36
Reflection and Refraction
If macular
surface is
flat, strong
echo
If macular
surface
irregular,
echo poor
Macular Pathology
If unable to get quality
retinal spike, review
chart for possible
macular pathology
Alert surgeon
B-scan if poor view of
fundus
Good Resolution
The ability of the
machine to
display two
echoes as
separate spikes
when they are
close together,
one behind the
other
Proper Gain Level
Degree of
amplification of
echoes on display
screen
Adjusting affects
sensitivity of display
Affects resolution
The volume
Too high, lose
resolution
Too low, difficult to
get spikes
Using Gain Too High
Possible to get erroneously short
measurement!
AEL 23.69 AEL 24.99
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Whats the Proper Gain
Setting?
Good
resolution of
retina and
sclera--
whatever that
takes!
Calculating Distance
The biometer displays
the spikes on the screen
by measuring how long it
took the sound to travel
from one structure to the
next and back again at
the given velocity
Converts that time to
distance with the
formula:
Distance =
Velocity X Time/2
AEL 25.80 LT 4.41 ACD 3.49
Calculating Distance
Therefore we must
use the correct
velocity between
each spike
The velocities used
rely on the examiner
choosing the correct
eye type
AEL 25.80 LT 4.41 ACD 3.49
Sound Velocity
Sound
velocity
(speed) is
dependent
on the
density and
stiffness of
the medium
it is passing
through
Sound Velocity
Cornea = 1,641 m/sec
Aqueous = 1,532 m/sec
Lens = 1,641 m/sec
Vitreous = 1,532 m/sec
AEL 25.18 LT 4.41 ACD 2.87
Average Velocity for Phakic Eyes
~ 1,550 m/sec
Some use 1,548 m/sec
Others use 1,552 m/sec
AEL 22.81mm
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Aphakic Velocity
1,532 m/sec
Still have aqueous
and vitreous
No lens velocity to
factor in
Pseudophakic Velocity
1,532 m/sec +
Correction
Factor
for implant
material
Pseudophakic Eyes
Multiple artifact spikes in vitreous cavity
Caused by reverberations from IOL
The more dense the IOL material, the more artifact
Do we really need to know
IOL material?
PMMA = 22.75 Acrylic = 22.55 Silicone = 21.55
Now What!?!?
How do I get an
accurate
measurement if I
dont have the
proper velocity on
my machine?
Use APHAKIC
setting and add
correction factor to
end result!
Sound Velocities/Correction Factors
for Various IOL materials
Material Velocity Correction Factor
PMMA 2,718 m/sec +0.4
Acrylic 2,120 m/sec +0.2
Silicone 980 ~1100 m/sec -0.4 to -1.0
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Velocity and Silicone Oil
Velocity of oil slower than vitreous = 980 m/sec
Causes erroneously long vitreous length
ACD and LT accurate
OCB helpful if cataract not too dense to utilize
and patient can fixate
Use velocity conversion equation to correct for
vitreous length, then add back to ACD and LT
980 x AVL = TVL
1532
Velocity and Silicone Oil
AEL through oil = 30.36 mm
AVL = 22.83 mm (30.36 - 2.92 - 4.61)
980 x 22.83 = 14.6 mm = TVL
1532
14.6 + 2.92 + 4.61 = 22.13 mm = true eye length
30.36 22.10
Velocity and Silicone Oil
Fellow Eye: Oil-Filled Eye: Same eye measured with unit
23.82 mm 32.40 23.97 mm that has oil setting: 23.92 mm
Gates/Eye Type Settings
Calipers on the
screen
The actual measuring
points
A measurement
occurs between each
pair of gates
Number of gates on
different eye types
varies by
manufacturer
AEL 25.80 LT 4.41 ACD 3.49
Humphrey 820/Paradigm P20
Not
Displayed
Sonomed A5500
8
PacScan 300A (Sonomed Inc)
I
3
A
BD
-Biometer (Innovati ve Imaging Inc)
Axis II v 2.04 Dynami c 2 (Quantel Medical Inc)
Cornea Ant/Post Lens Retina/Sclera
Axis II v 1.1(Quantel Medical Inc)
Not
Displayed
AccuSonic A-Scan Plus (Accutome Inc)
Check Gate Placement -
Pseudophakia
18.11 mm 24.14 mm
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Check Gate Placement
Dense Cataracts
AEL 22.65 LT 4.76 ACD 2.72 AEL 22.72 LT 5.79 ACD 2.72
Check Gate Placement
Dense PSC with Reverberation
AEL 23.16 LT 11.33 ACD 3.16 AEL 22.72 LT 4.77 ACD 3.16
Contact Technique
Probe in contact with cornea
Hand-held or slit-lamp
Most popular but least accurate
(0.10 mm at best)
Takes longer to do than immersion!
Contact Technique
Corneal compression
always a factor
Tech-dependent
IOP dependent
Greater risk of corneal
abrasion
Greater variation of
readings so must delete
then do more
`+`+
`e+^4
Fluid Meniscus
Fluid meniscus between probe tip and
cornea
Erroneously long measurement
Rinse eye before scan
Contact Technique
If must do contact, gentle on/off technique
Recline patient for less compression
Sit down on an adjustable stool
Place machine where screen easily seen
Monitor ACD carefully!
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Contact Technique-
Visual Axis Alignment Not Enough!
AEL 25.18 LT 4.41 ACD 2.87 AEL 25.80 LT 4.41 ACD 3.49
Immersion Technique
Probe immersed in
shell of saline
Most accurate/no
corneal compression
(0.0126 - 0.05 mm
depending on
manufacturer)
Why it was called a waterbath
Immersion Technique
No tech-dependency
Less risk for corneal abrasion
Faster technique
More consistency
Less repeating
Gold Standard of Care
Immersion Technique
Hansen Shells
Anesthetize eye
Place shell on limbus
Fill with contact lens
saline by squirting
stream against inner rim
Place probe in saline
and align
Prager Shell
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Immersion Biometry
Probe seen as
spike on left or
off the screen,
depending on
manufacturer
Corneal spike to
right of probe
Corneal spike
now has two
peaks
Immersion Biometry
Both corneal peaks should be 100% high or
not exactly on corneal vertex
Contact vs. Immersion
AEL 22.69 LT 5.23 ACD 2.58 AEL 22.93 LT 5.17 ACD 2.92
Multiple Technician Biometry
Study of One Eye
M. Bryan Waldron, CCOA, ROUB
87 technicians from USA and Europe
obtained five readings on same eye of one
subject with Accutome Accusonic
Skill levels varied: certified/non-certified,
most with no immersion experience, some no
biometry experience
Total of 435 measurements of OD
Average 24.54 mm, std deviation 0.03 mm
OCB: 24.56 mm
When is Contact Method
Necessary?
Patients who have had glaucoma
surgery with filtering blebs--
cannot insert scleral shell flush
with the limbus
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Zeiss
IOLMaster
IOL Master
IOL Master
How Does Immersion Compare
with the IOL Master?
Per Dr. Haigis:
Partial coherence interferometry is a non-contact,
user- and patient-friendly method for axial length
determination and IOL planning with an accuracy
comparable to that of high-precision immersion
ultrasound.
Its accuracy is superior to that of the commonly
used applanation method and is directly
comparable to that of high-precision immersion
ultrasound.
Graefes Arch Clin Exp Ophthalmol (2000) 238:765-773
IOL Master
In his first study of 134 eyes, 12% could not be
measured:
Among the reasons were inability to cooperate
(fixate), tremor, respiratory distress, severe tear
film problems, keratopathy, corneal scarring,
mature cataract, nystagmus, lid abnormalities,
vitreous hemorrhage, membrane formation,
maculopathy and retinal detachment.
Thus it seems that with present technology the
eyes of 9-12% of the patients of a university eye
clinic cannot be measured by laser
interferometry. In these cases, ultrasound
biometry will continue to be indispensable.
Graefes Arch Clin Exp Ophthalmol (2000) 238:765-773
Quality of OCB Measurement
Clear signal
High SNR (> 2.5)
Low changes in repeat measurements, within
0.1 mm
Visibility of secondary maxima, shape of peak
Clear media
Good fixation
Correct setting IOL type, silicone oil
No contact examinations prior to measurement
(applanation tonometry, schirmer)
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Uncertain OCB Measurement
Low SNR ( < 1.6 2.0)
Inconsistent measurements
Only one out of several measurements usable
Artificial reverberation signals in
pseudophakia
Spike bad (i.e. double peak)
Artifacts by surface abnormalities
Measurement to first signal in macular
pathology, i.e. ERM
In uncertain cases comparative immersion
ultrasound measurement
Zeiss IOL Master
Advantages & Disadvantages
Non-contact
Accurate AEL (0.03 mm)
As accurate as immersion
User-friendly
Patient-friendly
As fast as immersion
Can measure through
silicone oil and staphylomas
easily if cataract not too
dense
? Inaccurate ACD
No lens thickness
Cant use with dense NSCs,
PSCs
Cant use with vitreous
opacity
Cant use when poor fixation
High cost
No spike pattern for
detection of possible
pathology
Difficult with macular
pathology
Error with RPE defects?
Possible extra spike with
pseudophakia
Sizing Up Your Biometry Options
Ophthalmology Management, April 2005
Along with the immersion ultrasound
technique, partial coherence interferometry has
rendered the applanation method obsolete
when calculating a highly accurate IOL power is
the goal.
There is scant defense for applanation
anymore given the refractive demands of our
cataract patients, our refractive lens exchange
patients and even more so, the patients who
have already had refractive surgery once.
Mark Packer, MD
If You Utilize OCB
You Still Need Immersion Unit!
All patients deserve highest level
standard of care, not just the ones
with milder cataracts
For those patients who cannot be
measured with IOL Master you
must perform immersion to get
same level of accuracy
Beware the phrase:
Ive got a good one for you!
The High Myope
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The High Myope
High Myopia
The eye is misshapen, oval or elongated rather
than round
Macula on a slope
Perpendicularity impossible
Eyes may be different lengths -- The shorter the
eye the more symmetrical, the longer the eye the
more asymmetrical
Posterior Staphyloma
Can occur in the high
myope
Uvea bulging into
thin, stretched sclera
Most common in
posterior pole
Macula within bulge
Perpendicularity
impossible
Measurements vary
greatly
OCB helpful
Posterior Staphyloma and B-Biometry
Align B-scan with HMAC
position (probe on corneal
vertex, marker nasal)
Measure vitreous length by
placing calipers on center of
posterior lens surface and again
4.5 mm down from center of
optic disc
Compare this to vitreous
lengths on varying A-scan
measurements
Use the A-scan measurement
that has the matching vitreous
length
Use correct velocity for vitreous
of 1532 m/sec
Posterior Staphyloma and B-Biometry
Can measure total axial length on B-scan from anterior
corneal surface to macula using 1550 m/sec
Use extra gel so no corneal compression
Can be hard to see corneal echoes within artifacts
appears as small double-line
24.67 on A-scan 24.70 on B-scan
Posterior Staphyloma and B-Biometry
Vit length = 21.06 mm Vit length = 21.08 mm
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Posterior Staphyloma
Patient C
Posterior Staphyloma
Patient C
OD: -23.50 + 1.00 x 112 =
20/400 ecc
with macular hemorrhage
B-Scan = 25.18 mm vitreous
32.77 mm
- 4.82 LT
- 2.82 ACD
25.13 mm vitreous
-3.0 D IOL needed
Posterior Staphyloma
Patient C
OS: -20.50 sph = 20/70
B-Scan = 23.94 mm vitreous
31.77 mm
- 4.87 LT
- 2.92 ACD
23.98 mm vitreous
-1.0 D IOL needed
Posterior Staphyloma
Patient C
Post-operative results:
OD sc: 20/100 ecc
OS sc: 20/40
MR: +0.50 + 1.25 x 110 = 20/70 ecc
-0.25 sph = 20/40+
Posterior Staphyloma
Patient B
OD: -32.0 sph = 20/60
B-Scan = 23.74 mm
32.19 mm
- 5.58 LT
- 2.87 ACD
23.74 vitreous
-7.0 D IOL needed
Posterior Staphyloma
Patient B
OS: -32.0 sph = 20/40
B-Scan = 23.93 mm
32.29 mm
- 5.64 LT
- 2.77 ACD
23.88 vitreous
-7.0 D IOL needed
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Posterior Staphyloma
Patient B
Post-Op Results:
OD sc: 20/60
MR: -1.25 + 1.75 x 75 = 20/40
OS: No surgery
Posterior Staphyloma
Patient E
-30.0 CTLs OU
with -3.00 specs
OD cc: 20/30
OS cc: HM
brunescent NSC
Retinal spike so far
to right, off the
screen!
Posterior Staphyloma
Patient E
Used B-scan to measure vitreous length
ACD and LT from biometry
Vitreous: OD: 33.91 mm OS: 34.89 mm
Posterior Staphyloma
Patient E
Total length:
OD: 41.17 mm OS: 42.03 mm
-10.0 D IOL highest power available
Posterior Staphyloma
Patient E
Post-Op Results:
OD sc: 20/70, with -3.00 specs = 20/30+
OS sc: 20/70, with -3.00 specs = 20/30+
Other applications for B-Biometry
Vit = 15.75 Vit = 17.47
Vit =15.80 Vit = 17.43
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Other applications for B-Biometry
Vit = 15.41 Vit = 14.41
Vit = 15.34 Vit = 14.36
Anomalous A-Scan Patterns
Anomalous A-Scan Patterns Anomalous A-Scan Patterns
Anomalous A-Scan Patterns
OD: 23.38 OS: 21.24
Anomalous A-Scan Patterns
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Anomalous A-Scan Patterns Anomalous A-Scan Patterns
Anomalous A-Scan Patterns Anomalous A-Scan Patterns
Anomalous A-Scan Patterns
Anomalous A-Scan Patterns
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Anomalous A-Scan Patterns
Why we need a B-scan prior to
cataract surgery
Cataract extracted, MD couldnt get IOL in
Seemed to be bumping into something
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