Perspectives in Medicine (2012) 1, 8688

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 8688
journal homepage: www.elsevier.com/locate/permed

Four-dimensional ultrasound imaging in

neuro-ophthalmology
Ekaterina Titianova a,b,, Sylvia Cherninkova c, Sonja Karakaneva a,
Boyko Stamenov d
a

Clinic of Functional Diagnostics of Nervous System, Military Medical Academy, 3 Georgi Soiski str., 1606 Soa, Bulgaria
Medical Faculty, Soa University, 1 Koziak str., 1407, Soa, Bulgaria
c
Clinic of Neurology, University Hospital Alexandrovska, 1 Georgi Soiski str., 1431 Soa, Bulgaria
d
Department of Neurology, Pleven Medical University, 8 G. Kochev str., 5800 Pleven, Bulgaria
b

KEYWORDS
4D ultrasound
imaging;
Optic disc swelling;
Optic nerve edema;
Retinal detachment;
Macular degeneration

Summary
Purpose: To demonstrate diagnostic abilities of spacetime (4D) ultrasound imaging in patients
with eye pathology and some neuro-ophthalmic syndromes.
Methods: Fifteen healthy controls and 15 patients with eye pathology (papilledema, retinal
detachment, macular degeneration and intraocular metastasis) were studied by multimodal
(color duplex, B-ow and 3D/4D imaging) sonography.
Results: Normal optic disc resulted in a smooth and sharp contour without swelling. Papilledema
was presented as a hyperechoic prominence into the vitreous. On its side the optic sheath diameter was increased in association with the degree of optic disc swelling. The retinal detachment
was imaged as a hyperechoic undulating membrane, the neovascular macular degeneration
as a hyperechoic membrane behind the retina, and the intraocular metastasis as irregular
unifocal formation into the vitreous.
Conclusions: The 4D neuro-ophthalmo-sonology helps for the quick and non-invasive volume
imaging of the type, size, location and severity of optic disc and optic nerve edema and its
differentiation from other types of eye lesions.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Introduction
The conventional ultrasound methods are widely used in
ophthalmology for evaluating the eye structures (lens,

Corresponding author at: Clinic of Functional Diagnostics of Nervous System, Military Medical Academy, 3 Georgi Soiski str., 1606
Soa, Bulgaria. Tel.: +359 2 9225454.
E-mail addresses: titianova@yahoo.com (E. Titianova),
s cherninkova@abv.bg (S. Cherninkova), s karakaneva@abv.bg
(S. Karakaneva), bb stamenov@abv.bg (B. Stamenov).

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

doi:10.1016/j.permed.2012.02.016

vitreous, chambers, retina, optic discs and optic nerves)

and eye circulation (ophthalmic arteries and veins) mainly
in the presence of cataract or other processes, hindering the ophthalmoscopy [13]. Recently the volume 3D/4D
eye ultrasound imaging in adults has been introduced [4]
which provides additional information for the structural
and functional eye changes in normal and pathological
conditions.
The aim of the study was to demonstrate the
diagnostic abilities of 4D ultrasound imaging in
patients with eye pathology and neuro-ophthalmic
syndromes.

4D ultrasound imaging in neuro-ophthalmology

Figure 1

Figure 2

Figure 3
(C).

87

Normal B-mode sonogram of the eye (A), 4D optic disc (B) and optic nerve (C) images.

Spacetime imaging of mild (A) and severe (B) optic disc swelling, associated with optic nerve edema (C).

4D imaging of retinal detachment (A), wet macular (neovascular) degeneration (B) and intraocular choroidal metastasis

Materials and methods

Results

Fifteen healthy controls (10 women and 5 men, mean age

47 10 years, age range 2169 years) and 15 patients (9
women and 6 men, mean age 45 17 years, age range
2184 years) with visual problems were studied: 10 patients
with papilledema, 3 patients with retinal detachment, 1
man with macular degeneration and 1 man with right
intraocular choroidal metastasis. Multimodal sonography
(color duplex, B-ow and 3D/4D imaging) was used for the
evaluation of eye morphology and circulation (Logic 7, GE).
The optic nerve sheath was measured 3 mm distal to the
optic disc [5].

The normal eye had a typical circular hypoechoic B-mode

image with well seen structures inside: a thin hypoechoic
cornea (parallel to the eyelid), anechoic anterior and posterior chambers (lled with liquid), anechoic lens, hyperechoic
iris and ciliary body (linear structures extending from the
peripheral globe towards lens) and relatively echolucent
vitreous. The normal retina was not able to be differentiated from the choroidal layers. The optic nerve caused a
hypoechoic shadow away from the globe. The same structures had also a typical 4D ultrasound image the optic disc
had a sharp contour without swelling into the vitreous and

88
the optic nerves were with relatively symmetrical sheath
diameters on both sides (Fig. 1).
In the presence of optic nerve head pathology we found
relatively specic 4D images. Papilledema was presented as
a contoured hyperechoic prominence into the vitreous. Its
degree correlated with the severity of edema, measured by
ophthalmoscopy. On the same side the optic sheath diameter
was increased in association with the degree of optic disc
swelling (Fig. 2).
The spacetime imaging contributed for the quick distinguish of neuro-ophthalmic syndromes from other ophthalmic
lesions. Retinal detachment was seen as a hyperechoic undulating membrane in the posterior to lateral globe. Blood
vessels had grown up from the choroid behind the retina in
the case of wet macular (neovascular) degeneration producing hyperechoic membrane into the vitreous. The choroidal
metastasis was imaged as a heterogenic irregular unifocal
formation within the lateral part of the affected vitreous
with a feeding vessel connecting the formation with the
choroidea (Fig. 3).

Discussion
Our study shows that spacetime ultrasound imaging gives
additional information for the type, location and severity
of the eye structures and allows their real time volume
assessment in normal and disease conditions. All available
4D ultrasound data in the literature are for studying fetal
behavior and prenatal eye movements during pregnancy [6],

E. Titianova et al.
therefore we could not compare our ndings with other volume ultrasound ophthalmic studies in adults.

Conclusions
The 4D neuro-ophthalmo-sonology helps for the quick volume imaging of the type, size, location and severity of optic
disc and optic nerve edema and its differentiation from
other ophthalmic lesions. It may be helpful in avoiding the
need from lumbar puncture, CT or MRI.

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