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A Beginner's Guide to Ultrasound Biomicroscopy  GO BACK

Dr. Sowkath Ali Department of Ophthalmology and visual sciences, Khoo Teck Puat Hospital, Singapore

Dr. Eunice Goh Department of Ophthalmology,Tan Tock Seng Hospital, Singapore

Dr. John Kan Department of Ophthalmology,Tan Tock Seng Hospital, Singapore

 Articles Miscellaneous Uvea and Intraocular In ammation Imaging Vitreoretina Review

Introduction:
Anterior segment ocular imaging has gone through various inventions starting from the
ultrasound in the 20th century to the recent AS- OCT.1 Ultrasound bio-microscopy, one of
the ocular imaging devices is a high-resolution technique, which allows in vivo assessment
of the structures of the anterior segment of the eye where cross-sectional images of ocular
structures are obtained at microscopic resolution. 2The higher frequency of UBM ranging
between 35 and 50 MHz, gives a depth of about 4 mm and an axial and lateral resolution
of approximately 25 and 50 microns, respectively. 3 Being a non-invasive technique, READ ALSO
efficient regardless of the clarity of the optical media and due to its portability can be
performed both in adults and children with no complications.4 The internal acoustic Fifty Percent in
characteristics of UBM, accompanied by the very fine backscatter speckle patterns, permit Ophthalmology
clear differentiation of ocular tissue at various levels.5 UBM imaging has been very useful Documentation &
in understanding the dynamics behind the mechanism of various ocular pathologies
Drawing in
especially angle-closure glaucoma. This chapter discusses the various clinical applications
Ophthalmology
of the UBM both in the diagnosis and management of ocular pathologies.
Fellowship in Cornea
Background:
Peripheral Retinal
Degenerations
History of Ophthalmic Ultrasound:
How to Present a
Ophthalmic ultrasound for diagnostic imaging of the eye was initially attributed to the work
Case of Corneal Ulcer
of Mundt and Hughes (A-scan), Baum and Greenwood (B-scan) in the early 1950s. 6,7
in the Examination
Even though, there have been huge improvements in the development of technology since
then, the centre frequency of ophthalmic ultrasound units has almost, remained at or near Therapeutic
10 MHz. 6 Although certainly useful for assessment of various ocular pathologies, the Keratoplasty : A
resolution obtainable at 10 MHz is poorer than that of current generation ophthalmic Comprehensive
imaging devices like OCT. Hence ophthalmic ultrasound used initially was not useful in the Review
diagnosis and management of anterior segment disorders especially glaucoma due to its
poor resolution. To overcome this problem, UBM was invented which uses a frequency of Choroidal
35- 50 MHz and hence better resolution. Neovascular
Membrane
History of UBM: Per uorocarbons in

UBM was first introduced in the early 1990’s by theFoster and Pavlin group to overcome Ophthalmology
the difficulties due to an ultrasound B scan as described above. 8 Zeiss-Humphrey’s Learn from the
ultrasound microscopy was an outgrowth of the work by the Foster group. 9 The Zeiss- Masters: Tips & Tricks
Humphrey UBM consisted of a 50 MHz probe which provided a scan rate of 8 Hz, giving
in the Management of
real-time imaging, with scans consisting of 256 lines over a 5 mm × 5 mm field. 9 The Ultra
Pediatric Cataract 1
link Artemis -2 UBM invented by the Coleman group, which is no longer in use
emphasized the processing of raw radiofrequency echo data acquired in sequential planes Covid Time: Standard
suitable for 3-D analysis of the ocular structures.10 Recent versions of UBM produced by Operating Procedures
various groups including Optikon, Sonomed use higher scan rate and higher frequency (80 of Various
MHz by IScience) for higher resolution imaging of the angle.10 Ophthalmic Societies
& Institutes
Mechanism of Acoustics and Ultrasound:
Ten Tips for
The image quality produced by the ultrasound is dependent on the three factors - Postgraduates
frequency of the ultrasound, the length of the pulse and the ratio of the focal length to the Preparing for Exams
transducer diameter (f-number) and.8 Higher frequency and shorter focal length are
Computer Vision
usually associated with higher resolution of the images but poorer penetration and hence
the transducer is the critical component for proper image resolution. The transducer is Syndrome
moved linearly over a 5 * 5 mm image field in the current generation UBM devices, which
generates sonographic data along each of 512 lines and the signal produced is amplified in
proportion to the depth from which it originated using so called ‘time-gain POWERPOINT
compensation’. 8
Uveitis Investigations
The measurement accuracy of the imaging system is dependent on the following 4 factors - & Treatment
the stability of mechanical motion, lateral resolution, axial resolution, and the pixel size of
Evaluation Of
the image. 8The lateral resolution depends on the distribution of ultrasound in the field of
Proptosis
the transducer, which has a width at half maximum given by the product of the wavelength
and the f-number. The axial resolution depends on the speed of sound in the various Target Intraocular
tissues and determined by ‘Instrument axial resolution’ and ‘measurement precision’.8 Pressure
The following table demonstrates the differences between convention USG B scan and
Intraocular Lens
UBM (Table 1)
Peripheral Iridotomy

PARAMETER UBM ULTRASOUND B SCAN Contact lens

Femtosecond laser in
ophthalmology
Frequency 50 MHz 10 MHz
Herpetic eye disease
study
Axial resolution 30 150
Ocular changes in
pregnancy

Lateral resolution 60 450 Anatomy of sixth

nerve

F ratio 2 3
READ BLOG

“There is no “right” or
“wrong” technique for
UBM Technique and Interpretation: cataract surgery.”:

Currently, there are two techniques for performing UBM – The immersionshell technique Dr.Uday Devgan
and the clear scan method without using scleral shell.11 In the latter technique, the "Powerpoint
patient can sit upright without going for the supine position. The UBM examination presentations can be
technique is almost similar to B-mode ultrasound where the transducer direction and
a good resource for a
manipulation of the probe is guided by looking at the image on the screen, the major
refresher course but
difference being finer movements are required for performing UBM. The patient is
never for primary
examined in a supine position facing the ceiling for the immersion scleral shell technique.
(Figure 1) After applying topical anesthetic drops, a specially-designed eyecup of 22 to 24 learning": Prof. Amod
mm diameter (scleral shell) is used to separate the eyelids and filled with a viscous, Gupta
sonolucent coupling fluid such as methylcellulose (1-2.5%). The images are stored in an An Autobiography of
electronic format on a computer attached to the device and the derivation of
an Unknown Uveitis
measurements from the images has to be done on the UBM’s computer unit or a PC which
Specialist
uses specific software to process and display the images.8
Tips to prepare for
the DNB,
Ophthalmology
Examination

KISS: Keep it simple

silly

Figure 1: Examination technique of UBM in supine

position
 Figure 2: Transducer probe of conventional UBM

UBM Instrumentation:
The main parts of a conventional ultrasound biomicroscopy machine are

1. Transducer – The main probe can be either handheld (Figure 2) or mounted on an

articulate arm connected to the main unit (As pointed in figure 3)
2. Computer with the main processing unit which acquires real-time images (Figure 3)

Figure 3: Instrumentation of
UBM
with arrows showing the –
computer with main unit,
articulate arm and the
transducer
attached to the articulate
arm

Angle Parameters in UBM:

The following quantitative angle parameters were proposed by Pavlin et al for quantitative
measurement of angle recess and its subsequent use in angle-closure management.8

1. AOD - Distance between the trabecular meshwork and the iris at 500 microns
anterior to the scleral spur

2. TCPD - Distance between the trabecular meshwork and the ciliary process at 500
microns anterior to the scleral spur
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3. IT1 - Iris thickness at 500 microns anterior to the scleral spur

4. IT2 - Iris thickness at 2 mm from the iris root

5. IT3 - Maximum iris thickness near the pupil margin

6. ICPD - Distance between the iris and ciliary process along the line of TCPD

7. ILCD- Contact between the iris and the lens

8. TIAθ1 - Angle of the angle recess

UBM images of the normal anterior

chamber angle

Clinical Applications:
Sclera

UBM is only able to examine the area of the sclera anterior to the equator due to the area
limited by the scleral shell. 8 Typical UBM feature of the sclera is a regular high reflectivity
signal with relatively lower reflective tissue surrounding or inside. It is commonly used to
differentiate structural abnormalities of the sclera or episcleral tissues like ciliary
staphyloma. It is also useful for the assessment of treatment outcomes of scleritis
especially the reduction of inflammation and measuring the thickness of sclera with
immunosuppressive agents.8

Cornea

UBM can differentiate the cross-sectional structure of cornea where except for the
Descemet’s membrane and the endothelium all the other 3 layers can be differentiated by
the reflectivity. 8,9 Hence UBM has been used to quantitative measurement of corneal
edema, Descemet’s membrane detachment, qualitative measurement of corneal dystrophy,
and various other pathologies. Pavlin et al. were the first to describe UBM imaging of the
cornea.8, 9 Before the advent of AS-OCT, UBM can be used to measure scar depth, which
may be a significant factor in patient management for choosing the type of surgery and
candidate selection in refractive corneal surgery. 9 For measuring corneal thickness,
compared to conventional pachymeters, UBM has the advantage of allowing imaging and
biometry of 2-D corneal cross-sections instead of at individual positions thus giving a more
precise measurement of corneal thickness.12

UBM has been used for assessment of the cornea following excimer laser photo
keratectomy and various other refractive procedures. Allemann et al. used the Artemis-2
prototype UBM to quantify scar density which uses 3D generation of echo images. 13
Reinstein et al. modified this system by using an arc- scanner to image the full width of
the cornea following laser in situ keratomileuses and demonstrated visualization of the
flap, measurement of residual stromal thickness and epithelial compensation for curvature
changes induced by ablation of underlying stromal tissue.14 Reinstein et al, also used the
same technique for quantifying changes in early keratoconus patients and demonstrated
significant parameters for screening purposes.15

Glaucoma:
The main clinical application of UBM involves the opening of the anterior chamber angle
and its subsequent value in the clinical management of angle-closure glaucoma. Pavlin et
al. showed the utility of UBM in characterizing several forms of glaucoma, including
plateau iris syndrome, pupillary block, secondary angle closure in pseudophakic eyes, and
various other forms of angle-closure glaucoma.16

Pupillary Block: In pupillary block, forward bowing of the iris from the root to the pupil
margin in the presence of a formed posterior chamber due to pressure difference between
anterior and posterior chamber. Laser iridotomy will result in flattening of the iris, by
relieving the anterior/posterior chamber pressure differential. UBM will demonstrate little
iris bowing, but rather anterior positioning of the ciliary body and closing of the sulcus. It
can clearly differentiate whether the pupillary block is related to lens-related factors or
angle related factors.8

UBM images of primary angle-closure

Plateau Iris Syndrome: In plateau iris syndrome, the UBM plays a most important role by
allowing demonstration of anterior displacement of the ciliary processes and sulcus
closure.8 UBM can also be useful for diagnostic imaging of aqueous misdirection syndrome,
which is characterized by a flattened anterior chamber, typically following glaucoma
surgery.8

Secondary Angle Closure in Pseudophakic Eyes: UBM has also been shown to be of
value in elucidating the etiology of pseudophakic pupillary block glaucoma. Pavlin et al
demonstrated the findings of pigment dispersion glaucoma with iris concavity, consistent
with the hypothesis that iris-lens chafing is responsible for the dispersion of pigment
particles. 17

Ciliary Body Effusion Syndrome: Ciliary body effusion secondary to drugs can be
demonstrated by anterior rotation of the ciliary body, cystic spaces in the ciliary body, and
surrounding sclera by UBM. It also plays a role in the management of the condition by
doing serial UBM after withdrawing the offending drugs.8, 9

Glaucoma Surgery:

Peripheral Iridotomy and Iridoplasty Peripheral iridotomy remains the cornerstone of

the management of angle-closure secondary to pupillary block which results in a significant
increase in the angle width by eradicating the pupil block mechanism. UBM is a valuable
tool in measuring the angle width pre and post laser iridotomy and Iridoplasty.8, 9

Cyclophotocoagulation Laser Cyclophotocoagulation, a cyclodestructive procedure for

refractory glaucoma patients who have failed trabeculectomy or tube shunt procedure, or
patients with minimal useful vision and uncontrolled IOP, or those being reluctant for
surgery. It is done by two methods – trans-scleral and endo Cyclophotocoagulation.
Accurate positioning of the laser probe is challenging in the destructive eyes and
complications UBM is useful in the observation of postoperative changes and identification
of postoperative complications.8, 9

Trabeculectomy It is one of the most widely performed glaucoma surgery procedures for
glaucoma. UBM allows visualizing the status of surgical openings, outflow channel, and
filtering bleb and useful for identifying the causes of operation failure.8, 9, 18

Uveitis Intermediate uveitis is an insidious type of uveitis characterized by inflammatory

cells in the anterior vitreous, inferior pars plana. Because it can be seen by routine
examination, the patients are often presented as secondary cataract, iris synechiae,
vitreous floaters and cystoid macular edema. UBM is able to detect these changes and
therefore able to provide further evidence for the diagnosis. 8, 9 Reduction in the number
of ciliary processes and ciliary body detachment due to membrane traction plays a key role
in the management of complications secondary to pars planitis especially hypotony.8, 9

Figure 8 UBM image of cyclodialysis cleft

UBM vs AS-OCT
AS-OCT is a newly evolved technique, used for imaging of anterior segment of the eye.
Compared to AS-OCT, the main strength of UBM is its ability to visualize structures behind
the iris, including the ciliary body and lens. 19 However, disadvantages compared to AS-OCT
include the need for a water-bath immersion with direct contact to the eye which was
overcome by the latest clear scan technique, longer image acquisition times, and the need
for an experienced operator. Even though for certain form of glaucoma like ciliary body
effusion, aqueous misdirection syndrome, UBM still remains the standard diagnostic tool,
AS-OCT has its own advantages in angle-closure glaucoma as well. 19 However, for anterior
segment tumours, AS-OCT offers clear-cut advantage over UBM.

The following table demonstrates the differences between UBM and AS-OCT (Table 2)

PARAMETER UBM AS-OCT

Learning curve Requires a skilled Easy to operate

operator
Short learning curve
Long learning curve

Axial resolution Low High

Depth of resolution High Low

Can visualize structures Limited visualization of

beyond iris pigment structures posterior to iris
epithelium pigment epithelium

Field of view Small wide

Image acquisition time Slow fast

In Ocular surface squamous neoplasia, AS-OCT shows a clear advantage by showing

intralesional details and providing useful diagnostic information for management and
follow-up. Conversely, in non-pigmented iris tumors, UBM was superior in identifying the
posterior border of lesions with higher reproducibility compared to AS-OCT. 19, 20 Despite
having a limited field of view and depth of visualization due to shadowing from keratinized
and pigmented lesions, AS-OCT can be a reliable alternative in selected tumors since it is a
fast, non-invasive and non-contact imaging technique. Despite the advantages of both UBM
and AS-OCT imaging in anterior segment tumors, none of them is a substitution for biopsy,
which still remains the gold standard for the diagnosis of ocular surface tumors.

Conclusion
UBM is an excellent tool for anterior segment imaging and in the diagnosis of various
ocular pathologies. Despite the advent of newer imaging modalities like AS-OCT, UBM still
has a role in the management of certain disorders due to its axial and lateral resolution
and depth of penetration.

References:
 1. Ishikawa H. Anterior segment imaging for glaucoma: OCT or UBM?. Br J Ophthalmol.
2007;91(11):1420-1421. doi:10.1136/bjo.2007.121038

2. Pavlin CJ, Foster FS. Ultrasound biomicroscopy of the eye. New York: Springer & Verlag;
1995.

3. Pavlin CJ, Haraseiwicz K, Sherar MD, Foster FS. Clinical use of ultrasound biomicroscopy.
Ophthalmology. 1991;98(3):287–295.

4. Ishikawa H, Schuman JS. Anterior segment imaging: ultrasound biomicroscopy.

Ophthalmol Clin North Am. 2004;17(1):7–20.

5. Mannino G, Papale A, De Bella F. Biomicroscopia ad ultrasuoni [Ultrasound

biomicroscopy]. Fabiano Editore; 2004. Italian.

6. Mundt GH, Hughes WF. Ultrasonics in ocular diagnosis. Am J Ophthalmol 1956;42:488–98.

[PubMed:13362453]

7. Baum G, Greenwood I. The application of ultrasonic locating techniques to ophthalmology.

II. Ultrasonic slit-lamp in the ultrasonic visualization of soft tissues. Arch Ophthalmol
1958;60:263–79.

8. Overview of Ultrasound Biomicroscopy.Mingguang He, Dandan Wang, Yuzheng Jiang.

Journal of Current Glaucoma Practice, January-April 2012;6(1):25-53

9. Reinstein DZ, Silverman RH, Coleman DJ. High-frequency ultrasound measurement of the
thickness of the corneal epithelium. Refract Corn Surg 1993;9:385–7.

10. High-resolution ultrasound imaging of the eye – a review. Ronald H Silverman, PhD. Clin
Experiment Ophthalmol. 2009 January ; 37(1): 54–67.

11. Ama Sadaka, Prager T, Beaver H, Malik A. A novel use of ultrasound biomicroscopy. Eye
(Lond). 2018;32(2):474-475. doi:10.1038/eye.2017.190

12. Greyrose SE, Starr CE, Lloyd HO, Silverman RH. Comparative central corneal thickness by
ultrasound pachymetry, Artemis-2, and Visante. IOVS 2008;49 ARVO E-Abstract 1020.

13. Allemann N, Chamon W, Silverman RH, et al. High-frequency ultrasound quantitative

analyses of corneal scarring following excimer laser keratectomy. Arch Ophthalmol
1993;111:968–73.[PubMed: 8328940]

14. Reinstein DZ, Silverman RH, Coleman DJ. Very high-frequency ultrasound corneal analysis
identifies anatomic correlates of optical complications of lamellar refractive surgery.
Ophthalmology.1999;105:474–82. [PubMed: 10080202]

15. Reinstein, DZ.; Archer, T.; Gobbe, M. Stability of LASIK in corneas with forme fruste or
suspect keratoconus, where keratoconus was excluded by epithelial thickness mapping.
American Academy of Ophthalmology Annual Meeting; 9 Nov 2008; Atlanta, GA.

16. Pavlin CJ, Harasiewicz K, Foster FS. Ultrasound biomicroscopy of anterior segment
structures in normal and glaucomatous eyes. Am J Ophthalmol 1992;113:381–9.

17. Pavlin CJ, Macken P, Trope GE, et al. Accommodation and iridotomy in the pigment
dispersion syndrome. Ophthalmic Surg Lasers 1996;27:113–20.

18. Yamamoto T, Sakuma T, Kitakawa Y. An ultrasound biomicroscopic study of filtering blebs

after mitomycin C trabeculectomy. Ophthalmology 1995;102:1770–76

19. Huang D, Swanson EA, Lin CP, et al. Optical coherence tomography. Science.
1991;254:1178-1181.

20. Janssens K, Mertens M, Lauwers N, de Keizer RJ, Mathysen DG, De Groot V. To Study and
Determine the Role of Anterior Segment Optical Coherence Tomography and Ultrasound
Biomicroscopy in Corneal and Conjunctival Tumors. J Ophthalmol. 2016;2016: 1048760.

Ophthalmology
Lectures
Cybersight Is An Online
Training and Mentorship
Service For Eye Health
Orbis Cybersight Professionals!
  Articles Miscellaneous Uvea and Intraocular In ammation Imaging Vitreoretina

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Dr. Sowkath Ali

Department of Ophthalmology and visual sciences, Khoo Teck Puat Hospital, Singapore

Sowkath Ali completed fellowship in uveitis at Sankara Nethralaya, Chennai in 2017. He is currently
working as resident physician in Department of Ophthalmology at Khoo Teck Puat hospital,
Singapore since 2017.

Dr. Eunice Goh

Department of Ophthalmology,Tan Tock Seng Hospital, Singapore

Dr. Eunice Goh is a medical o cer at the Department of Ophthalmology in Tan Tock Seng Hospital,
Singapore. She is interested in research and has presented her work at several international
conferences. Currently, her research is centered around elds of uveitis and polypoidal choroidal
vasculopathy.

Dr. John Kan

Department of Ophthalmology,Tan Tock Seng Hospital, Singapore

Dr. John Kan is an Ophthalmology resident at the National Healthcare Group, Singapore. He is
currently involved in research concerning ocular trauma and minimally invasive glaucoma surgery.

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