Yonago Acta medica 2005;48:57–62

Clinical Evaluation of a Three-Dimensional Ultrasonography
System in the Ophthalmic Field
Takeshi Kumagami*, Yuji Sasaki, Atsushi Yamasaki, Takashi Baba, Jiro Hasegawa,Kazuki Matsuura† and Akihiko Tamai‡
Division of Ophthalmology and Visual Science, Department of Medicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine and †Departmentof Biomedical Science, Institute of Regenerative Medicine and Biofunction, Tottori University Graduate School of Medical Sciences, Yonago 683-8504, *Clinic of Ophthalmology,Nagasaki Municipal Hospital, Nagasaki 850-8555 and ‡Clinic of Ophthalmology, Hino Hospital Association Hino Hospital, Hino 689-4504 Japan
Clinical use of a 3-dimensional ultrasonography system with a new ophthalmic imaging
device using conventional 2-dimensional ultrasound tomography in the ophthalmic field
was evaluated in 5 patients with different ocular conditions. With the system, surface
rendering and volume measurement were easy in 3-dimensional ultrasonographic examinations. In a patient with rhegmatogenous retinal detachment, the surface rendering
made the image cube transparent, revealing interior surface details. In a patient withlens luxation resulting from Marfan’s syndrome, the shape of luxated spherophakia wasdetected stereographically. In a patient with choroidal detachment, we could evaluate
the effect of administration of aspirin on the amelioration of this disease by measuring
the volume of the choroidal lesion. In a patient with aberration of a lens fragment into
subretinal space during cataract surgery, we grasped the whole ocular condition in the3-dimensional image only by just one manipulation. In a patient with optic disc melanocytoma, we could detect the volume change in detail using the 3-dimensional imagessaving system. No discomfort occurred in these patients during examination. Basedupon the above findings, we considered that this device was useful in making diagnosis
and grasping the whole ocular conditions and outcome in breathtaking 3-dimensionalviews, and in causing no discomfort for patients.
Key words: 3-dimensional images-saving system; 3-dimensional ultrasonography system; 2-dimensional ultrasound tomography; surface rendering; volume measurement

It has been 3 and half decades since ophthalmic
ultrasound was at the forefront of ultrasound technology when the first array scanner was built for
ophthalmic use (Buschmann, 1992). Since then,conventional ophthalmic ultrasonography has been
an established diagnostic technique that is essential for clinical practice of ophthalmology. Theeye has advantages in the use of 3-dimensional
imaging technology rather than in the use of 2-dimensional technology: the eye is reasonably small,which means the 3-dimensional ultrasound images
require only moderate amounts of random accessmemory, and it is relatively immobile with a highfluid content and is well known as an excellent

Abbreviations: B-mode, brihtness mode; B-scan, brightness scan; IOL, intraocular lens57

T. Kumagami et al.
acoustic medium, with no air or calcification in it(Downey et al., 1996).
Thus a newly devised 3-dimensional ultrasonography system using conventional 2-dimensional
ultrasound tomography has been evaluated in imaging the eye, along with the current developmentof computers (Downey et al., 1996; Cusumano etal., 1998; Finger et al., 1998; Fisher et al., 1998;
Romero et al., 1998; Endo et al., 2000). Using thisnew system, we examined 5 patients with different
ocular diseases, and summarized the observations.

Materials and Methods
Five representative patients with different ocularconditions were selected for clinical evaluation ofa 3-dimensional ultrasonography system in August
1998, and examined over 2 years to September
2000 at our Clinic of Ophthalmology, Tottori University Hospital. The tenets of the Declaration ofHelsinki were followed. Upon giving informedconsent, all patients participated in the presentstudy. They were asked to grade the level of discomfort during the examination as mild, moderateor severe according to the report of Downey andhis co-workers (1996).

Fig. 1. Rendering image of the 3-dimensional ultrasonography of the left eye of patient 1 with rhegmatogenous retinal detachment with vitreous hemorrhage. It
reveals the inside view of the detached retinal surface
and vitreous hemorrhage. A, anterior side; DR, detached retina; S, superior side; T, temporal side; VH,vitreous hemorrhage

central axis. A personal computer (Power Macintosh 7600, Apple Computer, Inc., Cupertino, CA)
controlled the probe motion, which simultaneouslyrecorded a series of 2-dimensional B-scan images.
The numerous 2-dimensional images obtained
were reconstructed into a 3-dimensional image byusing a 3-dimensional visualization software run
on another personal computer (Power MacintoshG4, Apple Computer, Inc.). The data reconstruction time was 140 s.
The visualization software allowed the data
to be viewed in different ways. The 3-dimensional
image as a multi-sided object (cube) could besliced in any direction. With the 3-dimensional
images-saving system, this device could measure
the length, the area and even the volume of target
lesions in the eye, including surface rendering as anadvanced feature.
The whole procedures of an examination including patient set-up, scanning review, data recon-3-Dimensional ultrasonography
Three-dimensional ultrasonographic examinations
were performed with a 3-dimensional ultrasoundtomogram (i-Scan Ophthalmic Tomographic Ultrasound, Ophthalmic Technologies Inc., Tronto,
Canada). To obtain the 3-dimensional ultrasoundimage, the conventional brightness mode (B-mode)
probe was inserted into a motorized, hand-heldprobe rotation assembly (Scanner Asembly, Ophthalmic Technologies Inc.), and held gently against
the patient’s lid. The probe was held in a position
to obtain a coronal image, avoiding the lens as applied for standard brightness scan (B-scan) ultrasonography. Methyl-cellulose solution (1%) was used
as a sound coupling agent on the transducer tip.
The inserted B-mode probe was rotated about
180 degrees by the Scanner Assembly through its58

3-Dimensional ultrasonography in ophthalmic fieldstruction and 3-dimensional image examination,
were completed within 7 min in the present survey.
Patients and Observations

aPatient 1 was a 66-year-old man with rhegmatogenous retinal detachment with vitreous hemorrhage
in the left eye. Figure 1 shows a rendering imageby 3-dimensional ultrasonography of the left eye
using a rendering surface technique, indicating
the inside view of the detached retinal surface andvitreous hemorrhage. The rendering image makes
it easy to comprehend the relation between the detached retina and vitreous hemorrhage. That is, thesurface rendering made the image cube transparent,
revealing interior surface details.
Patient 2 was a 45-year-old woman with lens
luxation resulting from Marfan’s syndrome in theleft eye. Figure 2a shows a 3-dimensional image ofa sagittal section of the left eye observed at the supine position. It is possible to see the spherophakia
dropped at the bottom of the posterior pole. Figure
2b shows another 3-dimensional view at the seating position, which clearly visualized the dropped
spherophakia moving to the equator.
Patient 3 was a 72-year-old woman with choroidal detachment which occurred 3 years after
intraocular lens (IOL) implantation in the left eye.
Figure 3a shows a 3-dimensional image in a frontal section of the left eye at the first examination,
which revealed choroidal detachment on the temporal side. Figure 3b shows another 3-dimensionalview obtained 3 days after the oral administrationof aspirin (1.2 g/day). It was difficult to decide
whether this treatment was effective or not. Then,
we measured the volume of the choroidal lesionusing an integral technique described below, after
tracing the area of choroidal detachment in a given“slice” by an examiner. As a result, the volume of
the choroidal lesion was 783 mm3 before the treatment (Fig. 3a), but 3 days after the treatment, thevolume was decreased to 601 mm3 (Fig. 3b). Following the continuous administration for 7 days,
the volume became 191 mm3 (Fig. 3c). Thus we
could evaluate the effect of the aspirin treatment

bFig. 2. Sagittal sections of the 3-dimensional images ofthe left eye of patient 2 with Marfan’s syndrome showing lens luxation. LL, luxated lens.
a: At the supine position.
b: At the seating position.

on the amelioration of this entity by measuring thevolume of the choroidal lesion. In fact, the choroidal lesion kept being decreased and finally disappeared 22 days after the aspirin treatment: thesechanges were also detected on the 3-dimensionalviews at the final stages of the treatment.
Patient 4 was an 80 -year-old woman withaberration of a lens fragment into subretinal space
during cataract surgery of the right eye. A sagittal

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T. Kumagami et al.
section of a 3-dimensional image showed a lensmass under the detached retina (Fig. 4), which happened to occur during the surgery. We could not
see the fundus ophthalmoscopically due to severe
phacolytic inflammation after the surgery. The
3-dimensional ultrasonography seems to be valuable in grasping the unpredictable condition of theinvisible fundus like in this patient, because thisnew imaging system can detect the whole ocular
information by just one manipulation.
Patient 5 was a 39-year-old man with melanocytoma of the optic disc in the right eye. Figure
5a shows a frontal section of the rendering image,where the protuberant lesion on the optic disc wasclearly detected. Figure 5b shows sagittal slices of
the tumor lesion stepping to 1 mm. With the integral technique, the volume of the melanocytoma
could be calculated by moving the outlining processor to adjacent “slices” known distances away(for example, 1 mm) and repeating the outlining
process. The volume of the structure was obtainedby summing the area in each “slice” and multiplying it by the distance between “slices”. That is, wecan detect the volume change in detail using the3-dimensional images-saving system. The volumeabc

Fig. 3. Frontal sections of the 3-dimensional images ofthe left eye of patient 3 with choroidal detachment after
IOL implantation. The choroidal lesion in each slice
can be traced to measure its volume. A, anterior side; S,superior side; T, temporal side.
a: At the first examination.
b: 3 days after the administration of aspirin (1.2 g/day).
c: 7 days after the aspirin treatment.

Fig. 4. Sagittal section of the 3-dimensional image ofthe right eye of patient 4 with aberration of a lens fragment into subretinal space during cataract surgery. DR,
detached retina; LF, lens fragment.

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3-Dimensional ultrasonography in ophthalmic fieldab

Fig. 5. Rendering images of the 3-dimensional ultrasonography of the right eye of patient 5 with melanocytoma of
the optic disc.
a: A frontal section of the rendering image. A, anterior side; M, melanocytoma of the optic disc; N, nasal side; S,superior side.
b: Sagittal slices of optic disc melanocytoma stepping to 1 mm. The tumor lesion in each slice can be traced tomeasure its volume.

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T. Kumagami et al.
measurement seems to be very useful to follow up
the tumor lesion.
No patients answered any discomfort when
they were asked to grade the level of discomfort(Downey et al., 1996) face to face during the examination.

ferred by usual methods of digital data transfer (forexample, diskettes, telephone lines and computer
networks), remote consultations and discussion arepossible (Downey et al., 1996). That is, the ability to transfer this digital data through computer
networks makes it easy to communicate its information. Further work is required to widen clinicalutility of this newly devised 3-dimensional ultrasonography system even in the ophthalmic field.

Discussion
The 3-dimensional i-Scan Ophthalmic Tomographic Ultrasound used in the present study is quite
simply a new way to look at B-scan ultrasound.
By capturing and combining hundreds of separate
2-dimensional images, it provides breathtaking
3-dimensional views of the eye. Advanced features
such as surface rendering and volume measurement
are also easy to use.
Indeed, conventional 2-dimensional ophthalmic ultrasonography is an established diagnostic
technique and is essential for clinical practice ofophthalmology (Buschmann, 1992), but 3-dimensional ultrasonography has many possible advantages to make an important contribution to clinicalpractice even of such several other diseases as malignant melanoma of the iris and ciliary body (Cusumano et al., 1998), choroidal melanoma (Downeyet al., 1996; Finger et al., 1998; Romero et al.,1998), traumatized eye with hypotony (Cusumanoet al., 1998), post-traumatic vitreous hemorrhage
and retinal detachment (Downey et al., 1996), choroidal hemorrhage and associated retinal detachment (Cusumano et al., 1998), Behçet’s disease
resulting in invisible fundus due to intraocular inflammation (Endo et al., 2000) and displaced IOLin the anterior segment (Cusumano et al., 1998), as
well as the presently described ocular diseases.
In conclusion, this device is useful in making
diagnosis and grasping the whole ocular conditions
and outcome in the breathtaking 3-dimensional
images, with no patient discomfort. The volume
measurement seems to be very useful to follow up
the tumor, as this device is equipped with the 3-dimensional images-saving system. Moreover, as the3-dimensional images are digital and can be trans-Acknowledgments: We express our sincere thanks toProfessor Yoshitsugu Inoue, Division of Ophthalmology
and Visual Science, Department of Medicine of Sensory
and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, for his generous help.
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Received January 27, 2005; accepted March 15, 2005
Corresponding author: Akihiko Tamai, MD62