Full text of DOI:10.1007/s12009-000-0086-2

A B S T R A C T
Thirty-nine eyes of 33 patients with anterior and/or intermediate
uveitis and 2 patients with scleritis underwent ultrasound biomi-
croscopy (UBM) for evaluation of the anterior segment and ciliary
body. In patients with intermediate uveitis (30 eyes), intraocular
lens–related uveitis (7 eyes), and pseudophakic uveitis (1 eye), UBM
revealed changes in the iris, ciliary body and adjacent structures,
which supplemented the clinical diagnosis in inflammatory eye dis-
eases, especially when the view was occluded.
O R I G I N A L A R T I C L E
Ultrasound Biomicroscopy in Anterior
Segment Inflammatory Disorders
Jyotirmay Biswas, MS, Muna P. Bhende, MS, &
Sandeep V. Mondkar, DOMS
ltrasound biomicroscopy (UBM) is a new modality
U
of diagnostic imaging using ultrasound waves to
produce a 2-dimensional real-time view of the anterior
segment of the eye in B-mode. The technique was first
described by Pavlin and associates1 in 1990 and its clin-
ical application was described in 1991.2 The method
involves developing and incorporating high-frequency
(50 to 100 MHz) ultrasound transducers into a clinical
B-scan device capable of producing images in the liv-
ing eye up to a depth of 4 mm with axial and lateral res-
olution approaching 50 µm. Thus, a 2-dimensional view
of the anterior segment is produced. Internal acoustic
characteristics help in tissue differentiation, which is
aided by a very fine backscatter speckle pattern at
high frequencies. In uveitic entities, UBM has been
reported to be beneficial in imaging an inflammatory
mass in pars planitis3 and a shallow anterior chamber
in Vogt-Koyanagi-Harada syndrome.4 Roy and cowork-
ers5 presented a report of the application of UBM in a
small series of anterior, intermediate, and intraocular
lens (IOL)–induced uveitis. They highlighted the
potential of UBM in the diagnosis and therapeutic
decision-making process by producing information not
otherwise available through clinical examination.
We report here a study of the role of UBM in the
anterior segment evaluation of anterior and interme-
diate uveitis, IOL-related uveitis, pseudophakic
endophthalmitis, and scleritis.
Materials & Methods
Between July and October 1997, thirty-three patients
(39 eyes) with uveitis and 1 patient (1 eye) with
Reprints:
Jyotirmay Biswas, MS, Vision Research Foundation, 18 College Road, Madras 600 006,
India.
The authors are from the Medical and Vision Research Foundation, Chennai, India.
ANN OPHTHALMOL. 2000;32(4):301–306
301

pseudophakic endophthalmitis with a limited view of
the fundus were evaluated by UBM. In addition, 2
patients with scleritis or sclerouveitis were evaluated
by UBM. A standard uveitis work-up was done in all
cases of uveitis, which included salient features in the
history, ophthalmic examination including a detailed
slit-lamp examination, and indirect ophthalmoscopy
with scleral depression. Ancillary tests such as B-scan
ultrasonography and fundus fluorescein angiography
(when needed) were done to arrive at an anatomical
diagnosis of the uveitic entity. With the use of the
naming-meshing system, a short differential diagno-
sis was made in each case. Subsequently a tailored
laboratory investigational procedure was adopted
using Nozik’s approach.6 Most of the cases were inter-
mediate uveitis (25 cases) or anterior uveitis with sus-
picion of intermediate uveitis (5 eyes). All the above
eyes had occlusion and seclusion of the pupil and/or
complicated cataract, which precluded the view of the
pars plana by indirect ophthalmoscopy with scleral
depression following pupillary dilation. Seven eyes
had IOL-related uveitis. One of the cases was later
diagnosed as pseudophakic endophthalmitis. One eye
had a differential diagnosis of scleritis or scleral
tumor; another eye had sclerouveitis.
field of view of 5 mm, and scan penetration of 4 to 5
mm, was used. The procedure was similar to the con-
ventional immersion technique of ultrasound exami-
nation, with the patient supine and the eye to be
examined anesthetized with a topical anesthetic. A
polymethyl methacrylate (PMMA) eyecup of a suitable
size was inserted between the eyelids to keep them
open and facilitate the use of a coupling solution (2.5%
methylcellulose). The transducer was positioned over
the eye and the anterior segment was scanned. The
various structures and meridians were scanned by
asking the patient to move the eye in different direc-
tions. We performed UBM evaluation of the pars plana
and ciliary body to rule out structural changes due to
inflammation, the structural damage caused by IOL,
and for resolving a diagnostic dilemma (scleral mass).
A therapeutic decision regarding the timing of
cataract extraction and the need for posterior sub-
Tenon injection of depot steroid (triamcinolone ace-
tonide, 40 mg) in patients with intermediate uveitis
was based on the UBM findings.
Results
Of 39 eyes that underwent UBM, 25 eyes had a history
or previous documentation of intermediate uveitis by
us or by the referring ophthalmologist. Five eyes had
a diagnosis of anterior uveitis, but the patients had a
history of seeing floaters suggestive of intermediate
uveitis. Findings of UBM in these cases include homo-
geneous mass of moderate reflectivity, indicating
presence of exudates over the pars plana (10 eyes)
(Figs 2A and 2B); moderately reflective membrane in
the vitreous (6 eyes); and membrane over the pars
plana (4 eyes) (Figs 3A and 3B). The ciliary body and
pars plana were normal in 5 eyes despite clinical sus-
picion of intermediate uveitis or previous history of
intermediate uveitis. In case of exudates or mem-
branes over the pars plana, cells and membranes in
the adjacent vitreous seen on UBM, periocular depot
steroid injection (triamcinolone acetonide, 40 mg) was
given if not otherwise contraindicated. We also
deferred cataract surgery by at least 3 months in such
cases. One patient who had repeated UBM examina-
tion 3 months after the posterior sub-Tenon injection
of triamcinolone acetonide showed disappearance of
exudates and formation of membranes, indicating the
utility of such examination for assessing the response
to treatment.
An ultrasound biomicroscope (Humphrey Instru-
ments, model 840, Humphrey Instruments, division of
Carl Zeiss Inc., San Leandro, Calif) (Fig 1) with a 50-
MHz transducer, providing a resolution of 50 µm, a
Of 7 eyes with IOL-induced uveitis, 1 had gross
hypotony with ciliochoroidal detachment and a cyclo-
dialysis cleft evident on UBM (Fig 4). One eye had iris
adhesions to the anterior surface of the IOL optic;
with the haptic seen in the ciliary body and ciliary
body edema (Figs 5A and 5B). In 1 eye, 1 haptic of the
IOL was seen in the capsular bag and 1 was in the sul-
cus, and in another eye there was iris tuck and pupil-
lary capture. In
1 case of post IOL-induced
uveitis/endophthalmitis, which required diagnostic
vitrectomy, Propionibacterium acnes was identified
by microbiological study from the vitrectomy speci-
Fig 1.—Ultrasound biomicroscope (Humphrey Instruments model 840). Note the track
ball (t) and gantry (g).
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Fig 2A.—Slit-lamp photograph of a case of suspected intermediate uveitis with
occlusion of the pupil.
men. Ultrasound biomicroscopy was ordered when
there was a recurrence of inflammation. It showed a
rim of capsule with a clump of highly reflective echoes
(Fig 6), probably a plaque of P acnes necessitating fur-
ther intravitreal antibiotic therapy. In 1 case for which
a diagnosis of scleral tumor vs nodular scleritis was
entertained, echolucent areas in the nodule were
observed, suggestive of inflammatory edema (Figs 7A
and 7B). In another patient with sclerouveitis and
complicated cataract, scleral edema was observed by
UBM as an area of increased scleral thickness with
variable reflectivity.
Fig 2B.—Ultrasound biomicroscopy photograph of the same eye as in Fig 2A showing
multiple opacities of medium reflectivity (arrows) in the vitreous over the pars plana
(pp).
ers.3 They found a homogeneous mass of medium
reflectivity over the pars plana in a case in which a
posterior subcapsular cataract precluded complete
fundus visualization. Subsequently, lensectomy and
vitrectomy confirmed the diagnosis of intermediate
uveitis. Evaluation of the pars plana can be often dif-
ficult in a case of intermediate uveitis due to forma-
tion of complicated cataract, which has been reported
in 13% to 61% of eyes.7 The majority of such cataracts
are posterior subcapsular or posterior cortical. Such
cataracts were found to be quite significant to pre-
clude the view in about 15% of cases in one series.8
Anterior uveitis in a typical case of intermediate
uveitis is usually mild and nongranulomatous. Poste-
rior synechiae formation was relatively uncommon
and was seen in 18% of cases in one series.9 Children
with intermediate uveitis can have more severe
Discussion
In uveitic entities in which a view of the peripheral
part of the fundus and pars plana is difficult due to a
small pupil or posterior synechiae, imaging of exu-
dates and membranes over the ciliary body and pars
plana can be of substantial benefit, both in the evalu-
ation of anatomical extent of involvement and in sub-
sequent treatment. The utility of UBM in the
diagnosis of intermediate uveitis in case of media
opacities was reported by Garcia-Feijoo and cowork-
Fig 3A.—Slit-lamp photograph of an eye with anterior uveitis with a small pupil and
complicated cataract. The case previously was diagnosed as intermediate uveitis.
Fig 3B.—Ultrasound biomicroscopy photograph of the same eye as in Fig 3A showing
a membrane of medium reflective echoes adhered to the pars plana (arrows).
ANN OPHTHALMOL. 2000;32(4)
303

Five eyes had normal pars plana or ciliary body
despite clinical suspicion of pars planitis or previous
history of documentation of pars planitis by others or
us. This could be due to an inability of UBM to detect
early changes or to a regressed stage of pars planitis.
It is also possible that some of these eyes had only
anterior uveitis with spillover inflammation in the
anterior vitreous.
Histopathologic studies of the intermediate uveitis
are rare and are done only in the advanced stages. In
such a study, collapsed vitreous with dense organiza-
tion in the pars plana region and mild to moderate
degree of chronic inflammation develop in the ciliary
body in advanced stages. Such changes corresponded
to the clinical finding of pars plana exudate, also
called “snow banking.”10 Imaging of such exudates are
possible by UBM, providing immense diagnostic and
therapeutic value.
We believe that a major advantage of UBM study in
intermediate uveitis is its ability to rule out an active
inflammation over the pars plana region, mainly for
decision making in cataract surgery with or without
IOL implantation. Cataract extraction in intermediate
uveitis is considered to be safe if it is done in the even-
tual “burnt out” phase.9 Presence of inflammatory
debris would warrant postponement of cataract
extraction.11,12 We deferred surgery in all cases who had
evidence of exudates over pars plana, edema of ciliary
body, and cells in the vitreous on UBM. Patients who
had membrane in the pars plana and/or atrophy of cil-
iary body were advised to undergo cataract extraction
after preoperative systemic and periocular steroid
therapy. One patient in our series, at presentation, had
a small pupil in both eyes due to posterior synechiae.
One eye of this patient had an IOL implantation else-
where, with postoperative exacerbation of inflamma-
Fig 4.—Ultrasound biomicroscopy photograph of an eye with chronic IOL-induced
uveitis, which had undergone vitrectomy earlier. Subsequently, the patient had gross
hypotony with hypotonic maculopathy. Photograph shows a cyclodialysis cleft
(arrows).
inflammation and posterior synechiae. Intermediate
uveitis associated with sarcoidosis can have granulo-
matous uveitis and tends to develop more anterior
segment complications than does anterior uveitis.7
Due to the referral nature in a tertiary ophthalmic
care center like ours, many of our cases had chronic
and recalcitrant intermediate uveitis leading to vari-
ous anterior segment complications, such as posterior
synechiae and complicated cataract. In our series of 30
eyes with either intermediate uveitis or suspicion of
intermediate uveitis, 25 eyes (83.3%) had evidence of
existing or previous inflammation in the ciliary body
or pars plana, or both. In 10 eyes, active inflammation
was suspected due to evidence of a mass of moderate
reflectivity in the pars plana region. Six of these eyes
also had cells or membranes in the vitreous. Four eyes
had membrane over the pars plana, probably indicat-
ing healed intermediate uveitis.
Fig 5B.—Ultrasound biomicroscopy photograph of the same eye as in Fig 5A showing
synechial adhesion of the IOL optic (o) to the posterior surface of the iris and the hap-
tic (h) within the ciliary body as well as ciliary body edema.
Fig 5A.—Clinical photograph of a case of chronic IOL-induced uveitis with a distort-
ed pupil due to posterior synechiae.
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ANN OPHTHALMOL. 2000;32(4)

medical treatment, and surgical removal is indicated.
Ciliochoroidal detachment due to a cyclodialysis cleft
is a known complication following intraocular surgery.
In a case reported by Minamoto and coworkers,13 UBM
revealed ciliochoroidal detachment, which was missed
by indirect ophthalmoscopy. Subsequent vitrectomy
and fluid-gas exchange combined with diathermy
around the site of the sclerotomy caused the regres-
sion of ciliochoroidal detachment, which was con-
firmed by UBM. In our series, a cyclodialysis cleft
with ciliochoroidal detachment was observed by UBM
in a case of chronic uveitis and hypotony following
IOL implantation. Detection of this complication was
important in the subsequent management of the case,
as it resulted in resolution of hypotony and improve-
ment of vision.
Inflammation of the sclera usually can be diag-
nosed accurately by torch light, slit-lamp examina-
tion. However, in 1 of our cases (Fig 7A), a diagnosis of
scleral tumor was made by the referring ophthalmolo-
gist. A clinical evaluation by us revealed suspicion of
scleritis with autoimmune endotheliitis of the cornea.
Investigation revealed a raised erythrocyte sedimen-
tation rate and positive antinuclear antibody, support-
ing an underlying collagen disease. Ultrasound
biomicroscopy demonstrated a localized nodule of
variable reflectivity compared with the adjacent nor-
mal sclera, indicating inflammatory scleral edema.
Subsequently, treatment with a systemic nonsteroidal
agent caused substantial regression of the scleral
mass, thereby confirming the diagnosis made by clin-
ical examination and UBM. Pavlin and Foster14 and
Pavlin and coworkers15 reported features of episcleritis
and scleritis of various types (eg, diffuse, nodular, and
necrotizing). Ultrasound biomicroscopy can image the
sclera at a resolution sufficient to measure thickness
and delineate pathologic changes such as scleral
edema due to scleritis or scleral thinning in necrotiz-
ing scleritis. The margin of the sclera can also be dif-
Fig 6.—Ultrasound biomicroscopy photograph showing clump of exudates behind the
iris and the ciliary body junction (arrow) in an eye with pseudophakic endophthalmi-
tis that had recurrence of inflammation following vitrectomy.
tion and resulting extensive posterior synechiae lead-
ing to occlusion of the pupil and iris-IOL adhesion. In
this case, UBM showed evidence of exudates in the
pars plana in the operated eye. These findings empha-
size the need for an accurate preoperative evaluation
by UBM of the status of inflammation in the pars
plana region.
Intraocular lens implantation can also lead to post-
operative intraocular inflammation, due to surgical
trauma; hypersensitivity to lens protein; malposition-
ing of the IOL haptics; or a low-grade, delayed-onset
endophthalmitis caused by P acnes. In our series of
pattern of uveitis in a referral center, 8.8% cases of
anterior uveitis were IOL induced.6 Determination of
the haptic position in patients with suspected IOL-
induced uveitis is also of potential diagnostic and
therapeutic value. A malpositioned IOL with iris and
ciliary body touch can be the cause of recurrent
uveitis. Such uveitis often cannot be controlled with
Fig 7A.—Slit-lamp photograph showing multiple nodular masses in the sclera and
corneal haze.
Fig 7B.—Ultrasound biomicroscopy photograph of the same eye as in Fig 7A showing
echolucent spaces (arrows) in the sclera (SC) consistent with inflammatory edema.
ANN OPHTHALMOL. 2000;32(4)
305

ferentiated from overlying episcleral tissue and the
underlying ciliary body and choroid. Such precise
imaging of structures is not possible with B-scan
ultrasound, even with water bath. Ultrasound biomi-
croscopy can supplement clinical findings and detect
the precise location of episcleral and scleral inflam-
mation, and it also can provide views of adjacent
choroidal, retinal, and vitreous changes.15 It is also of
additional value in a diagnostic dilemma of corneal
involvement associated with scleritis and vice versa.
The corneoscleral junction can be well outlined due to
higher reflectivity of the sclera than the cornea.
Our limited experience indicates that UBM, a new
noninvasive modality, is useful in selected conditions
of various types of uveitis, such as anterior uveitis
with small pupil to rule out associated inflammation
in the pars plana region. It also useful in cases of inter-
mediate uveitis to confirm the diagnosis by delineat-
ing exudates and membrane in the pars plana. Such
information was found to be useful in medical man-
agement, in decision making, in cataract surgery, and
evaluation of therapy. In IOL-induced uveitis, UBM
confirms the position of the IOL haptics; structural
damage, if any, caused by the IOL; and in scleritis cys-
tic spaces in the sclera. We emphasize, however, that
UBM has limitations, as its depth of penetration is
only 4 to 5 mm. When the view is totally occluded, a
conventional B-scan ultrasound is indicated for
assessment of the vitreous, retina, and choroid. This
can be supplemented by UBM for imaging the ciliary
body, pars plana, and adjacent vitreous.
done for the refinement of techniques, clinical corre-
lation, and parameters for quantitative UBM.
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