Sudanese Journal of Ophthalmology

: 2020  |  Volume : 12  |  Issue : 1  |  Page : 23--26

Evaluation of role of ophthalmic ultrasonography in ophthalmic examination precataract surgery

Raghda F Mutwaly1, Yazan S Gammoh2, Mustafa Abdu3,  
1 Department of Ophthalmic Medical Photography, Faculty of Optometry and Visual Sciences, Al-Neelain University, Khartoum; Department of Optometry Science, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman, Jordan
2 Department of Optometry Science, Faculty of Allied Medical Sciences, Al-Ahliyya Amman University, Amman, Jordan
3 Department of Contact Lenses, Faculty of Optometry and Visual Sciences, Al-Neelain University, Khartoum, Jordan; Department of Optometry, Faculty of Applied Medical Sciences, University of Jeddah, Jeddah, KSA

Correspondence Address:
Dr. Yazan S Gammoh
P.O. Box 121, Amman 19328


Aim: The aim of this study is to determine the importance of ophthalmic ultrasonography in investigation before cataract surgery, with a view to identify common posterior segment lesions in elderly patients. Subjects and Methods: A cross-sectional prospective study was conducted at AlNeelain University Eye Hospital, Khartoum, Sudan, on 220 eyes of 220 elderly patients (50–90 years) with senile cataract in one eye in the period from January to September 2018. Grade of cataract was evaluated using the slit-lamp examination. A-scan biometry and B-scan ultrasonography were taken before cataract surgery using Echo Scan (Nidek, US-4000). High gain (80–120 dB) and medium gain (50–70 dB) sensitivity were used. Dynamic B-scan was used to enhance differential diagnosis in cases with vitreous changes. Results: The mean age of the sample was 60.46 ± 10.64 years with 120 males and 100 females. Grade of cataract reported was as follows: 40% Grade II, 50% Grade III, and 10% Grade IV. Visual acuity (VA) had a negative correlation with grade of cataract (P < 0.001). All patients had visual impairment before cataract surgery with a mean VA of 0.10 ± 0.17. Posterior lesions detected were as follows: Asteroid hyalosis (22.73%), vitreous haemorrhage (10%), posterior staphyloma (7.27%), posterior vitreous detachment (6.36%), retinal detachment and retinoschisis (4.55% each), and ciliary body tumor (1.82%). Conclusion: Most common posterior segment lesion found in elderly patients is asteroid hyalosis, while ciliary body tumor is the only neoplastic lesion found. Ophthalmic ultrasonography is essential for the detection of undetected posterior segment lesions in eyes with dense cataract and is recommended to be done routinely before cataract surgery.

How to cite this article:
Mutwaly RF, Gammoh YS, Abdu M. Evaluation of role of ophthalmic ultrasonography in ophthalmic examination precataract surgery.Sudanese J Ophthalmol 2020;12:23-26

How to cite this URL:
Mutwaly RF, Gammoh YS, Abdu M. Evaluation of role of ophthalmic ultrasonography in ophthalmic examination precataract surgery. Sudanese J Ophthalmol [serial online] 2020 [cited 2021 May 10 ];12:23-26
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Full Text


Ophthalmic ultrasound is based on sonolucent waves produced through an oscillation of particles within a medium. The frequency commonly used in the diagnostic ophthalmic ultrasound for posterior segment is in the range of 8–10 MHz.[1],[2],[3] There are four modes of ophthalmic ultrasound which include A-mode, B-mode, M-mode, and Doppler ultrasound.[4],[5] The brightness mode (B-scan) provides a cross-sectional image which would assist the clinician in the determination of the topography of lesions.[6],[7] Ophthalmic ultrasonography has advanced over the years enabling the clinician to study the posterior segment of the eye even in the presence of opaque media such as dense cataract.[8],[9]

Senile cataract is a physiological age-related degeneration that occurs in elderly participants after 50 years of age and result in gradual loss of vision.[3] It is an opacification of the crystalline lens associated with severe decrease of vision depending on its density.[4],[10] When the density of cataract is high, ophthalmoscopy cannot be used to view the interior ocular structures lying behind the lens as the light produced by the ophthalmoscope cannot pass through opaque media. In contrast, ultrasound can pass through this opaque media and can provide an assessment of the posterior segment of the eye.[3],[5]

Previous studies have showed that B-scan ultrasonography is of value before cataract surgery.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] One study demonstrated that 23.5% of elderly patients had posterior vitreous detachment while 4% had retinal detachment.[6] Furthermore, another study has concluded that posterior staphyloma (7.9%) was common in old patients.[7] It has also been determined that 19.6% of elderly patients had posterior segment pathology; the common lesion was posterior staphyloma (7.2%), retinal detachment was 4.5%, and vitreous hemorrhage was 2.5%.[9] A study conducted on elderly patients with nontraumatic cataract have shown a 1.77% prevalence of asteroid hyalosis, 1.03% for posterior vitreous detachment, 1.47% for retinal detachment, while 1.91% had vitreous hemorrhage.[1]

Our experience at a tertiary eye care center in Sudan through the clinical examination of elderly patients before cataract surgery raised potential need for B-scan ultrasonography as there were some posterior segment lesions reported after cataract surgery which could have been the leading cause of postsurgical blindness. As B-scan ultrasonography was not routinely conducted in these cases, it is not possible to determine if postsurgical blindness or severe visual impairment could be attributed to co-morbid lesion that was not detected or diagnosed before surgery. Thus, the present study aims to highlight the importance of ophthalmic ultrasonography before cataract surgery as an investigative procedure to detect a hidden lesion.

 Subjects and Methods

A prospective, cross-sectional study was conducted in the department of medical photography at a tertiary eye center based in Khartoum, Sudan, on 220 eyes of 220 elderly patients (50–90 years) with senile cataract in the period from January to September 2018. Patients' consent to publish data obtained was taken as part of routine patient admission procedure before surgery. Patients were informed that their participation was voluntary, and they can withdraw from the study at any time without giving any reason. All procedures conformed to the declaration of Helsinki. All examinations were performed for one eye of each patient by the same operator under free-living condition.

Two-dimensional display (B-scan) ultrasound was performed before cataract surgery for all patients. Detailed history was taken, and preliminary examinations using slit-lamp examination including determination the grade of cataract. Best-corrected visual acuity (VA) assessment was conducted using a Snellen acuity chart. For the purpose of data analysis, VA results were converted from Snellen notation to decimal notation. Patients with previous diagnosis of posterior segment lesions were excluded in addition to those who had previous history of ocular surgery or trauma. A Nidek Echo Scan Model US-4000 was used with a probe of direct contact to closed eye after the application of gel. B-scan along with A-scan was taken with different views which included anterio-posterior, longitudinal, and transverse views. High gain (80–120 dB) and medium gain (50–70 dB) sensitivity were used. However, dynamic B-scan was used to enhance differential diagnosis in such cases with vitreous changes. Statistical analysis was performed using the statistical analysis software (IBM SPSS 20, IBM Corp., Armonk, NY, USA). Descriptive statistics (mean ± standard deviation, frequency) were carried out for all the study parameters. Pearson's correlation and cross-tabulation were used to find the correlation between variables with confidence level set at 95% and significance at P > 0.05.


A total of 220 patients (220 eyes); 120 (54.4%) males and 100 (45.6%) females, with senile cataract were enrolled in this study. The age profile of the participants is shown in [Table 1].{Table 1}

[Table 2] classifies the participants as per the cataract grade based on silt-lamp examination. Grade II is considered as immature cataract, mature cataract is classified as Grade III while Grade IV indicates hypermature cataract. There was no significant difference between grade of cataract in both gender (P = 0.147).{Table 2}

Furthermore, all patients presented with visual impairment before cataract surgery with a mean VA of 0.10 ± 0.17 [Table 3]. VA had significant negative correlation with grade of cataract (r = −0.849, P < 0.001).{Table 3}

B-scan ultrasound revealed various posterior segment pathologies that were observed in both genders, with 57% of patients presenting with posterior segment lesions. [Table 4] shows the distribution of posterior segment lesions detected in the population sample. There were no gender-based differences in posterior segment lesions detected in the study population (P = 0.353).{Table 4}


This hospital-based study reports on the prevalence of poster segment lesions in a sample of elderly patients in Sudan. The most common age group expected to present with senile at a tertiary eye care facility was revealed to be between 50 and 70 years. In addition, it has been observed that more than half of study population were males (54.4%), which is in alignment with reports from developing countries where gender inequality is observed in seeking cataract surgical services.[16]

Half of the elderly patients examined in this study had mature cataract, which is classified as Grade III on slit lamp-based grading. Grade III is the common grade for cataract surgery selection. In this grade, the lens appears thicker and denser on the B-scan ultrasound and causes diminution of the VA. All the patients in the study had visual impairment and their VA significantly decrease with increase the grade of cataract (P < 0.001). Cataract has long been recognized as the leading cause of vision impairment and blindness in Sudan, which calls for extensive campaigns to conduct cataract surgeries to reduce the burden of vision impairment and improve the quality of life of the elderly.[17]

B-scan ultrasound evaluation has demonstrated that more than half (57.77%) of the study population had posterior segment lesions. Asteroid hyalosis (22.73%) was the common posterior segment lesion in elderly patients. This is in agreement with other studies conducted in other parts of the world such as India (22%) and South Africa (23%).[4],[11] The spikes of A-scan in asteroid hyalosis may be higher than the retinal spikes, leading to false results in the calculation of intraocular lens (IOL) power because the axial eye length will appear shorter than normal. Furthermore, if the density of asteroid hyalosis is high, postoperative vision may not reach to the desired normal VA.[18] Thus, it is imperative for the clinicians to perform B-scan ultrasonography to detect asteroid hyalosis and prevent mistakes in IOL selection.

Vitreous hemorrhage (10%) found in the current study is similar to previously reported prevalence in a study conducted in Pakistan (12%).[7] Furthermore, posterior vitreous detachment (7%) was found to be in agreement with the data obtained in Bahrain (9%).[9] Vitreous hemorrhage and posterior vitreous detachment may result from systemic diseases such as diabetes and hypertension.[19] Our study did not excluded patients with systemic diseases which would attribute to the prevalence observed. Investigation of management of systemic diseases in patients is recommended to reduce the ocular manifestations of systemic diseases.

Posterior staphyloma was found to be more prevalent than previously reported in the African continent.[11] This could be an indication of higher prevalence of myopia, possibly high myopia among the study's population.[20] However, as data regarding refractive error was not readily available, the marked difference in posterior staphyloma prevalence between Sudanese elderly and elderly in Niger cannot be easily attributed solely to refractive error. Posterior staphyloma would present with an axial length of the eye longer than 23 mm and proves it difficult to make accurate IOL power calculation, especially when optic nerve is involved.[20] Thus, B-scan along with A-scan is recommended in cases with posterior staphyloma to ensure the lens position and to ensure accurate IOL calculation.

Higher incidence of retinoschisis (4.55%) and retinal detachment (4.55%) was found compared to available literature (Pakistan; 3%).[7] These lesions can be attributed to systemic diseases such as diabetes and hypertension; however, as data regarding systemic diseases in the sample was not available, the role of systemic diseases in the presentation of these lesions in the current sample cannot be determined. In the case of retinal detachment, a combination surgery of cataract and retinal detachment is recommended to provide better visual outcome.

Ciliary body tumor was the only neoplastic disease found in Sudanese elderly patients unlike South Africa where choroidal melanoma (1%) was the only neoplasia reported in patients with cataract.[10] However, it is difficult to compare between data available from South Africa and the current study as the South African study had a wide range of age groups which included children, youth, and elderly participants while our study included only elderly people. Furthermore, our study included only senile cataract while the study conducted in South Africa included various types of cataract. Nevertheless, ocular oncology of elderly patients needs further investigation and follow-up.


The study demonstrated that ophthalmic ultrasonography is essential prior to performance of cataract surgery as it would assist in the detection of comorbid posterior pathologies of the eye, determination of correct planning for surgery, and measurement of IOL power correctly. In addition, the most common posterior segment lesion in elderly patients is asteroid hyalosis. However, neoplastic lesions are expected to be rare in this age group, with ciliary body tumor being the only neoplastic lesion found in the current study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Qureshi MA, Laghari K. Role of B-scan ultrasonography in pre-operative cataract patients. Int J Health Sci (Qassim) 2010;4:31-7.
2Salman A, Parmar P, Vanila CG, Thomas PA, Jesudasan CA. Is ultrasound essential before surgery in eyes with advanced cataracts? J Postgraduate Med 2006;52:19-22.
3Meenkashi V, Jyothirmayi T, Sree B. Role of B-scan ultrasonography in cataract patients in a Tertiary care centre. Res gat 2015;22:15-25.
4Pereira GM, Nassaralla BA, Nassaralla JJ. The role of ocular echography before cataract surgery. Invest Ophthalmol Vis Sci 2004;45:352-65.
5Sheikh FU, Narsani AK, Jatoi SM, Sheik ZA. Preoperative posterior segment evaluation by ultrasonography in dense cataract. Pak J Ophthalmol 2009;25:135-40.
6Garg J, Tirkey E, Jain S, Lakhatakia S, Tiwari A. B-scan ultrasonography in eye with advanced cataracts: A useful prognostic tool. J Evol Med Dent Sci 2015;4:6372-7.
7Zafar D, Sajad AM, Qadeer A. Role of B-Scan ultrasonography for posterior segment lesions. Pak J LUMHS 2008;7:7-12.
8Bello TO, Adeoti CO. Ultrasonic assessment in pre-operative cataract patients. Niger Postgrad Med J 2006;13:326-8.
9Anteby II, Blumenthal EZ, Zamir E, Waindim P. The role of preoperative ultrasonography for patients with dense cataract: A retrospective study of 509 cases. Ophthalmic Surg Lasers 1998;29:114-8.
10Murthy G, Gupta SK, John N, Vashist P. Current status of cataract blindness and Vision 2020: The right to sight initiative in India. Indian J Ophthalmol 2008;56:489-94.
11Javed EA, Ali CH, Ahmed I, Hussain M. Diagnostic applications of B-Scan. Pak J Ophthalmol 2007;23:80-3.
12Mendes MH, Betinjane AJ, Cavalcante Ade S, Cheng CT, Kara-José N. Ultrasonographic findings in patients examined in cataract detection-and-treatment campaigns: A retrospective study. Clinics (Sao Paulo) 2009;64:637-40.
13Perry LJ. The evaluation of patients with traumatic cataracts by ultrasound technologies. Semin Ophthalmol 2012;27:121-4.
14Kalpna BN, Murali B. Cataract and posterior segment risk factors. Med Res Chron 2015;2:226-34.
15Chanchlani M, Chanchlani R. A study of posterior segment evaluation by B-Scan in hyper mature cataract. J Clin Exp Ophthalmol 2016;7:516.
16Lewallen S, Courtright P. Gender and use of cataract surgical services in developing countries. Bull World Health Organ 2002;80:300-3.
17Beiram MM. Blindness in the Sudan: Prevalence and causes in Blue Nile Province. Bull World Health Organ 1971;45:511-5.
18Astbury N, Ramamurthy B. How to avoid mistakes in biometry. Community Eye Health 2006;19:70-1.
19Vitreous Hemorrhage: Diagnosis and Treatment. American Academy of Ophthalmology. Available from:}rticle/vitreous-hemorrhage-diagnosis-treatment-2. [Last accessed on 2020 Jul 13].
20Ohno-Matsui K, Jonas JB. Posterior staphyloma in pathologic myopia. Prog Retin Eye Res 2019;70:99-109.