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We were really involved in the Candeliere Merlicco et al 1 article concerning the use of the transorbital ultrasonography for measuring optic nerve atrophy in multiple sclerosis.We would like to congratulate the authors for their interesting work, but we would like to comment the methods they used to measure the optic nerve (ON) diameter.The authors used the B scan technique, an examination broadly utilized to diagnose ocular diseases, 2-7 that unfortunately is not sensitive enough in measuring orbital structures, as it is affected by the so-called blooming effect. 8-16 This effect is due to the lack of a standard sensitivity setting and should not be confused with the Doppler related blooming effect. It means that, if we measure the ON image with a lower sensitivity setting, this will give bigger ON dimensions compared to the ones obtained with an increased sensitivity setting.This effect could be misleading if we suppose a difference inferior to 0.5 mm, as it happens when we measure ON sheath diameter, but less important when we deal with large lesions. So, our suggestion should be to use the so-called standardized A scan technique, which can be much more accurate although it is a little bit more difficult to perform and it requires some skill. 17,18

In recent years, ultrasonographic measurement of the optic nerve sheath diameter (ONSD) has been widely used to identify the presence of increased intracranial pressure (ICP). Intracranial hypertension is a life-threatening condition that can be caused by various neurological and non-neurological disorders, and it is associated to poor clinical results. Ultrasonography could be used to qualitatively and efficiently detect ICP increases, but to reach this purpose, clear cut-off values are mandatory. The aim of this review is to provide a wide overview of the most important scientific publications on optic nerve ultrasound normal values assessment published in the last 30 years. A total of 42 articles selected from PubMed medical database was included in this review. Our analysis showed that ocular ultrasonography is considered to be a valuable diagnostic tool, especially when intracranial hypertension is suspected, but unfortunately this research provided conflicting results that could be due to the different ultrasound protocols. This is mainly caused by the use of B scan alone, which presents several limitations. The use of B-scan coupled with the standardized A-scan approach could give more accurate, and reliable ultrasound evaluation, assuring higher data objectivity.

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Optical coherence tomography angiography (OCTA) is a non-invasive diagnostic instrument that has become indispensable for the management of age-related macular degeneration (AMD). OCTA allows quickly visualizing retinal and choroidal microvasculature, and in the last years, its use has increased in clinical practice as well as for research into the pathophysiology of AMD. This review provides a discussion of new technology and application of OCTA in intermediate and late AMD.

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Idiopathic intracranial hypertension (IIH) is a disease with a heterogeneity of possible causes, which needs to be quickly diagnosed. Ocular ultrasonography could be considered a useful tool to diagnose this condition in a fast and non-invasive way. In fact, Karl Ossoinig had already proposed this diagnostic tool in the 1970s for the evaluation of intracranial pressure changes under several pathological conditions, including idiopathic intracranial hypertension. The aim of this review is to analyze scientific articles published in the last 30 years concerning the use of ocular ultrasonography to assess optic nerve indices in patients with idiopathic intracranial hypertension. Specifically, 15 published articles found in PubMed database were included and analyzed in the present review. Our conclusion suggests that ocular ultrasonography is a reliable diagnostic technique to be utilized in all the cases of suspected raised intracranial pressure. To obtain the best possible accuracy and precision in the least invasive way, standardized A-scan seems to be the best choice.