public void Foo(Image image)
{
    // This change won't be seen by the caller: it's changing the value
    // of the parameter.
    image = Image.FromStream(...);
}

public void Foo(ref Image image)
{
    // This change *will* be seen by the caller: it's changing the value
    // of the parameter, but we're using pass by reference
    image = Image.FromStream(...);
}

public void Foo(Image image)
{
    // This change *will* be seen by the caller: it's changing the data
    // within the object that the parameter value refers to.
    image.RotateFlip(...);
}