Dual-axis confocal microscopy for point-of-care pathology

Miniature line-scanned dual-axis confocal microscope for versatile clinical use

A miniature optical-sectioning fluorescence microscope with high sensitivity and resolution would enable non-invasive and real-time tissue inspection, with potential use cases including early disease detection and intraoperative guidance. Previously, we developed a miniature MEMS-based dual-axis confocal (DAC) microscope that enabled video-rate optically sectioned in vivo microscopy of human tissues. However, the device's clinical utility was limited due to a small field of view, a non-adjustable working distance, and a lack of a sterilization strategy. In our latest design, we have made improvements to achieve a 2x increase in the field of view (600 × 300 µm) and an adjustable working distance range of 150 µm over a wide range of excitation/emission wavelengths (488-750 nm), all while maintaining a high frame rate of 15 frames per second (fps). Furthermore, the device is designed to image through a disposable sterile plastic drape for convenient clinical use. We rigorously characterize the performance of the device and show example images of ex vivo tissues to demonstrate the optical performance of our new design, including fixed mouse skin and human prostate, as well as fresh mouse kidney, mouse intestine, and human head and neck surgical specimens with corresponding H&E histology. These improvements will facilitate clinical testing and translation.

Intraoperative Imaging and Optical Visualization Techniques for Brain Tumor Resection: A Narrative Review

Advancements in intraoperative visualization and imaging techniques are increasingly central to the success and safety of brain tumor surgery, leading to transformative improvements in patient outcomes. This comprehensive review intricately describes the evolution of conventional and emerging technologies for intraoperative imaging, encompassing the surgical microscope, exoscope, Raman spectroscopy, confocal microscopy, fluorescence-guided surgery, intraoperative ultrasound, magnetic resonance imaging, and computed tomography. We detail how each of these imaging modalities contributes uniquely to the precision, safety, and efficacy of neurosurgical procedures. Despite their substantial benefits, these technologies share common challenges, including difficulties in image interpretation and steep learning curves. Looking forward, innovations in this field are poised to incorporate artificial intelligence, integrated multimodal imaging approaches, and augmented and virtual reality technologies. This rapidly evolving landscape represents fertile ground for future research and technological development, aiming to further elevate surgical precision, safety, and, most critically, patient outcomes in the management of brain tumors.

Miniature side-view dual axes confocal endomicroscope for repetitive in vivo imaging

A side-view dual axes confocal endomicroscope is demonstrated that can be inserted repetitively in hollow organs of genetically engineered mice for in vivo real-time imaging in horizontal and vertical planes. Near infrared (NIR) excitation at λex = 785 nm was used. A monolithic 3-axis parametric resonance scan mirror was fabricated using micro-electro-mechanical systems (MEMS) technology to perform post-objective scanning in the distal end of a 4.19 mm diameter instrument. Torsional and serpentine springs were designed to "switch" the mode of imaging between vertical and horizontal planes by tuning the actuation frequency. This system demonstrated real-time in-vivo images in horizontal and vertical planes with 310 µm depth and 1.75 and 7.5 µm lateral and axial resolution. Individual cells and discrete mucosal structures could be identified.

In vivo microscopy as an adjunctive tool to guide detection, diagnosis, and treatment

SIGNIFICANCE

There have been numerous academic and commercial efforts to develop high-resolution in vivo microscopes for a variety of clinical use cases, including early disease detection and surgical guidance. While many high-profile studies, commercialized products, and publications have resulted from these efforts, mainstream clinical adoption has been relatively slow other than for a few clinical applications (e.g., dermatology).

AIM

Here, our goals are threefold: (1) to introduce and motivate the need for in vivo microscopy (IVM) as an adjunctive tool for clinical detection, diagnosis, and treatment, (2) to discuss the key translational challenges facing the field, and (3) to propose best practices and recommendations to facilitate clinical adoption.

APPROACH

We will provide concrete examples from various clinical domains, such as dermatology, oral/gastrointestinal oncology, and neurosurgery, to reinforce our observations and recommendations.

RESULTS

While the incremental improvement and optimization of IVM technologies should and will continue to occur, future translational efforts would benefit from the following: (1) integrating clinical and industry partners upfront to define and maintain a compelling value proposition, (2) identifying multimodal/multiscale imaging workflows, which are necessary for success in most clinical scenarios, and (3) developing effective artificial intelligence tools for clinical decision support, tempered by a realization that complete adoption of such tools will be slow.

CONCLUSIONS

The convergence of imaging modalities, academic-industry-clinician partnerships, and new computational capabilities has the potential to catalyze rapid progress and adoption of IVM in the next few decades.

Dual-axis confocal configuration for depth sensitive fluorescence spectroscopy

The dual-axis confocal (DAC) configuration provides a high axial resolution, long working distance (WD), and large dynamic range. These properties can reveal depth-resolved fluorescence spectra. We present a depth sensitive fluorescence spectroscopy based on the DAC configuration. The system enables high axial resolution of 3.23 µm and a long WD of 3.73 mm compared to that of 4.68 µm and 2.1 mm for comparable single-axis confocal configurations, respectively. Besides, a DAC configuration also offers a superior dynamic range and rejection of out-of-focus scattered light based on the principle of Huygens-Fresnel integrals. Additionally, to locate the target layer, the collection path of the DAC configuration will be used as the other illumination path, forming a dual-axis illumination configuration. These beam paths are used to locate the target layer using a white light imaging system with a commercial low numerical aperture objective. A multi-layer fluorescence phantom of Barrett's esophagus containing fluorescein isothiocyanate and Alexa Fluor 514 was used to verify the principle of depth-resolved fluorescence spectroscopy. The results show that the DAC configuration can collect fluorescence spectra from microscopic regions with high axial resolution.

Automated vessel diameter quantification and vessel tracing for OCT angiography

Optical coherence tomography angiography (OCTA) is capable of non-invasively imaging the vascular networks within circulatory tissue beds in vivo. Following improvements in OCTA image quality, it is now possible to extract vascular parameters from imaging data to potentially facilitate the diagnosis and treatment of human disease. In this paper, we present a method for automated mapping of vessel diameter down to the individual capillary level, through gradient-guided minimum radial distance (MRD). During validation using well-characterized microfluidic flow phantoms, this method demonstrated superior consistency and a nearly threefold decrease in error when compared to currently accepted techniques. In addition, the MRD technique exhibited a high tolerance to rotation of the vasculature pattern. We also incorporated a modified A* path searching algorithm to trace vessel branches and calculate the diameter of each branch from the OCTA images. After validation in vitro, we applied these algorithms to the in vivo setting through analysis of mouse cortical vasculature. Our algorithm returned results that followed Murray's law, until reaching the capillary level, agreeing well with known physiological data. From our tracing process, vessel tortuosity and branching angle could also be measured. Our techniques provide a platform for the automated evaluation of the vasculature and may aid in diagnosis of vascular diseases, especially those resulting in regional early-stage morphological changes.

Use of Intraoperative Fluorophores

Fluorescence-guided surgery provides surgeons with improved visualization of tumor tissue in the operating room to allow for maximal safe resection of brain tumors. Multiple fluorescent agents have been studied for fluorescence-guided surgery. Both nontargeted and targeted fluorescent agents are currently being used for glioblastoma multiforme visualization and resection. Fluorescence detection in the visible light or near infrared spectrum is possible. Visualization device advancements have permitted greater detection of fluorescence down to the cellular level, which may provide even greater ability for the neurosurgeon to resect tumors.

Real-time video mosaicking to guide handheld in vivo microscopy

Handheld and endoscopic optical-sectioning microscopes are being developed for noninvasive screening and intraoperative consultation. Imaging a large extent of tissue is often desired, but miniature in vivo microscopes tend to suffer from limited fields of view. To extend the imaging field during clinical use, we have developed a real-time video mosaicking method, which allows users to efficiently survey larger areas of tissue. Here, we modified a previous post-processing mosaicking method so that real-time mosaicking is possible at >30 frames/second when using a device that outputs images that are 400 × 400 pixels in size. Unlike other real-time mosaicking methods, our strategy can accommodate image rotations and deformations that often occur during clinical use of a handheld microscope. We perform a feasibility study to demonstrate that the use of real-time mosaicking is necessary to enable efficient sampling of a desired imaging field when using a handheld dual-axis confocal microscope.

Dynamic imaging and quantification of subcellular motion with eigen-decomposition optical coherence tomography-based variance analysis

The dynamic properties of subcellular organism are important biomarkers of the health. Imaging subcellular level dynamics provides effective solutions for evaluating cell metabolism and testing the responses of cells to pathogens and drugs in pharmaceutical engineering. In this paper, we demonstrate an innovative approach to contrast the subcellular motion by using eigen decomposition (ED)-based variance analysis of time-dependent complex optical coherence tomography signals. This method reveals a superior advantage of contrast to noise ratio when compared with the approach that employs intensity decorrelation. Furthermore, the eigen values derived from ED processing are calculated and applied to assess the power ratios of complex signal invariance that decreases exponentially along time dimension. The validation experiments are performed on the patterned samples of yeast powder mixed with gelatin/TiO2 water solution. Additionally, the proposed method is used to image mouse cerebral cortex in normal and pathological conditions, suggesting the practicality of variance power mapping in analyzing cortical neural activities. The technique promises efficient measurement of subcellular motions with high sensitivity and high throughput for in vivo and in situ applications.

Toward Quantitative Neurosurgical Guidance With High-Resolution Microscopy of 5-Aminolevulinic Acid-Induced Protoporphyrin IX

Low-power fluorescence microscopy of 5-ALA-induced PpIX has emerged as a valuable intraoperative imaging technology for improving the resection of malignant gliomas. However, current fluorescence imaging tools are not highly sensitive nor quantitative, which limits their effectiveness for optimizing operative decisions near the surgical margins of gliomas, in particular non-enhancing low-grade gliomas. Intraoperative high-resolution optical-sectioning microscopy can potentially serve as a valuable complement to low-power fluorescence microscopy by providing reproducible quantification of tumor parameters at the infiltrative margins of diffuse gliomas. In this forward-looking perspective article, we provide a brief discussion of recent technical advancements, pilot clinical studies, and our vision of the future adoption of handheld optical-sectioning microscopy at the final stages of glioma surgeries to enhance the extent of resection. We list a number of challenges for clinical acceptance, as well as potential strategies to overcome such obstacles for the surgical implementation of these in vivo microscopy techniques.

Label-free in vivo pathology of human epithelia with a high-speed handheld dual-axis confocal microscope

There would be clinical value in a miniature optical-sectioning microscope to enable in vivo interrogation of tissues as a real-time and noninvasive alternative to gold-standard histopathology for early disease detection and surgical guidance. To address this need, a reflectance-based handheld line-scanned dual-axis confocal microscope was developed and fully packaged for label-free imaging of human skin and oral mucosa. This device can collect images at >15  frames/s with an optical-sectioning thickness and lateral resolution of 1.7 and 1.1  μm, respectively. Incorporation of a sterile lens cap design enables pressure-sensitive adjustment of the imaging depth by the user during clinical use. In vivo human images and videos are obtained to demonstrate the capabilities of this high-speed optical-sectioning microscopy device.

Visualization technologies for 5-ALA-based fluorescence-guided surgeries

INTRODUCTION

5-ALA-based fluorescence-guided surgery has been shown to be a safe and effective method to improve intraoperative visualization and resection of malignant gliomas. However, it remains ineffective in guiding the resection of lower-grade, non-enhancing, and deep-seated tumors, mainly because these tumors do not produce detectable fluorescence with conventional visualization technologies, namely, wide-field (WF) surgical microscopy.

METHODS

We describe some of the main factors that limit the sensitivity and accuracy of conventional WF surgical microscopy, and then provide a survey of commercial and research prototypes being developed to address these challenges, along with their principles, advantages and disadvantages, as well as the current status of clinical translation for each technology. We also provide a neurosurgical perspective on how these visualization technologies might best be implemented for guiding glioma surgeries in the future.

RESULTS

Detection of PpIX expression in low-grade gliomas and at the infiltrative margins of all gliomas has been achieved with high-sensitivity probe-based visualization techniques. Deep-tissue PpIX imaging of up to 5 mm has also been achieved using red-light illumination techniques. Spectroscopic approaches have enabled more accurate quantification of PpIX expression.

CONCLUSION

Advancements in visualization technologies have extended the sensitivity and accuracy of conventional WF surgical microscopy. These technologies will continue to be refined to further improve the extent of resection in glioma patients using 5-ALA-induced fluorescence.