In vivo near-infrared dual-axis confocal microendoscopy in the human lower gastrointestinal tract

The development and clinical application of microscopic endoscopy for in vivo optical biopsies: Endocytoscopy and confocal laser endomicroscopy

Endoscopies are crucial for detecting and diagnosing diseases in gastroenterology, pulmonology, urology, and other fields. To accurately diagnose diseases, sample biopsies are indispensable and are currently considered the gold standard. However, random 4-quadrant biopsies have sampling errors and time delays. To provide intraoperative real-time microscopic images of suspicious lesions, microscopic endoscopy for in vivo optical biopsy has been developed, including endocytoscopy and confocal laser endomicroscopy. This article reviews recent advances in technology and clinical applications, as well as their shortcomings and future directions.

Exact Scan Patterns of Rotational Risley Prisms Obtained with a Graphical Method: Multi-Parameter Analysis and Design

Rotational Risley prisms are one of the fastest two-dimensional (2D) optomechanical scanning systems. Their drawback is the strong non-linearity of the scan patterns they produce, in contrast to the most common (but slower) raster scanning modalities of 2D dual axis galvanometer scanners (GSs) or Micro-Electro-Mechanical Systems (MEMS) with oscillatory mirrors. The aim of this work is to develop a graphical method, which, to our knowledge, we have introduced to determine and characterize, using a commercially-available mechanical design program (for example CATIA V5R20 (Dassault Systems, Paris, France)) to simulate the exact scan patterns of rotational Risley prisms. Both the maximum and minimum angular and linear deviations of this type of scanner are deduced theoretically to characterize the outer diameter/Field-of-View (FOV) and the inner diameter (of the blind zone) of its ring-shaped patterns, respectively. This multi-parameter analysis is performed in correlation with the shape of the scan patterns, considering the four possible configurations of laser scanners with a pair of rotational Risley prisms, as well as all their parameters: prisms angles, refractive indexes, rotational speeds, distance between the two prisms, and the distance from the system to the scanned plane. Marshall’s synthetic parameters are also considered, i.e., the ratios of the rotational velocities and of the angles of the prisms. Rules-of-thumb for designing this optomechanical scanner are extracted from this analysis, regarding both shapes and dimensions of the scan patterns to be produced. An example of experimental validation completes the mathematical analysis and the performed simulations.

Low-cost, chromatic confocal endomicroscope for cellular imaging in vivo

We have developed a low-cost, chromatic confocal endomicroscope (CCE) that can image a cross-section of the tissue at cellular resolution. In CCE, a custom miniature objective lens was used to focus different wavelengths into different tissue depths. Therefore, each tissue depth was encoded with the wavelength. A custom miniature spectrometer was used to spectrally-disperse light reflected from the tissue and generate cross-sectional confocal images. The CCE prototype had a diameter of 9.5 mm and a length of 68 mm. Measured resolution was high, 2 µm and 4 µm for lateral and axial directions, respectively. Effective field size was 468 µm. Preliminary results showed that CCE can visualize cellular details from cross-sections of the tissue in vivo down to the tissue depth of 100 µm.

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.

Handheld endomicroscope using a fiber-optic harmonograph enables real-time and in vivo confocal imaging of living cell morphology and capillary perfusion

Confocal laser endomicroscopy provides high potential for noninvasive and in vivo optical biopsy at the cellular level. Here, we report a fully packaged handheld confocal endomicroscopic system for real-time, high-resolution, and in vivo cellular imaging using a Lissajous scanning fiber-optic harmonograph. The endomicroscopic system features an endomicroscopic probe with a fiber-optic harmonograph, a confocal microscope unit, and an image signal processor. The fiber-optic harmonograph contains a single mode fiber coupled with a quadrupole piezoelectric tube, which resonantly scans both axes at ~ 1 kHz to obtain a Lissajous pattern. The fiber-optic harmonograph was fully packaged into an endomicroscopic probe with an objective lens. The endomicroscopic probe was hygienically packaged for waterproofing and disinfection of medical instruments within a 2.6-mm outer diameter stainless tube capable of being inserted through the working channel of a clinical endoscope. The probe was further combined with the confocal microscope unit for indocyanine green imaging and the image signal processor for high frame rate and high density Lissajous scanning. The signal processing unit delivers driving signals for probe actuation and reconstructs confocal images using the auto phase matching process of Lissajous fiber scanners. The confocal endomicroscopic system was used to successfully obtain human in vitro fluorescent images and real-time ex vivo and in vivo fluorescent images of the living cell morphology and capillary perfusion inside a single mouse.

Single-Pixel MEMS Imaging Systems

Single-pixel imaging technology is an attractive technology considering the increasing demand of imagers that can operate in wavelengths where traditional cameras have limited efficiency. Meanwhile, the miniaturization of imaging systems is also desired to build affordable and portable devices for field applications. Therefore, single-pixel imaging systems based on microelectromechanical systems (MEMS) is an effective solution to develop truly miniaturized imagers, owing to their ability to integrate multiple functionalities within a small device. MEMS-based single-pixel imaging systems have mainly been explored in two research directions, namely the encoding-based approach and the scanning-based approach. The scanning method utilizes a variety of MEMS scanners to scan the target scenery and has potential applications in the biological imaging field. The encoding-based system typically employs MEMS modulators and a single-pixel detector to encode the light intensities of the scenery, and the images are constructed by harvesting the power of computational technology. This has the capability to capture non-visible images and 3D images. Thus, this review discusses the two approaches in detail, and their applications are also reviewed to evaluate the efficiency and advantages in various fields.

Miniature fluorescence molecular tomography (FMT) endoscope based on a MEMS scanning mirror and an optical fiberscope

We present a novel FMT endoscope by using a MEMS scanning mirror and an optical fiberscope. The diameter of this highly miniaturized FMT device is only 5 mm. To our knowledge, this is the smallest FMT device we found so far. Several phantom experiments based on indocyanine green (ICG) were conducted to demonstrate the imaging ability of this device. Two tumor-bearing mice were systematically injected with tumor-targeted NIR fluorescent probes (ATF-PEG-IO-830) and were then imaged to further demonstrate the ability of this FMT endoscope for imaging small animals.

Advanced endoscopic methods in gastrointestinal diseases: a systematic review

Endoscopic imaging is the main method for detecting gastrointestinal diseases, which adversely affect human health. White light endoscopy (WLE) was the first method used for endoscopic examination and is still the preliminary step in the detection of gastrointestinal diseases during clinical examination. However, it cannot accurately diagnose gastrointestinal diseases owing to its poor correlation with histopathological diagnosis. In recent years, many advanced endoscopic methods have emerged to improve the detection accuracy by endoscopy. Chromoendoscopy (CE) enhances the contrast between normal and diseased tissues using biocompatible dye agents. Narrow band imaging (NBI) can improve the contrast between capillaries and submucosal vessels by changing the light source acting on the tissue using special filters to realize the visualization of the vascular structure. Flexible spectral imaging color enhancement (FICE) technique uses the reflectance spectrum estimation technique to obtain individual spectral images and reconstructs an enhanced image of the mucosal surface using three selected spectral images. The i-Scan technology takes advantage of the different reflective properties of normal and diseased tissues to obtain images, and enhances image contrast through post-processing algorithms. These abovementioned methods can be used to detect gastrointestinal diseases by observing the macroscopic structure of the digestive tract mucosa, but the ability of early cancer detection is limited with low resolution. However, based on the principle of confocal imaging, probe-based confocal laser endomicroscopy (pCLE) can enable cellular visualization with high-performance probes, which can present cellular morphology that is highly consistent with that shown by biopsy to provide the possibility of early detection of cancer. Other endoscopic imaging techniques including endoscopic optical coherence tomography (EOCT) and photoacoustic endoscopy (PAE), are also promising for diagnosing gastrointestinal diseases. This review focuses on these technologies and aims to provide an overview of different technologies and their clinical applicability.

2D Au-Coated Resonant MEMS Scanner for NIR Fluorescence Intraoperative Confocal Microscope

The electrostatic MEMS scanner plays an important role in the miniaturization of the microscopic imaging system. We have developed a new two-dimensional (2D) parametrically-resonant MEMS scanner with patterned Au coating (>90% reflectivity at an NIR 785-nm wavelength), for a near-infrared (NIR) fluorescence intraoperative confocal microscopic imaging system with a compact form factor. A silicon-on-insulator (SOI)-wafer based dicing-free microfabrication process has been developed for mass-production with high yield. Based on an in-plane comb-drive configuration, the resonant MEMS scanner performs 2D Lissajous pattern scanning with a large mechanical scanning angle (MSA, ±4°) on each axis at low driving voltage (36 V). A large field-of-view (FOV) has been achieved by using a post-objective scanning architecture of the confocal microscope. We have integrated the new MEMS scanner into a custom-made NIR fluorescence intraoperative confocal microscope with an outer diameter of 5.5 mm at its distal-end. Axial scanning has been achieved by using a piezoelectric actuator-based driving mechanism. We have successfully demonstrated ex vivo 2D imaging on human tissue specimens with up to five frames/s. The 2D resonant MEMS scanner can potentially be utilized for many applications, including multiphoton microendoscopy and wide-field endoscopy.

Fabrication and characterization of large numerical aperture, high-resolution optical fiber bundles based on high-contrast pairs of soft glasses for fluorescence imaging

Fabrication and characterization of flexible optical fiber bundles (FBs) with in-house synthesized high-index and low-index thermally matched glasses are presented. The FBs composed of around 15000 single-core fibers with pixel sizes between 1.1 and 10 μm are fabricated using the stack-and-draw technique from sets of thermally matched zirconium-silicate ZR3, borosilicate SK222, sodium-silicate K209, and F2 glasses. With high refractive index contrast pair of glasses ZR3/SK222 and K209/F2, FBs with numerical apertures (NAs) of 0.53 and 0.59 are obtained, respectively. Among the studied glass materials, ZR3, SK222, and K209 are in-house synthesized, while F2 is commercially acquired. Seven different FBs with varying pixel sizes and bundle diameters are characterized. Brightfield imaging of a micro-ruler and a Convallaria majalis sample and fluorescence imaging of a dye-stained paper tissue and a cirrhotic mice liver tissue are demonstrated using these FBs, demonstrating their good potential for microendoscopic imaging. Brightfield and fluorescence imaging performance of the studied FBs are compared. For both sets of glass compositions, good imaging performance is observed for FBs, with core diameter and core-to-core distance values larger than 1.6 μm and 2.3 μm, respectively. FBs fabricated with K209/F2 glass pairs revealed better performance in fluorescence imaging due to their higher NA of 0.59.

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.

MEMS Actuators for Optical Microendoscopy

Growing demands for affordable, portable, and reliable optical microendoscopic imaging devices are attracting research institutes and industries to find new manufacturing methods. However, the integration of microscopic components into these subsystems is one of today's challenges in manufacturing and packaging. Together with this kind of miniaturization more and more functional parts have to be accommodated in ever smaller spaces. Therefore, solving this challenge with the use of microelectromechanical systems (MEMS) fabrication technology has opened the promising opportunities in enabling a wide variety of novel optical microendoscopy to be miniaturized. MEMS fabrication technology enables abilities to apply batch fabrication methods with high-precision and to include a wide variety of optical functionalities to the optical components. As a result, MEMS technology has enabled greater accessibility to advance optical microendoscopy technology to provide high-resolution and high-performance imaging matching with traditional table-top microscopy. In this review the latest advancements of MEMS actuators for optical microendoscopy will be discussed in detail.

Scanning MEMS Mirror for High Definition and High Frame Rate Lissajous Patterns

Scanning MEMS (micro-electro-mechanical system) mirrors are attractive given their potential use in a diverse array of laser scanning display and imaging applications. Here we report on an electrostatic MEMS mirror for high definition and high frame rate (HDHF) Lissajous scanning. The MEMS mirror comprised a low Q-factor inner mirror and frame mirror, which provided two-dimensional scanning at two similar resonant scanning frequencies with high mechanical stability. The low Q inner mirror enabled a broad frequency selection range. The high definition and high frame rate (HDHF) Lissajous scanning of the MEMS mirror was achieved by selecting a set of scanning frequencies near its resonance with a high greatest common divisor (GCD) and a high total lobe number. The MEMS mirror had resonant scanning frequencies at 5402 Hz and 6702 Hz in x and y directions, respectively. The selected pseudo-resonant frequencies of 5450 Hz and 6700 Hz for HDHF scanning provided 50 frames per second with 94% fill factor in 256 × 256 pixels. This Lissajous MEMS mirror could be utilized for assorted HDHF laser scanning imaging and display applications.

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

Dual-axis confocal (DAC) microscopy is an optical imaging modality that utilizes simple low-numerical aperture (NA) lenses to achieve effective optical sectioning and superior image contrast in biological tissues. The unique architecture of DAC microscopy also provides some advantages for miniaturization, facilitating the development of endoscopic and handheld DAC systems for in vivo imaging. This article reviews the principles of DAC microscopy, including its differences from conventional confocal microscopy, and surveys several variations of DAC microscopy that have been developed and investigated as non-invasive real-time alternatives to conventional biopsy and histopathology.

Near-infrared probe-based confocal microendoscope for deep-tissue imaging

In this work, a near-infrared probe-based confocal microendoscope (pCM) with a 785 nm laser source, a long working distance, and a probe with diameter of 2.6 mm that can be compatible with a conventional endoscope is demonstrated to produce deep-tissue images at cellular resolutions with enhanced contrast and signal-to-noise ratio. Theoretical simulations and experiments confirm that near-infrared light can optimize the image quality. Abundant details of mouse esophagus obtained at different depths demonstrate the system's ability to image deep tissues at cellular resolutions, which makes it possible to diagnose diseases in the digestive tract in real time, laying a solid foundation for clinical applications.

3D NIR-II Molecular Imaging Distinguishes Targeted Organs with High-Performance NIR-II Bioconjugates

Greatly reduced scattering in the second near-infrared (NIR-II) region (1000-1700 nm) opens up many new exciting avenues of bioimaging research, yet NIR-II fluorescence imaging is mostly implemented by using nontargeted fluorophores or wide-field imaging setups, limiting the signal-to-background ratio and imaging penetration depth due to poor specific binding and out-of-focus signals. A newly developed high-performance NIR-II bioconjugate enables targeted imaging of a specific organ in the living body with high quality. Combined with a home-built NIR-II confocal set-up, the enhanced imaging technique allows 900 µm-deep 3D organ imaging without tissue clearing techniques. Bioconjugation of two hormones to nonoverlapping NIR-II fluorophores facilitates two-color imaging of different receptors, demonstrating unprecedented multicolor live molecular imaging across the NIR-II window. This deep tissue imaging of specific receptors in live animals allows development of noninvasive molecular imaging of multifarious models of normal and neoplastic organs in vivo, beyond the traditional visible to NIR-I range. The developed NIR-II fluorescence microscopy will become a powerful imaging technique for deep tissue imaging without any physical sectioning or clearing treatment of the tissue.

Frequency selection rule for high definition and high frame rate Lissajous scanning

Lissajous microscanners are very attractive in compact laser scanning applications such as endomicroscopy or pro-projection display owing to high mechanical stability and low operating voltages. The scanning frequency serves as a critical factor for determining the scanning imaging quality. Here we report the selection rule of scanning frequencies that can realize high definition and high frame-rate (HDHF) full-repeated Lissajous scanning imaging. The fill factor (FF) monotonically increases with the total lobe number of a Lissajous curve, i.e., the sum of scanning frequencies divided by the great common divisor (GCD) of bi-axial scanning frequencies. The frames per second (FPS), called the pattern repeated rate or the frame rate, linearly increases with GCD. HDHF Lissajous scanning is achieved at the bi-axial scanning frequencies, where the GCD has the maximum value among various sets of the scanning frequencies satisfying the total lobe number for a target FF. Based on this selection rule, the experimental results clearly demonstrate that conventional Lissajous scanners substantially increase both FF and FPS by slightly modulating the scanning frequencies at near the resonance within the resonance bandwidth of a Lissajous scanner. This selection rule provides a new guideline for HDHF Lissajous scanning in compact laser scanning systems.

In vivo cellular-level real-time pharmacokinetic imaging of free-form and liposomal indocyanine green in liver

Indocyanine green (ICG) is a near-infrared fluorophore approved for human use which has been widely used for various clinical applications. Despite the well-established clinical usage, our understanding about the microscopic in vivo pharmacokinetics of systemically administered ICG has been relatively limited. In this work, we successfully visualized real-time in vivo pharmacokinetic dynamics of the intravenously injected free-form and liposomal ICG in cellular resolution by utilizing a custom-built video-rate near infrared laser-scanning confocal microscopy system. Initial perfusion and clearance from blood stream, diffusion into perisinusoidal space, and subsequent absorption into hepatocyte were directly visualized in vivo. The quantification analysis utilizing the real-time image sequences revealed distinct dynamic in vivo pharmacokinetic behavior of free-form and liposomal ICG.

New Endoscopic Imaging Technology Based on MEMS Sensors and Actuators

Over the last decade, optical fiber-based forms of microscopy and endoscopy have extended the realm of applicability for many imaging modalities. Optical fiber-based imaging modalities permit the use of remote illumination sources and enable flexible forms supporting the creation of portable and hand-held imaging instrumentations to interrogate within hollow tissue cavities. A common challenge in the development of such devices is the design and integration of miniaturized optical and mechanical components. Until recently, microelectromechanical systems (MEMS) sensors and actuators have been playing a key role in shaping the miniaturization of these components. This is due to the precision mechanics of MEMS, microfabrication techniques, and optical functionality enabling a wide variety of movable and tunable mirrors, lenses, filters, and other optical structures. Many promising results from MEMS based optical fiber endoscopy have demonstrated great potentials for clinical translation. In this article, reviews of MEMS sensors and actuators for various fiber-optical endoscopy such as fluorescence, optical coherence tomography, confocal, photo-acoustic, and two-photon imaging modalities will be discussed. This advanced MEMS based optical fiber endoscopy can provide cellular and molecular features with deep tissue penetration enabling guided resections and early cancer assessment to better treatment outcomes.

Visualizing Epithelial Expression in Vertical and Horizontal Planes With Dual Axes Confocal Endomicroscope Using Compact Distal Scanner

The epithelium is a thin layer of tissue that lines hollow organs, such as colon. Visualizing in vertical cross sections with sub-cellular resolution is essential to understanding early disease mechanisms that progress naturally in the plane perpendicular to the tissue surface. The dual axes confocal architecture collects optical sections in tissue by directing light at an angle incident to the surface using separate illumination and collection beams to reduce effects of scattering, enhance dynamic range, and increase imaging depth. This configuration allows for images to be collected in the vertical as well as horizontal planes. We designed a fast, compact monolithic scanner based on the principle of parametric resonance. The mirrors were fabricated using microelectromechanical systems (MEMS) technology and were coated with aluminum to maximize near-infrared reflectivity. We achieved large axial displacements [Formula: see text] and wide lateral deflections >20°. The MEMS chip has a 3.2×2.9 mm² form factor that allows for efficient packaging in the distal end of an endomicroscope. Imaging can be performed in either the vertical or horizontal planes with [Formula: see text] depth or 1 ×1 mm² area, respectively, at 5 frames/s. We systemically administered a Cy5.5-labeled peptide that is specific for EGFR, and collected near-infrared fluorescence images ex vivo from pre-malignant mouse colonic epithelium to reveal the spatial distribution of this molecular target. Here, we demonstrate a novel scanning mechanism in a dual axes confocal endomicroscope that collects optical sections of near-infrared fluorescence in either vertical or horizontal planes to visualize molecular expression in the epithelium.

Fluorescein as a topical fluorescent contrast agent for quantitative microendoscopic inspection of colorectal epithelium

Fiber bundle microendoscopic imaging of colorectal tissue has shown promising results, for both qualitative and quantitative analysis. A quantitative image quality control and image feature extraction algorithm was previously designed for quantitative image feature analysis of proflavine-stained ex vivo colorectal tissue. We investigated fluorescein as an alternative topical stain. Images of ex vivo porcine, caprine, and human colorectal tissue were used to compare microendoscopic images of tissue topically stained with fluorescein and proflavine solutions. Fluorescein was shown to be comparable for automated crypt detection, with an average crypt detection sensitivity exceeding 90% using a combination of three contrast limit pairs.

Visualizing epithelial expression of EGFR in vivo with distal scanning side-viewing confocal endomicroscope

Confocal endomicroscopy is an emerging imaging technology that has recently been introduced into the clinic to instantaneously collect "optical biopsies" in vivo with histology-like quality. Here, we demonstrate a fast scanner located in the distal end of a side-viewing instrument using a compact lens assembly with numerical aperture of 0.5 to achieve a working distance of 100 μm and field-of-view of 300 × 400 μm². The microelectromechanical systems (MEMS) mirror was designed based on the principle of parametric resonance and images at 5 frames per second. The instrument has a 4.2 mm outer diameter and 3 cm rigid length, and can pass through the biopsy channel of a medical endoscope. We achieved real time optical sections of NIR fluorescence with 0.87 μm lateral resolution, and were able to visualize in vivo binding of a Cy5.5-labeled peptide specific for EGFR to the cell surface of pre-cancerous colonocytes within the epithelium of dysplastic crypts in mouse colon. By performing targeted imaging with endomicroscopy, we can visualize molecular expression patterns in vivo that provide a biological basis for disease detection.

Differential structured illumination microendoscopy for in vivo imaging of molecular contrast agents

Fiber optic microendoscopy has shown promise for visualization of molecular contrast agents used to study disease in vivo. However, fiber optic microendoscopes have limited optical sectioning capability, and image contrast is limited by out-of-focus light generated in highly scattering tissue. Optical sectioning techniques have been used in microendoscopes to remove out-of-focus light but reduce imaging speed or rely on bulky optical elements that prevent in vivo imaging. Here, we present differential structured illumination microendoscopy (DSIMe), a fiber optic system that can perform structured illumination in real time for optical sectioning without any opto-mechanical components attached to the distal tip of the fiber bundle. We demonstrate the use of DSIMe during in vivo fluorescence imaging in patients undergoing surgery for cervical adenocarcinoma in situ. Images acquired using DSIMe show greater contrast than standard microendoscopy, improving the ability to detect cellular atypia associated with neoplasia.

Line-scanning fiber bundle endomicroscopy with a virtual detector slit

Coherent fiber bundles can be used to relay the image plane from the distal tip of an endomicroscope to an external confocal microscopy system. The frame rate is therefore determined by the speed of the microscope's laser scanning system which, at 10-20 Hz, may be undesirably low for in vivo clinical applications. Line-scanning allows an increase in the frame rate by an order of magnitude in exchange for some loss of optical sectioning, but the width of the detector slit cannot easily be adapted to suit different imaging conditions. The rolling shutter of a CMOS camera can be used as a virtual detector slit for a bench-top line-scanning confocal microscope, and here we extend this idea to endomicroscopy. By synchronizing the camera rolling shutter with a scanning laser line we achieve confocal imaging with an electronically variable detector slit. This architecture allows us to acquire every other frame with the detector slit offset by a known distance, and we show that subtracting this second image leads to improved optical sectioning.

Integrated monolithic 3D MEMS scanner for switchable real time vertical/horizontal cross-sectional imaging

We present an integrated monolithic, electrostatic 3D MEMS scanner with a compact chip size of 3.2 × 2.9 mm(2). Use of parametric excitation near resonance frequencies produced large optical deflection angles up to ± 27° and ± 28.5° in the X- and Y-axes and displacements up to 510 μm in the Z-axis with low drive voltages at atmospheric pressure. When packaged in a dual axes confocal endomicroscope, horizontal and vertical cross-sectional images can be collected seamlessly in tissue with a large field-of-view of >1 × 1 mm(2) and 1 × 0.41 mm(2), respectively, at 5 frames/sec.

Miniature in vivo MEMS-based line-scanned dual-axis confocal microscope for point-of-care pathology

There is a need for miniature optical-sectioning microscopes to enable in vivo interrogation of tissues as a real-time and noninvasive alternative to gold-standard histopathology. Such devices could have a transformative impact for the early detection of cancer as well as for guiding tumor-resection procedures. Miniature confocal microscopes have been developed by various researchers and corporations to enable optical sectioning of highly scattering tissues, all of which have necessitated various trade-offs in size, speed, depth selectivity, field of view, resolution, image contrast, and sensitivity. In this study, a miniature line-scanned (LS) dual-axis confocal (DAC) microscope, with a 12-mm diameter distal tip, has been developed for clinical point-of-care pathology. The dual-axis architecture has demonstrated an advantage over the conventional single-axis confocal configuration for reducing background noise from out-of-focus and multiply scattered light. The use of line scanning enables fast frame rates (16 frames/sec is demonstrated here, but faster rates are possible), which mitigates motion artifacts of a hand-held device during clinical use. We have developed a method to actively align the illumination and collection beams in a DAC microscope through the use of a pair of rotatable alignment mirrors. Incorporation of a custom objective lens, with a small form factor for in vivo clinical use, enables our device to achieve an optical-sectioning thickness and lateral resolution of 2.0 and 1.1 microns respectively. Validation measurements with reflective targets, as well as in vivo and ex vivo images of tissues, demonstrate the clinical potential of this high-speed optical-sectioning microscopy device.

Imaging Functional Nucleic Acid Delivery to Skin

Monogenic skin diseases arise from well-defined single gene mutations, and in some cases a single point mutation. As the target cells are superficial, these diseases are ideally suited for treatment by nucleic acid-based therapies as well as monitoring through a variety of noninvasive imaging technologies. Despite the accessibility of the skin, there remain formidable barriers for functional delivery of nucleic acids to the target cells within the dermis and epidermis. These barriers include the stratum corneum and the layered structure of the skin, as well as more locally, the cellular, endosomal and nuclear membranes. A wide range of technologies for traversing these barriers has been described and moderate success has been reported for several approaches. The lessons learned from these studies include the need for combinations of approaches to facilitate nucleic acid delivery across these skin barriers and then functional delivery across the cellular and nuclear membranes for expression (e.g., reporter genes, DNA oligonucleotides or shRNA) or into the cytoplasm for regulation (e.g., siRNA, miRNA, antisense oligos). The tools for topical delivery that have been evaluated include chemical, physical and electrical methods, and the development and testing of each of these approaches has been greatly enabled by imaging tools. These techniques allow delivery and real time monitoring of reporter genes, therapeutic nucleic acids and also triplex nucleic acids for gene editing. Optical imaging is comprised of a number of modalities based on properties of light-tissue interaction (e.g., scattering, autofluorescence, and reflectance), the interaction of light with specific molecules (e.g., absorbtion, fluorescence), or enzymatic reactions that produce light (bioluminescence). Optical imaging technologies operate over a range of scales from macroscopic to microscopic and if necessary, nanoscopic, and thus can be used to assess nucleic acid delivery to organs, regions, cells and even subcellular structures. Here we describe the animal models, reporter genes, imaging approaches and general strategies for delivery of nucleic acids to cells in the skin for local expression (e.g., plasmid DNA) or gene silencing (e.g., siRNA) with the intent of developing nucleic acid-based therapies to treat diseases of the skin.

Video-rate in vivo fluorescence imaging with a line-scanned dual-axis confocal microscope

Video-rate optical-sectioning microscopy of living organisms would allow for the investigation of dynamic biological processes and would also reduce motion artifacts, especially for in vivo imaging applications. Previous feasibility studies, with a slow stage-scanned line-scanned dual-axis confocal (LS-DAC) microscope, have demonstrated that LS-DAC microscopy is capable of imaging tissues with subcellular resolution and high contrast at moderate depths of up to several hundred microns. However, the sensitivity and performance of a video-rate LS-DAC imaging system, with low-numerical aperture optics, have yet to be demonstrated. Here, we report on the construction and validation of a video-rate LS-DAC system that possesses sufficient sensitivity to visualize fluorescent contrast agents that are topically applied or systemically delivered in animal and human tissues. We present images of murine oral mucosa that are topically stained with methylene blue, and images of protoporphyrin IX-expressing brain tumor from glioma patients that have been administered 5-aminolevulinic acid prior to surgery. In addition, we demonstrate in vivo fluorescence imaging of red blood cells trafficking within the capillaries of a mouse ear, at frame rates of up to 30 fps. These results can serve as a benchmark for miniature in vivo microscopy devices under development.

Trends in fluorescence image-guided surgery for gliomas

Mounting evidence suggests that a more extensive surgical resection is associated with an improved life expectancy for both low-grade and high-grade glioma patients. However, radiographically complete resections are not often achieved in many cases because of the lack of sensitivity and specificity of current neurosurgical guidance techniques at the margins of diffuse infiltrative gliomas. Intraoperative fluorescence imaging offers the potential to improve the extent of resection and to investigate the possible benefits of resecting beyond the radiographic margins. Here, we provide a review of wide-field and high-resolution fluorescence-imaging strategies that are being developed for neurosurgical guidance, with a focus on emerging imaging technologies and clinically viable contrast agents. The strengths and weaknesses of these approaches will be discussed, as well as issues that are being addressed to translate these technologies into the standard of care.

Molecular imaging needles: dual-modality optical coherence tomography and fluorescence imaging of labeled antibodies deep in tissue

Molecular imaging using optical techniques provides insight into disease at the cellular level. In this paper, we report on a novel dual-modality probe capable of performing molecular imaging by combining simultaneous three-dimensional optical coherence tomography (OCT) and two-dimensional fluorescence imaging in a hypodermic needle. The probe, referred to as a molecular imaging (MI) needle, may be inserted tens of millimeters into tissue. The MI needle utilizes double-clad fiber to carry both imaging modalities, and is interfaced to a 1310-nm OCT system and a fluorescence imaging subsystem using an asymmetrical double-clad fiber coupler customized to achieve high fluorescence collection efficiency. We present, to the best of our knowledge, the first dual-modality OCT and fluorescence needle probe with sufficient sensitivity to image fluorescently labeled antibodies. Such probes enable high-resolution molecular imaging deep within tissue.

Micromachined tethered silicon oscillator for an endomicroscopic Lissajous fiber scanner

This work reports micromachined tethered silicon oscillators (MTSOs) for endoscopic Lissajous fiber scanners. An MTSO comprises an offset silicon spring for stiffness modulation of a scanning fiber and additional mass for modulation of resonant scanning frequency in one body. MTSOs were assembled with a resonant fiber scanner and enhanced scanning reliability of the scanner by eliminating mechanical cross coupling. The fiber scanner with MTSOs was fully packaged as an endomicroscopic catheter and coupled with a conventional laparoscope and spectral domain OCT system. The endomicroscope was maneuvered with the integrated laparoscope and in vivo swine tissue OCT imaging was successfully demonstrated during open surgery. This new component serves as an important element inside an endoscopic Lissajous fiber scanner for early cancer detection or on-demand minimum lesional margin decision during noninvasive endoscopic biopsy.

Modeling and Simulation of a Parametrically Resonant Micromirror With Duty-Cycled Excitation

High frequency large scanning angle electrostatically actuated microelectromechanical systems (MEMS) mirrors are used in a variety of applications involving fast optical scanning. A 1-D parametrically resonant torsional micromirror for use in biomedical imaging is analyzed here with respect to operation by duty-cycled square waves. Duty-cycled square wave excitation can have significant advantages for practical mirror regulation and/or control. The mirror's nonlinear dynamics under such excitation is analyzed in a Hill's equation form. This form is used to predict stability regions (the voltage-frequency relationship) of parametric resonance behavior over large scanning angles using iterative approximations for nonlinear capacitance behavior of the mirror. Numerical simulations are also performed to obtain the mirror's frequency response over several voltages for various duty cycles. Frequency sweeps, stability results, and duty cycle trends from both analytical and simulation methods are compared with experimental results. Both analytical models and simulations show good agreement with experimental results over the range of duty cycled excitations tested. This paper discusses the implications of changing amplitude and phase with duty cycle for robust open-loop operation and future closed-loop operating strategies.

Advances in imaging probes and optical microendoscopic imaging techniques for early in vivo cancer assessment

A new chapter in the history of medical diagnosis happened when the first X-ray technology was invented in the late 1800s. Since then, many non-invasive and minimally invasive imaging techniques have been invented for clinical diagnosis to research in cellular biology, drug discovery, and disease monitoring. These imaging modalities have leveraged the benefits of significant advances in computer, electronics, and information technology and, more recently, targeted molecular imaging. The development of targeted contrast agents such as fluorescent and nanoparticle probes coupled with optical imaging techniques has made it possible to selectively view specific biological events and processes in both in vivo and ex vivo systems with great sensitivity and selectivity. Thus, the combination of targeted molecular imaging probes and optical imaging techniques have become a mainstay in modern medicinal and biological research. Many promising results have demonstrated great potentials to translate to clinical applications. In this review, we describe a discussion of employing imaging probes and optical microendoscopic imaging techniques for cancer diagnosis.

A three-degree-of-freedom thin-film PZT-actuated microactuator with large out-of-plane displacement

A novel three degree-of-freedom microactuator based on thin-film lead-zirconate-titanate (PZT) is described with its detailed structural model. Its central rectangular-shaped mirror platform, also referred to as the stage, is actuated by four symmetric PZT bending legs such that each leg provides vertical translation for one corner of the stage. It has been developed to support real-time in vivo vertical cross-sectional imaging with a dual axes confocal endomicroscope for early cancer detection, having large displacements in three axes (z, θ_x, θ_y) and a relatively high bandwidth in the z-axis direction. Prototype microactuators closely meet the performance requirements for this application; in the out-of-plane (z-axis) direction, it has shown more than 177 μm of displacement and about 84 Hz of structural natural frequency, when two diagonal legs are actuated at 14V. With all four legs, another prototype of the same design with lighter stage mass has achieved more than 430 μm of out-of-plane displacement at 15V and about 200 Hz of bandwidth. The former design has shown approximately 6.4° and 2.9° of stage tilting about the x-axis and y-axis, respectively, at 14V. This paper also presents a modeling technique that uses experimental data to account for the effects of fabrication uncertainties in residual stress and structural dimensions. The presented model predicts the static motion of the stage within an average absolute error of 14.6 μm, which approaches the desired imaging resolution, 5 μm, and also reasonably anticipates the structural dynamic behavior of the stage. The refined model will support development of a future trajectory tracking controller for the system.

Large Stroke Vertical PZT Microactuator With High-Speed Rotational Scanning

A thin-film piezoelectric microactuator using a novel combination of active vertical translational scanning and passive resonant rotational scanning is presented. Thin-film lead-zirconate-titanate unimorph bending beams surrounding a central platform provide nearly 200-μm displacement at 18 V with bandwidth greater than 200 Hz. Inside the platform, a mirror mount, or mirror surface, supported by silicon dioxide spring beams can be excited to resonance by low-voltage; high-frequency excitation of the outer PZT beams. Over ±5.5° mechanical resonance is obtained at 3.8 kHz and ±2 V. The combination of large translational vertical displacements and high-speed rotational scanning is intended to support real-time cross-sectional imaging in a dual axes confocal endomicroscope.

Lissajous fiber scanning for forward viewing optical endomicroscopy using asymmetric stiffness modulation

We report a fully packaged and compact forward viewing endomicroscope by using a resonant fiber scanner with two dimensional Lissajous trajectories. The fiber scanner comprises a single mode fiber with additional microstructures mounted inside a piezoelectric tube with quartered electrodes. The mechanical cross-coupling between the transverse axes of a resonant fiber with a circular cross-section was completely eliminated by asymmetrically modulating the stiffness of the fiber cantilever with silicon microstructures and an off-set fiber fragment. The Lissajous fiber scanner was fully packaged as endomicroscopic catheter passing through the accessory channel of a clinical endoscope and combined with spectral domain optical coherence tomography (SD-OCT). Ex-vivo 3D OCT images were successfully reconstructed along Lissajous trajectory. The preview imaging capability of the Lissajous scanning enables rapid 3D imaging with high temporal resolution. This endoscopic catheter provides many opportunities for on-demand and non-invasive optical biopsy inside a gastrointestinal endoscope.

Comparison of line-scanned and point-scanned dual-axis confocal microscope performance

The point-scanned dual-axis confocal (PS-DAC) microscope has been shown to exhibit superior capability to reject out-of-focus and multiply scattered light in comparison to its conventional single-axis counterpart. However, the slow frame rate (typically <5 Hz) resulting from point-by-point data collection makes these systems vulnerable to motion artifacts. While video-rate point-scanned confocal microscopy is possible, a line-scanned dual-axis confocal (LS-DAC) microscope provides a simpler means of achieving high-speed imaging through line-by-line data collection, but sacrifices contrast due to loss of confocality along one dimension. Here we evaluate the performance trade-offs between an LS-DAC and PS-DAC microscope with identical spatial resolutions. Characterization experiments of the LS-DAC and PS-DAC microscopes with tissue phantoms, in reflectance mode, are shown to match results from Monte Carlo scattering simulations of the systems. Fluorescence images of mouse brain vasculature, obtained using resolution-matched LS-DAC and PS-DAC microscopes, demonstrate the comparable performance of LS-DAC and PS-DAC microscopy at shallow depths.

Targeted vertical cross-sectional imaging with handheld near-infrared dual axes confocal fluorescence endomicroscope

We demonstrate vertical cross-sectional (XZ-plane) images of near-infrared (NIR) fluorescence with a handheld dual axes confocal endomicroscope that reveals specific binding of a Cy5.5-labeled peptide to pre-malignant colonic mucosa. This view is perpendicular to the tissue surface, and is similar to that used by pathologists. The scan head is 10 mm in outer diameter (OD), and integrates a one dimensional (1-D) microelectromechanical systems (MEMS) X-axis scanner and a bulky lead zirconate titanate (PZT) based Z-axis actuator. The microscope images in a raster-scanning pattern with a ±6 degrees (mechanical) scan angle at ~3 kHz in the X-axis (fast) and up to 10 Hz (0-400 μm) in the Z-axis (slow). Vertical cross-sectional fluorescence images are collected with a transverse and axial resolution of 4 and 5 μm, respectively, over a field-of-view of 800 μm (width) × 400 μm (depth). NIR vertical cross-sectional fluorescence images of fresh mouse colonic mucosa demonstrate histology-like imaging performance with this miniature instrument.

Advancing the translation of optical imaging agents for clinical imaging

Despite the development of a large number of promising candidates, few contrast agents for established medical imaging modalities have successfully been translated over the past decade. The emergence of new imaging contrast agents that employ biomedical optics is further complicated by the relative infancy of the field and the lack of approved imaging devices compared to more established clinical modalities such as nuclear medicine. Herein, we propose a navigational approach (as opposed to a fixed "roadmap") for translation of optical imaging agents that is (i) proposed through consensus by four academic research programs that are part of the cooperative U54 NCI Network for Translational Research, (ii) developed through early experiences for translating optical imaging agents in order to meet distinctly varied needs in cancer diagnostics, and (iii) adaptable to the rapidly changing environment of academic medicine. We describe the pathways by which optical imaging agents are synthesized, qualified, and validated for preclinical testing, and ultimately translated for "first-in-humans" studies using investigational optical imaging devices. By identifying and adopting consensus approaches for seemingly disparate optical imaging modalities and clinical indications, we seek to establish a systematic method for navigating the ever-changing "roadmap" to most efficiently arrive at the destination of clinical adoption and improved outcome and survivorship for cancer patients.

Progress in molecular imaging in endoscopy and endomicroscopy for cancer imaging

Imaging is an essential tool for effective cancer management. Endoscopes are important medical instruments for performing in vivo imaging in hollow organs. Early detection of cancer can be achieved with surveillance using endoscopy, and has been shown to reduce mortality and to improve outcomes. Recently, great advancements have been made in endoscopic instruments, including new developments in optical designs, light sources, optical fibers, miniature scanners, and multimodal systems, allowing for improved resolution, greater tissue penetration, and multispectral imaging. In addition, progress has been made in the development of highly-specific optical probes, allowing for improved specificity for molecular targets. Integration of these new endoscopic instruments with molecular probes provides a unique opportunity for significantly improving patient outcomes and has potential to further improve early detection, image guided therapy, targeted therapy, and personalized medicine. This work summarizes current and evolving endoscopic technologies, and provides an overview of various promising optical molecular probes.