Tiresias: A knight's move

“If you can dream – and not make dreams your master;”

Rudyard Kipling

My friends,

Tiresias has addressed many issues regarding Optiscan’s Confocal Laser Endomicroscopy. He has addressed its obvious immediate application in the clinic in screening and diagnosis of variety of cancers in the clinic, oral cancer, skin cancer, gastrointestinal cancer, head and neck cancer, cervical cancer. He has also talked at length on the replacement of frozen section biopsies, the bane of surgeons, histopathologists and hospitals’ lives, with CLE real-time digital pathology. He has also discussed at length the immediate application of Optiscan technology in the operating theatre in detection of cancer margins and the possibility of actual complete removal of all cancer cells in malignant brain tumours, breast cancer, oral cancer, head and neck cancer, cervical cancer, and other cancers. With further developments of the technology and the development of molecular and molecular immunological pathology, the possibilities are impossible to enumerate. This is a revolution. Tiresias has raised possibilities, many possible applications, and dreams of many others. Today he would like to indulge and muse on just one such application he has not mentioned previously.

A long time ago Tiresias played, first-hand, with the original iteration of Optiscan’s Stratum confocal endomicroscope design examining the skin cancers. Now, Tiresias is not a dermatological histopathologist, though he is no stranger to histology or histopathology. When examining the CLE histopathology, he was happy in seeing the usual strictures of the in vivo skin histology. He could distinguish the dermal and epidermal structures at cellular level. He could see hair follicles and blood vessels and capillaries and red blood cells. Tiresias then noticed something he wasn’t expecting to see. He saw nerves tracking between the skin cells. Ever since then Tiresias has though and dreamt and visualised those nerves in his mind’s eve. And why has that remained with him? Well, my friends, a very common complaint patients seek medical attention for is peripheral neuropathy. The commonest of peripheral neuropathy is burning, tingling painful feet, there are many causes, the most common being diabetes and age.

Currently, there is no way to practically test and monitor these peripheral neuropathies. The conventional electrical nerve conduction studies do not test the small nerve fibres in the skin which are the main cause of these symptoms. Similarly monitoring diabetic patients with peripheral neuropathy is currently very primitive. Essentially it involves using a single camel hair and asking the patient if they can feel it touching the foot, or using a tuning fork applied to the toes of the ankles and asking the patient if they can feel that. Patients with progression of the neuropathy can be tested by taking a biopsy of the toe or the fingertip and examining the skin under conventional light microscopy. This is however rarely done for obvious reasons. The last thing one wants to do is to biopsy toes of patients with diabetes or other conditions of the peripheral nerves, as these patients have poor healing which only leads to infections, ulcers, and amputations. Just think of what the peripheral neuropathy in leprosy used to lead to. But one can see peripheral nerves with Opti scan CLE! Just dream with Tiresias for a moment. Tiresias sees patients with burning tingling feet, they have a topical dye, which highlights the nerves, painted onto the toes and nerves examined and a permanent digital record is obtained. As happens now, all patients with diabetes go to an ophthalmologist once or twice a year to have the retinas photographed; so all patients with the sensory symptoms, both diabetic and non-diabetic, can be examined, photographed and monitored. And this is a very very common problem. Tiresias is not just dreaming!