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This review provides an overview of optical biopsy for colorectal lesions, focusing on the Eastern perspective-particularly recent advancements in Japan. Optical biopsy aims to predict the histopathology of colorectal lesions in real time during colonoscopy, distinguishing neoplastic from non-neoplastic lesions and assessing invasion depth. This paper examines various image-enhanced endoscopy techniques: narrow-band imaging (NBI) with the Japan NBI Expert Team classification, pit pattern analysis, and endocytoscopy using NBI and methylene blue staining. Additionally, it explores the evolving role of optical diagnosis in guiding expanded endoscopic treatment strategies for T1 and even selected T2 colorectal cancers, outlining future prospects for optical biopsy.