Justin Engelmann

Jamie Burke, Justin Engelmann, Charlene Hamid et al.

Purpose: To develop an open-source, fully-automatic deep learning algorithm, DeepGPET, for choroid region segmentation in optical coherence tomography (OCT) data. Methods: We used a dataset of 715 OCT B-scans (82 subjects, 115 eyes) from 3 clinical studies related to systemic disease. Ground truth segmentations were generated using a clinically validated, semi-automatic choroid segmentation method, Gaussian Process Edge Tracing (GPET). We finetuned a UNet with MobileNetV3 backbone pre-trained on ImageNet. Standard segmentation agreement metrics, as well as derived measures of choroidal thickness and area, were used to evaluate DeepGPET, alongside qualitative evaluation from a clinical ophthalmologist. Results: DeepGPET achieves excellent agreement with GPET on data from 3 clinical studies (AUC=0.9994, Dice=0.9664; Pearson correlation of 0.8908 for choroidal thickness and 0.9082 for choroidal area), while reducing the mean processing time per image on a standard laptop CPU from 34.49s ($\pm$15.09) using GPET to 1.25s ($\pm$0.10) using DeepGPET. Both methods performed similarly according to a clinical ophthalmologist, who qualitatively judged a subset of segmentations by GPET and DeepGPET, based on smoothness and accuracy of segmentations. Conclusions: DeepGPET, a fully-automatic, open-source algorithm for choroidal segmentation, will enable researchers to efficiently extract choroidal measurements, even for large datasets. As no manual interventions are required, DeepGPET is less subjective than semi-automatic methods and could be deployed in clinical practice without necessitating a trained operator.

Justin Engelmann, Amos Storkey, Miguel O. Bernabeu

Image quality remains a key problem for both traditional and deep learning (DL)-based approaches to retinal image analysis, but identifying poor quality images can be time consuming and subjective. Thus, automated methods for retinal image quality scoring (RIQS) are needed. The current state-of-the-art is MCFNet, composed of three Densenet121 backbones each operating in a different colour space. MCFNet, and the EyeQ dataset released by the same authors, was a huge step forward for RIQS. We present QuickQual, a simple approach to RIQS, consisting of a single off-the-shelf ImageNet-pretrained Densenet121 backbone plus a Support Vector Machine (SVM). QuickQual performs very well, setting a new state-of-the-art for EyeQ (Accuracy: 88.50% vs 88.00% for MCFNet; AUC: 0.9687 vs 0.9588). This suggests that RIQS can be solved with generic perceptual features learned on natural images, as opposed to requiring DL models trained on large amounts of fundus images. Additionally, we propose a Fixed Prior linearisation scheme, that converts EyeQ from a 3-way classification to a continuous logistic regression task. For this task, we present a second model, QuickQual MEga Minified Estimator (QuickQual-MEME), that consists of only 10 parameters on top of an off-the-shelf Densenet121 and can distinguish between gradable and ungradable images with an accuracy of 89.18% (AUC: 0.9537). Code and model are available on GitHub: https://github.com/justinengelmann/QuickQual . QuickQual is so lightweight, that the entire inference code (and even the parameters for QuickQual-MEME) is already contained in this paper.

Justin Engelmann, Ana Villaplana-Velasco, Amos Storkey et al.

A retinal trait, or phenotype, summarises a specific aspect of a retinal image in a single number. This can then be used for further analyses, e.g. with statistical methods. However, reducing an aspect of a complex image to a single, meaningful number is challenging. Thus, methods for calculating retinal traits tend to be complex, multi-step pipelines that can only be applied to high quality images. This means that researchers often have to discard substantial portions of the available data. We hypothesise that such pipelines can be approximated with a single, simpler step that can be made robust to common quality issues. We propose Deep Approximation of Retinal Traits (DART) where a deep neural network is used predict the output of an existing pipeline on high quality images from synthetically degraded versions of these images. We demonstrate DART on retinal Fractal Dimension (FD) calculated by VAMPIRE, using retinal images from UK Biobank that previous work identified as high quality. Our method shows very high agreement with FD VAMPIRE on unseen test images (Pearson r=0.9572). Even when those images are severely degraded, DART can still recover an FD estimate that shows good agreement with FD VAMPIRE obtained from the original images (Pearson r=0.8817). This suggests that our method could enable researchers to discard fewer images in the future. Our method can compute FD for over 1,000img/s using a single GPU. We consider these to be very encouraging initial results and hope to develop this approach into a useful tool for retinal analysis.

Jamie Burke, Justin Engelmann, Samuel Gibbon et al.

Optical coherence tomography (OCT) and scanning laser ophthalmoscopy (SLO) of the eye has become essential to ophthalmology and the emerging field of oculomics, thus requiring a need for transparent, reproducible, and rapid analysis of this data for clinical research and the wider research community. Here, we introduce OCTolyzer, the first open-source toolkit for retinochoroidal analysis in OCT/SLO data. It features two analysis suites for OCT and SLO data, facilitating deep learning-based anatomical segmentation and feature extraction of the cross-sectional retinal and choroidal layers and en face retinal vessels. We describe OCTolyzer and evaluate the reproducibility of its OCT choroid analysis. At the population level, metrics for choroid region thickness were highly reproducible, with a mean absolute error (MAE)/Pearson correlation for macular volume choroid thickness (CT) of 6.7$μ$m/0.99, macular B-scan CT of 11.6$μ$m/0.99, and peripapillary CT of 5.0$μ$m/0.99. Macular choroid vascular index (CVI) also showed strong reproducibility, with MAE/Pearson for volume CVI yielding 0.0271/0.97 and B-scan CVI 0.0130/0.91. At the eye level, measurement noise for regional and vessel metrics was below 5% and 20% of the population's variability, respectively. Outliers were caused by poor-quality B-scans with thick choroids and invisible choroid-sclera boundary. Processing times on a laptop CPU were under three seconds for macular/peripapillary B-scans and 85 seconds for volume scans. OCTolyzer can convert OCT/SLO data into reproducible and clinically meaningful retinochoroidal features and will improve the standardisation of ocular measurements in OCT/SLO image analysis, requiring no specialised training or proprietary software to be used. OCTolyzer is freely available here: https://github.com/jaburke166/OCTolyzer.

Justin Engelmann, Alice D. McTrusty, Ian J. C. MacCormick et al.

Ultra-widefield (UWF) imaging is a promising modality that captures a larger retinal field of view compared to traditional fundus photography. Previous studies showed that deep learning (DL) models are effective for detecting retinal disease in UWF images, but primarily considered individual diseases under less-than-realistic conditions (excluding images with other diseases, artefacts, comorbidities, or borderline cases; and balancing healthy and diseased images) and did not systematically investigate which regions of the UWF images are relevant for disease detection. We first improve on the state of the field by proposing a DL model that can recognise multiple retinal diseases under more realistic conditions. We then use global explainability methods to identify which regions of the UWF images the model generally attends to. Our model performs very well, separating between healthy and diseased retinas with an area under the curve (AUC) of 0.9206 on an internal test set, and an AUC of 0.9841 on a challenging, external test set. When diagnosing specific diseases, the model attends to regions where we would expect those diseases to occur. We further identify the posterior pole as the most important region in a purely data-driven fashion. Surprisingly, 10% of the image around the posterior pole is sufficient for achieving comparable performance to having the full images available.

Justin Engelmann, Jamie Burke, Charlene Hamid et al.

Purpose: To develop Choroidalyzer, an open-source, end-to-end pipeline for segmenting the choroid region, vessels, and fovea, and deriving choroidal thickness, area, and vascular index. Methods: We used 5,600 OCT B-scans (233 subjects, 6 systemic disease cohorts, 3 device types, 2 manufacturers). To generate region and vessel ground-truths, we used state-of-the-art automatic methods following manual correction of inaccurate segmentations, with foveal positions manually annotated. We trained a U-Net deep-learning model to detect the region, vessels, and fovea to calculate choroid thickness, area, and vascular index in a fovea-centred region of interest. We analysed segmentation agreement (AUC, Dice) and choroid metrics agreement (Pearson, Spearman, mean absolute error (MAE)) in internal and external test sets. We compared Choroidalyzer to two manual graders on a small subset of external test images and examined cases of high error. Results: Choroidalyzer took 0.299 seconds per image on a standard laptop and achieved excellent region (Dice: internal 0.9789, external 0.9749), very good vessel segmentation performance (Dice: internal 0.8817, external 0.8703) and excellent fovea location prediction (MAE: internal 3.9 pixels, external 3.4 pixels). For thickness, area, and vascular index, Pearson correlations were 0.9754, 0.9815, and 0.8285 (internal) / 0.9831, 0.9779, 0.7948 (external), respectively (all p<0.0001). Choroidalyzer's agreement with graders was comparable to the inter-grader agreement across all metrics. Conclusions: Choroidalyzer is an open-source, end-to-end pipeline that accurately segments the choroid and reliably extracts thickness, area, and vascular index. Especially choroidal vessel segmentation is a difficult and subjective task, and fully-automatic methods like Choroidalyzer could provide objectivity and standardisation.

Jamie Burke, Samuel Gibbon, Justin Engelmann et al.

Purpose: The purpose of this study was to introduce SLOctolyzer: an open-source analysis toolkit for en face retinal vessels in infrared reflectance scanning laser ophthalmoscopy (SLO) images. Methods: SLOctolyzer includes two main modules: segmentation and measurement. The segmentation module uses deep learning methods to delineate retinal anatomy, and detects the fovea and optic disc, whereas the measurement module quantifies the complexity, density, tortuosity, and calibre of the segmented retinal vessels. We evaluated the segmentation module using unseen data and measured its reproducibility. Results: SLOctolyzer's segmentation module performed well against unseen internal test data (Dice for all-vessels = 0.91; arteries = 0.84; veins = 0.85; optic disc = 0.94; and fovea = 0.88). External validation against severe retinal pathology showed decreased performance (Dice for arteries = 0.72; veins = 0.75; and optic disc = 0.90). SLOctolyzer had good reproducibility (mean difference for fractal dimension = -0.001; density = -0.0003; calibre = -0.32 microns; and tortuosity density = 0.001). SLOctolyzer can process a 768 x 768 pixel macula-centred SLO image in under 20 seconds and a disc-centred SLO image in under 30 seconds using a laptop CPU. Conclusions: To our knowledge, SLOctolyzer is the first open-source tool to convert raw SLO images into reproducible and clinically meaningful retinal vascular parameters. SLO images are captured simultaneous to optical coherence tomography (OCT), and we believe SLOctolyzer will be useful for extracting retinal vascular measurements from large OCT image sets and linking them to ocular or systemic diseases. It requires no specialist knowledge or proprietary software, and allows manual correction of segmentations and re-computing of vascular metrics. SLOctolyzer is freely available at https://github.com/jaburke166/SLOctolyzer.

Jamie Burke, Justin Engelmann, Charlene Hamid et al.

The choroid is a key vascular layer of the eye, supplying oxygen to the retinal photoreceptors. Non-invasive enhanced depth imaging optical coherence tomography (EDI-OCT) has recently improved access and visualisation of the choroid, making it an exciting frontier for discovering novel vascular biomarkers in ophthalmology and wider systemic health. However, current methods to measure the choroid often require use of multiple, independent semi-automatic and deep learning-based algorithms which are not made open-source. Previously, Choroidalyzer -- an open-source, fully automatic deep learning method trained on 5,600 OCT B-scans from 385 eyes -- was developed to fully segment and quantify the choroid in EDI-OCT images, thus addressing these issues. Using the same dataset, we propose a Robust, Resolution-agnostic and Efficient Attention-based network for CHoroid segmentation (REACH). REACHNet leverages multi-resolution training with domain-specific data augmentation to promote generalisation, and uses a lightweight architecture with resolution-agnostic self-attention which is not only faster than Choroidalyzer's previous network (4 images/s vs. 2.75 images/s on a standard laptop CPU), but has greater performance for segmenting the choroid region, vessels and fovea (Dice coefficient for region 0.9769 vs. 0.9749, vessels 0.8612 vs. 0.8192 and fovea 0.8243 vs. 0.3783) due to its improved hyperparameter configuration and model training pipeline. REACHNet can be used with Choroidalyzer as a drop-in replacement for the original model and will be made available upon publication.

Justin Engelmann, Diana Moukaddem, Lucas Gago et al.

Purpose: To investigate whether Fractal Dimension (FD)-based oculomics could be used for individual risk prediction by evaluating repeatability and robustness. Methods: We used two datasets: Caledonia, healthy adults imaged multiple times in quick succession for research (26 subjects, 39 eyes, 377 colour fundus images), and GRAPE, glaucoma patients with baseline and follow-up visits (106 subjects, 196 eyes, 392 images). Mean follow-up time was 18.3 months in GRAPE, thus it provides a pessimistic lower-bound as vasculature could change. FD was computed with DART and AutoMorph. Image quality was assessed with QuickQual, but no images were initially excluded. Pearson, Spearman, and Intraclass Correlation (ICC) were used for population-level repeatability. For individual-level repeatability, we introduce measurement noise parameter λ which is within-eye Standard Deviation (SD) of FD measurements in units of between-eyes SD. Results: In Caledonia, ICC was 0.8153 for DART and 0.5779 for AutoMorph, Pearson/Spearman correlation (first and last image) 0.7857/0.7824 for DART, and 0.3933/0.6253 for AutoMorph. In GRAPE, Pearson/Spearman correlation (first and next visit) was 0.7479/0.7474 for DART, and 0.7109/0.7208 for AutoMorph (all p<0.0001). Median λ in Caledonia without exclusions was 3.55\% for DART and 12.65\% for AutoMorph, and improved to up to 1.67\% and 6.64\% with quality-based exclusions, respectively. Quality exclusions primarily mitigated large outliers. Worst quality in an eye correlated strongly with λ (Pearson 0.5350-0.7550, depending on dataset and method, all p<0.0001). Conclusions: Repeatability was sufficient for individual-level predictions in heterogeneous populations. DART performed better on all metrics and might be able to detect small, longitudinal changes, highlighting the potential of robust methods.

Justin Engelmann, Miguel O. Bernabeu

Artificial Intelligence in medicine is traditionally limited by the lack of massive training datasets. Foundation models, pre-trained models that can be adapted to downstream tasks with small datasets, could alleviate this problem. Researchers at Moorfields Eye Hospital (MEH) proposed RETFound-MEH, a retinal foundation model trained on 900,000 images, including private hospital data. Recently, data-efficient DERETFound was proposed providing comparable performance while being trained on only 150,000 publicly available images. However, both these models required very substantial resources to train initially and are resource-intensive in downstream use. We propose a novel Token Reconstruction objective that we use to train RETFound-Green, a retinal foundation model trained using only 75,000 publicly available images and 400 times less compute. We estimate the cost of training RETFound-MEH and DERETFound at \$10,000 and \$14,000, respectively. RETFound-Green could be trained for less than \$100, with equally reduced environmental impact. RETFound-Green is also far more efficient in downstream use: it can be downloaded 14 times faster, computes vector embeddings 2.7 times faster which then require 2.6 times less storage space. Despite this, RETFound-Green does not perform systematically worse. In fact, on various task on three downstream datasets from Brazil, India and China, it performs best on 68 tasks out of 119 comparisons, versus 21 for DERETFound and 13 for RETFound-MEH. Our results suggest that RETFound-Green is a very efficient, high-performance retinal foundation model. We anticipate that our Token Reconstruction objective could be scaled up for even higher performance and be applied to other domains beyond retinal imaging.

Yukun Zhou, Paul Nderitu, Jocelyn Hui Lin Goh et al.

Medical foundation models, pre-trained with large-scale clinical data, demonstrate strong performance in diverse clinically relevant applications. RETFound, trained on nearly one million retinal images, exemplifies this approach in applications with retinal images. However, the emergence of increasingly powerful and multifold larger generalist foundation models such as DINOv2 and DINOv3 raises the question of whether domain-specific pre-training remains essential, and if so, what gap persists. To investigate this, we systematically evaluated the adaptability of DINOv2 and DINOv3 in retinal image applications, compared to two specialist RETFound models, RETFound-MAE and RETFound-DINOv2. We assessed performance on ocular disease detection and systemic disease prediction using two adaptation strategies: fine-tuning and linear probing. Data efficiency and adaptation efficiency were further analysed to characterise trade-offs between predictive performance and computational cost. Our results show that although scaling generalist models yields strong adaptability across diverse tasks, RETFound-DINOv2 consistently outperforms these generalist foundation models in ocular-disease detection and oculomics tasks, demonstrating stronger generalisability and data efficiency. These findings suggest that specialist retinal foundation models remain the most effective choice for clinical applications, while the narrowing gap with generalist foundation models suggests that continued data and model scaling can deliver domain-relevant gains and position them as strong foundations for future medical foundation models.

Justin Engelmann, Amos Storkey, Miguel O. Bernabeu

Deep learning (DL) models are very effective on many computer vision problems and increasingly used in critical applications. They are also inherently black box. A number of methods exist to generate image-wise explanations that allow practitioners to understand and verify model predictions for a given image. Beyond that, it would be desirable to validate that a DL model \textit{generally} works in a sensible way, i.e. consistent with domain knowledge and not relying on undesirable data artefacts. For this purpose, the model needs to be explained globally. In this work, we focus on image modalities that are naturally aligned such that each pixel position represents a similar relative position on the imaged object, as is common in medical imaging. We propose the pixel-wise aggregation of image-wise explanations as a simple method to obtain label-wise and overall global explanations. These can then be used for model validation, knowledge discovery, and as an efficient way to communicate qualitative conclusions drawn from inspecting image-wise explanations. We further propose Progressive Erasing Plus Progressive Restoration (PEPPR) as a method to quantitatively validate that these global explanations are faithful to how the model makes its predictions. We then apply these methods to ultra-widefield retinal images, a naturally aligned modality. We find that the global explanations are consistent with domain knowledge and faithfully reflect the model's workings.

Justin Engelmann, Stefan Lessmann

Class imbalance is a common problem in supervised learning and impedes the predictive performance of classification models. Popular countermeasures include oversampling the minority class. Standard methods like SMOTE rely on finding nearest neighbours and linear interpolations which are problematic in case of high-dimensional, complex data distributions. Generative Adversarial Networks (GANs) have been proposed as an alternative method for generating artificial minority examples as they can model complex distributions. However, prior research on GAN-based oversampling does not incorporate recent advancements from the literature on generating realistic tabular data with GANs. Previous studies also focus on numerical variables whereas categorical features are common in many business applications of classification methods such as credit scoring. The paper propoes an oversampling method based on a conditional Wasserstein GAN that can effectively model tabular datasets with numerical and categorical variables and pays special attention to the down-stream classification task through an auxiliary classifier loss. We benchmark our method against standard oversampling methods and the imbalanced baseline on seven real-world datasets. Empirical results evidence the competitiveness of GAN-based oversampling.