Diabetes-related retinal conditions can be detected by examining the posterior of the eye. By contrast, examining the anterior of the eye can reveal conditions affecting the front of the eye, such as changes to the eyelids, cornea, or crystalline len
s. In this work, we studied whether external photographs of the front of the eye can reveal insights into both diabetic retinal diseases and blood glucose control. We developed a deep learning system (DLS) using external eye photographs of 145,832 patients with diabetes from 301 diabetic retinopathy (DR) screening sites in one US state, and evaluated the DLS on three validation sets containing images from 198 sites in 18 other US states. In validation set A (n=27,415 patients, all undilated), the DLS detected poor blood glucose control (HbA1c > 9%) with an area under receiver operating characteristic curve (AUC) of 70.2; moderate-or-worse DR with an AUC of 75.3; diabetic macular edema with an AUC of 78.0; and vision-threatening DR with an AUC of 79.4. For all 4 prediction tasks, the DLSs AUC was higher (p<0.001) than using available self-reported baseline characteristics (age, sex, race/ethnicity, years with diabetes). In terms of positive predictive value, the predicted top 5% of patients had a 67% chance of having HbA1c > 9%, and a 20% chance of having vision threatening diabetic retinopathy. The results generalized to dilated pupils (validation set B, 5,058 patients) and to a different screening service (validation set C, 10,402 patients). Our results indicate that external eye photographs contain information useful for healthcare providers managing patients with diabetes, and may help prioritize patients for in-person screening. Further work is needed to validate these findings on different devices and patient populations (those without diabetes) to evaluate its utility for remote diagnosis and management.
As machine learning has become increasingly applied to medical imaging data, noise in training labels has emerged as an important challenge. Variability in diagnosis of medical images is well established; in addition, variability in training and atte
ntion to task among medical labelers may exacerbate this issue. Methods for identifying and mitigating the impact of low quality labels have been studied, but are not well characterized in medical imaging tasks. For instance, Noisy Cross-Validation splits the training data into halves, and has been shown to identify low-quality labels in computer vision tasks; but it has not been applied to medical imaging tasks specifically. In this work we introduce Stratified Noisy Cross-Validation (SNCV), an extension of noisy cross validation. SNCV can provide estimates of confidence in model predictions by assigning a quality score to each example; stratify labels to handle class imbalance; and identify likely low-quality labels to analyze the causes. We assess performance of SNCV on diagnosis of glaucoma suspect risk from retinal fundus photographs, a clinically important yet nuanced labeling task. Using training data from a previously-published deep learning model, we compute a continuous quality score (QS) for each training example. We relabel 1,277 low-QS examples using a trained glaucoma specialist; the new labels agree with the SNCV prediction over the initial label >85% of the time, indicating that low-QS examples mostly reflect labeler errors. We then quantify the impact of training with only high-QS labels, showing that strong model performance may be obtained with many fewer examples. By applying the method to randomly sub-sampled training dataset, we show that our method can reduce labelling burden by approximately 50% while achieving model performance non-inferior to using the full dataset on multiple held-out test sets.
Despite its high prevalence, anemia is often undetected due to the invasiveness and cost of screening and diagnostic tests. Though some non-invasive approaches have been developed, they are less accurate than invasive methods, resulting in an unmet n
eed for more accurate non-invasive methods. Here, we show that deep learning-based algorithms can detect anemia and quantify several related blood measurements using retinal fundus images both in isolation and in combination with basic metadata such as patient demographics. On a validation dataset of 11,388 patients from the UK Biobank, our algorithms achieved a mean absolute error of 0.63 g/dL (95% confidence interval (CI) 0.62-0.64) in quantifying hemoglobin concentration and an area under receiver operating characteristic curve (AUC) of 0.88 (95% CI 0.86-0.89) in detecting anemia. This work shows the potential of automated non-invasive anemia screening based on fundus images, particularly in diabetic patients, who may have regular retinal imaging and are at increased risk of further morbidity and mortality from anemia.
