Detection of severity level of diabetic

retinopathy using Bag of features model

Mona Leeza 
 
Humera Farooq

First published: 10 July 2019

 
https://doi.org/10.1049/iet-cvi.2018.5263
Citations: 3

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Abstract
Diabetic retinopathy is a vascular disease caused by uncontrolled diabetes. Its early detection can save
diabetic patients from blindness. However, the detection of its severity level is a challenge for
ophthalmologists since last few decades. Several efforts have been made for the identification of its limited
stages by using pre‐ and post‐processing methods, which require extensive domain knowledge. This study
proposes an improved automated system for severity detection of diabetic retinopathy which is a dictionary‐
based approach and does not include pre‐ and post‐processing steps. This approach integrates pathological
explicit image representation into a learning outline. To create the dictionary of visual features, points of
interest are detected to compute the descriptive features from retinal images through speed up robust
features algorithm and histogram of oriented gradients. These features are clustered to generate a dictionary,
then coding and pooling are applied for compact representation of features. Radial basis kernel support
vector machine and neural network are used to classify the images into five classes namely normal, mild,
moderate, severe non‐proliferative diabetic retinopathy, and proliferative diabetic retinopathy. The proposed
system exhibits improved results of 95.92% sensitivity and 98.90% specificity in relation to the reported state
of the art methods.

1 Introduction
Diabetes mellitus (DM) is regarded as a challenging disease for public health worldwide. According to
epidemiological studies aging, longer duration of DM and cardiovascular complications may lead to diabetic
retinopathy (DR) [[1], [2]]. DR could be a major reason for blindness in the working‐age population [[3]] having
no clear clue at its early stage until it progresses and affects vision badly. Its progression may cause retinal
damage and loss of vision or blindness. Patients diagnosed with type‐I and type‐II diabetes have a chance to
suffer DR. In the first five years of diagnosis, type‐I patients have almost no chance of DR but one in every five
patients with newly diagnosed type‐II diabetes have DR [[4]]. Chance of DR increases with time, almost all
type‐I diabetic patients have DR after 15 years of diagnosis of diabetes while this ratio is one‐third for type‐II
diabetes in the same period of time [[5]].

Currently, some ophthalmologists use computer‐aided diagnosis (CAD) systems to diagnose DR and its
severity level but this detection of severity level is based on the number of DR‐lesions present in the retina. DR
can be divided into two main classes namely non‐proliferative DR (NPDR) and proliferative DR (PDR), [[6]] and
NPDR can be further classified into three classes namely mild, moderate, and severe.

Microaneurysm (M), hard exudates (HEs), soft exudates or cotton wool spots (CWS), hemorrhage (H), and
neovascularisation are the lesions of DR [[6]]. M is small swelling on the walls of blood vessels inside retina
that is caused due to loss of pericyte. Capillaries are not observable from conventional fundus images, Ms
become visible like isolated red dots not attached to any blood vessel. Diabetic patients may get this
abnormality in the retina, moreover, it is the initial detectable sign of DR. Hs lie in the inner part of the retina
and are formed when Ms or walls of capillaries become fragile and get burst. It is similar to the M when small
in size. HEs are formed when protein leaks from blood vessels. HEs are waxy and yellow or white deposits of
protein and lipid which leaks from the arteries when arteries become weak due to Ms. CWS or soft exudates
are formed when leakage of blood vessels block the vessels. They are fluffy and are white in colour. As the
capillary break down progresses, the retina becomes ischemic and triggers the growth of the new cells as an
attempt for revascularisation of the tissues deprived of oxygen. Neovascularisation is caused due to the
abnormal progression of tiny and leaky blood vessels. These abnormal blood vessels are tenuous and can
grow anywhere inside the retina. Figure 1 shows a pathological image having some of these lesions.

Fig. 1
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Pathological images with labelled anomalies
NPDR is caused when blood vessels are damaged inside the retina resulting in the leakage of blood or fluid. It
soaks the retina and hence swells macula which affects the function of the retina. The lesions present at this
stage of DR are M, HEs, soft exudates or CWS, and H [[7]]. Among the three types of NPDR, in mild NPDR, a few
Ms are present inside the retina and some loss of vision is experienced by the patients. However, moderate
NPDR can be detected by the presence of HE, CWS, and H, whereas in severe NPDR, HE and leakage of blood
and fluid severely affect the retina.

PDR is an advanced stage of DR; at this stage blood vessels inside retina are obstructed. As a result, the retina
is deprived of nutrition and thus sends signals for the nourishment; hence new blood vessels grow inside the
retina. Although the birth of infant vessels is not harmful, however, due to their fragile nature, these may lead
to leakage, loss of vision, or even blindness.

DR lesions can appear anywhere in the retina and this complication makes the detection of five DR‐levels a
difficult and tedious task for ophthalmologists and hence motivates researchers to design efficient CAD
systems. Literature revealed that many researchers proposed efficient methods [[8]-[13]] for DR‐lesion
detection and CAD systems [[14]-[25]] for identification of severity levels of DR. Some of these studies
proposed the automated methods to detect severity of DR on the basis of DR‐lesions which is quite similar to
the one usually practiced by ophthalmologists. Detection of DR‐lesions depends on the expert domain
knowledge as well as pre and post processing of images. In contrast, some of the methods
[[21], [22], [26], [27]] used visual features without pre‐ and post‐processing steps to diagnose DR and its
severity levels.

Detection of exudates was proposed in [[8], [10]] using fuzzy C‐means clustering after applying colour
normalisation and local contrast enhancement as pre‐processing steps. Segmented patches were classified as
exudate and non‐exudate using a neural network (NN) classifier. Comparative classification of exudates was
also proposed by [[11]] using support vector machines (SVMs) and NNs. SVM, nearest neighbor, and Naive
Bayes classifiers were used to detect exudates candidates in [[12]]. Fifteen features were used in the
investigation with no former segmentation for the detection of the candidates, instead of this the pixel‐based
features were computed including intensity, hue, number of edge pixels, the difference of Gaussian filter
responses, and standard deviation of intensity. A pixel classification method was used to introduce a system
for the extraction of red lesions [[13]]. K‐nearest neighbour (KNN) classifier was used to classify the pixels of
vessels and red lesions.

Detection of four severity levels of DR namely normal, moderate NPDR, severe NPDR, and PDR was proposed
in [[25]]. Six features based on area and perimeter of red, green, and blue (RGB) layers were extracted from
120 retinal images after applying contrast enhancement method as pre‐processing. Three‐layered feed‐
forward NN (FFNN) was used for classification and achieved sensitivity and specificity of 90 and 100%,
respectively. Although, the authors have shown an effort to achieve better efficiency of classification they
could not detect mild NPDR. Retinal images were classified only into three classes of DR namely normal,
moderate NPDR, and severe NPDR using a tree‐type classifier Random Forests in [[14]]. Adaptive histogram
equalisation was applied for contrast enhancement and median filters for removal of noise. Blood vessels
were segmented using the matched filter. The global threshold was used to convert the filtered matched
image into its binary image. Normal blood vessels were eliminated by using bounding box technique before H
candidate detection which was identified by transforming the bright values in hue saturation value space and
then applying gamma correction on RGB to highlight brown regions. Authors reported 90% accuracy in normal
case and 87.5% accuracy in moderate and severe NPDR cases. However, the authors did not identify mild
NPDR and PDR and therefore, the algorithm is not based on the characteristics of blood vessels.

The bag of words approach with scale‐invariant feature transform (SIFT) and SVM classifier was used in [[21]]
to detect only three stages of DR namely normal, NPDR, and PDR. In total, 64‐bin histograms were created and
neighbourhood of 3 × 3 for each pixel was considered to form a feature vector of 64‐D. In total, 425 retinal
images were manually assembled from publicly available well‐known databases DIARETDB0, DIARETDB,
STARE, and MESSIDOR for experiments and achieved 87.61% mean accuracy. An automatic screening system
was proposed to classify retinal images into three classes namely normal, NPDR, and PDR [[24]]. The authors
proposed a system that involved processing of fundus images for extraction of abnormal signs, such as the
area of HEs, the area of blood vessels, bifurcation points, texture, and entropies. Thirteen statistically
significant features were used to feed into Decision Tree, SVM and probabilistic NN (PNN). The proposed
algorithm achieved 96.15% accuracy, 96.27% sensitivity, and 96.08% specificity using PNN classifier. Similarly,
classification of DR into three stages such as normal, NPDR, and PDR was proposed using SVM in [[15]].
Morphological techniques and texture analysis methods were applied as image processing techniques. The
detected features such as HEs, homogeneity, and contrast and area of blood vessels were fed to the SVM. The
reported results of classification were accuracy = 93%, sensitivity = 90%, and specificity = 100%. However, the
proposed algorithms did not distinguish among levels of NPDR such as mild, moderate, and severe.

Identification of four stages of DR such as no DR, mild NPDR, moderate NPDR, and severe NPDR on the basis
of the number of Ms was proposed in [[16]]. Contrast adjustment method was used in the inverted green
channel for reduction of non‐uniform illumination and for the contrast enhancement. Then Median filter was
applied to pre‐processed images for removal of noise. This was followed by an extended minima
transformation. Ten images were tested to investigate the performance of the designed algorithm and
compared the result with hand‐drawn ground‐truth images by ophthalmologists. Sensitivity and predictive
values were used for evaluation and reported as 98.89 and 89.70%, respectively. The authors did not consider
PDR cases in the study. DR lesions such as Ms, HE, and CWS were detected using the bag of visual words
(BoVW) [[26]]. Speed up robust feature (SURF) and mid‐soft coding with max‐pooling were applied. DR1, DR2,
and MESSIDOR databases were used and achieved an area under the curve (AUC) of 97.8% for exudates
detection and AUC of 93.5% while detecting red lesions. However, the authors used different data sets to
validate the proposed method, but the method could only be used to detect DR lesions and after that, the
results could be used for identification of severity levels manually on the basis of type and count of lesions.

An automated system for the detection and classification of DR was proposed in [[17]]. The proposed
algorithm was designed to discriminate normal and abnormal images, then abnormal images were further
classified into three classes of NPDR and reported 98.52% accuracy. Mean‐ and variance‐based techniques
were applied for subtraction of background and removal of noise using saturation, hue, and intensity
channels. Images obtained by applying the adaptive contrast enhancement method were used as the input for
Gabor filter banks to detect the DR lesions. A feature vector based on colour, intensity, shape, and statistical
features was designed for the classification of NPDR stages using modified m‐Mediods‐based classifier with
the Gaussian mixture model. Although authors reported better accuracy of classification, they did not consider
PDR level. Similarly, several DR lesions (such as fovea region), the thickness of vessels, and area of blood
clotting were identified to detect normal, mild, moderate, and severe NPDR using KNN in [[18]]. However, the
accuracy of the proposed system was not demonstrated, as the authors did not show numerical results. In
[[20]], an automated method was proposed to detect four subsets of DR grades. In this study, normal, mild
NPDR, moderate and severe NPDR, and PDR were identified by reporting 85% accuracy. Since the authors did
not discriminate between severe and moderate classes, the proposed algorithm could only characterise blood
vessels.

Bag of words was implemented to classify retinal images as normal and abnormal in [[27]]. Identification of
severity levels of DR was not considered in this case. SVM, Naïve Bayes, FFNN, Decision Tree, and OR Logic
classifiers were used. Similarly, the classification of retinal images into five stages of DR using NN and SVM was
proposed with 80% accuracy in [[19]]. Authors used the modified region growing method for segmentation of
optic disk and morphological operations for blood vessels. In this study, normal and abnormal images were
first classified using NN with the features based on mean, variance, area, and entropy then SVM was used for
classification of abnormal images into four stages. Since the proposed method used pre‐ and post‐processing
steps the technique was computationally expensive for the classification of DR into five stages.

An automated method for diagnosis of five severity levels of DR was proposed in [[23]]. Retinal images were
taken from Kaggle data set and were pre‐processed for colour normalisation using OpenCV package. Images
were resized before applying convolutional NN (CNN) for classification task and reported the results with
sensitivity = 30%, specificity = 95%, and accuracy = 75%. However, the authors had put great efforts for the
classification but achieved low sensitivity. Grading of DR on two privately collected datasets (8788 images and
1745 images) was reported in [[28]]. Retinal images were pre‐processed and used to train CNN for multiple
binary classification. The algorithm was designed to predict whether the retinal image belonged to (i)
moderate or worse DR only, (ii) severe or worse DR only, (iii) referable diabetic macular edema (DMO) only, or
(iv) fully gradable. The reported sensitivity for moderate or worse DR was 90 and 87%, respectively, whereas
98% specificity was reported for both data sets. In total, 84 and 88% of sensitivity and 99 and 98% of specificity
were achieved for severe or worse DR and 91 and 90% of sensitivity and 98 and 99% of specificity were
achieved for DMO only, respectively.

In [[29]], the authors applied CNN to discriminate stages of NPDR such as normal, mild, moderate, and severe.
Data set was obtained by collecting images from Kaggle and Messidor. The authors designed classification
models of secondary, tertiary, and quaternary stages. The transfer learning‐based approach was applied after
pre‐processing, data augmentation, and training. Sensitivity was recorded as 85, 29, and 75% for no DR, mild,
and severe DR, respectively. However, in quaternary classification, the authors described that the deep CNN
was unable to discriminate multiclass classification. It is also noticeable that the PDR case was not considered
in this study.
Deep visual features (DVF) were used [[22]] for classification of DR into five stages namely normal, mild NPDR,
moderate NPDR, severe NPDR, and PDR. The authors used dense Color‐SIFT to extract points of interest and
associated SIFT descriptors, then, gradient location–orientation histogram was applied to it. The log‐polar
location grid method was used to compute SIFT descriptors. After normalising these features DVF and deep
NN were used to classify 750 images (150 for each class) and reported 92.18% of sensitivity and 94.50% of
specificity on an average. In this study, the retinal data set of various stages were assembled from different
databases: 60 and 36 mild NPDR from DIARETDB1 and MESSIDOR, respectively, 40 and 396 images of foveal
avascular zone from MESSIDOR in which 12 and 88 were from normal, 4 and 96 were from moderate, 12 and
88 were from severe NPDR, and 12 and 88 were from PDR, respectively. In total, 250 images (50 for each class)
were collected from Private Hospital Universitario Puerta del Mar (HUPM, Cádiz, Spain). However, the authors
reported a better accuracy of classification for five severity levels of DR, but 92.18% of sensitivity and 94.5% of
specificity still need to be improved as sensitivity and specificity have great significance in medical diagnosis.

From the above discussion of the current progress of automatic methods for grading of DR, some facts can be
emphasised. Some of the previous methods rely more on the precise segmentation of DR lesions which is
hard to achieve and moreover, expensive computationally. Furthermore, errors in the segmentation process
can affect the performance of the CAD systems. In addition to the above discussion, it is noticeable that
previous methods proposed the techniques to distinguish between NPDR and PDR. Grading of severity levels
of DR was proposed by only a few studies including [[19], [22], [23]]. These techniques were developed for the
classification of five severity levels of DR. The method proposed in [[19]] used pre‐processing methods and
reported 80% accuracy; CNN was used in [[23]] and 30% sensitivity was reported, which was considerably low;
and in [[22]] a visual features‐based approach without pre‐processing was proposed and achieved significant
results (sensitivity = 92.18% and specificity = 94.50%) but it needs to be improved since sensitivity and
specificity have high significance in medical diagnosis. Therefore, the task of identification of severity levels
remains to be a challenge.

2 Methodology
Automated severity detection of DR (SDDR) is proposed in the current research through bag of features (BoF)
technique. It is an adaptive approach to represent the image in a robust way and is used for the classification
of images in computer vision. Adaptiveness of BoF is one of its advantages as it allows image collection to be
processed and it also identifies visual patterns of the whole image collection [[30]]. The approach is proposed
to detect five severity levels of DR and its architecture is shown in Fig. 2. The details of each step are given in
the following subsections.
Fig. 2
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Architecture of proposed methodology

2.1 Creation of codebook/dictionary

Feature extraction is the key step in image classification problems. Moreover, classification results depend on
the selection of features which is a difficult task. In the current approach, BoF containing visual features is
used for classification of retinal images into five stages. Local features are extracted from the retinal images
using SURF [[31]] descriptor. SURF quickly computes distinctive descriptors, which is the main advantage of it.
In addition, it is invariant to image transformations such as image rotation, illumination changes, scale
changes, and minor change in the viewpoint. Moreover, SURF is a good feature descriptor of low‐level
representation. The construction process of SURF includes interest point detection, major point localisation in
scale space, and orientation assignment.

Laplacian of Gaussian (LoG) approximations with box filters are used to estimate second‐order Gaussian
kernel  . To calculate intensities of rectangles within the input image LoG filters of size 9 × 9
with    = 1.2 are used. Grid selection method having grid step of [8 8] and the block width of [32 64 96 128] is
used in the computation of points of interest (PoI) for SURF descriptor. Haar wavelet responses of size   in
the direction of x and y are calculated to compute the primary direction of features. A square window
descriptor of size   is constructed around each PoI. Each square window is divided into 4 × 4 subregions.
Haar wavelets of 2 s are calculated within each subregion, hence the total length of each feature descriptor is
4 × 4 × 4 = 64. In order to generate a codebook, K‐means clustering algorithm is used and all the local features
are clustered together independently using K = 500. Here K indicates the size of dictionary/codebook, however,
codebook size is not significant in medical images [[32]]. An average of 32,770 vectors was identified for all
lesions as well as for normal features to form 500 clusters.

2.2 Feature encoding and pooling

The idea of creating BoF has some cons: one is some valuable information can be lost during quantisation of
visual words and other is the loss of spatial information. In order to solve such problems, coding and pooling
are applied in the current approach.

Midlevel features are designed using coding for compact representation of local features and to preserve
relevant information. Consider F to be the set of descriptors with P‐dimension for each image in the training
set such that   and a visual dictionary of codewords

is  . Purpose of encoding is to calculate code for F with C. As a result, each

descriptor fi is assigned to the nearest visual feature within the dictionary by using  . Thus a
vector U is formed that contains corresponding words of each descriptor; it is usually termed as hard
assignment coding [[33]]. Visual dictionary is represented as  , where  .

A process to accumulate several local descriptor encodings into a single representation is termed as pooling. It
is considered as one of the crucial steps in the BoVW representation and is followed by

coding  , where α indicates the assigned codewords to local feature vectors. Pooling
is attained by two methods; one is summation and other is taking the maximum response, but max‐pooling is
an effective choice [[34]]. In the present approach, the max‐pooling method is used in which the largest value
is selected from the midlevel features that are corresponding to the codewords (here the max‐pooling
corresponds to the number of words with high frequencies).

(1)

Histograms of oriented gradient (HOG) is also constructed for each image to combine with the SURF visual
features, Z in (1) represents the bag of visual features. The feature vector used in the present work is of
dimension  .

2.3 Identification of severity level

The classification of severity levels of DR into five classes namely normal, mild NPDR, moderate NPDR, severe
NPDR, and PDR are identified using bag of visual features with two classifiers SVM and artificial NN (ANN).

2.3.1 Support vector machine

A supervised learning algorithm SVM [[35]] is used for the classification of input images. If the classification
problem was linear then SVM generated two hyperplanes ( ), such that no sample points lie
between these two planes. If training data is a set of points   and if   is their labels, then the hyperplane's

equation is  , where w is weight vector while b denotes bias. All samples with   lie on one
side of the plane and belong to one class and samples with   lie on the other side of the hyperplane
and belong to the other class. In the present case, the classification problem is not linear, the images are
classified into five classes, i.e. no DR, mild DR, moderate NPDR, severe NPDR, and NPDR. For classification in
higher dimensions, SVM with radial basis function (RBF) kernel were used, which can be defined as (2).

(2)

 is the kernel for samples  ,   with  , and   is the square of Euclidean
distance between two feature vectors. Experiments are repeated using a ten‐fold cross‐validation method.

2.3.2 Artificial neural network

Nonlinear four‐layered ANN with backpropagation is used, which consists of one input layer, two hidden
layers, and one output layer. ANN configuration consists of 500 input nodes, 50 hidden units on each hidden
layer, and five output nodes that correspond to normal, mild NPDR, moderate NPDR, severe NPDR, and PDR.
Backpropagation algorithm is used for the training of network. Gradient descent is implemented to reduce
mean squared error between actual error rate and network output. The network is used until one of the
following conditions is satisfied.
 (i). Maximum gradient.

 (ii). Maximum epoch.

 (iii). Maximum goal.

An activation function ‘log sigmoid’ is implemented on the first hidden layer. The second hidden layer is
connected to the output layer and a transfer function ‘softmax’ is used for the generation of output. Only
layers and their connections are made during the construction of ANN. The Nguyen–Widrow method is used
to initialise the values of these connections and biases. It distributes the active region of each neuron
according to the input space. Although the values are assigned randomly in the active region, slightly different
results were achieved on each iteration. Then according to the data sets, these randomly assigned values of
parameters are trained.
The scaled conjugate backpropagation technique is applied for the training of ANN according to the obtained
visual features. For avoiding overfitting, validation check is performed; it also monitors the performance of
updated parameters. Results are compiled at six validation checks and 19 epochs with a gradient equal to
0.055387 and values of bias and weights are saved, in which the minimum validation error has occurred.
Performance of the network is measured by the accurate classification of test samples.

3 Experimental setup
In the current method visual dictionary is created by extracting visual features of each image through SURF
and HOG using grid selection of [8 8], block width of [32 64 96 128] with the standard deviation of    = 1.2,
then the extracted visual features are grouped using K‐means clustering algorithm with k = 500. Each centre of
the cluster is considered as a codeword and the collection of these codewords form a dictionary. These visual
features are used for classification of retinal images into five classes through SVM and ANN. SVM with RBF
kernel using   is applied to discriminate the visual features. For validation of results, ten‐fold cross‐
validation checks are performed by preserving the same ratio of images on each fold. The proposed approach
is also tested using ANN and compared with the results achieved by SVM and ANN. The structure of ANN
includes one input layer with 500 nodes, two hidden layers with 50 active nodes and one output layer with five
nodes. The results of ANN are compiled on 6 validation checks and 19 epochs with a gradient equal to
0.055387. Confusion matrices are computed to show the statistical results.

To test the proposed approach, data set is taken from the Kaggle National Data Science Bowl, Kaggle is a
platform founded by Anthony John Goldbloom in April 2010 for analytical competitions of machine learning
and for predictive modelling.

The data set for detection of DR containing 35126 images was released by Kaggle [[36]] for a competition
announced in 2015. Retinal images were having a high resolution of around 6 megapixels in 24‐bit depth,
annotated with patient ID and left and right eye. In the current study, 390 images (78 of each class) from
35,126 were selected using a random sampling method. The selected set of 390 retinal images, include 78
normal and 312 pathological images. From the selected data set, 70% images were used for training, 15% for
testing, and 15% for validation. An example of a healthy retina and retinal images having four severity levels of
DR are shown in Fig. 3.

Fig. 3
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Example of pathological images arranged in increasing severity levels of DR

(a) No DR, (b) Mild NPDR, (c) Moderate NPDR, (d) Severe NPDR, and (e) PDR

The proposed SDDR system was implemented in MATLAB R2015b on a running operating system (Windows
10) Intel processor system with 8 GB RAM, Core i3 64‐bit. The feature extraction part took 6.32 s per image on
an average, and the training of extracted features that was performed by SVM took an average of 2.57 s.
However, when the test was performed the image needed an average of 6.44 s time for classification.

3.1 Experimental results

In this section, the detailed quantitative analysis of the proposed SDDR system is given. For performance
evaluation and comparison of proposed SDDR system with state of the art methods, sensitivity, specificity,
positive predictive value (PPV), and accuracy are computed. True positive (TP), true negative (TN), false positive
(FP), and false negative (FN) values are calculated for each severity level of DR. In the present study, TP means
that a person is affected by the disease and is diagnosed correctly, TN means that a person's actual and
estimated values are negative. FP means that the person does not have the disease but is diagnosed positive.
However, FN is followed when the person is diagnosed negative but actually has the disease, this description is
summarised in Table 1. Results achieved using visual features with SVM and ANN are computed in the form of
confusion matrices and shown in Figs. 4 and 5, respectively. These confusion matrices are used to calculate
the sensitivity, specificity, PPV, and accuracy indices. In the conventional analysis for a diagnostic test,
sensitivity and specificity are considered as primary indices of accuracy [[37]].

Table 1. Description of TP, FP, TN, and FN for classification of retinal images

Description Normal image in classification Image affected by DR in classification

normal image in actual TP FN

image affected by DR in actual FP TN

 Description Normal image in classification Image affected by DR in classification

Fig. 4
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Classification of DR grading using SVM
Fig. 5
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Classification of DR grading using ANN

It is defined earlier that there are 390 retinal images containing 78 images of each class. Figure 4 shows the
output of SVM classifier which indicates that all the normal and PDR images are classified correctly, 75 images
of each mild and severe NPDR classes are classified correctly, and 68 images of moderate NPDR class are
classified correctly. The results computed from the confusion matrix mentioned in Fig. 4 are shown in Table 2.
These results show TP, TN, FP, and FN of sensitivity, specificity PPV, and accuracy of the proposed SDDR
system though SVM. The calculated indices are sensitivity = 95.92%, specificity = 98.90%, PPV = 95.74%, and
accuracy = 98.30%.

Table 2. Evaluation performance for DR grading using visual features + SVM

DR stage TP FN FP TN Sensitivity, % Specificity, % PPV, % Accuracy, %

normal 78 0 4 308 100 98.7 95.1 99

mild NPDR 75 3 0 312 96.2 100 100 99.2

moderate NPDR 68 10 3 309 87.2 99 95.8 96.7

sever NPDR 75 3 7 305 96.2 97.8 91.5 97.4

 DR stage TP FN FP TN Sensitivity, % Specificity, % PPV, % Accuracy, %

PDR 78 0 3 309 100 99 96.3 99.2

overall result 95.92 98.90 95.74 98.30

The output of ANN is shown in Fig. 5; it shows that 62 images are correctly classified in the normal case, 76
images in the mild NPDR class, 62, 69, and 58 images in the moderate NPDR, severe NPDR, and PDR cases,
respectively. TP, TN, FP, and FN are given in Table 3 and are used to calculate sensitivity, specificity, PPV, and
accuracy of the proposed SDDR system through ANN: sensitivity=83.83%, specificity=95.97%, PPV=83.82% and
accuracy=92.92%.

Table 3. Evaluation performance for DR grading using visual features + ANN

DR stage TP FN FP TN Sensitivity, % Specificity, % PPV, % Accuracy, %

normal 62 12 19 297 83.78 93.99 76.54 92.05

mild NPDR 76 14 7 293 84.44 97.67 91.57 94.62

moderate NPDR 62 11 12 305 84.96 96.21 83.78 91.03

sever NPDR 69 14 14 293 83.13 95.44 83.13 92.82

PDR 58 12 11 309 82.86 96.56 84.06 94.10

overall result 83.83 95.97 83.82 92.92

It can be noticed from Table 4 that the proposed SDDR system achieved better results (shown in bold) while
using visual features + SVM. By using visual features + SVM, the proposed system gives the best results in PDR
case (sensitivity = 100%, specificity = 99%) and then in normal cases (sensitivity = 100%, specificity = 98.7%), in
mild NPDR cases (sensitivity = 96.2%, specificity = 100%), in severe NPDR cases (sensitivity = 96.2%, specificity = 
97.8%), and in moderate cases (sensitivity = 95.92% and specificity = 99%). On an average, the proposed SDDR
system achieved sensitivity of 95.92% and specificity of 98.90% using visual features + SVM.

Table 4. Performance comparison of SVM and ANN

 Proposed method Sensitivity, % Specificity, % PPV, % Accuracy, %

visual features  + ANN 83.83 95.97 83.82 92.92

visual features  + SVM 95.92 98.90 95.74 98.30

3.2 Comparative study

It is significant to note that all the existing automated systems have used different databases, but the purpose
of comparison is to show that the system proposed in the present study has performed well when the authors
compared the sensitivity and specificity with other studies. For the comprehensive comparative study, they
compared the results achieved by the current approach with the previous methods of pre‐ and post‐
processing methods, CNN classification method, and visual dictionary‐based approach. The authors compared
the sensitivity and specificity of each severity level of DR (normal/no DR, mild, moderate and severe NPDR, and
PDR) achieved by the proposed SDDR system with some state of the art methods. Table 5 shows the
comparison of the results of the proposed and the previous methods.

Table 5. Performance and time per image comparison of the proposed and previous state of the art methods
on the basis of DR severity levels

Methods Verma et Carson Lam et Pratt et Abbas et Proposed

al. [[14]] al. [[28]] al. [[23]] al. [[22]] method

Severity levels Sn, % Sp, % Sn, % Sp, % Sn, % Sp, % Sn, % Sp, % Sn, % Sp, %

normal/no DR 67.70 72.60 85 — 95 61.78 94.10 97.60 100 98.7

mild NPDR 71.30 75.43 29 — 0 100 92.23 96.99 96.2 100

moderate — — — — 22.95 94.92 88.45 93.25 87.2 99

NPDR

severe NPDR 78.50 83.34 75 — 7.81 99.82 88.43 92.16 96.2 97.8

PDR — — — — 44.33 98.22 89.30 92.21 100 99

total Result — — — 30 95 92.18 94.50 95.92 98.90

 Methods Verma et Carson Lam et Pratt et Abbas et Proposed
al. [[14]] al. [[28]] al. [[23]] al. [[22]] method

time taken per — — 0.04 s 07 s 6.44 s

image

 Sn, sensitivity; Sp, specificity.

It is observable that the comparison in Table 5 is made on the basis of achieved sensitivity and specificity of
individual severity level and the average time that an image needed to get classified. The techniques of pre‐
and post‐processing for the classification of retinal images into only three classes were proposed in [[14]],
retinal images were classified into five severity levels using CNN in [[23]], Carson Lam et al. [[28]] proposed
secondary, tertiary, and quaternary classification using deep CNN while the classification of retinal images into
five severity levels using visual features with deep learning NN was proposed in [[22]], therefore, the authors
compared the sensitivity and the specificity of each class individually. It can also be noticed from Table 5 that
our proposed method is taking less time to classify a retinal image as compared with [[22]]. The algorithm
proposed in [[23]] took lesser running time per image but the achieved sensitivity was very low.

It is necessary to discuss that in MESSIDOR database [[38]], some of the images were marked wrong such as
image Base 11/20051020_63045_0100_PP.tif was marked as an image with severe NPDR while according to the
latest updates, it is a normal image. Similarly, image Base 11/20051020_64007_0100_PP.tif belongs to severe
NPDR instead of mild NPDR, image Base 11/20051020_63936_0100_PP.tif relates to mild NPDR instead of
severe NPDR, and image Base 13/20060523_48477_0100_PP.tif belongs to the class severe NPDR instead of
moderate NPDR.

Similarly, image Base 20051202_55626_0400_PP.tif is now marked as moderate NPDR and

20051205_33025_0400_PP.tif is marked as severe NPDR. This update is available on MESSIDOR webpage and
can affect the results of the previously proposed methodologies that were tested on these images. This given
update can increase or decrease the efficiency of an automated system.

4 Discussion
People with uncontrolled diabetes fall under the condition of DR, therefore, its diagnosis at the earlier stage is
essential, as it impairs the retina if it remains to be undiagnosed. Hence, it requires an immediate need to
consult an ophthalmologist. Since eye examinations are expensive, therefore, a large number of people are
deprived of adequate treatment. Currently, the ophthalmologists use manual methods for screening of DR;
these methods are expensive and require medical experts who have extensive domain knowledge. In contrast,
automatic methods for diagnosis of DR use image processing and machine learning techniques to yield better
and consistent results. The technique of automatic diagnosis is exclusively used nowadays through more
established and refined CAD systems. Medical images are used in CAD systems to detect lesions of the retina
for the diagnosis. It can provide many advantages, for instance, it reduces time, manpower, and cost while
analysing a large set of images. Identification of five stages of DR is essential to detect the exact type of DR.
Therefore, the present work focused on the detection of five stages of DR.

The viability of an automated detection and recognition system can be demonstrated by its results, therefore,
to test the proposed SDDR system the authors used 390 retinal images. Sensitivity and specificity achieved by
the proposed SDDR system show that on an average, many retinal images are correctly classified. However,
the proposed SDDR system misclassified a few images. It can be noticed from Table 2 that the normal and
PDR classes achieved the highest sensitivity of 100% and moderate class achieved the lowest sensitivity of
87.2%. The reason is that the approach used in the current work makes a dictionary of PoI. As normal class
consisted of all healthy retinas having only normal features, the detected PoI of all healthy images were the
same and had almost the same frequency. PDR has all lesions in abundance including neovascularisation,
thus, the frequency of each PoI is high for all PDR images and it is made easy for the proposed automated
system to recognise a subject. In the case of moderate NPDR, the reason for achieving the lowest sensitivity is
that since the number of Ms in moderate NPDR should be >5 and <15 and the number of Hs ranges from 0 to
4, while in the case of severe NPDR the number of Ms should be >15 and H is greater than or equal to 5. Thus,
Ms can be misclassified as H if large in size and can misclassify the image from moderate to severe NPDR.
Owing to this reason, seven images of moderate NPDR were misclassified as severe NPDR, which decreased
the sensitivity of this class.

In the past decades, the researchers relied on the segmentation of some components of the retinal images
and focused more on the methods of pre‐ and post‐processing to detect the limited stages of DR. These
methods consider segmentation as a pre‐processing step and extraction, selection, and classification of
features as post‐processing steps. Furthermore, CNN is considered as one of the deep learning architectures
and was used for classification of medical images in the field of medical diagnosis, but it is hard to train its
model on image pixels, in practice. Therefore, in this study, the authors used visual features to detect five
severity levels of DR using Kaggle data set. It was also noticed that MESSIDOR is the only database for DR that
provides images for four stages of DR, images for PDR are not provided. Kaggle data set provided retinal
images for five severity levels of DR, which are used in a few studies including [[23], [28]]. It is shown in the
literature review that many researchers [[14]-[25]] have devoted their efforts for the detection of the stages of
DR. Detection of five stages of DR was proposed in [[23]] using Kaggle data set and CNN and in [[22]] through
visual features and deep NN using private data collected from a local hospital.

The authors proposed an improved severity detection system which identifies five severity levels of DR
through visual features and SVM and achieved better results (sensitivity = 95.92%, specificity = 98.90%) when
compared with the automated system for identification of five severity levels of DR proposed in [[22], [23]].
The advantage of the proposed SDDR system with regard to the evaluation of severity levels of DR by medical
experts is its high sensitivity and specificity. It can eradicate the need of medical experts in the examination of
diabetic retinal images and a CAD system can be designed to recognise the DR cases according to its severity.
Dictionary‐based approach is easy to apply due to its simplicity, and adaptive nature of BOF approach is one
of its important advantages. Another advantage is robustness to obstruct, affine transfiguration and its
efficiency of computation. All these characteristics are useful in the analysis of medical images. However, a
huge set of features is a disadvantage of this algorithm since an increase in the number of features can
proceed to be overfitting.

Misclassification of few images is the limitation of the proposed approach which the authors intend to
overcome in the future. They have planned to use different colour schemes and to select the one which
signifies the better representation of lesions in the images. They did not consider the DR with maculopathy in
this study, therefore, the method can be applied for the classification of DR with and without maculopathy, i.e.
the severity levels of DR as normal and mild NPDR with and without maculopathy, moderate NPDR with and
without maculopathy, severe NPDR with and without maculopathy, and PDR with and without maculopathy.
The method of the visual dictionary may help in the diagnosis of other diseases such as for detection of
malignant melanoma, to classify colorectal tumours and for detection of polyps.

5 Conclusions
In the present work SDDR system is proposed for classification of five severity levels of DR using visual
features and a radial basis kernel SVM. This study focuses on the identification of severity levels of DR without
applying pre‐ and post‐processing on the images. It can be noticed from the literature that many studies were
devoted to the identification of limited severity levels. They emphasised more on the detection of DR lesions
and the resultant severity level. This method of identification is still used by medical experts. In addition, the
correct detection of DR lesions is difficult due to the miscellany of lesion appearance. In contrast, few
researchers proposed automated methods for identification of five severity levels of DR, among those few
used pre‐ and post‐processing methods, while others worked on visual features approach. In contrast with
these state of the art methods, the present study used visual features with a simple classifier. Hence, this
study did not focus on the characterisation of lesions such as Ms, exudates, or blood vessels on the images,
which ultimately reduced computational time and error propagation.

The present research mainly emphasised on accuracy and adaptability of the use of visual features (SURF and
HOG) and radial basis kernel SVM. The evaluation of the proposed SDDR system was calculated using
sensitivity, specificity, and accuracy and tested it on 390 images (78 per class). The obtained sensitivity is
95.92%, specificity is 98.90%, and accuracy is 98.30%. The specificity of 98.90% is considered as good in
automated detection, specially, it is used for triaging. Table 5 provides the evidence that the proposed SDDR
system has achieved better specificity than the previously proposed methods.

Finally, the proposed SDDR system is greatly significant for the automated diagnosis of DR and its five‐stage
detection. As detection of all stages of DR is a vital requirement in the highly growing rate of the disease, the
sensitivity of 95.92% and specificity of 98.90% achieved by the proposed SDDR system can be used to
integrate a CAD system with this one.
6 Acknowledgments
This work is being conducted and supervised under the ‘Intelligent Systems and Robotics’
research group at Computer Science Department, Bahria University, Karachi, Pakistan.