Intelligence-Based Medicine 5 (2021) 100038

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Intelligence-Based Medicine
journal homepage: www.sciencedirect.com/journal/intelligence-based-medicine

Glaucoma detection in retinal fundus images using U-Net and supervised

machine learning algorithms☆
Rutuja Shinde
Department of Computer Engineering, Pune Institute of Computer Technology, Savitribai Phule Pune University, Pune, India

A R T I C L E I N F O A B S T R A C T

Keywords: Background and objective: Glaucoma is a neuro-degenerative eye disease developed due to an increase in the Intra-
Cup to disc ratio ocular Pressure inside the retina. Being the second largest cause of blindness worldwide, it can lead the person
Inferior superior nasal temporal towards complete blindness if an early diagnosis does not take place. With respect to this underlying issue, there
Blood vessel extraction
is an immense need of developing a system that can effectively work in the absence of excessive equipments,
Support vector machine
Neural network
skilled medical practitioners and also is less time consuming.
Adaboost Methods: This work proposes an offline Computer-Aided Diagnosis (CAD) system for glaucoma diagnosis using
retinal fundus images. This application is developed using image processing, deep learning and machine learning
approaches. Le-Net architecture is used for input image validation and Region of Interest (ROI) detection is done
using brightest spot algorithm. Further, the optic disc and optic cup segmentation is performed with the help of
U-Net architecture and classification is done using SVM, Neural Network and Adaboost classifiers.
Results: The accuracy of 99% is achieved using Le-Net for input image validation. Considering the application of
brightest spot algorithm, an accuracy of 98.67% is achieved for ROI extraction. Further, a dice-coefficient of 0.93
and 0.87 was attained for the segmentation of optic disc and optic cup respectively using U-Net architecture.
Using SVM, Neural Network and Adaboost classifiers, the proposed methodology managed to achieve a classi­
fication accuracy, recall, specificity and sensitivity of 100%, thus proving the system to be reliable and
promising.
Conclusions: In conclusion, the proposed desktop application is easy to use and can play a major role in early
glaucoma detection. The modular design of the CAD system is made up of a set of standalone components that
can be used for a variety of different tasks for detecting and classifying glaucoma. Due to the model being trained
on a variety of different datasets, the system proves to be robust and more accurate.

1. Introduction
Glaucoma is an eye disease that vandalizes the optic nerve and
Retinal Nerve Fiber Layer (RNFL), ultimately leading to blindness if left
untreated. In this condition, the fluid builds in the anterior part of the
retina thereby increasing pressure in the eye and causing the destruction
of the optic nerve. Estimation claims that the total number of cases
worldwide will rise to 79.6 million by 2020 and 111.8 million by 2040.
It has also been estimated that Asians would comprise of 47% of those
with glaucoma and 87% of those with Angle Closure Glaucoma (ACG)
[28]. People having age greater than 60 tend to be at a higher risk [34].
Furthermore, it is the second leading cause of blindness in the world. In
order to prevent irreversible vision loss and structural damage incurred,
an early detection of the same is very crucial [28].
The word “fundus” derived from Latin language, refers to the part of
the eyeball that lies opposite to the pupil. Thus, a photograph of the
interior surface of the eye is regarded as the fundus image [12]. Apart
from funduscopic images, there are also other imaging techniques
namely Scanning Laser Polarimetry, Heidelberg Retina Tomography
(HRT) and Optical Coherence Tomography (OCT) [2], but the cost of
these equipments comes across as a barrier in the context of affordability
for many of the hospitals worldwide. There fore we work on glaucoma
detection using fundus images which are an affordable alternative for
health practitioners.
Increased Intra-Ocular Pressure (IOP) gives rise to the occurrence of
structural changes in the anatomy of the eye. In a retinal fundus image,
an Optic Disc (OD) is the region where blood vessels and the nerve fibers
enter the retina. An Optic Cup (OC) is the central bright portion of the

☆
This research project has been sponsored by the National Institute of Ophthalmology (NIO), Pune.
E-mail address: rutujadshinde1994@gmail.com.

https://doi.org/10.1016/j.ibmed.2021.100038
Received 3 October 2020; Received in revised form 7 May 2021; Accepted 1 July 2021
Available online 14 July 2021
2666-5212/© 2021 The Author. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
R. Shinde
retina and lies within the optic disc. Fig. 1 describes these terminologies
diagrammatically. In case of glaucoma, the structural changes incurred
cause the optic cup to get enlarged which is termed as the phenomenon
of “cupping”. Thus, the Cup-to-Disc Ratio (CDR) proves to be a mean­
ingful indicator for glaucoma detection. Another considerable indicator
is termed as the Inferior Superior Nasal Temporal (ISNT) rule. Blood
vessel extraction also has its importance in glaucoma detection as blood
vessels state the health condition of an organ and hence the eyesight.
From the literature surveyed in section 2, it is found that most of the
researchers have worked with relatively small number of images, fundus
images from private datasets and with datasets that lack real time var­
iations in image quality. This hampers the robustness of the system.
There is a need to develop a model which works for images acquired
under different environmental conditions [16]. Also, there is scope in
enhancing the classification accuracy as much as possible.
The main contribution of this research work lies in diagnosis of
glaucoma with the help of interpretation of retinal fundus images. This
motive is accomplished by the development of a Computerised detection
(CAD) system in the form of a desktop application for the assistance of
health practitioners. The proposed method accomplishes automatic
screening of glaucoma diagnosis and classifies an input image as glau­
comatous or healthy. Deep learning approaches such as LeNet, U-Net
and Neural Network (NN) have been used in the process of glaucoma
detection which is completely offline. As a result, clinicians in rural
areas can also be able to efficiently use this application for their diag­
nosis. As glaucoma diagnosis is a time consuming procedure and re­
quires skilled professionals, no special skills are required to work with
developed application. The proposed algorithm uses three features
namely CDR, ISNT ratio of Neuro-retinal Rim (NRR) and blood vessels as
the decision criteria for glaucoma detection. A majority voting system
developed using SVM and NN classifiers and adaboosting technique has
been used in an attempt to classify the input to be either normal or
glaucomatous. Also, our work contributes in the advancement in the
field of glaucoma detection in following manner:
• Developing a robust system by training the model with different
kinds of datasets containing varied characteristics of fundus images
and increasing the number of training and testing images.
• Increasing number of classifiers in order to enhance generalization
power of the system.
• Ensuring that features used for classification are significant in the
context of the results achieved.
2. Related work
2.1. ROI extraction
Agarwal et al. [3] extracted ROI by calculating spatially the optic cup
centre and locating a square region with a radius ‘r’ around it. Initially,
the coordinates of optic disc are approximated further obtaining the
actual coordinates for the same. While [27] used four categories of
Fig. 1. Fundus images showing landmarks namely Optic Disc, Optic Cup, blood
vessels and Neuro-retinal Rim [20].
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Intelligence-Based Medicine 5 (2021) 100038
image processing methods namely, pixel brightness transformations,
geometric transformations, confined region of the processed image. and
return back to its normal stage in order to locate the ROI. A
non-automated method by manual cropping of ROI is used [10]. Nar­
asimhan and Vijayarekha [22] used an approximate area around the
brightest point obtained from G-plane of RGB fundus image. Further [7]
applied intensity weighted centroid method to calculate OD centre.
Unlike finding the brightest spot, ROI was detected by screening in­
tensity values of OD in RGB colour plane [4].
2.2. OD and OC segmentation
Soltani et al. [35] in their work, attempted to segment optic disc with
the help of Laplace, Sobel and Canny contour detection methods. Canny
detector provided good results in disc detection and localization. On the
other hand Laplacian operator provides lowest accuracy and is more
susceptible towards the noise in the image. In the work of Aquino et al.
[6], OD localization was done by selecting the best result from the three
methods, maximum difference method, maximum variance method and
low pass filter method. Further, circular hough transform was applied
for OD boundary segmentation. Finally, Elliptical template-based
approach and Circular template-based approach were used for OD seg­
mentation where the later approach proved to yield better results
comparatively. Deformable models face local energy minima and curve
initialization problems. In order to overcome this drawback, curvature
and texture constrained composite weighted (CTCRW) algorithm was
proposed. This algorithm uses Gabor texture energy and mean curvature
features in order to calculate the edge weights [25]. Pal and Chatterjee
[24] performed morphological operations and histogram equalization
on an RGB image for OD edge enhancement. OD boundary was detected
using canny edge detector and segmented using flood fill algorithm.
Hatanaka et al. [15] attempted to extract the optic disc on the basis
of shape and colour of the fundus image. P-tile thresholding method was
applied on all the three channels of an RGB image. An approximate optic
disc was obtained by the combination of the three images and canny
edge detector was applied. The optic cup was obtained by profile anal­
ysis using blue component. Finally, the vertical CDR was used for
glaucoma diagnosis. Whereas in Ref. [17], the localization of optic cup
was done using contour method based on morphological operations and
that of the optic cup was done by ROI based segmentation using
component labelling algorithm. The optic disc and cup segmentation
was done using red and green channels respectively from a RGB fundus
image. Das et al. [10] used watershed transform for OD and OC seg­
mentation. The red channel of an RGB color space whereas ‘a’ plane
from the Lab color space respectively were used for segmentation pur­
pose. In the work of [22], OD and OC segmentation was performed using
K-means clustering algorithm. Ahmad et al. [4] in their work, consid­
ered V-plane from the HSV color space whereas green channel from RGB
color space for OD and OC segmentation respectively. Kim et al. [18]
used U-Net in combination with Fully Convolutional Networks (FCN) for
OD and OC segmentation. Both binary and multiclass FCNs were used
for segmentation.
2.3. Feature extraction
Glaucoma diagnosis was performed using ISNT rule [29]. Followed
by performing morphological operations, CDR was calculated [37]. In
order to increase the accuracy, a mask generation approach using the OD
centroid for extracting the Neuroretinal Rim width was put forward [9].
Local entropy thresholding was used for blood vessels extraction. Based
on the obtained CDR and ISNT values [22]. RNFLD features have been
used for glaucoma progression monitoring [26]. Deep CNN was used to
extract distinguishable features from glaucomatous and healthy images.
Al Ghamdi et al. [5], proposed a novel self-learning technique by
labelling unlabelled data using CNN architecture and training the same.
The CNN architecture was fine-tuned and trained in supervised fashion
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

over the labelled dataset. As stated earlier, the condition of blood vessels
plays a key role in describing the health status of an eye. Considering
this, Balasubramanian et al. [8] in their work performed extraction of
blood vessels using Gabor filter, morphological operations and
threshold-ing. Histogram of Oriented Gradients was used for feature
extraction. Gabor filters provide good results in image texture analysis.
2.4. Classification
Classification was done using k-Nearest Neighbour (k-NN), Support
Vector Machine and Bayes classifier [22]. Classification was done based
on the obtained CDR and ISNT values. Vijapur and Kunte [36] propose
Pearson –R coefficients as the feature for the segmentation of OD and
OC. This feature describes the variations in mean intensity of an image.
Recurrent Neural Network (RNN) was used for classification [26].
VGG-16 model was used for glaucoma classification. Authors in Li et al.
[19] explored seven ConvNets namely AlexNet, VGG-16, VGG-19,
GoogLeNet, ResNet-50 and ResNet-152. AlexNet yields best results when
SVM classifier was used for classification.
3. Data
A collection of 6 datasets has been used. RIM-ONE, DRISHTI-GS,
DRIONS-DB, JSIEC and DRIVE are publicly available datasets. NIO is a
private dataset obtained from NIO hospital, Pune. Table 1 comprises of
the datasets used for proposed methodology and the number of images
in each of the datasets. The model training is not performed on indi­
vidual datasets instead has been trained by collectively training all the
images in 6 datasets together. All the images are resized to a fixed
dimension of 512 × 512.
3.1. Segmentation
As a result, a dataset comprising of 2264 images is used for as a part
of training and validation set in OD segmentation while that of 1768
images is used for OC segmentation for the same. These images are
annotated in such a way that the pixel intensity value of regions of OD
and OC is equal to 1 while the remaining area is set to a pixel intensity
value of 0. The boundaries of optic cup and disc were marked under the
surveillance of experienced health professionals.
3.2. Feature extraction and classification
Feature extraction and classification steps require both segmented
OD and OC for a particular input image. Hence the aforementioned 520
fundus images used to train the model for OC segmentation have been
used for feature extraction and classification purposes.
4. Proposed methodology
The proposed CAD pipeline comprises of four steps described in
sections 4.1, 4.2, 4.3 and 4.4 respectively. The input images are pro­
cessed further only if the image is fundus image. After the validation
step, the Region of Interest (ROI) is extracted from input image. Next,
the optic disc and cup segmentation is performed using the U-Net ar­
chitecture. Followed by segmentation, feature extraction is performed.
Finally, classification is done based on these features and the input
image is predicted to be either glaucomatous or healthy. Instead of
training a Neural Network with the dataset, the aforementioned meth­
odology was chosen for the following two reasons. Firstly, the typical
machine learning steps resulted into commendably high accuracy. The
features selected for classification were considered after studying the
structural changes occurring in the eyesight which were reflected in the
fundus images. The generalized CAD pipeline has been shown in Fig. 2.

A total of 666 labelled fundus images have been used for the purpose
of segmentation. In order to train the CNN model for optic cup seg­
mentation, 146 images from the preconsidered 666 images were found
to have ill-defined optic cup boundaries and hence were discarded. The
dataset is split in the ratio (70%–15% - 15%) as (training set-validation
set and test set) respectively. The revised test set comprises of 100 im­
ages (15%) of the original 666 images for OD segmentation. The dis­
tribution comprises of 16 images from each of the RIM-ONE, DRISHTI-
GS, DRIONS-DB and JSIEC datasets while 18 images from DRIVE and
NIO datasets respectively. In case of OC segmentation using U-Net and
classification using SVM, adaboost and NN, the revised test set consti­
tuted 78 (15%) of the original 520 images. The distribution comprises of
13 images from each of the datasets respectively. In an attempt to obtain
a well trained model, the number of images are needed to be increased.
Thus image augmentation is performed to increase the dataset size by
rotating all the images with degrees, specifically, 45◦ , 90◦ and 170◦ . The
images were rotated by 170◦ and not 180◦ as not much difference be­
tween the OD and OC of original images and their corresponding 180◦
rotated counterparts was seen because both types of images were sym­
metrical to each other. Three augmented copies per image were made
for the training and validation sets. Also, images and their augmented
counterparts were not split between training and validation sets.

Table 1
Datasets used for training and testing.
Dataset Number of images

RIM-ONE 169
DRISHTI-GS 101
DRIONS-DB 110
NIO 118
JSIEC 124
DRIVE 44
Total 666
Fig. 2. Generalized CAD pipeline.

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R. Shinde
4.1. Input image validation
Before proceeding towards glaucoma detection, this step is incurred
in order to ensure that no other input except a fundus image is being
processed. The purpose of input image validation is to check whether the
provided input image is nothing else other than a fundus image. Being
the first and foremost step as described in Fig. 2, the binary classification
is performed using LeNet CNN architecture. LeNet is chosen for this
purpose due to following reasons: (a) It can be trained in very less time
(b) It does not need any GPUs for training (c) It has a compact archi­
tecture that suffices the needs of image classification.
For developing the fundus image classifier, the dataset used as a part
of non-fundus images consists of 10,672 images while that of fundus
images constitutes 1845 images. The UKBench dataset [1] is used as a
part of non-fundus images dataset and consists of random images. In
order to increase the dataset, apart from pre-existing 666 fundus
im-ages, an addition of 1179 images of good quality are added from
Kaggle dataset thus making a total of 1845 images. The reason that the
added 1179 images are not used in further stages is that these images are
unlabelled. Hence the ground truth i. e whether they are glaucoma or
normal images is unknown. However, the added images aid in sub­
stantial assistance to the dataset required for this purpose because, in
order to develop a fundus image classifier, being acquainted with the
fact that the dataset used for training LeNet model is categorized into
fundus/non-fundus images, solely suffices the need of the algorithm.
The internal classification (glaucoma or normal) of fundus images
therein is unneeded and out of the scope for constructing a fundus image
classifier. Images of dimension 256 × 256 are used for the purpose of
training LeNet model.
As shown in Fig. 3, the LeNet architecture consists of two sets of
convolutional, activation, and pooling layers, followed by a fully-
connected layer, activation, another fully-connected, and finally a
softmax classifier. The model was trained in 25 epochs with a learning
rate of 0.0001, decay rate of 4e-6 and a batch size of 32. Using ReLU as
the activation function, binary cross entropy as a loss function along
with Adam optimizer, 99% accuracy is achieved using LeNet. The soft­
max classifier returns a list of probabilities of the input image belonging
to that class. The class label having the largest probability is chosen as
the final prediction for the input image.
4.2. ROI extraction
The Region of Interest (ROI) is a portion of an image that is
considered to perform operations upon, as a part of a particular objec­
tive. Along with increased accuracy, ROI extraction, described in Fig. 2,
is needed to reduce the computation cost as well the computation time.
It can be achieved manually or automatically. In case of fundus images,
the portion including and around the disc is considered to be the ROI of a
fundus image. As a characteristic of retinal fundus image, generally the
pixel with highest intensity value lies in the optic cup. With the help of
this fact, we propose a more robust, automatic method for ROI extrac­
tion known as the brightest spot algorithm.
In traditional method, initially, the input image is converted into
grayscale image. Then coordinates of pixel having highest intensity
Fig. 3. LeNet architecture.
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Intelligence-Based Medicine 5 (2021) 100038
value is considered to be the brightest spot for further processing. A ROI
is cropped along a defined radius around the considered brightest spot.
This method is easy but has certain drawbacks: (a) The method is prone
to noise, for example unneeded higher intensity values in the back­
ground. (b) Fundus images suffer from poor illumination during image
acquisition process. As a result, an unwanted variation in brightness is
retained in fundus images.
In order to overcome the above challenges, fundus image denoising
plays a key role in adding robustness to the algorithm. The core concept
is that noise occurs at higher spatial frequencies whereas features to be
extracted are contained in lower frequencies. In order to remove high
frequency noise from the grayscale image, we apply gaussian blur. As a
result the pixels with very high intensity values are averaged out due to
intensity impact of their neighbouring pixels. Gaussian smoothing
denoises an image by averaging out higher intensity values using a
kernel size. The gaussian kernel size of (65, 65) is used and sigma value
is set to 0. Higher kernel size helps in better denoising and hence the
mentioned kernel size is set by trial and error method. Using this kernel
size, we were able to achieve very high accuracy in ROI detection on the
datasets used. After this pre-processing step, coordinates of the pixel
with highest intensity value is found from the gaussian blurred image
and a circle around the pixel is drawn with a radius equivalent to
gaussian kernel size mentioned above. Consequently, the x and y co­
ordinates needed for the purpose of cropping the image in a rectangular
format are achieved by subtracting radius value from x and y co­
ordinates of the pixel having highest intensity value that is obtained
from the gaussian blurred image.
The dimension of an ROI extracted image is 512 × 512. This image is
further used as an input in segmentation, feature extraction and classi­
fication steps. The data were split into training, validation and testing
with ratios of 70%, 15%, 15% respectively. Trial and error process for
finding the correct Gaussian window size is performed on training and
validation images. Accuracy is tested on testing images which were not
used in the above step. Fig. 4 illustrates the procedure of ROI extraction
along with comparative results achieved using traditional and robust
methods. Fig. 4(G) shows a gaussian blurred image obtained using
grayscale image shown in Fig. 4(B). A heatmap shows pixel values with
similar intensity by assigning a unique colour to the group. The heatmap
obtained using traditional method represented by Fig. 4(C) shows
highest intensity values in orange colour. The heatmap in Fig. 4(H)
shows that noise in Fig. 4(C) is overcome after filtering the image and
hence correct brightest spot is located. Comparing numerically, the
highest pixel intensity value before applying gaussian blur is 199
(incorrect) while post gaussian blur application is 169 (correct). With
the help of this algorithm, 98.67% accuracy was obtained for the pur­
pose of ROI detection and extraction.
4.3. Optic disc and optic cup segmentation
We use the revolutionary U-Net architecture which is a fully con­
volutional neural network used for biomedical image segmentation,
illustrated in Fig. 2. The core reasons behind adopting this model for OD
and OC segmentation are described as follows:
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

• It requires much fewer images for training.

• Achieves results that are competitive with the existing state-of-the-
art methodologies.
• It overcomes all the challenges that occur during OD and OC seg­
mentation, as described in section 5.

The architecture, shown in Fig. 5 consists of a contracting path and

an expansive path. The contracting path is responsible for feature
extraction while the expansive path combines spatial information with
high resolution features to obtain the required segmentation map. The
contracting path is a neural network that comprises of a series of con­
volutional layers followed by Rectified Linear Unit (ReLU) and max
pooling layers. Initially, the input image is passed through convolutional
layer that constitutes a filter with spatial resolution of 3 × 3 pixels.
Further, ReLU activation, described in the function below, is applied.
The function is denoted by positive part of its argument:
ReLU(x) = max(0, x) (1)

where x is the input to a neuron.

Then, the 2 × 2 max pooling layer reduces dimensions of the input
layer by selecting the maximum value from each cluster of neurons and
converting it into a single neuron in the next layer. As a part of model
optimization, the proper tuning of parameters and weight initialization
is necessary. Using batch normalization, the inputs to the layers within
the network are normalized with the help of statistical features namely
mean and covariance of the current mini-batch. In order to address the
problem of overfitting, a dropout layer as a part of regularization is
applied where the values of nodes having probability greater than p are
survived. The dropout regularization of 0.5 has been applied. Stochastic
Gradient Descent (SGD) is used as the optimization method. In SGD one
sample per iteration is randomly shuffled and chosen and gradient of the
cost function is computed. This method is computationally less expen­
sive as compared to gradient descent algorithm. (x1, y1), …, (xn, yn) is the
given set of training examples where xi ∈ Rm and yi ∈ k (yi ∈ − 1, 1 for
classification) the aim is to learn a linear scoring function f (x) = wT x +
b with model parameters w ∈ Rm and intercept b , Rm.
The sign of function f(x) is used as a decision criteria for binary
classification. The regularized training error is given by,

1∑ n
E(w, b) = L(yi , f (xi )) + αR(w) (2)
n i=1

where,

L = loss function that measures model (mis)fit.

R = regularization term (aka penalty) that penalizes model
complexity.
α = non-negative hyperparameter that controls the regularization
strength.

The update rule for SGD is given below,

[ ]
∂R(w) ∂L(wT xi + b, yi )
w←w − η α + (3)
∂w ∂w

where,

η = learning rate which controls the step-size in the parameter space.

b = The intercept is updated similarly but without regularization.

Finally, Sigmoid function (Si) described below is used to limit the

output values of the segmentation map between (0, 1).

Fig. 4. ROI extraction using Brightest Spot algorithm. Figures B, C, D, E and F 1

Si (x) = (4)
are the results obtained by traditional method. Figures G, H, I, J and K are the 1 + e− x

results obtained by the application of proposed method.

Dice coefficient is used as the metric based on which model training

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R. Shinde
Fig. 5. U-Net architecture.
is done. It is the quantification of spatial overlap between actual results
and the results reproduced using CNN for segmentation of OD and OC.
The similarity coefficient, where 0 indicates no spatial overlap while 1
indicates a complete spatial overlap, has been adopted in order to
validate segmentation results obtained using U-Net. As the generated
output would be a binary segmentation map, dice coefficient loss. DL is
used as the loss function for optic disc and cup segmentation. Dice co­
efficient. DC is described as follows,
2|a ∩ b|
DC = (5)
|a| ∪ |b|
DL = 1 − DC (6)
where,
a = binary vector of the intensity values of the ground truth image.
b = binary vector of the intensity values of the predicted image.
∩ = represents an intersection between two input binary vectors |a|
and |b|.
∪ = represents union between two input binary vectors |a| and |b|.
Using the dataset described in section 3.1, the dimensions of images
used for training are set to 256 × 256 after completion of the process of
ROI extraction. The learning rate applied is 0.0004 and momentum is set
to 0.95. A batch size of 2 is used, in order to decrease the amount of GPU
memory needed. The U-Net model for segmentation is efficiently trained
in 150 epochs. Further, 80% of images are used for training while the
remaining 20% are used for testing the efficiency of the trained U-Net
model. The proposed algorithm is implemented using Python 3.7 and
trained on NVIDIA GPU Tesla 4 and CUDA version 10.1. Keras frame­
work with tensorflow backend is used for training both the neural net­
works used namely LeNet and U-Net. Fig. 6 illustrates the predicted
segmented optic disc and cup images in comparison with their respec­
tive ground truth images.
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Intelligence-Based Medicine 5 (2021) 100038
4.4. Feature extraction
The conversion of images into a category of features is termed as
feature extraction. Two amongst the three features used in this work are
extracted from optic disc and optic cup whereas the third feature is
based on blood vessels extraction. The areas of OD and OC regions that
are extracted from the segmented optic disc and cup are used for
calculating CDR value. Along with CDR, ISNT ratio for both NRR and
blood vessels is calculated as a decision criteria for glaucoma detection,
outlined in Fig. 2.
4.4.1. Cup-to-disc ratio assessment
The optic cup to disc ratio is the most widely used feature for glau­
coma detection. The reason behind it is that whenever an individual is
affected with glaucoma due to some substantial amount of strain pro­
duced in the retina, the phenomenon of cupping occurs. We calculate
CDR using the area of OC and OD. The binary images obtained from
optic cup and disc segmentation are used for area calculation. The
following formula is incorporated for CDR evaluation.
[ cup area ]
CDR = 2 × (7)
disc area
CDR value ≥ 0.5 is considered to be glaucomatous and lesser than
that is considered to be healthy [4].
4.4.2. Extraction of ISNT quadrants and ratio evaluation
In some cases, due to large area of cup and disc, CDR value of the
person being tested can be high, even though the person is healthy. In
order to overcome this drawback, another decision criteria that evalu­
ates Neuroretinal Rim in ISNT quadrants is applied. Neuroretinal Rim is
the area of an optic disc that remains after exclusion of optic cup from
the area of the optic disc. In the case of glaucoma, as a consequence of
cupping, the NRR width in ISNT quadrants becomes disproportionate.
For a healthy eye the rim area is in the order where I > S > N > T. NRR
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

Fig. 6. Optic cup and optic disc segmentation using U-Net architecture. Curves in blue and red indicate contours of ground truth and predicted boundaries
respectively. (A) Input fundus image, (B) Indicates predicted and ground truth boundaries of optic cup,(C) Indicates predicted and ground truth boundaries of optic
disc. Jaccard Coefficient is denoted by JC.

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R. Shinde Intelligence-Based Medicine 5 (2021) 100038

area is calculated in ISNT quadrants. Fig. 7 shows the four regions in

which NRR is divided and also the violation of ISNT rule for a glau­
comatous image has been shown.
With the help of the obtained optic disc and optic cup from the
segmentation step, XOR operation is performed on both the images in
order to obtain the NRR [29]. The result is shown in Fig. 8. Next step is
the extraction of NRR in ISNT quadrants. For this purpose, a binary mask
is generated taking into consideration the quadrant wise degrees
described in Fig. 7 (A). Each generated mask shown in Fig. 9 is of the
dimension of 512 × 512 which is equivalent to the size of the input
image. The generated mask is rotated 90◦ to extract rim width in all the
four quadrants.
Rim width in the respective quadrants is obtained by performing
AND operation between the NRR image and the corresponding mask [4].
The results attained after performing these operations are shown in
Fig. 10. Further, the rim area belonging to every quadrant is calculated
by counting the number of white pixels in the image. Finally, the ratio of
NRR is calculated by using following formula,
[ ∑ ]
1 + (RI , RS )
RimArea ratio = ∑ (8)
1 + (RN , RT )

where,

RI = Rim area in inferior quadrant

RS = Rim area in superior quadrant
RN = Rim area in nasal quadrant Fig. 8. Extracted NRR using XOR operation.
RT = Rim area in temporal quadrant

The rim width ratio is lesser in healthy cases whereas high in case the
patient has glaucoma.

4.4.3. Extraction of blood vessels in ISNT quadrants and ratio evaluation

The consequences of the structural changes occurring in the fundus

Fig. 9. Generated masks in four ISNT quadrants (A) Inferior region; (B) Su­
perior region; (C) Nasal region; (D) Temporal region.

of an eye are used as the decision making criteria for glaucoma detec­
tion. Similarly, it is found that in case of abnormality, the blood vessels
tend to shift more towards the nasal side. Using this concept as a factor
for abnormality detection, blood vessels ratio is used as the third feature
for glaucoma diagnosis [23].
Fig. 7. (A) Four regions of NRR division. (B) Rim width in ISNT region in both Initially, the green channel of an input RGB fundus image is extracted
the cases [29].

8
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

as the visibility of blood vessels is more clear in green channel compared

to the red and blue channels. Then green channel of the input image is
converted into grayscale and Contrast Limited Adaptive Histogram
Equalization (CLAHE) is applied. CLAHE is used in an attempt to
enhance the edges and improve local contrast such that the intensity
values in the region of blood vessels is lesser as compared to remaining
part of the grayscale image. Application of CLAHE also helps in
denoising due to histogram clipping and redistribution of intensity
values across the entire image. The blood vessels in grayscale image
were optimally visible from the background when grid size of (6, 6) was
applied and the clipping limit equal to 4 was set. Further we use bot­
tomhat transform in order to enhance darker blood vessels in a bright
fundus image. The reason behind selection of bottom-hat filter is that it
enhances high intensity pixel values (blood vessels) as compared to the
low intensity pixel values in the following manner. First the morpho­
logical closing operation is performed. Next, the closed image is sub­
tracted from input image. This results into the ultimate extraction of
blood vessels. The equation of bottomhat transform has been described
as follows.
Tb (f ) = [(f * b) − f ] (9)

where,

Tb(f) = Bottom-hat transform of input image

f = input image
‘*’ = closing operation
b = structuring element
Fig. 10. Rim width in the four ISNT quadrants.

Fig. 11. Threshold selection for blood vessel segmentation.

9
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

Structuring element (SE) of size (15, 15) is used for closing operation.
In order to obtain an appropriate threshold for mapping the blood ves­
sels into a binary image, a histogram analysis of the grayscale converted
green channel of the input image and bottom-hat filtered image is per­
formed. In the example shown in Fig. 11, we can observe that the pixels
with least intensity values of the histogram plot in Fig. 11 (B), indicate
blood vessels. To the contrary, in the bottom-hat filtered image, the
brightest pixels shown in Fig. 11 (D) comprise of the blood vessels. It was
noticed that the lowest intensity value in a green channel image was
approximately the highest intensity value for its corresponding bottom-
hat filtered image. From the aforementioned facts, it is able to conclude
that the threshold value should approximately lie within this range. The
threshold value (T) is chosen using following formula:
T = 3.15 × (σ) (10)
√̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅̅
∑N 2
i=1 (yi − y)
σ= (11)
N

where,

σ = standard deviation
N = number of pixels intensity values
y = mean of all the pixel intensity values
y = pixels intensity values

Lastly, a binary image containing only the blood vessels is obtained

by using thresholding operation shown in Fig. 12 (D). Further, the
extracted blood vessels image is divided into ISNT quadrants in a similar
manner as described in section 4.3.
The blood vessels ratio is calculated using following formula,
[ ∑ ]
1 + (BI , BS )
Blood VesselsArea ratio = ∑ (12)
1 + (BN , BT )

where,

BI = Area covered by blood vessels in inferior quadrant

BS = Area covered by blood vessels in superior quadrant
BN = Area covered by blood vessels in nasal quadrant
BT = Area covered by blood vessels in temporal quadrant

The result of blood vessels in ISNT quadrants is shown in Fig. 12.

4.5. Classification

In order to develop a robust application, the classification system has

been generalized by gaining predictions from three supervised algo­
rithms. The features used are CDR, ISNT NRR ratio and ISNT blood
vessel ratio, described in section 4.4. Final decision is made using hard
majority voting. A total of 520 images are used for classification out of
which 380 images are glaucomatous while 140 are healthy cases. In
order to train the SVM and adaboost and NN classifiers, 70% of images
were used for training and 15% each for validation and testing
respectively.
Fig. 12. Blood Vessels extraction and their distribution in ISNT quadrants.
sample. Very small values of gamma create a risk of overfitting the
model and become insensitive towards regularization parameter. The
regularization parameter C tries to maintain a balance between margin
maximization and corresponding misclassifications. Optimal results
were achieved for the dataset used when value of gamma was equal to 1
and that of C was set to 10.

4.5.1. Classification using SVM 4.5.2. Classification using NN

SVM is chosen as one of the classifiers because it avoids overfitting by
provision of various regularization parameters. Also, SVM has been
widely used by researchers to perform binary classification for glaucoma
detection because it is able to separate linearly inseparable data into
linearly separable data with the help of the kernel trick. However, se­
lection of correct parameters and kernels is challenging but choosing
them accurately would help in attaining noteworthy results.
For the purpose of classification, SVM classifier with RBF kernel is
used. The parameter gamma defines the range of influence of a training
The reason behind application of NN for glaucoma classification is
that (a) the neurons acquire knowledge by themselves speedily and with
high accuracy (b) work efficiently in real time conditions.
The Multilayer perceptron model is a fully connected deep neural
network comprising of one input layer, two hidden layers and one
output layer. First hidden layer is composed of three neurons whereas
the second layer constitutes two neurons. ReLU is used as an activation
function for hidden layers whereas Sigmoid function is applied to the
output layer. Binary cross entropy, described in the equation below, is

10
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

used as a loss function as it tends to decrease the dissimilarity between Et = training error,
actual and predicted values. α = weight of the classifier,
h(xi) = output hypothesis,
∑
C=2
BC = − gi log(Sigm(pi )) (13) E (F) = error function
i=1
The chosen base estimator is decision tree classifier for which the
BC = gi log(Sigm(pi )) − (1 − gi )log(1 − Sigm(Pi )) (14) parameters, max depth as well as the learning rate is equal to 1. The
maximum number of estimators at which boosting is terminated, i. e,
where, estimators is set to 50 while random state is equal to 20. As compared to
the recall value achieved using decision tree algorithm, adaboost
BC = Binary Cross-entropy, ensemble technique that consisted of decision tree as the base classifier
C = Number of classes, helped in achieving a recall value of 100%, thus making adaboost
g = ground truth values, ensemble learning a better choice for glaucoma classification.
p = predicted values,
Sigm ( ) = Sigmoid function 4.5.4. Final prediction
The working principle of majority voting is such that after every
Adam, derived from adaptive moment estimation is used as an model makes a prediction for the input instance in terms of [0/1] i. e
optimizer because learning rates are computed based on the parameters, [healthy/glaucoma], the final prediction is the one that is made by
thus helping overcome saddle points during training. The model was atleast two-third of the three classifiers that are described in section 4.5.
trained in 120 epochs whereas a batch size of 2 helped in acquiring The results prove that a percentage of glaucoma cases have been
optimal results. From Fig. 13, it can be observed that loss per epoch correctly classified.
decreases gradually and eventually becomes 0.
5. Results and discussion
4.5.3. Classification using adaboost
The meta-learning approach with the help of adaboost technique is This section discusses results obtained by the algorithms used for
selected in order to increase the efficacy of binary classification using input image validation, segmentation, feature extraction and classifi­
decision tree. It is an iterative algorithm that strengthens the classifier cation. We also compare the results of proposed methodology with other
by reducing the bias error by taking into consideration the difference work and present statistical analysis of the features used for
between predicted and the actual values. Following equation describes classification.
parameters of a boosted classifier. In the proposed CAD pipeline, the foremost step is to detect whether
∑
T the input image is a retinal fundus image. The detection is done using
Ft (x) = [ft (x)] (15) LeNet architecture and the results are discussed in Fig. 14. As seen in the
t=1 figure, the training loss is almost equal to the validation loss indicating
that the model has been very well trained.
where,
Optic disc and optic cup play the most crucial role in the classifica­
tion process because of the evaluation of two features, namely, CDR and
Ft (x) = boosted classifier,
ISNT ratio are solely based upon the accuracy of segmentation. From the
ft = weak learner,
literature surveyed in section 2, although the optic cup and disc seg­
x = input,
mentation using image processing techniques helps in achieving note-
T = total number of classifiers
worthy results, the techniques face major challenges. These techniques
are highly impacted by fundus image quality. Fundus images are prone
The training error Et is described as follows:
to illumination inhomogeneities, colour, contrast, saturation, image
∑
Et = E[Ft− 1 (xi ) + αt h(xi )] (16) resolution, quality of sensors etc. On the other hand, most of the image
i processing algorithms consider the similar set of features for medical

where,

Fig. 14. Training loss and accuracy using LeNet architecture fundus/non-
Fig. 13. Decrease in loss during training phase of Neural Network. fundus image classification.

11
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

image analysis and thus glaucoma detection. As a result, these factors Table 2
give rise to a few limitations in OD and OC segmentation that are Result comparison for Optic Disc and Optic Cup segmentation.
described as follows: (a) The methods are sensitive towards image dis­ Author Dataset Dice Score
tortions and noise. For example, the presence of gaussian noise in fundus
OD OC
image can influence segmentation results. (b) Structural characteristics
of a fundus image are not reflected in histogram analysis. Therefore, this DRIONS-DB 0.94 –
Sevastopolsky [33] RIM-ONE v.3 0.95 0.82
may impact glaucoma assessment. (c) The probability of performance DRISHTI-GS – 0.85
efficiency on cross dataset evaluation is low. Maninis et al. [21] DRIONS-DB 0.97 –
(d) Threshold selection is not always straightforward. Thus the deep RIM-ONE v.3 0.96 –
learning, U-Net model proves to be the best algorithm for semantic RIM-ONE v.3
Ferreira et al. [31] 0.84
segmentation for segmentation of OD and OC with high accuracy. –
DRISHTI-GS
Fig. 15 illustrates the stages of glaucoma detection process starting from Yin et al. [38] Origa-light 0.83
ROI extraction to glaucoma classification. Five random images were DRISHTI-GS
selected each from the testing sets of five datasets used for training the RIM-ONE
model. The accuracy in class prediction confirms that the model has Proposed methodology DRIONS-DB 0.93 0.87
NIO
been well trained and is highly reliable. DRIVE
In the work of Sevastopolsky [33], U-Net was used for segmentation JSIEC
with an advantage of reduced glaucoma prediction time. The input
images were pre-processed using CLAHE. Strategies like dropout layer
and data augmentation were applied for better performance [21]. Fer­ Table 3
reira et al. [31] used U-Net Convolutional Neural Network architecture Feature-wise mean and standard deviation values of healthy and glaucoma cases
only for optic disc segmentation and achieved commendable results. for training examples.
Unlike Sevastopolsky [33], in our work, there is no need of image
Features Glaucoma Healthy
pre-processing and can be segmented as it is. Table 2 shows that our
proposed methodology has achieved. mean ± SD mean ± SD

Table 3 describes the range of values under which healthy and CDR 0.8 ± 0.320 0.2 ± 0.240
glaucomatous cases lie. In case of non-glaucomatous cases, the feature Blood Vessel Ratio 2.9 ± 0.160 1.5 ± 0.250
ISNT Ratio 1.6 ± 2.890 1.1 ± 0.216
values are smaller as compared to glaucomatous cases. As the training
samples increase, the performance of the system shows an improvement
in the accuracy. In order to compare the significance of extracted fea­ statistical test that is used to calculate differences in results across
tures with respect to the classifiers applied for glaucoma classification, samples taken from dissimilar populations. For an input matrix [mij ]N×k,
the Friedman statistical test has been applied to the experimental re­ the rank matrix [r.j], which is the mean, is calculated at the intersection
sults. Statistical analysis helps in the determining whether the experi­ of every row (i,k). “N” is the number of rows (classification models)
mental results are probably due to chance or else they carry some factor whereas “k” is the number of columns (features) in the input matrix. The
of interest to the concerned topic. Friedman test is a nonparametric

Fig. 15. Results achieved using proposed methodology. Column (A) represents ROI extracted images from 5 different datasets. Images in columns (B) and (C) display
the segmented images of OD and OC respectively using U-Net architecture. Column (D) illustrates the extracted Neuro-retinal Rim. Images in columns (E) shows the
distribution of NRR in four ISNT quadrants. Column (F) shows detected blood vessels on an optic disc image masked with predicted optic disc in column (B). Columns
(G), (H) and (I) display the values obtained for CDR, ISNT Ratio and Blood vessel ratio respectively.

12
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

Friedman statistic Fr is given by: test set, and the other five datasets are used for training and vali­
k ( )2 dation by using all the datasets described in section 3.1. Further, to
∑
Fr =
12N
r.j −
k+1
(17) verify whether the proposed methodology works up to the mark in
k(k + 1) j=1 2 facing real world challenges, the trained model was tested on two
completely different and publicly available, HRF and APTOS data­
If N > 15 or k > 4, the p-value is given by:
sets, in order to ensure whether generalization is achieved.
( )
P χ 2k− 1 ≥ Fr (18)

where, 5.1. Performance on HRF dataset

χ 2k− 1 = critical value obtained for chi-square test at (k-1) degrees k-1
of freedom.
The p-value is obtained from tables prepared for Friedman test. If p-
value is greater than, the null hypothesis H0 is rejected else we fail to
reject H0. Failure to reject H0 indicates that the experiment carried out is
statistically significant.
In our experimentation, Friedman test has been applied to the data
described in Table 4. Null hypothesis H0 can be stated as:
H0 = The impact of ensemble of features on classification accuracy
remains unchanged.
The test results indicated that an ensemble of features significantly
altered the classification accuracy (Fr = 8.3, degrees of freedom = (4, 4),
p-value < 0.05). Using Friedman test, the p-value obtained is 0.021 (p-
value < α), whereas the critical value CV described in Friedman table at
(4,4) degrees of freedom is 7.8 (Fr > CV). Thus, we fail to reject the null
hypothesis H0 factualising the hypothesis that all the three features
prove to be significant for the purpose of accurate classification.
In the work of Ruengkitpinyo et al. [30], 9 features were extracted
using ISNT rule and SVM classifier was used for glaucoma image clas­
sification. Deepika and Maheswari [11], performed pre-processing by
extraction of green component from the RGB image, CLAHE for blood
vessel extraction and Active Contour Models for feature extraction.
Hatanaka et al. [14] proposed comparison of the optic disc profiles, the
profile for glaucoma cases appeared to be a broad mountain with short
skirt while that for healthy cases tended to appear as a narrow mountain
with long skirts. Morphological closing and opening operations using
structuring element were applied for segmentation [32]. In proposed
methodology, the ensemble of classifiers and selection of significant
features provided an advantage over others in achieving excellent re­
sults. Considering the results, as summarized in Table 5, this work has
achieved remarkable results and we believe that the developed desktop
app would prove to be highly reliable for health practitioners across the
world.
• Addressing the first issue, whether training the model with different
kinds of datasets and increasing the number of training and testing
images developed a robust model, Table 2 provides sufficient evi­
dence that proposed methodology shows competent dice scores as
compared to other works.
• We also raised concerns regarding generalization power of the sys­
tem by obtaining predictions from more than one number of classi­
fiers. To suffice with this purpose, each of the six datasets is used as a
Table 4
Testing results displayed in the form of macro-averaged F-1 scores, post training
individual/multiple classifiers with individual/multiple features. Columns
include features abbreviated as Cup-to-Disc Ratio (CDR), ISNT Ratio (ISNT) and
Blood Vessel Ratio (BVR).
Model/Features CDR ISNT BVR CDR + ISNT + BVR
SVM 100 100 100 100
NN 41 40 75 49
Adaboost 42 50 72 55
SVM + NN 100 100 100 100
+ Adaboost
From the obtained accuracy results indicated in Table 6, it can be
seen that our method could eliminate noise by accurately segmenting
lesion images interfered by dark spots contained in HRF dataset and
could successfully predict negative and positive cases. Also, it demon­
strates the precision, recall and F1 scores achieved on HRF dataset.
5.2. Performance on APTOS dataset
Asia Pacific Tele - Ophthalmology Society (APTOS) is a real-world
dataset, comprising of noise in images containing artifacts under­
exposed or overexposed. The images are gathered from multiple clinics
using a variety of cameras over an extended period of time, which in­
troduces further variation. As a result, working with such a dataset be­
comes a challenging task. From 250 fundus images taken from APTOS
dataset and labelled to be glaucomatous or healthy, 130 images are
glaucomatous while 120 images are normal. After testing these images
upon the proposed model, the system could achieve precision, recall and
F1 scores as 99.1%, 98.3% and 98.7% respectively, indicated by Table 6.
• The images in DrishtiGS dataset constituted patients between 40 and
80 years of age while 25–90 years for that of Drive dataset. Rim-One
dataset consists of high quality images with special focus on OD
segmentation. Drions-DB comprises of all the images from Caucasian
ethnicity having 53 years as the mean age of all the patients. Images
from JSIEC and NIO datasets have varied illumination conditions.
From the results presented in Table 6, it is visible that the proposed
system was well trained and attained high accuracy when tested with
images from unknown dataset. Also, Tables 7 and 8 elucidate that
images were well segmented despite the heterogeneity in image
conditions.
As anticipated, the results show that the model is generalized and can
work efficiently with unknown images. A high sensitivity is necessary
for a model developed in healthcare domain, since it implies that the
cases having disease are rarely misdiagnosed. As evident from Table 6,
the proposed methodology has achieved noteworthy sensitivity scores
that are greater than 96% in case of all the described datasets. Results
described therein thus demonstrate that the proposed model is robust to
different datasets that come from unique sources.
• Also, we focused on accuracy enhancement by ensuring that pro­
vided features carry significance in glaucoma classification. In this
context, the Friedman statistical test ensures that the features carry
significance in classification whereas high F1 scores were analysed
when the ensemble of classifiers was used for classification purpose.
Our method is superior to other methods as we consider three fea­
tures for glaucoma diagnosis with higher percentage of correct
classification.
As a result, the proposed methodology is clinically significant, as the
classification accuracy outperforms the accuracy obtained by existing
methods. In order to check whether the model is prone to overfitting, 10-
fold cross validation was performed. Table 9 describes the cross vali­
dation results obtained while training the models for OD and OC seg­
mentation. Also, it could be stated that, if the model was prone to
overfitting or was overfitted, it would not have absolutely performed

13
R. Shinde Intelligence-Based Medicine 5 (2021) 100038

Table 5
Performance comparison of supervised machine learning algorithms for Glaucoma detection.
Author Classifier Dataset Accuracy Specificity Sensitivity

Ruengkitpinyo et al. [30] SVM Mettapracharak 90% 91.5% 92.6%

Hospital, Thailand
Deepika and Maheswari [11] SVM, ANFIS HRF dataset 97.7% 82% 95.7%
Hatanaka et al. [14] ANN, RBF, IMAGEnet 78% 80% 75%
k-NN, SVM
Septiarini and Harjoko [32] SVM 60 images 90% 100% 80%
Guo et al. [13] Deep CNN DRISHTI-GS1, 76.42% 76.2% 76.61%
ORIGA
DRISHTI-GS
Proposed Methodology SVM, NN, Adaboost RIM-ONE 100% 100% 100%
DRIONS-DB
NIO
DRIVE
JSIEC

Table 6 Table 9
Quantitative result comparison by calculating accuracy, specificity, sensitivity, Accuracy, specificity, sensitivity, precision and F1 score metrics obtained after
precision and F1 score values on respective test datasets while the ensemble of performing cross validation while training U-Net model for OD and OC
classifiers is trained on remaining datasets for proposed model. Images in the segmentation.
datasets marked with (*) symbol have been tested without training images Dataset Accuracy Specificity Recall Precision F1
therein on the proposed model. Score
Test dataset Accuracy Specificity Recall Precision F1 Score OD 97.9 95.1 99.1 97.9 98.5
RIM-ONE 96.9 95.9 97.9 96 96.9 OC 89.4 80.5 96.6 86 91
DRISHTI 98 97.5 98.3 98.3 98.3
DRIONS 99 98.2 100 98.1 99
97.5
NIO 98.3 100 95.2 100
well while predicting labels for images from completely unseen datasets,
JSIEC 99.1 98.7 100 97.7 98.8
DRIVE 97.6 95.8 100 95 97.4 namely, HRF and APTOS. In order to check the robustness of the
*HRF 98.8 99.2 98.3 99.1 98.7 developed model, HRF and APTOS datasets were not used as a part of
*APTOS 98.2 97.5 99.3 98.7 98.2 training, in an attempt to test the model against unknown set of images.
Average 98.8 99 98.7 98.9 98.8 The results have been described in Table 6 of the manuscript. Following
are a few limitations of the proposed work:

Table 7
• It cannot detect the presence of Peri-Papillary Atrophy (PPA) which
Comparison of optic disc segmentation results from U-Net for each dataset. could affect in defining boundary while performing OD segmentation
Following metrics (in average percentage) have been calculated on respective and CDR calculation. However, ISNT and Blood vessel ratios lied
test datasets while the proposed model is trained on remaining datasets. within the range in such cases and therefore misclassification could
U-Net RIM DRISHTI DRIONS NIO JSIEC DRIVE
be avoided.
-ONE -GS -DB • The model cannot be trained on unlabelled dataset. Furthermore, the
U-Net model for OD and OC segmentation is based on semantic
Input 169 101 110 118 124 44
Jaccard 0.988 0.976 0.978 0.974 0.980 0.957 segmentation. This implies that there must be an availability of bi­
Precision 0.959 0.969 0.971 0.974 0.954 0.990 nary images representing OD and OC in fundus images in the form of
Recall 0.979 0.940 0.957 0.95 0.976 0.904 groundtruth.
F1 Score 0.969 0.954 0.964 0.962 0.965 0.926
Specificity 0.944 0.941 0.948 0.987 0.975 0.956
Accuracy 0.964 0.94 0.954 0.974 0.975 0.931
6. Conclusions

The novelty of this research work lies in developing a methodology

that is robust and well generalized to real time fundus images. This
Table 8
paper proposes the development of a desktop application as a part of an
Comparison of optic cup segmentation results from U-Net for each dataset.
automated CAD system for glaucoma detection using retinal fundus
Following metrics (in average percentage) have been calculated on respective
test datasets while the proposed model is trained on remaining datasets. images. Images input to the system are validated using deep learning
approach known as LeNet. Despite of it being a compact CNN archi­
U-Net RIM DRISHTI DRIONS NIO JSIEC DRIVE
tecture, the accuracy obtained is commendable. ROI extraction using the
-ONE -GS -DB brightest spot algorithm is presented. In this algorithm, the image is
Input 169 101 110 118 124 44 converted into grayscale and preprocessed using gaussian blur in order
Jaccard 0.868 0.853 0.909 0.896 0.9 0.92 to improve the accuracy of ROI detection. Further, the segmentation of
Precision 0.979 0.984 0.985 0.92 0.947 0.88 optic disc and optic cup is done using U-Net architecture. U-Net proves
Recall 0.970 0.969 0.971 0.902 0.873 0.923
F1 Score 0.974 0.977 0.978 0.910 0.848 0.931
to be a very efficient algorithm for medical image segmentation.
Specificity 0.971 0.973 0.974 0.966 0.882 0.878 Further, three features namely, CDR, NRR ISNT ratio and Blood Vessels
Accuracy 0.97 0.977 0.972 0.91 0.89 0.970 ISNT ratio have been considered as the decision criteria for glaucoma
detection. A binary mask of dimensions similar to that of the input image

14
R. Shinde
is used to distribute the image into four ISNT quadrants. The area of the
image in every quadrant is used to further calculate the ISNT ratio. The
p-value < 0.05 indicates that the features used and classifiers applied are
significant in terms of glaucoma detection. Finally, using these three
features as the input parameters, the classification is done using majority
voting attained from SVM, NN and adaboost algorithms. It is observed
that the choice of classification method influences both accuracy and
efficiency. Summarizing further, the objectives of the research work
have also been stated and results demonstrate that the mentioned
challenges have been tackled using methodologies discussed above.
To further conclude, the proposed pipeline can be used by any system
and is completely offline. The desktop application can contribute to
medical practitioners in decision making and also in early detection of
glaucoma thus helping a patient in avoiding an irreversible loss that
would have caused to their eyesight. Furthermore, as a part of future
work, we intend to extend the domain of proposed methodology to other
types of medical images, for example, OCTA images. Also, more number
of features can be considered apart from those described in proposed
methodology.
Declaration of competing interest
The author declares that there are no conflicts of interests.
Acknowledgements
Funding: No external funding sources supported this research article.
We specially thank Dr. Aditya Kelkar from NIO, Pune for his valuable
contribution in provision and classification of the images.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ibmed.2021.100038.
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