Proceedings of the 26th Annual International Conference of the IEEE EMBS
San Francisco, CA, USA • September 1-5, 2004
Retinal Image Analysis to Detect and Quantify Lesions Associated with
Diabetic Retinopathy
C. I. Sánchez1,2, R. Hornero1,2, M. I. López2, J. Poza1,2
1
Dep. de Teoría de la Señal y Comunicaciones, ETSI-Telecomunicación, University of Valladolid, Spain.
2
Instituto de Oftalmobiología Aplicada (IOBA), University of Valladolid, Spain.
Abstract—An automatic method to detect hard exudates, a
lesion associated with diabetic retinopathy, is proposed. The
algorithm found on their color, using a statistical classification,
and their sharp edges, applying an edge detector, to localize
them. A sensitivity of 79.62% with a mean number of 3 false
positives per image is obtained in a database of 20 retinal
image with variable color, brightness and quality. In that way,
we evaluate the robustness of the method in order to make
adequate to a clinical environment. Further efforts will be done
to improve its performance.
Keywords— Diabetic retinopathy, hard exudates, image
processing, retinal images.
I. INTRODUCTION
D IABETIC retinopathy (DR) is a severe eye disease
that affects many diabetic patients. It remains one
of the leading causes of blindness and vision defects in
developed countries. There exist effective treatments that
inhibit the progression of the disease provided that it would
be diagnosed early enough. But DR is usually asymptomatic
in its beginning, so diabetic patients do not undergo any eye
examination until it is already too late for an optimal
treatment and severe retinal damages have been caused.
Regular retinal examinations for diabetic patients guarantee
an early detection of DR reducing significantly the incidence
of blindness cases. Because of great prevalence of diabetes,
mass screening is time consuming and requires many trained
graders to examine the fundus photographs searching retinal
lesions. A reliable method for automated assessment of the
presence of lesions in fundus images will be a valuable tool
in assisting the limited number of professional and reducing
the examination time.
This paper focuses only in the automatic detection of one
of the lesions associated with DR: hard exudates. They
usually appear in the fundus photographs as small yellow-
white patches with sharp margins and different shapes.
Among lesions caused by DR, exudates are one of the most
occurring early lesions [1]. So the detection and
quantification of them will contribute to the mass screening
and assessing of DR.
Some investigations in the past have identified retinal
exudates in fundus images based on their gray level [2], [3],
their high contrast [4-7] or their color [8],[9]. Because the
brightness, contrast and color of exudates vary a lot among
different patients and, therefore, different photographs, these
0-7803-8439-3/04/$20.00©2004 IEEE
method would not work in all the images used in clinical
environment. The main improvement introduced by the
technique described in this paper is its robustness to the
variable appearance of retinal fundus images to obtain an
optimal performance in all types of images, in contrast to
these other approaches.
II. METHODOLOGY
The method attempts to detect hard exudates using two
features of this lesion: its color and its sharp edges. So hard
exudates extraction is carried out in the following stages:
x Detection of the optic disk and the blood vessels
x Detection of yellowish objects in the image.
x Detection of objects in the image with sharp edges.
x Combination of the previous steps to detect
yellowish objects with sharp edges.
A. Detection of the optic disk and the blood vessels
In order to localize these main features, we build on some
works developed by other authors. We follow the method
proposed in [7] to detect the center of the optic disk (OD).
This method determined a number of candidate regions with
the brightest pixels in intensity image. Then the PCA based
model approach is applied to the candidate regions to give
the final location of the OD. We also detect the disk
boundary using a snake driven by an external field
v(x,y)=[u(x,y),v(x,y)] called Gradient Vector Flow (GVF)
[10] over the image f(x,y).
2 2 2 2 2 2
H ³³ P (u x  u y  v x  v y )  ’f v  ’f dxdy (1)
In this work the snake is initialized automatically as a
circle placed in the center of the OD localized previously.
The blood vessels are segmented applying the matched
filter method described in [11] to enhance blood vessels and
thresholding the image obtained.
B. Detection of yellowish objects
The detection of this kind of objects is carried out
performing color segmentation based on the statistical
classification method described in [8] and [9]. This method
found on the fact that if a group of features can be defined
so that the objects in an image map to nonintersecting
classes in the feature space, then we can easily identify
different objects classifying them into corresponding classes
1624
by a certain rule. For our algorithm, we have to discriminate
between two classes: yellowish objects and background,
which are perfectly characterized using only three color
features (the illuminance of the pixels in each plane
(R,G,B)). In order to map all the pixels in the image to one
of these classes, an appropriate discriminant function has to
be defined. Using the posterior probability and Bayes’
theory, we can obtained the minimum distance discriminant
T
Di ( x) ( X  C i ) ( X  C i ) , (2)
where i=1,...,N and N is the number of classes (in our case
N=2).
So for each pixel X(xR,xG,xB), the distances Dyell(X) and
Dback(X) are calculated. If Dyell(X) is less than Dback(X), then
the pixel X is classified as yellowish lesion, otherwise it is
classified as background. Cyell and Cback denote the center of
each class in RGB space, which characterize the color of the
yellowish objects and the background respectively.
Therefore, one problem has to be resolved before applying
this method: the definition of the features center Cyell and
Cback. In [8] and [9], they are selected as a global value after
obtaining them from different windows in training samples.
In that way, it is taken for granted that all the images have
the same fundus color, and that the exudates and the
background appear with the same illumination and color. In
practice, there is a wide variation in the color of fundus from
different patient, strongly correlated to skin pigmentation
and iris color. So, global values for Cyell and Cback can work
in some images but fail in others. This problem can be
resolved using specified feature centers for each image. To
define them avoiding user interaction, we have to find pixels
belonging to both classes in all the images.
For background, we select a group of pixels that
surrounds the contour of the OD obtaining in section A. And
because of the fact that the OD usually has the same color as
the exudates, the pixels that belong to the OD are used to
identify the color of the yellowish objects. So we obtain for
each fundus photograph the values of Cyell and Cback:
1 m
C yell ¦ Yi
mi 1
, (3)
1 n
Cback ¦ Bi
ni 1
where m and n are the number of pixels in yellowish and
background region respectively that are used to calculate
these centers and Yi and Bi are the vectors of the three color
features in the different region
Because of lighting variation, decreasing color saturation,
skin pigmentation, etc, the color of lesions in some regions
of an image may appear dimmer than the background color
that is located in another region and would be wrongly
classified. So it is of crucial importance to perform an
1625
adjustment for non-uniformity of illumination. But if a
general method to avoid this phenomenon is applied, the
color in some fundus photograph, due to the wide variation
of this feature in different patients, could be modified
introducing some strange effects. In this work, we use a new
color image. This image is obtained performing an operation
of the channels (N1, N2, N3) of the NTSC color space
N1' 1.5 N1  N 2  N 3 , (4)
and then converting the image obtained (N1´,N2, N3) into the
RGB color space again. In that way, we improve both
contrasting attributes of lesions and the overall color
saturation in the image, achieving that the OD and the
exudates appear with the same color independently of their
location (Fig. 1.(b)).
Hard exudates and other yellowish objects can be
detected applying the minimum distance discriminant to all
the pixels of this image, as shown in Fig. 1.(c).
As well as hard exudates, other yellowish regions are
detected, as the optic disk, other lesions (cotton wool spots
and drusen), artifacts, etc.
C. Detection of objects with sharp edges
An edge-finding operator can characterize the edge
strength of the objects of an image. So, in our case, Kirsch’s
mask (5) and different rotations of it are applied to the green
component of the color fundus and the maximum response
of them is selected to detect the edges in the fundus
photograph.
§ 5 5 5·
¨ 3 0  3¸ (5)
¨ ¸
©  3  3  3¹
Thresholding this image at grey level T1, we obtain
objects with sharpest edges (Fig. 1.(d)). T1 is a parameter of
the algorithm. If T1 is chosen too low, the sensitivity
increases but the specificity decreases.
Other objects in the images with sharp edges are also
detected, as the optic disk, blood vessels, haemorrhages, etc
D. Combination of the two previous images
To detect only hard exudates and remove all the false
positives introduces in the previous stages, we combine the
two images obtained using a Boolean operation, feature-
based AND. In feature-based AND, ON pixels in one binary
image are used to select objects (connected groups of ON
pixels) in another image. Here we use the image with
objects with sharp edges to select object in the image with
yellowish elements, because in the last one the lesions are
detected completely, not only their contours. In this way, we
obtain lesions characterized by the two desired features:
yellowish color and sharp edge.
 (a)
(c)
Fig. 1. Images obtained applying the method to (a), (b) image after the enhancement, (c) detection of the yellowish objects, (d) detection of the objects
with sharp edges.
Fig. 2. Detection of hard exudates presented in Fig. 1. (a).
After that, we also get some false positives due to the
papillary region and some artifacts near the vessels (because
the reflection in young people). To reduce them, we remove
a dilated version of the segmentation result of the detection
of the OD and of the vessel in section . Fig. 2. shows the
final image.
1626
(b)
(d)
III. RESULTS
We have tested the algorithm on an data base of twenty
576x768 digital images taken with a TopCon TRC-NW6S
Non-Mydriatic Retinal Camera and have compared the
results obtained by the algorithm with the performance of a
specialist who marked the exudates on these images.
For evaluation of the detection performance of the system
the number of true and false positive clusters have to be
determined for each image in the test set, while the
segmentation threshold T1 is varied. In this way the true
positive (TP) rate can be plotted as a function of the number
of false positive (FP) detections per image, using free-
response receiver operating characteristic (FROC) curve.
Each decision threshold results in a corresponding operating
point on a curve. We believe that FROC analysis is an
appropriate measure for our detection system, because there
will be a trade-off between the TP rate and the number of FP
detections per image. A true exudate is considered detected
if the detected cluster overlaps at least 50% of its area. All
findings outside the criterion are considered as false
detections. The curve obtained is shown in Fig. 3., obtaining
a T1=0.8 a sensitivity of 79.62%.
IV. DISCUSSION
The best perfomance is achieved at the operation point
with a sensitivity of 79.62% with a mean number of 3.2
false detections per image. Some exudates are not detected
due to their proximity to blood vessels or because they
appear very faint, even after the proposed enhancement.
Missing faint exudates has not a crucial importance since
even human experts are not sure about some ambiguous
regions. In the present work we have evaluated the system
on an independent database of retinal images with variable
characteristics to investigate its robustness. Due to the lack
of a common database and a reliable way to measure the
performance, it is difficult to compare the performance of
our method related to those reported in the literature.
Although some work [5], [7] show superior performance
than our algorithm, the main improvement is that a good
performance is obtained overall independently on the color,
illumination, size, etc, keeping FPs low. This independence
on the aspect of the image is obtained using a particular
method for each image (to enhance them, to obtain the color
of the background and exudates), unlike other authors which
use global approaches for all of them. So the behavior of our
algorithm is appropriate for a clinical environment.
But there are some problems that deserve comment. First
of all, the algorithm depends on other detection tasks, as the
detection of the OD and blood vessels, making the results
dependent of the successful of these method. This indicates
the further necessity of improving the robustness of these
task. On the other hand, we have used the color of the OD to
characterize yellowish regions but this can not represent the
its real color. It could be a good idea to localize some
exudates firstly and then use their color.
V. CONCLUSION
In this work we have evaluated an automated detection
scheme for one of the primary signs of DR: hard exudates.
This lesion was identified by its color, using a statistical
classification, and its sharpness of its edges, applying a
Kirsch operator. After applying our method to 20 fundus
photograph, the detection sensitivity for the hard exudates
jumped from 65% to 85% when the number of FPs was kept
low (3/image). Our results suggest that the system is
competent to complement the screening of DR of
ophthalmologists in their daily practice because it is very
robust in the face of changes of the characteristic of the
images. Future work will address the issue of improving the
sensitivity by improving the results of other tasks, as the
detection of OD and blood vessels, and trying to localize
faint and small hard exudates.
1627
100
90
80
70
60
T P rat e
50
40
30
20
10
0
0 5 10 15 20
FP p er im age
Fig. 3. FROC curve for a database of 20 retinal images using the
developed method.
REFERENCES
[1] D. Klein, B. E.. Klein, S. E. Moss et al, “The Wisconsin
epidemiologic study of diabetic retinopathy. VII. Diabetic
nonproliferative retinal lesions,” Ophthalmol., vol. 94, pp. 1389–
1400, 1986.
[2] N. P. Ward, S. Tomlinson, and C. J. Taylor, “Image analysis of
fundus photographs – The detection and measurement of
exudates associated with diabetic retinopathy,” Ophthalmol., vol.
96, pp. 80–86, 1989.
[3] R. Philips, J. Forrester, and P. Sharp, “Automated detection and
quantification of retinal exudates,” Graefe’s Arch. Clin. Exp.
Ophthalmol., vol. 231, pp. 90–94, 1993.
[4] K. Akita and H. Kuga, “A computer method of understanding
ocular fundus images,” Pattern Recogn., vol. 21, no. 6, pp. 431–
443, 1982.
[5] T. Walter, J.-C. Klein, P. Massin, and A. Erginay, “A
contribution of image processing to the diagnosis of diabetic
retinopathy – Detection of exudates in color fundus images of the
human retina,” IEEE. Trans. Med. Imag., vol. 21, no. 10, pp.
1236–1243, Oct. 2002.
[6] H. Li and O. Chutatape, “Fundus image features extraction,” in
Proc. 22nd Annual Int. Conf. of the IEEE Engin. Med. Biol. Soc.,
EMBS’00, Chicago, IL, pp. 3071–3073.
[7] H. Li and O. Chutatape,, “A model-base approach for automated
feature extraction in fundus images,” in Proc. 9th. Int. Conf. of
the IEEE Comp. Vision, ICCV’ 03, Nice, France, pp. 50–53.
[8] K. G. Goh, W. Hsu, M. L. Lee, and H. Wang, “ADRIS: an
automatic diabetic retinal image screening system,” in Medical
Data Mining and Knowledge Discovery, Ed. K. J. Cios, NJ:
Springer-Verlag, 2000, pp. 181–210.
[9] H. Wang, W. Hsu, K. G. Goh, and M. Lee , “An effective
approach to detect lesions in color retinal images,” IEEE
Conference on Computer Vision and Pattern Recognition, vol. 2,
pp. 181–186, Jun. 2000.
[10] C. Xu and J. L. Prince, “Snake, shapes and gradient vector flow,”
IEEE. Trans. Imag. Process., vol. 7, no. 3, pp. 359–369, Mar.
1998.
[11] S. Chaudhuri, S. Chatterjee, N. Katz, M. Nelson, and M.
Goldbaum, “Detection of blood vessels in retinal images using
two-dimensional matched filters,” IEEE. Trans. Med. Imag., vol.
8, no. 3, pp. 263–269, Sep. 1989.