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Procedia Computer Science 167 (2020) 57–66

International Conference on Computational Intelligence and Data Science (ICCIDS 2019)

International Conference on Computational Intelligence and Data Science (ICCIDS 2019)
Automatic detection and grading of diabetic maculopathy using
Automatic detection and grading of diabetic maculopathy using
fundus images
fundus images
G G Rajputaa, B M Reshmibb, Rajesh I Scc
G G Rajput , B M Reshmi , Rajesh I S
a
Computer Science Department ,akkamahadevi Women’s University, Vijayapura,Karnataka,India
b
Department
a of Information
Computer Science Science & Engineering,
Department Basaveshwar
,akkamahadevi Women’s Engineering College, Bagalkot, Karnataka, India
University, Vijayapura,Karnataka,India
b c
DepartmentSchool of Computing
of Information & Information
Science Technology,
& Engineering, REVA Engineering
Basaveshwar University, Begaluru, Karnataka,
College, Bagalkot, India
Karnataka, India
c
School of Computing & Information Technology, REVA University, Begaluru, Karnataka, India

Abstract
Abstract
Diabetic maculopathy is one of the leading complications of diabetes that is measured as the significant reason for vision
misfortune
Diabetic among individuals
maculopathy is one ofaround the globe.
the leading In this paper,
complications a two stage
of diabetes that approach is proposed
is measured for automatic
as the significant detection
reason and
for vision
misfortune
grading of among
diabeticindividuals
maculopathyaround
basedtheonglobe. In this paper,
mathematical a two stage
morphology. Mainlyapproach is proposed
two features for automatic
are needed for thedetection
detectionand
of
grading of diabetic
maculopathy. One is maculopathy
the macula andbased
otherononemathematical morphology.
is hard exudates, Mainly location
based on macula two features are Disc
and Optic needed fordiameter,
(OD) the detection of
macular
section has been
maculopathy. One drawn. We validate
is the macula and othertheone
presence or absence
is hard exudates, of hard
based exudates
on macula in the
location andmacula section
Optic Disc (OD)and severitymacular
diameter, of the
section has been
maculopathy drawn. We
was assessed. Thevalidate the presence
experiment or absence
results performed of hardfrom
on images exudates
publicindatabase
the macula section and indicate
i.e., MESSIDOR severitythat
of the
maculopathy
proposed method was achieved
assessed. encouraging
The experiment results performed on images from public database i.e., MESSIDOR indicate that the
results.
proposed method achieved encouraging results.
© 2019 The Authors. Published by Elsevier B.V.. This is an open access article under the CC BY-NC-ND license
© 2019
© 2020 The
The Authors.
Authors. Published
Published by
by Elsevier
Elsevier B.V..
B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Peer-review under responsibility of the scientific committee of the International Conference on Computational Intelligence and
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
Peer-review under responsibility of the scientific committee of the International Conference on Computational Intelligence and Data
Peer-review
Data Science
Science under responsibility
(ICCIDS
(ICCIDS 2019).2019) of the scientific committee of the International Conference on Computational Intelligence and
Data Science (ICCIDS 2019)
Keywords:Diabetic Maculopathy, Hard Exudates, Fovea, Macula, Optic Disk.
Keywords:Diabetic Maculopathy, Hard Exudates, Fovea, Macula, Optic Disk.

1. Introduction
1. Introduction
Diabetic Maculopathy (DM) is caused due to spillage of liquid rich in fat from harmed retinal blood vessels.
Diabetic of
Aggregation Maculopathy
these liquids(DM)
calledishard
caused due toclose
exudates, spillage of central
to the liquid point
rich inoffat
thefrom
retinaharmed retinal
i.e. macula as blood
showedvessels.
in the
Aggregation of these
Fig. 1. Prompts liquids
bending called
of the focalhard exudates,
vision [1]. close to the central point of the retina i.e. macula as showed in the
Fig. 1. Prompts bending of the focal vision [1].

Corresponding Author Emai-Id : is.rajesh081@gmail.com

Corresponding Author Emai-Id : is.rajesh081@gmail.com

1877-0509© 2019 The Authors. 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/)
1877-0509© 2019 The Authors. Published by Elsevier B.V.. This is an open access article under the CC BY-NC-ND license
Peer-review under responsibility of the scientific committee of the International Conference on Computational Intelligence and Data Science
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
(ICCIDS 2019)
Peer-review under responsibility of the scientific committee of the International Conference on Computational Intelligence and Data Science
(ICCIDS 2019)

1877-0509 © 2020 The Authors. 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/)
Peer-review under responsibility of the scientific committee of the International Conference on Computational Intelligence and Data
Science (ICCIDS 2019).
10.1016/j.procs.2020.03.182
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(2019) (2020) 57–66
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Fig. 1. Condition of the diabetic maculopathy in color retinal fundus image;

(a) Hard exudates in the macular area; (b) Enlarged hard exudates.

Development of DM is moderate and quiet, regular with no manifestations in the beginning periods. If the DM is not
notable in the beginning period, the damage to the macular area or visual field is irreversible and can prompt visual
deficiency. So the compulsory screening of diabetic eye helps in recognizing DM at starting stage and decrease the
risk of serious vision misfortune. This paper gives an automatic detection and grading of DM using color retinal
fundus image. The DM severity level depends upon how close hard exudates are to the focal point of macula. In the
Clinical Significant Diabetic Maculopathy (CSME) stage, a great portion of the retinal blood vessels are injured and
the leakage zone rises. The condition where exudates are far from the macular region is sometimes called Clinically
Non-Significant Diabetic Maculopathy (Non CSME). Here the patient won't understand that he is influenced as
there are no obvious indications.

2. Related work
There are number of methods/techniques for detection and grading of DM, some of them are discussed below.

In [8] explored a technique for automatic detection of DM. Supervised learning approach is used to extract the
global features present in the fundus images. The severity of disease is assessed exploiting a rotational asymmetry
metric (movement design) by looking at the symmetry of macular district. Method is tested on openly accessible
databases like DIARETDB1 and MESSIDOR.

In [10] explored a strategy for division of DM in fluoresce in angiograms. The proposed methodology relies
upon showing the macular picture in early time distribution using 2D Gaussian surfaces which is then subtracted
from the late time span picture to update the DM regions. The consequent complexity picture is divided using
Gaussian Mixture Model (GMM).

A method for characterization of exudative maculopathy using FCM grouping and phony neural frameworks is
illuminated in [11]. The creators have uncovered affectability of 92 % and particularity of 82 % on some adjacent
dataset. Method is slightly better than the standard back propagation but more expensive.

In [12] the macula is limited, and hard exudates are perceived using bunching and clustering and mathematical
morphology. In perspective on the region of the exudates, the diabetic maculopathy seriousness level is
characterized in abnormal fundus image. Method is less expensive and provides user interface for speedy analysis
but less effective for poor quality images

Motivated by the above attempts, we aim to design and develop a two stage methodology for automatic detection
and grading of DM from color fundus images

3. Proposed methodology
The proposed method for detection of DM is broadly classified as local and global methods. The goal of the local
methods [3, 4, 5, and 6] is to detect maximum number of Hard Exudates (HEs) whereas global methods [7, 8, and 9]
relax these criteria and try to ensure that detected bright pixels correspond to hard exudates. A two stage
methodology given in Fig. 2.
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Fig. 2. Flow diagram of detection and grading of DM.

The proposed algorithm for detection and grading of DM comprises several steps and is given below:
Algorithm I: Grading of DM Severity Level
Input: Color retinal fundus images
Output: Detection and grading of DM

[Stage 1: Locating HEs in the macula area and finding of DM]

1. Read retinal fundus image
2. Apply median filter to the retinal image for noise removal
3. [Detection of HEs in the macula area] Perform the following steps
3.1 Detect color edges in the retinal image
3.2 Enhance contrast of the retinal image
3.3 Apply morphology operator, extended minima transform with empirical threshold, h=0.9 to extract one or
more number of exudates
3.4 Complement the image
3.5 Obtain Field of View (FOV) mask from the retinal image
3.6 Extract blood vessels from the original input retinal image
3.7 If any objects are matching in the image (output of step 3.4) resulting after execution of steps 3.5 and 3.6,
remove those objects from the image (Gunns dots and residual of FOV mask)
3.8 Extract OD
3.9 Extract fovea center
3.10 Locate macula region in the binary image and remove residual of OD
3.11 Perform post processing to remove non exudates
3.12 If no exudates found in the macula region then display’ Non DM image’ and go to step 5 else save output
image as I1, display ‘DM image’ and go to step 4

4. [Stage 2: Extracting maximum number of exudates in the macula region and grading of DM]
Perform the following steps
4.1 Repeat steps 1, 2 and 3.1 to 3.11 (In step 3.3, use empirical threshold value 0.58 to perform extended minima
transform)
4.2 Save the resulted image as I2 and Combine I1 and I2, the resulting binary image consisting of maximum
number of exudates by retaining small exudates
4.3 Perform post processing to remove non exudates
4.4 Extract 3 different regions of the macula, compute total area (in pixels) of the HEs in these regions and based
on the spreading of HEs in the different areas of the macula, the image is classified as CSME or NON CSME
5. End.
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The steps of the algorithms are described below

Stage 1: Locating hard exudates in the macula region and detection of DM
Pre-processing: To remove the noise median filter [15] is applied to the input retinal image as shown in Fig. 3.

a b

Fig. 3. (a) Input retinal image; (b) Retinal image after applying median filter.

Locating hard exudates: Exudates are detected based on mathematical morphology. We are not relying on
classification methods for detection of exudates. Simple noise elimination rules are constructed using morphological
operators to identify structures other than non-exudates( bright objects) like, FOV contour, optic disc, nerve fiber
reflections, Gunns dots and other small artifacts. Detection of exudates in the macula region consists of the
following steps: color edge detection, contrast enhancement, segmentation of exudates in the entire retinal image,
complementing the exudates segmented image, removal of non-exudates (OD, FOV contour and Gunns dots),
localizing hard exudates in the macula area and performing post processing to remove small artifacts (nerve fiber
reflections) in the macula area.

Color edge detection: The color image has a vector of color components assigned to each pixel. Direct formulas for
the Jacobian Eigen (JE) values are used [16] so this function is vectorized and produces good results without
sacrificing performance, illustrated in Fig. 4 (a). Image contrast is enhanced using histogram equalization (Fig. 4
(b)).
b
a

Fig. 4. (a) Color edges detected; (b) Contrast enhanced image.

Segmentation of hard exudates: Exudates are identified by applying morphology operator called extended minima
transform [17]. The threshold value (h) is selected empirically and is set to 0.9. The result of applying extended
minima transform using the threshold to the pre-processed image and complementing the resulting image are shown
in Figure5.
a b

Fig. 5. (a) Retinal image after applying extended minima transform; (b) Complemented retinal image.
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Elimination of unwanted bright objects: In addition to OD, there are some other bright structures like FOV
contour, Gunns dots (reflections common on young patients) [18] in the retinal fundus images and are depicted in
Fig. 6 (b). Extremely bright areas along with FOV border as given in Fig. 6 (a).

a b

Fig. 6. (a) Retinal image containing FOV contour with bright border; (b) Retinal image with Gunns dots.

These bright regions can cause false detections. The FOV mask is created for the reference image which does not
contain much bright objects, because our aim is to extract only FOV contour from the reference image (Figure7 (a))
using the above algorithm I ( Perform steps 1, 2 and 3.1 to 3.4 only). The empirical threshold 0.9 (algorithm step
3.3) is used to perform extended minima operation for extracting FOV mask (Figure7 (b)). The FOV mask is
dilated by using diamond shape structuring element of size 8 and the resulting image is given in Figure7 (c). FOV
contour with bright region is removed by performing exclusive OR operation between FOV mask of the referenced
image and complemented image. The retinal image (binary) with FOV removed is shown in Fig. 7 (d).

Fig. 7. (a) Reference retinal image; (b) FOV contour segmented for reference image; (c) FOV contour dilated; and
(d) Retinal image after removing FOV contour.

Gunns dots originally are small white dots, every now and then observable overlaying the huge vessels near the optic
nerve. Gunns dots existence depends on lighting condition. Blood vessel mask is required to remove the Gunns dots.
The Gunns dots are removed by performing exclusive OR operation between blood vessels segmented image and
FOV masked image and it is illustrated in Fig. 8.
a b

Fig. 8. (a) Blood vessel segmented retinal image; (b) Retinal image after removal of Gunns dots.

Blood vessels are segmented as follows: Green plane of the input image is extracted and then complemented.
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Complemented image is enhanced using Adaptive Histogram Equalization (AHE). Opening operation (erosion
followed by dilation) is performed on resulting image to remove round shaped objects using ball shaped structuring
element of radius 8. By subtracting contrast enhanced image and morphologically opened image OD is removed.
The resulting image is converted into binary using threshold value 0.1 and then all small objects smaller than 400
pixels are removed from the image. Other types of bright objects are available in the retinal image like nerve fiber
reflections [19]; these are treated after localizing exudates in the macula area (post processing in the macula). And
such types of objects are shown in Fig. 9.

Fig. 9. Cropped retinal image with nerve fiber reflections annotated.

Detection of macula ROI and its center (Fovea): For fovea identification we have proposed a new method [20]. In
this method fovea is localized with the help of localized OD center and diameter (See Figure10 (a)). Automatic
detection of fovea is based on mathematical morphology. The macula ROI is marked using the fovea center pixel
coordinates. Then the candidate exudates are identified only in this macula ROI. The residues of optic disc (bright
object, leads to false detection of exudates) in binary image is removed using detected OD (See Figure10 (b)). The
algorithms for detection of fovea center comprises of two stages, detection of OD followed by localization of fovea
center and are described [22].

Locating hard exudates in the macula area: Once the macula center (Fovea center as pixel coordinates) is located,
using this as a center point, a circular binary mask of radius 2 times Disc Diameter (DD) is created. Macula region is
extracted from the above binary image. Other small artifacts like nerve fiber reflections (bright objects) are
eliminated by performing morphological opening operation using diamond shape structuring element of size 3.
Next, the presence or absence of exudates in the macula region is determined. After detection of one or more
number of exudates in the macula region, the system will discriminate non DM images from DM images. If the
resulting binary image contains no exudates, the image is considered as non DM image (no diabetic maculopathy).
If the image contains one or more number of exudates, the image is considered as DM image (retinal image with
DM), is saved as I1 and we perform operations of stage 2 for localizing maximum number of exudates in the macula
and grading of diabetic maculopathy.

Stage 2: Locating maximum number of hard exudates in the macula region and grading of DM
The original input image should undergo the steps 1, 2 and 3.1 to 3.11 of the algorithm (these are the steps used in
stage1 except step 3.12) and these steps are described in the previous section). In step 3.3, we use empirical
threshold value 0.58 to perform extended minima operation for segmentation of hard exudates in the retinal image.
The resulting binary image is saved as I2. We add I1 (output image of stage 1) and I2. The artifacts
(NFL reflections) other than exudates are removed from binary images that have fewer than 15 pixels, producing
another binary image, containing only true exudates. This is illustrated in Fig. 10.
 Author name / Procedia Computer Science 00 (2019) 000–000 7
G G Rajput et al. / Procedia Computer Science 167 (2020) 57–66 63

a b

c d

Fig. 10. (a) Output binary image of stage 1 (I1); (b) Binary image with possible exudates (I2) ; (c) After adding I1
and I2 ; and (d) After post processing in the macula region.

For grading of DM grading grid is drawn based on the OD diameter as shown in (Fig. 11). R1 region is drawn with
1/3 of the OD diameter, R2 is drawn with 1 times the OD diameter and R3 is drawn with 2 times the OD diameter.

Fig. 11. Exudates area covered by three different regions of macula.

The grading grid for grading the severity of DM is shown in Fig. 12 and the same is overlaid on the original retinal
image.
a b

Fig. 12. Final output (a) Binary retinal image with grading grid; (b) Overlay of (a) on original retinal image.

4. Results and discussion

Publicly available database, MESSIDOR [21] is used to validate the proposed technique. We have used 94 retinal
images. The performance of the proposed technique is calculated using sensitivity, specificity and accuracy.
Complete coding was done using MATLAB R2009a with Intel(R) Core(TM) 2 Quad CPU, clock of 2.40GHz, and
4GB of RAM memory.
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Hard exudates detection in the macular region: In order to perform detailed evaluation for exudates detection,
true exudates in the macula area are manually marked by the ophthalmologist and the sample annotated hard
exudates in the macula region. Table 1 depicts performance analysis of the proposed hard exudates detection method
and it yields sensitivity of 83.87 %, specificity of 86.66 % and accuracy of 85.95%.

Table 1. Hard exudates detection; Result analysis.

True Positives True Negatives False Positives False Negatives
(Total number of (Total number of Total number of Total number of
retinal images=26) retinal images=94) retinal images=94) retinal images=26)
26 78 12 05

Detection of DM: The proposed method yields sensitivity of 100%, specificity of 94.12% and accuracy of 95.75%
for discriminating non DM images from DM images and the confusion matrix is given in the Table 2 below. True
Positive Rate (TPR), False Positive Rate (FPR), Area under Curve and Precision is calculated below.

Table 2. Confusion matrix for detection of DM.

Total number of Predicted Predicted Total
retinal images=94 (Non DM) (DM)
Actual (Non DM) 64 (TN) 4(FP) 68
Actual (DM) 0(FN) 26(TP) 26
Total 64 30 94
�� ��
TPR = = =1
��� ��

�� �
FPR = = = 0.0588
��� ��

��������� ���.�����
Area Under Curve (AUC) = = = 97.06%
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�� ��
Precision= = = 86.67%
����� ��

�� ��
Recall = = = 100%
��� ��

The important features of our proposed method for detection and grading of DM as compared to the other
approaches listed in the literature are as follows:
 Combining the goals of local [3,4,5, and 6]and global methods to detect hard exudates [7,8,9]
 Not relying on classification methods for detection of exudates
 Hard exudates detection is robust with respect to image variability
 Simple noise elimination rules are constructed using morphological operators to identify non exudates
(bright objects like, optic disc, nerve fiber reflections, gunns dots and other small artifacts). It is, to the
limit of the author’s knowledge, the first method to be able to successfully process images containing
Gunns dots. Few authors have treated NFL reflections and FOV contour[19]
 Simple features are used to grade DM without using classifiers. Most of the authors have used classifiers to
grade DM severity levels [6,13]

The comparison of detection of hard exudates and whole system for grading of DM is given in Tables 3 and 4
respectively
 Author name / Procedia Computer Science 00 (2019) 000–000 9

G G Rajput et al. / Procedia Computer Science 167 (2020) 57–66 65

Table 3. Comparison of the proposed hard exudates detection method.

Authors Method Sensitivity Specificity Accuracy
Alireza Osareh et al. [ 11] Fuzzy C Means Clustering 92% 82% -
Acharya U. et al. [21 ] Higher Order Spectra 82% 88% -
Color Edge Detection And
Proposed method 83.875 86.66% 85.95%
Mathematical Morphology

Table 4. Comparison of the proposed diabetic maculopathy detection approach.

Authors Method Database Sensitivity Specificity Accuracy
Lim et al. [ 3] Watershed Transform MESSIDOR 80.9% 90.25% -

Sai Deepak et al. Asymmetric Motion MESSIDOR 95% 90% -

[8] Pattern
Proposed method Mathematical MESSIDOR 89.47% 100% 92.31%
Morphology

5. Conclusion
In this paper efficient and novel method for the automatic detection of anatomical features like optic disc, and
macula (fovea center) and pathological feature like hard exudates in digital color retinal images based on
mathematical morphology has been proposed. This has led to the development of automated system for detection
and severity level grading of DM. The method is able to deal with images showing large variability in terms of
quality and presence of artifacts. In order to reach this goal our proposed method uses precise exudates and macula
segmentation with simple noise elimination rules. The proposed method has been validated on publicly available
MESSIDOR database and has been compared with state of the art methods. The experiment result shows that the
new method performs better and it uses few parameters compared to other methods. Currently exudates are detected
in macula region only. The exudates detection is extended to the entire image which is left here as future work. The
system finds its direct application during the screening of eye diseases for ever increasing diabetic population.

Acknowledgement
Thanks to MESSIDOR venture for giving the retinal pictures. The authors might want to express gratitude toward
Dr. Shivakumar Hiremath, Joshi Eye Hospital, Bagalkot, and Karnataka, India for his important recommendations.

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