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org (E-ISSN 2348-1269, P- ISSN 2349-5138)

Retinal Problems and its Analysis Using Image

Processing: A review
1
S.D.Mendhule, 2Dr.R.J.Bhiwani
1
M.E. (Scholar), 2Profrssor
1
Dept. of Electronics and Telecommunication,
1
Babasaheb Naik College of Engineering, Pusad, India
________________________________________________________________________________________________________
Abstract: Diabetic-related eye disease is a major cause of preventable blindness in the world. It is a complication of diabetes
which can also affect various parts of the body. When the small blood vessels have a high level of glucose in the retina, the vision
will be blurred and can cause blindness eventually. This is known as diabetic retinopathy (DR). Regular screening is essential in
order detect the early stages of diabetic retinopathy for timely treatment to prevent or delay further deterioration. The various
retinal problems may include Microaneurysm (MA), Exudates, and Haemorrhages. In this paper various techniques are reviewed
to reduce the cost and increase productivity and efficiency for ophthalmologists.

IndexTerms - Diabetic Retinopathy (DR), Image Processing, Retinal problems.

________________________________________________________________________________________________________
1. INTRODUCTION
According to recent estimates, in 2017 approximately 425 million people worldwide in the 20–79 year age group are detected
diabetes, and by 2045, 629 million people of the adult population, is expected to be affected by it [1]. The largest increases will take
place in the regions dominated by developing economies. The prevalence of diabetes is rising all over the world due to population
growth, aging, urbanization, changing life style, increase of obesity and physical inactivity. Unlike in the West, where older persons
are most affected, diabetes in Asian countries is disproportionately high in young to middle-aged adults. This could have long-
lasting adverse effects on a nation’s health and economy, especially for developing countries. The International Diabetes Federation
(IDF) estimates the total number of people in India with diabetes to be around 72.9 million in 2017, rising to 134.3 million by
2045[1],making the India diabetic capital of the World. The ratio of ophthalmologists to the number of diabetic patient is very low.
Ophthalmologists in India are insufficient to tackle the growing diabetic population. India has one ophthalmologist per Lac. This
ratio is even smaller for rural areas. Today diabetic retinopathy is a third cause of blindness in India.

The “Top Ten” countries in the world, in terms of the number of people with diabetes, for 2017 and 2045, are shown in Table 1.

Table 1: Top ten countries/territories for number of people with diabetes

(Age group 20-79 years), 2017 and 2045 [1]

Expected Number
Number of people
of people
Rank Country /Territory with diabetes 2017
with diabetes 2045
(millions)
(millions)
1 China 114.4 119.8
2 India 72.9 134.3
3 U.S. 30.2 35.6
4 Brazil 12.5 20.3
5 Mexico 12.0 21.8
6 Indonesia 10.3 16.7
7 Russian Federation 8.5 16.5
8 Egypt 8.2 16.7
9 Germany 7.5 16.2
10 Pakistan 7.5 16.1
2. Diabetic Retinopathy:
It is a complication of diabetes, especially for those with type 2 diabetes. High blood sugar levels over a period of time can
damage the blood vessels in the retina, making them, swell and leak. In some cases it may also happen that they block blood from
passing through. These lead to growth of abnormal new blood vessels in the retina. All of these conditions affect the vision
adversely leading ultimately to loss of vision.
Although diabetic retinopathy is caused by prolonged high blood sugar level, prolonged high blood pressure has an additive
effect. The risk of the condition increases with age and duration of uncontrolled blood sugar. The high glucose levels in the blood
vessels damage the sensitive small blood vessels in the retina causing haemorrhages, exudates and even swelling of the retina.
When this occurs, the retina is deprived of oxygen which in turn leads to the growth of abnormal blood vessels. A condition known

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as proliferative diabetic retinopathy. The retina detects light and converts it to signals sent through the optic nerve to the brain.
Diabetic retinopathy may stop this process and cause loss of vision as shown in Figure 1.

.
A B
Figure 1: Influence of diabetes on vision: (A) normal vision; (B) diabetic retinopathy
2.1 Types of Diabetic retinopathy:
2.1.1 Nonproliferative diabetic retinopathy (NPDR): It is an early stage of diabetic retinopathy. In this stage, tiny blood
vessels within the retina leak blood or fluid. The leaking fluid causes the retina to swell or to form deposits.

2.1.2 Proliferative diabetic retinopathy (PDR): or advanced diabetic retinopathy, is the stage where new blood vessels begin
to grow within the retina. These new blood vessels are usually abnormal and grow in the center of the eye. This growth is
accompanied by haemorrhages, exudates, occlusions and vision defects.

2.2 Abnormalities associated with Diabetic Retinopathy:

Following are the main abnormalities that are associated with the Diabetic Retinopathy
2.2.1 Microaneurysms: These are the first clinical abnormality to be noticed in the eye. They may appear in isolation or in
clusters as tiny, dark red spots or looking like tiny haemorrhages within the light sensitive retina. Their sizes ranges from 10-
100microns i.e. less than 1/12th the diameter of an average optics disc and are circular in shape, at this stage, the disease is not eye
threatening.

2.2.2 Haemorrhages: Occurs in the deeper layers of the retina and are often called ‘blot’ haemorrhages because of their round
shape.

2.2.3 Hard exudates: These are one of the main characteristics of diabetic retinopathy and can vary in size from tiny specks to
large patches with clear edges. As well as blood, fluid that is rich in fat and protein is contained in the eye and this is what leaks out
to form the exudates. These can impair vision by preventing light from reaching the retina.

2.2.4 Soft exudates: These are often called ‘cotton wool spots’ and are more often seen in advanced retinopathy.

2.2.5 Neovascularisation: This can be describe as abnormal growth of blood vessels in areas of the eye including the retina and
is associated with vision loss. This occurs in response to ischemia, or diminished blood flow to ocular tissues. If these abnormal
blood vessels grow around the pupil, glaucoma can result from the increasing pressure within the eye. These new blood vessels
have weaker walls and may break and bleed, or cause scar tissue to grow that can pull the retina away from the back of the eye.
When the retina is pulled away it is called a retinal detachment and if left untreated, a retinal detachment can cause severe vision
loss, including blindness. Leaking blood can cloud the vitreous (the clear, jelly-like substance that fills the eye) and block the light
passing through the pupil to the retina, causing blurred and distorted images. In more advanced proliferate retinopathy; diabetic
fibrous or scar tissue can form on the retina.

Figure 2: Showing Abnormalities associated with Diabetic Retinopathy

This paper reviews the various retinal problems and techniques to analyze the elementary lesions for seriousness of the retinal
disease. The microaneurysm and haemorrhage detection can be used to grade the progression of DR into four stages: no DR, mild
DR, moderate DR and severe DR, as shown in Table 2.

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Table 2.Grading criteria of Diabetic Retinopathy
DR Grade Parameters
Grade 0 (No DR) MA = 0 & H = 0
Grade 1 (Mild) 1 ≤ MA 5 & H = 0
Grade 2 (Moderate) 5 < MA < 15 or 0 < H ≤ 5
Grade 3 (Severe) MA ≥ 15 or H > 5
Captions: MA = Microaneurysm, H = Haemorrhage

3. Literature Survey on Image Pre-Processing:

Detecting abnormalities associated with fundus image, the images have to be pre-processed in order to correct the problems of
uneven illumination problem, non-sufficient contrast between lesions and image background pixels and presence of noise in the
input fundus image. Aside from aforementioned problems, this section also highlights colour space conversion and image size
standardization for the system. In this section, various techniques for the preprocessing has been discussed.

In the method proposed by C.I.O. Martins et al. [2], [6] image preprocessing is performed on the green-plane Igreen of the
original RGB color image Iorg. This operation can be viewed as a shade correction procedure and consists in removing low
gradient regions from the green channel image Igreen. The image Ibg results from median filtering the Igreen image with a kernel
of 25x25 pixels. The size of the median filter kernel was chosen such that it is wider than the widest blood vessel in the used set of
images. The shade corrected image (Isc) is the difference between Igreen and Ibg, i.e., Isc = Igreen − Ibg.

A.J. Frame et al. [3] uses a technique of shade correction to remove illumination variations in the image by smoothing the
image with a large scale median filter and subtracting the filtered image from the original. The shade-corrected image is then
normalized to have the same maximum and minimum grey levels as the original image.

Akara Sopharak et al. [4] apply median filter on green band image to reduce the noise before Contrast Limited Adaptive
Histogram Equalization [8], then shade correction algorithm is applied to the green band in order to reduce background variation
due to non-uniform illumination. 35X35 median filter applied to the image to correct background variation.

3.1. Literature Survey on Lesion detection:

3.1.1. Microaneurysms:
Akara Sopharak and et al. [7] used segmentation technique to detect fine microaneurysms, from non-dilated pupils. The process
consists of two segmentation steps: a) Coarse segmentation using mathematic morphology and b) Fine segmentation using naive
Bayes classifier. A total of 18 microaneurysms features were extracted by naive Bayes classifier. The detected microaneurysms are
validated by comparing at pixel level with ophthalmologists’ data.

Balint Antal et al. [12] proposed an ensemble-based framework to improve microaneurysm detection. They proposed a
combination of internal components of microaneurysm detectors, namely preprocessing methods and candidate extractors, and
approach for microaneurysm detection.

Atsushi Mizutani et al. [15] investigated a computerized method for the detection of microaneurysms on retinal fundus images.
After image preprocessing, candidate regions for microaneurysms were detected using a double-ring filter. Any potential false
positives located in the regions corresponding to blood vessels were removed by automatic extraction of blood vessels from the
images. Twelve image features were determined, and the candidate lesions were classified into microaneurysms or false positives
using the rule-based method and an artificial neural network. The true positive fraction of the proposed method was 0.45 at 27 false
positives per image. Forty-two percent of microaneurysms in the 50 training cases were considered invisible by the consensus of
two co-investigators. When the method was evaluated for visible microaneurysms, the sensitivity for detecting microaneurysms
was 65% at 27 false positives per image.

Pallawala et al [11] proposed a microaneurysm segmentation and detection algorithm that is based on generalized eigenvectors
of affinity matrix. This technique is robust and has a minimal interference from other structures and lesions achieve 93% accuracy
in the detection of microaneurysms.

Quellec et al. [22] proposed lesion template in sub bands of wavelet transformed images. The optimization process is based on a
genetic algorithm followed by Powell’s direction set descent. Results are evaluated on 120 retinal images analyzed by an expert and
the optimal wavelet is compared to different conventional other wavelets. These images are of three different modalities: there are
colour photographs, green filtered photographs and angiographs. Depending on the imaging modality, microaneurysms were
detected with a sensitivity of respectively 89.62%, 90.24% and 93.74% and a positive predictive value of respectively 89.50%,
89.75% and 91.67%.

3.1.2 Exudates:
Amel et al. [5] combines k means clustering algorithm and mathematical morphology to detect hard exudates in retinal images
and obtained sensitivity of 95.92%, predictive value of 92.28% and accuracy of 99.70% using a lesion-based criterion.
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Hussain et al [23] adopt a combination of coarse and fine segmentation to detect hard exudates. The result is achieved with
89.7% sensitivity, 99.3% specificity and 99.4% accuracy. A limitation of this method is that it occasionally fails to exclude some
non-exudate objects particularly those that have similar features to real exudates. A limitation of their work is that it occasionally
fails to exclude some non-exudate objects particularly those that have similar features to real exudates.
Jaafar et al. [16] presents an automated method for the detection of bright lesions (exudates) in retinal images. In their work, an
adaptive thresholding based on a novel algorithm for pure splitting of the image is proposed. A coarse segmentation based on the
calculation of a local variation for all image pixels is used to outline the boundaries of all candidates which have clear borders. A
morphological operation is used to refine the adaptive thresholding results based on the coarse segmentation results. Using a
clinician reference standard (ground truth), images with exudates were detected with 91.2% sensitivity, 99.3% specificity, and
99.5% accuracy. Limitations occurs due to some incorrect non-exudates detection which are caused by those artifacts that have
similar features of real exudates.

Zohra et al. [9] proposed a computer based approach for the detection of diabetic retinopathy stage using color fundus images
.The features are extracted from the raw images using the image processing techniques and fed to the support vector machine
(SVM) and demonstrated a sensitivity of 97.5% for the classifier with the specificity of 100%.

3.1.3 Haemorrhages
Joshi et al. [14] propose algorithm in three main steps 1. Color image enhancement 2.Image subtraction to extract blood vessels
and haemorrhages and 3.Use of set of optimally adjusted morphological operators to suppress blood vessels and to highlight only
haemorrhages. These automatically detected haemorrhages are validated by comparing with expert ophthalmologists’ hand-drawn
ground-truths. Quantitative performance of algorithm is evaluated by calculating sensitivity and specificity and predictive value
(PV). The overall sensitivity, specificity and PV obtained are 89.49%, 99.89%, and 98.34% respectively. Draw of this method is
that it cannot detect faint and small haemorrhages.

Acharya et al. [24] based on the morphological operation and „Ball' shaped structuring element. The Haemorrhages were
detected by subtracting blood vessels from Haemorrhage candidates.

Godlin et al. [25] analyzed hemorrhage detection in retinal fundus images using classifier and segmentation methods. All the
database images into the pre-processing steps and some meaning full features are extracted from the images. Then ANFIS classifier
utilized to normal and abnormal images, this abnormal category into the hemorrhage detection process with help of segmentation
technique. Here Region growing (RG) with threshold optimization techniques are considered its known as Modified RG (MRG) to
get the maximum accuracy in the hemorrhage segmenting process.
Figure 3. shows graphical comparison of various methods for lesion detection

Figure 3: Comparison graph of various methods for lesion detection

4. Publically available data:
A list of public data repositories for retinal image analysis.
This section lists the public retinal data sets known to us. Unless otherwise stated, all data sets listed are easily reachable by a
Google search. Most descriptions are excerpts from the referred websites.

4.1 DRIVE [26] these photographs were obtained from a DR screening program in The Netherlands. The screening population
consisted of 400 diabetic subjects between 25-90 years of age. 40 photographs were randomly selected, 33 without and 7 with DR
signs. [13]

4.2 STARE [17] It consists of 31 images of healthy retinas and 50 images of retinas with disease, acquired using a TopCon TRV-
50 fundus camera at 35 field-of view, and subsequently digitized at 605x700 pixels in resolution, 24 bits per pixel (standard RGB).

4.3 MESSIDOR [27] contains 1200 eye fundus colour digital images of the posterior pole, acquired by 3 ophthalmologic
departments using a colour video 3CCD camera. Each set is divided into 4 zipped sub sets containing each 100 images in TIFF
format and an Excel file with medical diagnoses for each image. MESSIDOR set, have been made available by the Department of
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Electronic, Computer Systems and Automatic Engineering, University of Huelva, Spain at www.uhu.es/retinopathy/muestras/
Provided_ Information.zip. [18]

4.4 DIARETDB1 [28] consists of 89 colour fundus images. 84 contain at least mild non-proliferative DR signs (microaneurysms)
and 5 are considered normal. The data correspond to a good (not necessarily typical) practical situation, where images are
comparable and can be used to evaluate the general performance of diagnostic methods. [19]

4.5 ROC [29] Consist of set of 100 digital colour fundus photographs selected from a large data set (150000 images). Department
of Ophthalmology at the University of Iowa, were asked to annotate all microaneurysms and all irrelevant lesions in all 100 images
in the test and training set. [20]

4.6 REVIEW [30] It includes 16 images with 193 vessel segments, demonstrating a variety of pathologies and vessel types. These
image sets contain 5066 manually marked profiles. Images were assessed by three independent experts, who marked the vessel
edges. AREDS (Age Related Eye Disease Study; https://web.emmes.com/study/areds/, http://www.areds2.org/) is a major clinical
trial sponsored by the National Eye Institute (NEI) at the National Institutes of Health (http://www.nei.nih.gov/amd/), involving
several US centers working on ARMD. [21]

4.7 ARIA [31] contains colour fundus images collected at St Paul's Eye Unit and the University of Liverpool, UK, as part of the
ARIA project. The data is organised into three categories, namely, age-related macular degeneration subjects, healthy control-group
subjects, and diabetic subjects.

4.8 BIOIMLAB [32] The Univ of Padova, Italy, maintains a number of publicly available data sets for several measurements,
including vessel tortuosity ( 60 images from normal and hypertense patients; 30 images of retinal arteries of similar length and
calibre, 30 images of retinal veins of similar length and calibre, Matlab data structures).

4.9 HEI-MED [33] It is a collection of 169 fundus images. The data set contains a mixture of ethnic groups, with roughly 60%
African- American, 25% Caucausian, and 11% Hispanic.

5. CONCLUSION
There are various challenges in the automatic detection of lesions in diabetic retinopathy. The ratio of ophthalmologists to the
number of diabetic patient is very low. Ophthalmologists in India are insufficient to support the growing diabetic population.
This paper reviews different preprocessing and feature extraction methods proposed by various authors for diabetic lesions
detection along with the comparison between various techniques in terms of sensitivity and specificity. Recently there are many
automated techniques presented for the detection of diabetic disease with their grading of severity. The basic aim of this paper is to
introduce the concepts of DR, different publically available data sets used, and different techniques presented for detection of DR.
Paper summarizes the number of people with diabetes, types of retinopathy and abnormalities associated with it.
This paper act as a resource for future researchers interested in automated lesion detection which may reduce the cost and increase
productivity and efficiency for ophthalmologists.

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