Bridging Restoration and Diagnosis: A Comprehensive Benchmark for Retinal Fundus Enhancement

Progress in AI-based retinal image analysis has advanced with foundation models, yet evaluating their reliability remains challenging. Performance reported on a single dataset does not capture how models behave under dataset shift, across clinical definitions, or for different patient subgroups. This limitation is particularly critical in medical imaging analysis, where robustness, calibration, and fairness are essential for safe deployment. We introduce FOCUS (Foundation Ophthalmic Cross-Dataset Understanding under Shift), a cross-dataset benchmark for evaluating retinal fundus models that considers vision-only encoder models (VM), vision-language dual-encoder models (VLM), and multimodal large language models (MLLM). FOCUS harmonizes binary diabetic retinopathy, referable diabetic retinopathy, and glaucomatous optic neuropathy tasks across ten public datasets spanning diverse geographies, acquisition conditions, and label protocols. The benchmark evaluates models through a unified analysis layer that measures ranking performance, calibration, subgroup disparities, and image-quality robustness. We present a large-scale evaluation covering 532 base configurations and 228 MLLM configurations adapted through supervised fine-tuning with low-rank adaptation (LoRA). Results show that no model family consistently dominates across tasks and datasets: general VM encoders achieve the strongest average ranking performance, medical MLLMs are competitive but variable, and dual encoder VLMs benefit substantially from lightweight adaptation. Fine-tuning improves in-domain performance but exhibits heterogeneous transfer to external datasets, particularly in calibration. These findings demonstrate that retinal model evaluation is inherently multidimensional. FOCUS provides a practical framework and public benchmark to assess generalization, reliability, and robustness beyond single-dataset leaderboards

Background: Retinal fundus imaging is central to the early diagnosis of sight-threatening conditions including diabetic retinopathy, glaucoma, and retinal vein occlusion. Clinical utility of fundus images is routinely compromised by non-uniform illumination, motion blur, and low contrast - artefacts that increase the risk of diagnostic error. Effective image enhancement is therefore a prerequisite for reliable computer-aided ophthalmic diagnosis. Methods: This study proposes a two-stage image enhancement pipeline combining luminosity correction via HSV colour space decomposition with Contrast Limited Adaptive Histogram Equalization (CLAHE) applied exclusively to the Value (V) channel. Experiments are conducted on the publicly available DRIVE dataset (40 retinal fundus images, 584 x 565 pixels, Canon CR5 camera, ophthalmologist-annotated ground truth). Quantitative evaluation employs Peak Signal-to-Noise Ratio (PSNR), Structural Similarity Index (SSIM), and Contrast-to-Noise Ratio (CNR). Baseline comparisons include standard Histogram Equalization (HE) and Adaptive Histogram Equalization (AHE). A binary masking step is subsequently applied to isolate hyper-reflective regions consistent with vascular pathology. Results: The proposed method achieves PSNR = 29.3 dB, SSIM = 0.91, and CNR = 3.12 - outperforming HE (PSNR = 21.4 dB, SSIM = 0.74) and AHE (PSNR = 23.1 dB, SSIM = 0.79) across all metrics, with an average processing time of 0.14 seconds per image. Conclusions: The combined luminosity-CLAHE pipeline yields measurably superior contrast and structural fidelity compared to established baseline methods, with processing speed compatible with clinical screening workflows. Limitations and directions for deep-learning-based comparison are discussed.

Generative image models such as diffusion models can improve performance on clinically relevant tasks by offering deep learning models supplementary training data. However, most conditional diffusion models treat disease stages as independent classes, ignoring the continuous nature of disease progression. This mismatch is problematic in medical imaging because continuous pathological processes are typically only observed through coarse, discrete but ordered labels as in ophthalmology for diabetic retinopathy (DR). We propose an ordinal latent diffusion model for generating color fundus images that explicitly incorporates the ordered structure of DR severity into the generation process. Instead of categorical conditioning, we used a scalar disease representation, enabling a smooth transition between adjacent stages. We evaluated our approach using visual realism metrics and classification-based clinical consistency analysis on the EyePACS dataset. Compared to a standard conditional diffusion model, our model reduced the Fréchet inception distance for four of the five DR stages and increased the quadratic weighted $κ$ from 0.79 to 0.87. Furthermore, interpolation experiments showed that the model captured a continuous spectrum of disease progression learned from ordered, coarse class labels. Code available at https://github.com/berenslab/OrdinalDiffusionModels.