Fundus Image-based Glaucoma Screening via Retinal Knowledge-Oriented Dynamic Multi-Level Feature Integration

Glaucoma is a progressive optic neuropathy characterized by irreversible damage to the optic nerve, making timely diagnosis critical to prevent permanent vision loss. Although deep learning has demonstrated promising performance in automated glaucoma detection, existing approaches often overlook feature refinement, suffer from class imbalance, and rely on individual classifiers that limit prediction robustness. To address these challenges, this paper proposes a hybrid glaucoma detection framework that integrates attention-enhanced deep feature extraction with heterogeneous ensemble learning. Specifically, deep representations are extracted using InceptionV3 and subsequently refined by incorporating the Convolutional Block Attention Module (CBAM) to enhance discriminative retinal features. To improve classification robustness, the extracted features are classified using multiple machine learning models together with Single-Level Ensemble (SLE) and Double-Level Ensemble (DLE) strategies, while SMOTE combined with Tomek Links (SMOTE+TL) is employed to alleviate class imbalance. Furthermore, a systematic comparison of handcrafted, deep, and attention-enhanced deep feature representations is conducted. Experimental evaluation on two public retinal fundus datasets demonstrates that deep feature-based methods consistently outperform handcrafted feature-based methods, while the proposed attention-enhanced framework achieves the best overall performance. Furthermore, Grad-CAM visualizations confirm that the proposed model focuses on clinically relevant retinal regions, providing interpretable evidence on the model's prediction process.

Glaucoma is a leading cause of irreversible blindness worldwide, yet most automated diagnosis systems rely on opaque deep-learning models that offer little clinical interpretability. We present GlaKG, a biomarker-centric fundus knowledge graph that integrates structural biomarkers, clinically grounded rules, and image features to produce traceable reasoning for glaucoma diagnosis and risk stratification. GlaKG encodes six entity types (Fundus Image, Optic Disc, Neural Rim, Pathology, Diagnosis, Risk Level), eight relation types, and 11 clinically validated rules into a unified graph, so that every prediction is accompanied by an explicit reasoning chain linking biomarker evidence to activated clinical rules. To keep knowledge-based reasoning strictly separate from label information, we adopt a post-processing fusion framework that combines ResNet50 image embeddings with a normalized KG reasoning-chain score via a tunable weight alpha, with all fitting confined to the training split. On a publicly available, AI-annotated fundus dataset, GlaKG reaches F1 = 0.9953 for binary glaucoma classification and 0.930 accuracy with 0.922 weighted F1 for four-class risk stratification; we report openly that the dataset's biomarker annotations are highly label-correlated, and therefore frame these figures as an upper bound attainable with clean structured biomarkers rather than as leakage-free image-only performance. Feature-importance analysis shows KG-derived and biomarker features contributing near-equally (51.1% vs. 48.9%), and the reasoning chain flags borderline cases by exposing low chain scores rather than failing silently. GlaKG's central contribution is therefore a clinically auditable reasoning framework that complements raw predictive performance by explicitly exposing the biomarker evidence and rule activations behind each decision.

Glaucoma is a progressive eye disease that can lead to irreversible vision loss if not detected at an early stage. Conventional diagnostic procedures are often time-consuming and rely heavily on expert interpretation, limiting their scalability for large-scale screening. In this study, glaucoma detection is investigated under two evaluation settings: sample-wise, where individual samples are analyzed independently, and patient-wise, where data from each patient are aggregated for final prediction. An automated multimodal framework is proposed that integrates fundus images with clinical data. Under the sample-wise setting, detection is performed using fundus images and clinical features individually, as well as through their multimodal combination. Under the patient-wise setting, predictions are obtained by aggregating multiple fundus image representations with corresponding clinical information for each patient. Deep visual features are extracted using a Vision Transformer (ViT) architecture and classified using classical machine-learning models, with a stacking-based ensemble of the three best-performing classifiers employed to optimize performance. Experiments conducted on the publicly available PAPILA dataset demonstrate strong diagnostic performance, achieving 97.47% accuracy and a 97.50% F1-score for sample-wise multimodal classification, and 98.97% accuracy and F1-score for subject-wise detection. The proposed framework is further deployed as an end-to-end web-based platform to support automated glaucoma screening and clinical decision support.