EFIQA: Explainable Fundus Image Quality Assessment via Anatomical Priors
Authors: Pengwei Wang, José Morano, Qian Wan, Hrvoje Bogunović
Organizations: Institute of Artificial Intelligence, Center for Medical Data Science, Medical University of Vienna, Austria · Christian Doppler Lab for Artificial Intelligence in Retina, Medical University of Vienna, Austria
Abstract
Image quality control is vital for a wide range of downstream applications. Deep learning-based image quality assessment methods typically train classifiers on dataset-specific quality labels, inheriting two limitations: (1) generalization is tied to the labeling criteria of the training set and (2) these methods cannot provide spatial feedback on where the quality is degraded, lacking explainability. In this work, we propose EFIQA, a framework that requires no quality-related supervision and produces spatial quality maps by design. Rather than learning what is degradation" from human-annotated labels, EFIQA learns what should be there" by leveraging anatomical priors. For fundus photography, we instantiate this as a two-stage approach, by first training an unsupervised anomaly detector via masked anatomical inpainting to identify regions of missing vasculature, and then distilling this prior knowledge into a shallow adapter mapping features of a frozen foundation model to precise quality maps. External-dataset evaluation demonstrates that this label-free approach with minimal adaptation achieves better performance and explainability compared with supervised methods across benchmarks with different quality criteria, highlighting its potential for real-world applications.
Color fundus photography (CFP) is the most common ophthalmic imaging modality for large-scale screening. However, it is highly susceptible to degradations, making robust fundus image quality assessment (FIQA) crucial. The criteria for what constitutes high-quality at the image level vary across clinical tasks, making FIQA dependent on expert knowledge. This motivated the development of automated methods and datasets. While existing datasets aim to standardize image-level quality, their criteria often differ. Furthermore, image-level labels preclude the quantitative evaluation of localized degradations, which is essential for trustworthy FIQA. We argue that pixel-level FIQA based on anatomical visibility represents a more task-agnostic, explainable approach. In this work, we introduce FunPiQ, the first FIQA benchmark to provide pixel-level quality annotations. In addition, we propose EFIQA-CP, an explainable-by-design (EBD) method that uses quality pseudo-labels based on anatomical visibility to train a CNN via Non-Negative Positive-Unlabeled learning. Extensive evaluations of classification methods with post-hoc explanations, anomaly detection methods, and EBD methods demonstrate the superior performance of the last and, particularly, of EFIQA-CP.
Visual Question Answering (VQA) holds great promise for clinical support, particularly in ophthalmology, where retinal fundus photography is essential for diagnosis. However, ophthalmic VQA benchmarks primarily emphasize answer accuracy, neglecting the explicit visual evidence necessary for clinical interpretability. In this work, we introduce FundusGround, a new benchmark for clinically interpretable ophthalmic VQA with spatially-grounded lesion evidence. Specifically, we propose a three-stage pipeline that collects 10,719 fundus images with 15,595 image-level meticulously annotated lesions. To ensure anatomical consistency and clinical validity, all lesions are spatially localized using the Early Treatment Diabetic Retinopathy Study (ETDRS) grid, enabling standardized mapping to nine clinically meaningful retinal regions. Built upon this structured lesion evidence, 72,706 questions are then generated spanning four formats: open-ended, closed-ended, single-choice, and multiple-choice. We further benchmark multiple general- and medical- large vision-language models using dual metrics for answer accuracy and lesion-level reasoning. The experiments demonstrate that incorporating lesion-level visual evidence consistently improves model performance and transparency, highlighting the necessity of explicit spatial grounding for reliable and explainable ophthalmic VQA.
Face Image Quality Assessment (FIQA) aims to assess the recognition utility of face samples and is essential for reliable face recognition (FR) systems. Existing approaches require computationally expensive procedures such as multiple forward passes, backpropagation, or additional training, and only recent work has focused on the use of Vision Transformers. Recent studies highlighted that these architectures inherently function as saliency learners with attention patterns naturally encoding spatial importance. This work proposes ATTN-FIQA, a novel training-free approach that investigates whether pre-softmax attention scores from pre-trained Vision Transformer-based face recognition models can serve as quality indicators. We hypothesize that attention magnitudes intrinsically encode quality: high-quality images with discriminative facial features enable strong query-key alignments producing focused, high-magnitude attention patterns, while degraded images generate diffuse, low-magnitude patterns. ATTN-FIQA extracts pre-softmax attention matrices from the final transformer block, aggregate multi-head attention information across all patches, and compute image-level quality scores through simple averaging, requiring only a single forward pass through pre-trained models without architectural modifications, backpropagation, or additional training. Through comprehensive evaluation across eight benchmark datasets and four FR models, this work demonstrates that attention-based quality scores effectively correlate with face image quality and provide spatial interpretability, revealing which facial regions contribute most to quality determination.