Interpretable AI plus Handheld, Portable Retinal Photographs: A Low-Cost Glaucoma Screening Solution for West Africa

Early and accurate glaucoma detection is critical to prevent irreversible vision loss, yet existing AI methods often rely on unimodal inputs and lack interpretability. We present GlaBoost, a multimodal gradient boosting framework that unifies three complementary signals for glaucoma risk prediction: fundus image embeddings from a pretrained convolutional encoder,free-text neuroretinal rim assessments encoded by a transformer-based language model, and structured ophthalmic biomarkers. These modalities are fused into a single representation and classified by an enhanced XGBoost model.On two real-world annotated datasets, GlaBoost consistently outperforms unimodal and generic multimodal baselines. Feature importance analysis highlights the cup-to-disc ratio, rim thinning, and the ISNT rule as the dominant predictors, yielding clinically consistent and interpretable decisions. GlaBoost offers a transparent and scalable foundation for multimodal decision support in ophthalmology.

Large language models (LLMs) show promise in medical image interpretation but suffer from hallucination, limited accuracy, and run-to-run inconsistency. We developed and validated an agentic AI framework integrating LLMs with specialized deep learning tools for glaucoma detection from fundus photography. The workflow had three steps: (1) LLM initial assessment; (2) function calling to invoke specialized tools for image quality (QAModel, FundaQ-8), glaucoma classification (SwinV2-Tiny), and optic disc/cup segmentation (SegFormer-B0); and (3) LLM reflection integrating the initial impression with tool outputs. Two LLMs (Gemini 2.5 Flash, GPT-5.4 mini) were evaluated on two public datasets (ORIGA, n=100; RIM-ONE-v3, n=100) under uncropped and cropped fields of view; all images were independently graded by a masked fellowship-trained glaucoma specialist. The agentic workflow improved classification accuracy by 16 to 47 percentage points across all conditions, reaching within 6 points of the specialist; on RIM-ONE-v3 the best configurations matched the specialist accuracy of 88%. LLM-alone approaches failed in two ways: GPT-5.4 mini showed positive bias (sensitivity 95-100%, specificity 0-5%), while Gemini 2.5 Flash varied stochastically between runs; the agentic workflow corrected both. Cup-to-disc ratio error fell 15-50% (MAE 0.156-0.228 to 0.104-0.132), and correlation with specialist grading rose from weak (r=0.12-0.39) to moderate-strong (r=0.59-0.84). Run-to-run consistency rose from near-random (kappa as low as -0.01) to near-perfect (kappa up to 0.96). Integrating LLMs with specialized tools addressed key limitations of LLM-alone approaches, including over-diagnosis and run-to-run variability. Gains held for both LLMs, suggesting generalizability across backbones, and may signal a shift from monolithic models toward orchestrated multi-agent systems in medical AI.

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.