Measurement-Aware Multimodal LLM for No-Reference Low-Dose CT Quality Assessment

Medical Image Quality Assessment (IQA) serves as a critical safety gate for clinical AI, yet existing approaches rely on scalar metrics that fail to capture the descriptive, expert-like evaluation process central to clinical practice. We introduce MedQ-Bench, a comprehensive benchmark for language-based medical IQA evaluation with MLLMs, establishing a perception--description paradigm across 5 imaging modalities and over 40 quality attributes. The benchmark comprises two complementary tasks: MedQ-Perception probes low-level visual attribute discrimination via 2,600 expert-annotated perceptual queries; MedQ-Description covers both no-reference and comparison description sub-tasks with 708 expert-annotated samples, evaluated through a four-dimensional judging protocol. Comprehensive evaluation of 23 state-of-the-art MLLMs reveals that current models exhibit only preliminary and unstable capabilities, and highlights the urgent need for targeted optimization of MLLMs in medical IQA. Project & Dataset: https://github.com/liujiyaoFDU/MedQ-Bench

Multimodal large language models (MLLMs) have shown strong potential for image quality assessment (IQA) by improving consistency between quality ratings and their underlying reasoning. However, most approaches supervise reasoning through human-provided ratings and rarely examine whether it faithfully reflects image quality. Rating accuracy alone does not ensure faithful reasoning; a shared reward also obscures supervision sources and may reinforce unfaithful reasoning when a correct rating occurs by chance. To improve the faithfulness and reliability of blind IQA, we aim to (1) decouple credit assignment for reasoning and rating and (2) provide verifiable supervision for faithful reasoning. We introduce MR-IQA-2, an actor-editor-judge framework that operationalizes reasoning-editing-reflection. The actor generates quality reasoning for an input image, and the editor revises the image according to the identified quality factors. A frozen judge compares the original and edited images and provides reflective supervision for the actor's reasoning. MR-IQA-2 further uses fine-grained credit assignment to decouple reasoning and rating supervision. Judge feedback supervises reasoning, whereas human ratings supervise the predicted rating. Masked token-specific updates distinguish these signals while preserving the causal relation from reasoning to rating. Across IQA benchmarks, MR-IQA-2 achieves competitive rating alignment with humans. Visual reflection also enables richer and more faithful visual understanding beyond rating, which may inform image-quality optimization and related downstream tasks. Code is available at https://github.com/RobinY99/MR-IQA-2.

Image Quality Assessment (IQA) in open-world environments remains challenging due to limited generalization and interpretability. Recent approaches based on multimodal large language models (MLLMs) introduce textual reasoning for quality prediction, yet their judgments rely heavily on semantically biased internal representations, making them insensitive to low-level perceptual degradations. We propose IQA-T1, a tool-based visual evidence reasoning framework that augments MLLM reasoning with explicit perceptual observations. During inference, the model autonomously invokes specialized analysis tools to generate structured visual evidence, such as noise residual maps, gradient statistics, and frequency spectra, which are progressively integrated into the reasoning process. To support this paradigm, we construct Q-Tool, a dataset containing 11k multimodal reasoning chains grounded in tool-generated evidence. Extensive experiments on seven IQA benchmarks show that IQA-T1 achieves the best overall performance across datasets while producing interpretable and evidence-grounded quality assessments. Code and dataset are available at https://github.com/zibuyu-02/IQA-T1.