Predicting systemic diseases in fundus images: systematic review of setting, reporting, bias, and models’ clinical availability in deep learning studies


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Background Analyzing fundus images with deep learning techniques is promising for screening systematic diseases. However, the quality of the rapidly increasing number of studies was variable and lacked systematic evaluation. Objective To systematically review all the articles that aimed to predict systemic parameters and conditions using fundus image and deep learning, assessing their performance, and providing suggestions that would enable translation into clinical practice. Methods Two major electronic databases (MEDLINE and EMBASE) were searched until August 22, 2023, with keywords ‘deep learning’ and ‘fundus’. Studies using deep learning and fundus images to predict systematic parameters were included, and assessed in four aspects: study characteristics, transparent reporting, risk of bias, and clinical availability. Transparent reporting was assessed by the TRIPOD statement, while the risk of bias was assessed by PROBAST. Results 4969 articles were identified through systematic research. Thirty-one articles were included in the review. A variety of vascular and non-vascular diseases can be predicted by fundus images, including diabetes and related diseases (19%), sex (22%) and age (19%). Most of the studies focused on developed countries. The models’ reporting was insufficient in determining sample size and missing data treatment according to the TRIPOD. Full access to datasets and code was also under-reported. 1/31(3.2%) study was classified as having a low risk of bias overall, whereas 30/31(96.8%) were classified as having a high risk of bias according to the PROBAST. 5/31(16.1%) of studies used prospective external validation cohorts. Only two (6.4%) described the study’s calibration. The number of publications by year increased significantly from 2018 to 2023. However, only two models (6.5%) were applied to the device, and no model has been applied in clinical. Conclusion Deep learning fundus images have shown great potential in predicting systematic conditions in clinical situations. Further work needs to be done to improve the methodology and clinical application.
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