Cited by 43Retinal Imaging and AnalysisArtificial Intelligence in HealthcareRetinal Diseases and Treatments

Use of artificial intelligence with retinal imaging in screening for diabetes-associated complications: systematic review

Open access
Yang, Qianhui, Bee, Yong Mong, Lim, Ciwei Cynthia, Sabanayagam, Charumathi, Yim-Lui Cheung, Carol, Wong, Tien Yin, Ting, Daniel S.W., Lim, Lee-Ling +6 more·2025·eClinicalMedicine

Abstract

Background: Artificial Intelligence (AI) has been used to automate detection of retinal diseases from retinal images with great success, in particular for screening for diabetic retinopathy, a major complication of diabetes. Since persons with diabetes routinely receive retinal imaging to evaluate their diabetic retinopathy status, AI-based retinal imaging may have potential to be used as an opportunistic comprehensive screening for multiple systemic micro- and macro-vascular complications of diabetes. Methods: We conducted a qualitative systematic review on published literature using AI on retina images to detect systemic diabetes complications. We searched three main databases: PubMed, Google Scholar, and Web of Science (January 1, 2000, to October 1, 2024). Research that used AI to evaluate the associations between retinal images and diabetes-associated complications, or research involving diabetes patients with retinal imaging and AI systems were included. Our primary focus was on articles related to AI, retinal images, and diabetes-associated complications. We evaluated each study for the robustness of the studies by development of the AI algorithm, size and quality of the training dataset, internal validation and external testing, and the performance. Quality assessments were employed to ensure the inclusion of high-quality studies, and data extraction was conducted systematically to gather pertinent information for analysis. This study has been registered on PROSPERO under the registration ID CRD42023493512. Findings: From a total of 337 abstracts, 38 studies were included. These studies covered a range of topics related to prediction of diabetes from pre-diabetes or non-diabeticindividuals (n = 4), diabetes related systemic risk factors (n = 10), detection of microvascular complications (n = 8) and detection of macrovascular complications (n = 17). Most studies (n = 32) utilized color fundus photographs (CFP) as retinal image modality, while others employed optical coherence tomography (OCT) (n = 6). The performance of the AI systems varied, with an AUC ranging from 0.676 to 0.971 in prediction or identification of different complications. Study designs included cross-sectional and cohort studies with sample sizes ranging from 100 to over 100,000 participants. Risk of bias was evaluated by using the Newcastle-Ottawa Scale and AXIS, with most studies scoring as low to moderate risk. Interpretation: Our review highlights the potential for the use of AI algorithms applied to retina images, particularly CFP, to screen, predict, or diagnose the various microvascular and macrovascular complications of diabetes. However, we identified few studies with longitudinal data and a paucity of randomized control trials, reflecting a gap between the development of AI algorithms and real-world implementation and translational studies. Funding: Dr. Gavin Siew Wei TAN is supported by: 1. DYNAMO: Diabetes studY on Nephropathy And other Microvascular cOmplications II supported by National Medical Research Council (MOH-001327-03): data collection, analysis, trial design 2. Prognositc significance of novel multimodal imaging markers for diabetic retinopathy: towards improving the staging for diabetic retinopathy supported by NMRC Clinician Scientist Award (CSA)-Investigator (INV) (MOH-001047-00).

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  • Models constructed with clinical data such as electronic health records, laboratory tests, and imaging are the most widely used due to their high accessibility.

    “At the feature level, models constructed with clinical data such as EHR [148, 149], laboratory tests [150, 151], and imaging [152, 153] are the most widely used due to their high accessibility.”

    From Artificial intelligence-powered prediction of diabetic complications: from clinical data to molecular omics (2026) · cites this paper as [153]

    The Introduction (page unavailable) describes retinal-imaging AI models and says retinal images can be obtained during routine examinations, making their use easy to scale. This supports the imaging example and its accessibility, but the paper does not establish that imaging-based models are among the most widely used model types. The EHR and laboratory-test examples have separate citations and are not attributed to this source. (LLM, conf=0.84)

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Authors
Yang, Q., Bee, Y. M., Lim, C. C., Sabanayagam, C., Yim-Lui Cheung, C., Wong, T. Y., Ting, D. S. W., Lim, L.-L., Li, H., He, M., Lee, A. Y., Shaw, A. J., Keong, Y. K., & Wei Tan, G. S.
Affiliations
  • Singapore National Eye Center (SG)
  • Singapore General Hospital (SG)
  • Tianjin Medical University Eye Hospital (CN)
  • University of Malaya (MY)
  • Shanghai Jiao Tong University (CN)
  • Hong Kong Polytechnic University (HK)
  • University of Washington (US)
  • Duke University (US)
  • National Heart Centre Singapore (SG)
Venue
eClinicalMedicine
Publisher
Elsevier BV
Published
2025-03
Volume
81
Pages
103089
ISSN
2589-5370 (ISSN-L)
OpenAlex
W4407698494
Cited by
38
References
98
Citations by year
2026: 23 · 2025: 15
FWCI
6.00
Type
journal article
Language
en
Open access
Locations
  • EClinicalMedicine (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • PolyU Institutional Research Archive (Hong Kong Polytechnic University) (publishedVersion, cc-by-nc-nd)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
National Medical Research Council (OFLCG/001/2017, MOH-CSAINV21jun-005, MOHOFLCG22may-0003)
Topics
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Retinal Imaging and Analysis
  • Health Sciences › Health Professions › Health Information Management › Artificial Intelligence in Healthcare
  • Health Sciences › Medicine › Ophthalmology › Retinal Diseases and Treatments
Keywords
artificial intelligence, retinal imaging, diabetic retinopathy, diabetes complications, diabetic microvascular complications, diabetic macrovascular complications, color fundus images, optical coherence tomography, opportunistic screening, diabetes prediction, retinal biomarkers, deep learning, risk of bias, external validation, training data quality, algorithm interpretability, explainable AI, clinical implementation barriers, health equity

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