Comprehensive Evaluation of OCT-based Automated Segmentation of Retinal Layer, Fluid and Hyper-Reflective Foci: Impact on Clinical Assessment of Diabetic Retinopathy Severity

Diabetic retinopathy (DR) is a leading cause of vision loss, requiring early and accurate assessment to prevent irreversible damage. Spectral Domain Optical Coherence Tomography (SD-OCT) enables high-resolution retinal imaging, but automated segmentation performance varies, especially in cases with complex fluid and hyperreflective foci (HRF) patterns. This study proposes an active-learning-based deep learning pipeline for automated segmentation of retinal layers, fluid, and HRF, using four state-of-the-art models: U-Net, SegFormer, SwinUNETR, and VM-UNet, trained on expert-annotated SD-OCT volumes. Segmentation accuracy was evaluated with five-fold cross-validation, and retinal thickness was quantified using a K-nearest neighbors algorithm and visualized with Early Treatment Diabetic Retinopathy Study (ETDRS) maps. SwinUNETR achieved the highest overall accuracy (DSC = 0.7719; NSD = 0.8149), while VM-UNet excelled in specific layers. Structural differences were observed between non-proliferative and proliferative DR, with layer-specific thickening correlating with visual acuity impairment. The proposed framework enables robust, clinically relevant DR assessment while reducing the need for manual annotation, supporting improved disease monitoring and treatment planning.