# From Pixels to Explanations: Interpretable Diabetic Retinopathy Grading with CNN-Transformer Ensembles, Visual Explainability and Vision-Language Models

arXiv: https://arxiv.org/abs/2604.23079 · HTML: https://mlsanity.com/paper/2604.23079/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Medical vision-language models, one of 16 directions in Multimodal LLMs / vision-language models.
- Builds on 13 of its 36 references that are in the map.
- First posted on arXiv 25 Apr 2026.

## Placed in

- Multimodal LLMs / vision-language models / [Medical vision-language models](https://mlsanity.com/mllm/medical-vision-language-models/)

## Builds on (most cited first, 13 of 13)

- [Deep Residual Learning for Image Recognition](https://mlsanity.com/paper/1512.03385/) (2015)
- [Swin Transformer: Hierarchical Vision Transformer using Shifted Windows](https://mlsanity.com/paper/2103.14030/) (2021)
- [Grad-CAM: Visual Explanations from Deep Networks via Gradient-based Localization](https://mlsanity.com/paper/1610.02391/) (2016)
- [Densely Connected Convolutional Networks](https://mlsanity.com/paper/1608.06993/) (2016)
- [EfficientNet: Rethinking Model Scaling for Convolutional Neural Networks](https://mlsanity.com/paper/1905.11946/) (2019)
- [BERTScore: Evaluating Text Generation with BERT](https://mlsanity.com/paper/1904.09675/) (2019)
- [Training data-efficient image transformers & distillation through attention](https://mlsanity.com/paper/2012.12877/) (2020)
- [CLIPScore: A Reference-free Evaluation Metric for Image Captioning](https://mlsanity.com/paper/2104.08718/) (2021)
- [LLaVA-Med: Training a Large Language-and-Vision Assistant for Biomedicine in One Day](https://mlsanity.com/paper/2306.00890/) (2023)
- [Albumentations: fast and flexible image augmentations](https://mlsanity.com/paper/1809.06839/) (2018)
- [FunBench: Benchmarking Fundus Reading Skills of MLLMs](https://mlsanity.com/paper/2503.00901/) (2025)
- [Enhancing DR Classification with Swin Transformer and Shifted Window Attention](https://mlsanity.com/paper/2504.15317/) (2025)
- [XDR-LVLM: An Explainable Vision-Language Large Model for Diabetic Retinopathy Diagnosis](https://mlsanity.com/paper/2508.15168/) (2025)

## Abstract (arXiv)

The quality of diabetic retinopathy (DR) screening relies on the ability to correctly grade severity; however, many deep-learning (DL) classifiers cannot be easily interpreted in the clinical context. This study presents a methodology that combines strong discriminative models with multimodal explanations, converting retinal pixels into clinically interpretable outputs. Using the APTOS 2019 benchmark, we evaluated six representative CNN- and transformer-based backbones under a controlled protocol with stratified five-fold cross-validation. We then compared ensembling strategies (hard voting, weighted soft voting, stacking) and investigated a hybrid class-level fusion variant to exploit grade-specific advantages. For interpretability, we produced Grad-CAM++ visual attribution maps and short textual rationales using vision-language models (VLMs) conditioned on the fundus image and classifier outputs under conservative prompting constraints. Modern CNN backbones (ResNet-50 and ConvNeXt-Tiny) provided the strongest single-model baselines, with cross-validated QWK up to 0.919 and 0.914, respectively. Ensembling improved ordinal agreement, and weighted soft voting was the most consistent across folds (QWK 0.934 +/- 0.017). Hybrid class-level fusion was competitive but did not yield a statistically reliable improvement over standard fusion in paired fold comparisons (Holm-adjusted p >= 1.000). For explanation quality, Grad-CAM++ offered plausible but coarse localization, and VLM rationales were generally grade-consistent. Quantitatively, VLM variants showed a trade-off between clinical completeness and template-level semantic similarity (coverage 0.700 vs. BERTScore 0.072), while image-text alignment was comparable (CLIPScore approximately 0.34).