# Uncertainty-Aware Last-Layer Adaptation of RETFound for Referable Diabetic Retinopathy Screening Under Dataset Shift

arXiv: https://arxiv.org/abs/2607.02569 · HTML: https://mlsanity.com/paper/2607.02569/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 6 of its 15 references that are in the map.
- First posted on arXiv 30 Jun 2026.

## Builds on (most cited first, 6 of 6)

- [On Calibration of Modern Neural Networks](https://mlsanity.com/paper/1706.04599/) (2017)
- [Selective Classification for Deep Neural Networks](https://mlsanity.com/paper/1705.08500/) (2017)
- [Weight Uncertainty in Neural Networks](https://mlsanity.com/paper/1505.05424/) (2015)
- [Simple and Principled Uncertainty Estimation with Deterministic Deep Learning via Distance Awareness](https://mlsanity.com/paper/2006.10108/) (2020)
- [Laplace Redux -- Effortless Bayesian Deep Learning](https://mlsanity.com/paper/2106.14806/) (2021)
- [FusionFM: Fusing Eye-specific Foundational Models for Optimized Ophthalmic Diagnosis](https://mlsanity.com/paper/2508.11721/) (2025)

## Abstract (arXiv)

This paper presents a safety-centered empirical evaluation of uncertainty-aware last-layer adaptation for referable diabetic retinopathy screening using RETFound, a self-supervised vision-transformer retinal foundation model used here as a frozen feature encoder, and the public APTOS 2019 and DDR diabetic retinopathy fundus image datasets. We compare a cached-feature softmax head, post-hoc temperature scaling, variational Bayesian last-layer heads, a diagonal Laplace last-layer approximation, and an SNGP-style cached-feature head. On APTOS, uncertainty-aware operating points improved sensitivity and selective-referral behavior. The strongest APTOS selective-referral result deferred approximately 20 percent of cases and reduced accepted-case false negatives to zero while preserving high accepted-case specificity. However, threshold tuning also reduced false negatives at high false-positive cost, so false-negative reduction alone was not unique to Bayesian modeling. On DDR, native Bayesian heads qualitatively reproduced the APTOS direction but with weaker tradeoffs, while the APTOS-trained SNGP checkpoint transferred poorly and failed to provide useful external selective-referral behavior. These results highlight the value of safety-centered evaluation beyond aggregate accuracy: uncertainty-aware last-layer heads can improve internal safety-oriented operating points, but trustworthy retinal screening claims require explicit safety-coverage evaluation and second-dataset validation under shift.