# PARAGraph: Pathology-Anatomy-Aware Hierarchical Graph for Diabetic Retinopathy Grading

arXiv: https://arxiv.org/abs/2608.08368 · HTML: https://mlsanity.com/paper/2608.08368/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 15 of its 32 references that are in the map.
- First posted on arXiv 8 Aug 2026.

## Builds on (most cited first, 15 of 15)

- [Attention Is All You Need](https://mlsanity.com/paper/1706.03762/) (2017)
- [An Image is Worth 16x16 Words: Transformers for Image Recognition at Scale](https://mlsanity.com/paper/2010.11929/) (2020)
- [U-Net: Convolutional Networks for Biomedical Image Segmentation](https://mlsanity.com/paper/1505.04597/) (2015)
- [Swin Transformer: Hierarchical Vision Transformer using Shifted Windows](https://mlsanity.com/paper/2103.14030/) (2021)
- [Graph Attention Networks](https://mlsanity.com/paper/1710.10903/) (2017)
- [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)
- [Axiomatic Attribution for Deep Networks](https://mlsanity.com/paper/1703.01365/) (2017)
- [Learning Deep Features for Discriminative Localization](https://mlsanity.com/paper/1512.04150/) (2015)
- [RISE: Randomized Input Sampling for Explanation of Black-box Models](https://mlsanity.com/paper/1806.07421/) (2018)
- [ERASER: A Benchmark to Evaluate Rationalized NLP Models](https://mlsanity.com/paper/1911.03429/) (2019)
- [A Benchmark for Studying Diabetic Retinopathy: Segmentation, Grading, and Transferability](https://mlsanity.com/paper/2008.09772/) (2020)
- [GREEN: a Graph REsidual rE-ranking Network for Grading Diabetic Retinopathy](https://mlsanity.com/paper/2007.09968/) (2020)
- [XAI-MeD: Explainable Knowledge Guided Neuro-Symbolic Framework for Domain Generalization and Rare Class Detection in Medical Imaging](https://mlsanity.com/paper/2601.02008/) (2026)

## Abstract (arXiv)

Diabetic retinopathy (DR) remains a leading cause of vision loss among working-age adults worldwide, making reliable severity grading clinically important. Despite strong performance, most deep models formulate DR grading as image-level classification and do not explicitly model clinically grounded evidence, such as lesion types and spatial relations. In this paper, we propose PARAGraph, a Pathology-Anatomy-Aware Hierarchical Graph framework for DR grading. PARAGraph represents each image as a three-level hierarchical graph with lesion-level nodes, intermediate category and region nodes, and global anatomical and semantic nodes. To incorporate medical priors into nodes, we construct an optic disc-fovea-anchored coordinate frame that provides a scale- and rotation-normalized retinal reference system. Within this frame, lesion nodes are encoded with category, normalized area, and anatomical coordinates. To mitigate noisy lesion segmentation, PARAGraph uses a dual-fusion strategy that introduces global visual context into a graph semantic node and a decision-level prediction branch, improving robustness when lesion evidence is unreliable. Extensive experiments on Messidor-2, APTOS, and DDR show that PARAGraph achieves consistent DR grading performance over state-of-the-art methods. Interpretability and robustness analyses further demonstrate that its predictions are clinically grounded, closely associated with lesion evidence and robust to lesion segmentation noise.