Reliability of using retinal vascular fractal dimension as a biomarker in the diabetic retinopathy detection

The retinal fractal dimension (FD) is a measure of vasculature branching pattern complexity. FD has been considered as a potential biomarker for the detection of several diseases like diabetes and hypertension. However, conflicting findings were found in the reported literature regarding the association between this biomarker and diseases. In this paper, we examine the stability of the FD measurement with respect to (1) different vessel annotations obtained from human observers, (2) automatic segmentation methods, (3) various regions of interest, (4) accuracy of vessel segmentation methods, and (5) different imaging modalities. Our results demonstrate that the relative errors for the measurement of FD are significant and FD varies considerably according to the image quality, modality, and the technique used for measuring it. Automated and semiautomated methods for the measurement of FD are not stable enough, which makes FD a deceptive biomarker in quantitative clinical applications.