TWLR: Text-Guided Weakly-Supervised Lesion Localization and Severity Regression for Explainable Diabetic Retinopathy Grading

Accurate medical image analysis can greatly assist clinical diagnosis, but its effectiveness relies on high-quality expert annotations Obtaining pixel-level labels for medical images, particularly fundus images, remains costly and time-consuming. Meanwhile, despite the success of deep learning in medical imaging, the lack of interpretability limits its clinical adoption. To address these challenges, we propose TWLR, a two-stage framework for interpretable diabetic retinopathy (DR) assessment. In the first stage, a vision-language model integrates domain-specific ophthalmological knowledge into text embeddings to jointly perform DR grading and lesion classification, effectively linking semantic medical concepts with visual features. The second stage introduces an iterative severity regression framework based on weakly-supervised semantic segmentation. Lesion saliency maps generated through iterative refinement direct a progressive inpainting mechanism that systematically eliminates pathological features, effectively downgrading disease severity toward healthier fundus appearances. Critically, this severity regression approach achieves dual benefits: accurate lesion localization without pixel-level supervision and providing an interpretable visualization of disease-to-healthy transformations. Experimental results on the FGADR, DDR, and a private dataset demonstrate that TWLR achieves competitive performance in both DR classification and lesion segmentation, offering a more explainable and annotation-efficient solution for automated retinal image analysis.