AI-Based RGB Image Generation From RG Fundus Images Using Pix2Pix: Validation by Quantitative and Observer-Based Evaluations.

Purpose: The purpose of this study was to evaluate the accuracy and perceptual quality of red-green-blue (RGB) fundus images generated from red-green (RG) images using Pix2Pix-based generative adversarial network (GAN). Methods: RG images were extracted from original RGB images recorded by a newer model of the Optos system by turning off the blue laser source. A conditional GAN based on the Pix2Pix architecture was trained to convert this extracted RG image to an RGB image. The performance was evaluated quantitatively by using a five-fold cross-validation and assessments with structural similarity index measure (SSIM), peak signal-to-noise ratio (PSNR), learned perceptual image patch similarity (LPIPS), mean absolute error (MAE), and root mean square error (RMSE). To assess the perceptual accuracy, 39 ophthalmologists examined 60 randomly selected images, 30 true and 30 generated RGB images, using Google Form-based interface. They were instructed to classify each image as a true or an artificial intelligence (AI)-generated image. Results: The generated images had high similarity to the original RGB images (SSIM = 0.97 ± 0.00; PSNR = 35.74 ± 0.17 decibel [dB]; LPIPS = 0.09 ± 0.00; MAE = 1.76 ± 0.04; and RMSE = 4.25 ± 0.10). The overall correct classification rate was 57.1%. Certain lesion types, such as epiretinal membrane and optic disc cupping, had higher discrimination rates. The receiver operating characteristic (ROC) analysis across all evaluations yielded an area under the curve (AUC) of 0.497 (P = 0.314). Conclusions: Pix2Pix-based GANs can generate perceptually and structurally consistent RGB images from RG images without lesion-specific attention mechanisms. Translational Relevance: This method enables a reinterpretation of legacy RG fundus images and may support future AI diagnostic applications.