# A Fully Automated Pipeline for a Robust Conjunctival Hyperenia Estimation  
[PERSON]  
1 eDIMESLab, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, 40138 Bologna, Italy; [EMAIL_ADDRESS] (N.C.); [EMAIL_ADDRESS] (E.G. ); [EMAIL_ADDRESS] (E.M.)  
[PERSON]  
1 eDIMESLab, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, 40138 Bologna, Italy; [EMAIL_ADDRESS] (N.C.); [EMAIL_ADDRESS] (E.G. ); [EMAIL_ADDRESS] (E.M.)  
[PERSON]  
2 Ophthalmic Unit, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, 40138 Bologna, Italy; [EMAIL_ADDRESS] (F.G.); [EMAIL_ADDRESS] (F.B. ); [EMAIL_ADDRESS] (P.V.) [PERSON]  
1 eDIMESLab, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, 40138 Bologna, Italy; [EMAIL_ADDRESS] (N.C.); [EMAIL_ADDRESS] (E.G. ); [EMAIL_ADDRESS] (E.M.)  
Footnote 1: email: eDIMESLab, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, 40138 Bologna, Italy; [EMAIL_ADDRESS] (N.C.); [EMAIL_ADDRESS] (E.G. ); [EMAIL_ADDRESS] (E.M.)  
Footnote 28: email: carcencelli  
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@unibo.it  
Footnote 24: email: email: [EMAIL_ADDRESS]  
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Hyperemia is commonly evaluated using qualitative grading scales, where the conjunctival hyperemia is compared to a set of standardized pictures (template images or references). These reference pictures are images artificially generated using software, painted, or real photographs. The clinician establishes the score by matching the patient conjunctiva to the reference one that he considers the most similar. This measure is performed for each eye independently. There are many grading scales proposed in literature for the hyperemia estimation. [PERSON] (1978), [PERSON] (1989), and [PERSON] (1989) proposed descriptive grading scales; [PERSON] et al. (1984) and [PERSON] (1990) proposed art illustrations for the evaluation of single condition grading scales; [PERSON] et al. (1992) and [PERSON] (1999) extend the previous evaluation to multiple conditions; [PERSON] and [PERSON] (1982), [PERSON] (1998), [PERSON] (1987), [PERSON] et al. (1982), [PERSON] (1992), and [PERSON] et al. (1998) introduce the use of photographic references. The latest proposed reference images were generated using computer graphic ([PERSON], 2009). Each scale is associated with a different set of reference images and each of them is focused on a different aspect of the hyperemia estimation; for instance, the conjunctival redness in the Efron Grading Scales for Contact Lens Complications [1] is expressed through five images depicting 1-5 grading ranging from normal to severe. A critical issue of these assessments is their reproducibility: the template matching evaluation is an intrinsic operator-dependent procedure and thus it is affected by subjectivity. The reproducibility of the image acquisition and moreover the hyperemia evaluation are determined by the experience of the operating clinician, and it can be affected by several experimental conditions, leading to imprecisions and biases [4; 5]. Generally, the automation of the clinical exam provides a support for the clinical laboratory or clinical practice assessment through faster and more reliable evaluation and reducing the reliance on the operator expertise for the evaluation [6]. Several authors have already proposed semi-automated grading systems for the hyperemia quantification, offering semi-supervised pipelines to process the patient's images [7]. All of these methods facilitate the clinician operations providing a series of automated processing steps, which, however, require the human intervention (e.g., a manual selection of the region of interest and color values) [3; 8; 9; 10; 11; 12; 13; 14]. At the same time, they allow for introducing new quantitative grading scales that are difficult to relate to the standard clinical assessments.