Response to: ‘Comment on: ‘Foundation model-based haemoglobin concentration estimation and anaemia risk assessment from retinal fundus images”

Response to: ‘Comment on: ‘Foundation model-based haemoglobin concentration estimation and anaemia risk assessment from retinal fundus images”. We thank Arif for highlighting that the clinical value of retinal haemoglobin prediction depends on the pathway in which it is used. We agree that discrimination alone is insufficient, and that disease prevalence, referral capacity, access to confirmatory testing, and the consequences of false-positive and false-negative results should guide the selection of operating thresholds.

The scope of the present study was to evaluate the feasibility and interpretability of adapting pretrained foundation models for haemoglobin estimation from fundus photographs, rather than to establish clinical utility within a specific workflow. In this context, the health-promotion programme served as a source of paired retinal imaging and reference-standard laboratory data for model development and evaluation, rather than representing the intended deployment pathway. Accordingly, the present study does not establish whether retinal haemoglobin prediction can reduce blood sampling, alter referral decisions, or improve downstream clinical management.

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