ORBIT: A Prognostic World Model for Ocular Reasoning Based on Imagined Trajectories

Abstract

The longitudinal management of blinding fundus diseases constitutes a Partially Observable Markov Decision Process (POMDP) necessitating a critical precision-risk trade-off between intervention and over-treatment, as true pathology is often obscured in static observations. However, existing paradigms fail to address this complexity. Traditional vision models remain uninterpretable and memoryless, and while Vision-Language Models (VLMs) excel in semantic understanding, they rely on unsafe open-loop text reasoning lacking the anatomical grounding essential for clinical safety. Furthermore, robust learning is hindered by the scarcity of process supervision in sparse clinical records. To bridge this gap, we introduce the {Logic-Constrained Abductive Data Engine}. Operating on a ``Propose-and-Verify'' paradigm, it validates MLLM-Proposed biomarkers against clinical and temporal logic to reconstruct dense pathological states from sparse outcomes. Building on this foundation, we propose ORBIT, the first ophthalmic Prognostic World Model. Uniquely, ORBIT employs counterfactual visual foresight to imagine anatomical futures under different treatments, anchoring decisions in Closed-Loop Anatomical Verification rather than linguistic probabilities. Experiments demonstrate that ORBIT effectively captures disease evolution and establishes a new paradigm for autonomous diagnosis and reliable decision-making in complex ophthalmic environments.