Abstract / Summary
Ophthalmic decisions require probabilities tied to a clinical question, a candidate set and an operating policy. We present OphJev, an endpoint-aware System One framework that combines frozen image and text representations, candidate scoring, schema-specific calibration and selective generalist queries for fundus and OCT imaging. Across eight external resources, multiple representation families, three generalist sizes and three seeds, controlled interventions separate the effects of wording, supervision and computation. Schema-aware affine calibration lowers mean held-out Brier loss and selective risk in all eight primary image--text configurations. On HYGD, matched-supervision fusion raises AUROC from 0.772 to 0.798, while a separate gain-routing policy lowers Brier from 0.618 to 0.599 using at most 20\% logical generalist image calls. These effects demonstrate complementary decision-level capabilities rather than universal gains: external transfer and larger specialist banks remain cohort dependent. A retrospective text extension evaluates 1,996 clinical notes and 91 ophthalmic questions; validation-based calibration improves note probability scores, while a lexical control remains strong. OphJev provides an auditable decision framework; prospective clinical benefit remains unvalidated.