ELEMENT: Multi-Modal Retinal Vessel Segmentation Based on a Coupled Region Growing and Machine Learning Approach

Early detection of vision-threatening conditions such as diabetic retinopathy, glaucoma, and age-related macular degeneration depends on retinal fundus image analysis, but manual assessment is slow and expert-dependent. Automated convolutional neural networks classify fundus images accurately yet act as black boxes, and existing retinal vessel segmentation methods lose discriminative power under pathology and seldom exploit attention or transformer backbones. Using the FIVES and DRIVE fundus datasets, we develop a two-pipeline framework that pairs four-class disease classification with attention- and transformer-based vessel segmentation, organised in three stages: (1) FIVES images are augmented by rotation and horizontal and vertical flips and used to fine-tune eight ImageNet-pretrained CNNs: ResNet101, DenseNet169, Xception, InceptionV3, DenseNet121, InceptionResNetV2, ResNet50, and EfficientNetB0. (2) Five gradient-based explanation methods, Grad-CAM, Grad-CAM++, Score-CAM, Faster Score-CAM, and Layer-CAM, are computed on the final convolutional block of each classifier and compared qualitatively across architectures. (3) Ten U-Net variants are benchmarked for vessel segmentation: TransUNet (hybrid CNN--Transformer encoder) and Attention U-Net (gated skip connections), evaluated with ResNet50V2, ResNet101V2, and ResNet152V2 backbones, along with additional Attention U-Net configurations using DenseNet backbones, and the fully transformer-based Swin-UNet. ResNet101 gives the highest classification accuracy: 94.17% (F1 0.942) $>$ 88.33% for EfficientNetB0. For segmentation, the architecture ranking is consistent on both datasets: Attention U-Net $>$ TransUNet $>$ Swin-UNet. The strongest configuration is Attention U-Net with a ResNet101V2 backbone: FIVES IoU 0.722, Dice 0.838; DRIVE IoU 0.648, Dice 0.787, lifting DRIVE IoU 60.80 $\rightarrow$ 64.83 over a prior custom U-Net.

A retinal vessel analysis is a procedure that can be used as an assessment of risks to the eye. This work proposes an unsupervised multimodal approach that improves the response of the Frangi filter, enabling automatic vessel segmentation. We propose a filter that computes pixel-level vessel continuity while introducing a local tolerance heuristic to fill in vessel discontinuities produced by the Frangi response. This proposal, called the local-sensitive connectivity filter (LS-CF), is compared against a naive connectivity filter to the baseline thresholded Frangi filter response and to the naive connectivity filter response in combination with the morphological closing and to the current approaches in the literature. The proposal was able to achieve competitive results in a variety of multimodal datasets. It was robust enough to outperform all the state-of-the-art approaches in the literature for the OSIRIX angiographic dataset in terms of accuracy and 4 out of 5 works in the case of the IOSTAR dataset while also outperforming several works in the case of the DRIVE and STARE datasets and 6 out of 10 in the CHASE-DB dataset. For the CHASE-DB, it also outperformed all the state-of-the-art unsupervised methods.

Learning from minimal human supervision is a long-standing goal in medical image analysis, where dense expert annotations are costly. We study retinal vessel segmentation in an extreme semi-supervised setting with one annotated image and a pool of unlabeled images. We propose ESRVS, which selects a representative reference image for manual annotation and transfers vessel cues using target-domain-adapted DINOv3 features. ESRVS constructs a multi granular vessel prototype, combines prototype-similarity maps with a physics-inspired prior to generate initial pseudo-labels, and refines the transferred supervision through weighted pseudo-label training and adversarial refinement. Across eight public datasets, ESRVS achieves the best Dice and clDice on six datasets, and the best HD95 on all eight datasets among the compared semi-supervised methods, although those methods use 10 to 20% labeled data. With Mask2Former, ESRVS retains on average 93.7% of fully supervised Dice and 95.1% of fully supervised clDice. These results demonstrate the potential of foundation-model label propagation for highly label-efficient retinal vessel segmentation. Code is available at https://github.com/IAANNH/ESRVS.