Balanced Prompt Adaptation against Entropy-Induced Collapse for Test-Time Binary Segmentation

Test-time adaptation (TTA) aims to mitigate distribution shifts by adapting models with unlabeled target data at inference time. While TTA with vision-language models (VLMs) has shown promising results in classification, extending it to medical image segmentation remains challenging. In this setting, the adaptation gains from optimizing on VLM-generated predictions are often outweighed by the degradation to the VLM's strong pretrained features caused by noisy, update-driven learning, resulting in limited and unstable improvements. We therefore propose Memory-Supported Synergistic Adaptation (MSSA), a novel training-free TTA framework for medical image segmentation. Without updating model parameters, MSSA dynamically selects reliable image-text predictions to construct an online memory, uses them as text-guided semantic priors, and couples them with cross-image structural alignment for robust adaptation. Specifically, MSSA consists of (i) a noise-aware memory construction module that filters and stabilizes cross-modal predictions, and (ii) a relevance-driven prototype alignment module that aligns the target sample with structurally consistent memory samples and their reliable predictions to improve adaptation. Extensive experiments on multiple medical segmentation benchmarks demonstrate that MSSA consistently improves VLM-based segmentation models and outperforms existing fine-tuning-based TTA methods by a clear margin, with gains of up to 12.2% DSC and 11.7% mIoU. Project page: https://lingrayy.github.io/MSSA/ .

Segmenting images is critical for visual understanding but demands extensive pixel-level annotations. Foundational models have enabled new paradigms for predicting new classes guided by textual prompts, without annotations from the target domain. Yet, on specialized target domains, far from the original pre-training, their performance degrades. We study the errors of existing methods under such domain-shift, finding that misclassification rather than mask generation is the main culprit. To address this, we introduce the novel problem of Few-Shot Visual Adaptation for text-prompted Segmentation. This kind of adaptation has been largely studied for image classification, but it remains unexplored for segmentation. We tackle this task with Prototype Adaptation (PrAda), a novel, parameter-efficient method that adapts a frozen text-prompted segmentation model. Our approach learns class-specific prototypes by combining fine-grained pixel features and high-level transformer representations, which are then fused with the original text-based predictions through a learned importance factor. This preserves the model's zero-shot potential while enabling strong adaptation to new domains. Experiments across semantic, instance, and panoptic segmentation on five benchmarks demonstrate that PrAda yields significant improvements over state-of-the-art and proposed baselines.

Open-vocabulary semantic segmentation (OVSS) enables pixel-level prediction over arbitrary text-specified vocabularies and has shown strong generalization on common benchmarks. However, OVSS performance often degrades in specialized domains such as medical imaging, remote sensing, and industrial inspection, where dense pixel-level masks for adaptation are costly to obtain and require domain-specific expertise. We propose a preference-guided adaptation framework that replaces dense mask supervision with binary preferences. We observe that different prompt templates produce systematically different segmentations for the same image, a phenomenon we call prompt disagreement, and we repurpose it as a built-in source of preference supervision. Building on this, we mine localized preference queries from regions of high cross-template uncertainty, and adapt the OVSS model with Region-Localized Preference Optimization (RLPO) together with consistency regularization that stabilizes updates outside the queried region. Across extensive experiments on the MESS benchmark, the proposed method achieves consistent gains across diverse OVSS backbones without any pixel-level annotation, and remains effective under noisy preferences. Our code is available at https://github.com/blue-531/pref-ovss.