Observer Choice and Threshold Selection in Retinal Vessel Segmentation: A Subject-Separated Evaluation

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.

Accurate retinal vessel segmentation is important for computer-aided ophthalmic analysis, yet thin vessels, low contrast, and severe foreground-background imbalance remain challenging for encoder-decoder networks. This paper presents U-PEN Mamba, a U-shaped retinal vessel segmentation architecture that couples progressive nonlinear feature expansion with selective state-space modeling. The proposed network enriches local vessel responses with progressive expansion, models long-range spatial dependencies through a Mamba Global Context (MGC) block with linear sequence complexity, and uses attention-based decoder fusion to recover fine vascular boundaries. We evaluate U-PEN Mamba on CHASE DB1 and DRIVE using a consistent patch-based preprocessing pipeline and compare it with convolutional, attention-based, transformer-based, and Mamba-based segmentation baselines. U-PEN Mamba obtains the best mean intersection over union among the compared methods, achieving 0.8394 on CHASE DB1 and 0.8221 on DRIVE, with Dice scores of 0.8187 and 0.8078, respectively, using 21.6M trainable parameters. Ablation studies show that the MGC block contributes the largest gain over the U-Net baseline, while projection dimension and state size provide practical accuracy-efficiency control. These results indicate that selective state-space modeling is a promising global-context mechanism for parameter-efficient retinal vessel segmentation. Code is available at: https://github.com/areyesan/UPEN_Mamba.

Vascular structures in the retina contain important information for the detection and analysis of ocular diseases, including age-related macular degeneration, diabetic retinopathy and glaucoma. Commonly used modalities in diagnosis of these diseases are fundus photography, scanning laser ophthalmoscope (SLO) and fluorescein angiography (FA). Typically, retinal vessel segmentation is carried out either manually or interactively, which makes it time consuming and prone to human errors. In this research, we propose a new multi-modal framework for vessel segmentation called ELEMENT (vEsseL sEgmentation using Machine lEarning and coNnecTivity). This framework consists of feature extraction and pixel-based classification using region growing and machine learning. The proposed features capture complementary evidence based on grey level and vessel connectivity properties. The latter information is seamlessly propagated through the pixels at the classification phase. ELEMENT reduces inconsistencies and speeds up the segmentation throughput. We analyze and compare the performance of the proposed approach against state-of-the-art vessel segmentation algorithms in three major groups of experiments, for each of the ocular modalities. Our method produced higher overall performance, with an overall accuracy of 97.40%, compared to 25 of the 26 state-of-the-art approaches, including six works based on deep learning, evaluated on the widely known DRIVE fundus image dataset. In the case of the STARE, CHASE-DB, VAMPIRE FA, IOSTAR SLO and RC-SLO datasets, the proposed framework outperformed all of the state-of-the-art methods with accuracies of 98.27%, 97.78%, 98.34%, 98.04% and 98.35%, respectively.