PURPOSE: This study aims to evaluate the cost-effectiveness of two aromatase inhibitors for the adjuvant treatment of women with postmenopausal hormone receptor positive early breast cancer, and to find the most reasonable treatment option when the population is stratified by the nodal status. METHODS: A Markov model was developed with defining six Markov states based on breast cancer progression. The annual probabilities of recurrence by adjuvant treatment (anastrozole, letrozole, and tamoxifen) were estimated from the published studies in the overall population and in the node negative and node positive groups. The costs of the defined breast cancer events were measured by the micro-costing method based on the 2009 National Health Insurance Fee Schedule and the third Clinical Guideline of Breast Cancer Treatment. Anastrozole and letrozole were compared with tamoxifen respectively, using the same Markov model. The incremental cost-effectiveness ratios for the overall population and each subgroup were estimated. RESULTS: Anastrozole was more effective and costly than tamoxifen with anastrozole costing an additional Korean Won (KRW) 22,461,689 per quality-adjusted life year (QALY). Letrozole showed a similar incremental cost of KRW 21,004,142 per QALY. In the node negative group, anastrozole was the most cost-effective with an incremental cost of KRW 19,717,770 per QALY, while letrozole was the most cost-effective with an incremental cost of KRW 8,150,512 per QALY for the node positive group. The sensitivity analysis showed that these results were robust. CONCLUSION: The subgroup analysis clearly demonstrated which treatment was superior among the aromatase inhibitors in terms of the cost-effectiveness. Such a finding was not confirmed for the case of the overall population. The implication of this study is that the decision makers should be careful when generalizing the cost-effectiveness results. The stratified analysis in this context may help reach a reasonable decision for allocating medical resources.
Aromatase Inhibitors ; Breast ; Breast Neoplasms ; Cost-Benefit Analysis ; Costs and Cost Analysis ; Fee Schedules ; Female ; Humans ; National Health Programs ; Nitriles ; Quality-Adjusted Life Years ; Recurrence ; Tamoxifen ; Triazoles

Purpose: We report successful eyeball-preserving management of a patient with a large choroidal melanoma. We combined partial lamellar sclerouvectomy (PLSU) with ruthenium (Ru)-106 plaque brachytherapy.Case summary: A 48-year-old woman with a history of asthma visited our clinic with a chief complaint of gradual loss of vision at the nasal side of her right eye (best-corrected visual acuity 0.6). Fundus examination revealed a mushroom-shaped, dark choroidal mass 17.1 mm (basal diameter) × 14.2 mm (apical height). There was no evidence of distant metastasis. To remove the tumor while preserving the eyeball, we combined PLSU and simultaneous Ru-106 plaque brachytherapy with the patient under hypotensive general anesthesia. At 6 weeks postoperatively, trans pars plana vitrectomy with silicone oil injection was performed to remove the vitreous hemorrhage and treat the retinal detachment. Intravitreal bevacizumab (Avastin, Genentech Inc., San Francisco, CA, USA) (0.05 mL, 1.25 mg) was injected every 2 months to prevent the development of radiation retinopathy. No residual tumor, recurrence, or distant metastasis was noted during follow-up of 2 years. The patient was stable with no ocular complications at her last visit (2 years postoperatively). Conclusions Contrary to what we expected and despite the surgical difficulties, PLSU combined with Ru-106 plaque brachytherapy is a useful eyeball-preserving strategy even when encountering a very large choroidal melanoma (diameter > 16 mm and apical height > 10 mm). Such a melanoma was previously believed to be treatable only via enucleation.

Purpose: To report a successful case of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy performed in a noncompliant pediatric patient using the lateral decubitus position and a conventional slit-lamp-based laser system under general anesthesia.Case summary: Progression of a thick posterior capsular opacity with associated vision loss (best-correct visual acuity of 0.1) was detected in a nine-year-old child with a past history of cataract surgery in his right eye. Diagnosed with pediatric uveitis at the age of five, he had been treated previously using a combination of topical and systemic corticosteroids, which led to the development of the cataract and subsequent surgery 16 months later. Severe photophobia prevented outpatient-based laser treatment, and the patient underwent our modified procedure. Under general anesthesia, the patient was placed in a lateral decubitus position with the use of a long intubation tube. The height of the bed and table-based laser system was adjusted so as to minimize strain when positioning the child’s head. Successful laser capsulotomy was performed within 10 minutes, and the entire anesthesia time was less than 30 minutes. The patient experienced immediate improvement in symptoms, showing a visual acuity of 1.0, which has been sustained as of his most recent visit, 3 months postoperatively. The patient experienced no ocular or anesthesia- related complications. Conclusions Nd:YAG laser capsulotomy performed by careful positioning (lateral decubitus) under general anesthesia is a viable strategy for the safe and efficient removal of posterior capsular opacities in children with poor compliance.

Purpose: To report a successful case of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy performed in a noncompliant pediatric patient using the lateral decubitus position and a conventional slit-lamp-based laser system under general anesthesia.Case summary: Progression of a thick posterior capsular opacity with associated vision loss (best-correct visual acuity of 0.1) was detected in a nine-year-old child with a past history of cataract surgery in his right eye. Diagnosed with pediatric uveitis at the age of five, he had been treated previously using a combination of topical and systemic corticosteroids, which led to the development of the cataract and subsequent surgery 16 months later. Severe photophobia prevented outpatient-based laser treatment, and the patient underwent our modified procedure. Under general anesthesia, the patient was placed in a lateral decubitus position with the use of a long intubation tube. The height of the bed and table-based laser system was adjusted so as to minimize strain when positioning the child’s head. Successful laser capsulotomy was performed within 10 minutes, and the entire anesthesia time was less than 30 minutes. The patient experienced immediate improvement in symptoms, showing a visual acuity of 1.0, which has been sustained as of his most recent visit, 3 months postoperatively. The patient experienced no ocular or anesthesia- related complications. Conclusions Nd:YAG laser capsulotomy performed by careful positioning (lateral decubitus) under general anesthesia is a viable strategy for the safe and efficient removal of posterior capsular opacities in children with poor compliance.

Purpose: We report a rare case of deep vein thrombosis and pulmonary embolism that occurred following 2 weeks in the prone position after a trans pars plana vitrectomy with gas tamponade to treat rhegmatogenous retinal detachment.Case Summary: A 49-year-old man without a remarkable medical history visited our clinic complaining of gradual vision loss on the inferior side of the left eye. In fundus examinations, rhegmatogenous retinal detachment involving the macula with multiple tears was noted. After trans pars plana vitrectomy with gas tamponade, the patient was encouraged to maintain a prone position for retinal reattachment. However, after 2 weeks in the prone position, he complained of right calf pain and swelling. The department of cardiovascular surgery was consulted immediately and deep vein thrombosis and pulmonary embolism were diagnosed. After deep vein thrombectomy and anticoagulation therapy, the lower extremity symptoms improved and the patient was stable during follow-up with a well attached retina. Conclusions When prolonged prone positioning after retina surgery is necessary, careful monitoring for the possibility of deep vein thrombosis and pulmonary embolism is required, especially in high-risk patients.

Objective: To investigate the relationship between maximal tongue protrusion length (MTPL) and dysphagia in post-stroke patients. Methods: Free tongue length (FTL) was measured using the quick tongue-tie assessment tool and MTPL was measured using a transparent plastic ruler in 47 post-stroke patients. The MTPL-to-FTL (RMF) ratio was calculated. Swallowing function in all patients was evaluated via videofluoroscopic swallowing study (VFSS), PenetrationAspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Videofluoroscopic Dysphagia Scale (VDS). Results: The MTPL and RMF values were significantly higher in the non-aspirator group than in the aspirator group (MTPL, p=0.0049; RMF, p<0.001). MTPL and RMF showed significant correlations with PAS, FOIS and VDS scores. The cut-off value in RMF for the prediction of aspiration was 1.56, with a sensitivity of 84% and a specificity of 86%. Conclusion There is a relationship between MTPL and dysphagia in post-stroke patients. MTPL and RMF can be useful for detecting aspiration in post-stroke patients.

Purpose: To evaluate the therapeutic effects and safety of oral spironolactone (SPRL) in patients with central serous chorioretinopathy (CSC). Materials and Methods: The medical records and imaging data of patients diagnosed with CSC and treated with SPRL were retrospectively reviewed. Central macular thickness (CMT), subretinal fluid (SRF) height, subfoveal choroidal thickness (SFCT), and best-corrected visual acuity (BCVA) at baseline, at 1, 3, and 6 months, and at the last visit after the treatment were analyzed. Results: In total, 103 patients with 107 eyes were included. The mean age of the patients was 51.5±9.3 years, and 77 (72.0%) were male. The mean follow-up duration was 48.6±40.2 weeks. The mean duration of oral SPRL therapy was 15.5±13.4 weeks. CMT, SRF height, and SFCT improved significantly at 1, 3, and 6 months after SPRL therapy and at the last follow-up. BCVA, however, showed no significant change at any time point. The rate of complete resolution of SRF at 1 month was higher in those with chronic CSC than in those with acute CSC (21.1% vs. 6.0%, respectively). Recurrence occurred in 14 (13.1%) eyes after the complete resolution of SRF. Older age (p=0.001), a greater number of previous intravitreal bevacizumab injections (p=0.006), and poor initial visual acuity (p=0.048) were associated with recurrence. No permanent adverse effects were observed. Conclusion Oral SPRL showed therapeutic benefits in patients with CSC in terms of SRF resolution, but relatively frequent recurrence was observed, especially in older patients.

Purpose: This study aimed to determine the incidence and visual outcomes of pachychoroid neovasculopathy (PNV) in patients initially diagnosed with central serous chorioretinopathy (CSC). Methods: In this study, 144 patients aged 20 to 55 years with treatment-naive chronic CSC, defined as the persistence of subretinal fluid (SRF) for ≥6 months, were retrospectively enrolled. Patients with PNV at the initial evaluation were categorized as group 1, whereas those who developed new-onset PNV during follow-up were categorized as group 2. Patients without PNV until the end of the follow-up were categorized as group 3. Results: Over a mean follow-up period of 49.9 ± 39.9 months, new-onset PNV was diagnosed in 11.8% of patients with CSC. The time taken to reach the initial resolution was longest in group 1 (group 1, 11.13 ± 10.70 months; group 2, 8.14 ± 7.90 months; group 3, 7.32 ± 9.55 months), although these differences were not statistically significant. The numbers of injections needed to achieve initial resolution were 3.76 ± 5.90, 1.64 ± 2.06, and 1.74 ± 4.33 in groups 1, 2, and 3, respectively, with no significant differences. SRF recurrence was recorded in seven patients (29.2%) in group 1, nine (64.3%) in group 2, and 28 (26.7%) in group 3. The recurrence rates were significantly higher in group 2 than those in group 1 or 3. At the end of the follow-up period, significant improvements in best-corrected visual acuity were achieved in groups 1 and 3, compared with baseline, but not in group 2. Conclusions Patients with chronic CSC with new-onset PNV exhibited higher SRF recurrence and worse visual outcomes compared to those with initial PNV or those with chronic CSC without PNV. Our study emphasizes the importance of routine screening for prompt diagnoses of new-onset PNV in individuals with chronic CSC.

Purpose: This study aimed to determine the incidence and visual outcomes of pachychoroid neovasculopathy (PNV) in patients initially diagnosed with central serous chorioretinopathy (CSC). Methods: In this study, 144 patients aged 20 to 55 years with treatment-naive chronic CSC, defined as the persistence of subretinal fluid (SRF) for ≥6 months, were retrospectively enrolled. Patients with PNV at the initial evaluation were categorized as group 1, whereas those who developed new-onset PNV during follow-up were categorized as group 2. Patients without PNV until the end of the follow-up were categorized as group 3. Results: Over a mean follow-up period of 49.9 ± 39.9 months, new-onset PNV was diagnosed in 11.8% of patients with CSC. The time taken to reach the initial resolution was longest in group 1 (group 1, 11.13 ± 10.70 months; group 2, 8.14 ± 7.90 months; group 3, 7.32 ± 9.55 months), although these differences were not statistically significant. The numbers of injections needed to achieve initial resolution were 3.76 ± 5.90, 1.64 ± 2.06, and 1.74 ± 4.33 in groups 1, 2, and 3, respectively, with no significant differences. SRF recurrence was recorded in seven patients (29.2%) in group 1, nine (64.3%) in group 2, and 28 (26.7%) in group 3. The recurrence rates were significantly higher in group 2 than those in group 1 or 3. At the end of the follow-up period, significant improvements in best-corrected visual acuity were achieved in groups 1 and 3, compared with baseline, but not in group 2. Conclusions Patients with chronic CSC with new-onset PNV exhibited higher SRF recurrence and worse visual outcomes compared to those with initial PNV or those with chronic CSC without PNV. Our study emphasizes the importance of routine screening for prompt diagnoses of new-onset PNV in individuals with chronic CSC.

Purpose: This study sought to compare the long-term outcomes of surgeries for retinal detachment (RD) secondary to viral or parasitic infectious retinitis. Methods: A total of 47 eyes that received pars plana vitrectomy with or without scleral buckling due to RD secondary to polymerase chain reaction-proven viral (cytomegalovirus, varicella zoster virus, and herpes zoster virus) or parasitic (toxoplasma and toxocara) retinitis from October 1, 2006, to June 30, 2023, in a single medical center were retrospectively enrolled. Results: Mean follow-up period was 59.03 ± 55.24 months in viral retinitis and 34.80 ± 33.78 months in parasitic retinitis after primary reattachment surgery. During follow-up, nine eyes (24.3%) with viral retinitis and five eyes (50.0%) with parasitic retinitis developed retinal redetachment. Visual acuity success at final follow-up was achieved in 19 eyes (51.4%) with viral retinitis and six eyes (60.0%) with parasitic retinitis (p = 0.64). The incidence of retinal redetachment during the 1st postoperative year was significantly higher in parasitic retinitis compared with viral retinitis (crude incidence, 0.21 vs. 0.85; p = 0.02). Hazard ratio analysis adjusted for age and sex showed 4.58-fold (95% confidence interval, 1.22–17.27; p = 0.03) increased risk of retinal redetachment in parasitic retinitis compared with viral retinitis during the 1st postoperative year. Tamponade with silicone oil and preoperative diagnostic vitrectomy were associated with significantly decreased risk of retinal redetachment in patients with parasitic retinitis. Conclusions Compared with RD secondary to viral retinitis, RD secondary to parasitic retinitis showed higher incidence of retinal redetachment during the 1st postoperative year. Tamponade with silicone oil and preoperative diagnostic vitrectomy were associated with significantly decreased risk of retinal redetachment in patients with parasitic retinitis.