{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T18:05:50Z","timestamp":1779991550282,"version":"3.53.1"},"reference-count":23,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T00:00:00Z","timestamp":1779926400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>This study evaluated the cost-effectiveness of routine screening for acetylcholine receptor antibody (AChR-Ab) and thyroid function tests (TFT) in patients with acquired comitant esotropia (ACE) without overt signs of myasthenia gravis (MG) or thyroid eye disease (TED). A retrospective cost\u2013utility analysis was conducted in 110 patients at a Thai tertiary hospital between 2014 and 2024. A decision tree combined with a 10-year Markov model compared two strategies: no routine screening (symptom-triggered testing) and universal baseline screening with AChR-Ab and TFT. Costs were expressed in 2024 Thai Baht (THB) from a healthcare sector perspective, and outcomes were measured in quality-adjusted life years (QALYs). Model uncertainty was assessed using one-way sensitivity analyses and probabilistic sensitivity analysis with 10,000 simulations, incorporating downstream costs of follow-up, confirmatory evaluation, and treatment. In the base-case analysis incorporating real-world diagnostic accuracy, universal screening yielded higher QALYs (109.56 vs. 105.45) but also higher costs (\u0e3f2,826,680 vs. \u0e3f1,653,500), resulting in an incremental cost-effectiveness ratio (ICER) of \u0e3f285,360 per QALY gained. This exceeded Thailand\u2019s willingness-to-pay threshold of \u0e3f160,000\u2013200,000 per QALY, indicating that universal screening was not cost-effective. Probabilistic sensitivity analysis showed that most simulations were located in the northeast quadrant of the cost-effectiveness plane, reflecting greater effectiveness with higher cost, with many exceeding the willingness-to-pay threshold. Key drivers included MG prevalence, utility loss from undiagnosed MG, and AChR-Ab test cost. TFT screening contributed minimal benefit due to the very low prevalence of thyroid dysfunction. Universal AChR-Ab screening may improve early detection of MG in ACE, but it was not cost-effective under current assumptions. Exploratory targeted screening appeared relatively more efficient, and symptom-triggered thyroid testing may be a more appropriate approach. These findings are preliminary and require validation in larger studies.<\/jats:p>","DOI":"10.1371\/journal.pone.0350280","type":"journal-article","created":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T17:32:52Z","timestamp":1779989572000},"page":"e0350280","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["A preliminary cost-utility analysis of routine myasthenia gravis and thyroid dysfunction screening in acquired comitant Esotropia"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2088-8639","authenticated-orcid":true,"given":"Worapot","family":"Srimanan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Phawasutthi","family":"Keokajee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sunita","family":"Sawangsribanterng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,5,28]]},"reference":[{"issue":"1","key":"pone.0350280.ref001","doi-asserted-by":"crossref","first-page":"79","DOI":"10.4103\/tjo.TJO-D-23-00084","article-title":"Acute acquired comitant esotropia: Current understanding of its etiological classification and treatment strategies","volume":"15","author":"N Nishikawa","year":"2024","journal-title":"Taiwan J Ophthalmol"},{"key":"pone.0350280.ref002","first-page":"2856128","article-title":"Acute acquired comitant esotropia in adults: Is it neurologic or Not","volume":"2016","author":"TK Erkan","year":"2016","journal-title":"J Ophthalmol"},{"issue":"4","key":"pone.0350280.ref003","doi-asserted-by":"crossref","DOI":"10.1097\/WNO.0000000000001056","article-title":"Comitant ocular deviation in myasthenia gravis","volume":"41","author":"T Pike-Lee","year":"2021","journal-title":"J Neuroophthalmol"},{"issue":"3","key":"pone.0350280.ref004","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1016\/j.jaapos.2009.01.009","article-title":"Decompensating esophoria as the presenting feature of myasthenia gravis","volume":"13","author":"GE Arblaster","year":"2009","journal-title":"J AAPOS"},{"key":"pone.0350280.ref005","article-title":"Thyroid eye disease with divergence insufficiency causing recurrent falls in an elderly patient","author":"WC Lai","year":"2022","journal-title":"Cureus"},{"issue":"10","key":"pone.0350280.ref006","doi-asserted-by":"crossref","first-page":"1170","DOI":"10.1001\/jamaneurol.2015.1444","article-title":"Clinical utility of acetylcholine receptor antibody testing in ocular myasthenia gravis","volume":"72","author":"CE Peeler","year":"2015","journal-title":"JAMA Neurol"},{"issue":"4","key":"pone.0350280.ref007","doi-asserted-by":"crossref","DOI":"10.1097\/WNO.0000000000001061","article-title":"The usefulness of anti-acetylcholine receptor binding antibody testing in diagnosing ocular myasthenia gravis","volume":"41","author":"IY Chung","year":"2021","journal-title":"J Neuroophthalmol"},{"issue":"2","key":"pone.0350280.ref008","doi-asserted-by":"crossref","first-page":"83","DOI":"10.3121\/cmr.2016.1309","article-title":"Biochemical testing of the thyroid: TSH is the best and, oftentimes, only test needed \u2013 a review for primary care","volume":"14","author":"MT Sheehan","year":"2016","journal-title":"Clin Med Res"},{"key":"pone.0350280.ref009","year":"2004"},{"issue":"3","key":"pone.0350280.ref010","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1001\/archinte.1989.00390030032006","article-title":"Sensitivity, specificity, and cost-effectiveness of the sensitive thyrotropin assay in the diagnosis of thyroid disease in ambulatory patients","volume":"149","author":"ET de los Santos","year":"1989","journal-title":"Arch Intern Med"},{"key":"pone.0350280.ref011","doi-asserted-by":"crossref","first-page":"1567","DOI":"10.2147\/OPTH.S307951","article-title":"Acute acquired comitant esotropia: Etiology, clinical course, and management","volume":"15","author":"A Lekskul","year":"2021","journal-title":"Clin Ophthalmol Auckl NZ"},{"issue":"9","key":"pone.0350280.ref012","doi-asserted-by":"crossref","first-page":"2661","DOI":"10.1007\/s00417-023-06047-8","article-title":"Yearly changes in cases of acute acquired comitant esotropia during a 12-year period","volume":"261","author":"Y Okita","year":"2023","journal-title":"Graefes Arch Clin Exp Ophthalmol"},{"key":"pone.0350280.ref013","doi-asserted-by":"crossref","first-page":"2211","DOI":"10.2147\/OPTH.S530750","article-title":"Comparing park table - 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