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**Background:** Cataract surgery is an effective and commonly utilized procedure and can significantly improve quality of life and restore economic productivity. Certificate of need (CON) laws aim to regulate healthcare facility expansion and equipment acquisition to curtail costs, enhance quality, and ensure equitable access to care. However, little is known about the impact of CON laws on cataract surgery utilization and reimbursement. **Objectives:** To compare utilization and reimbursement for non-complex cataract surgery in CON and non-CON states. **Methods:** This retrospective database review analyzed publicly available data from the Centers for Medicare and Medicaid Services from 2017 to 2021 to identify the Medicare beneficiaries who underwent non-complex cataract surgery using Current Procedural Terminology code 66984 in Medicare outpatient hospitals. Utilization and reimbursement patterns were analyzed in states with and without CON laws using the compound annual growth rate, with reimbursement adjusted by the US Bureau of Labor Statistics Consumer Price Index. **Results:** The Centers for Medicare and Medicaid Services reported 893 682 non-complex cataract surgeries in the study period; of these, 609 237 were in CON and 280 215 in non-CON states. Inflation-adjusted reimbursement increased in both CON (1.17%) and non-CON (1.83%) states, while the reimbursement in non-CON states was greater than the national average adjusted reimbursement (1.67%). Utilization of non-complex cataract surgery declined during the study period in both CON and non-CON states. A larger decline in utilization was observed in CON states (−7.32%) than in non-CON states (−6.49%). Utilization was slightly higher in non-CON than in CON states for each year except 2019. **Discussion:** Utilization of non-complex cataract surgery by Medicare beneficiaries declined over the study period in both CON and non-CON states, possibly impacted by the COVID-19 pandemic. Inflation-adjusted reimbursement adjusted for Consumer Price Index increased more in non-CON than CON states, possibly reflecting shifts in market dynamics in CON-regulated states. **Conclusions:** Surgeons and policymakers should consider the implications of CON laws on the utilization and reimbursement of cataract surgery. Further study is necessary to ascertain whether these trends persist beyond 2021.

Purpose Microscopic ophthalmic surgery requires an understanding of three-dimensional (3D) spaces within the eye. Recently, there has been an increase in 3D video training tools in health care. Studies have evaluated the efficacy of 3D tutorials in general surgery, but little has been published within ophthalmology. We present a randomized study evaluating differences in surgically naïve trainees after watching either a 2D or 3D phacoemulsification tutorial. Design This was a double-blind, randomized study. A group of third and fourth year medical students at our institution were randomized with stratified randomization based on prior surgical courses to control for differences in baseline surgical skill. The two study arms were watching 2D or 3D instructional videos on phacoemulsification (Richard Mackool). Methods Participants received a preliminary survey and participated in an hour-long microscopic surgery session. During the session, participants performed tasks evaluating baseline microscopic spatial awareness and surgical skill. The students were then instructed to watch either a 2D or 3D video on phacoemulsification based on their randomized study arm. During the postintervention session, participants performed the biplanar incision and capsulorhexis steps of cataract surgery discussed in the video on model eyes. Students were evaluated on speed and overall capsulorhexis quality. Results Thirty-one students qualified for the study and completed the microscopic surgery session. Students in both groups had similar baseline speed and quality of preintervention microscopic tasks (p > 0.05 for all tasks). Postintervention, students randomized to the 3D video performed significantly faster than the 2D group for biplanar incision (11.1 ± 5.5 s vs. 20.7 ± 10.5 s, p = 0.001). There were no statistically significant differences found between the groups in capsulorhexis timing (p = 0.12) or quality score (p = 0.60). Conclusions 3D video surgical training tutorials may improve speed of certain steps of cataract surgery for surgically naïve ophthalmology trainees. Given the limited sample size of this study, further investigation of their effectiveness is warranted.

Background Scoring for the United States Medical Licensing Examination (USMLE) Step 1 was recently announced to be reported as binary as early as 2022. The general perception among program directors (PDs) in all specialties has largely been negative, but the perspective within ophthalmology remains uncharacterized. Objective This article characterizes ophthalmology residency PDs' perspectives regarding the impact of pass/fail USMLE Step 1 scoring on the residency application process. Methods A validated 19-item anonymous survey was electronically distributed to 111 PDs of Accreditation Council for Graduate Medical Education-accredited ophthalmology training programs. Results Fifty-six PDs (50.5%) completed the survey. The median age of respondents was 48 years and the majority were male (71.4%); the average tenure as PD was 7.1 years. Only 6 (10.7%) PDs reported the change of the USMLE Step 1 to pass/fail was a good idea. Most PDs (92.9%) indicated that this will make it more difficult to objectively compare applicants, and many (69.6%) did not agree that the change would improve medical student well-being. The majority (82.1%) indicated that there will be an increased emphasis on Step 2 Clinical Knowledge (CK) scores, and many (70.4%) felt that medical school reputation will be more important in application decisions. Conclusion Most ophthalmology PDs who responded to the survey do not support binary Step 1 scoring. Many raised concerns regarding shifted overemphasis on Step 2 CK, uncertain impact on student well-being, and potential to disadvantage certain groups of medical students including international medical graduates. These concerns highlight the need for reform in the ophthalmology application process.

Objective: To report a diagnosis of hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome following initial presentation with multiple cutaneous lesions. Design: Case report. Design classification: N/A. Setting: Academic tertiary care center. Patient(s): 27-year-old nulligravid woman who presented with multiple red-brown lesions on her skin found to have cutaneous and uterine leiomyoma. Intervention(s): Biopsy of cutaneous lesions and fertility sparing robot-assisted laparoscopic myomectomy (RALM). Main outcome measures(s): Histological assessment of uterine leiomyoma. Results(s): Pathologic examination of uterine leiomyoma revealed diffuse atypia and fumarate hydratase loss phenotype concerning for genetic syndrome. Follow-up DNA sequencing via Sanger sequencing confirmed a pathogenetic R2333H mutation consistent with HLRCC. Conclusion(s): Consideration of HLRCC on differential diagnosis when patients present with cutaneous nodules and atypical or early onset uterine leiomyoma provides opportunity for early surveillance, family member testing, and more thoughtful surgical planning. Precis: 27-year-old woman with multiple cutaneous lesions is found to have uterine leiomyomas and undergoes robotic myomectomy. Genetic testing of uterine leiomyomas reveals mutation in fumarate hydratase, etiologic in hereditary leiomyomatosis and renal cell cancer (HLRCC).

Abstract Background The Accreditation Council for Graduate Medical Education in ophthalmology lists the use of information technology to optimize learning as a common program requirement. The use of technology in published studies often takes the form of e-learning. No study to date outlines what methods are preferred by residents and faculty in United States Ophthalmology programs. Objective We conducted a needs assessment to evaluate the current state of technology in teaching and learning in an ophthalmology residency program, to identify barriers to using technology, and to determine areas for future curriculum development. Methods We used an anonymous online survey to assess current residents and faculty within our ophthalmology residency program. Results Residents identified their primary learning styles as visual and kinesthetic and they preferred videos and online question banks. More than 35% of faculty respondents “never” use technology in teaching. Among faculty who do use technology, online quizzes and videos were the most common modalities used to supplement lectures. Common barriers to incorporating technology included lack of time, lack of knowledge of available technologic tools, and lack of skill in using technology. Both faculty and residents identified a Web platform for curricular elements and a feedback app as potentially beneficial additions to the curriculum. Each group rated an app to receive feedback more highly than an app to provide it. The two groups disagreed on the usefulness of online quizzes. There was variability among faculty responses regarding the usefulness of technology in teaching. Conclusion Our needs assessment identified areas of agreement among residents and faculty as well as mismatches and barriers regarding the use of technology to support learning by ophthalmology residents. Our study is an example of a best practice for use of a needs assessment to provide a framework for curriculum development and program improvement in an individual program. Further research is needed to generalize these results across ophthalmology programs.

Abstract Background The authors sought to determine if resident operative time in cataract extraction and intraocular lens insertion (CE/IOL) affects early visual outcomes and post-operative recovery. They further sought to investigate if attending surgeons can reduce resident operative time. Methods This retrospective, chart-review, case series at single Veterans Affairs Hospital (VA Tennessee Valley Healthcare System) studied resident cataract surgeries between March 1, 2018 and March 31, 2020. Following power analysis, 420 eyes of 400 patients from all resident cataract surgeries were included. Eyes with attending as primary surgeon, laser-assisted cataract surgery, or concurrent secondary procedures were excluded. Linear mixed effect models were used to study the association between operative time and visual outcomes while adjusting for covariates including cumulative dissipated energy, preoperative factors, and intraoperative complications. Results Longer operative time was statistically associated with worse post-operative-day 1 (POD1) pinhole visual acuity (PH-VA) adjusting for cumulative dissipated energy and other operative factors (p = 0.049). Although resident physicians were the primary surgeons, the operative times were different between the ten supervising attending surgeons in the study (p