Decision Making


“It’s when you realize that you are out of time that you must focus on not rushing.”


TASK AT HAND: This week I’m thinking about the last minute, the eleventh hour, time as it expires. We are constantly rushed and hurried in our professional commitments and personal relationships. In these pressured moments, we tend to rush when, in fact, we should be deliberate and purposeful with our strategy. As time slips away, we can succumb to bad decisions but there are strategies you can use to avoid errors in these situations.

“As time expires, each second is worth more.”

First, realize that, as time expires, each second is worth more. I like to think of the eleventh hour in terms of relativity. Although one second is one second, in the closing moments of an assignment or instances where a quick decision is required, I like to think of those seconds as “more valuable” than previous ones. When you only have minutes to act, each second is crucial. When you have days to decide, deliberation can be consummate with a longer time window, and seconds seem to matter less.

Previously, on the Decision Triage post of the Sunday Surgical Scrub (you can find it here), I emphasized that, in the last minute, every decision must be made right away and that all triages become urgent in this context. For example, in surgery, I imagine expanding each second to feel like minutes so that I can carefully execute the maneuvers that will bring the outcomes that are required. If there is an unforeseen complication or adverse event – where there is a very small amount of time to correct the error – it is here, I cannot rush! Realizing each second here is worth more than at any other time during the surgery, I can focus solely on these intense junctures. This approach allows speed and efficiency, without ever being rushed or forced into shortcuts.

“Quiet your mind, then plan and execute!”

The feeling of “running out of time” is an external force. It comes from outside you and is then transferred onto your inner self. This creates needless self-inflicted pressure. Quiet your mind, then plan and execute! When you are left with what seems as no time and limited options, still your mind and see beyond the time frame. Find the character of the decision  and align yourself with the basic principles of what you want to achieve.


MEDICINE & MACULA: I was in Toronto this weekend for the 56th Annual Walter Wright Symposium, Retina 2016: A Practical Approach to Navigating the Future.


On Saturday, I presented a talk on my approach and techniques for infectious endophthalmitis. The evolving paradigm calls for early surgery and aggressive treatment to salvage vision from this devastating infectious condition.



GRATIS: “Why do they call it rush hour when nothing moves?” -Robin Williams


My best to you,

David Almeida

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SSS face punch

“Everyone has a plan ’till they get punched in the mouth.” Mike Tyson


TASK AT HAND: This week I’m thinking about strategy setbacks. We all have to soothe the bumps, bruises, blisters and burns associated with negotiating the often rocky landscape of our evolving strategies on the way to successful solutions.

But what happens when you hit a wall with your strategy? Or as Mike Tyson aptly summarizes – what happens when you and your plan get punched in the mouth? As much as your strategy may be well-being, it’s at this point that we must clarify core principles to break through.

What do you do when your best laid plans, your carefully tailored approach, your curated strategy stall? I have found 3 approaches to help navigate these difficult times.

1. Realize and accept that you will eventually get punched in the mouth. It will happen sooner than you think. It will happen multiple times. “Any time you think you have the game conquered, the game will turn around and punch you right in the nose” (Mike Schmidt). Denial of this truism will cause you to hold faulty strategies and you will fail to see the emerging landscape. Don’t bother with the padding…


2. When you get hit, be receptive and flexible. This is counter-intuitive because the first reaction is to get defensive. The ability to be receptive allows you to discover what details you missed. Then, flexibility allows you to adapt your strategy to the new conditions. Being flexible does not mean quitting on your plan. “Take things as they are. Punch when you have to punch. Kick when you have to kick” (Bruce Lee). Be open and receptive but remain committed. This is counter-intuitive but is of immense advantage.

3. The ability to take a punch is good, but the ability to avoid one is best. Your ability to navigate assaults is a defining property of your defensive strategic framework. “In the battle of existence, talent is the punch; tact is the clever footwork” (Wilson Mizner). Your strategy is your footwork – it will provide you with the needed defence for when you under duress, and it will allow you to counter when an opening occurs.

In chemistry, a transition state is a temporary high-energy configuration existing between two stable forms. The transition state corresponds to the highest potential energy along a reaction path. It is often violent and tumultuous but the potential energy allows for the formation of new stable forms. Think of these periods of your life – times of setbacks and shock – as transition states and look for ways to harness the potential energy to form an improved baseline.


MEDICINE & MACULA: Check out our most recent publication, Retinal Injury Secondary to Laser Pointers in Paediatric Patients. Our study describes children who had laser-related retinal injury to the macula due to the mishandling of the laser pointer devices.

Peds citation

Peds laser figure

Thank you Pediatrics for publishing our study! Check out the study here.


GRATIS: There is no shame in taking a punch, and there is much character growth in our ability to transition into an improved form during the difficult transition states. However, there may be times where you find yourself constantly under assault. If this occurs, you may have to punch back. Unfortunately, this is the only currency some understand.

“You punch me, I punch back. I do not believe it’s good for one’s self-respect to be a punching bag.” Ed Koch


My best to you,

David Almeida

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triage decision sss

“Don’t fight the problem, decide it.” -George C. Marshall


TASK AT HAND: This week I’m thinking about triage. In medicine, triage is the process of assigning degrees of urgency. In any hospital Emergency Department, you will find a Triage desk that functions to grade the severity of your ailment. Triage decides if your problem is an emergency (must be assessed and resuscitated right away), emergent (needs assessment very soon), urgent (important but can usually wait some amount of time), or nonurgent (can wait). An emergency has the potential to kill or seriously harm your patient and needs to be addressed right now. An emergent condition has the potential to inflict significant morbidity and cannot be delayed any significant amount of time. An urgent state needs to be assessed but usually lacks immediate temporal gravity.

Over the years, I have found that you can apply this same triage process to decision making. One can formulate strategy by triaging decisions and prioritizing subsequent actions. Whether you are taking inventory of personal sentiments, deciding on a strategy for an ambitious project, or developing a new idea, the ability to triage allows you to set priorities, execute strategy, and engage in effective delegation. The goal of decision triage is to emerge from the deluge of questions with a set of priorities aligned with your strategy. Clarity for success by means of deciding how to tackle multiple problems.


I triage decisions using these same emergency principles: an emergency requires an answer or decision right now – no exceptions! I reply to all emergent decisions within 12-24 hours. For urgent decisions, I reassess later. Nonurgent matters tend to be delegated elsewhere. Try this next time you are asked to solve a problem or your input is required. If the issue has immediate consequences, deal with it straightaway. Don’t procrastinate and don’t delay. Is it emergent? If so, you have some time. Relatively urgent? Maybe you can delegate this task or move it down your prioritized to-do list.

In triaging decisions, will almost always find conflict and disagreement because, what to one is an emergency, to another is only urgent. What do you do when this occurs? Make sure you communicate clearly so that trust is built in your assessment skills. Lead by example and never trivialize the conflicts of others. When in doubt, have the best interests of others in mind. Selfish behavior is based out of insecurity. Act selfless and create value for others in your triage. This is a key principle of successful decision making.

“Nothing is more difficult, and therefore more precious, than to be able to decide.” –Napoleon Bonaparte

As the quote above emphasizes, the ability to decide deserves your judicial attentiveness. Decision making and strategy are topics we revisit frequently here on the Sunday Surgical Scrub and you can think of decision triage at the top of the algorithm. Once you decide on the priority of the decision, you can use the many tools presented here to resolve the crux of your conflict and put forward the best decision.


Caregiver burden fig

MEDICINE & MACULA: Check out our new systematic review pertaining to depression and burden among caregivers of patients with visual impairment. While caregiving allows those with vision problems to better adapt, it has been shown to take a toll on the caregiver on various levels, such as invoking depression and burden. Recognition of this is key for awareness, prevention and management.

burden study paper

Thank you International Ophthalmology for publishing our study! Check out the study here.

GRATIS: One last note on the decision triage system above. By frequently using this method of triage for decision making, I have found a wonderful unexpected side effect: I gain perspective by realizing that few things are a true emergency that require destabilization to correct. This calming vantage point will allow you to appreciate that many decisions – whether we like or not – are just not that important. Find those that are, prioritize them, and then successfully attend to them.

My best to you,

David Almeida

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Take from all things their number and all shall perish.
Saint Isidore of Seville, Etymologies (Book III, c.600)


TASK AT HAND: This week I’m thinking about “quantity” and the tangible aspects of strategy. A few weeks ago we discussed the intangibles of decision making and I thank you for the enthusiastic response. Today, contrasting with the quality or intangibles of a decision, you can think of tangibles as decision making items that have inherently associated metrics – a quantity that we can explore to make better decisions.

In medicine, when eliciting the history of an illness from a patient, the quantity is many times simply a number: how bad is your pain? 0 is no pain and 10 is the most pain you can imagine – what is your pain? This simple metric has massive impact and aids your diagnostic workflow significantly. In strategy, think of this quantity as tangible aspects of decision making that can be measured. When teaching, I often refer to these tangible metrics as the quantity relevant to my strategy.

measuring tape

For example, you may purchase a car for intangible qualities like how it makes you feel or your first memory of that model. On the other hand, quantity or tangibles metrics would include items like horsepower, fuel economy, braking distance, etc. One can quickly appreciate that these metrics can get very extensive so I have created 3 B’s – basic components for ease of applicability to any decision.


1.   Bank: this is your budget and contains all aspects of funding critical to your decision. How much in your bank?

2.   Bread: raw materials, intellectual capital, workforce, customer base. This describes the resource metrics relevant to your decision. How much bread do you have?

3.   Brawn: This is the amount of effort you have to put into a decision; 0 is no effort and no action desired while 10 is an all-consuming action. How much effort are you willing to put into a strategy?


In my opinion, you need 2 of these 3 to be positive for you to have a beneficial quantity component to your strategy. The power of this simple approach is that it can be applied to any scenario. For example, let us suppose you are considering moving to a new city. Palo Alto is a very innovative part of the country, but it is also very expensive. If your bank is low (small budget), you don’t have much bread (unsecured job or resources), but your brawn is high (highly motivated to move there), this is still not the best decision from a tangible metric point of view.

Let’s do another: your single site business is thinking of expanding to another state. Your bank is good (selling well enough to support another site), your bread is positive (growing customer base, physical space to accommodate a second location is doable), but your effort is low (2 out 10 because you really don’t want to deal with expansion). Based on quantity, this would be a positive decision to make so you should carefully consider it.


piggy bank

Use quantity – the application of tangible metrics – to your professional and personal decision-making to clarify measurable components of your strategy. Don’t neglect what you can measure! An experiment is a question which science poses to Nature, and a measurement is the recording of Nature’s answer.” (Max Planck)



MEDICINE & MACULA: As the Max Planck quote shows above, metrics and science are intrinsically link, but, as a scientist, a major task is to ask difficult questions. A recently published commentary refreshes the importance of learning from failed experiments – and the importance of trying again. To effectively achieve this, the author concludes that communicating your struggles to others, asking for help, and accepting it when it is offered allows you to foster the needed resilience to cope with fear of failure and find your success.

The study was published July 29 in the journal Science. Check out the study here.



DA Sx Maneuvers

GRATIS: Thank you Retinal Physician for showcasing my new technique on Surgical Maneuvers Tip of the Month! In it, I describe the repair of complex retinal detachments secondary to viral retinitis. This novel technique combines triamcinolone-assisted chromovitrectomy with silicone oil tamponade and intraoperative antiviral therapy with foscarnet. Check out the article here.


My best to you,

David Almeida

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“If I’m going to live, I want to live fully, very intensely, because I am an intense person. It would ruin my life if I had to live partially.”

Ayrton Senna (1960-1994), 3-time Formula One World Champion


TASK AT HAND: This week I’m thinking about passion and what it means to live days immersed in the strength of barely controllable emotion. Passion, as a source of energy, can be oppressed by the many tasks and distractions endlessly intruding into our lives. However, I have found that, being reacquainted with your passion is a revitalizing elixir of energy, focus and determination that cannot be neglected. Consequently, I have found three strategies to ensure that passion is a tenet not lost or neglected.

Passion in decision-making. When formulating decisions and employing strategies in your business or professional life, don’t neglect to acquaint yourself with your drives and desires. Some aspects are best decided dispassionately; but, similar to what we talked about last week with intangibles, core fundaments require a degree of enthusiasm, self-expression, and identity to fulfill the full potential of the decision in question. “Passion to a person is what gas is to a car. Without it, you won’t go anywhere!” (Alex Haditaghi; Softly, As I Leave Her). Many times, amongst decision options without major distinction, choosing the one best aligned with your passion will provide opportunities not previously foreseen.

Passion in your personal relationships. A personal relationship without some element of passion is mere acquaintance. Strive to consistently surround yourself with people who stoke the fires of vitality: those that challenge you, those that ask you to grow, and those that allow you to change. It reminds me of an Avett Brothers lyric: “I wanna have friends that I can trust, that love me for the man I’ve become not the man I was” (The Perfect Space).


Passion in your daily life. Finally, irrespective of your professional and personal endeavors, please commit to one act that you are passionate about each day. This need not be for more than a few minutes – but stay connected to that drive daily. Don’t lose this connection because, this connection, is very much a defining part of who you are.

When you look back – if you must – recall a life lived with passion! Days filled with this barely controllable emotion that allows you to create and touch the lives of others in fantastical and wonderful ways. Find passion and “Let us live so that when we come to die even the undertaker will be sorry” (Mark Twain).


MEDICINE & MACULA: Interesting study in PNAS that, after reviewing 9 studies and 2100 participants, found a consistent reduction in the clarity of people’s memory of their past unethical actions. The communication finds that people who acted unethically are the least likely to remember the details of their actions. That is, people experience “unethical amnesia”: unethical actions tend to be forgotten and, when remembered, memories of unethical behavior become less vivid over time than memories of other types of behaviors. Because of unethical amnesia, people are more likely to act dishonestly repeatedly over time. This important publication advances the science of dishonesty, memory, and decision making.


Check out the study here.


GRATIS: “A study can be made against invasion by an army; no stand can be made against invasion by an idea.” –Victor Hugo


My best to you,

David Almeida

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hand print identity

“In the social jungle of human existence,

there is no feeling of being alive without a sense of identity.”

Erik Erikson


TASK AT HAND: This week I’m thinking about the intangibles of strategy. We are well versed in the tangible data of decision making: spreadsheets, SWOT analyses, and projections. But today, let’s look at the intangibles – those aspects that are sometimes neglected when we devise a strategic plan .


Let me divert for a couple of sentences… In medicine, one of the ways we can describe a patient complaint is in terms of “quality”: how does it make them feel? Similarly, I adopt this same descriptor to strategy and have arrived at three distinct aspects of the quality, or intangibles, of a decision or strategy: satisfaction, opportunity lost, and identity.


Satisfaction. Good decisions need to make sense. Good decisions need to respect budgets and achieve objectives. Great decisions should satisfy. That is, they should provide adequate information or proof so that they are convincing. Extrapolating, effective decisions should convince stakeholders of its ascribed path. Try this next time you have a conflict or decision and are considering options. Ask yourself if the decision you have arrived at satisfies the need or problem at hand. At this moment, you realize: “The ultimate victory in competition is derived from the inner satisfaction of knowing that you have done your best and that you have gotten the most out of what you had to give.” (Howard Cosell)


Opportunity Lost. Most are familiar with the microeconomic concept of opportunity cost: the value of the best alternative forgone where, given limited resources, a choice needs to be made between several mutually exclusive alternatives (Investopedia). Assuming the best choice is made, it is the “cost” incurred by not enjoying the benefit that would have been had by taking the second best available choice. The latter can sometimes become arcane, esoteric, and neglected in strategy. I frequently use the term opportunity lost to highlight the fact that, in making a certain decision, what have you given up in turn? This is not simply the best alternative foregone, but all other options lost. In my opinion, this drives home the professional, personal and intangible consequences of the decisions I make.


Identity. This one is simple. The best decision available, if it does not identify with who you are, with what message your business is trying to convey, or leaves you with doubt about ethics, is a decision that is not congruent with your identity. Be careful with these! Decisions without respect for identity risk entering a path without direction. Actions without regard will leave you in an abyss; this void expands without reflection and consideration.

solo business man

As you continue to improve your personal and professional strategy, remember the power of intangibles to transform good decisions into great ones! Satisfaction, opportunity lost and identity are integral components to the quality of the decision you make.


MEDICINE & MACULA: Interesting study found that excessive stress can cause memory problems in women who had survived breast cancer. This study examined 1,800 breast cancer survivors and found that those with a greater level of physical activity had higher levels of self-confidence and less stress, and as a result fewer perceived memory problems.

If you didn’t know already, it seems the benefits of exercising regularly are practically limitless!

The study was published July 8 in the journal Psycho-Oncology. Check out the study here.



GRATIS: Check out our new paper: Bimanual pars plana vitrectomy for removal of a dislocated DSAEK graft from the vitreous cavity published in Retinal Cases & Brief Reports. We describe a new technique for removing dislocated grafts.

PPV K graft 1PPV K graft 2


My best to you,

David Almeida

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“There is only one success – to be able to spend your life in your own way.”

Christopher Morley


TASK AT HAND: This week I’m thinking about success; a nebulous concept that for millennia has eluded many. Last week, a friend asked me how I define “success” – not happiness, not satisfaction – simply success. This enigmatic question consumed a lengthy conversation that I believe worthwhile to revisit here.


I believe success occurs in one of two ways: either you spend your days doing what your love or you craft a life where you subsidize – with money, creativity or effort – time for that which you love. Furthermore, those we love and love us, are fundamental cornerstones of success. Our relationships with those we care about is absolutely critical: clichés like the influential who neglects loved ones is not success.


Let’s take this first part: do what you love. I am reminded of Mark Twain’s words: “The secret of success is making your vocation your vacation.” This is the ultimate achievement and what I regard as success – no qualifiers needed. Unfortunately, this exists only in a minority of cases. If you are lucky to have this in your life – cherish, craft and confirm it because, “when love and skill work together, expect a masterpiece” (John Ruskin). Now, success is filled with bumps, bruises and bile so never confound it with convenience, which actually tends to degrade your ability to grow.


But, what happens when the above is not the case? In my opinion, the majority of people aren’t lucky enough to love their career or job. This is an unfair reality of civilization. However, this is not a problem: what you then have to do – to achieve success – is develop a routine that allows you to constantly revisit that which you love. Dislike your job? No problem – this does not mean you can’t be successful. Find pockets of time, a circle of friends, actions and hobbies, a lover and family that bring you closer to success and that which you love. This could mean saving for a vacation, biking with a group of friends – it doesn’t matter – as long as you are on that byway which is intrinsically yours. As the quote above implies, success is singular to you! If you find yourself at odds with this goal, remember: “success is not final, failure is not fatal: it is the courage to continue that counts” (Winston Churchill). Continue to craft the life that finds in it your success.

As you move forward, don’t feel that you have to adopt my definition in any way. But, realize that you need to define this term for yourself – this is essential if you are ever going to achieve success.



business success

MEDICINE & MACULA: In line with our discussion, let’s move over to the business literature. Here is a case study driving the point that if the sole purpose of your business or career is to make money, you’re destined for mediocrity. Change your story so that meaning is first priority and money second.

Check out the study here.


GRATIS: Given today’s topic, I leave you with a few words from Frank…

“Regrets, I’ve had a few

But then again, too few to mention

I did what I had to do and saw it through without exemption

I planned each charted course, each careful step along the byway

And more, much more than this, I did it my way

“My Way” –Frank Sinatra



Go out. Find success. Your Way.

My best to you,

David Almeida

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“Success is simple. Do what’s right, the right way, at the right time.” Arnold H. Glasow


TASK AT HAND: This week I’m thinking about time. Specifically, how to decide on timing for optimal execution of strategy; in other words, what is the right time for a given action?

When considering strategy, and within the paradigm of planning and execution, timing is crucial to the latter. You have to ask yourself, when do I have to act? What is the optimal time for me to achieve the outcome I desire? You may know how to act, but the question here is – when to act? The key then is deciphering how much time you have. We will quickly see that this is not always possible, and in fact, morphs into an existential question in its broadest extension – how much time do I have left? But that is for another day…


You can decipher how much time exists by deconstructing this strategic element of decision making into 3 scenarios.

1)  Defined time period. This is the easy one and applies to a large share of your strategic decision making. This applies to scenarios where you have a defined timeline (e.g., decision is due in 10 days). In these instances, it is best to allocate the minimum resources to achieve the goal within that time frame. Use the time you have!

2)  Undefined time period. Now it’s getting harder… With an undefined time period, you have time competition. With no known timeline, you have to allocate resources in a judicial manner to achieve your desired outcome with external time competition present. In these cases, you almost always gain an edge by executing promptly! This is more significant if you are in a novel market with possibility for a first-mover advantage – the advantage gained by the initial occupant of a market segment. If you have the possibility for technological leadership, you need to move fast!

3)  Asymmetric time period. This is the most complex situation and relates to decisions with external competition as well as internal factors; it also most analogous to surgery where – at any time – there can be total destabilization forces (complications). In these instances, decision analysis has to find the “window of minimal conflict” which designates the optimal timing for execution.

For example, cataract (clouding of the natural eye lens) extraction was initially performed as “couching” where a needle was use to push the lens out of the visual axis into the back part of the eye. As you can imagine, this provides terrible visual results and was riddled with complications. This technique operated within a window of maximal conflict: you perforated the eye without a proper wound, you did not control the inflammation, and you failed to replace the refractive element of the eye. Instead, modern cataract surgery relies on proper wound construction, excellent visualization, etc. to find the right time to remove the cloudy cataract – using minimal ultrasonic energy within a stable eye – at a time of minimal conflict to achieve the best possible outcomes.

There is another benefit to operating within a window of minimal conflict. If you happen to execute the wrong decision, damage limitation and error correction are simpler. Contrastingly, high stakes – or decisions made within windows of maximum conflict – requires you to take on excess risk and need to be carefully leveraged.


Next time you have a decision, deconstruct and decipher the time window you are operating in; then, execute the right way at the right time!


MEDICINE & MACULA: Our new case, Distinguishing optic pathway glioma and retinitis pigmentosa with visual field testing, reviews the challenging issue of visual field defects in retinitis pigmentosa (an inherited retinal disease) and optic glioma (a brain cancer). It was published in Canadian Journal of Ophthalmology (Volume 51, Issue 3). Check out the study here.



GRATIS: Happy Father’s Day to all those who have served, and continue to serve, as role models and teachers. Thank you!


My best to you,

David Almeida

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wrong way

“The years teach much that the days never know.” Ralph Waldo Emerson


Task at hand: This week I’m thinking about negative outcomes. Times when life gives us the proverbial lemons… Surgery and life mirror each other in the interplay between action, reaction, and consequence. Sometimes – despite our best efforts, despite our best strategy, despite our best analysis of the situation – there are negative, untoward, unfavorable outcomes. In surgery, these are complications. In life, more commonly, these are hurdles and stumbling blocks that hinder our relationships and goals.


The question then, becomes, how do you effectively deal with these negative outcomes that invariably come our way?

There are three main attitudes that I use to deal with negative outcomes – whether they be in life or in surgery. First and foremost, do not over-react! What is done now is history, so you have to immediately start planning for the next step. The idea of not over-reacting is absolutely crucial, and almost guarantees your ability for damage limitation. You must stay calm, stay focused, and try to assess what just happened. In surgery, you will sometimes encounter a complication. If you are not careful, your rush “to fix” this first complication that instant, can cause you much bigger difficulties. I can’t stress this enough: the idea of not over-reacting is paramount.


This brings us to attitude number two: Take inventory of the perceived negative outcome. Is this a decision that’s been poorly executed? Have you offended someone? People tend to over-react and speak endlessly in these situations… Don’t do this! Instead, hold space. “Holding space” is a concept that I’ve come to appreciate. The idea is that you take inventory of the situation by actively listening and consciously processing information. You don’t have to say anything. You don’t have to do anything, but you have to consciously be there. For example, if someone comes up to you and says, “You did this wrong”, it’s very easy to get defensive; it’s easy to start talking, to start moving in a counter direction (usually defensive). Instead, try holding space. Hold that moment there, and you’ll see that the silence, and the pensive aspect has a powerful effect – it can diffuse tension and allow you to empathy in stressful momemnts.

The final one is – and I’ve said this before – plan and execute. This is always your go-to strategy. You have to plan. Then you execute. You have to develop a strategy, followed by its application. What was the negative outcome? Was there an unhappy patient? Was a co-worker offended in the way that you dominated a meeting? Was it a friend who feels abandoned? Whatever it is, you make a plan, and you execute the correction.

These are the three attitudes I have found to successfully mitigate negative outcomes. There’s no way to avoid conflict or complications: these are the crucible of character that you will encounter, undoubtedly, many times. The adage that calm seas don’t make for a skilled mariner – it’s the storm that brings it out – rings true. Remember: don’t over-react! Instead, hold space, and plan your escape.



Medicine & Macula: Interesting article in the open access journal, Medical Practice & Reviews, on Computer Vision Syndrome (CVS). It can affect anyone who spends three or more hours a day in front of computer monitors and – worldwide – up to 70 million workers are at risk for CVS (risk factors include prior ocular history and poor ergonomics). The most common symptoms include headache, eye strain, double vision, dry eyes (burning, foreign-boy sensation), and eye fatigue.

While a better understanding of the pathophysiology underlying CVS is necessary, I try to always remind patients that when you are in front of a monitor, you blink approximately one-third less than normal. Consequently, artificial tears and lubricating drops are excellent to maintain a happy ocular surface and the integrity of your cornea-tear film interface.

Check out the study here



Gratis: Our new case, Central retinal artery occlusion in a young HIV-infected patient on Highly Active Anti-Retroviral Therapy (HAART), has been published online ahead of print by Retinal Cases & Brief Reports. Thank you for all the positive feedback! Check out the paper here



My best to you,

David Almeida

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mnfl final

Task at hand: This week I’m once again thinking about decision making; specifically, decision analysis and how to achieve success in your decision making process. As you know, I like to borrow from the spheres of medicine, science and business when constructing my models and frameworks. When diagnosing a patient, physicians will investigate “associated factors” –  what are the related symptoms, history, or other issues that may be contributing to the suspected underlying diagnosis? Similarly, when looking at the decision or conflict at hand, spend some time deciphering the associated factors. These are always pertinent to the outcome you are trying to achieve.


Let me use a simplified example for you here. With spring in full swing, let’s say you are trying to decide on a particular plant for your garden. Our simplified desired successful outcome of this decision is to pick a plant that will not only grow – but thrive – through the seasons. Consequently, we can quickly deduce that the “associated factors” will include environment (weather, rain, soil quality), resource availability (how much time do you have to tend to the plant, what is your budget for seed), and appearance (do you want a pretty flower or a unique plant).


The best method I have found to uncover the associated factors of a particular decision is through visualization. The concept of “visualization” is common ranging from sports to cognitive-behavioral therapy. Here, I am ascribing visualization as an act to appreciate all the forces acting on your decision. I’m always surprised at how much I uncover through this process and realize that our decisions are heavily indebted to a lot of extraneous influences: it is usually not possible to remove these factors so one would be wise to figure them out!


I actually use a lot of visualization in surgery as well – many times, the surgeon’s view is compromised secondary to many possible factors. In these challenging instances, my visualization of the problem at hand and the role of my immediate environment allow me to continue without being deviated in a negative manner. So, next time you are pondering a difficult conflict – visualize the relevant associated factors – and give yourself some clarity on your way to success!


Medicine & Macula: The first US universal newborn ocular screening initiative was recently published in the journal Ophthalmology. It showed that fundus hemorrhages are common in healthy newborns, especially in those born by vaginal delivery (9 times more likely) and in forceps assisted delivery. While the long-term consequences of retinal hemorrhages on visual development remain unknown, it is important to have empirical knowledge that these are common. The issue of child abuse and shaken baby syndrome are a natural extension of this topic, and key points of differentiation (vitreous hemorrhage, retinal hemorrhages in multiple layers, traumatic retinoschisis) in the latter need to be emphasized.

Check out the study here


Gratis: Thanks to American Journal of Ophthalmology Case Reports for recently publishing our study on Delayed fungal endophthalmitis secondary to Curvularia.


Check out the paper here



Happy Memorial Day!

My best to you,

David Almeida

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