Sunday Surgical Scrub

“Always take your job seriously, never yourself.” – General Fox Connor would routinely tell this to his young protégé, Dwight D Eisenhower


TASK AT HAND: This week I’m thinking about decisions and discernment; that is, how to best judge the decisions we make. Recently, The Ophthalmologist published one of my articles on the framework of Decision Diagnosis and how to apply the PACT strategy for effective decision making.

PACT refers to Practice, Assess, Collect and Triage. If you are struggling with decision making, then Decision Diagnosis can help you make a PACT as follows:

Practice: Practice makes permanence. Practice with purpose and passion and it will transform and allow for positive development. You need to break the cycle of mindless practice and instill passion and purpose in the skills you hope to hone.

Assess the problem: Identify the character of the conflict. Ask open-ended questions like who, what, when, where and why? Without knowing the character of the problem, the best decision may elude you.

Collect information: Who are the people, places and things relevant to your decision?

Triage: Define how much time you have to make the decision in question. Triage your decision to assess if you need to resolve it right away or if it can be dealt with as a lower priority?

This framework should illuminate key characteristics of decisions and help you discern the best strategy to effectively reach your desired outcomes. Most importantly, clarity in discernment will allow to avoid decision malaise and guide you to fruitful and focused decisions!

I want to express sincere thanks to The Ophthalmologist for publishing my article in the February 2018 issue. You can find the article here.


MEDICINE & MACULA: Also in the February 2018 issue of The Ophthalmologist, you will find the article, When primary scleral buckling should be considered – and how to succeed by Alexander Ringeisen, Ed Ryan and myself.

We go over why scleral buckling is still the treatment of choice for certain retinal detachments and which patients are the best candidates for a primary scleral buckle. The article is aimed at ophthalmology residents and vitreoretinal fellows and provides an overview of when primary buckling should be considered. Furthermore, it provides guidance on which techniques will help success rates, as well as when to avoid a primary buckle.

Here is a patient who presented with a traumatic dialysis and underwent primary scleral buckling for repair. Postoperative fundus image shows the retina reattached with excellent visual outcomes.

You can check out the entire publication here.


GRATIS:  Many thanks again to The Ophthalmologist for showing our work in the February 2018 issue! Check out for a wide array of fantastic content.


My best to you,

David Almeida

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“We sail within a vast sphere, ever drifting in uncertainty, driven from end to end.” –Blaise Pascal

TASK AT HAND: Happy New Year! It’s a new year and the Sunday Surgical Scrub returns today with two concepts worth a year of pontification. This week I’m thinking about risk and uncertainty. One of the favorite tasks I undertake on the Sunday Surgical Scrub is too analyze terms that are commonly used interchangeably but which should not. This is another example. Risk and uncertainty are frequently used to describe some aspect of unknown events or trends. Some use risk as a measure of uncertainty – this is incorrect.

Risk is a property you can measure and assess. It should be used to describe an exposure to a harm. For example, you can calculate the risk of developing lung cancer based on exposure to cigarette smoking. Risk relies on metrics to comparing populations and their relative exposure to the risk in question. Another example is the insurance industry which measures and ascribes risk for harms like disability, death or destruction of property.

How can you use risk in your approach to strategy? Look for situations where you can measure, or at the very least have comparable exposures, to assess your risk. For example, an entrepreneur hopes to open a store and is trying to decide on locations. Metrics like number of businesses in the area, income for the surrounding zip codes, employment figures, etc. can all be used to arrive at measures of viability of such a venture.

Now, uncertainty is a different beast. Uncertainty is tough to measure and, consequently, has a large degree of chance involved. The current soaring price of the digital currency Bitcoin is an example. There is a finite number of Bitcoins (approximately 21 million) so this represents a scarce digital resource with no useful metrics to analyze to assess the risk of a price decrease (or increase). Another example is weather prediction. Although sophisticated weather models exist, and we can find values for risk of rain or snow, there is still an element of uncertainty that precludes precise determination.

Uncertainty, due to the element of chance, has the opportunity for massive rewards or major losses. Whereas risk tends to lend itself to calculated gains or losses, uncertainty is where dramatic swings can occur. As a general pearl, if you can find a competitive advantage to describe uncertain outcomes, you need to develop and exploit these. These can be parlayed into a potential novel first-mover advantage or give you a significant competitive edge in market competition.

The call to action from today’s Sunday Surgical Scrub is to look for opportunities to analyze elements of risk and uncertainty in personal decisions, professional opportunities or instances involving complex decision making. Understand what the risk of exposure is and the degree of uncertainty becomes clear. The choice is then whether you want to accept that risk and uncertainty in the options available.


MEDICINE & MACULA: Wiliam Osler wrote, “medicine is a science of uncertainty and an art of probability”. These are wonderful words! Today I present a case of a young patient who suffered a retinal detachment secondary to a giant retinal tear (GRT) in the setting of trauma. Historically, surgical success rates for the management of GRTs were poor. The risks of failure from redetachment and proliferative vitreoretinopathy (PVR) were high. Modern surgical techniques have mitigated the risk of poor outcomes and improve our success rates significantly.

Here is the intraoperative view of a patient with a giant GRT secondary to trauma. Note the massive tear rolled over on itself. As mentioned above, these eyes are at high risk for the development of PVR. This case has further increased risk of PVR due to the young age of the patient.

I employed scleral buckle, vitrectomy, membranectomy, endolaser and long-acting gas tamponade (C3F8) for surgical repair. Here is the view at the end of the case.

Long-term follow-up shows an excellent outcome where the patient recovered most of their vision. You can see the laser demarcation in this montage photo.


Here is the optical coherence tomography (OCT) shows good macular anatomy and foveal architecture.


GRATIS: “There is no such uncertainty as a sure thing.” -Robert Burns


My best to you,

David Almeida

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Welcome to the Sunday Surgical Scrub 2017 Year in Review! It’s been a fast-paced 12 months and I want to, first and foremost, thank everyone for their continued support and interest. I’m going to highlight some of the top posts, news and research findings from over the past year. Here we go…


TASK AT HAND: This year I covered a multitude of topics but these stand out. In March, I deliberated on the key differences between productivity and creativity. Productivity – how we think – can be thought of as the grammar or syntax of a sentence. Creativity – what we think – are the words, concepts and emotions in that sentence. I think of productivity as the order and arrangement of a composition whereas creativity is the unique melody. While productivity tends to have basis on ordered and logical processes, creativity can be borne out of entropy and randomness.

Creativity, in an unproductive individual, may emit a flash in the pan, but rarely creates enough light to sustain the night. At some point, creative findings need to be distilled into elements of capable comprehension. Seek a state of wholeness where both the synthesis and organization of new thoughts and ideas coexist. Find congruency in their relationship. Take time when you are pondering problems or reflecting on ramifications, and break down the elements of your decisions into the aspects of productivity (how you think) and creativity (what you think). This will give you valuable insight into the overall process. You will be surprised at your creativity, and you will appreciate the process for decoding it. You can find the original post here.

A concept that continues to require emphasis stems from the Stoic teaching of control. In October, we concluded that we are not in control! The illusion of control is a powerful mirage that commonly creates a façade we believe to be actually present. While the desire for control may be real, in actuality, control is an illusion that can impair our judgement and create anguish and anxiety that does not exist. How can we give up on the illusion of control? First, realize you are not in control. All you can control is your reaction to events. Second, since you are not in control, then to worry is pointless. You can find the post here.

Over the course of 2017, I discussed various logical fallacies and errors of bias on the Sunday Surgical Scrub. The ability to recognize bias is essential for survival. To be cognizant that we are strongly attracted to our own beliefs and that these biases, left unchecked, increase our vulnerability for errors needs to be constantly addressed. In February, we highlighted the trap of confirmation bias. Confirmation bias, also known as the confirmation trap, occurs when we procure data and information that aligns with our beliefs and ignore that which runs counter to our arguments. Bias in opinion is easier to detect and correct; however, confirmation bias – when we actively seek out information to back our preconceived beliefs – is dangerous. How do you avoid the confirmation trap? Be a cynic. Act like a doubter. Question as a skeptic. Question both the quality of the data and the validity of the source as a means to be on guard against this insidious type of erroneous logic.

In September, I extolled grit; a trait commonly alluded to while, at the same time, rarely well-defined or understood. Most people identify grit as a requisite trait for success and development yet few can define its crystalline qualities. Grit is unyielding courage in the face of hardship. Grit allows your character to carry on despite conflicts and confusion. Without grit, you risk being swallowed by the tides of misfortune and disaster. You can find the original post here. 

Finally, in November, I summarized the two certainties in life: death and taxes. Remember, death is guaranteed. This is not simply for macabre effect. This is actually a wonderful liberation that we should use our talents and energy to effect genuine meaning in our lives and the those we come in contact with. The anxiety and worry surrounding most items is not necessary and often hinders our duty in the latter regard.


MEDICINE & MACULA: Earlier this year, I published a book entitled, Decision Diagnosis: Seven Antidotes to Decision Procrastination.

Big thanks for the interest and in making it an Amazon best seller in multiple categories and in multiple countries. Many sincere thanks! The paperback and kindle version can be found here.


CASE OF THE YEAR: I am grateful for another productive year that saw our research team publish numerous studies, case reports and surgical techniques. However, none garnered as much interest and attention as our case report, Deer Tick Masquerading as Pigmented Conjunctival Lesion (Robin K. Kuriakose, Lorna W. Grant, Eric K. Chin, David R.P. Almeida) published in the American Journal of Ophthalmology Case Reports.

In it, we report a unique case of tick penetration of a black-legged deer tick (Ixodes scapularis) into the conjunctiva. Despite the low risk for Lyme disease, doxycycline was prescribed for prophylaxis.

In any case of suspected tick penetration to the ocular surface, immediate ophthalmologic consultation and prompt removal as well as attention paid to the Infectious Diseases Society of America guidelines regarding prophylaxis. You can find the study here.

Later in the year, this case was highlighted in a special mystery cases issue of New Retina MD entitled, The Adventure of the Upstate Traveler: A camper brings home an unintended souvenir from a camping trip (Robin Kuriakose, Lorna Grant, Eric Chin & David Almeida).

You can find the case here.


GRATIS: Lastly, I would be amiss if I did not look back on October 1st and the once in a lifetime chance to share the court with Mr Karim Abdel Gawad for a squash event hosted by Boast Squash here in MN.

Gawad is a professional squash player from Egypt who reached World No. 1 in May 2017. It was humbling and an honor to share the court with a fierce talent like Gawad. I had a blast and thankful to Gawad for having some fun with us amateurs!


Thanks for reading.


Happy new year and best wishes to you and your loved ones in 2018!

David Almeida

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“I only go out to get me a fresh appetite for being alone.” -Lord Byron


TASK AT HAND: This week I’m thinking about time alone. Whereas loneliness is traditionally considered a painful state, solitude can recharge and rekindle our energy and creativity. Time alone needs to be time well spent and is an essential component of renewing the acquaintance with ourselves. There is no potential for authenticity without being comfortable in your skin.

“There is no potential for authenticity without being comfortable in your skin.”

Whether you are introvert or an extrovert, time alone pays dividends. For introverts, the act of “recharging” usually involves time alone. As a group, introverts tend to do better at consistently carving out time or reflection. For extroverts, who typically renew their energy with others, there needs to be regular commitment to the act of solitude.


A few quick tips to maximize time alone.

1.    Time alone outdoors trumps most activities indoors. Nature walks are king.

2.    Your smartphone will ruin every precious sound moment of silence. Airplane mode is essential to protect ourselves from the endless distraction of our smartphones. Refuse to let your smartphone notify you of anything else going on.

3.    A few minutes are ok. Time alone is akin to meditation and a few minutes will sometimes do. You don’t need to clear a weekend or isolate an afternoon; rather, find small pockets of time in daily routines that offer you the investment of time alone.

4.    Initially, your time alone may cause you to feel bored or restless. This is a superficial transient state and will quickly fade into calmness.


I consider time alone an investment in development. Like sleep restores physiological processes, solitude guides your assessment and planning. Social partnership is necessary, but at times, you need to break away alone. This is a wonderful time of year where we celebrate holidays with family, friends and loved ones; however, time alone can be hard to find. Use the quick tips above to maximize the fleeting moments that you may encounter.

Finally, I’ll leave you with this thought: how can others appreciate or tolerate you if you can’t tolerate or appreciate yourself?


MEDICINE & MACULA: Here are stills from a surgical video of a patient I recently operated on. She had cataract surgery complicated by a massive intraoperative choroidal hemorrhage. After waiting approximately 10 days and following closely with serial echography, I took the patient to surgery for choroidal hemorrhage drainage.

In this technique, an anterior infusion is secured and the intraocular pressure is increased to 60mmHg. Next, using a 25-gauge platform, a non-valved cannula-trocar is introduced 7mm posterior to the limbus in the most detached quadrant. The latter can be determined with preoperative or intraoperative echography and the choroidal height should be at least 5mm.

Introduce the trocar with a flat approach forming an incident angle of about 20 degrees to the sclera. Here you see placement of the 25-gauge cannula 7 mm posterior to the limbus.

Finally, open the cannula and, if placement is correct, the hemorrhage will drain effortlessly. Maintain the intraocular pressure at 60mm Hg during active drainage. Here you see copious amount of dark hemorrhage draining from the trocar with the infusion running.


A few quick surgical tips:

–       Avoid the 3 and 9 meridians to spare ciliary nerves from possible trauma.

–       If possible, drain the inferotemporal quadrant first as this site is easiest to access.

–       If doing a vitrectomy at time of drainage, avoid an air-fluid exchange because choroidals often recur during this step and may push fluid posteriorly, endangering the macula. Instead, use non-compressible mediums like balanced salt solution or silicone oil.


GRATIS: “Life could be wonderful if people would leave you alone.” -Charlie Chaplin


My best to you,

David Almeida

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“Always do what you are afraid to do.” -Ralph Waldo Emerson

TASK AT HAND: This week I’m thinking about success; specifically, the fear of success. Success, this nebulous and enigmatic concept, fascinates me in that it is desired and revered but, at the same time, can create fear and depression.

In a previous Sunday Surgical Scrub, I defined the achievement of success 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 (you can find the blog post here). In my opinion, there are no other acceptable definitions of success.

But where do the elements of fear come from when we discuss success?

Is fear just an apparition of objectives that have not yet been achieved? Or does fear and success represent a more complex interplay?

There are two aspects of the fear of success that we will discuss here. First, as the Emerson quote above states, there is a natural fear of the unknown. Success, usually in terms of achievement, represents a journey we have not yet completed. Consequently, a fear of unknown outcomes is a common reaction and akin to the fear of an adventurer seeking discovery. One should use this fear as a motivator for that which we desire, pursue and value.

The second aspect of fear in the context of success is more troubling and is applicable to instances where some success has already been achieved. Whether it be in business, sports, arts or simple hobbies, past success can confound further progress. The fear of success here is dependent on emotional factors where previous success leads to expected future success. The fear of not being able to “back it up” can leave us feeling like an imposter. This fear can cause us to shy away from opportunities which limits our ability for success. This can create stagnation and hinder our willingness to take on fresh challenges.

Stagnation breeds depression which creates paralysis.

How do you overcome the fear of success?

The answer, and I’ve touched on this with the Sunday Surgical Scrub before, requires a commitment to acquainting yourself with the energy and passion to move beyond this fear (check out this Sunday Surgical Scrub blog post here). Remember, worst case scenario is you don’t back it up and fail. So, what? There is no apocalyptic outcome here. There is no fatal end. You will still move on but maybe at a slower pace or in a more prolonged route. Take your task or objective seriously but realize that this fear is miniscule and let it not hold you back from that which you define as success.


MEDICINE & MACULA: Last week I played in the Beyond Walls Squash Week held at the Commodore Club in St Paul MN.

Beyond Walls is an incredible organization aimed at promoting academic excellence, healthy lifestyles and access to meaningful opportunities for all youth. It is a year-round scholar/athlete approach to youth development and out-of-school time for 6th to 12th grade students. It uses a one-to-one academic mentoring with physical fitness via the racquet sport of squash aimed at community engagement and college-readiness. You can find more information here.

I won the amateur A singles squash draw with a bevy of tough matches! I won this tournament in 2016 and was very excited to repeat in 2017. I’ll keep working hard and try for the three-peat in 2018…

In addition to amateur singles, there was a professional singles tournament, a pro-am doubles and an amateur doubles draw.

With sincere gratitude, I thank everyone involved for their energy in growing the sport of squash in the Twin Cities!!


GRATIS: “Courage is resistance to fear, mastery of fear, not absence of fear.” -Mark Twain


My best to you,

David Almeida

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“More matter with less art.”

Queen Gertrude, speaking to Polonius, in Hamlet (Act 2, scene 2)


TASK AT HAND: This week I’m thinking about Shakespeare’s Hamlet. Specifically, in Act 2, there is long speech by the verbose politician Polonius. Queen Gertrude, Hamlet’s mother, quips: “More matter with less art.” She is calling for Polonius to tone down the fancy speech and get to the point.

In both modern times and past cultures, the ability to get to the point is valued but unfortunately underutilized. Thomas Jefferson wrote, “The most valuable of all talents is that of never using two words when one will do.” Language allows humans a medium of communication unmatched by any other species; however, it also has the potential to create misunderstanding and confusion. Clarity is many times lost in excess.

What is the best strategy to pursue this principle of “more matter with less art”?

How do you remain direct without over-simplification?

Albert Einstein perhaps best describes the optimal approach to answer this question: “Everything should be made as simple as possible, but not simpler”. Be deliberate in your content and message. Be as specific as possible in your brand. But don’t dumb it down. Be surgical in your commitment to cut out that which lacks value, purpose or breadth.

Let us conclude today’s Sunday Surgical Scrub with a call to action of more substance, less rhetoric! Nothing more.


MEDICINE & MACULA: Here are some images of me using Alcon’s NGENUITY 3D visualization system for removal of epiretinal membrane (ERM, also known as a macular pucker).

An ERM occurs when there is cellular proliferation over the macula. In many instances, this membrane remains mild and does not have any significant effect on the macula or the person’s vision. However, in other cases, membranes become prominent leading to vision loss and metamorphopsia. For visually significant membranes, vitrectomy with membranectomy is needed to remove the proliferative tissue and restore the normal macular anatomy.

The Beaver Dam Eye Study (Ophthalmology 2015;122:787) showed a prevalence for ERM of 34.1% so this is a very common surgery I perform. Above is a high-magnification image of the ERM being removed with microsurgical forceps.


GRATIS: “Less is more.” -Ludwig Mies van der Rohe


My best to you,

David Almeida

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“All you need is the plan, the road map, and the courage to press on to your destination.” -Earl Nightingale

TASK AT HAND: This week I’m thinking about DADA. This abbreviation is borrowed from the covert playbook of spies and intelligence agents. The idea is to have a blueprint to evaluate, plan and execute in an instant. I commonly refer to DADA as “strategy on the run” because of the ease and rapidity of its use. Whether you are under duress or require a quick plan, here is how you can use DADA – Data, Analysis, Decision and Action – to quickly formulate a strategy.

DATA What information is available to you? Quickly gather all the information possible to best assess the situation. This can be something as simple as taking note of where the exists in a room are to more detailed accounts such as viewpoints of the people you are negotiating with.

ANALYSIS Analyze the information. The benefits of DADA are brevity so you want to make this analysis quickly. If you are under physical danger, you need to determine the likelihood of harm. Another example; if you are negotiating, you need to determine what the highest/lowest price you will go or the best alternative in case you fail to achieve a compromise.

DECISION Make a decision. You have gathered the requisite pertinent information and analyzed the possible outcomes. Decision involves reasoning an outcome you will be content with. With DADA, you are usually looking at short term plans and outcomes so this decision needs to be effective immediately.

ACTION Now, you must act! As I mentioned above, DADA is “strategy on the run”: it’s an excellent framework to quickly develop and execute plans of action around objectives. What is your objective? In situations where you may be in danger, safety is your primary objective; consequently, the decision is either to flee or stay and possibly have an altercation. You need to have made your analysis for the likelihood of each.

Next time you need a quick framework, consider DADA – Data, Analysis, Decision and Action – to formulate a plan. You don’t need to be Jason Bourne to make use of this technique’s effectiveness for situational awareness!


MEDICINE & MACULA: One of my favorite surgeries is retinal detachment repair. Each retinal detachment has subtle differences that make no two exactly alike. I like the fact that you can fix them multiple ways: vitrectomy, scleral buckle, vitrectomy with scleral buckle, air versus gas versus oil tamponade, approach to subretinal fluid drainage, membrane peeling in detached versus attached retina, etc.

Recently, I performed retinal re-attachment surgery on a monocular patient with severe colobomas in both eyes. A coloboma is a structural defect and can involve the iris, retina, optic nerve or choroid. It’s a congenital defect that occurs when the choroid fissure fails to close up completely before a child is born. In the patient’s good eye, they suffered a retinal detachment with vitreous hemorrhage. Here you see me performing vitrectomy.

Note the extensive coloboma present with a sole band of retinal tissue extending through the macula that provides photoreceptors and vision to this patient.

The patient did very well with full return to the vision they had before the retinal detachment!


GRATIS: “A really great talent finds its happiness in execution.” -Johann Wolfgang von Goethe


My best to you,

David Almeida

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“God cannot alter the past, though historians can.” -Samuel Butler

TASK AT HAND: This week I’m thinking about revisionist history. This is a more complex topic than it seems. On the one hand, you cannot go back and revise history to fit your viewpoint. You can have an opinion on historical accounting but factual history must remain honest. Contrasting, our personal history displays more variance and offers us vast opportunity for accountability and ownership.

Let me illustrate the above point with an example. Go back and, sometime in the last five years, identify something you quit. Now, uncover the reasons why you quit that activity, pursuit or hobby.

Would the reasons why you would quit today be the same as they were when it happened?

What has changed?

When you start this self-reflection exercise you see that views change. The reasons for choices in the past evolve over time; sometimes into species that barely resemble their original proforma. Not surprisingly, we change. Consequently, our views evolve.

The goal of this exercise is to become a scientist with our history. Nikola Tesla stated, “The history of science shows that theories are perishable. With every new truth that is revealed we get a better understanding of Nature and our conceptions and views are modified.” We need to develop the skill to revisit strategies from the past and evaluate them under the light of who we are today. To forge new considerations so that we avoid previous pitfalls and can succeed when opportunities present themselves.

How can we apply this for improved decision making and strategy?

Use this exercise of reflecting on previous choices as a means to review your history. This can be of significant utility when you are faced with similar conflicts. Don’t simply apply the same strategy as in the past. Look to the past strategy, revise it with who you are today, and see if it still applies. Usually it does not. Revise your strategy and apply an improved framework.


MEDICINE & MACULA: This is a case of idiopathic intermediate uveitis, also known as pars planitis, showing peripheral inflammatory snowbanking.

Intermediate uveitis involves inflammation of the posterior part of the ciliary body and peripheral retina (pars planitis). It consists of mostly vitreous inflammation (“snowballs”) and may associated with inflammatory cells on the pars plana (“snowbanks”). In pure intermediate uveitis, there is usually no retinal findings, although patients may have a mild iritis.

In total, approximately 80-90% of intermediate uveitis cases are idiopathic pars planitis. Other causes include sarcoid, syphilis, inflammatory bowel disease, multiple sclerosis, lyme, tuberculosis, Behcet disease, Whipple disease and lymphoma.


GRATIS: “History repeats itself, first as tragedy, second as farce.” -Karl Marx


My best to you,

David Almeida

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“I draw from the absurd three consequences, which are my revolt, my freedom, and my passion.” –Albert Camus


TASK AT HAND: This week I’m thinking about consequences; specifically, our personal consequences. The way you live has consequences. For Camus, he emphasized revolt, freedom and passion. For many years I have esteemed this quote as a reminder that struggling with the consequences of our actions is a worthwhile and rewarding duty. The concepts that Camus brings forth – revolt, freedom, and passion – are requisites for review here on today’s Sunday Surgical Scrub.

REVOLT How do you effectively express revolt? In my opinion, there is no better approach than the constant unyielding pursuit of independent thought. The struggle to hold back the convenience of conformity is a revolt we must pursue each day. Don’t let an hour go by where you don’t question dogma and doctrine. We have discussed this multiple of times here on the Sunday Surgical Scrub because this is something YOU NEED TO DO! Whether it’s fake news, peer pressure or groupthink, you need to revolt with independent thought.

FREEDOM From the bastion of independent though comes the freedom for independent action; the latter is not possible without the former. Necessity for autonomy, and the liberty to act independent without discrimination is, unfortunately, another consequence that cannot be forgotten for any lapse of time. Look at the daily news and you will see numerous examples of this consequence.

PASSION Finally, with passion, we surge the courage to pursue our desires. From the inception of independent thought, to the freedom of independent action, the final culmination is the courage to pursue these desires in our daily lives. The courage to pursue our desires – driven by passion – is perhaps the greatest of effects on the consequences we are capable of.

So, the call to action with today’s Sunday Surgical Scrub is to look carefully at our thoughts, actions and desires and ensure they are part of the pursuit of worthwhile consequences.


MEDICINE & MACULA: Here is a case of severe recurrent acanthamoeba infection presenting initially as keratitis, followed by sclerokeratitis and histolopathology-confirmed endophthalmitis.

For the first time, we document acanthamoeba involvement in all ocular layers. This severe case demonstrates that despite persistent medical and surgical intervention, eradication of organisms may not be possible.

This is the first case reported with confirmed choroidal involvement (histology shown above) and we have previously published this in a work entitled, Acanthamoeba Endophthalmitis After Recurrent Keratitis And Nodular Scleritis (Zaid Mammo, David RP Almeida, Matthew A Cunningham, Eric K Chin & Vinit B Mahajan), in the journal Retinal Cases and Brief Reports.

You can find the complete study here.


GRATIS: “Nobody ever did, or ever will, escape the consequences of his choices.” -Alfred A. Montapert


My best to you,

David Almeida

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“In this world, nothing can be said to be certain, except death and taxes.” -Benjamin Franklin


TASK AT HAND: This week I’m thinking about death and taxes. Let me digress for a few sentences. This past week, on Thursday November 2nd, Republican lawmakers unveiled a sweeping revision of the tax code. Don’t worry, we are in no way going to get into the tax bill here on the Sunday Surgical Scrub. However, as I reviewed the proposal, it reminded me about the famous Benjamin Franklin quote above and the search for absolutes.

Today’s Sunday Surgical Scrub is about absolutes and our longing to grasp onto these as a means to reduce the anxiety of life and its transitions. We look for absolutes to reduce the inherent entropy of life. There is an overwhelming desire to find order and sense in the events that shape our days. But – and this should be apparent to anyone one of us who have attempted to exert control over extraneous circumstances that we cannot dictate – this is an anxious futile state. Instead, as we discussed on last week’s Sunday Surgical Scrub (you can find it here)you are not in control! As you master your ability to let go of this need for control, you find the peace it brings.

What does this have to do with death and taxes?

You can use death and taxes as reminders of absolutes. Everyone will die. Everyone has to pay taxes. If you are looking to grab onto absolutes, here are two that should make you relaxed that everything else is transient and you need not worry about it. In fact, you can argue that the paying of taxes is a somewhat negotiable and varied, albeit with consequences. I like this rationalization because it means that there is only one absolute.

Death is guaranteed.

This is not simply for macabre effect. This is actually a wonderful liberation that we should use our talents and energy to effect genuine meaning in our lives and those we come in contact with. The anxiety and worry surrounding most items is not necessary and often hinders our duty in the latter regard.


MEDICINE & MACULA: Here is a color fundus photograph of a patient with intraocular inflammation secondary to sarcoidosis. Sarcoidosis is a chronic systemic granulomatous disease from an exaggerated cellular immune response to a variety of self antigens or non-self antigens.

Characteristic funduscopic findings in posterior segment involvement include periphlebitis, sheathing of vessels, perivenous exudates and multiple small round chorioretinal lesions.


GRATIS: “The only difference between death and taxes is that death doesn’t get worse every time Congress meets.” -Will Rogers


My best to you,

David Almeida

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