Author's Posts

TASK AT HAND: This week I’m thinking about a dear friend and talented vitreoretinal surgeon colleague, Dr R Rishi Gupta. He has a new book – Reflections of a Pupil: What Your Med School and Ophthalmology Textbooks Can’t Teach You (But What Your Mentors, Colleagues and Patients Will) – and I’m very excited to present a selected excerpt from the book here. The book goes beyond facts and protocols and, as you engage each page, you discover the wisdom of a mentor and the essence of  the intangibles needed to succeed in medicine, in surgery and on our own journey. Enjoy!

DON’T LET THE FALL CRUSH YOU. During our lifelong pursuit of bettering ourselves in our craft, there are peaks and there are valleys. Never does this ring truer than during our training or first year of independent practice. Sometimes the valleys can feel really deep . . . really dark . . .and really lonely. After a particularly tough case that I took to heart, a mentor of mine saw that I was struggling. “Don’t let the fall crush you,” he said. “Your heart and head were in the right place. There are a lot of people who will need you. Don’t let singlesetbacks stop you from growing so you can help all those otherswho will need you.”

Medicine has come a long way, yet there are still many diseases and conditions for which we lack the technology or understanding to be able to heal our patients. In some cases, people present too late; in other cases, they present with something too complex for the tools we have at hand. There will be problems that we won’t be able to fix. There will be eyes that we cannot save. Although that does not sit well with any of us, we have to be able to accept that reality. For some physicians, this is more difficult than it is for others. We all take pride in our work and it is not easy for us to live through failure.

It is normal to feel grief when an outcome is not what we would hope for. I love this evocative quote from the French vascular surgical pioneer René Leriche: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation of his failures.” Finding the time to grieve is important. Feel it. Be upset. Be angry. Be sad. Be frustrated. But then control and contain it. Break down the case with a colleague or mentor and take time to reflect.

During an OR day, we may need to compartmentalize and delay this emotional process and be ready to pick ourselves back up quickly in order to give our best for our next patient. Resiliency is an extremely important quality to develop. We owe it to our patients to be strong. Keep these two sayings in your back pocket for the inevitable rainy day:

1. When nothing is going right, go left!
2. Whenever I feel blue, I remind myself to start breathing again.

MEDICINE & MACULA: The book reviews have been outstanding! “The book brilliantly demonstrated the harmony of understanding basic facts of a patient problem balanced with confidence and experience” (Carol L. Shields, MD). “This should be required reading for every ophthalmology resident and fellow” (Charles C. Wykoff, MD PhD). “A superb piece of work that will certainly be an important resource for many years to come in the ophthalmology community” (David Sarraf, MD).

My favorite review comes from Robert L. Avery MD: “He [Dr Gupta] is certainly leading an examined life, and by relaying his reflections on both the good and the bad along his path, he provides useful insight to all of us, whether we are young ophthalmologists or not.” The necessity for us to look inwards – to dissect our core beliefs and biases – will always be a fundamental base of virtue and improvement.

Thank you Dr Gupta for an outstanding contribution!

GRATIS: You can get your copy from Amazon Canada here. For US customers, you can buy on US Amazon site here.

The website Millennial Eye recently featured Reflections of a Pupil as a “must have book for the beginning ophthalmologist”. You can read the blog post here.

My best to you,
David Almeida

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Happy Thanksgiving!

TASK AT HAND: Today is a very special Thanksgiving edition of the Sunday Surgical Scrub! First and foremost, I want to wish you a Happy Thanksgiving here from Charlotte, North Carolina! I hope you have a wonderful and safe holiday with your loved ones wherever you are.

Let me ask you, what’s the first thing a patient does when they are seeking a new physician? Do they look them up in a phone book? I’m not sure these exist anymore.

Ask a trusted friend? Perhaps.

Look them up online? Definitely!

The growth of online physician reviews and social media now provides patients and colleagues a wealth of information not previously available. Consequently, it is more important than ever for physicians to have a professional online and social media presence. In fact, a sound online strategy should be the driving force behind all online physician interactions.

In response to this interest and growing demand, my colleague and friend Dr Jay Sridhar, host of the retina podcast Straight From The Cutter’s Mouth and Assistant Professor of Clinical Ophthalmology at the Bascom Palmer Eye Institute in Miami, Florida, have been hard at work creating a course on online strategy for physicians.

Who is this course best suited for? This course is primarily curated for physicians who are looking to develop their online presence and provides fundamental strategies for utilizing online and social media for communication and practice building. Ideally suited for both new physicians or those who have been practicing for years but are now beginning to craft their online media presence.

In the modern digital world, physicians – whether they be ophthalmologists, interns or primary care doctors – need to understand the importance of personal branding and social media. The course is a series of lectures that we’ve presented in multiple continents and you can now take part in this digital content anytime from the ease of your home or office.

You can find the course here. Enjoy!

GRATIS: We are launching the course officially tomorrow on Black Friday, but I’m making it available to subscribers of the Sunday Surgical Scrub right now. You can get 50% off by using the promo code LAUNCH.

My best to you,
David Almeida

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“The total entropy of any isolated system will increase over time, approaching a maximum value.” -The Second Law of Thermodynamics 

TASK AT HAND: This week I’m thinking about entropy. Entropy is the universal tendency towards disorder and disorganization. Newton’s Second Law of Thermodynamics surmises that the total entropy of an isolated system – the total degree of chaos – can never decrease over time.

Why are we talking about the laws of thermodynamics here early on a Sunday morning?

Now, there are extensive aspects of Newton’s second law that discuss usable energy and how, as energy is used, entropy increases. But, let’s put all that aside and simply think about this: over time, chaos will only increase. As time elapses, disintegration will grow. Over time, you will not be made whole, but rather, randomness will win out.

The second law of thermodynamics is not simply a physical principle, it’s a physical law that governs the world we inhabit. Consequently, we can use this principle and apply it to the randomness we encounter. Realizing that no matter what we do, there is an overwhelming tendency for chaos to increase, should liberate us from the anxiety of compulsion and control.

Consider entropy as a surrogate of randomness. No matter how good your strategy is, no matter how aligned objectives and techniques are – randomness and chaos will still increase. It is our responsibility to be cognizant of this eventuality and have the adaptive mindset to control our responses. In other words, when you become a victim of randomness, smile at the fact that this is simply a physical law of the world we live in. When circumstances consume you, don’t despair, it’s part of the physical world we live in.

“The law that entropy increases—the Second Law of Thermodynamics—holds, I think, the supreme position among the laws of Nature.” 

Sir Arthur Stanley Eddington, Gifford Lectures (1927) & The Nature of the Physical World (1928)

The call to action from today’s Sunday Surgical Scrub is to be aware of the Second Law of Thermodynamics and the fact that chaos will never decrease; over time, randomness will continue to increase. Be aware that the increasing chaos around us needs to be met with our ability to let go of control and appreciate these immutable forces. Don’t let the growing disorder and disorganization result in disappointment! Forego the reaction – the energy lost in trying to control this inevitable outcome – and let this incontrovertible thermodynamic law allow you to appreciate the radiance of randomness.

MEDICINE & MACULA: After 3 years at VitreoRetinal Surgery in Minnesota, the Almeida’s are moving to Charlotte, North Carolina!

These transitions are always complex because, as hard as it is to leave a place you like, the overwhelming excitement at the opportunities and challenges that lie ahead have the ability to conjure fantastic growth. I am grateful for my time in Minnesota and the privilege to have taken care of so many patients! Moreover, I am thankful to all the wonderful colleagues and friends we have made during our time in the Land of 10 000 Lakes.

In North Carolina, I will be joining Metrolina Eye Associates in Charlotte and I am elated at being part of a dynamic group and the prospect of caring for the patients of North Carolina and beyond.

Finally, I am thrilled at the upcoming adventure that I get to partake in with my wife, children and family! As always, I thank you for your kind support!


GRATIS: Happy Mother’s Day! To my beautiful wife Jasmine, to my caring mother Maria Fernanda, and to all those whom superlatives fall short in describing the courage of our mothers and role models.


My best to you,
David Almeida

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“In matters of opinion, opinions do not matter.”


TASK AT HAND: This week I’m thinking about opinions. In all honesty, I don’t care much for them. Too often, opinions are hollow with numerous logical fallacies. Opinions are the least valid form of any argument or proposition.

“Opinions are the least valid form of any argument or proposition.”

I like to divide basic personal systems of thought into 3 pillars: facts, beliefs and opinions. Facts are truth and constructed from scientific evidence. You cannot have opinions about facts. Debating facts is tedious; instead, debate the methods that created those facts. Consequently, facts should be the least anxiety-provoking evidence we face because, bearing witness to their actuality, is enough.

Next, we have beliefs. We may have personal beliefs, but these should be entirely of the self and with regard to some personal set of ethics. For example, belief in how to conduct oneself, the value of character, truth and forgiveness are all worthwhile beliefs. Beliefs can support personal growth and skill development. However, beliefs should be focused only as an intrinsic system of self and not for a group. You should not project your beliefs onto others because this is where the pain of judgment resides. Keep your beliefs to yourself and accept that others have beliefs that may be different. Don’t expect anyone to disparage your tenets and don’t denigrate the beliefs of others. In a tense culture, division among beliefs needs to be avoided. The need to judge the beliefs of others will create anxiety so avoid this projection.

Lastly, and of the lowest form, is opinion. Opinions are, by definition, factually fragmented and incongruous in their reasoning. Pundits and their opinions are commonplace, so you have to be careful to not be fooled. Opinion, disguised as logical argument, will attempt to sway your better judgment. However, the sooner you recognize that opinions do not matter, the sooner you will be lifted into the tranquility of not needing to engage them.

“The sooner you recognize that opinions do not matter, the sooner you will be lifted into the tranquility of not needing to engage them.”

Next time you feel the need to give your opinion, hold back – tell yourself “opinions do not matter”. The next time you are enticed by someone’s hot take, disregard it like a dirty stain – remember, “opinions do not matter”. The anxiety of opinions are of trivial value and offer you no credence. By abandoning the frivolousness of opinion, you are left with facts and beliefs, of which you can use to forge matters of character and morality of the self – the only items that are of any significance.

The Sunday Surgical Scrub is a blog and created with the aim of expounding beliefs that supersede opinion. By challenging opinions, we can uncover the bedrock of our belief system, allowing us to refine a personal ethical subscription.


MEDICINE & MACULA: A couple of week ago, Mpls.St.Paul Magazine released their list of the 2018 Rising Star Top Doctors. I am very grateful for being selected again this year and express kind thanks to the blue-ribbon committee for their recognition and support.

However, as I discussed above, this honor or award is simply an opinion. It is an external watermark put forth by a peer group. I am thankful for this but, from my personal vantage point, the more important element is my belief that caring for patents is a privilege that I value and regard with enthusiasm and engagement. My desire for excellence in patient care comes from the simple philosophy of “how would I treat a family member?” I attempt to treat every patient like they are my mother, or brother, or child. I believe this will always guide one to deliver superior care. Opinion on this matter is nonsensical, my belief can be used to further realize these elements of duty.


GRATIS: “Stubborn and ardent clinging to one’s opinion is the best proof of stupidity.” -Michel de Montaigne

My best to you,

David Almeida

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“You change or you hide your head in the sand.” -Tony Gilroy

TASK AT HAND: This week I’m thinking about the Ostrich Effect which describes how we can sometimes turn a blind eye to negative information. The name comes from the common belief that ostriches bury their hands in the sand to avoid danger.

Two quick points:

First, the common belief that ostriches bury their heads in the sand to avoid danger is false.

Second, the ostrich effect is a type of willful ignorance; a form of denial.


The ostrich effect is a term originally coined by the financial world to describe investors who purposefully ignore or avoid negative financial information. The behavior is a defense mechanism where an individual avoids exposure to information that may cause discomfort, anxiety or pain. Generically, the ostrich effect is termed Information Aversion to describe an individual or group foregoing unpleasant information.

Information aversion can manifest in a myriad of manners ranging from unhealthy relationships (denial in seeing certain unfavorable traits a partner or friend may possess) to a poor work environment (avoiding unpleasant dialogue concerning your occupation for fear of confrontation).

How can we avoid information aversion?

The most common error I see when combating the ostrich effect is the confusion between information aversion and information overload. Too often, we partake in the duplicity of avoiding necessary confrontation claiming information overload. In these cases, we falsely project that there is too much noise for any valid meaning to be extracted. Nonsensical! The issue is we are choosing to avoid information because we know there are items present that provoke anxiety and fear.

When confronted with this possibility, ascertain your pain points. Be honest and elaborate on what aspects may be challenging to confront. A simple pearl to facilitate this process involves tackling these difficult topics in times of peace and prosperity. Contrasting, during periods of  setbacks, the desire to avoid “heaping on more” on the negative makes us especially susceptible to information aversion. By assessing these difficult propositions from a balanced mindset, you allow yourself a greater degree of honesty. It is here where we can reconcile the negative and unpleasant information with your goals and objectives.


MEDICINE & MACULA: On Friday March 9, I had the privilege of returning to Queen’s University in Kingston, Ontario, Canada as visiting professor and guest speaker.


I enjoyed 9 years at Queen’s University for my medical school training and ophthalmology residency. It’s hard to believe 5 years have elapsed since. I had a wonderful time connecting with mentors, colleagues and friends and grateful for the opportunity.

I presented Grand Rounds on Endophthalmitis Update: Current Trends & Techniques focusing on our recent endophthalmitis after intravitreal injection publication as well as surgical techniques for this devastating condition. Below is an image of early vitrectomy in a case of infectious endophthalmitis (pardon the blurry image which is due to inflammatory debris commonly limiting optimal visualization).

Then, I had the real pleasure of spending a few hours with the Queen’s ophthalmology residents as we undertook a tour-de-force review of uveitis. Below is a case of posterior uveitis secondary to syphilis.

I was thoroughly impressed by the resident knowledge base and proud to be an alumni of Queen’s medical training!


GRATIS: “Putting our heads in the sand won’t stop the inexorable advancement of technology.” Cathy Engelbert


My best to you,

David Almeida


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“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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