 I'm pretty jealous of the celebrity endorsements that Nick had in his. Unfortunately, I wasn't able to find anyone that had this particular disorder, but I think it'll still be interesting. So as I've already been introduced, my name's Scott Buticofer. I'm a visiting fourth-year student from the University of Washington School of Medicine and I'm going to be presenting a case today that I worked on with a resident at the University of Washington. This was also with the support of two faculty members at the UWI Institute and this is a case of endobacter cloacae, post-surgical endophthalmitis. And I'm going to start by briefly discussing the case, presenting the case, and then I'll discuss a little bit more about post-surgical endophthalmitis, particularly with this organism. So our patient was a 67-year-old man who presented with very typical signs of bilateral cataracts. He had blurry vision and glare. His past medical history was significant for diabetes and hypertension, but he didn't have any past ocular history. The right eye was 20 over 60, left eye 20 over 100. And so we went ahead with a plan in place to perform intraocular surgery, removing and replacing the lens, and that went forth without any complications. So on post-operative day number one, he presented in the morning with a visual acuity of 20 over 100. And on SlitLamp exam, there were signs of anterior chamber inflammation, so mildly increased intraocular pressure, but there's no hypopian present, and so he was instructed just to use prednisolone drops and present again in the afternoon for re-examination. Six hours later, he had subjective worsening of his vision. Visual acuity was now 20 over 300. The SlitLamp exam now showed one millimeter hypopian and also corneal edema. So he was presumed at this time to have endophthalmitis and was promptly tapped and injected with vancomycin and septazidine, broad-spectrum antibiotics covering for gram-positive and gram-negative organisms. He was also instructed to use a topical antibiotic, set home with prednisolone, to continue, and was also started on a daily oral levofloxacin. So unfortunately, post-operative day number two, the patient did not return due to a miscommunication, but he presented again on day number three, and his visual acuity was now counting fingers at three feet. The SlitLamp exam revealed that most of his signs were resolving. There was decreased inflammation in the anterior chamber. And the cultures that were collected were now growing gram-negative rods, which is an ominous sign, as will be shown later in the presentation, as gram-negative rods are usually associated with a much poorer outcome from endophthalmitis. On post-operative day number four, those cultures were then found to be positive for enterobacter resistant to ampicillin and sensitive to septazidine. By post-operative day number six, his symptoms and signs had resolved. And after a 14-day course of levofloxacin, the best corrected visual acuity of 20 over 60 was obtained. So now a little bit more information on post-cateric endophthalmitis. The overall incidence is somewhere between .05 and .68 percent. Many studies report different rates on this. It is a rare occurrence. And there are several risk factors that have been identified for a poor outcome. The first being earlier onset, typically associated with the worst outcome. The worst vision presents as the worst that typically ends at the end. And also, cause of organisms other than coagulase negative staphylococcus tend to have a poor outcome. And as you can see on this table that I put together, gram positives represent the vast majority of organisms that cause endophthalmitis. And this is thought to be because these are normal ocular flora that are present before and after surgery. While gram-negative organisms, including entrobacter, represent less than 10 percent in both of these studies of the cause of endophthalmitis. To speak a little bit more about entrobacter cloacae specifically, it was first reported by a Dr. Rose in 1966. This is a gram-negative, rod-shaped, facultative anaerobic. And it's present in about 40 to 60 percent of normal human GI flora. It has become an important nosocomial infection in the last couple of decades because it has resistant to multiple disinfectants, multiple antimicrobials. But it's still very rare in endophthalmitis cases, which is why I wasn't able to find any celebrity endorsements, unfortunately. There's only been 14 cases reported in the literature. And in all of these reported cases, the outcome has been uniformly poor, one achieving only hand motion, one achieving light perception, and 11 with no light perception, even despite treatment. Now, this table, though entrobacter is too rare to accurately determine its incidence alone, other studies have reported that the outcomes associated with the various infectious organisms and their final visual acuity. And as you can see here, coagulase-negative stapolococcus, the majority, about 60 percent in this study by Lawani, were able to achieve greater than 20 over 40 final visual acuity, with very few, only two, less than five over 200. If you go down the chart, particularly gram-negative organisms, you see that there's a much less likely incidence of achieving a final visual acuity of greater than or equal to 20 over 40. And here, I've compiled the results from a few studies. The endophthalmitis filtrectomy study in 1996, Lil'Wani was at Basco Palmer in 2008, and Kijil from the Netherlands in 2009. And this slide, again, shows that with coagulase-negative stapolococcus, they're pretty uniform in their results, achieving about a 60 percent rate of 20 over 40 final visual acuity. However, when you go down the chart, you see that there's much more spread that begins to occur. This is likely because these are, you know, rare causes of endophthalmitis, which is already a very rare disease. So the sample size is very small. It's hard to accurately assess just, you know, how often we can achieve different, a visual acuity of greater than or equal to 20 over 40 in these organisms. Now, whenever we find an infection, we want to start treatment as early as possible, hoping to minimize the damage to the eye and achieve a better result. Kijil reported that the percentage of patients who presented with endophthalmitis, signs within three days of surgery by the organism, was, that was cultured from the vitreous taps. And as you can see here, grand positive coagulase-negative staff, about 38 percent of the cultures that grew this were able to, they began to present with signs of endophthalmitis within three days of surgery. On the other hand, 100 percent of the cultures that grew gram-negative rods presented within three days of surgery with signs of endophthalmitis. This finding and the finding above that showed worse visual acuity outcomes with gram-negative organisms is the data that's used to link together the fact that there's a connection between early presentation and worse outcomes. However, Kijil found that there was no significant association of time from surgery to signs of endophthalmitis with a final visual acuity of greater than or equal 20 over 40. So now there are some hypotheses as to why organism type leads to these very different results. The first being organism virulence. And virulence is really a general term that is often used. It's describing the specific endotoxins and proteases that each of these organisms create a very unique milieu with. And as a result, there's widely different results both in the progression of the disease and in the final visual acuity reached. The condition of the eye at presentation also reflects the violence of this organism, but also reflects the duration of the infection and the hostability to respond to the infection. And as shown in the Kijil case, there is an unclear picture of the importance of early treatment to achieve a final visual acuity of greater than 20 over 40. Early onset indicates that there might be an increased virulence of the cause of organism and therefore an expected worse outcome. But rapid diagnosis is also associated with more rapid treatment. So the results are kind of muddled and it's, though there is a general consensus that early treatment will lead to improved sight, there is not clear evidence that it will lead to a final visual acuity of greater than or equal to 20 over 40. Of course, the last important factor in why different organisms cause greater or less damage to the eye is due to the susceptibility or resistance of two antibiotics of each organism. And Han and his group took the endophthalmitis filtrectomy study and they tested the isolates for susceptibilities to commonly used broad-spectrum antibiotics. All of the grand positives tested were susceptible to vancomycin and about 89% of the gram negatives were susceptible to amicacin and septazidine and 11% were resistant to both. In reports by Merza and his case series of entrobacter cloacae endophthalmitis, his isolates were found to be resistant to gentamycin and cephasolin, which unfortunately were the drugs that he chose to treat his patients with and likely contributed to the very poor outcomes that he saw. So in summary, identification of the infecting organism is important because it has an impact on the presentation and also the final visual outcome. But it's better to be lucky than to be good. And what I mean by that is saying by treating with broad-spectrum antibiotics quickly, we can treat against most infectious organisms and have a good chance at a positive outcome. But it's difficult to accurately measure how organisms other than coag negative staff, which is common, respond to the appropriate treatment due to the small numbers reported. The minimal inhibitory concentration, even for partially resistant organisms, is likely orders of magnitude lower than the concentrations that are reached in the eye after intravitural injection with antibiotics. So even though you may not choose the ideal antibiotic for the organism that's infecting the eye, there's a good chance that you'll be covering the organism and still do a good job at treating the eye. When the culture returns, the broad-spectrum antibiotics that you've already started your patient on will likely have done more for the final visual acuity than any changes you might make to your treatment based on the susceptibility reports that you get back. So the only thing I'll say in conclusion now is that even very virulent organisms, such as entrobacter, can be treated and have a good outcome with effective early treatment and a little bit of luck. I would like to acknowledge Jason Dottori, who's the resident who performed the surgery and also saw this patient clinic and worked with me on developing this case report, as well as the expertise of Dr. Vemmela Khand and Dr. Slebaugh, who helped us with this. Thank you. You have very rare complication. So I don't want to jump to conclusions too quickly. Yeah. The fact that they did the right thing on task. Right. So I'm happy to be lucky. Right. So that raises the issue. If you have a leaky wound. Thank you very much. Thank you.