ORIGINAL ARTICLE  
Visual Outcome in Pars Plana Vitrectomy for Acute  
Postoperative Endophthalmitis after Cataract  
Surgery  
Abdul Rafio Soomro1, Fayaz Ahmed Soomro2, Munawar Hussain3, Abdul Qadeem Soomro4  
Nazia Qidwai5, Anas Bin Tariq6  
1-6Al-Ibrahim Eye Hospital, Isra Postgraduate Institute of Ophthalmology, Karachi  
ABSTRACT  
Purpose: To determine the visual outcomes in patients undergoing pars plana-vitrectomy (PPV) for acute post-  
operative endophthalmitis after cataract surgery.  
Study Design: Quasi experimental study.  
Place and Duration of Study: Isra Postgraduate Institute of Ophthalmology, Al- Ibrahim Eye Hospital, Malir,  
Karachi for a period of 2 years.  
Material and Methods: Thirty-three patients were selected using non-probability convenient sampling technique.  
Patients with acute postoperative endophthalmitis after cataract surgery diagnosed clinically and on B-scan, with  
visual acuity of only perception of light were included while patients with better visual acuity and any other types  
of endophthalmitis were excluded. PPV was performed in all cases and the patients were examined post-  
operatively on 1st day, 3rd day, 1, 2 and 3 weeks after surgery. During these follow ups, visual acuity was  
recorded, detailed slit lamp and fundus examination was performed. Using SPSS version 20.0, chi-square test  
was applied to test for significance keeping p-value of < 0.05 as significant.  
Results: Out of 33 patients 19 (57.6%) were males and 14 (42.4%) were females. Mean age of the patients was  
54.50 ± 14.14 years. On 1st post-operative day 8 patients (24.2%) showed improvement of visual acuity from  
perception of light to finger counting while 02 (6.1%) patients reported visual acuity of 6/60. On final visit at 3rd  
week postoperatively, 19 patients (57.6%) had visual acuity of finger counting, 08 patients (24.2%) had hand  
movement and 06 (18.2%) patients reported a visual acuity of 6/60.  
Conclusion: PPV for acute post-cataract endophthalmitis if performed at appropriate time can result in  
favourable outcomes in terms of visual acuity.  
Key Words: Pars Plana Vitrectomy, endophthalmitis, Cataract surgery.  
How to Cite this Article: Soomro AR, Soomro FA, Hussain M, Qadeem A, Soomro, Qidwai N, Tariq AB. Visual  
Outcome in Pars Plana Vitrectomy (PPV) for Acute Postoperative Endophthalmitis after Cataract Surgery. Pak J  
Ophthalmol. 2020, 36 (3): 236-240.  
Doi: 10.36351/pjo.v36i3.991  
of the eye (vitreous and aqueous) that affects the  
vision. Prevalence of clinical endophthalmitis ranges  
INTRODUCTION  
Endophthalmitis is a purulent intraocular inflammation  
from 0.04% to 0.15%. The culture proven  
endophthalmitisis 0.02% and 0.08% worldwide1.  
Correspondence to: Anas Bin Tariq  
Al-Tibri Medical College, Karachi  
Email: anastariq93@gmail.com  
However, the prevalence of endophthalmitis in  
Pakistan is 5.1 – 7.5%, according to various local  
reports2,3. Endophthalmitis results from a rapidly  
Received: January 31, 2020  
Revised: February 29, 2020  
Accepted: May 4, 2020  
growing infection or invasion of micro-organisms into  
236  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 236-240  
Visual Outcome in Pars Plana Vitrectomy for Acute Postoperative Endophthalmitis after Cataract Surgery  
the eye often after intraocular surgery. Moreover, it  
Intraocular administration of antibiotic is regarded  
as the basic step in endophthalmitis management.  
Controversy exists regarding simultaneous use of  
intravitreal injection of dexamethasone. A wide  
spectrum of antibiotics such as vancomycin,  
ceftazidime and amikacin are administered  
intravitreally as treatment. However, in case of fungal  
endophthalmitis; amphotericin B, miconazole and  
voriconazole are the drugs of choice10.  
may be caused by open-eye injury or by infection of  
cornea. Bacteria are the most common cause of  
endophthalmitis, followed by fungi and less commonly  
parasites4. The inflammatory response caused by  
microorganisms and their toxins lead to immediate and  
irreparable damage to photoreceptors or other retinal  
cells and may persist even after the infection has  
settled. Endophthalmitis is classified according to the  
duration, the way microorganisms enter the eye and  
the form of agents (e.g. bacteria, fungi) involved in the  
pathogenesis of the disease5. Two types of  
endophthalmitis can be differentiated depending on the  
route in which the microorganisms enter the eye:  
Pars plana vitrectomy (PPV) is the standard  
treatment for refractory and fulminant acute post-  
cataract  
surgery  
endophthalmitis.  
Immediate  
vitrectomy is suggested in the cases of progressively  
deteriorating visual acuity or endophthalmitis induced  
by virulent bacteria11.  
exogenous  
endophthalmitis can also be categorized as post-  
operative endophthalmitis or post-traumatic  
and  
endogenous6.  
Exogenous  
The endophthalmitis vitrectomy study (EVS)  
considers pars plana vitrectomy only for patients with  
visual acuity of light perception whereas some studies  
suggest early pars plana vitrectomy for all patients  
with post-operative endophthalmitis12. The purpose of  
our study was to determine the visual outcomes in  
patients undergoing pars plana-vitrectomy (PPV) for  
acute post-operative endophthalmitis after cataract  
surgery.  
endophthalmitis, depending on the etiology. The most  
common form of endophthalmitis is postoperative  
endophthalmitis. This accounts for about 70% of all  
cases of endophthalmitis. It occurs when the whole  
thickness of the cornea or sclera is penetrated during  
intraocular surgery and occasionally after extraocular  
procedures such as suturing of a scleral buckle,  
strabismus surgery, pterygium surgery and corneal  
suture removal.  
MATERIAL AND METHODS  
A Quasi Experimental Study with non probability  
convenient sampling technique was conducted on 33  
Approximately  
90%  
of  
post-operative  
endophthalmitis occur after cataract surgery as it the  
most common intraocular surgery. Most common  
agents responsible for postoperative endophthalmitis  
are staphylococci and streptococci7. Incidence of  
endophthalmitis depends on risk factors, which include  
old age (> 85 years of age), rural living, male gender,  
and immunosuppressive conditions like diabetes  
mellitus. After infection, signs and symptoms appear  
rapidly, typically within one or two days, or  
sometimes up to six days after surgery. Clinical  
features include eye pain that gets worse after  
procedure or eye injury, reduced vision, redness, pus,  
swollen eyelids, blurred vision, discomfort and  
photophobia8.  
patients  
at Isra Postgraduate  
Institute of  
Ophthalmology, Al-Ibrahim Eye Hospital, Malir,  
Karachi during a span of 2 years to determine the  
visual outcome after pars plana vitrectomy in acute  
postoperative endophthalmitis following cataract  
surgery.  
Patients with acute postoperative endophthalmitis  
after cataract surgery diagnosed clinically and on B-  
scan and having visual acuity of light perception were  
included in the study. Whereas, patients with any other  
endophthalmitis, traumatic or endogenous were  
excluded.  
After taking consent, data of the patients was  
collected from Outpatient Department (OPD), cataract  
clinic and surgical retina clinic at Al-Ibrahim Eye  
Hospital. Patients were explained the method and  
significance of the research. Patients were asked about  
complaints, glaucoma history, night blindness,  
surgery, trauma, drugs, contact lens and history of  
taking medicines. Tests included visual acuity, slit  
Endophthalmitis is diagnosed by investigations  
such as vitreous culture and B-scan ultrasonography.  
Nearly 30% of post-operative endophthalmitis patients  
are culture-negative therefore, isolating the causative  
organism is the mainstay of treatment. For tests like  
gram staining, culture, polymerase chain reaction  
(PCR) analysis, sampling of aqueous or vitreous  
humor must be done at the first visit9.  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 236-240  
237  
Abdul Rafio Soomro, et al  
lamp biomicroscopy, regurgitation test, pupillary  
reactions and fundus examination.  
on the 1st postoperative day. Eight patients (24.2%)  
showed improvement of visual acuity from perception  
of light to finger counting while 02 (6.1%) patients  
reported visual acuity of 6/60. On the 7th postoperative  
day, 20 (60.6%) patients reported visual acuity of  
perception of light to hand movement while 06  
(18.2%) patients reported improvements in their visual  
acuity and 07 (21.2%) patients reported a visual acuity  
of 6/60. On the final visit that is on 21st postoperative  
day, 19 patents (57.6%) had visual acuity of finger  
counting, while 08 patients (24.2%) showed visual  
improvement of only hand movement. Only 6 (18.2%)  
patients reported a visual acuity of 6/60 (Table 1).  
Standard 3-port pars plana vitrectomy was  
performed and intravitreal injections of vancomycin  
and amikacin were administered. Patients were  
examined post-operatively on 1st day, 3rd day, 1, 2 and  
3 weeks after PPV. During these examinations, visual  
acuity was checked with Snellen chart. Other tests  
included a detailed slit lamp and fundus examination.  
Alcon Accurus Microtome Vitrectomy machine  
with endo-illumination, disposable suction cutting  
vitrectomy cutter, endodiathermy and infusion cannula  
were used. Laser was done with Alcon Ophthalas 532  
Eyelite frequency doubled Nd: YAG laser photo-  
coagulator with disposable endolaser probe. Vitreous  
substitutes were Balanced Salt Solution, Perflouro  
carbon liquid (Octadecaflourodecahydronaphthalene  
98% - Micromed) and Silicon oil (Polydimethyl  
Siloxane 100% – RS OIL) with viscosity of 1000 –  
5000 CST.  
DISCUSSION  
Visual outcomes after pars plana vitrectomy (PPV)  
have been reported to vary in literature. Generally,  
outcomes have been found to be worse than that after  
cataract surgery, probably due to underlying retinal  
pathology and its association with a poor visual  
potential. Even though good visual outcomes have  
been observed in a few patients, but some large studies  
have shown poor post-operative visual improvement  
among these patients. In this study although slight but  
definite improvement in visual acuity was reported  
among 31 (93.9%) patients. The improvements were  
from perception of light and hand movement to finger  
counting.  
Analysis of data was carried out using SPSS  
version-20.0. All categorical variables including pre-  
operative visual acuity, visual acuity on subsequent  
follow-up examinations, and early post-operative  
complications were identified by frequencies and  
percentages.  
RESULTS  
In a study by Dave VP et al, the mean visual  
acuity at the time of presentation of endophthalmitis  
was 6/240 with mean duration of endophthalmitis  
being 4 ± 6.89 days. After treatment, slight but  
insignificant improvement in visual acuity was  
reported showing that in only 50% of the cases, mean  
visual acuity had improved to 6/90 having a p-value of  
0.3113. In contrast, our study reported a visual  
improvement in 90% of cases. Higher mean age,  
duration of endophthalmitis and the poorer pre-  
operative visual acuity can explain this difference.  
Out of 33 patents 19 (57.6%) were males and 14  
(42.4%) were females. Mean age of the patients was  
54.50 ± 14.14 years. Most of the patients 51.5% were  
55-60 years of age. The mean time between  
endophthalmitis and PPV was 7.03 ± 1.97 days.  
Table 1: Visual recovery according to time.  
Variable  
n (%)  
Perception of light-Hand  
23 (69.69%)  
1st Postoperative movement  
Day  
Vision improvement  
6/60  
Perception of light-Hand  
movement  
Visual improvement  
6/60  
Perception of light-Hand  
movement  
8 (24.24%)  
2 (6.06%)  
A study on 70 patients of acute endophthalmitis  
undergoing therapeutic PPV reported a significant  
improvement (p-value < 0.001) in visual acuity of  
patients from 6/120 at pre-operative stage to finger  
counting and hand movements. However, the  
significant improvement in visual outcomes was  
reported in only 33% of patients14. Similarly, a case  
series of 05 patients by Leng T et al also reported an  
improvement of visual acuity to around 6/30 in the  
20 (60.60%)  
1st Week  
Postoperative  
6 (18.18%)  
7 (21.21%)  
19 (57.57%)  
3rd Week  
Postoperative  
Vision improvement  
6/60  
8 (24.24%)  
6 (18.18%)  
Out of 33 patients, 23 (69.7%) patients reported visual  
acuity between perception of light and hand movement  
238  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 236-240  
Visual Outcome in Pars Plana Vitrectomy for Acute Postoperative Endophthalmitis after Cataract Surgery  
patients; nevertheless, the sample size was very small  
to comment further15.  
diagnosis and surgical intervention using PPV is a  
necessity in optimizing visual outcomes.  
A
study by Kunimoto et al reported an  
The limitations of the study include a limited  
sample size, short follow-up period where visual  
acuity might have been better or more improved in a  
longer follow-up. The study might not be immune  
from observer as well as selection bias. Further studies  
on a larger sample size and with prolonged follow-up  
time might help in estimating the improvement in  
visual outcomes of the patients. However, due to the  
condition’s relative rarity, it is difficult to study large  
number of cases.  
improvement in visual acuity from perception of light  
to counting fingers, which was similar to our  
findings16. In contrast another study reported overall  
poor outcomes with final visual outcome being  
perception of light, no light perception or  
evisceration17. In another study by Maneschg OA et al,  
the mean visual acuity before PPV was hand  
movement (HM) and light perception (LP) which did  
not significantly improve after PPV18. Narsani AK in a  
study on 97 patients reported a visual acuity of 6/60 or  
worse in 80 (82.5%) patients at presentation and at  
post-operative follow up at 9th week found an  
improvement in visual acuity better than 6/60 in 75  
(77.3%) patients. While 6 (6.2%) patients ended up in  
no perception of light19. On the contrary, Thapa R et al  
reported another study of 34 patients of acute  
endophthalmitis treated with PPV having a mean age  
CONCLUSION  
PPV for acute post-cataract endophthalmitis if  
performed at appropriate time can result in favourable  
outcomes in terms of visual acuity.  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
of 56  
±
19.5 years and mean duration of  
endophthalmitis of 13 ± 11.6 days. After a mean  
follow-up duration of 4.3 months, visual acuity was  
found to improve in two-thirds (67.67%) of cases with  
a good vision of 6/18 or better in 17.6% of patients20.  
Similarly, in our study, improvement in visual acuity  
was reported in 93% of cases, however improvement  
was limited and mean follow up time in our study was  
3 weeks as compared to 4.3 months follow up time  
period in the above study. In another study by Park et  
al, on 28 patients, 29.6% eyes were eviscerated21. In a  
study investigating 250 patients of post-cataract  
surgery endophthalmitis undergoing PPV, 51.6% of  
patients reported to have a final visual acuity of 6/1222.  
Likewise, another study reported that 49% of patients  
showed visual acuities of 6/1223. Among some other  
studies done in Asia, a study in India reported a final  
visual acuity of 6/12 in 29.41% patients while a study  
in Singapore reported a final best corrected visual  
Conflict of Interest  
Authors declared no conflict of interest.  
Authors’ Designation and Contribution  
Abdul Rafio Soomro; Consultant Ophthalmologist:  
study design, manuscript writing, final review.  
Fayaz  
Ahmed  
Soomro;  
Senior  
Consultant  
Ophthalmologist: Concept, design & final approval of  
study.  
Munawar Hussain; Assistant Professor: Concept,  
design & corrections of the study.  
Abdul Qadeem Soomro; Associate Professor: Concept  
& design of study, final approval of study.  
acuity of 20/40 in 50.5% of the cases24,25  
.
Nazia Qidwai; Associate Professor: Concept & final  
approval of study.  
The reported visual outcomes of patients  
undergoing PPV for post-cataract surgery  
Anas Bin Tariq; Lecturer: Data collection, data  
analysis & write-up.  
endophthalmitis have been seen to vary from study to  
study. Differences of mean age, gender, nationality,  
time and duration of diagnosis and presentation,  
surgical expertise all tend to have an effect on the final  
outcome of the patients. Globally, post-operative  
endophthalmitis remains one of the most serious  
complications of cataract surgery. Therefore, early  
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