Clinical Characteristics and Outcomes of Endophthalmitis Before and During the COVID-19 Pandemic


Purpose: To evaluate the clinical characteristics and visual acuity outcomes of patients who presented with endophthalmitis prior to and during the coronavirus disease 2019 (COVID-19) pandemic.

Methods: This multicenter retrospective case series with historical controls included consecutive patients presenting with any form of endophthalmitis from March 1, 2019 to September 1, 2019 (pre-COVID-19) and from March 1, 2020 to September 1, 2020 (COVID-19) at Mayo Clinic Rochester (MCR), Health System (MCHS), Arizona (MCA), and Florida (MCF) sites. Cases were divided into “pre-COVID-19” versus “COVID-19” groups depending on when they first presented with endophthalmitis.

Results: Twenty-eight cases of endophthalmitis presented to all Mayo Clinic sites during the study period. Of these, 10 patients presented during the first six months of the COVID-19 pandemic. During the same six-month period the year prior, 18 patients presented with endophthalmitis. Endophthalmitis etiology (post-injection, post-cataract extraction, post[1]glaucoma filtering surgery, post-pars plana vitrectomy, endogenous, and others) was similar between both groups (P = 0.34), as was post-injection endophthalmitis rate (P = 0.69), days to presentation (P = 0.07), initial management (P = 0.11), culture-positivity rate (P = 0.70), and need for subsequent pars plana vitrectomy (P = 1). Visual acuity outcomes were similar between both groups at six months, however, the mean LogMAR visual acuity at presentation was worse in the COVID-19 group compared to the pre-COVID-19 group (2.44 vs 1.82; P = 0.026).


Conclusion: Clinical characteristics and the post-injection endophthalmitis rate were similar during both periods, however, patients presented with worse vision during the pandemic suggesting that the pandemic may have contributed to delayed presentation, regardless, outcomes are still poor.


COVID-19; Endophthalmitis; Intravitreal injections

1. The Royal College of Ophthalmologists. COVID-19 resources: National government & health organisations updates [Internet]. Available from: https://www.rcophth. national-government-health-organisations-updates/ 2020;34:1189–1192.

2. American Academy of Ophthalmology: ONE Network. Recommendations for urgent and nonurgent patient care [Internet]. 2020 March 18. Available from:

3. Wong RLM, Ting DSW, Wan KH, Lai KHW, Ko CH, Ruamviboonsuk P, et al. COVID-19: Ocular manifestations and the APAO prevention guidelines for ophthalmic practices. Asia-Pac J Ophthalmol 2020;9:281–284.

4. Rodríguez-Ares T, Lamas-Francis D, Treviño M, Navarro D, Cea M, Lopez-Valladares MJ, et al. SARS-CoV-2 in conjunctiva and tears and ocular symptoms of patients with COVID-19. Vision 2021;5.

5. Arora R, Goel R, Kumar S, Chhabra M, Saxena S, Manchanda V, et al. Evaluation of SARS-CoV-2 in tears of patients with moderate to severe COVID-19. Ophthalmology 2021;128:494–503.

6. Azzolini C, Donati S, Premi E, Baj A, Siracusa C, Genoni A, et al. SARS-CoV-2 on ocular surfaces in a cohort of patients with COVID-19 from the Lombardy region, Italy. JAMA Ophthalmol 2021;139:956–963.

7. Romano MR, Montericcio A, Montalbano C, Raimondi R, Allegrini D, Ricciardelli G, et al. Facing COVID-19 in ophthalmology department. Curr Eye Res 2020;45:653– 658.

8. Starr MR, Israilevich R, Zhitnitsky M, Cheng QE, Soares RR, Patel LG, et al. Practice patterns and responsiveness to simulated common ocular complaints among US ophthalmology centers during the COVID-19 pandemic. JAMA Ophthalmol 2020;138:981–988.

9. Analysis: Ophthalmology lost more patient volume due to COVID-19 than any other specialty. Eyewire [Internet]. 2020 Nov 5. Available from:

10. Borrelli E, Grosso D, Vella G, Sacconi R, Querques L, Zucchiatti I, et al. Impact of COVID-19 on outpatient visits and intravitreal treatments in a referral retina unit: Let’s be ready for a plausible ”rebound effect”. Graefes Arch Clin Exp Ophthalmol 2020;258:2655–2660.

11. dell’Omo R, Filippelli M, Virgili G, Bandello F, Querques G, Lanzetta P, et al. Effect of COVID-19-related lockdown on ophthalmic practice in Italy: A report from 39 institutional centers. Eur J Ophthalmol 2022;32:695–703.

12. Leng T, Gallivan MD, Kras A, Lum F, Roe MT, Li C, et al. Ophthalmology and COVID-19: The impact of the pandemic on patient care and outcomes: An IRIS® Registry Study. Ophthalmology 2021;128:1782–1784.

13. Pellegrini M, Roda M, Lupardi E, Di Geronimo N, Giannaccare G, Schiavi C. The impact of COVID-19 pandemic on ophthalmological emergency department visits. Acta Ophthalmol 2020;98:e1058–e1059.

14. Poyser A, Deol SS, Osman L, Kuht HJ, Sivagnanasithiyar T, Manrique R, et al. Impact of COVID-19 pandemic and lockdown on eye emergencies. Eur J Ophthalmol 2021;31:2894–2900.

15. Savastano A, Ripa M, Savastano MC, Kilian R, Marchini G, Rizzo S. Impact of the COVID-19 pandemic on ophthalmologic outpatient care: Experience from an Italian tertiary medical center. Ann Med 2021;53:1349–1357.

16. Wickham L, Hay G, Hamilton R, Wooding J, Tossounis H, da Cruz L, et al. The impact of COVID policies on acute ophthalmology services-experiences from Moorfields Eye Hospital NHS Foundation Trust. Eye 2020;34:1189–1192.

17. Yen CY, Fang IM, Tang HF, Lee HJ, Yang SH. COVID-19 pandemic decreased the ophthalmic outpatient numbers and altered the diagnosis distribution in a community hospital in Taiwan: An observational study. PLoS One 2022;17:e0264976.

18. Agarwal R, Sharma N, Patil A, Thakur H, Saxena R, Kumar A. Impact of COVID-19 pandemic, national lockdown, and unlocking on an apex tertiary care ophthalmic institute. Indian J Ophthalmol 2020;68:2391–2395.

19. Romano F, Monteduro D, Airaldi M, Zicarelli F, Parrulli S, Cozzi M, et al. Increased number of submacular hemorrhages as a consequence of coronavirus disease 2019 lockdown. Ophthalmol Retina 2020;4:1209–1210.

20. Li J, Zhao M, She H, Chandra A. The impact of the COVID-19 pandemic lockdown on rhegmatogenous retinal detachment services-experiences from the Tongren Eye Center in Beijing. PLoS One 2021;16:e0254751.

21. Patel LG, Peck T, Starr MR, Ammar MJ, Khan A, Yonekawa Y, et al. Clinical presentation of rhegmatogenous retinal detachment during the COVID-19 pandemic: A historical cohort study. Ophthalmology 2021;128:686–692.

22. Jung JJ, Chang JS, Oellers PR, Ali MH, Do BK, Tseng JJ, et al. Impact of coronavirus disease 2019 restrictions on retinal detachment: A multicenter experience. Ophthalmol Retina 2022;6:638–641.

23. Schranz M, Georgopoulos M, Sacu S, Reumueller A, Reiter GS, Mylonas G, et al. Incidence and surgical care of retinal detachment during the first SARS-CoV-2 lockdown period at a tertiary referral center in Austria. PLoS One 2021;16:e0248010.

24. Das AV, Dave VP. Effect of lockdown and unlock following COVID-19 on the presentation of patients with endophthalmitis at a tertiary eye center over one year. Cureus 2021;13:e19469.

25. Gregori NZ, Feuer W, Rosenfeld PJ. Novel method for analyzing Snellen visual acuity measurements. Retina 2010;30:1046–1050.

26. Rush RB, Rush SW. Outcomes in patients resuming intravitreal anti-vascular endothelial growth factor therapy following treatment delay during the coronavirus-19 pandemic. Retina 2021;41:2456–2461.

27. Douglas VP, Douglas KAA, Vavvas DG, Miller JW, Miller JB. Short- and long-term visual outcomes in patients receiving intravitreal injections: The impact of the coronavirus 2019 disease (COVID-19)-related lockdown. J Clin Med 2022;11.

28. Song W, Singh RP, Rachitskaya AV. The effect of delay in care among patients requiring intravitreal injections. Ophthalmol Retina 2021;5:975–980.

29. Stone LG, Grinton ME, Talks JS. Delayed follow-up of medical retina patients due to COVID-19: Impact on disease activity and visual acuity. Graefes Arch Clin Exp Ophthalmol 2021;259:1773–1780.

30. Lum F, Li S, Liu L, Li C, Parke DW, Williams GA. The pandemic is not associated with endophthalmitis decrease after anti-vascular endothelial growth factor injections. Ophthalmology 2022;129:719–721.

31. LaCroce SJ, Wilson MN, Romanowski JE, Newman JD, Jhanji V, Shanks RMQ, et al. Moraxella nonliquefaciens and M. osloensis are important moraxella species that cause ocular infections. Microorganisms 2019;7.

32. Song G, Liang G, Liu W. Fungal co-infections associated with global COVID-19 pandemic: A clinical and diagnostic perspective from China. Mycopathologia 2020;185:599– 606.

33. Fossataro F, Martines F, Neri P, Allegri P, Pece A. Management of presumed candida endophthalmitis during the COVID-19 pandemic: Case report and review of the literature. Eur J Ophthalmol 2022:11206721221092190.

34. Agarwal M, Sachdeva M, Pal S, Shah H, Kumar RM, Banker A. Endogenous endophthalmitis: A complication of COVID-19 pandemic: A case series. Ocul Immunol Inflamm 2021;29:726–729.