Editorial The Impact of COVID-19 on Ophthalmology Practice: Changes and Controversies in Endophthalmitis Risk Mohammad Riazi, MD Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, USA J Ophthalmic Vis Res 2023; 18 (3): 249–251 The COVID-19 pandemic imposed major risks to both ophthalmologists and patients, resulting in significant changes to ophthalmology practices around the world. Non-urgent ophthalmic services were temporarily halted, with a gradual reopening in a stepwise manner. In a 2020 survey conducted by the American Society of Retina Specialists (ASRS), about 40% of respondents indicated a reduction in staff. In some areas, ophthalmologists were redirected to serve in COVID-related areas such as emergency wards or intensive care units. The pandemic has also accelerated the adoption of virtual visits and digital patient management. Detection of viral RNA particles in ocular secretions suggested the possibility of transmission through the eyes, resulting in recommendations for eye protection for ophthalmologists (such as slit lamp shields, goggles, or eye shields) and mandatory mask- wearing and temperature screenings for both patients and staff. Virtual visits were introduced in some areas to compensate for decreased patient numbers, and vaccination and testing protocols Correspondence to: Mohammad Riazi, MD; Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, USA. Email: mriazies@hs.uci.edu Received: 10-08-2022 Accepted: 15-02-2023 Access this article online Website: https://knepublishing.com/index.php/JOVR DOI: 10.18502/jovr.v18i3.13771 were established. Mask-wearing might be thought to reduce the rate of endophthalmitis by reducing exposure to nasopharyngeal and oral flora, but it may also increase the flow of air and germs from the nose and oral cavity to the eyes. Tight-fitting face masks used without adhesive tapes resulted in the highest amount of bacterial growth around the subject’s eye.[1] Sakamoto et al reported an increased rate of post-vitrectomy endophthalmitis in the COVID era, with more germs originating from the oral cavity.[2] Several case reports have shown a link between COVID-19 and ocular disorders, including conjunctivitis, keratitis, uveitis, and retinal vascular occlusions. The pathogenesis, in some cases, involves attachment of viral spike proteins to cell receptors such as angiotensin-converting enzyme 2 (ACE-2) and cleavage by protein trans-membrane serine protease 2 (TMPRSS2) for cell entry in ocular tissues.[3] However, other mechanisms of viral infection such as alterations in coagulation cascades or immune function may also play a role. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Riazi M. The Impact of COVID- 19 on Ophthalmology Practice: Changes and Controversies in Endophthalmitis Risk. J Ophthalmic Vis Res 2023;18:249–251. © 2023 Riazi. THIS IS AN OPEN ACCESS ARTICLE DISTRIBUTED UNDER THE CREATIVE COMMONS ATTRIBUTION LICENSE | PUBLISHED BY KNOWLEDGE E 249 http://crossmark.crossref.org/dialog/?doi=10.18502/jovr.v18i3.13771&domain=pdf&date_stamp=2019-07-17 https://knepublishing.com/index.php/JOVR Editorial; Riazi Presentation of various ophthalmic disorders has been reported to change during the COVID era. Most of these differences may be attributed to limited access to providers, use of personal protective devices, and patient hesitancy/self- isolation, causing delayed presentation or referral. During the lockdown period, Das and Dave reported an increase in proliferative retinopathy or sight-threatening conditions among diabetic patients.[4] Reports have also suggested an association between COVID infection and fungal sepsis or fungal ophthalmic involvement.[5] In the current issue of Journal of Ophthalmic and Vision Research (JOVR), two papers address changes in the rate of endophthalmitis among tertiary ophthalmic centers during the COVID-19 pandemic. One paper by Dr. Karimi and colleagues[6] examines the risk of acute endophthalmitis after intravitreal injections associated with the widespread use of face masks. These authors compared 28,085 injections in the pre-COVID era with 10,717 injections during the COVID era and found no significant differences in the rate of endophthalmitis after injections (0.032% in pre-COVID era vs 0.037% in COVID era). Although the use of masks helps limit the spread of the virus, it entails potential side effects, such as dry eye, infectious keratitis, or even endophthalmitis. In a study involving simulated intravitreal injections, Patel et al showed that adhesive taping at the superior edge of the patients’ mask could decrease the rate of bacterial dispersion to the level of an N95 mask.[1] In Karimi’s paper patients wore masks during the COVID era, but held their masks under their nose during the injection, which avoids re-direction of air flow towards the eyes. Another paper by Dr. Fortes and colleagues[7] is a multi-center retrospective case series that evaluates clinical characteristics and visual outcomes of patients with endophthalmitis before and during the COVID-19 pandemic. The authors found similar etiology for endophthalmitis in both groups, as well as similar final visual outcomes at six months. However, the mean logMAR visual acuity at presentation was worse during the pandemic as compared to the pre- COVID period, which may be due to delayed presentation (18 days vs 7 days). Despite reports of irreversible damage in neovascular AMD, retinal vein occlusion, or retinal detachment due to delayed referral in the COVID era,[8, 9] Fortes[7] did not find a significant difference in the final outcome in patients with endophthalmitis. On the other hand, Das and Dave[4] reported an increase in the number of endogenous endophthalmitis and a decrease in post-traumatic forms during the COVID era, which is in contrast to the report by Fortes et al.[7] Nevertheless, Fortes did not find a significant difference in the rate of post-injection endophthalmitis during the pandemic, which is in agreement with Karimi’s paper and the IRIS registry study.[10] In summary, the COVID-19 era has resulted in significant changes in ophthalmology practices worldwide, including delayed patient referrals, universal mask-wearing by both patients and providers, and direct/indirect ocular involvement by the virus. Although there are conflicting reports in the literature regarding the impact of these changes on the incidence of postoperative and post-injection endophthalmitis, the two studies included in this issue of JOVR provide evidence that there have been no significant changes in the rate of endophthalmitis during the COVID era. Financial Support and Sponsorship None. Conflicts of Interest None. REFERENCES 1. Patel SN, Mahmoudzadeh R, Salabati M, Soares RR, Hinkle J, Hsu J, et al. Bacterial dispersion associated with various patient face mask designs during simulated intravitreal injections. Am J Ophthalmol 2021;223:178–183. 2. Sakamoto T, Terasaki H, Yamashita T, Shiihara H, Funatsu R, Uemura A, et al. Increased incidence of endophthalmitis after vitrectomy relative to face mask wearing during COVID-19 pandemic. Br J Ophthalmol. DOI: 10.1136/bjophthalmol-2022-321357 3. Maurin C, He Z, Mentek M, Verhoeven P, Pillet S, Bourlet T, et al. Exploration of the ocular surface infection by SARS- CoV-2 and implications for corneal donation: An ex vivo study. PLoS Med 2022;19:e1003922. 4. 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. 5. Tsatsakis A, Calina D, Falzone L, Petrakis D, Mitrut R, Siokas V, et al. SARS-CoV-2 pathophysiology and its clinical implications: An integrative overview of the 250 JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 18, Issue 3, July-Sept 2023 Editorial; Riazi pharmacotherapeutic management of COVID-19. Food Chem Toxicol 2020; 146:111769. 6. Karimi S, Nikkhah H, Mohammadzadeh A, Ramezani A, Nouri H, Abtahi S-H. Intravitreal injections and face masks: Endophthalmitis risk before and during the COVID-19 pandemic. J Ophthalmic Vis Res 2023;18:283–288. 7. Fortes BH, Tailor PD, Xu TT, Churchill RA, Starr MR. Clinical characteristics and outcomes of endophthalmitis pre-COVID-19 pandemic versus during the COVID-19 pandemic. J Ophthalmic Vis Res 2023;18:289–296. 8. 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. 9. Patel LG, Peck T, Starr MR, Ammar MJ, Khan MA, Yonekawa Y, et al. Clinical presentation of rhegmatogenous retinal detachment during the COVID-19 pandemic: A historical cohort study. Ophthalmology 2021;128:686–692. 10. 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. JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 18, Issue 3, July-Sept 2023 251