Study: COVID-19 Elevates Likelihood of Keratitis Progressing to Endophthalmitis

Portrait of optometrist analyzing patient’s eyes
After 3 similar endophthalmitis cases in only 2 months, investigators suspect a link to the coronavirus.

Coronavirus disease 2019 (COVID-19) may be associated with an elevated risk for patients with keratitis to experience rapid perforation, leading to endophthalmitis, according to a case series presented at the American Academy of Ophthalmology 2020 meeting.1

The presentation focused on 3 cases at 1 health center in New York — the Northwell Health Ophthalmology Department. The patients, all positive for the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, included 1 male and 2 females ranging from 64 years to 68 years old.1

Occurrences of keratitis leading to rapid perforation and endophthalmitis are rare, according to the investigation.2 The presentation pointed to a 2012 study showing only 27 of 9934 eyes in a 15-year period experienced endophthalmitis following keratitis.2

The current report calls the 3 cases, presenting in such a short span of time, a “notable increase” and even a “cluster.” Since all 3 patients were diagnosed with COVID-19, the research speculates that incidence of keratitis or the progression to endophthalmitis may suggest the potential for the eye to be the “end organ” succumbing to either the damage caused by an unregulated immune response, damage caused by vascular events, or damage caused by neuro-invasion. The presentation also considered the possibility that the eye could be directly infected and suffer tissue damage through, or due to, the affinity for ACE-2 receptors of the coronavirus.1

Each of the 3 patients had a different organism on culture: Streptococcus pneumoniae, Serratia marcescens, and Candida parapsilosis. The Streptococcus pneumoniae patient recovered. The patient with the Serratia marcescens infectionunderwent enucleation on the fourth day of hospitalization. The Candida parapsilosis patient experienced renal failure associated with COVID-19 and died two weeks following the keratitis diagnosis. The report shows that all 3 patients had an “unusual rapid onset of severe ocular inflammation.”1

The study notes that all patients had known systemic conditions as well (diabetes, renal disease, and rheumatoid arthritis, respectively). It also allows for a potential limitation of selection bias.1

The investigators report that this “significant number of patients with keratitis, perforation and endophthalmitis with profound vision loss during a 2-month period at a COVID-19 pandemic epicenter may be associated with COVID-19 infection and warrants attention.”1


1 Schrier A, Smith E, Mehta I, et al. Keratitis progressing to endophthalmitis: a cluster in an epicenter of COVID-19. Presented at: American Academy of Ophthalmology 2020 Annual Meeting; November 13-15, 2020. Abstract PO081.

2. Henry C, Flynn H, Miller D, Forster R, Alfonso E. Infectious keratitis progressing to endophthalmitis: a 15-year study of microbiology, associated factors, and clinical outcomes. Ophthalmology. 2012;119(12):2443–2449. doi: 10.1016/j.ophtha.2012.06.030