Characteristics and Management of Ocular Involvement in Individuals with Mpox Disease

Canalicular obstructions after monkeypox infection

We report two cases of lacrimal obstruction after ocular infection with monkeypox virus (MPX) in the 2022 outbreak. One of them was a distal canalicular obstruction and the other was a proximal canalicular obstruction. In the first days of MPX they presented with conjunctivitis and periocular skin vesicles. Several months after the ophthalmic condition was cured, they showed persistence of epiphora, and the lacrimal problem was diagnosed. The photographs taken during the inflammation of the anterior pole were reviewed and vesicles located in the same area as the canalicular damage were observed. One patient underwent a canaliculodacryorhinostomy and the other an exploratory punctoplasty. Both surgical operations failed to restore normal tear flow. Lacrimal drainage disorders related to ocular MPX have not yet been described. And, in addition, these cases are the first relation of viral vesicular skin lesions and canalicular obstructions.

Ocular Manifestations of Mpox and Other Poxvirus Infections: Clinical Insights and Emerging Therapeutic and Preventive Strategies

Poxvirus infections, particularly those caused by the monkeypox virus, have emerged as significant public health threats. Ocular manifestations constitute a severe potential clinical complication associated with these infections, potentially resulting in permanent visual impairment in afflicted patients. This review aimed to examine the clinical spectrum of ocular manifestations associated with mpox and other poxvirus infections and to evaluate current management strategies alongside emerging therapeutic interventions and prevention strategies. A comprehensive literature search was performed across major databases to identify studies reporting ocular involvement in poxviral infections. Ocular involvement in poxviral infections ranges from mild conjunctivitis and eyelid lesions to severe keratitis with potential vision loss. Mpox-related ocular manifestations are more prevalent in unvaccinated and immunocompromised individuals. Although early antiviral intervention and supportive care are critical, clinical outcomes vary considerably across viral clades. Emerging evidence indicates that tecovirimat may reduce lesion severity, although its impact on accelerating recovery remains limited. Moreover, vaccine strategies, particularly the MVA-BN (JYNNEOS) vaccine, appear to decrease ocular complications, despite regional disparities in access and implementation. Ocular complications pose a significant clinical challenge in mpox and related poxviral infections. This review highlights the need for early diagnosis and integrated treatment approaches that combine antiviral therapy, supportive care, and targeted vaccination. Further research is essential to refine treatment protocols and assess the long-term outcomes in diverse patient populations.

Atypical mucocutaneous manifestations of MPOX: A systematic review

MPOX is an orthopoxvirus whose infection has been declared a Public Health Emergency of International Concern in 2022 and 2024. It proved to be a virus with markedly heterogeneous and varied clinical presentation. We performed a systematic PubMed review of articles reporting cases of different clinical manifestations of MPOX until October 2024. The infection has mainly affected men who have sex with men. After 4 to 10 days of incubation, it presents with mucocutaneus lesions and systemic symptoms. Some anatomical sites have shown clinical particularities. Genital edema is a potentially serious complication. The ocular and ear/nose/throat area are other infrequent sites with specific manifestations. MPOX whitlow affects the third finger of the dominant hand and may be associated with extensive inflammation and proximal lymphangitis. Bacterial superinfection is a common complication in the genital area with good response to antibiotic treatment. Immunosuppressed patients may develop severe inflammation and necrosis resulting in poor prognosis. Some authors propose ulceronecrotic MPOX as a defining condition of AIDS. The involvement of women has been exceptional in the current outbreak and has predominantly affected the vulva. Some patients such as healthcare workers, atopics, and people who get tattoos are at risk of developing specific lesions via nonsexual routes. Other atypical manifestations include maculopapular rash and inguinal patch. MPOX is a highly relevant and ongoing infection that can present with multiple atypical manifestations, and the knowledge of which is of great importance to the clinician. We present a unique systematic review of atypical presentations of this infection that may be associated with significant morbidity and mortality, especially in the immunocompromised population.

Mpox Virus and its ocular surface manifestations

The Mpox virus (MPXV) is the causative agent of human Mpox disease - a debilitating rash illness similar to smallpox. Although Clade I MPXV has remained endemic to West and Central Africa, Clade II MPXV has been responsible for many outbreaks worldwide. The most recent outbreak in 2022 resulted from the rapid spread of a new clade of MPXV, classified into Clade IIb - a distinct lineage from the previously circulating viral strains. The rapid spread and increased severity of Mpox disease by the Clade IIb strain have raised the serious public health imperative of better understanding the host and viral determinants during MPXV infection. In addition to typical skin rashes, including in the periorbital area, MPXV causes moderate to severe ophthalmic manifestations - most commonly, ocular surface complications (e.g., keratitis, conjunctivitis, blepharitis). While ocular manifestations of Clade I Mpox within the Congo basin have been well-reported, global incidence trends of ocular Mpox cases by Clade IIb are still emerging. Given the demonstrated ability of all MPXV strains to auto-inoculate ocular tissue, alongside the enhanced transmissibility of the Clade IIb virus, there is an urgent need to elucidate the mechanisms by which MPXV causes ocular anomalies. In this review, we discuss the viral and genomic structures of MPXV, the epidemiology, and pathology of systemic and ocular Mpox, as well as potential prophylactic and therapeutic interventions.

Ocular Complications of Mpox: Evolving Understanding and Future Directions

Mpox (formerly known as monkeypox), an infectious disease caused by the monkeypox virus (MPXV), has been endemic in regions of Central and Western Africa. In 2022, the global spread of the clade IIb MPXV led to a multinational outbreak, primarily affecting sexual transmission networks among men who have sex with men. Despite interventions, new cases have continued to emerge. In Africa, the spread of a novel strain of clade I MPXV, clade Ib, has prompted a Public Health Emergency of International Concern designation by the World Health Organization in August 2024. This article provides an updated overview of the epidemiology, systemic, and ocular manifestations, highlighting the clinical features, diagnostic testing, and implications relevant to ophthalmologists and eye care providers, including infection prevention and control measures. The ocular manifestations of mpox primarily involve the ocular surface and anterior segment, with presentations ranging from conjunctivitis to severe, vision-threatening keratitis and uveitis. While the 2022 to 2024 Clade IIb outbreak has shown a lower incidence of ocular involvement compared with previous outbreaks, the potential for significant visual morbidity remains. Treatment involves both systemic and topical therapies, with tecovirimat being the primary systemic option, though its efficacy and ophthalmic bioavailability remain under investigation. Ongoing surveillance and research are essential to further understand the epidemiology and ophthalmic features of mpox and, ultimately, to optimize prevention and treatment strategies for patients.

Mpox Keratitis: A Case Report and Review

PURPOSE

Mpox is a rare infectious disease. Lack of knowledge among eye care professionals regarding mpox keratitis greatly reduces the likelihood of diagnosis and effective management. This report and review seek to increase the knowledge of mpox keratitis among eye care professionals.

METHODS

We report a patient with mpox keratitis who underwent successful penetrating keratoplasty, with 20 years of follow-up. A systematic literature search and review of cases of mpox keratitis from 1970 to 2024 was performed.

RESULTS

A total of 24 articles and 2 abstracts reporting 35 cases of mpox keratitis were identified. A frequency of 0.5% to 1.0% may be the lower range of mpox keratitis among symptomatic patients with a confirmed mpox diagnosis. Mpox keratitis occurred with and without systemic mpox. Initial misdiagnoses were common (40%). Polymerase chain reaction results aided clinical diagnosis. Corneal disease ranged from mild epitheliopathy to fulminant ulcerative keratitis. Outcomes ranged from 20/20 acuity to no light perception. In the absence of fulminant systemic disease, tecovirimat was associated with clinical improvement of mpox keratitis in almost all cases. Our case is the only known report of successful penetrating keratoplasty for mpox keratitis and the only case whereby monkeypox virus was cultured from the corneal surface.

CONCLUSIONS

Mpox keratitis is rare but can result in severe vision loss and blindness. Systemic tecovirimat seems to be effective in treating mpox keratitis, although the low frequency of keratitis precludes clinical trials. Topical steroids may extend virus survival in the cornea. Polymerase chain reaction may help confirm mpox corneal involvement.

Persistent Monkeypox-Associated Keratouveitis in a Post-LASIK Cornea: A Case Report With Flap Removal

PURPOSE

This study aimed to report a case of persistent keratouveitis associated with mpox virus infection in an immunocompetent patient with a history of laser-assisted in situ keratomileusis (LASIK), leading to the need for flap removal.

METHODS

A comprehensive literature review was conducted, and a detailed case report was presented.

RESULTS

A 44-year-old immunocompetent male patient with a history of LASIK and HIV infection presented with conjunctival and corneal lesions indicative of mpox infection. Despite initial topical treatment, the condition worsened, leading to severe epithelial and stromal keratitis with anterior chamber inflammation. Polymerase chain reaction testing confirmed the presence of mpox virus in conjunctival, corneal, and aqueous humor samples. The patient underwent various treatments, including tecovirimat, oral and topical corticosteroids, and topical trifluridine, and eventually flap removal with amniotic membrane application. Subsequent polymerase chain reaction testing of the aqueous humor yielded negative results, and the cornea gradually reepithelialized without inflammation. After 8 months, the patient's eye remained stable, with a central stromal scar.

CONCLUSIONS

This case highlights the rare occurrence of mpox-associated keratouveitis and emphasizes the challenges faced in its management. The successful outcome achieved through a combination of antiviral therapy, antiinflammatories, and surgical intervention underscores the importance of a multidisciplinary approach in managing such cases.

Monkeypox-related ophthalmic disease

Monkeypox (Mpox) is an acute febrile rash illness caused by the Mpox virus. The ongoing international outbreak since mid-2022 has spread worldwide, including Taiwan. Ocular involvement in Mpox infection is uncommon, including external and ocular surface lesions. Here, we describe a man who developed unilateral blepharoconjunctivitis and preseptal cellulitis, followed by the appearance of skin symptoms 6 days after the ocular manifestations. Samples taken from his oropharynx and skin lesions tested positive for the Mpox virus through a polymerase chain reaction test. He was hospitalized for isolation with topical lubricant, antibiotic, and acyclovir eye ointment until the skin lesions healed. However, on the day of discharge, punctate epithelial keratitis was observed in the same eye. The corneal lesion also tested positive for the Mpox virus. His keratitis progressed to dendritic ulceration, and treatment with tecovirimat was initiated. Initially, his corneal ulcer responded well to tecovirimat, but 12 days later, it deteriorated along with cells in the anterior chamber. To treat his condition, low-dose steroid and ganciclovir eye drops were administered. Eventually, the patient experienced resolution of the corneal lesion, leaving a scar.

Mpox-Related Ophthalmic Disease: A Retrospective Observational Study in a Single Center in Mexico

Mpox-related ophthalmic disease has been reported as infrequent. We retrospectively describe the ocular manifestations present in 11 of 100 patients with confirmed mpox; 9 were people with HIV. We suggest that an ophthalmological evaluation should be performed in all patients with ocular symptoms or moderate and severe mpox disease.