What are the complications, preventative measures, and treatments of ocular monkeypox?

By Dr. Chinta SidharthanOct 20 2022Reviewed by Aimee Molineux

In the Centers for Disease Control and Prevention’s (CDC) report published in the Morbidity and Mortality Weekly Report researchers described five monkeypox cases presenting ocular complications. They discussed the treatments and preventative measures for ocular monkeypox.

Background

The monkeypox outbreak in 2022 resulted in over 26,000 cases in the U.S. While most skin lesions in these cases resolved with no or minimal treatment, lesions near vulnerable regions such as the eyes resulted in complications. Monkeypox virus, generally introduced into the eye through autoinoculation, can cause conjunctivitis, keratitis, and even vision loss.

Ocular monkeypox is defined as the development of ocular disease in a patient with suspected or confirmed monkeypox, which cannot be explained by any condition other than monkeypox. The present report describes the symptoms, treatments, and outcomes of five patients who developed ocular monkeypox between July and September 2022. Two were infected with human immunodeficiency virus (HIV) and were immunocompromised.

Ocular monkeypox cases

Patient A was a 20- to 29-year-old HIV-positive male who was not taking antiretroviral therapy (ART) and presented rashes on his arms, chest, and buttocks that indicated a monkeypox infection. He developed itching, pain, discharge, swelling, and photosensitivity in the left eye after ten days. When his ocular symptoms worsened, trifluridine drops were administered to his left eye, and tecovirimat was given intravenously.

Despite improvement and discharge, the patient was readmitted with deteriorating vision in the left eye and increasing facial lesions. The eye examination revealed keratitis, conjunctivitis, and an ulcer in the conjunctiva. A conjunctival lesion swab was positive for Orthopoxvirus. The intravenous tecovirimat treatment and trifluridine drops were restarted. The patient remained admitted at the hospital at the time of the report, and his prognosis was unknown.

Patient B was another HIV-positive male between 30 and 39 years, not receiving ART therapy. He had rashes on his legs, chest, face, and perianal region, with one lesion on the nose close to the right eye. Swab tests were positive for Orthopoxvirus, and he was initiated on ART and prescribed tecovirimat for two weeks. Worsening facial lesions and the expansion of the nose-bridge lesion into his right eye resulted in conjunctivitis in the right eye, nodular and conjunctival lesions, and corneal ulcers. He was administered intravenous tecovirimat and trifluridine drops and discharged after ten days upon improvement.

Patients C and D were previously healthy males between 30 and 39 years of age. Patient C presented at the hospital with perianal lesions and rectal pain. He developed lesions on his abdomen, penis, and wrist. He experienced right eye pain, discharge from the eyes, redness, and subsequently, bilateral conjunctivitis, which the doctors attributed to autoinoculation. He was treated with tecovirimat until all symptoms resolved.

Patient D developed a groin rash, swelling, redness, and pain in the right eye. The ocular symptoms worsened with periorbital swelling, multiple eyelid lesions, conjunctivitis, ulcers on the eyelid margins, and lesions on the conjunctiva. No vision changes were noted. Swab samples from the conjunctival lesions tested positive for Orthopoxvirus. The patient was treated with antibacterial, trifluridine eye drops, and oral tecovirimat.

The fifth patient (patient E) was a previously healthy female between 30 and 39 years old who had vaginal pustular lesions, which spread to her buttocks, back, forehead, chin, and left eyelid. Eye examination detected a bulbar conjunctival lesion, left eye conjunctivitis, and nodules in the subconjunctival. She was treated with trifluridine eye drops and oral tecovirimat.

Preventative measures

The CDC recommends that monkeypox patients adhere to hand hygiene and avoid touching the eyes or using contact lenses. Healthcare practitioners are advised to be vigilant for ocular monkeypox symptoms, as the disease can result in loss of vision. Monkeypox patients showing signs of ocular diseases should be administered visual examinations and treatment, and public health officials must be notified of the case.

Conclusions

To summarize, the present CDC report discussed five cases of ocular monkeypox, of which two patients were HIV-positive and not receiving ART. One HIV-positive patient experienced vision loss, and his prognosis remains unknown. Most cases have been treated with trifluridine eye drops and oral tecovirimat, and adherence to the therapeutic regimen results in significant improvements.

The CDC recommends stringent hygiene protocols to avoid autoinoculation, which includes hand washing and avoidance of contact lenses or any contact with the eyes. They advise healthcare providers to administer tests immediately for suspected ocular monkeypox cases and initiate empiric treatments in the interim.