Human MPox (Monkeypox) Virus Membranous Keratoconjunctivitis With Transient Corneal Hypoesthesia and Late Symblepharon Formation: A Novel Case and Clinical Implications

Abstract

The aim of this study was to describe a case of corneal involvement as an early manifestation of ocular disease in the 2022 human mpox (monkeypox) virus outbreak.Methods: This is a single case report with longitudinal care.Results: A 47-year-old immunocompetent man presented with viral conjunctivitis before development of skin lesions or systemic symptoms. Subsequently, he developed membranous keratoconjunctivitis and a corneal epithelial defect. Orthopoxvirus-positive polymerase chain reaction test from his ocular surface was positive. The epithelial defect did not heal with conservative treatment but was successfully treated with amniotic membrane transplantation over 8 days. Reduced corneal sensation was noted after epithelial healing, and polymerase chain reaction from the ocular surface remained positive at 17 days from symptom onset, with slowly recovering conjunctivitis at 21 days. Continued membrane formation required repeated removal but significantly improved with topical corticosteroid treatment after epithelial healing by 29 days of symptom onset. Corneal sensation normalized by 87 days from symptom onset at which time symblepharon were noted but PCR testing from the ocular surface was negative. Conclusions:Early corneal involvement of human monkeypox virus is possible. Transient corneal hypoesthesia may be due to acute inflammation. Chronic inflammatory changes can result in symble-pharon. These findings have potential implications in patient care and corneal donation.

Persistent and Severe Mpox Keratitis Despite Systemic and Topical Treatment

“…Keratoconjunctivitis with transient corneal hypesthesia due to mpox is also described in another case report, needing amniotic graft. 12 Ultimately, this case series of 2 patients from Androudi et al 3 refers to characteristics very similar to ours: elevated intraocular pressure, association of topical corticosteroid use with poor disease outcome, patient not fully forthcoming about sexual/mpox history, persistent ED, and use of autologous serum tears. In addition, a case involving a 53-year-old man with HIV has been documented.…”

“…Finally, recent case reports have described clinical improvement of ocular mpox after amniotic membrane transplantation. 12 In our case, the patient denied any sexual exposure, despite having a recent history of genital monkeypox. Considering the well-established prevalence of sexual transmission of monkeypox during the 2022 outbreak, it seems that the patient might not have felt the necessary confidence and anonymity to disclose these sensitive clinical details in our outpatient setting.…”

“…As with herpes viruses, the mpox damaged different ocular anterior structures, such as the corneal epithelium, peripheral stroma and endothelium, the limbus, or the trabeculum. The persistence of the ED, together with the corneal and conjunctival anesthesia and lack of a subbasal plexus in the in vivo confocal microscopy, suggest a virus with neurotropism, as Uner et al 12 also describe in their manuscript.…”

“…Finally, recent case reports have described clinical improvement of ocular mpox after amniotic membrane transplantation. 12…”

Spectrum of ophthalmic manifestations in monkeypox virus infection worldwide: Systematic review and meta-analysis

“… Author (Year) Country Type of Study Study population Age Case confirmation Ocular Manifestation (n/N) Laterality Was the first manifestation? Uner (2023) [ 28 ] USA Case report 1 47 y, male PCR Preseptal cellulitis, membranous Keratoconjunctivitis with Transient Corneal Hypoesthesia. Unilateral Yes.…”