Monkeypox Virus and Ophthalmology—A Primer on the 2022 Monkeypox Outbreak and Monkeypox-Related Ophthalmic Disease

Abstract

ImportanceAn ongoing global monkeypox virus outbreak in 2022 includes the US and other nonendemic countries. Monkeypox ophthalmic manifestations may present to the ophthalmologist, or the ophthalmologist may be involved in comanagement. This narrative review creates a primer for the ophthalmologist of clinically relevant information regarding monkeypox, its ophthalmic manifestations, and the 2022 outbreak.ObservationsMonkeypox virus is an Orthopoxvirus (genus includes variola [smallpox] and vaccinia [smallpox vaccine]). The 2022 outbreak is of clade II (historically named West African clade), specifically subclade IIb. In addition to historic transmission patterns (skin lesions, bodily fluids, respiratory droplets), sexual transmission has also been theorized in the current outbreak due to disproportionate occurrence in men who have sex with men. Monkeypox causes a characteristic skin eruption and mucosal lesions and may cause ophthalmic disease. Monkeypox-related ophthalmic disease (MPXROD) includes a spectrum of ocular pathologies including eyelid/periorbital skin lesions, blepharoconjunctivitis, and keratitis). Smallpox vaccination may reduce MPXROD occurrence. MPXROD seems to be rarer in the 2022 outbreaks than in historical outbreaks. MPXROD may result in corneal scarring and blindness. Historical management strategies for MPXROD include lubrication and prevention/management of bacterial superinfection in monkeypox keratitis. Case reports and in vitro data for trifluridine in other orthopoxviruses suggest a possible role for MPXROD. Tecovirimat, cidofovoir, brincidofovir and vaccinia immune globulin intravenous may be used for systemic infection. There is a theoretical risk for monkeypox transmission by corneal transplantation, and the Eye Bank Association of America has provided guidance. Smallpox vaccines (JYNNEOS [Bavarian Nordic] and ACAM2000 [Emergent Product Development Gaithersburg Inc]) provide immunity against monkeypox.Conclusions and RelevanceThe ophthalmologist may play an important role in the diagnosis and management of monkeypox. MPXROD may be associated with severe ocular and visual morbidity. As the current outbreak evolves, up-to-date guidance from public health organizations and professional societies are critical.

Severe Monkeypox Infection of the Eye and Periocular Region

“…Ocular and periocular mpox infection has been described in limited case reports and series. 13 These reports include case of conjunctivitis 5,14-17 (with or without follicles), keratitis 5 and periocular skin involvement 5,15,17 . However, most involvement in the reported cases is mild without long-term sequela.…”

“…Additional systemic therapies include, vaccination vaccinia IVIG Local treatment of ocular involvement is reported with tri uridine which shows in vitro activity against orthopoxviruses. 13 While debridement of necrotic tissue is reasonable to prevent bacterial superinfection it is not likely to prevent disease progression and is not a mainstay of therapy.…”

Novel severe oculocutaneous manifestations of human monkeypox virus infection and their historical analogues

“…As of January, 2023 nearly 30 000 cases of mpox have been confirmed in the USA alone and over 80 000 cases have been confirmed worldwide. 3 , 4 …”

“…Mpox-related ophthalmic disease, for example, is presently rare (occurring in <1% of patients with mpox) when compared with preceding outbreaks but has the potential to cause permanent visual impairment and blindness. 4 , 5 , 6 , 7 The US Centers for Disease Control and Prevention (CDC) now classifies the eyes as a so-called special hazard anatomic site. 7 Additionally, immunocompromised patients, such as those with AIDS, have shown increased variability and severity of mpox.…”

“…Monkeypox virus is closely related to other orthopoxviruses, namely variola virus (responsible for smallpox), vaccinia virus (the main component of the smallpox vaccine), and cowpox virus. 4 When compared at the nucleotide scale, studies have shown that any two orthopoxviruses share 96% of their core genomes. 9 Because of high genetic and antigenic similarity, vaccination with vaccinia virus not only confers immunity against variola virus but also provides approximately 85% co-immunity against monkeypox virus.…”