Key Points
- Monkeypox virus infection can affect vulnerable anatomic sites, including the eyes, which may require specific therapeutic management and considerations.
- Involvement of the eyes can be a vision-threatening condition and should be treated urgently.
- There are very few data on the effectiveness of currently available therapeutics and on the outcomes of ocular Monkeypox virus This guidance will be updated as new data become available.
Ocular Manifestations of Monkeypox Virus Infection
Ocular involvement is a potentially debilitating manifestation for people experiencing Monkeypox virus infection.[ 1 ]Monkeypox virus may enter the eye via autoinoculation[ 2 ] and cause a range of problems from mild to severe, including conjunctivitis, blepharitis, keratitis, corneal ulcer, corneal scarring, and rarely loss of vision.[ 3 ] In a 2014 study in the Democratic Republic of the Congo, 23% of patients with confirmed Monkeypox virus infection had conjunctivitis.[ 1 ] The majority (62%) of these patients were young children (<10 years of age), and patients with conjunctivitis were more likely to be “bed-ridden”, suggestive of more severe disease.[ 1 ]
In the current ongoing Monkeypox virus outbreak, ocular involvement has been uncommon with retrospective evidence reporting that less than 1% of individuals had eye involvement.[ 4 ] Differences are likely Monkeypox virus clade-related, but are also potentially related to the mode of transmission, as the epidemiology and risk factors associated with the current outbreak are different from previous outbreaks.[ 5 ] As data emerge related to the spectrum of phenotypes of disease caused by the current viral clade, additional information on the true rate of ocular involvement may become available.
Complications of Ocular Monkeypox Virus Infection
Corneal scarring and vision loss are potential severe consequences of ocular involvement of Monkeypox virus infection.[ 3 ] Bacterial superinfection of corneal ulcerations can cause severe complications. Recent reports have documented periobital and facial lesions with RT-PCR evidence of Monkeypox virus in association with corneal and conjunctival findings. The constellation of facial and ocular symptoms was observed in association with systemic symptoms (e.g., fever, painful cervical adenopathy) and risk factors for sexual transmission.[ 6,7 ]
Evaluation of Suspected Ocular Monkeypox Virus Infection
If ocular involvement of Monkeypox virus is suspected, then ophthalmologic consultation should be strongly considered for a thorough evaluation and continued monitoring of the patient’s condition and extent of disease, especially in cases of vision changes, eye pain, or increasing redness.
Acute Monkeypox virus infection can currently be diagnosed by 2-stage RT-PCR testing, first for non-variola orthopox virus (OPX) followed by Monkeypox virus.[ 8 ] Swabs of lesions on the conjunctiva are acceptable specimens for RT-PCR testing to confirm the presence of Monkeypox virus in a patient with conjunctival involvement. Clinical judgement should be used in assessing the stability of underlying eye structures, and caution should be taken with obtaining swabs if corneal ulcers or severely painful lesions are present.
Slit lamp examination and dilated funduscopic examination can be helpful for determining whether anterior segment structures (conjunctiva, cornea, iris) or posterior segment structures (retina, nerve, choroid) are involved. Infection prevention and control precautions and equipment disinfection protocols are recommended when examining patients at the slit lamp biomicroscope.
A patient with suspected or confirmed Monkeypox virus infection should be placed in a single-person room with the door closed. If the patient is transported outside of their room, they should use well-fitting source control (e.g., medical mask) and have any exposed skin lesions covered with a bandage, sheet or gown. PPE used by healthcare personnel who enter the patient’s room or perform any eye examination should include gown, gloves, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), and a NIOSH-approved particulate respirator equipped with N95 filters or higher. For infection prevention and control measures to take when evaluating a person suspected of having monkeypox, see: Infection Prevention and Control of Monkeypox in Healthcare Settings.
Preventive Measures
To reduce risk for autoinoculation of the eye, frequent handwashing and avoidance of eye rubbing should be discussed with patients who have monkeypox.
Prophylactic treatment with topical trifluridine could be considered for patients with lesions on their eyelids, near the eye, or for children under the age of 8 and others unable to follow instructions about hand hygiene and avoidance of hand-eye contact. This decision should be made in consultation with an ophthalmologist or specialist in infectious diseases, particularly as prolonged use of trifluridine eye drops can result in corneal epithelial toxicity.[
