In the Centers for Disease Control and Prevention (CDC) report published in the Morbidity and Mortality Weekly Report, researchers described five cases of monkeypox that had eye complications. They discussed the treatments and preventive measures for eye pox.
Study: Ocular Monkeypox — United States, July–September 2022. Image credit: Sakharova Anastasia/Shutterstock
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The 2022 monkeypox outbreak resulted in more than 26,000 cases in the United States. While most of the skin lesions in these cases resolved without treatment or with minimal treatment, lesions near vulnerable regions such as the eyes led to complications. Monkeypox virus, usually introduced into the eye by autoinoculation, can cause conjunctivitis, keratitis, and even vision loss.
Ocular smallpox is defined as the development of eye disease in a patient with suspected or confirmed smallpox, which cannot be explained by any other condition other than smallpox. This report describes the symptoms, treatments, and outcomes of five patients who developed eye pox between July and September 2022. Two were infected with the human immunodeficiency virus (HIV) and were immunosuppressed.
Cases of eye pox
Patient A was an HIV-positive man aged 20–29 years who was not taking antiretroviral therapy (ART) and had rashes on his arms, chest, and buttocks suggestive of monkeypox infection. She developed itching, pain, discharge, swelling, and photosensitivity in her left eye after ten days. When her ocular symptoms worsened, she was given trifluridine drops in her left eye and intravenous tecovirimat.
Despite improvement and discharge, the patient was readmitted with deterioration of vision in the left eye and increased facial lesions. Eye examination revealed keratitis, conjunctivitis, and a conjunctival ulcer. A swab from a conjunctival lesion was positive for Orthopoxvirus. Intravenous treatment with tecovirimate and trifluridine drops was restarted. The patient remained hospitalized at the time of the complaint and his prognosis was unknown.
Patient B was another HIV-positive man aged 30–39 years, who was not receiving ART therapy. He had rashes on his legs, chest, face and perianal region, with a lesion on his nose near his right eye. Swab tests were positive for Orthopoxvirus, and he was started on ART and prescribed tecovirimate for two weeks. Worsening facial lesions and expansion of the nasal bridge lesion in the right eye resulted in conjunctivitis in the right eye, nodular and conjunctival lesions, and corneal ulcers. He was given intravenous tecovirimate and trifluridine drops and discharged after ten days of improvement.
Patients C and D were previously healthy men between 30 and 39 years of age. Patient C presents to the hospital with perianal lesions and rectal pain. He developed injuries to his abdomen, penis and wrist. He experienced right eye pain, eye discharge, redness, and later bilateral conjunctivitis, which 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. Ocular symptoms worsened with periorbital swelling, multiple eyelid lesions, conjunctivitis, lid margin ulcers, and conjunctival lesions. No changes in vision were observed. Swabs from the conjunctival lesions were positive for Orthopoxvirus. The patient was treated with antibacterials, trifluridine eye drops and oral tecovirimate.
The fifth patient (Patient E) was a previously healthy woman aged 30–39 years who presented with vaginal pustular lesions, which spread to the buttocks, back, forehead, chin, and left eyelid. Ocular examination revealed a bulbar conjunctival lesion, conjunctivitis of the left eye, and subconjunctival nodules. She was treated with trifluridine eye drops and oral tecovirimate.
Preventive measures
The CDC recommends that monkeypox patients adhere to hand hygiene and avoid touching their eyes or wearing contact lenses. Health professionals are advised to be on the lookout for symptoms of eye pox, as the disease can lead to vision loss. Patients with monkeypox who show signs of eye disease should be given visual examinations and treatment, and public health officials should be notified of the case.
Conclusions
In summary, the present CDC report discussed five cases of ocular pox, 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 tecovirimate, and adherence to the therapeutic regimen results in significant improvements.
The CDC recommends strict hygiene protocols to prevent self-inoculation, including hand washing and avoiding contact lenses or any contact with the eyes. They advise healthcare providers to administer tests immediately for suspected cases of eye pox and initiate empiric treatments in the interim.