Annals of Medicine and Surgery · 2 authors, 2 centres
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Monkeypox virus (MPXV) can cause ocular complications including conjunctivitis, blepharitis, keratitis, and corneal scarring, which may lead to blindness. Ocular involvement is more common in unvaccinated individuals and those infected via animal sources. Ophthalmologists should consider monkeypox in patients presenting with ophthalmic symptoms and febrile prodrome, and hygiene education and vaccination are key preventive measures.
**Background:** Monkeypox virus (MPXV) is a double-stranded DNA virus of the Orthopoxvirus genus that causes a self-limiting disease with vesiculopustular rashes. Although historically endemic in Africa, MPXV has caused outbreaks beyond Africa, including in the United States (2003), UK (2018), Singapore (2019), and a large European outbreak in May 2022 with no clear epidemiological links. As of November 2022, there were X laboratory-confirmed cases and Y deaths globally. Ocular complications are a recognized but underappreciated aspect of MPXV infection, with potential for corneal scarring and blindness. This letter reviews the ophthalmic manifestations of monkeypox to raise awareness among ophthalmologists.
**Methods:** This is a narrative review (letter to editor) summarizing published literature on ocular manifestations of monkeypox. The authors cite multiple studies, including case series and outbreak reports, to describe the spectrum of ophthalmic complications and their clinical significance.
**Key Results:** Ocular manifestations of MPXV include blepharitis, conjunctivitis, conjunctival ulcer, eyelid lesions, photophobia, keratitis, and loss of vision. In a study of 282 patients by Ježek et al., conjunctivitis and eyelid edema were common. Hughes et al. found that MPXV patients with conjunctivitis had more systemic symptoms (nausea, chills, oral ulcers, sore throat, malaise, lymphadenopathy, photophobia). The frequency of conjunctivitis, blepharitis, and corneal scarring is higher in unvaccinated smallpox cases and children under 10 years. Photophobia without other ocular involvement was reported in 22% of patients, severe keratitis in 7.5%, and corneal scarring in 4% (based on references 8 and 12). Severe ocular sequelae are more common in unvaccinated individuals. Blindness and conjunctivitis are more frequent in cases infected from animal sources than from person-to-person transmission. In MPXV-endemic areas, corneal scarring and endophthalmitis occur in 9–23% of infected patients.
**Clinical Implications:** Ophthalmologists should suspect monkeypox in patients presenting with conjunctivitis, blepharitis, keratitis, or corneal lesions accompanied by febrile prodromal symptoms. Direct self-inoculation is a proposed route for ocular involvement, highlighting the need for hygiene education for MPXV patients. Although most ocular complications have PCR-positive eye swabs, suspected bacterial superinfection may warrant topical lubricants and vitamin supplementation to support immunity. Vaccination against smallpox appears protective against severe ocular complications. Wide-scale surveillance and immunization of at-risk individuals are crucial to reduce ocular morbidity and blindness from monkeypox.