ORIGINAL ARTICLE

Ocular Complications of Mpox: Evolving Understanding

and Future Directions
Jack Begley, BS,* Timothy Kaftan, BS,* Helen Song, MD,* Tolulope Fashina, MD, MPH,*
Caleb D. Hartley, MPH,* Nam Nguyen, BS,* Ian Crozier, MD,†
Jean-Claude Mwanza, MD, PhD, MPH,‡§ and Steven Yeh, MD*‖¶#

care providers, including infection prevention and control mea-

Abstract: Mpox (formerly known as monkeypox), an infectious sures. The ocular manifestations of mpox primarily involve the
disease caused by the monkeypox virus (MPXV), has been en- ocular surface and anterior segment, with presentations ranging
demic in regions of Central and Western Africa. In 2022, the from conjunctivitis to severe, vision-threatening keratitis and
global spread of the clade IIb MPXV led to a multinational uveitis. While the 2022 to 2024 Clade IIb outbreak has shown a
outbreak, primarily affecting sexual transmission networks lower incidence of ocular involvement compared with previous
among men who have sex with men. Despite interventions, new outbreaks, the potential for significant visual morbidity remains.
cases have continued to emerge. In Africa, the spread of a novel Treatment involves both systemic and topical therapies, with
strain of clade I MPXV, clade Ib, has prompted a Public Health tecovirimat being the primary systemic option, though its effi-
Emergency of International Concern designation by the World cacy and ophthalmic bioavailability remain under investigation.
Health Organization in August 2024. This article provides an Ongoing surveillance and research are essential to further un-
updated overview of the epidemiology, systemic, and ocular derstand the epidemiology and ophthalmic features of mpox and,
manifestations, highlighting the clinical features, diagnostic ultimately, to optimize prevention and treatment strategies for
testing, and implications relevant to ophthalmologists and eye patients.
Key Words: Mpox, monkeypox virus (MPXV), clade Ib, clade
From the *Truhlsen Eye Institute, University of Nebraska Medical
Center, Omaha, NE; †Clinical Monitoring Research Directorate, IIb, epidemiology, ocular manifestations, conjunctivitis, kerati-
Frederick National Laboratory for Cancer Research, Frederick, MD; tis, infection prevention and control, clade 1a
‡Department of Ophthalmology, University of North Carolina,
Chapel Hill, NC; §Department of Ophthalmology, University of (Int Ophthalmol Clin 2024;64:15–22)
Kinshasa, Kinshasa, Democratic Republic of Congo; ‖Global Center
for Health Security, University of Nebraska Medical Center, Omaha,
NE; ¶National Strategic Research Institute, University of Nebraska INTRODUCTION AND EPIDEMIOLOGY UPDATE
Medical Center, Omaha, NE; and #Emory Eye Center, Emory Mpox (formerly termed monkeypox) is an infectious
University School of Medicine, Atlanta, GA. disease caused by the monkeypox virus (MPXV), a dou-
This project was supported by the National Eye Institute of the National ble-stranded DNA orthopoxvirus. Mpox (caused by clade
Institutes of Health under award number R01 EY029594 (SY) and
R01 EY031894-01A1 (JCM). This project has been funded in part I and clade II MPXV) has been endemic in Central and
with federal funds from the National Cancer Institute, National In- Western Africa, respectively, for decades. In 2022, the new
stitutes of Health, under Contract No. 75N91019D00024 (IC). global spread of clade IIb MPXV to nonendemic areas
Funding support is also provided by the Macula Society Retina Re- prompted urgent global attention and the declaration of a
search Foundation Cox Family Grant, Association for Research in Public Health Emergency of International Concern
Vision and Ophthalmology Mallinckrodt Foundation Young Inves-
tigator Award, and the Stanley M. Truhlsen Family Foundation, Inc. (PHEIC) by the World Health Organization (WHO; July
The content is solely the responsibility of the authors and does not nec- 2022). In the context of this ongoing outbreak, the ma-
essarily represent the official views of the National Institutes of jority of cases were associated with sexual transmission
Health or the views or policies of the Department of Health and networks in men who have sex with men. Public health
Human Services, nor does mention of trade names, commercial
products, or organizations imply endorsement by the U.S. Govern-
interventions, including around behavioral change and
ment. vaccination, contributed to a decline in cases, leading to
The authors declare that they have no conflicts of interest to disclose. the lifting of the PHEIC by May 2023, though new cases
Reprints: Steven Yeh, MD, Department of Ophthalmology and Visual continue to be reported.
Sciences, University of Nebraska Medical Center, 985540 Nebraska
Medical Center, Omaha, NE 68198-5540 (e-mail: syeh@unmc.edu).
However, long before the recent clade IIb mpox
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, epidemic, increasing case numbers of clade I mpox have
Inc. This is an open access article distributed under the terms of the been reported in endemic areas over several decades,
Creative Commons Attribution-Non Commercial-No Derivatives particularly in the Democratic Republic of the Congo
License 4.0 (CCBY-NC-ND), where it is permissible to download and (DRC). In part, the increase was thought to be related to
share the work provided it is properly cited. The work cannot be
changed in any way or used commercially without permission from the waning of cross-protective immunity afforded by
the journal. smallpox vaccination.1,2 More recently, during and in the
DOI: 10.1097/IIO.0000000000000536 background of the clade IIb epidemic, a dramatic increase

Int Ophthalmol Clin  Volume 64, Number 4, Fall 2024 www.internat-ophthalmology.com | 15

Begley et al Int Ophthalmol Clin  Volume 64, Number 4, Fall 2024

in the numbers of clade I mpox cases in DRC, including ratios (1.4% to over 10%) compared with clade II MPXV
newly affected geographic areas, has occurred. Fur- infection (case fatality ratio: 0.1% to 3.6%).10 However,
thermore, sustained human-to-human (H2H) transmission severe and fatal disease after clade IIb infection has been
of a newly identified clade Ib MPXV variant, including described in severely immunocompromised patients, most
along sexual transmission networks, has recently been notably in untreated people living with HIV/AIDS
reported from South Kivu, DRC.3,4 The combination of (PLWHA) with low CD4 counts.11 During the current
the high burden of clade I mpox in DRC and the recent clade I mpox outbreak in the DRC, 67% of cases and 78%
regional spread (to Burundi, Kenya, Rwanda, and of deaths have occurred among individuals aged 15 or
Uganda) prompted a new declaration of a global PHEIC younger.12
in August 2024. Risk factors for infection include close contact with
According to the WHO, 99,176 laboratory-con- infected humans or animals. Mouth-to-mouth, face-to-
firmed mpox cases, 535 probable cases, and 208 deaths face, skin-to-skin, and mouth-to-skin contact can all result
have been reported globally from January 1, 2022 to June in transmission of mpox.8 People who have contact with
30, 2024.5 More recently, the largest proportion of cases clothing, bedding, towels, or other surfaces that have been
has been detected in Africa, with 43.5% of new cases in contacted by a person with mpox are also at risk.8 In the
May 2024 and 60.7% of new cases in June 2024 occurring recent 2022 to 2024 clade IIb epidemic, sexual trans-
in this region.5,6 In 2024, 99% of new mpox cases in Africa mission networks among men who have sex with men and
were reported in the DRC,5 where thus far, mpox is ex- sex workers have driven H2H transmission. In endemic
clusively caused by clade I MPXV (associated with higher areas in Africa, transmission has been presumed to be
case fatality rates).3 Recent genomic surveillance in DRC predominantly driven by repeated zoonotic spillovers
suggests increases are driven both by zoonotic spillovers of (with some but nonsustained H2H transmission); how-
clade Ia MPXV (in known endemic areas) and H2H ever, sustained H2H associated with new clade Ib MPXV
transmission of novel clade Ib MPXV (in eastern DRC virus infections, including in sexual transmission net-
and new regional spread).7 works, suggests an increasing role for H2H spread.4,7 In-
deed, the high burden of cases in children younger than
15 years in the DRC suggests a complex interplay of zo-
SYSTEMIC MANIFESTATIONS AND RISK onotic spillover and H2H transmission.13
FACTORS FOR MPOX
After exposure to MPVX, the incubation period
ranges from 1 to 21 days,8 although most patients develop OPHTHALMIC MANIFESTATIONS
symptoms or signs of disease within 7 to 14 days.9 Com- In the complex disease background described pre-
mon presenting symptoms and signs include fever, lym- viously, mpox-related ophthalmic disease is predom-
phadenopathy, myalgias, fatigue, headache, and rash.8,9 inantly a disease of the ocular surface and anterior
Characteristic disseminated skin lesions classically begin segment, although ocular presentations may be wide-
on the face and spread centrifugally in a typical mono- ranging (Tables 1 and 2). A case series published recently
morphic progression (vesicles to pustules to umbilicated by Finamor et al40 described the initial development of
lesions to crusted scabs) over 2 to 4 weeks. However, in the ophthalmic manifestations varying between 7 days and
context of the global clade IIb MPXV epidemic, atypical 47 days after the onset of skin lesions. These findings can
disease was frequently reported; over half of patients de- be categorized into external and ocular manifestations.
veloped a rash before or at the same time as other The external manifestations involve periorbital cutaneous
symptoms and signs.8 In addition, initial skin or muco- lesions that closely resemble those found elsewhere on the
cutaneous lesions were commonly noted at likely sites of body.41 The ocular manifestations include conjunctivitis,
oral or anogenital initial exposure.8 keratitis, and uveitis.41
Common complications of mpox include bacterial Conjunctivitis is most commonly described, having
superinfections (skin and soft tissue infections, pneumo- been reported in ∼20% of cases in endemic areas during
nia, and sepsis), oral and conjunctival mucocutaneous le- previous outbreaks, with the majority of cases affecting
sions (leading to dysphagia/odynophagia and eye pain), children.42 Both membranous43 and pseudomembranous44
severe lymphadenopathy (causing pain and oropharyngeal conjunctivitis have been reported, often requiring repeated
or respiratory compromise), and nausea/vomiting and membrane removal. Historically, the presence of con-
abdominal pain. Compromised oral intake related to the junctivitis has been associated with a more severe disease
above, in the setting of high insensible losses (fever, high course.33 However, limited case series and reports during
burden of skin lesions), leads to volume depletion and/or the 2022 to 2024 clade IIb epidemic have yet to identify a
severe dehydration. Although conjunctival involvement is similar association.45–47
common, severe ocular complications are infrequent. Mpox-related corneal disease can present with a
Particularly during the clade IIb global epidemic, ano- variety of different clinical features. Geographic
genital complications (urethritis and proctitis associated corneal ulcers,16,19,25,26,28,29,32,43 limbitis,16,23,28,30,31 ser-
with severe pain) have been described. Encephalitis and piginous epithelial keratitis,22–27,48 peripheral ulcerative
myocarditis are rarely described.8 Mpox caused by clade I keratitis,18,20,21,26,29,38 stromal edema,19,26,31,38 keratic
MPXV infection is associated with higher case fatality precipitates,16,17,22,24,25 and corneal perforation14–16 have

16 | www.internat-ophthalmology.com Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
 Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.

Int Ophthalmol Clin

TABLE 1. Notable Cases of Ocular Mpox


Volume 64, Number 4, Fall 2024
Study Location Year Clade Notable clinical features Treatment Outcome
Carrubba et al14 New York, USA 2023 II Corneal perforation Oral and IV tecovirimat, Vaccinia Bilateral globe rupture, death
IVIG
Bacorn et al15 Maryland, USA 2022 II Corneal perforation Oral and IV tecovirimat, Vaccinia No light perception death
IVIG, trifluridine
Nguyen et al16 California, USA 2023 II Corneal perforation, limbitis, geographic Oral and IV tecovirimat, IV Opacified and vascularized cornea
corneal ulcer, keratic precipitates cidofovir, trifluridine
Croasdale et al17 Wisconsin, USA 2003 II Geographic corneal ulcer, limbitis, stromal Trifluridine Secondary bacterial infection requiring
edema corneal transplant
Cash-Goldwasser unspecified 2022 II Peripheral ulcerative keratitis Oral and IV tecovirimat, trifluridine “Profound visual impairment”
et al18
Vasquez-Peres et al19 London, United 2023 II Geographic corneal ulcer, stromal edema Oral tecovirimat, trifluridine “Count fingers”, severe corneal scarring
Kingdom
Bhamray-Sanchez New Jersey, USA 2023 II Peripheral ulcerative keratitis, stromal edema Oral tecovirimat and trifluridine “Hand motion” visual acuity
et al20
Flores et al21 Spain 2023 II Peripheral ulcerative keratitis Oral tecovirimat 20/200 vision, corneal leukoma,
symblepharon
Finamor et al22 São Paulo, Brazil 2023 II Serpiginous epithelial keratitis, diffuse anterior Oral tecovirimat, topical Partial resolution with residual corneal
scleritis fluorometholone opacities
Doan et al23 Paris, France 2023 II Serpiginous epithelial keratitis, limbitis Oral tecovirimat, trifluridine, IV 20/30 visual acuity, corneal
cidofovir neovascularization, corneal scar
Alsarhani et al24 Toronto, Canada 2023 II Serpiginous epithelial keratitis, disciform Oral tecovirimat Resolution with mild residual scar
keratitis, stromal edema, keratic precipitates,
iritis
Androudi et al25 Larissa, Greece 2023 II Serpiginous epithelial keratitis, geographic Oral valacyclovir, oral tecovirimat 20/200 visual acuity, corneal haze
epithelial ulcer, anterior chamber cell
Pazos et al26 Barcelona, Spain 2023 II Serpiginous epithelial keratitis, geographic Oral tecovirimat Resolution
epithelial ulcer
Arteaga-Rivera Mexico City, Mexico 2023 II Serpiginous epithelial keratitis Interferon alfa-2b Resolution
www.internat-ophthalmology.com

et al27
Lamas-Francis et al28 Santiago, Spain 2022 II Geographic epithelial ulcer, limbitis, anterior Oral tecovirimat Resolution with faint residual haze
chamber cell
Malciolu-Nica et al29 Bucharest, Romania 2023 II Peripheral ulcerative keratitis IV tecovirimat 20/25 visual acuity, residual corneal scar

Ocular Complications of Mpox

Ditta et al30 Tennessee, USA 2022 II Limbitis, stromal infiltrate Trifluridine, oral teocvirimat Partial resolution with residual infiltrates
Avila et al31 Bogota, Colombia 2023 II Limbitis, anterior chamber cell, stromal edema IV acyclovir, IV ceftriaxone, 20/50 visual acuity, partial resolution
prednisolone
Raccagni et al32 Milan, Italy 2023 II Geographic epithelial ulcer Oral tecovirimat Resolution with residual corneal opacity
IG indicates immune globulin; IV, intravenous.
| 17
Begley et al Int Ophthalmol Clin  Volume 64, Number 4, Fall 2024

all been reported during the 2022 to 2024 outbreak.

Conjunctivitis, periorbital lesions, episcleritis, keratitis

Conjunctivitis, periocular lesions, corneal ulcerations,
Corneal involvement can also lead to bacterial super-

Periorbital lesions, conjunctivitis, or keratitis

infection, further increasing the risk for visual morbidity

corneal stromal edema, anterior uveitis

including corneal scarring, vision impairment, need
for corneal transplant, and phthisis bulbi.17,49 Mpox-
related uveitis can occur in the form of anterior

Conjunctivitis (15%)
Periorbital lesions
Ocular findings

uveitis,14,17,22,24–28 disciform keratitis with endothelial

Eyelid lesion (9%)

Keratitis (6%)
Conjunctivitis

Unspecified

plaques,16,24 and scleritis.16,22,41

Keratitis

Keratitis Nguyen et al16 reported a case of isolated ocular

mpox in 2023, illustrating that skin lesions and systemic
prodromal symptoms are not a prerequisite for the de-
velopment of ocular disease. In their report, MPXV ge-
nomic material was isolated from the anterior chamber
and detected through RNA-deep sequencing as part of an
extensive workup for undifferentiated necrotizing anterior
scleritis and keratitis. The patient was started on oral te-
covirimat, topical trifluridine, and weekly ophthalmic be-
tadine washes before being transitioned to intravenous
(IV) tecovirimat and cidofovir 4 months later due to a
Percentage of ocular

worsening in vision-to-light perception only. Three weeks

involvement (%)

after the initiation of IV therapy, the ocular disease

showed no improvement, and the eye remained reverse-
23.1

4.1

1.0
1.1
2.6

0.3

15
11

transcriptase polymerase chain reaction (PCR) positive for

1

MPXV with an opacified and vascularized cornea.

While the corneal manifestations of mpox can all
lead to significant scarring and visual morbidity, the
overall incidence rate of corneal involvement appears to
be lower with clade II MPXV infections. Recent studies
from France,23,37 Spain,26 and Mexico38 reported rates of
Total
cases
294

282

197
185
264
880

588

160
100

keratitis of 0.34% to 1.0%, much lower than the 4% in-

cidence of keratitis reported in 1987 during an MPXV
clade I outbreak.34 However, a study from Nigeria pub-
lished in 2023, which likely included primarily MPXV
Cases with ocular

clade II cases, found a 6% incidence of keratitis.39,50

involvement

Ocular involvement appears to be less prevalent

during the ongoing 2022 to 2024 clade IIb mpox
68

11

24
2
2
7
9

2
11

outbreak.35,47 According to data from the WHO, as of

June 30, 2024, conjunctivitis has only been reported in
0.6% of cases.5 Recent studies from Europe found rates of
ocular involvement to be similarly low, at 1.0%,35 1.1%,36
Clade involved

and 0.8%.37 These cases were predominantly caused by

unspecified

clade II MPXV, suggesting a decreased rate of ocular in-

II
II
II
II

II
II

volvement as compared with that caused by clade I

I

MPXV infection, in which involvement at least of the

TABLE 2. Incidence of Ocular Involvement

DRC indicates Democratic Republic of the Congo.

conjunctiva was reported in ∼20% of cases from 2010 to

2014.33 The frequency of ocular involvement in mpox
2010-

1980-
Year

2014

1985
2022
2022
2022
2023

2023

2023
2023

caused by newly identified MPXV clade Ib strains in the

DRC is unknown and will require ongoing disease sur-
veillance.
Location

England

Nigeria
Mexico
France

France
Spain

Spain
DRC

DRC

DIAGNOSTIC CRITERIA
The diagnosis of mpox involves a combination of
Rodríguez-Badillo

clinical characteristics, epidemiologic criteria, and labo-

ratory testing. The U.S. Centers for Disease Control and
al33

Ogoina et al39
Mailhe et al37
Catala et al36

Pazos et al26

Doan et al23
Jezek et al34

Patel et al35

Prevention (CDC) has established case definitions to help

Hughes et

categorize possible mpox infections.51 Epidemiologic cri-

et al38
Study

teria include any of the following within 21 days of illness

onset: (1) having contact with a person with a similar

18 | www.internat-ophthalmology.com Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
Int Ophthalmol Clin  Volume 64, Number 4, Fall 2024 Ocular Complications of Mpox

appearing rash or who received a confirmed or probable and is approved by the European Medicines Agency and
diagnosis of mpox, (2) having intimate in-person contact the U.S. Food and Drug Administration (FDA) for the
with a social network experiencing mpox activity, (3) treatment of mpox, though only under an expanded access
traveling outside the United States to a country with indication.55 The safety and efficacy of tecovirimat for
confirmed cases of mpox or where MPXV is endemic, or mpox, however, is unknown, and clinical trials are ongoing.
(4) having contact with an animal or product derived from Tecovirimat is commonly administered orally in 600 mg
an animal species from areas of African endemicity. doses twice per day for 2 weeks, although shorter courses of
A “Suspect Case” is any patient with a new rash 5 to 7 days have proven to be effective in animal models.56
characteristic of mpox or someone who meets one of the While efficacy data supporting tecovirimat for the treat-
epidemiologic criteria.51 A “Probable Case” is a patient ment of mpox is pending, it should also be acknowledged
with no suspicion of other recent Orthopoxvirus exposure that ophthalmic bioavailability has not been well-charac-
(eg Vaccinia virus in ACAM2000 vaccinations) and terized.49
demonstration of orthopoxvirus DNA by PCR, immuno- Cidofovir, a viral DNA polymerase inhibitor most
histochemistry, electron microscopy or is positive for anti- commonly used in the treatment of cytomegalovirus reti-
Orthopoxvirus IgM within 4 to 56 days from rash onset.51 nitis, has been shown to have activity against MPXV in
A “Confirmed Case” is a patient with demonstrated pres- animal models.57 Of note, prolonged exposure to cidofovir
ence of MPXV DNA by PCR, next-generation sequencing, during the treatment of mpox (or for any indication) can
or culture from a clinical specimen.51 lead to drug-induced uveitis.41 Brincidofovir, a viral pro-
drug of cidofovir, is FDA-approved for the treatment of
MONKEYPOX VIRUS DETECTION FROM smallpox in adults and children and has also proven to be
OCULAR TISSUES effective against orthopoxviruses in vitro and in animal
studies.57 Brincidofovir can be used in combination with
MPXV infection can be detected by direct molecular
tecovirimat but should be avoided in patients taking ci-
testing such as electron microscopy, sequencing, and PCR,
dofovir.
as well as through indirect serologic antibody testing such as
IV vaccinia immune globulin (VIGIV), an FDA-
enzyme-linked immunosorbent assay, immunofluorescence
approved treatment for complications of smallpox vacci-
assay, and immunohistochemistry.52 Reverse-transcriptase
nation, may be considered in severe cases of mpox where
PCR is the current gold standard for laboratory diagnosis
the development of robust immune response is impaired.
of mpox due to its high sensitivity and specificity.52,53 The
However, according to the CDC, VIGIV has no proven
utility of serologic testing for the diagnosis of mpox is
benefit in mpox infection, and it is unknown whether a
limited due to cross-reactivity between orthopoxviruses.52
person infected with MPXV would benefit from treatment.
This permits factors such as recent vaccination or infection
In addition, concerns exist regarding a possible association
with other orthopoxviruses to interfere with accurate testing
between VIGIV and increased corneal scarring,58 al-
for MPXV.52
though this has not been demonstrated in subsequent
PCR testing of conjunctival and corneal specimens
studies.49,59
can confirm the presence of MPXV. Finamor and col-
Topical therapies have also been explored for ocular
leagues reported a duration of ocular MPXV PCR pos-
mpox treatment. Trifluridine, an inhibitor of thymidine
itivity ranging from 19 to 145 days, and Raccagni et al32
phosphorylase most commonly used to treat herpes sim-
isolated MPXV from a conjunctival sample 8 months after
plex virus keratitis, can be considered for use in cases of
the onset of cutaneous lesions. These findings illustrate
mpox-associated conjunctivitis and is recommended by
that MPXV can persist in ocular tissues long after the
the CDC for the treatment of mpox-associated keratitis.54
resolution of cutaneous manifestations.40 Among the 5
However, several adverse ocular effects of trifluridine itself
cases reported by Finamor et al,40 a cycle threshold cutoff
have been described, including photophobia, corneal
value of 33.2 was identified for viral isolation. Positive
edema, punctate keratopathy, and keratitis sicca.60 In
PCR testing for MPXV occurred as early as 4 days after
addition, prior evidence from ocular cowpox infections
the onset of ocular symptoms.40 In addition to the con-
suggests that the coincident use of trifluridine and topical
junctiva and corneal surface, MPXV was detected in the
corticosteroids should be avoided.54 Topical antibiotics
aqueous humor in 1 of the 2 patients that were sampled
and lubricants are also recommended by the CDC in pa-
44 days after initial onset of disease.40 Routine ocular
tients with mpox-associated keratitis to prevent bacterial
sampling for MPXV in African settings has so far not been
superinfection.54 Topical interferon alfa-2b could also be
reported.
considered as an alternative treatment option in resource-
limited settings, but further investigation is needed.27
CURRENT AND EMERGING TREATMENT
OPTIONS
Treatment for the ocular manifestations of mpox in- THE ROLE OF VACCINATION IN THE
cludes both systemic and topical therapies. According to the PREVENTION OF OCULAR COMPLICATIONS
CDC, systemic therapy should be considered for all mpox While safety and efficacy data for any MPXV-spe-
patients with ocular involvement.54 Oral tecovirimat cific vaccine is lacking, 2 vaccines originally developed to
(TPOXX) is an inhibitor of the orthopoxvirus F13L gene prevent smallpox infection have been recommended for

Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. www.internat-ophthalmology.com | 19
Begley et al Int Ophthalmol Clin  Volume 64, Number 4, Fall 2024

prevention, JYNNEOS (Bavarian Nordic) and ACAM2000 positive for orthopoxvirus infection in the absence of other
(Emergent Product Development Gaithersburg Inc.)61 known etiology or tested positive for mpox.66
JYNNEOS, an attenuated, nonreplicating, live virus vaccine
administered subcutaneously in 2 doses, has been preferen- CONCLUSION AND FUTURE DIRECTIONS
tially recommended for the current mpox outbreak, in part Mpox-related ocular disease, including con-
due to its less severe side effect profile.62 Historical data, junctivitis, keratitis, and vision loss, has been long de-
while limited, suggests that vaccination may reduce the scribed but not well-characterized in the setting of endemic
burden of ocular disease. For example, the rate of mpox- mpox in Africa. Emerging and more highly resolved
associated conjunctivitis in the Congo Basin from 1981 to clinical characterization in case reports/series from the
1986 was 30% in unvaccinated persons versus 7% in vacci- ongoing clade IIb mpox global epidemic describe pre-
nated persons.49,63 However, other studies found no sig- dominantly ocular surface and anterior segment disease,
nificant difference in the rates of mpox-associated keratitis though at lower prevalence than that described historically
between the two groups.34 Further investigation is warranted in endemic mpox. Nonetheless, vision-threatening com-
to determine the relationship between vaccination status and plications have been similarly described. Moreover, the
a potential reduction in the incidence of the ocular mani- overall increasing burden and the recent surge in clade I
festations of mpox. mpox cases in DRC, including the new clade Ib strain
associated with sustained H2H transmission, has
prompted a new declaration of a PHEIC and coincident
INFECTION PREVENTION AND CONTROL concern for vision-threatening complications. Current
PRECAUTIONS management of mpox-related ocular disease often involves
Transmission of mpox can occur through contact a combination of systemic and topical therapies, but fur-
with infected wild animals, humans, or other con- ther investigation of these therapies is warranted. Infection
taminated materials. Both MPXV clade I and clade II can prevention and control measures remain critical in limiting
spread through direct H2H contact, but clade I MPXV the spread of the disease in health care settings. Continued
has not been associated with sexual transmission until surveillance and research are essential for monitoring the
recently in the DRC in 2023.3 Conjunctival viral shedding evolving epidemiology of mpox, characterizing oph-
has been reported in patients with mpox-associated con- thalmic disease and its complications, and optimizing the
junctivitis, but it is unclear whether conjunctival viral prevention and treatment of both systemic and ophthalmic
shedding occurs in patients without conjunctivitis.49,64 manifestations.
For patients with mpox, the CDC recommends fre-
quent handwashing and avoidance of eye rubbing to avoid
autoinoculation of the eye. Prophylactic treatment with REFERENCES
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