https://orcid.org/0000-0003-3206-8184
Monkeypox virus (MPXV) is a double-stranded DNA virus classified as an orthopoxvirus and causes Monkeypox (MPox). This means that it belongs to the same genus as variola, which causes smallpox, and vaccinia which is used in smallpox vaccines.Citation1 The first case was detected in humans in 1970 in the Democratic Republic of the Congo (DRC) in a 9-month-old boy who was not vaccinated against smallpox. From 1970 to 2003, all human cases only occurred in Western and Central Africa but most notably in the DRC.Citation2 These cases mainly occurred among children living in rural rainforests.Citation1 Based on clinical presentation and genomic sequencing, MPXV was classified into 2 clades. From 1981 to 2017, MPXV 1 caused 1–12% fatality rates during several outbreaks in the DRC. In 2017, 122 PCR-confirmed cases of MPXV 2 occurred in Nigeria.Citation1,Citation2 Smallpox vaccination was discontinued in 1980 and the rise of cases in the DRC as well as the outbreak in Nigeria were attributed to this discontinuation as well as the frequent butchering of bushmeat in these areas. The long-term efficacy of smallpox vaccination is unknown but it is estimated to be 85% effective in preventing MPox.Citation1 Both animal-to-human and human-to-human transmission are possible. Human-to-human transmission may be vertical or horizontal via direct contact, respiratory secretions or via fomites.Citation1
In July 2022, on account of the global spread of the disease, the World Health Organization (WHO) declared MPox a Public Health Emergency of International Concern.Citation3 Most cases were diagnosed in men who have sex with men (MSM) and present with a febrile illness with myalgia and a typical rash.Citation1 The differences and similarities between the 2022 outbreak and previous outbreaks have been well documented by Mitjà and colleagues but fall beyond the scope of this editorial.Citation1
Ocular manifestations of MPox have been referred to as Monkeypox-related ophthalmic disease (MPXROD).Citation4 To date, MPXROD has been uncommon and was calculated to be 6.2% by the CDC during the initial outbreak in New York City.Citation5 MPXROD includes eyelid lesions, conjunctivitis, keratitis and uveitis. In this issue of OII, we highlight a few cases and case series of MPXROD that have been accepted for publication.
Carvalho and colleagues from Brazil reported a 28-year-old MSM male with multiple umbilicated pustules, inguinal lymphadenopathy and an injected right eye.Citation6 Initial eye examination revealed vesicles on the bulbar conjunctiva but he later developed small keratic precipitates and 1+ cells in the anterior chamber which responded well to topical corticosteroid drops. After the eye problem had resolved, the patient tested negative again for HIV infection but positive for syphilis and was treated with intramuscular benzatine penicillin. Kleebayoon and Wiwanikit commented that MPox and Varicella-Zoster virus infections may co-exist and reminded readers that other potential causes of a similar presentation need to be excluded before ascribing it to MPXV.Citation7 Androudi and colleagues reported two cases, one from Greece and the other Switzerland, previously hospitalized for systemic MPox infection who presented with non-healing corneal ulcers and severely elevated intraocular pressure. Both cases deteriorated despite conservative management and only improved, and eventually resolved, once oral tecovirimat was added.Citation5 Lamas-Francis and colleagues from Spain reported a similar case of PCR-confirmed MPox corneal ulcer which also resolved after treatment with oral tecovirimat.Citation8 Lastly, Curi and colleagues from Brazil and Colombia reported a case series of seven patients with MPXROD.Citation3 Two had eyelid lesions while five had conjunctivitis with no intraocular involvement. All cases resolved without any sequelae and antiviral treatment was only required in two patients.
At present it seems reasonable to report that the ocular side-effects of MPXV infections are quite rare. Most cases in the literature either resolved spontaneously or with reasonably conservative medical management and visual outcomes were mostly good. We do not know what the future holds, but we can face the next challenge armed with the knowledge that not all new outbreaks necessarily lead to severe ocular morbidity or even mortality.
References
- Mitjà O, Ogoina D, Titanji BK, et al. Monkeypox. Lancet. 2023;401(10370):60–74. doi:10.1016/S0140-6736(22)02075-X.
- Mandja BAM, Brembilla A, Handschumacher P, et al. Temporal and spatial dynamics of monkeypox in democratic Republic of Congo, 2000–2015. Ecohealth. 2019;16(3):476–487. doi:10.1007/s10393-019-01435-1.
- Curi ALL, Rojas-Carabali W, Talero-Gutiérrez C, et al. Ophthalmic manifestations of monkeypox virus infection: a cases series. Ocul Immunol Inflamm. 2023;32(3):262–265. doi:10.1080/09273948.2023.2181823.
- Kaufman AR, Chodosh J, Pineda R. Monkeypox virus and ophthalmology—a primer on the 2022 monkeypox outbreak and monkeypox-related ophthalmic disease. JAMA Ophthalmol. 2023;141(1):78–83. doi:10.1001/JAMAOPHTHALMOL.2022.4567.
- Androudi S, Kaufman AR, Kouvalakis A, et al. Non-healing corneal ulcer and uveitis following monkeypox disease: diagnostic and therapeutic challenges. Ocul Immunol Inflamm. 2023;32(3):253–258. doi:10.1080/09273948.2023.2202746.
- Carvalho EM, Medeiros M, Veloso VG, Biancardi AL, Curi ALL. Monkeypox infection causing conjunctival vesicles and anterior uveitis. Ocul Immunol Inflamm. 2023;32(3):266–267. doi:10.1080/09273948.2023.2174884.
- Kleebayoon A, Wiwanitkit V. Comment on “Monkeypox infection causing conjunctival vesicles and anterior uveitis” – a concern on possible co-infection. Ocul Immunol Inflamm. 2023;32(3):268. doi:10.1080/09273948.2023.2193261.
- Lamas-Francis D, Treviño M, Pérez-Freixo H, Martínez-Perez L, Touriño R, Rodríguez-Ares T. Corneal ulcer due to monkeypox infection. Ocul Immunol Inflamm. 2022;32(3):259–261. doi:10.1080/09273948.2022.2153343.