Mpox Represents a Serious Threat to Sight

When a patient presented to Rubén Delgado Weingartshofer MD complaining of red eye, pain, and photophobia in the right eye, he knew something was off.

“He told me that one month before the red eye, he and his son had started suffering from fever and skin lesions that a paediatrician told them might be [similar to] hand, foot, and mouth disease. I asked him for a photo of those lesions; they were complicated pustules, they didn’t look like hand, foot, and mouth,” Dr Delgado Weingartshofer said.

A diagnosis of unspecific keratoconjunctivitis was made, but the prescribed ganciclovir gel five times per day ended up worsening the patient’s condition. Broad-spectrum topical and oral antibiotics had no effect either, though prednisolone drops (q12h) did achieve partial improvement.

Unsatisfied with these treatment results, Dr Delgado Weingartshofer ordered corneal swabs and scraping as part of a polymerase chain reaction test for herpes simplex virus and varicella-zoster virus. The results came back negative.

Finally, he performed two more tests: antibody serology for Coxsackie B virus and corneal and conjunctival swabs/posterior capsule rupture (PCR) for the monkeypox (Mpox) virus. The latter came back positive, leading to a final diagnosis of late-onset necrotising stromal keratitis due to Mpox.

“The patient was referred to hospital and placed under isolation to receive the proper treatment, which was tecovirimat (600 mg every 12 hours for 14 days) and trifluridine 1% eye drops. A supportive treatment with prophylactic topical antibiotics, topical steroids, and cycloplegia was also provided,” Dr Delgado Weingartshofer said.

Mpox is an infectious disease caused by a virus in the same family as smallpox, usually causing a painful or itchy rash, swollen lymph nodes, and flu-like symptoms. Most patients recover from the condition, but severe cases can result in pneumonia and corneal infections resulting in vision loss.

“One month after treatment, the patient’s ulcer was cured, though leucoma was present in the middle of the cornea,” Dr Delgado Weingartshofer said. “The patient’s pain was gone. However, his vision did not recover.”

Based on his experience, Dr Delgado Weingartshofer emphasised that Mpox ocular disease is uncommon but can threaten sight. Most cases are self-limiting blepharoconjunctivitis, but more severe cases can involve peripheral ulcerative keratitis, immune stromal keratitis, and severe chronic progressive keratouveitis.

“Late-onset ocular disease can be possible even after apparent resolution of the systemic infection. An early PCR confirmation and proper treatment with oral tecovirimat and topical 1% trifluridine are essential to reduce the risk of corneal melting and prevent vision loss,” Dr Delgado Weingartshofer said.

“If you have a patient with peripheral ulcerative keratitis refractory to corticosteroids or HSV keratitis with poor response to standard therapy, then you should suspect Mpox ocular disease upfront. This also applies to an ulcer that fails to respond to standard therapy.”

Dr Delgado Weingartshofer presented at the EuCornea annual congress in Porto, Portugal. 

Rubén Delgado Weingartshofer MD is an ophthalmologist specialising in cornea and ocular surface at the Barraquer Ophthalmology Centre in Barcelona, Spain. atenciousuari@santpau.cat