Ocular Lesions in Man With Monkeypox and COVID-19

What's the best way to manage ocular manifestations of monkeypox infection? That's the question that faced Ravneet S. Rai, MD, of the Zucker School of Medicine at Hofstra/Northwell in Manhasset, New York, and colleagues, as detailed in a JAMA Ophthalmology case report.

A 30-year-old man with mild congestion and cough and no significant medical history suddenly developed raised lesions on his penis. He reported having sex with men. He had been taking emtricitabine/tenofovir (Truvada) to reduce his risk of HIV, and had not been vaccinated for monkeypox.

On physical examination, lesions on the patient's hands, shoulders, and back were noted. The patient tested positive for SARS-CoV-2, and results of PCR testing from a genital swab were positive for monkeypox.

Due to a progressive increase in the patient's pain, he was admitted to the hospital. While his congestion and cough cleared, he developed lesions on the eyelid and conjunctiva of his right eye that resembled those on his penis, and an ophthalmologic consultation was requested.

The ophthalmologic consultation showed that the patient's visual acuity was 20/20 in both eyes, and his pupils were round and light-reactive with no afferent pupillary defect. Intraocular pressure was 12 mm Hg in the right eye and 14 mm Hg in the left eye. Both eyes demonstrated full extraocular movement, confrontational visual fields, and color plates. No evidence of preauricular lymphadenopathy was noted.

"Examination of the anterior chamber revealed trace injection with a 3×2-mm ulcer on the right lower palpebral conjunctiva, a 2×2-mm ulcer on the right caruncle, and a 3×3-mm papule on the right upper eyelid," Rai and team wrote.

The corneas of both eyes were clear. The anterior chamber was not examined for inflammation. Findings of the dilated fundus examination were not notable.

The team explained that they did not swab the ocular lesions, given their notable resemblance to the patient's genital papules, as well as those described in the literature. Tests for HIV proved to be negative.

Upon the patient's admission to hospital, he received tecovirimat (Tpoxx) 600 mg twice daily, which was continued for 14 days. His right eye was also treated with artificial tears every 4 hours, and erythromycin ointment 4 times daily. After 4 days, the lesions on the conjunctiva and caruncle had cleared, and the lesions on the margin of his upper eyelid flattened and became red. The patient's eye irritation resolved.

Genital lesions gradually scabbed over, with superficial bloody erosions, and their redness decreased. The patient did not develop any new lesions, and he was discharged on day 6 of treatment with no adverse effects.

Discussion

Rai and colleagues noted that this patient was "successfully treated with tecovirimat, an expanded-access investigational therapy, and conservative ocular management."

Infection with monkeypox, a double-stranded DNA virus within the Orthopoxvirus genus, generally lasts 2 to 4 weeks, and is typically self-limited. In addition to skin and systemic symptoms, "ocular manifestations include conjunctivitis, eyelid edema, keratitis, corneal scarring, and conjunctival lesions," the authors wrote.

According to a review of clinical features of monkeypox in 282 patients, "development of lymphadenopathy in the early stage of the illness is a distinctive hallmark that differentiates human monkeypox from smallpox and chickenpox."

Another review of ocular complications from acute monkeypox infection in mostly younger patients reported that those who had conjunctivitis also had a higher frequency of other symptoms, such as nausea, chills/sweating, oral ulcers, sore throat, general malaise, lymphadenopathy, and photophobia compared with those with no reported conjunctivitis. This review concluded that "conjunctivitis is likely predictive of the illness course," given that 47% of patients with that symptom reported being bedridden compared with 16% of patients for whom conjunctivitis was not reported.

In the absence of guidance on treating ocular manifestations of monkeypox, Rai and team noted that U.S. patients with orthopox viruses have received topical trifluridine, adding that its efficacy in monkeypox is not established.

They also described a patient from the U.K. who "presented with anal and skin vesicles, proctitis, and conjunctivitis with a vesicle on the lower eyelid and an ulcer on the medial bulbar conjunctiva of the left eye [who] was treated with topical neomycin, polymyxin B, and dexamethasone," noting that while the lesions on that patient's eyes and skin resolved after 3 weeks, the conjunctivitis persisted. It is unknown whether the treatment had a role in resolving this man's lesions, they added.

They suggested that "tecovirimat can be considered in patients with severe monkeypox disease," adding that its early use in animal studies has been associated with reduced mortality. They also pointed to a case series in humans that suggested that treatment with this drug may shorten the duration of illness.

"The current case demonstrates improvement of ocular pox lesions shortly after initiating tecovirimat and conservative ocular therapy," Rai and team concluded. "However, this single observation cannot determine with any reasonable degree of certainty whether similar improvement would have been seen in the absence of this treatment. As experience with ocular involvement increases, definitive therapies may be established."

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