Mpox Keratitis: A Case Report and Review

Abstract

Purpose: Mpox is a rare infectious disease. Lack of knowledge among eye care professionals regarding mpox keratitis greatly reduces the likelihood of diagnosis and effective management. This report and review seek to increase the knowledge of mpox keratitis among eye care professionals.

Methods: We report a patient with mpox keratitis who underwent successful penetrating keratoplasty, with 20 years of follow-up. A systematic literature search and review of cases of mpox keratitis from 1970 to 2024 was performed.

Results: A total of 24 articles and 2 abstracts reporting 35 cases of mpox keratitis were identified. A frequency of 0.5% to 1.0% may be the lower range of mpox keratitis among symptomatic patients with a confirmed mpox diagnosis. Mpox keratitis occurred with and without systemic mpox. Initial misdiagnoses were common (40%). Polymerase chain reaction results aided clinical diagnosis. Corneal disease ranged from mild epitheliopathy to fulminant ulcerative keratitis. Outcomes ranged from 20/20 acuity to no light perception. In the absence of fulminant systemic disease, tecovirimat was associated with clinical improvement of mpox keratitis in almost all cases. Our case is the only known report of successful penetrating keratoplasty for mpox keratitis and the only case whereby monkeypox virus was cultured from the corneal surface.

Conclusions: Mpox keratitis is rare but can result in severe vision loss and blindness. Systemic tecovirimat seems to be effective in treating mpox keratitis, although the low frequency of keratitis precludes clinical trials. Topical steroids may extend virus survival in the cornea. Polymerase chain reaction may help confirm mpox corneal involvement.

FIGURE 1.

Clinical progression of case patient ocular findings. A, Day 2 after symptom onset with right eyelid swelling and left eyebrow and back mpox lesions. B, Day 27, on referral to cornea service with a new corneal epithelial defect. C, Day 41, showing an enlarged irregular epithelial defect. D, Day 48, a week after increasing prednisolone acetate; the epithelial defect was almost resolved. E, Day 52, new limbitis with an associated corneal epithelial defect. F, Day 55, enlargement of the corneal epithelial defect. G–I, Over the following 2 weeks (days 62–76) with changing geographic epithelial ulcers. J, Day 88, pan-cultures, PCR, and lateral tarsorrhaphy performed. K, Day 100, initiation of trifluridine after positive MPXV culture, increasing stromal opacification. L, Day 119, trifluridine stopped after 2 consecutive weeks of negative MPXV cultures, with the epithelial defect persistent since day 50. M, Day 132, new-onset hypopyon with stromal infiltrate grows Streptococcus pneumoniae; corneal perforation occurs despite appropriate response to antibiotics. N, 20 years later with a clear corneal graft.