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Monkeypox Virus and Ophthalmology—A Primer on the 2022 Monkeypox Outbreak and Monkeypox-Related Ophthalmic Disease

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Importance  An ongoing global monkeypox virus outbreak in 2022 includes the US and other nonendemic countries. Monkeypox ophthalmic manifestations may present to the ophthalmologist, or the ophthalmologist may be involved in comanagement. This narrative review creates a primer for the ophthalmologist of clinically relevant information regarding monkeypox, its ophthalmic manifestations, and the 2022 outbreak.

Observations  Monkeypox virus is an Orthopoxvirus (genus includes variola [smallpox] and vaccinia [smallpox vaccine]). The 2022 outbreak is of clade II (historically named West African clade), specifically subclade IIb. In addition to historic transmission patterns (skin lesions, bodily fluids, respiratory droplets), sexual transmission has also been theorized in the current outbreak due to disproportionate occurrence in men who have sex with men. Monkeypox causes a characteristic skin eruption and mucosal lesions and may cause ophthalmic disease. Monkeypox-related ophthalmic disease (MPXROD) includes a spectrum of ocular pathologies including eyelid/periorbital skin lesions, blepharoconjunctivitis, and keratitis). Smallpox vaccination may reduce MPXROD occurrence. MPXROD seems to be rarer in the 2022 outbreaks than in historical outbreaks. MPXROD may result in corneal scarring and blindness. Historical management strategies for MPXROD include lubrication and prevention/management of bacterial superinfection in monkeypox keratitis. Case reports and in vitro data for trifluridine suggest a possible role in MPXROD. Tecovirimat, cidofovoir, brincidofovir and vaccinia immune globulin intravenous may be used for systemic infection. There is a theoretical risk for monkeypox transmission by corneal transplantation, and the Eye Bank Association of America has provided guidance. Smallpox vaccines (JYNNEOS [Bavarian Nordic] and ACAM2000 [Emergent Product Development Gaithersburg Inc]) provide immunity against monkeypox.

Conclusions and Relevance  The ophthalmologist may play an important role in the diagnosis and management of monkeypox. MPXROD may be associated with severe ocular and visual morbidity. As the current outbreak evolves, up-to-date guidance from public health organizations and professional societies are critical.

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Article Information

Accepted for Publication: September 15, 2022.

Published Online: November 3, 2022. doi:10.1001/jamaophthalmol.2022.4567

Correction: This article was corrected on January 19, 2023, to add information about previously reported patients with monkeypox virus ophthalmic disease and update information based on public health reports.

Corresponding Author: Roberto Pineda II, MD, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (roberto_pineda@meeei.harvard.edu).

Author Contributions: Dr Pineda had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Kaufman.

Drafting of the manuscript: Kaufman.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Kaufman.

Supervision: Chodosh, Pineda.

Conflict of Interest Disclosures: Dr Chodosh reported being a consultant to the US Food and Drug Administration, where he chairs an advisory committee for new ophthalmic medications; receiving grant support from the National Institutes of Health to study adenovirus keratitis; and receiving consultant fees from the US Food and Drug Administration outside the submitted work. Dr Pineda reported receiving royalties from Elsevier, personal fees from the data monitoring committees of Sanofi-Genzyme and Amgen, and consultant fees from Alcon outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by a Heed Fellowship awarded by the Heed Ophthalmic Foundation (Dr Kaufman).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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