Monkeypox Update

Early signs include conjunctivitis, blepharitis, and eyelid oedema. Cheryl Guttman Krader reports

As the number of monkeypox cases continues to rise, ophthalmologists have been advised to include this contagious infection in their differential diagnosis of patients presenting with the known ophthalmic manifestations.

The current global monkeypox outbreak began in May 2022, with multiple cases diagnosed in several non-endemic countries. As the number of cases climbed, human monkeypox was declared a global health emergency by the World Health Network on June 22, 2022. A total of 11,001 confirmed cases had been reported in 27 European Union/European Economic Area countries by the last week of July; nearly threefourths occurred in Spain, Germany, and France.

Monkeypox usually begins with lymphadenopathy and constitutional symptoms. Skin lesions generally develop after one to three days, but the rash may appear first, which for most individuals involves the face— including the periocular and ocular skin. Lymphadenopathy may affect the preauricular nodes, as occurs with conjunctivitis caused by other viral pathogens.

According to previous epidemiologic studies, more than 20% of individuals infected with monkeypox experience ophthalmic involvement such as conjunctivitis, blepharitis, and eyelid oedema as early signs. SIGNS AND SYMPTOMS The constitutional symptoms of monkeypox include fever, malaise, fatigue, headache, myalgia, and back pain. Sore throat, nasal congestion, and/or cough may be present. The characteristic skin rash appears first as macules and evolves with the formation of papules, vesicles, and then pustules that ulcerate, crust, and heal over a period of a few weeks.

Ophthalmic symptoms tend to develop later in the disease course, which experts report as predictive of a more severe case. These symptoms consist of photophobia and corneal involvement that can be severe with resultant scarring and visual loss.

Of note, previous analyses indicate ophthalmic manifestations in persons with monkeypox are more common in children and unvaccinated individuals than those who have received the smallpox vaccine. However, smallpox vaccine viral strains are also associated with ophthalmic manifestations.

Monkeypox virus Credit: WHO CARE AND PREVENTION Management for the infection is primarily symptomatic and may include ocular lubricants for the ocular manifestations. Trifluridine has been used to treat other Orthopoxvirusassociated corneal infections, but there is no published information about its use for monkeypox. Ophthalmologists should consider topical antibiotics to prevent secondary infections.

The incubation period for monkeypox ranges from 5 to 21 days (usually 6 to 13). Affected individuals are contagious from initial symptom development until the skin lesions completely heal. The disease is usually acquired through direct, intimate contact with an infected individual but can also occur via exposure to respiratory droplets or fomites contaminated with the virus.

Protection against infection includes wearing gowns, gloves, eye protection, and a fitted N95 mask. Patients known or suspected to have monkeypox should wear a mask, have their lesions covered with a gown or sheet, and isolate in a single-person room. There are no special requirements for air handling, cleaning, or disinfection, but laundry materials that have come in contact with an infected person should be handled with gloved hands.

Sources: 1. Abdelaal A, Serhan HA, Mahmoud MA, Rodriguez-Morales AJ, Sah R. “Ophthalmic manifestations of monkeypox virus”. Eye (Lond). 2022 Jul 27. Epub ahead of print. 2. https://extranet.who.int/publicemergency/