Mpox and the Eye: What Clinicians Need to Know

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On April 22, 2025, NETEC hosted a webinar titled “Ophthalmic Manifestations of Mpox: What Clinicians Need to Know.” This timely session focused on the range of mpox-related eye complications and the importance of early recognition and intervention to prevent long-term damage, including vision loss. Watch the webinar recording.

Ocular Complications: An Expanding Understanding

While mpox is more commonly associated with systemic symptoms and skin lesions, new research highlights the virus’s ability to affect the eyes. The webinar reviewed the spectrum of ocular manifestations:

• Conjunctivitis: The most frequently reported eye-related symptom, affecting nearly 9% of patients in some studies. Prevalence varies by outbreak and reporting strategy. It may present early and be mistaken for other common infections.
• Periocular Lesions: Characterized by umbilicated pustules around the eyes, sometimes misidentified as styes or other dermatologic conditions.
• Keratitis and Corneal Ulcers: Though less common, these severe complications can result in corneal scarring or permanent vision impairment. In one analysis, keratitis was observed in about 3.4% of mpox cases.
• Vision Loss: In rare cases, mpox has led to long-term or irreversible damage to visual acuity, especially when diagnosis is delayed.

Notably, some patients may present with isolated ocular symptoms without any visible skin involvement, posing a diagnostic challenge.

Mpox DNA in the Tear Film

A key finding shared during the webinar was the detection of mpox DNA in tear film. Viral DNA has also been confirmed in the conjunctiva, aqueous humor, and cornea—sometimes more than 100 days after initial infection. This underscores the potential for viral transmission and the need for heightened precautions when examining mpox patients.

Early Detection and Clinical Management

Timely diagnosis and treatment of ocular mpox can significantly improve outcomes. Clinicians are advised to maintain a high index of suspicion, especially during outbreaks or when working with immunocompromised patients. Key takeaways included:

• Conduct thorough eye examinations in suspected or confirmed mpox cases.
• Refer promptly to ophthalmology when signs of keratitis, ulceration, or vision changes are present.
• Use real-time PCR as the gold standard for diagnosing ocular mpox. Other methods like serology, LAMP, CRISPR-based tests, and viral culture were also reviewed during the webinar.
• Consider antiviral treatments. While no standard regimen exists, options include:
  • Systemic: Tecovirimat, Cidofovir, or Brincidofovir
  • Topical: Trifluridine (for ocular vaccinia), Ganciclovir gel, or Betadine

Infection Prevention and Control (IPC)

Environmental sampling has found that mpox virus can remain viable on surfaces for up to 15 days. Given this finding and the potential for viral shedding in tears, strict infection prevention measures are essential:

• Use appropriate personal protective equipment (PPE) during eye examinations.
• Reinforce hand hygiene protocols for both healthcare providers and patients.
• Follow clinical best practices during ocular exams to avoid cross-contamination: 
  • Work from the clean eye to the affected eye.
  • Avoid multi-use eye drop bottles when possible.
  • Use barriers (e.g., gauze) when touching periocular areas with active lesions.
• Educate patients to avoid touching or rubbing their eyes and maintain hand hygiene.

Mpox in the Field: Democratic Republic of the Congo (DRC) Case Study

The Democratic Republic of the Congo (DRC) has reported the highest number of mpox cases globally in recent years. The webinar highlighted key challenges and responses:

• High prevalence: Over 20% of Clade I cases from the DRC were reported to have ocular involvement in a prior report—this prevalence has exceeded more recent reports from other countries, particularly in association with cases of clade II mpox.
• Field challenges:
  • Scarce access to ophthalmic care in rural areas
  • Limited diagnostic tools and equipment
  • Operational delays due to conflict and power shortages

In response, local and global teams have launched training for Congolese ophthalmologists in preparation for clinics where mpox may be seen and for future mpox ophthalmic disease surveillance.

Lessons from Other Emerging Infectious Diseases

The webinar also compared mpox with other emerging and resurging pathogens known to cause eye disease, such as Ebola virus, Rift Valley Fever, and syphilis. Many of these pathogens, like mpox, are now recognized for their potential to persist in ocular tissue, with the potential for delayed complications that may affect vision.

Looking Ahead

Mpox’s ocular effects are an emerging area of clinical concern, and ongoing data collection and research will continue to inform best practices. Raising awareness among healthcare providers is essential to reducing complications, protecting vision, and limiting transmission.

For those who missed the live session, the full webinar recording is available on NETEC’s YouTube channel.