ARVO LIVE: Monkeypox eye disease in the immunocompromised

Ophthalmology Times® talked with Steven Carrubba, MD, about monkeypox skin disease and eye disease in patients who were immunocompromised in New York at this year's ARVO meeting.

Video transcript

Editor’s note: Transcript lightly edited for clarity.

Steven Carrubba, MD:

Hi, I'm Steven Carrubba. I am a resident physician at NYU Langone Medical Center in New York City. Today, I'm presenting on case of monkeypox. In New York, we saw a number of cases of advanced monkeypox skin disease and eye disease in patients who were very immunocompromised, mostly with HIV and AIDS.

We noticed that there was a progressive ulcer necrotic skin phenotype that can develop in these patients, who are severely immunosuppressed when they have very low CD4 counts. We saw similar findings on the eye as well. In the cases of corneal disease, both epithelial and stromal, we noted that there was a progressive expansion of monkeypox virus from an initial inoculation site, both on the skin and in the eye.

This is very similar to past ortho-pox viral diseases, including vaccinia, including diseases such as progressive vaccinia and vaccinated keratitis. Progressive vaccines are used to occur in patients who were inoculated with smallpox vaccine, and then developed a progressive cutaneous skin reaction in the case of severe immunosuppression. We suspect that a very similar disease can occur on the surface of the eye following inoculation with monkeypox virus.

We looked at histological samples, both of the skin and of the cornea in such cases, and we found a striking absence of T lymphocytic infiltrate, but a preservation of neutrophilic response suggesting that innate mechanisms are still intact, but we have cell mediated deficiency that's perhaps permitting this virus to expand without any containment.

So, this is important because it basically suggests that in cases of severe monkeypox keratouveitis, in patients who are immunosuppressed, using steroids may actually worsen the clinical phenotype and prolong the disease course. Our patients were treated mostly with tecoviramat therapy, immune reconstitution. and in the case of ophthalmic involvement, trifluridine eyedrops after which, if there was a persistent uveitis, we would consider steroid use as well, only after the closure of any epithelial defects.

Unfortunately, two of our patients passed away, who developed severe cutaneous skin manifestations including confluent gangrene of the face and the body. We do have a couple of patients who recovered quite nicely from monkeypox keratitis and keratouveitis, but they were typically immunocompetent patients.

We have one patient who was immunocompromised with HIV who developed essentially a corneal melt also in the sending of a tissue that was devoid of T lymphocytes. He required a keratoplasty, and he is fortunate to have preserved some vision.