Large Conjunctival Ulceration from Ocular Monkeypox

A 34-year-old transgender female with history of human immunodeficiency virus (HIV) presented to the emergency department with complaint of a painful rash. Vesiculopapular lesions were present on the hands, face, and genitals raising clinical suspicion for monkeypox. The lesions were positive for monkeypox (orthopoxvirus) by polymerase chain reaction (PCR) and the patient's absolute CD4 count was 19 cells/uL. Tecovirimat was initiated for treatment of monkeypox as well as bictegravir-emtricitabine-tenofovir for newly diagnosed acquired immunodeficiency syndrome (AIDS). Two weeks later, the patient developed left eye pain. External examination (Figure) revealed a healing monkeypox lesion present on the glabella (panel A), the left eye had temporal conjunctival injection, engorgement of the episcleral vessels, and a raised papule (panel B) that was PCR-positive for monkeypox. Higher magnification revealed conjunctival ulceration (panel C) with an epithelial defect demonstrated by green fluorescein staining under a cobalt blue light (panel D). The patient was started on erythromycin ointment and the lesion subsequently healed over the course of three weeks. As our understanding of ocular monkeypox evolves, it is apparent that the manifestations can be quite variable, ranging from classic papulovesicular eyelid lesions, conjunctivitis, keratitis, and subconjunctival nodules which can ulcerate as observed in this patient.

Fig. 1.

Slit lamp examination revealed a healing monkeypox lesion present on the glabella (panel A), temporal conjunctival injection, engorgement of the episcleral vessels, and a raised papule (panel B) that was PCR-positive for monkeypox. Higher magnification revealed conjunctival ulceration (panel C) with an epithelial defect demonstrated by green fluorescein staining under a cobalt blue light (panel D).