This document serves to provide information regarding the manifestations and management of ocular mpox infections within NSW.
Since 2022, there has been a global outbreak of mpox which has affected New South Wales and other Australian jurisdictions. Globally, the prevalence of ocular mpox varies greatly depending on the region, with 1% prevalence in Europe and up to 27% prevalence in Africa [1]. The complications from ocular mpox can be significant including corneal scarring and vision loss, and therefore prompt diagnosis and management are essential [2].
Mpox can enter the eye through autoinoculation and can cause ocular conditions such as conjunctivits, blepharitis, keratitis and corneal ulcers. It is also more common in young children [2]. Examples of these ocular conditions can be see in the clinical images below.
Image adapted from [3] Pazos, M. et al. Characteristics and Management of Ocular Involvement in Individuals with Monkeypox Disease. Opthamology. 2023 Jun;130(6): 655-688. doi: 10.1016/j.ophtha.2023.02.013. Copyright © 2025 Elsevier Inc. Source: https://www.sciencedirect.com/journal/ophthalmology
A. Membranous conjunctivitis with focal conjuctival erosion [3]
B. Membranous and mucropurulent conjunctivits [3]
C. Keratitis with corneal opacities [4]
D. Keratitis with dendritic like ulceration [5]
E. Anterior uveitis with keratitic precipates [4]
Patients presenting with signs and symptoms concerning for ocular mpox should have an eye swab collected and sent for testing. This can be a dry sterile swab (preferred) or a viral eye swab sent in a viral transport media [6]. If other viral pathogens are suspected a second swab should be collected and placed in a separate bag [7]. Swabs should also be collected from skin lesions and other sites such as rectal and nasopharyngeal swabs guided by relevant symptoms [7]. Clinicans should ensure they wear appropriate personal protective equipment when collecting samples including disposable fluid-resistant gown, disposable gloves, face shield or goggles, and a fluid-repellant surgical mask. Conside an N95 mask if the patient also has respiratory symptoms, or if there is a high-risk exposure event including prolonged exposure or serosol-generating activites [8].
According to the World Health Organization, patients with ocular manifestations of mpox are considered to have severe mpox infections, and hospital evaluation and possible admission is warranted [9]. Patients should be disussed with Ophthamology at Westmead Hospital. Antiviral medications can be obtained from the NSW Specialist Service for High Consequence Infectious Diseases (or the Infectious Diseases Physician on-call at Westmead Hospital) - see NSW Specialist Service for High Consequence Infectious Diseases for details [10].
In consultation with the above specialists, the below treatments may be recommended:
Other alternatives may include:
*Not currently available in Australia, contact the NSW Specialist Service for High Consequence Infectious Diseases for up-to-date availability.
IV vaccinia immunoglobulin may be considered on a case-by-case basis (based on evidence from animal models showing reduced corneal scarring) [2].
Topical lubricants and broad-spectrum topical antibiotics (e.g. chloramphenicol, ocuflox) to prevent secondary bacterial infections in cases with corneal ulcers and/or keratitis.
Topical steroids should be avoided (may prolong the presence of the virus in ocular tissue) [2].
Regular hand hygiene and avoidance of rubbing/touching the eye will help prevent autoinoculation of mpox [2]. Prophylactic topical trifluridine should be considered in patients with eyelid lesions or children/people not able to follow strict hygiene instructions [2].
1. Gandhi, AP, Gupta, PC, Padhi, BK, Sandeep, M, Suvvari, TK, Shamim, MA, Satapathy, P, Sah, R, Leon-Figueroa, DA, Rodriguez-Morales, AJ, Barboza, JJ, Dziedzic, A. 'Ophthalmic Manifestations of the Monkeypox Virus: A Systematic Review and Meta-Analysis'. Pathogens. 2023. 12 (3). Accessed doi:10.3390/pathogens12030452.
2. U.S Centers for Disease Control and Prevention. Interim Clinical Considerations for Management of Ocular Mpox. 2024. Available from: https://www.cdc.gov/mpox/hcp/clinical-care/ocular-infection.html
3. Pazos, M, Riera, J, Moll-Udina, A, Catala, A, Narvaez, S, Fuertes, I, Dotti-Boada, M, Petiti, G, Izquierdo-Serra, J, Maldonado, E, Chang-Sotomayor, M, Garcia, D, Camós-Carreras, A, Gilera, V, De Loredo, N, Peraza-Nieves, J, Ventura-Abreu, N, Spencer, F, Del Carlo, G, Blanco, J. L. 'Characteristics and Management of Ocular Involvement in Individuals with Monkeypox Disease'. Ophthalmology. 2023. 130, no. 6: 655–58. Accessed doi:10.1016/j.ophtha.2023.02.013.
4. Finamor, L. P. S., Mendes-Correa, M. C., Rinkevicius, M., Macedo, G., Sabino, E. C., Villas-Boas, L. S., de Paula, A. V., de Araujo-Heliodoro, R. H., da Costa, A. C., Witkin, S. S., Santos, K. L. C., Palmeira, C., Andrade, G., Lucena, M., de Freitas Santoro, D., da Silva, L. M. P., & Muccioli, C. 'Ocular Manifestations of Monkeypox Virus (MPXV) Infection with Viral Persistence in Ocular Samples: A Case Series'. International Journal of Infectious Diseases. 2024. Accessed doi:10.1016/j.ijid.2024.107071.
5. Yi-Ting, L., Chien-Hsien, H., Hwa-Hsin, F., Cheng-Kuo, C., & Pai-Huei, P. 'Monkeypox-Related Ophthalmic Disease'. Taiwan Journal of Ophthalmology. 2024. 14, no. 2: 279–83. Accessed doi:10.4103/tjo.TJO-D-23-00141.
6. Public Health Laboratory Network. Guidance on Mpox Patient Referral, Specimen Collection and Test Requesting. 2025. Available from: https://www.health.gov.au/sites/default/files/2025-01/phln-guidance-on-mpox-patient-referral-specimen-collection-and-test-requesting.pdf
7. New South Wales Health. Mpox NSW Control Guideline for Public Health Units. NSW Health. 2024. Available from: https://www.health.nsw.gov.au/Infectious/controlguideline/Documents/mpox-nsw-control-guideline.pdf
8. Public Health Laboratory Network. Mpox (Monkeypox virus infection) Laboratory case definition. 2023. Available from: https://www.health.gov.au/sites/default/files/2023-07/monkeypox-laboratory-case-definition.pdf
9. World Health Organization. Clinical Management and Infection Prevention and Control for Monkeypox. 2022. Available from: https://iris.who.int/bitstream/handle/10665/355798/WHO-MPX-Clinical_and_IPC-2022.1-eng.pdf?sequence=1
10. New South Wales Health. Information for clinicians treating patients with mpox who require hospitalisation. 2024. Available from: https://www.health.nsw.gov.au/Infectious/mpox/Pages/clinicians.aspx
11. Australian Centre of Disease Control. 2024 Mpox Treating Guidelines. 2024. Available from: https://www.health.gov.au/sites/default/files/2024-11/monkeypox-treatment-guidelines.pdf