Treatment outcomes and management of refractory mpox keratitis: a systematic review of patient-level case data

Background Mpox keratitis is a sight-threatening complication of monkeypox virus (MPXV) infection, yet systematic evidence on treatment outcomes remains limited. Objective To synthesize individual patient data on the clinical characteristics, treatment approaches, and visual outcomes of mpox keratitis. Methods A systematic review registered on PROSPERO ( CRD420261345543 ) was conducted in accordance with PRISMA 2020 guidelines. Electronic databases were searched from 1970-2026. Eligible studies reported at least one patient with confirmed mpox keratitis with individual treatment and outcome data. Risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists. Results Median age was 35 years (IQR 28-45); 86.6% were male; 46.3% HIV-positive; 92.5% Clade IIb. First-line success occurred in 16/63 [25.4% (95% CI 16.3-37.3%)], while 39/63 [61.9% (95% CI 49.6-72.9%)] were treatment-refractory. Re-epithelialisation was achieved in 47/67 [70.1% (95% CI 58.3-79.8%)]. Permanent visual impairment occurred in 16/62 [25.8% (95% CI 16.6-37.9%)]. Immunocompetent patients had higher re-epithelialisation (78.6% vs. 60.0%) and lower blindness (0% vs. 11.3%) than immunocompromised patients. Conclusion Mpox keratitis is characterised by low first-line success rates, high refractoriness, and significant visual morbidity. There is a need to establish prospective surveillance registries, including pharmacokinetic studies and clinical trials of promising antivirals to evaluate their efficacy and safety for topical use.