Prevalence, characteristics, and clinical course of mpox-related ophthalmic disease (MBOTE-EYE): a prospective cohort study in South Kivu, Democratic Republic of the Congo

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BACKGROUND: Systematic longitudinal ophthalmologist-led assessment of mpox-related ophthalmic disease (MPOXROD) is rarely reported. We aimed to characterise the prevalence and clinical course of MPOXROD under supportive management during a clade Ib outbreak. METHODS: MBOTE-EYE was a substudy nested within a prospective cohort in South Kivu, Democratic Republic of the Congo. All hospitalised patients with PCR-confirmed mpox (within the last 48 h) were eligible. Participants underwent ophthalmological examination at enrolment, discharge, and days 29 and 59. Conjunctival swabs were collected for monkeypox virus PCR. Risk factors for MPOXROD were assessed using mixed-effects Poisson regression. FINDINGS: Between Oct 28, 2024, and June 30, 2025, 310 participants were enrolled (median age 14·0 years [IQR 2·5-25·0]; 166 [54%] female). At enrolment, conjunctival disease was present in 112 (36% [95% CI 31-42]) participants, corneal disease in 24 (8% [5-11]), and anterior uveitis in two (1% [0-2]). Overall, 134 (43% [38-49]) participants developed MPOXROD during follow-up, most often bilaterally. Blindness following ulcerative keratitis occurred in two (1% [0-3]) of 224 participants. Periorbital lesions (adjusted risk ratio [aRR] 3·65 [95% CI 2·42-5·49]) and severe acute malnutrition (aRR 3·16 [1·22-8·22]) were associated with MPOXROD. PCR was done among 89 patients and cycle threshold values below 25 occurred exclusively during active MPOXROD. INTERPRETATION: Ophthalmic involvement in clade Ib mpox is common and frequently bilateral, with a substantial burden of keratitis and risk of vision loss. Systematic eye examinations should be integrated into mpox care, and targeted ophthalmic therapies should be developed. FUNDING: Canadian Institutes of Health Research and the International Development Research Centre, the European & Developing Countries Clinical Trials Partnership, and the Belgian Directorate-General for Development Cooperation and Humanitarian Aid.

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