Teaching NeuroImages: Herpes zoster ophthalmicus–related oculomotor palsy accompanied by Hutchinson sign
Gayatri S. Reilly and Robert K. Shin
Neurology. April 13, 2010; 74 (15) RESIDENT AND FELLOW SECTION
ARTICLE
A 51-year-old woman presented with acute diplopia. Findings include right ptosis, a dilated, unreactive pupil, and impaired adduction and vertical ductions (figure 1). A skin lesion was noted on the right tip of the nose, residual from a vesicular rash over the right forehead 3 weeks earlier (figure 1). MRI demonstrated enhancement of the cisternal third nerve, obviating the need for angiography (figure 2). The oculomotor palsy resolved within 3 months.
Figure 1 Partial ptosis, mydriasis, and exotropia consistent with a right oculomotor palsy
The skin lesion on the tip of the nose (Hutchinson sign) signifies involvement of the nasociliary branch of V1, which also innervates ocular structures.
Figure 2 T1-weighted MRI showing enhancement of the cisternal portion of the oculomotor nerve (arrow)
Oculomotor palsy may present weeks after herpes zoster ophthalmicus.1,2 Involvement of the tip of the nose (Hutchinson sign) is a strong predictor of ocular involvement, indicating involvement of the nasociliary branch of V1, which innervates both the tip of the nose and ocular structures such as the cornea, conjunctiva, and uvea.
Footnotes
Disclosure: Dr. Reilly reports no disclosures. Dr. Shin has received speaker honoraria from Bayer Schering Pharma and Teva Pharmaceutical Industries Ltd.
REFERENCES
- Chang-Godinich A, Lee AG, Brazis PW, Liesegang TJ, Jones DB. Complete ophthalmoplegia after zoster ophthalmicus. J Neuroophthalmol 1997;17:262–265.
- Quisling SV, Shah VA, Lee HK, et al. Magnetic resonance imaging of third cranial nerve palsy and trigeminal sensory loss caused by herpes zoster. J Neuroophthalmol 2006;26:47–48.
Video 3rd Nerve Palsy U-M Kellogg Eye Center in Ann Arbor
Published on Jun 20, 2014