Teaching NeuroImages: herpes zoster ophthalmicus-related oculomotor palsy accompanied by Hutchinson sign.

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. 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. REFERENCES 1. Chang-Godinich A, Lee AG, Brazis PW, Liesegang TJ, Jones DB. Complete ophthalmoplegia after zoster ophthalmicus. J Neuroophthalmol 1997;17:262–265. 2. 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. Figure 2 T1-weightedMRIshowingenhancement ofthecisternalportionofthe oculomotornerve (arrow)