Teaching NeuroImages: Hutchinson Sign in Herpes Zoster Ophthalmicus

A 42-year-old immunocompetent man developed left-sided orbital and temporal stabbing pain, accompanied by ipsilateral lacrimation and conjunctival injection with periorbital edema (figure 1A). On day 10, Hutchinson sign, which is defined as zoster skin lesions in the root, dorsum, and apex of the nose,¹ became evident with severe keratoconjunctivitis and iritis (figure 1B). PCR testing of blood revealed varicella-zoster virus and he was diagnosed with herpes zoster ophthalmicus (HZO). Hutchinson sign indicates the involvement of the nasociliary nerve, a branch of ophthalmic nerve innervating the eyelid, nose, and eye (figure 2), and is the strong predictor of the ocular complications of HZO.^1,2 Compared to HZO in the absence of Hutchinson sign, the presence of Hutchinson sign indicates a 3.4-fold increase in the risk of developing ocular inflammation and a 4-fold increase in the risk of developing corneal denervation.²