Comment on: “Herpes Zoster in neuro-ophthalmology: a practical approach”

We have read with great interest the recent article by Tao et al. [1] which provides the reader with a concise overview regarding the neuro-ophthalmic manifestations of herpes zoster and their management. However, we would like to make a comment regarding what in our opinion is a clinical misinterpretation of Hutchinson’s sign as a predictor of neuro-ophthalmic disease.

In 1866, Sir Jonathan Hutchinson documented “My cases [n = 13] are as yet too few in number to authorize a confident statement, but thus far I have never seen the whole side of the nose affected without also witnessing inflammation of the eye and I have never seen the eye inflame unless the side of the nose showed vesicles.” [2]. A prospective study carried out by Adam et al. [3] did not find any statistical significance between Hutchinson’s sign (nasociliary nerve involvement) and herpes zoster ophthalmicus (p = 0.184). However, statistical significance was approached when Hutchinson’s sign coexisted with blepharitis and conjunctivitis (p = 0.067). Furthermore, supratrocheal nerve involvement showed greater statistical significance (pvalue = 0.0004) for the development of herpes zoster ophthalmicus, whilst having a positive predictive value of 0.6 and a negative predictive value of 0.89 for associated eye involvement [3].