Treating Herpes Zoster Ophthalmicus With Antivirals Reduces Cerebrovascular Accident Risk

An eye infection of herpes zoster virus has caused corneal ulceration and necrosis. (Photo by © Dr. Charles J. Ball/CORBIS/Corbis via Getty Images)
Researchers investigate the incidence of cerebrovascular accidents in patients with herpes zoster ophthalmicus and assess its association with prompt antiviral therapy.

Administering antiviral agents within 3 days of rash onset may decrease the risk of cerebrovascular accident (CVA) in patients with herpes zoster ophthalmicus (HZO), according to a study published in the American Journal of Ophthalmology. 

Researchers retroscopically reviewed the records of 869 patients with HZO (median age at onset, 65.5 years; 52.5% men) presenting to a single center between 2006 and 2016. In total, 88% (n=765) of patients received antiviral therapy, 10.9% of patients did not receive it, and antiviral treatment was undocumented in 1% of patients. Among the cohort, 54.9% were given antiviral therapy within 72 hours of rash manifestation.  

CVA occurred within 12 months of HZO in 1.6% of participants and was more common in older patients (2.5% aged ≥65 years; 0.7% aged 40-65 years; 0.9% aged <40 years). CVA likelihood was highest immediately after HZO, and the median time to CVA was 2.3 months. Participants receiving acyclovir exhibited a 76.2% lower hazard of CVA (P =.022) compared with individuals who did not receive antiviral treatment within 72 hours.

Multivariate analysis revealed a higher CVA risk for patients who were administered antiviral treatment after 72 hours of rash onset and those not receiving antivirals (HR, 4.478 and 3.980, respectively), but this value did not reach significance in patients who were not treated with antivirals (P =.128).

“Patients with HZO would be expected to be particularly susceptible to a cerebrovascular event due to the proximity of the trigeminal ganglion to the cerebral arteries,” according to the researchers. “Given the mechanism involving direct arterial infection with [varicella zoster virus], it follows that antiviral treatment would have the potential to mitigate the risk or severity of vasculopathy and subsequent CVA, particularly when instituted promptly.”

Study limitations include a limited study sample size, retroscopic nature, single center design, and lack of access to unmeasured potential confounders. 


Meyer JJ, Liu K, Danesh-Meyer HV, Niederer RL. Prompt antiviral therapy is associated with lower risk of cerebrovascular accident following herpes zoster ophthalmicus. Am J Ophthalmol. Published online July 6, 2022. doi:10.1016/j.ajo.2022.06.020