Abstract
Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common acute optic neuropathy and one of the most common causes of sudden vision loss in the elderly. Recently, NAION has been associated with the use of phosphodiesterase type 5 inhibitors (PDE5i) in men with erectile dysfunction (ED). A causal relationship could not be established given the large number of men safely using PDE5i and the limited number of NAION cases reported in these men. ED and NAION share common risk factors; therefore, some men with ED should be expected to develop NAION. However, sudden vision loss or decreased vision in one or both eyes demands immediate cessation of PDE5i use and urgent patient assessment. No causal relationship between PDE5i and the development of NAION exists for the moment, yet physicians should be aware of a possible adverse reaction and inform patients accordingly.
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References and Recommended Reading
Papaharitou S, Athanasiadis L, Nakopoulou E, et al.: Erectile dysfunction and premature ejaculation are the most frequently self-reported sexual concerns: profiles of 9536 men calling a helpline. Eur Urol 2006, 49:557–563.
Hatzichristou DG, Pescatori ES: Current treatments and emerging therapeutic approaches in male erectile dysfunction. BJU Int 2001, 88:11–17.
Hatzimouratidis K, Hatzichristou DG: A comparative review of the options for treatment of erectile dysfunction: which treatment for which patient? Drugs 2005, 65:1621–1650.
Dundar SO, Dayanir Y, Topaloglu A, et al.: Effect of sildenafil on ocular hemodynamics in 3 months regular use. Int J Impot Res 2006, 18:282–286.
Gonzalez CM, Bervig T, Podlasek C, et al.: Sildenafil causes a dose-and time-dependent downregulation of phosphodiesterase type 6 expression in the rat retina. Int J Impot Res 1999, 11:S9–S14.
Jagle H, Jagle C, Serey L, et al.: Visual short-term effects of Viagra: double-blind study in healthy young subjects. Am J Ophthalmol 2004, 137:842–849.
Pomeranz HD, Bhavsar AR: Nonarteritic ischemic optic neuropathy developing soon after use of sildenafil (viagra): a report of seven new cases. J Neuroophthalmol 2005, 25:9–13.
Hatzichristou D: Phosphodiesterase 5 inhibitors and nonarteritic anterior ischemic optic neuropathy (NAION): coincidence or causality? J Sex Med 2005, 2:751–758.
Bella AJ, Brant WO, Lue TF, et al.: Non-arteritic anterior ischemic optic neuropathy (NAION) and phosphodiesterase type-5 inhibitors. Can J Urol 2006, 13:3233–3238.
Laties A, Sharlip I: Ocular safety in patients using sildenafil citrate therapy for erectile dysfunction. J Sex Med 2006, 3:12–27.
Hayreh SS, Zimmerman MB, Podhajsky P, et al.: Nocturnal arterial hypotension and its role in optic nerve head and ocular ischemic disorders. Am J Ophthalmol 1994, 117:603–624.
Arnold AC: Pathogenesis of nonarteritic anterior ischemic optic neuropathy. J Neuroophthalmol 2003, 23:157–163.
Johnson LN, Arnold AC: Incidence of nonarteritic and arteritic anterior ischemic optic neuropathy. Population-based study in the state of Missouri and Los Angeles County, California. J Neuroophthalmol 1994, 14:38–44.
Rucker JC, Biousse V, Newman NJ: Ischemic optic neuropathies. Curr Opin Neurol 2004, 17:27–35.
Buono LM, Foroozan R, Sergott RC, et al.: Nonarteritic anterior ischemic optic neuropathy. Curr Opin Ophthalmol 2002, 13:357–361.
Hattenhauer MG, Leavitt JA, Hodge DO, et al.: Incidence of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1997, 123:103–107.
Xu L, Wang Y, Jonas JB: Incidence of nonarteritic anterior ischemic optic neuropathy in adult Chinese: The Beijing Eye Study. Eur J Ophthalmol 2007, 17:459–460.
Nagai-Kusuhara A, Nakamura M, Kanamori A, et al.: Evaluation of optic nerve head configuration in various types of optic neuropathy with Heidelberg Retina Tomograph. Eye 2007.
Beck RW, Servais GE, Hayreh SS: Anterior ischemic optic neuropathy. IX. Cup-to-disc ratio and its role in pathogenesis. Ophthalmology 1987, 94:1503–1508.
Bollinger K, Lee MS: Recurrent visual field defect and ischemic optic neuropathy associated with tadalafil rechallenge. Arch Ophthalmol 2005, 123:400–401.
Feit RH, Tomsak RL, Ellenberger C, Jr.: Structural factors in the pathogenesis of ischemic optic neuropathy. Am J Ophthalmol 1984, 98:105–108.
Characteristics of patients with nonarteritic anterior ischemic optic neuropathy eligible for the Ischemic Optic Neuropathy Decompression Trial. Arch Ophthalmol 1996, 114:1366–1374.
Ischemic Optic Neuropathy Decompression Trial: twenty-four-month update. Arch Ophthalmol 2000, 118:793–798.
Nagy V, Steiber Z, Takacs L, et al.: Trombophilic screening for nonarteritic anterior ischemic optic neuropathy. Graefes Arch Clin Exp Ophthalmol 2006, 244:3–8.
Abu-Amero KK, Bosley TM: Prothrombotic and atherosclerotic risk factors lack significance in NAION patients harbouring mitochondrial DNA mutations. Br J Ophthalmol 2006, 90:119–120.
Hayreh SS, Jonas JB, Zimmerman MB: Nonarteritic anterior ischemic optic neuropathy and tobacco smoking. Ophthalmology 2007, 114:804–809.
McCulley TJ, Lam BL, Feuer WJ: A comparison of risk factors for postoperative and spontaneous nonarteritic anterior ischemic optic neuropathy. J Neuroophthalmol 2005, 25:22–24.
Weger M, Haas A, Stanger O, et al.: Chlamydia pneumoniae seropositivity and the risk of nonarteritic ischemic optic neuropathy. Ophthalmology 2002, 109:749–752.
Hayreh SS, Joos KM, Podhajsky PA, et al.: Systemic diseases associated with nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1994, 118:766–780.
Egan R: Prothrombotic and vascular risk factors in NAION. Ophthalmology 2000, 107:2116–2117.
Jacobson DM, Vierkant RA, Belongia EA: Nonarteritic anterior ischemic optic neuropathy. A case-control study of potential risk factors. Arch Ophthalmol 1997, 115:1403–1407.
Johnson LN, Botelho PJ, Kuo HC: Is smoking a risk factor for NAION (nonarteritic anterior ischemic optic neuropathy)? Ophthalmology 1994, 101:1322–1324.
Deramo VA, Sergott RC, Augsburger JJ, et al.: Ischemic optic neuropathy as the first manifestation of elevated cholesterol levels in young patients. Ophthalmology 2003, 110:1041–1046.
Goldenberg-Cohen N, Kramer M, Bahar I, et al.: Elevated plasma levels of interleukin 8 in patients with acute anterior ischaemic optic neuropathy. Br J Ophthalmol 2004, 88:1538–1540.
Hayreh SS, Podhajsky P, Zimmerman MB: Role of nocturnal arterial hypotension in optic nerve head ischemic disorders. Ophthalmologica 1999, 213:76–96.
Optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy (NAION) is not effective and may be harmful. The Ischemic Optic Neuropathy Decompression Trial Research Group. Jama 1995, 273:625–632.
Repka MX, Savino PJ, Schatz NJ, et al.: Clinical profile and long-term implications of anterior ischemic optic neuropathy. Am J Ophthalmol 1983, 96:478–483.
Dickersin K, Manheimer E, Li T: Surgery for nonarteritic anterior ischemic optic neuropathy. Cochrane Database Syst Rev 2006, 25(1):CD001538.
Jonas JB, Spandau UH, Harder B, et al.: Intravitreal triamcinolone acetonide for treatment of acute nonarteritic anterior ischemic optic neuropathy. Graefes Arch Clin Exp Ophthalmol 2007, 245:749–750.
Wilhelm B, Ludtke H, Wilhelm H: Efficacy and tolerability of 0.2% brimonidine tartrate for the treatment of acute non-arteritic anterior ischemic optic neuropathy (NAION): a 3-month, double-masked, randomised, placebo-controlled trial. Graefes Arch Clin Exp Ophthalmol 2006, 244:551–558.
Fujikado T, Morimoto T, Matsushita K, et al.: Effect of transcorneal electrical stimulation in patients with nonarteritic ischemic optic neuropathy or traumatic optic neuropathy. Jpn J Ophthalmol 2006, 50:266–273.
Tomsak R: PDE5 inhibitors and permanent visual loss. Int J Impot Res 2005, 17:547–549.
Janaky M, Fulop Z, Palffy A, et al.: Electrophysiological findings in patients with nonarteritic anterior ischemic optic neuropathy. Clin Neurophysiol 2006, 117:1158–1166.
The ischemic optic neuropathy decompression trial (IONDT): design and methods. Control Clin Trials 1998, 19:276–296.
Hayreh SS, Podhajsky PA, Zimmerman B: Ipsilateral recurrence of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 2001, 132:734–742.
Egan R, Pomeranz H: Sildenafil (Viagra) associated anterior ischemic optic neuropathy. Arch Ophthalmol 2000, 118:291–292.
Cunningham AV, Smith KH: Anterior ischemic optic neuropathy associated with viagra. J Neuroophthalmol 2001, 21:22–25.
Dheer S, Rekhi GS, Merlyn S: Sildenafil associated anterior ischaemic optic neuropathy. J Assoc Physicians India 2002, 50:265.
Pomeranz HD, Smith KH, Hart WM Jr, et al.: Sildenafil-associated nonarteritic anterior ischemic optic neuropathy. Ophthalmology 2002, 109:584–587.
Boshier A, Pambakian N, Shakir SA: A case of nonarteritic ischemic optic neuropathy (NAION) in a male patient taking sildenafil. Int J Clin Pharmacol Ther 2002, 40:422–423.
Sinha S, Pathak-Ray V, Ahluwalia H, et al.: Viagra or what? Eye 2004, 18:446–448.
Gruhn N, Fledelius HC: Unilateral optic neuropathy associated with sildenafil intake. Acta Ophthalmol Scand 2005, 83:131–132.
Peter NM, Singh MV, Fox PD: Tadalafil-associated anterior ischaemic optic neuropathy. Eye 2005, 19:715–717.
Escaravage GK, Jr., Wright JD, Jr., Givre SJ: Tadalafil associated with anterior ischemic optic neuropathy. Arch Ophthalmol 2005, 123:399–400.
Gedik S, Yilmaz G, Akova YA: Sildenafil-associated consecutive nonarteritic anterior ischaemic optic neuropathy, cilioretinal artery occlusion, and central retinal vein occlusion in a haemodialysis patient. Eye 2007, 21:129–130.
Gorkin L, Hvidsten K, Sobel RE, et al.: Sildenafil citrate use and the incidence of nonarteritic anterior ischemic optic neuropathy. Int J Clin Pract 2006, 60:500–503.
Boshier A, Wilton LV, Shakir SA: Evaluation of the safety of sildenafil for male erectile dysfunction: experience gained in general practice use in England in 1999. BJU Int 2004, 93:796–801.
Margo CE, French DD: Ischemic optic neuropathy in male veterans prescribed phosphodiesterase-5 inhibitors. Am J Ophthalmol 2007, 143:538–539.
McGwin G, Jr., Vaphiades MS, Hall TA, et al.: Non-arteritic anterior ischaemic optic neuropathy and the treatment of erectile dysfunction. Br J Ophthalmol 2006, 90:154–157.
Montorsi P, Ravagnani PM, Galli S, et al.: Association between erectile dysfunction and coronary artery disease: Matching the right target with the right test in the right patient. Eur Urol 2006, 50:721–731.
Pache M, Meyer P, Prunte C, et al.: Sildenafil induces retinal vasodilatation in healthy subjects. Br J Ophthalmol 2002, 86:156–158.
Polak K, Wimpissinger B, Berisha F, et al.: Effects of sildenafil on retinal blood flow and flicker-induced retinal vasodilatation in healthy subjects. Invest Ophthalmol Vis Sci 2003, 44:4872–4876.
Metelitsina TI, Grunwald JE, DuPont JC, et al.: Effect of viagra on retinal vein diameter in AMD patients. Exp Eye Res 2006, 83:128–132.
Grunwald JE, Metelitsina T, Grunwald L: Effect of sildenafil citrate (Viagra) on retinal blood vessel diameter. Am J Ophthalmol 2002, 133:809–812.
Metelitsina TI, Grunwald JE, DuPont JC, et al.: Effect of Viagra on the foveolar choroidal circulation of AMD patients. Exp Eye Res 2005, 81:159–164.
Koksal M, Ozdemir H, Kargi S, et al.: The effects of sildenafil on ocular blood flow. Acta Ophthalmol Scand 2005, 83:355–359.
Salomon O, Huna-Baron R, Steinberg DM, et al.: Role of aspirin in reducing the frequency of second eye involvement in patients with non-arteritic anterior ischaemic optic neuropathy. Eye 1999, 13:357–359.
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Hatzimouratidis, K. Phosphodiesterase type 5 inhibitors, visual changes, and nonarteritic anterior ischemic optic neuropathy: Is there a link?. Curr Urol Rep 8, 482–490 (2007). https://doi.org/10.1007/s11934-007-0053-1
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DOI: https://doi.org/10.1007/s11934-007-0053-1