Acute nonarteritic anterior ischemic optic neuropathy and exposure to phosphodiesterase type 5 inhibitors

J Sex Med. 2015 Jan;12(1):139-51. doi: 10.1111/jsm.12726. Epub 2014 Oct 31.


Introduction: Nonarteritic anterior ischemic optic neuropathy (NAION), a rare visual disorder, has been reported in men using phosphodiesterase type 5 inhibitors (PDE5i) for erectile dysfunction.

Aim: We examined whether intermittent use of PDE5i is associated with acute NAION onset within approximately five half-lives following drug ingestion.

Methods: One hundred two ophthalmology centers in the United States and Europe identified potential cases of NAION. An expert adjudication committee conducted a blind review of the records of those with recent PDE5i use to classify cases as Definite, Possible, or not NAION. Subjects provided information on PDEi use via telephone interview. Each NAION case's PDE5i exposure immediately prior to onset was compared against his recent patterns of use in an observational case-crossover design. A sample size of 40 cases with intermittent PDE5i exposure in the 30 days prior to NAION onset was needed to detect an odds ratio (OR) of 3.0 with 80% power.

Main outcome measures: The daily relative risk for acute NAION on days within five half-lives of PDE5i use vs. other days was estimated via an OR obtained from conditional logistic regression.

Results: Among 43 Definite NAION cases with PDE5i exposure in the prior 30 days, the OR was 2.15 (95% confidence interval [CI]: 1.06, 4.34). When 21 Possible NAION cases were included (n = 64), the OR was 2.36 (95% CI: 1.33, 4.19).

Conclusions: We found an approximately twofold increased risk of acute NAION within five half-lives of PDE5i use compared with use in a more prior time period. Bias from inaccurate recall of exposure was unlikely to have substantially affected the results. Based on our results, we estimate that weekly use of PDE5i adds three NAION cases per 100,000 men 50 years and older annually.

Trial registration: NCT00759174.

Keywords: Case-Crossover Study; Erectile Dysfunction (ED); Nonarteritic Anterior Ischemic Optic Neuropathy (NAION); Phosphodiesterase Type 5 Inhibitors (PDE5i); Sildenafil.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Case-Control Studies
  • Erectile Dysfunction / drug therapy*
  • Erectile Dysfunction / epidemiology
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Optic Neuropathy, Ischemic / chemically induced*
  • Optic Neuropathy, Ischemic / epidemiology
  • Optic Neuropathy, Ischemic / pathology
  • Phosphodiesterase 5 Inhibitors / adverse effects*
  • Phosphodiesterase 5 Inhibitors / therapeutic use
  • Risk Factors
  • United States / epidemiology


  • Phosphodiesterase 5 Inhibitors

Associated data