Howard D. Pomeranz

Nonarteritic ischemic optic neuropathy developing soon after use of sildenafil (Viagra): A report of seven new cases

Seven patients, aged between 50 and 69 years, had typical features of nonarteritic anterior ischemic optic neuropathy (NAION) within 36 hours after ingestion of sildenafil citrate (Viagra) for erectile dysfunction. Six patients had vision loss within 24 hours after use of the agent. Final visual acuity in the affected eye ranged from 20/20 to light perception. Both eyes were affected in one individual. All affected individuals had pre-existing hypertension, diabetes, elevated cholesterol, or hyperlipidemia. Seven similar cases have been previously reported. Sildenafil may provoke NAION in individuals with an arteriosclerotic risk profile.

Visual manifestations of visible and buried optic disc drusen.

Background: It has been reported that visible optic disc drusen are associated with decreased visual acuity and loss of peripheral visual field. Patients with buried optic disc drusen have not been as well characterized. Methods: An observational, retrospective review was made of 92 eyes with funduscopic or ultrasonographic evidence of optic disc drusen. Demographics, presenting symptoms, visual acuity, refractive error, intraocular pressure, presence of an afferent pupillary defect, cup-to-disc ratio, appearance of the optic nerve, and visual field were recorded. Results: Fifty-one (55%) of the eyes were symptomatic; among them, 63% had symptoms of visual acuity loss, and 49% had symptoms of visual field loss. Seventy-nine (86%) of the optic discs appeared abnormal on ophthalmoscopy, but only 42% of these had visible drusen. Forty-five (49%) of the eyes had a visual field defect, and 73% of these were nerve fiber bundle in type. Overall, 73% of optic discs with visible drusen had abnormal visual fields compared with only 36% of optic discs with buried drusen (P < 0.05). Conclusions: Among 92 eyes with optic disc drusen, only slightly more than 50% produced visual symptoms. Fewer than 50% of drusen were visible ophthalmoscopically. Buried optic disc drusen identified by ultrasound had a significantly lower frequency of associated visual field defects than did visible optic disc drusen.

The Relationship Between Phosphodiesterase-5 Inhibitors and Nonarteritic Anterior Ischemic Optic Neuropathy.

Background: A cause and effect relationship between phosphodiesterase-5 inhibitor (PDE5I) use and nonarteritic anterior ischemic optic neuropathy (NAION) has been hypothesized based on case reports. Evidence Acquisition: Review of literature. Results: Thirty-nine case reports in the peer-reviewed medical literature have documented a possible relationship between PDE5I consumption and NAION. However, pertinent details, such as the dose and frequency of PDE5I use, and elapsed time between ingestion and onset of vision loss, are lacking from many of these reports. Investigations regarding alterations in ocular perfusion in research subjects who ingested sildenafil have been inconclusive because they have not been performed on subjects with “disc at risk” or risk factors for NAION. One case-crossover study demonstrated a 2-fold increase in risk of NAION after ingestion of PDE5I. Conclusions: When a diagnosis of NAION is made, an inquiry should be made as to whether any PDE5I was ingested before the onset of vision loss. If so, the patient should be counseled regarding the possibility that continued PDE5I use may increase the risk of NAION in the fellow eye. Patients with a known history of previous NAION should be cautioned regarding the use of PDE5I for erectile dysfunction or pulmonary hypertension because of the potential increased risk of fellow eye involvement.

Intrachiasmal craniopharyngioma: treatment with a cisternal catheter drainage and radiation.

A 54-year-old woman who presented with headaches and bitemporal visual field loss had an MRI that disclosed a cystic lesion within the optic chiasm. Craniotomy yielded an inconclusive biopsy; incisional decompression of the cyst provided only temporary improvement in vision. When vision declined 3 months later, an MRI showed recurrence of the cyst. The patient underwent a second craniotomy with biopsy that revealed an adamantinomatous craniopharyngioma. Because of the dangers of surgical removal, the cyst was left in place and connected by catheter to the prechiasmatic cisternal subarachnoid space. She received 54 Gy of three-dimensional conformal x-irradiation. At the time of her last follow-up examination 28 months postoperatively, the patient had marked improvement in her visual acuity and visual fields; an MRI demonstrated that the cyst remained decompressed. Cisternal catheter drainage represents a novel approach to the treatment of this rare variant of craniopharyngioma.